Readers Write 1/6/12

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!

Building a Successful EMR Dress Rehearsal Program: Why it Matters
By Kathy Krypel

EMR implementations are not technology-only projects. They are care process redesign efforts enabled by technology. To that end, it is critical to engage care providers early in the planning and design process and throughout implementation and support. Dress rehearsals, in particular, let them to see how their decisions made during the build process “come to life” prior to actual go-live.

Dress rehearsals are detailed scripted care events that interweave complex processes from various members of the care team with the new EMR technology to simulate real care delivery experiences. There are different approaches to dress rehearsals, so picking the right one depends on the scope of the interactions, risk level, and process complexity. The most common ones are:

• Departmental. Scope is narrow, detail is deep. There are some significant procedures that do not happen frequently, but are so complex that organizations want to develop a dress rehearsal to make sure all roles and possible outcomes are addressed (e.g. transplants).
• Day in the Life. Scope is wide, detail is shallow. Day-in-the-life rehearsals are typically short (less than one hour) to perform and focus on workflows nurses, physicians, and other clinicians follow during their day.
• Integrated. Scope is wide, detail is deep. Integrated dress rehearsals are the most common type and usually last two to four hours. They focus on common workflows with multiple integration points.

The keys to successful dress rehearsals are preparation and participation. When the application teams, site leadership, and super users are fully engaged in both planning and execution, there’s greater buy-in up front, and there are fewer calls to the help desk after go-live.

Questions often come up during the planning phases concerning timing, issues communication, and degree of authenticity. While there’s no one right answer, the following responses to FAQs are based on our experience with successful dress rehearsals:

Timing: “Match timing with approach”

Day-in-the-life dress rehearsals can start as soon as some basic nursing and physician workflow(s) are built and ready for all to see. “Lunch and learn” sessions often offer end users a chance to see and interact with the system prior to go-live.

Integrated and department-specific dress rehearsals should be held as close to go-live as realistically possible. They are led by super users and attendees who have already been through training and practice sessions, so they are familiar with the system. This type of dress rehearsal offers end users one more chance to interact with the system before go-live and to follow their workflow through the care process.

Authenticity: “Keep it real”

Whenever possible, use the equipment and follow workflows accurately. However, make sure all of the pieces work in the dress rehearsal environment. The use of interfacing technology, when working smoothly, greatly contributes to end user confidence. When it doesn’t work, it adds to end user anxiety and impacts confidence in the technology.

Issue Resolution and Communication: “Write it down and follow up”

The dress rehearsal scribe needs to record any questions and concerns, and assign due dates for resolution. Consider using the time at the end to address issues. Often, the needed expertise is already attending/ participating, so problems can be readily resolved and changes approved.

Done at key points during the implementation project, dress rehearsals identify issues early on, so adjustments in technology and process can be made in time to retest and refine. This in turn increases the likelihood of a successful EMR implementation. Equally important, dress rehearsals engage care providers prior to system go-live, mitigating pre go-live anxiety and gaining their buy-in – all critical for achieving Meaningful Use.

Kathy Krypel is a senior associate with Aspen Advisors of Denver, CO.

VNAs and Enterprise Archiving – A Stepping Stone To Healthcare Data Management?
By Tim Kaschinske

At the same time that PACS are proliferating beyond radiology and into other disciplines (such as cardiology and orthopedics, for example), the responsibility for archiving and storing all of this DICOM data is moving away from individual departments (that have traditionally managed these environments) to a hospital’s central IT department. Healthcare CIOs have rolled up their sleeves and embraced the concept of a Vendor Neutral Archive (VNA) or Enterprise Archive as the best approach to managing this data storage challenge.

However, PACS is only one of many systems that a hospital has to manage; and healthcare data encompasses content from all manner of applications, both clinical and administrative. Consequently, a hospital’s storage systems also need to support everything from video to scanned documents to e-mail. Here are just a few of the activities and data types that need to be incorporated:

• Sleep Studies – where EEG and EKG waveforms are captured for brain and heart activity during sleep. Often this data is stored in a proprietary format.
  Endoscopy – where videos of the esophagus, stomach, or colon are captured.
• Scanned Documents – where paper documents that are scanned in and stored as PDF files.
• Laboratory Results – often transmitted using HL7 messages and stored in various formats.

To cope with these many and varied data types, hospitals need a VNA or Enterprise Archive that can deal with more than just DICOM data. In addition, to facilitate data exchange, these archives are adopting the XDS standard for cross-enterprise document sharing.

Over the next 12 months, more CIOs will adopt XDS-enabled archives as a standardized way to store, query and retrieve clinical and administrative content. In facilitating the registration, distribution ,and access across healthcare enterprises of electronic patient records, XDS enables IT to manage and share any document type. It works with DICOM (XDS-I) as well as multiple repositories indexed by a single enterprise registry.

As healthcare storage evolves, the VNA acronym will almost certainly be replaced with something that more accurately describes hospital storage systems. In reality, hospitals are looking for comprehensive healthcare data management. As such, hospitals need to adopt all the best practices typically associated with managing data across the Enterprise, such as:

• Data Protection – providing the ability to store additional copies of data to multiple locations and restore that data in the event of a disaster.
• Multi-media Support  – offering the ability to store and migrate data across different storage devices and media types, all independent of user applications.
• Data Versioning – enabling version control and management of data that can be restored in case of errors or corruption.
• Data Authentication – ensuring that data copied between sites or media types remains consistent and is not corrupted during the copy.
• Business Continuity – for the protection, preservation, and speedy restoration of systems and data during an outage.
• Data De-Duplication – providing the ability to detect multiple copies of identical data and store only one copy with multiple references.

Throughout 2012, hospital IT will be challenged to transform their PACS-centric storage into holistic healthcare data management systems. In the process, they will need to adopt a vendor neutral approach to their hardware and a data-agnostic approach to content. Just what we’ll end up calling it remains to be seen.

Tim Kaschinske is a consultant, healthcare solutions with BridgeHead Software.

2012 New Year’s Resolutions
By Vince Ciotti

Listed in order by their annual revenue, here are Vince Ciotti’s 2012 New Year’s resolutions for each of the leading HIS vendors:

1. McKesson:  Series will be sunset and Horizon announced as the go-forward product. Whoops, I’m sorry, that I meant to say Star is being sunset and Paragon is… oh, never mind!
2. Cerner: “ProFit” to be re-named “LossLeader” and targeted to hospitals whose CFOs and CIOs have a combined IQ of under 25 beds.
3. Siemens: will begin work on a new ERP suite for Invision which will allow them to automatically deduct monthly invoices from the AP system. The new system will be called Invasion.
4. GE: any hospitals that buy Centricity in 2012 will receive a free GE refrigerator for the first 30 patients registered in Centricity.
5. Epic: will sell to 100-bed and under hospitals provided they agree to send all inpatients to Verona for a two-week vacation to learn their EHRs. Epic will send one of its rookies to outpatient’s homes for training, but this will not earn them “good” maintenance rates on their EHRs.
6. Allscripts: will announce the complete integration of all of Eclipsys and Allscripts’ sales brochures, advertisements, PowerPoints, proposals and contracts. Work on disparate data bases and reports to commence in 2013.
7. Meditech: now that the Release 6 implementation line has reached 36 months from date of contract signing, orders are being taken for Release 7.
8. NextGen: announces an integrated solution combining their Opus, Sphere, and Prognosis HIS systems, to be called “Opusphernosis.”
9. QuadraMed: is renaming the integrated version of Affinity and QCPR as “Infinity,” the time it is estimated it will take to complete the project.
10. Keane: NTT wants its money back from Caritor, claiming that Optimum was not fully developed despite the many demos they observed, extensive marketing literature provided, written RFP response attached to the contract, and personal assurances they received from executives.
11. CPSI : is targeting the 500+ bed and up hospital market with a powerful new system that will run on two servers!
12. HMS: their new MedHost ED system is now being offered to hospitals without an ED at a special reduced price during the first quarter 2012.
13. Healthland: is planning a name change to Dairyland to emphasize their Midwest roots, strong service ethic, and diverse industry experience.

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

Readers Write 12/19/11

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!

View from the Healthcare Recruiter’s Chair
By Don Calhoun

Happy Holidays! As this year comes to an end, I thought I’d share some insight into the job market, hiring trends, tips for candidates, and tips for clients. Not to mention some observations that may or may not have anything to do with any of the above. The following are educated opinions with some fact sprinkled in.

The Job Market

We continue to see strong demand for implementation consultants, project managers, and practice directors. Shocking, right?

Instead of just trying to find one of the 1,000 Epic Certified “X” consultants to fill one of the 4,000 Epic Certified “X” consultant openings, we have employed a new strategy. Starting in 2012, we will be working with George Lucas on a controversial project. I can’t say a lot more at this time, but DNA will be involved.

Tips for Candidates

You may be looking for a better position, going through RIFs, or just putting EMR on your resume in the hopes that will create a bidding war for your services.

Tip #1. Recruiters see hundreds of resumes per week. They can become lazy. If you have experience with a vendor product, a particular system, or an integration tool, make sure it is on your resume. This is a world of keyword searches. If you don’t list these, you could be missing out.

Tip #2. If you have been at the same firm for sometime and have a feeling that they are underpaying you, talk to a recruiting firm. Some companies pay below-market value, and if you get comfortable in that role, you may be shortchanging yourself.

Tip #3. If you don’t mind travel, put that on your resume. If we stick with the theory that recruiters see hundreds of resumes per week and need to prioritize who to call first, the biggest slam-dunks will get that call. The slam-dunk has all of the pertinent information available – skills, software, general idea of rate/salary, and ability to travel.

Tips for Those Laid Off

Tip #1. Get on LinkedIn and make it known that you are looking for a new position. Put all of your skills, training, etc. on your profile.

Tip #2. Network like crazy.

Tip #3. If you have the drive and ability, think about starting your own firm. It doesn’t cost much to get incorporated in most states. You may be surprised about local work you can pick up.

Editorial Comment Section

When are large companies who think they can buy their way into healthcare going to learn that they are five years late to the dance? And that IT NEVER WORKS?? I wouldn’t be surprised if General Motors is a “healthcare” firm next year. Sorry – had to be done.

Clients

(Not ours — they already know this.)

Tip #1. Being thorough and expedient is a difficult trick to pull off when hiring, but it is a must in this market. Whoever dies with the best healthcare consultants wins. You must make this a priority in order to grow, create a great reputation, and have a happy work force. A couple of phone interviews are great, but at some point it is time to lock all decision-makers in a room with the candidate and make a decision. Some companies are hiring people two weeks after starting the process. Are you able to compete with that? If not, talk to HR/Recruiting and figure out a way to streamline your process. You will save yourself lots of recruiting dollars, disappointment with candidates you missed out on, and will ultimately have a stronger workforce.

Tip #2. Before deciding on a hiring initiative, reach out to some people in the recruitment business to see what the market is commanding in terms of salary, bonus, travel, time off, etc. Salary surveys run by third parties don’t seem to be in line with the real healthcare market (just my opinion). Ensure that you are making strong offers. I view the current healthcare market like NFL free agency. The best players want the top teams, the most dollars, and the best situation. Everybody wants the top free agents. Playing the lowball and hope they accept game isn’t going to get you anywhere.

Tip #3. If you decided to engage a search firm, make sure you know who is actually conducting the search and talking to candidates. You need experienced healthcare people talking to these candidates. I may get threats for saying this, but some firms put the big gun on the phone with you to sell you their services and then turn the search over to a “just out of college, took a recruiting job to pay the bills until my band makes it” recruiter. Make sure you talk to the people that are going to talk to your future employee.

I hope some of this provided some value. We’re off to an undisclosed location to meet with Mr. G. Lucas. An update should be coming soon.

Don Calhoun is founder and managing director of Executive Search Recruiting, LLC of Cornelius, NC.

Breakfast of Physician Champions!
By Daniela Mahoney

Culture eats strategy any day.

I think we have all heard this saying. More than ever, it proves to be true when I think of any initiative that involves providers, changes to their workflow, perceived loss of autonomy, and the sacrifice of something very, very precious — TIME.

Yet when introducing a new initiative, hospital and project leaders must somehow get everyone on board in a relatively short time frame and also convince them to embrace the new way of doing business.

So, you ask, where are the challenges?

Unwritten Rules

The relationship between organizations and their providers varies based on structure, history, leadership culture, and vision of the future. Therefore, for any organization, every new initiative is challenged by implicit unwritten rules that define and govern certain expectations, organizational design and behavior.

And moreover, initiatives that involve the introduction of advanced clinical systems to providers — particularly CPOE — are subject to the greatest scrutiny. These projects subsequently pose serious challenges to the unwritten rules because they raise a very fundamental question from providers: “If our present rules will no longer support what we know and feel comfortable with, what will it take to change these rules so we can create an environment that better aligns with the new vision of the organization?”

These days, most hospital leaders encounter this challenge when implementing a new system. Regardless of motive —whether implementing CPOE because the organization is on the fast track to meeting Meaningful Use or, more nobly, because “it is the right thing to do” to improve patient care and outcomes— the reality is that the unwritten rules must be rewritten upfront and early to successfully transform the staff culture and ensure quality and predictable patient outcomes with the new system in place.

Great Expectations

It’s about inclusion from the get-go. The staff culture has to be given serious consideration and be honestly and fully included in implementation plans from the time you begin talking about these new initiatives to the time they are executed and realized. I have witnessed noticeable and successful changes in culture only when the majority of the providers are aligned with the vision of the organization (I say “majority” because in most cases, non-academic organizations have difficulty achieving 100% buy-in from all providers.)

How do we go about learning what is important to your providers? What are their expectations and what are their fears? The answers to these questions are the elements that eventually create the adoption strategy map. And the pursuit for these answers is a concerted effort executed in the early phases of the implementation (although sometimes we get pulled in at the tail end of an implementation when things do not go as planned. This makes the recovery efforts more difficult and at times delays the initiatives!)

If done well, this initial Q & A or interview exercise yields a fairly clear plan, yielding one strategic decision to make about it:

• Should things be mandated and, if so, when and how?

Or,

• How will the support and training strategies need to be structured to make things manageable?

Constant Compromise

To me, the decision is a basic balance of give and take, a constant compromise where the art of negotiation reaches amazing peaks. This is when it is important for the CEO to have a close relationship with the medical staff and be actively involved and visible with these new initiatives. The CIO needs to think outside the box and not lead with the technology as the value proposition. A strong CMIO or physician champion should truly understand his/her peers and their workflows and master the art of negotiating.

The unwritten rules have to be explored. These are the rules that might imply that “nothing can be mandated to physicians”, that “physicians must always have individual choice and prerogative”, that if “I am not involved in a decision, I will not support it”, or that “variability is desired.” It reflects the true art of medicine and the uniqueness of every individual patient, that the art of medicine always trumps the science of medicine.

Understanding the unwritten rules from the beginning helps establish the appropriate path to implementation. For example, in one of our cultural assessments this year, we learned that the initial plans included a very aggressive deployment of CPOE, house-wide at once, with rapid expectations toward universal adoption (“mandate” is an ugly word.) As much as this approach is desired, it is more important to know if it could be executed successfully. In this particular case, the expectations of the medical staff were not integrated into the original plan. During the cultural assessment process, these expectations surfaced and were far from being consistent with the original plan.

Now, one can push and try to keep the plan as defined initially but, in the long run, this would alienate many (or probably most) of the providers. Why not take another look at the plan? And by employing a much more collaborative approach, see how it can be adjusted and eventually executed —successfully — while still attaining the same goals. Also, by doing this, the unwritten message from the CMO and other organizational leadership would be clear: “We do care about what you [providers] are telling us. We know it will not be easy to implement CPOE. But we are committed to working with you for all of us to succeed.”

Personal to Us, but System Agnostic

Culture is something personal to all of us —to any organization. CPOE touches clinicians at many different levels and inarguably creates significant disruptions in everyone’s routine. I truly believe that CPOE is the best thing we can do for our patients, but as I say this, I know that not all CPOE outcomes are the best. With a failure rate somewhere in the neighborhood of 30%, along with a long list of unintended consequences, it makes us realize that technology is only 15-20% of the challenge. The rest is all the change and optimization that needs to be done for this to work as intended.

We should also recognize and accept that provider culture is system agnostic. We can hope that the more advanced systems become easier to design solutions that support clinical processes. But it is naïve to believe that CPOE will be an easy project simply because you install the Cadillac version of a system. We have seen many successes with more modest versions of clinical systems and failures with very sophisticated ones and vice versa.

A system alone does not guarantee a successful outcome. It needs much more than that. As part of the team planning clinical initiatives for your hospital, please listen to your providers and understand your organizational history and its culture. Many of the answers to what it takes to succeed are right in front of you— you just have to look to see them.

Time for Breakfast!

I just returned from a visit oversees and came across this wonderful blini (Russian pancakes) recipe. I guarantee the entire family will love them, especially on cold winter mornings. I serve mine with 1 cup ricotta cheese, 1 tablespoon sugar, 1 teaspoon vanilla extract, and a scant ½ cup golden raisins added at the end once all other ingredients are mixed well.

Till next time, when we will talk more about the CPOE value proposition to providers. Safe and happy holidays to all!

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

iPatients?
By Vince Ciotti

An interesting week of news for our EMR world.

On Tuesday, the National Transportation Safety Board (NTSB) called for the first-ever nationwide ban on driver use of personal electronic devices while operating a motor vehicle. According to NHTSA, more than 3,000 people lost their lives last year in distraction-related accidents. NTSB Chairman Deborah A.P. Hersman stated, "It is time for all of us to stand up for safety by turning off electronic devices when driving. No call, no text, no update, is worth a human life."

The heart of their argument can be found in a few statistics:

• Globally, there are 5.3 billion mobile phone subscribers, or 77% of the world population. In the United States, that percentage is even higher – it exceeds 100%.
• A Virginia Tech Transportation Institute study of commercial drivers found that a safety-critical event is 163 times more likely if a driver is texting, e-mailing, or accessing the Internet.

Hersman concluded, "The data is clear; the time to act is now. How many more lives will be lost before we, as a society, change our attitudes about the deadliness of distractions?"

On Thursday, an article on the front page of The New York Times caught my eye while driving my RV down I-4, As Doctors Use More Devices, Potential for Distraction Grows. Wow, doctors? That’s our business! Reading on (while occasionally checking my mirrors before changing lanes), I read these amazing factoids:

• A peer-reviewed survey of 439 medical technicians published this year in Perfusion, a journal about cardio-pulmonary bypass surgery, found that 55% of technicians who monitor bypass machines acknowledged to researchers that they had talked on cellphones during heart surgery. Half said they had texted while in surgery.
• Scott J. Eldredge, a medical malpractice lawyer in Denver, recently represented a patient who was left partly paralyzed after surgery. The neurosurgeon was distracted during the operation, using a wireless headset to talk on his cell phone. “I’ve seen texting among people I’m supervising in the OR,” said Stephen Luczycki MD, an anesthesiologist and medical director in one of the surgical intensive care units at Yale-New Haven Hospital. “Amazon, Gmail, I’ve seen all sorts of shopping, I’ve seen eBay,” he said. “You name it, I’ve seen it.”

So who am I to pontificate on this seeming bit of common sense? Some of you may know I am also an avid vintage motorcycle buff (not loud Harleys, but quiet Hondas) and have published a few articles in bike magazines. My most recent was last year in Motorcyclist entitled Driven To Distraction. In it, I admonish my fellow bikers to wear bright clothing, flash headlights, etc. — anything so their 500-pound motorcycle gets the attention of the driver of a 5,000-pound SUV.

So after all our Herculean efforts the past few years to get our RNs to use BMV and eMARs and to coerce our MDs to use CPOE and EHRs, now some of them are over-using the technology! I guess it had to happen in this world of cell-phonies.

What’s a CIO to do? My suggestion: send the Times article to your CMO and CNO. They’ll do the rest. Clinicians are such consummate professionals, all they need are a few facts like the above and they will caution their staffs in a hurry. Will it be a total cure? No more than I’m likely to stop keying on my GPS while dodging semis. But it will make them aware of the problem, which is always the first step to addressing one.

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

My Christmas Wish
By Chip Perkins

I’ve been reading quite a bit lately about how important sharing data is to improving healthcare quality and outcomes, and reducing costs. The ability to share health data between patients, providers, specialist, and health plans is a key building block for patient centered medical home (PCMH) or accountable care organization (ACO) initiatives. 

But there is one more thing about data to consider. The data needs to be discrete. The data needs to be actionable. The data needs to be standardized. The data needs to be semantic. 

As healthcare systems ramp up their efforts to transition to ICD-10-CM/PCS, launch clinical documentation improvement projects, report Meaningful Use quality indicators, implement electronic lab reporting (ELR) to public health, and build analytic tools to monitor improvements in health outcomes, organizations will recognize the importance of leveraging controlled clinical vocabularies and terminologies such as SNOMED CT, LOINC and RxNorm. 

The standards exist. The standards turn raw data into semantic data. Now we have to build the use of standard terminologies into our health information technology infrastructure. 

I’m hoping Santa will put a little semantic interoperability into everyone’s stocking for Christmas.

Chip Perkins is managing director, CAP STS of College of American Pathologists of Deerfield, IL.

Readers Write 12/14/11

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!

Time for Health Plans, Providers, and Patients to Team Up
By S. Michael Ross, MD, MHA

Current healthcare spending is unsustainable and driving us over a cliff. Despite having some of the most expensive healthcare in the world, the United States consistently underperforms on most care quality metrics. Take, for example, a 2010 report published by The Commonwealth Fund comparing healthcare in the U.S. with healthcare in Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom. The upshot: Our system ranks low on quality, access, efficiency, and equity.

A major driver is that incentives are misaligned between health plans and providers. It can all be blamed on economics. Health plans typically sell insurance to employers based on the lowest price, while providers typically try to negotiate the highest possible fee schedules.

Whether we stand in the shoes of providers or health plans, I’m convinced that our goals must be the same: improve the quality and outcomes of healthcare and reduce costs. To achieve these shared goals, there needs to be alignment of payment to providers. Collaboration is one of the best ways to reach this end result. To foster a successful partnership, health plans and providers must get past this traditional adversarial relationship and facilitate a dialogue about delivering value.

It’s no secret that fragmented care is one reason our healthcare costs are so high and that patient safety is at increased risk. More than half of Medicare beneficiaries have five or more chronic conditions such as diabetes, arthritis, hypertension, and kidney disease, so they’re routinely receiving care from multiple physicians. Failure to coordinate that care often results in patients not getting needed care, receiving redundant care, or suffering an increased risk of medical error.

A major emerging trend to address care fragmentation is the patient-centered medical home (PCMH). PCMH is designed to introduce accountability for ensuring coordinated care across the healthcare continuum. Early adopters of this model report superior clinical outcomes, more satisfied patients, and lower total cost of care. Health plans are quickly moving to PCMH. Likewise, providers are showing high levels of interest; a recent Medical Group Management Association (MGMA) survey shows that 20 percent of provider respondents already are affiliated with a PCM and 70 percent more are receptive to the idea—especially when health plans offer financial incentives to participate.

To make PCMH successful, it’s imperative that we break down the traditional information silos. We can begin to contain double-digit premium increases and align costs with quality of care only when primary care physicians, specialists, hospitals, health plans, and patients all have access to each other’s data. Aggregating, analyzing, reconciling, and intelligently distributing that information will be critical to support optimally coordinated care in the PCMH paradigm.

Workflow integration also will be a key to success. To prevent mass confusion at the provider level, the myriad data sources must be presented in a consistent and uniform manner to be utilized most effectively. Large-scale multi-payer platforms integrated into practice workflows already exist and can be leveraged to support rapid deployment of PCMH. On a related note, data to support coordinated care must be accessible across all form factors (like portals, smart phones, and tablets) in accordance with user preferences.

When we combine the administrative and financial data collected by health plans with the clinical data collected by providers, we have the power to establish continuity, promote positive outcomes, and support value-based reimbursement. From there, we naturally will reduce costs and improve patient satisfaction.

Clearly, if we want to move forward with quality care, we must enable a much richer data exchange between providers and health plans. We have in our midst the opportunity to rapidly achieve superior clinical outcomes and better health of populations—and to bend the cost curve. The time to do it is now. This is our last best chance.

S. Michael Ross, MD, MHA is chief medical officer of NaviNet of Boston, MA.

Ivo Told Me Not To Do It
By Dana Sellers

I’ve known Encore’s founder, Ivo Nelson, since the 1980s. I’ve found out over the years that he’s almost always right. In fact, I thought he was outright wrong once, but it turned out I was mistaken. So when Ivo tells me to do something, I generally listen. But every once in a while, like a horse with the bit in its teeth, I just have to go my own way out of pure stubbornness.

The other day I told Ivo I wanted to write an article about how fantasy football is like modern day healthcare. Without even a second to think about it, he told me not to do it. Normally, I’d follow his advice, but somehow I haven’t been able to get the idea out of my head. So, against Ivo’s better judgment, here goes…

In the old days of football, I really only cared about my team. I’d watch that one game, and then I’d turn off the TV. I knew who my players were, and they didn’t really change week to week. The rules were simple, and the scoring was clearly understood.

Then my sons needed one more person to complete their college fantasy league and they voted me in. Yes, me — Mom. And all of a sudden, the world of football changed. No longer was football something that was contained within the boundaries of a single game. It suddenly became something that was far more about strategy outside the walls—about finding and aligning with the very best. I had to plan, prepare and strategize. I found myself watching football in a whole new way.

Data was key. In fact, I found that I needed real-time data — on performance, on injuries, on projections. Lots and lots of data. I signed up for Sunday Ticket and StatTracker. I used all the filters and views on Yahoo! to make game day decisions, trades, and plan my next move. I downloaded all the fantasy apps for iPhone. I needed data all the time, wherever I was.

I also found that the scoring rules had become a lot more complicated and were a moving target. I’m in two leagues now, and what works in one doesn’t necessarily work in the other. The same touchdown that could help me win in one league could put me out of competition in my other league. I’ll watch a game hoping that my Cowboys will win, but that one particular player will do all the scoring because any other result will cost me precious fantasy points.

Here comes the hard part that Ivo thought I couldn’t pull off. So how is this like today’s healthcare?

I think there are a lot of similarities. In healthcare today, it’s not enough to think within our walls and turn off the TV any more. We have to be watching what’s going on across the industry, strategizing and planning and thinking about how to align with the best and brightest to accomplish what has to be done.

And data is key. We’re all going to need lots and lots of data—about performance, about quality, about projections. We’re going to need to be able to slice and dice it and look at the data in whole new ways. We’ll want it accessible for the end-user/stakeholder so that when we need it, we can get to it, wherever and whenever we want it. Our stakeholders aren’t going to want to submit a query and wait for a stale report to come back. They’re going to want the data NOW, just like they have for their fantasy football team. Why should they settle for less in their real-world job?

Finally, scoring is the hardest part. In fantasy football, if you lose, only your pride is hurt. (Personally, my teams aren’t doing so well right now, but I’m going to make some changes and see what happens next week.) But in healthcare, the score can mean survival as a healthcare organization. And we don’t just live in two leagues, we have two different scoring systems emerging right now—fee-for-service and pay-for-performance. If you optimize for one, you can hurt yourself in the other if you’re not careful. Get really good at reducing readmissions and you may see your revenue drop. Survival today means managing a shifting reimbursement world, understanding how government and payer “scoring” is changing in an almost real-time way, and being able to change and adapt in a nimble manner.

In the past, you only needed to take care of yourself and pay attention to your own hospital and your own local NFL team. Simpler times. Then along came reform, consumerism, and fantasy football. Now you have to take a more global, whole league view. Watch national trends, watch the future of government intervention, reimbursement trends, offensive and defensive schemes, and manage a diverse roster. ACOs, ICD-10, MU, VBP, and comparative effectiveness … 32 QBs, 120 or so RBs and WRs.

There is so much information to absorb and so much going on month to month in healthcare and week to week in FFL. Take your eye off of any of it and you can get crushed. Miss a nuance in a new regulation or payer contract or that a team made a scheme or roster change and you can be devastated. So stay alert, and keep your eye on the ball….

Oh, and by the way, Ivo—my “Fightin’ Frogs” are gonna crush your “Guiness Stouts” on Sunday.

Dana Sellers is president and CEO of Encore Health Resources of Houston, TX.

Answering the Question: How to Achieve ROI for Healthcare BI
By Jim B-Reay

As hospitals make significant investments in EMRs — along with related updates to hospital billing, materials management, costing, and quality systems — they typically find that the promised analytics and reporting are not adequate. To tie together data from these disparate systems and even to optimize access to data within an integrated system, a Business Intelligence (BI) strategy is needed.

A typical BI strategy encompasses data governance; data staging and warehousing; tools for query, reporting, and dashboards; and a staffing model to build the initial framework and expand the architecture to serve the changing needs of the business.

For many organizations, this additional investment is hard to justify considering the outlays already made in their core systems. While working on one strategy recently, I was asked, “If we make this investment, how can we measure the direct return on investment (ROI)? What is the actual ROI of an investment in BI?”

To help the client answer these questions, I reached out to a dozen organizations, all of which have BI programs of some degree of maturity, and asked the very same questions. The responses I got were different and enlightening. I found that successful sites had a common theme: BI value is based on the use of the system to analyze data from various clinical and administrative systems and the willingness of the organization to act upon the findings to make changes that ultimately improve productivity and efficiency.

While these organizations varied in size, EMR maturity, and technology, I found commonalities in their responses.

A Cost of Doing Business

Many of the respondents stated that there wasn’t a planned ROI. They saw the investment in BI as a cost of doing business and considered BI as a necessary investment for which the value would be proven using the results from the analytics. Thus they did not establish clear financial goals beforehand. Instead, they identified gaps in their data environment that a BI strategy would address and chartered projects to suit.

Empower the Analysts (Plus a Little Insurance)

A smaller group of the participating organizations had a slightly clearer idea of what they’re trying to achieve with their BI investment: empowering their data and business analysts. In these cases, the organizations have fairly seasoned analysts who are clamoring for better tools to continue their roles as data analyzers.

This approach drives to more standardization of data and allows for replication of the current mysterious data manipulations of these trusted analysts. In addition, replacing the desktop database with an IT-maintained warehouse and a heavily macro-filled spreadsheet with a set of summary tables and dashboards provides a measure of insurance that the knowledge and analytics would be securely in place should the analyst decide to move on or could be used by others within the organization.

Targeted and Tactical

A core group of respondents challenged the premise of BI ROI by saying that BI has NO value to the organization in and of itself unless the project is matched to strategic initiatives. Their BI projects, interestingly enough, were often much smaller than the “insurance” or “build it and they will come” initiatives.

In all of these cases, there was a level of BI infrastructure required to make this all work, but the level of direct investment required was, in most cases, far less than a full soup-to-nuts data warehousing initiative. The ROI realized was the result of targeted, limited scope initiatives with only just enough infrastructure to deliver these results.

Although there were a few cases where it appeared that investments were being made to get BI in the door without truly understanding the solution on offer, those that had embarked on their BI strategies with a solid set of requirements and strong governance will be well served by their investment. There are complex questions that these organizations simply would not be able to answer without the data aggregation and query toolsets that an investment in BI brings.

But direct calculation of a return on investment can be difficult. For the “build it and they will come” group, they have made it clear they’re willing to let the ROI be determined through later projects. What the third group of respondents showed was that if you’re looking for ROI, you need a clear definition of scope and the organizational ability to respond to findings. It is possible to get an amazing ROI from a project with one smart analyst, some extract files, and an Access database. But it’s up to the organization to take that information and act on it, and it’s up to IT to build a support structure to ensure that that information continues to be available.

To design and implement a Business Intelligence initiative that delivers a positive ROI, start out with a limited scope and strong organizational support for acting on the findings. Select a single study area, get clinical support, and assign the most experienced analysts (second model) with support for data extracts as needed. Once you have proven value to the organization, look for ways to expand. Work to productionize the extracts and move the database off of the analyst’s desktop, so the value you get from that first study area is preserved and re-useable. Work on back-loading additional data as needed to expand the study area.

Find a second and third related organizational problem that could be piggybacked on the dataset you’re using and find an organizational sponsor who will take the action needed based on the BI data findings. If possible, expand the existing structures to contain the data needed for the new studies, but don’t create a tortured data model. Don’t be afraid to create another targeted data mart as needed.

In parallel with this first initiative, start building strong BI governance in the organization. Ensure that analysts across the organization are meeting regularly to discuss and document data standards and that wheel-reinvention is minimized. This can be a matrixed group rather than a formal reporting organization, but participation needs to be mandatory. The lead for this analyst group should be invited to executive-level steering meetings to listen for areas of frustration and concern with data and be able to both represent the work that is being done and bring the concerns back to the analyst team for action.

Through targeted initiatives, experienced analysts, and strong governance, BI projects will have a tangible ROI.

Jim B-Reay is a principal with Aspen Advisors of Pittsburgh, PA. 

Readers Write 12/5/11

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: this special edition of Readers Write features a special contribution from Sam Bierstock, for which the length limits were waived.

A 19th Century Perspective on Physician Adoption
By Sam Bierstock, MD

I first recognized that there was a pattern to the challenges of physician adoption of information technology in 2001. At that time, I convened a meeting of CMOs and clinical IT champions for hospital clinical information systems of all sizes, and quickly learned that they were all facing similar challenges. Basic human nature does not differ much, even in organizations that feel they are unique.

When I wrote about the importance of supporting what I called “Thoughtflow” as opposed to “workflow,” I was surprised by the widespread endorsement of the concept by clinicians, but disappointed by the sluggishness of vendor design processes to truly support the way clinicians think and work in an age of real-time data availability. I’ve been around long enough to start to see that begin to change, although I am not sure that this is because of vendor enlightenment or simply a generational turnover. The Israelites had to wander in the desert for 40 years to wait for a new generation of people to enter the Promised Land. Perhaps adoption is improving because of generational turnover as much as from demonstrable value.

A historical perspective dealing with the way healthcare was practiced during the second half of the 19th century, considering the patient safety issues of the day and the political climate, is intriguing. It says much about human nature, resistance to change – and the physician adoption champion of all champions, Joseph Lister.

In the 82 years between 1841 and 1923, six United States presidents died in office – four in the space of 40 years, five in 60 years. William Henry Harrison died of pneumonia and pleurisy in 1841. Zachary Taylor died of acute gastroenteritis in 1850 (with subsequent conspiracy theories suggesting that he was poisoned.) Abraham Lincoln was assassinated in 1864. James Garfield died after being shot by Charles Guiteau during his fourth month of service as president in 1881. William McKinley was assassinated by Leon Frank Czolgosz in 1901. William Harding died in office in 1920 of a “heart attack.”

We’ve had 10 presidents during the last 50 years. Comparing the timeframes, this rate of loss would be equivalent to us losing Kennedy, Nixon, Carter, Clinton, George Bush, Sr., and Obama while they were in office. Of the six presidents that died between 1841 and 1923, three had their fate tied to assassin’s bullets. Those occurred over the span of just 37 years (Lincoln 1864, Garfield 1881, and McKinley 1901.) One can only imagine the impact on the national psyche of these serial attacks on the lives of our presidents. One man in particular must have suffered a heavy emotional toll, for Robert Todd Lincoln bears the unique distinction of being the only person ever to be present at three presidential assassinations.

Regardless of the precipitating event, in many cases, the direct cause of death of these presidents was due to medical care that ranged from abysmal to totally incompetent.

In the later half of the 19th century, hospitals were not viewed as a place to go to recover from an illness or to have surgery. Hospitals were where you went to die. Surgeries were performed at home or similar environment. Illnesses such as influenza, mumps, diphtheria, or pneumonia – and especially infected wounds – were death sentences. In the absence of antibiotics, for instance, the vast majority of Civil War wounds resulted in death from infection.

Doctors’ standard operating garb were black smocks that they rarely washed or changed – if ever. A blood-encrusted smock was something of a status symbol and an indication of experience, and therefore presumed expertise. Surgical instruments were carried about in bacteria-laden, velvet-lined cases, and were not cleaned between operations beyond a quick wipe with a much-used handkerchief. If an instrument was dropped during a case, it was picked up off the filthy floor and used to continue the procedure (boots and shoes were not routinely cleaned off before entering the operating room). At Jefferson University in Philadelphia, the same table was used to dissect cadavers as was used to perform operations on live patients.

Things were so bad that the leading cause of death for hospitalized patients was termed “hospitalism.” Some thought that hospitalism was the result of toxic ether that surrounded hospitals.

In the 1880s, there were approximately 60 medical schools in the country – none certified by any organization – and students often had only one year of training. Until Lister came along — and for many years after he began to promote his theories about microbes causing infections — the idea of invisible organisms that could cause infection was laughable and readily dismissed by the vast majority of physicians.

Talk about a physician adoption challenge and patient safety!

In a political context, the state of presidential medical care went far beyond patient safety and had a direct impact on national policy and survival. This was a time when vice presidents were not hand-picked by the presidential candidates. They were selected by their party at their respective conventions, often by virtue of having the second largest number of nominating votes. As a result, the vice president and president were often of widely differing political views if not polar opposites, and often didn’t like each other very much.

James Garfield hardly ever spoke to his vice president, Chester Arthur. Garfield was vehemently opposed to the patronage system that infested national politics and Arthur was a product of it (although to his credit, he underwent a significant change in attitude once he assumed office.) Grover Cleveland and his second vice president, Adlai Stevenson, Sr., differed markedly on the key issue of the day, the gold standard versus the silver standard in our monetary system – an issue that had dire implications during a period of severe economic crisis. Woodrow Wilson and his vice president Thomas Marshall did not see or talk to each other while Wilson was incapacitated by a massive stroke until the day that Wilson left office.

None of these presidents relinquished power while ill or unable to perform their duties. Not until 1967, when the 25th Amendment to the Constitution was enacted after the death of John Kennedy, was the country assured that the vice president would assume presidential powers in the event that the president became unable to exercise his duties.

The death of a president during these times, therefore, had enormous impact on the direction of the country. Physicians caring for ill presidents were under enormous pressure to be sure that they could save their patients.

To avert public panic, presidents often went to great lengths to hide their human frailties and illnesses from the press. Unlike today, they were generally successful at doing so. Unknown to the populace, Abraham Lincoln became extremely ill with influenza for one month shortly after delivering the Gettysburg Address and lingered near death. Garfield did not die until two months after being shot, and aside from being subjected to the most barbaric care of any president, was reported to be in good condition and recovering steadily in bulletins issued to a nervous public several times a day. Chester Arthur suffered from “Bright’s Disease” (chronic nephritis) which he persistently denied publicly, but which took his life within two years of his leaving office.

Grover Cleveland underwent a secret operation to remove a presumed squamous cell carcinoma on his palate shortly after beginning his second term. (He is the only president to be elected twice in non-contiguous terms). In order to maintain secrecy, the procedure was performed on a friend’s yacht by a team of doctors who removed about a third of his palate, four teeth, and a portion of his upper jaw. He simply disappeared from public view during this time. He even kept his surgery secret from his vice president. When Adlai Stevenson wanted to know where the president was, Cleveland sent him on a length trip to the West Coast to keep him in the dark and to avoid the possibility that Stevenson would muster support for his position on the silver standard. In 1967, pathologists were finally allowed to examine the tissue removed from Cleveland’s mouth, which turned out to be a verrucous carcinoma – tumors that do not metastasize, but which can cause death local extensive local invasion.

Nor did the public know that Woodrow Wilson was rendered non-functional by a severe stroke toward the end of his presidency. In fact, few people knew that he had suffered several strokes prior to being elected for his first term. For the remainder of his last term in office, virtually all presidential decisions were made by his wife Edith – who, as a result, is often referred to as our first female president.

Warren Harding’s doctor, Dr. Charles Sawyer, was undoubtedly the most incompetent of presidential doctors. Appointed as the president’s private physician because of a long personal relationship, Sawyer had only one year of medical school training. Sawyer liked to prescribe medication based upon the color of the pill – once prescribing a dose of soda water with two pink pills for the president. Even though Harding was hypertensive and had significant orthopnea, exhaustion, and shortness of breath, Sawyer failed to recognize the clear symptoms of congestive heart failure, which he dismissed as “a touch of food poisoning.” Harding died in the Palace Hotel in San Francisco in 1923 at age 57 after a grueling trip to Alaska.

The most egregious care administered to a president by far was that applied to James Garfield – a man who would have undoubtedly been destined to greatness, but having served only 200 days in office, has been delegated to historical footnote status. Garfield was popular, exceedingly capable, honest, and brilliant. A man of natural congeniality, he withstood the most unimaginable procedures without complaint and generally in silence.

Garfield was shot by Charles Guiteau in the Baltimore and Potomac Railroad Station in Washington, DC on July 2, 1881 (now the site of the West Building of the National Gallery of Art.) He did not die until September 19 of the same year. During the assassination attempt, he was hit by two bullets, the first grazing one arm and the second entering his back. As he lay vomiting on the filthy station floor, his doctor inserted an unwashed finger into the back wound in an effort to locate the bullet. This was repeated multiple times by a series of doctors (16 physicians gathered), after which the wound was repeatedly probed with unsterile instruments. At one point, a probe became lodged between fragments of Garfield’s eleventh rib and removed only with great effort and resultant pain to the president. Dr. D.W. Bliss then used his finger to widen the wound so he could probe further. Over the next two months, Garfield was subjected to repeated probing of the wound with unsterile fingers and instruments, non-aseptic incisions to drain abscesses, and other invasive procedures in an effort to locate the bullet, which was, in fact, located harmlessly in fatty tissue behind the pancreas. Eventually, the original three-inch deep wound was converted to a twenty-inch long contaminated, purulent gash stretching from the president’s ribs to his groin.

Garfield’s original wound was entirely survivable even in the 1880s, and he would almost certainly have survived it had his doctors not repeatedly introduced sources of infection which ultimately resulted in his having systemic abscesses and resultant septicemia. Thousands of civil war veterans lived long lives with bullets embedded in their bodies. Garfield ultimately died of a ruptured splenic artery.

It is an interesting sidelight that a Herculean effort was made by Alexander Graham Bell to perfect his newly invented metal detector in time to save President Garfield. He worked tirelessly on the device day and night and devoted endless hours to this cause. X-rays had not yet been invented and it was deemed essential to locate the position of the bullet for possible removal. Bell was finally permitted to try his device on the president, and did so on two occasions. Garfield himself was apprehensive of the new device and was fearful of being electrocuted. Bliss, allowed Bell only to examine one side of Garfield’s body, being convinced that that was where the bullet was lodged (in fact, it lay on the opposite side.) To his great dismay, Bell detected a constant series of signals indicating metal over a diffuse area and could not understand why. He later learned that Garfield was lying on a brand new type of mattress – a coil mattress filled with metal springs.

And then there was the matter of facial hair.

In the second half of the 19th century, it was considered the norm for presidents to have facial hair, something unimaginable in our current image-conscious times.

Although John Quincy Adams and Martin Van Buren had extensive sideburns, presidents were clean shaven until Abraham Lincoln grew a beard when an 11-year-old girl suggested that he do so. For the next 52 years, facial hair became the trend, so much so that it became unimaginable for a president to be clean shaven. Beards were thought to prevent pulmonary problems and throat disease. The last president to serve with facial hair was Taft (who left office in 1913.) His successor Woodrow Wilson had a white beard during his illness and just prior to leaving office.

Beards and facial hair were almost an expectation of the day. One can only wonder about the magnitude of iatrogenic disease caused by the introduction of infectious agents by uncovered beards on physicians wearing blood-encrusted smocks and using filthy instruments during these times.

Enter Joseph Lister.

Lister spent much of the 1870s and 1880s trying to convince the world that germs existed and were the cause of wound infection. He was received with derision and frequent outright hostility. One medical journal editorial stated that, “We are as likely to be as ridiculed in the next century for our blind belief in the power of unseen germs as our forefathers were for their faith in the influence of spirits.” Doctors could simply not accept that microbes might be lurking in the air and on their hands.

In many cases, doctors might be persuaded to try antiseptic techniques by boiling their instruments prior to surgery, and at the same time be completely unaware of the need to maintain asepsis. If a previously sterilized instrument fell to the floor, it would be picked up and wiped off with an unsterile cloth and used to continue the operation. If infection resulted, the doctor would then dismiss Lister’s ideas.

Lister lectured and promoted his theories tirelessly, pointing to his own remarkable success in reducing post-operative infection. Gradually he began to gain a following, when doctors such as W.W. Keen began to use aseptic techniques in Philadelphia’s St. Mary’s Hospital after hearing Lister speak. The infection and mortality rates plummeted almost immediately, and other hospitals rapidly followed suit. Antiseptic techniques became the norm within a decade.

Lister died in 1912, having lived to see universal adoption of his aseptic techniques. He did not live to see the introduction of a household product bearing the unauthorized use of his name just two years later– Listerine mouthwash.

This historical perspective says much about human nature and resistance to change. Lister was committed to his cause, but encountered a 19th century version of the physician adoption challenges of the first decade of the 21st century. The possibility that a universal conversion to digitalized medicine will have the same impact on saving lives that aseptic techniques had seems unlikely, but it is clear that breaking through the boundaries of embedded practices has never been easy in our industry. Current day champions have a big set of shoes to fill.

Samuel R. Bierstock, MD, BSEE is the founder and president of Champions in Healthcare, LLC, a strategic consulting firm specializing in clinical information system implementation and healthcare IT business strategies.

Readers Write 11/21/11

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!

ICD-10 Déjà Vu
By M. Christine Kalish, MBA, CMPE

The American Medical Association (AMA) passed a resolution at its 2011 Interim Meeting mandating the group to "vigorously work to stop the implementation of ICD-10 and to reduce its unnecessary and significant burdens on the practice of medicine.” The resolution that the AMA will "do everything possible to let the physicians of America know that the AMA is fighting to repeal the onerous ICD-10 requirements on their behalf" continues.

Strong language, AMA, but the ICD-10 train has already left the station. And we have seen this sort of talk before —there is a sense of déjà vu here.

Remember the successful efforts of the AMA and other organizations to delay the original ICD- 10 implementation date of October 2011? That’s the day CMS originally targeted for mandatory ICD-10 adoption for physicians, hospitals, and payers.

The AMA’s point of contention about the October 2011 date was that physicians were not given sufficient time to upgrade all systems and then provide training and education. They also cited the cost would be significant and the expense of the implementation should be spread out over a longer timeline. The Bush administration allowed a delay until October 1, 2013 — two additional years.

After the announcement of the initial delay, a seemingly satisfied AMA led the way in providing resources for physician practices to transition to ICD-10 within the agreed-upon timeline.

So why the change of heart now?

Organizations have already invested significant resources in ICD-10 adoption. No one is arguing that the implementation is challenging and costly, especially on the heels of Meaningful Use and other healthcare reform measures. But the AMA seems to have forgotten that they helped architect (and then eventually approved) the October 2013 delay.

Also, the AMA or, more importantly, the physicians within the association, needs to realize that the benefits of ICD-10 far outweigh the costs of implementation.

ICD-9 is outdated and no longer effective. The numbering system cannot support the addition of the new codes. With time, attempts to find codes are increasingly difficult since some are being placed wherever there is a free space in the sequencing.

The rest of the world uses ICD-10. In fact, the rest of the world is getting ready to move to ICD-11. The US needs to not only catch up, we need to realize that sharing and comparing data with other countries yields better quality of care with increased clinical efficiency and improved outcomes.

The additional codes provided by ICD-10 afford another degree of specificity that will reduce claims processing costs by reducing recurrent requests for information during the billing process. Of course, there is the flip side: documentation will continue to be a challenge. For example, a physician may know specific information about a patient but not write it down, even though the additional documentation will help with outcome assessments and quality of care indicators. It’s up to the provider, but wouldn’t they want to show how their care provides exceptional patient outcomes?

Let’s proceed with some caution. Do not let this latest AMA decision stop or even slow the implementation of ICD- 10 within your organization. It seems that a better solution would be for the AMA to get back on the train and determine how to they can improve the transition process rather than try to derail it.

Change is never easy, but let’s not be in the same position another two years down the road and have déjà vu “all over again.”

M. Christine Kalish, MBA, CMPE is an executive consultant with Beacon Partners.

A Response to Vince’s Epic Article
By QuietOne

This is a counterpoint to Vince Ciotti’s Readers Write article, The Other Side of Epic.

I usually don’t comment, but I definitely had to say something here. Epic — like everything else — has its problems. However, Vince’s claim that Siemens Soarian or Cerner Millenium has "equal or better" functionality is totally laughable. I’ve worked with both and neither comes close.

Vince states that Epic is not an integrated solution because it lacks general ledger and payroll functionality. Cerner and Siemens (in Soarian) don’t, either. Siemens had GL/AP/payroll in their older SMS products, but they aren’t offering it any more and are selling SAP instead.

Furthermore, GL and payroll are probably the least of your worries. If you get Siemens, you’ll have to interface disparate clinical, patient financial, and pharmacy systems as well as a bunch of departmental systems, each of which have different platform, database, and hardware requirements. You’ll also have to deal with all the third-party components required to make the system work, some of which have to be purchased separately. Epic, on the other hand, truly is an integrated system with a single database used by all modules (as is Cerner Millennium.)

Speaking of databases, why does Vince call InterSystems Cache’ a "proprietary" database? It is proprietary, but so is Oracle (used by Cerner Millenium) and MS SQL (used by Siemens Soarian Clinical, Financial, and Scheduling). Incidentally, Siemens Pharmacy, which you "have to" get if you want a fully functional Soarian Clinical system, also uses the InterSystems Cache’ that Vince seems to dislike.

Some of Epic’s departmental modules are arguably weak, but the same can be said of Siemens and Cerner as well as most other vendors. That is the price you pay for an integrated solution.

There is talk that Epic doesn’t play well with other systems. I do not believe that to be true, either. In addition to your everyday HL7 interfaces, Epic has a module for real-time query/retrieve relationships with non-Epic EMRs. Cerner has equivalent functionality, but Siemens does not (although I assume they must be working on something or buying another bolt-on product). 

Epic, which has the best documentation I’ve ever seen, provides extensive documentation of their architecture, database, and APIs. As a last resort, you could dive into that. Obviously, the server-side MUMPS code is visible to customers since it’s interpreted, but I was stunned to find out that they also provide the client-side source code to customers as well, obviously with legal restrictions on how it can be used.  

I am not sure where Vince got the idea that Epic is less customizable than Siemens. Siemens Invision is very customizable, but Siemens Soarian definitely is not. 

For the record, I have no ties to any vendor.  I can honestly say that I have never seen a product or company that impresses me like Epic and I am definitely not prone to brainwashing. I also want to say that I really enjoy (most of) Vince’s articles. This last article bewilders me, though, because it would seem to suggest that he is either biased or misinformed. I am disappointed.

Readers Write 11/14/11

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!

Structured and Unstructured Data, I Adore You Both
By Deborah Kohn

Calling all electronic patient record systems (EPRS) structured data! Yes, all you electronic health / medical, administrative, and financial systems’ data elements that are binary, discrete, computer-readable, and, typically, are stored in relational databases with predefined fields … you tidy, typically core, transactional and mined elements. Hello? I’m talking about all you digital, patient demographic, financial, and clinical health data that are sitting in master patient indices, insurance claims, clinical histories, problem lists, orders, test results, care plans, and business intelligence reports — to mention just a few.

Meet unstructured data! Yes, all you EPRS data that are non-binary, non-discrete, sometimes only human-readable, and sometimes not stored in relational databases. This means all you digital, bit-mapped images, text, videos, audios, and vector graphics that are harnessed in word-processed summary reports, electronic forms, diagnostic radiology images, scanned document images, electrocardiograms, medical devices, and web pages – again, to mention just a few.

I know this might be an awkward introduction. However, I’m really happy to finally get you two data formats together. And, while this might be jumping the gun a bit, I really hope one day you two will get married! I know, I know. That is, after you’ve carefully sorted out all your differences and learned how to live together in peace and harmony for the betterment of patient care.

After all, I’m certain you heard the rumor that the “adoption” and “Meaningful Use” of “certified” diagnostic image-generation and management systems, such as a PACS for one or more of the “ologies”, might be included in Stage 2. In addition, heaven help if, given the revised Federal Rules of Civil Procedure Governing Electronic Discovery that became effective December 1, 2006, a patient’s electronic health/medical, administrative and financial episode-of-care records (I mean x-rays, bills, ECGs, orders, progress notes – the works!) are subpoenaed for that Weird News Andy case we recently read on Mr.HIStalk! So, don’t you think it’s time at least to begin acknowledging one another in public?

Who am I, you ask, to be so bold to introduce you to the other? I’m just one, frustrated HIT professional who specializes in most of the EPRS unstructured data and who observes that these data are rarely considered in EPRS strategies and purchases … until after the fact. Once considered, they divide provider organization departments right down the middle; those working with you, structured data, vs. those working with you, unstructured data. Don’t even get me started about integration and usability issues!

Come close, structured data, so I can tell you that I do adore you – especially when I search a database for one or more of you, and, quickly and easily, the search engine finds, retrieves, and even manipulates parts or all of you. On the other hand, what often makes me want to delete you is when you insist on snubbing unstructured data. I’ve even watched you try to convert some unstructured data, such as rich-text or video data, to your popular religion, using pretty-good-but-not-perfect artificial intelligence and recognition tools … just so that you can brag about how you were able to generate the complete health story with your qualities.

Unstructured data? After so many years working with you, you know that I love being able to retrieve your gorgeous, bit-mapped, raster images generated by that digital chest x-ray or computed tomography (CT) scan stored in a diagnostic image management system; or, listen over and over to your brilliant sound bytes generated by that digital stethoscope; or, fast forward your streaming videos / frames generated by that important cardiac catheterization study; or, admire the perfect lines connecting the series of points plotted by that fetal trace recording. On the other hand, what I can’t tolerate is when I am required to search, for example, a valuable narrative text for one or more of you, and after hours I still can’t find you!

Today there is no complete electronic patient health / medical, administrative or financial record system without both of you. Let me see a hand shake.

Deborah Kohn is a principal with Dak Systems Consulting  of San Mateo, CA.

Problem Lists:  Avoiding the Tragedy of the (Coded) Commons
By Dr. Jim

If we want to take better care of patients, we have to know what we did. To know what we did across a whole group, we need computers to crunch concepts that computers understand.  

But here lies a paradox. While we need structured data entry to enable useful analysis, too much structure complicates both data entry and analysis. The splitters (and payors) among us can create use cases that force the lumpers to accede to ever finer divisions until, for instance, a single ICD-10-PCS procedure code represents nearly an entire chart summary: “ICD-10-PCS 027334Z Dilation of Coronary Artery, Four or More Sites with Drug-eluting Intraluminal Device, Percutaneous Approach” e.g. There are upwards of 1,000 more angioplasty codes within ICD-10-PCS, all with a General Equivalence Mapping to a lesser number of ICD-9-CM Volume 3 codes.

Are my fellow clinicians napping off yet? If so, put on a hazmat suit before you do. What is hitting the fan now will be splattering you shortly if it is not doing so already. In the interest of being able to use our electronic records meaningfully, the movement is toward collaborative problem lists with structured entries documented by clinicians. This would be a good thing—an excellent thing—were it not for the concomitant explosion of  “structure” detail, the de facto  requirement that clinicians do the structured entry as part of their workflow, and the variety of workflow places and coded sources that potentially populate the “Problem List.” 

These sources include the SNOMED-CT and ICD-9/10-CM libraries for diagnoses. I won’t be surprised if a typical Problem List ends up including Procedural Codes as well from the  ICD-10-PCS and CPT/HCPCS libraries. While these procedural codes are not technically “problems,” and not currently Meaningfully Used (the current standard is for “ICD-9 and SNOMED-CT” pending the swap to ICD-10), it does not take a Workflow Scientist to predict that a clinician who documents a percutaneous angioplasty as a CPT code will have an expectation that the Problem List is automatically populated with that (coded) “diagnosis.” 

We are about to see electronic record-generated collaborative Problem Lists that are essentially a repository for the “workflow” output of every clinician who touched the patient. Diagnoses attached to ordered tests; diagnoses entered during a Hospital stay; ED diagnoses; prescription diagnoses; ambulatory diagnoses; imported diagnoses carried by CCDs … perhaps even diagnoses entered by billing services after discharge. It will be the plethora, and not the dearth, of finely-split coded data, which renders the Problem List less functional and the analytics related to it problematic. 

The challenge is to find ways to get to Meaningful Use without letting it prevent the record from being used meaningfully. It’s a great idea to have a collaborative Problem List from which every workflow can read and to which every workflow can write. But we must also focus on finding ways to preserve a Problem List which readily communicates a plain-English problems summary for all caregivers so that Meaningful Use does not morph it into an unnecessarily long and noisy collection of all the code-speak entered on a patient.

There is a need in the electronic record for good, coded, structured data. This does not mean it should replace clear communication.

Real-World Epic from the Ground-Level View
By Informaticist RN

I have worked as a nurse with Siemens Invision, Cerner, and Meditech and an implementation consultant for a leading HIS vendor (not Epic). I’ve also worked as an IT analyst at a major medical center implementing Epic ambulatory.

We had two Epic employees assigned to the ambulatory application, an application coordinator (AC) and an application manager (AM). Both were fresh out of college and obviously green to healthcare.

Our AC/AM would come out for a week at a time, with no agenda given in advance. When they were here, it was disorganized. Whether this was the hospital’s fault or Epic’s, I’m not sure.

Usually, the two Epic people would be typing away on their laptops and not meeting with anyone from the hospital. When I did have one-to-one meetings with them regarding the build we were working on, they were constantly on "Epigoogle" (Epic’s search engine) because they did not know answers to what seemed to me like basic questions.

After their visits, we received no follow-up on outstanding issues or status reports of things they were working on for us. Reaching them was always a challenge. Either by voice mail or e-mail, it could take days or weeks to get questions answered. Generally, it took escalating issues through our project manager just to get a response. We didn’t even get, "Saw your e-mail, working on issue, will get back to you." Nothing! Very poor customer service from them.

During what Epic calls validation sessions, we ran into many problems where scripts weren’t sent ahead of time for our review. Some sessions ended up with last-minute cancellations because Epic wasn’t prepared or hadn’t shared the necessary info with us. Very frustrating.

When build questions arose, the Epic AM preferred to fix the problem in our system herself rather than explain the answer to us so we could learn the system. Frustrating again!

These same AC/AM were also responsible for grading projects for certification. When clarification was needed for me to understand what I got wrong, they were unable to. That was actually a final answer I received from our AC — "I don’t know," and no offer to find who might know more or send on my project to someone more senior for grading.

It was really very disappointing because I was a better IC at the vendor I worked for than either of these two, but everyone at the hospital acted like they were so great because they come from Epic.

Readers Write 11/7/11

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 Other Side of Epic
By Vince Ciotti

It’s almost gotten boring to read about another large hospital or multi-IDN picking Epic. It’s as if they have no competitors in the high-end market, which is silly. Mckesson Horizon, Siemens Soarian, Cerner Millennium, GEs Centricty, and Allscripts / Eclipsys Sunrise all have equal or better functionality. What they don’t seem to have is a back door to sell a hospital’s C-Suite through the medical staff, an insurmountable advantage Epic has due to its ambulatory roots.

Having assessed a number of Epic hospitals and having several CIO friends relay their Epic experiences recently, I think it’s about time someone listed the many weaknesses of Epic instead of just more glowing testimonials (to be sure, every vendor has their strengths and weaknesses: one could list many things wrong with other vendor systems too.) This “other side” is intended to open the eyes of those who are considering Epic just because everyone else is.

• Rookie implementers. Epic hires fresh college graduates for their implementation consultants (IC), a practice that saves them a fortune in salaries and gives them malleable candidates to learn “the Epic way.” Unfortunately, these ICs are terribly naïve when it comes to hospitals and do poor work on site, mainly sitting in their offices and looking up questions in “Epigoogle,” their search engine. A hospital would be far better off with veterans that have many installs under their belt, plus several years working in healthcare, to know the many challenges that make hospitals one of the most difficult industries to automate.
• “Epic” costs. Epic charges huge sums for their software and implementation services, just like most other vendors — equal to or greater than license fees. However, there are internal costs that make an Epic budget just that: dozens of hospital FTEs from IT and every user department who need to travel to Verona for many weeks/months of training and testing. Factor in their salaries and the cost for replacement temps and the re-training for inevitable turnover and you can understand why clients like Kaiser and Sutter reported budget overruns of 2-3 times their initial cost estimates.
• The “Epic Way.” Time and again I have heard from CIOs who have gone through an epic install (lower case intended) that the only way to make an Epic implementation successful is to not change the system, but rather adopt your workflow to EpicCare. This is silly in light of the mega-bucks Epic charges. Vendors like Cerner and Siemens pride themselves in adopting their system to their clients’ workflow through screen painting and workflow engines. How can Epic dare charge so much, yet be so inflexible?
• What hardware? Like Meditech (which Epic seems to have copied many bad ideas from, like all employees having to live near headquarters, running up hospital travel costs), Epic does not sell hardware. It is your responsibility and good luck that you buy enough to achieve decent response times. Any problems, just call Dell or IBM and buy more servers. Contrast that with more sensible vendors like Eclipsys and GE that sell hardware and negotiate reasonable system response time guarantees where they will buy more servers if needed. And Epic’s proprietary Cache’ database does take many minutes to run even simple reports.
• Interfaces. What, you thought Epic was integrated? Well that’s true, except for “minor” applications like ERP (AP, GL, PR, HR and Materials). Even the smallest vendors in the industry — such as CPSI, Healthland and HMS — include functional, totally integrated ERP suites, let alone leaders like Meditech and Paragon. CPSI even offers totally integrated PACS and time and attendance modules. Many of Epic’s ancillary department systems are relatively weak compared to specialty vendors. For example, their Beaker LIS can’t hold a candle to SCC Soft Computing or Sunquest, and their ED suite pales in comparison to A4 or MedHost. So, you better add an interface engine, servers, and analysts to that bloated budget.
• Physician training. Physicians love the fact that they see the same Epic EHR in their practice as they see in the hospital, but for two minor problems. First, the Epic build is different for ambulatory versus inpatient order screens, so physicians have to learn two ways of entering orders, responding to alerts, etc. Second, they have to sit through 12 to 18 hours of training classes – factor those hourly expenses into your budget (physicians are not exactly low paid!) At least they don’t have to fly to Verona for weeks of indoctrination like your poor users and IT staff.
• High ratings. Epic has the highest ratings KLAS has ever seen, but think back to all the dozens of IT and user department staff who spend weeks and weeks getting brainwashed on the Epic way. How do you think QuadraMed or Keane’s scores would look if they required their clients to send dozens of FTEs to their headquarters for months of training or testing? And it they didn’t cooperate, they wouldn’t qualify for “good” software maintenance rates, running up their budgets even more. Is it cause or effect?

Well, I could go on, but I doubt Mr. HIStalk will publish much more heresy. Indeed, if he even publishes this, I’ll admire him even more than I do today, as no one in HIS circles seem to challenge Epic these days.

Again, every HIS vendor has their strengths and weaknesses. I could go on for pages of weaknesses about any vendor, not just Epic. It is just sad that everyone seems to conform to only praising Epic while ignoring these and other weaknesses. Anyone else have the nerve to join me in calling for more rationality when dealing with the Epic “cult?”

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

They’re Killin’ “Me”
by Richard E. and Joy Goodspeed

My colleagues present themselves with an air of professionalism both in dress and in conduct. However, they look sloppy when they forget some grammar basics in speech and emails. My biggest pet peeve is that they are killing “me.”

They don’t understand what happens to the first person singular personal pronoun (“I”) when it follows a preposition. If the pronoun is alone behind that preposition, they get it right, but when it is part of a group of two or more, it is usually wrong.

Grammar rules may be a little hard to understand, so I’ll illustrate with some examples.

Say I invite Tim to go to HIMSS with me. I tell you, “I invited Tim to go to HIMSS with me.” Good. Inga decides to come along to keep us out of trouble. I say: “Inga went to HIMSS with Tim and me.” My colleagues would say “Inga went to HIMSS with Tim and I,” and that’s bad grammar (killing “me,” . . . get it?). How do I know it’s bad? Take Tim out of that last sentence. Are you going to say “Inga went to HIMSS with I”? Of course not. “Inga went to HIMSS with me.” Sticking Tim into the middle of the action doesn’t change the need for “me.” The pronoun is the object of “with” (a preposition), so it’s got to be “me.”

Now you’re on a project, and you’re telling your partner about a physician who came to a project meeting to make a complaint. “The radiologist complained to the project team and me.” Right! Now you’re catching on. It’s not “the project team and I,” as it would not be “to I” if you were the only one there. “To me” and “to the project team and me” are both correct.

This discussion is all about the “objective case.” It makes sense that you use the objective case for the object of a preposition. However, “I” also changes to “me” when it is the object of a verb.

Suppose you are going to take Tim to the new ER. “I’m taking Tim to the ER.” There’s nothing hard about that. Along comes Inga. She’s going to take Tim to the ER, and you can come along. You tell Jane about it. “Inga’s taking Tim and I to the ER” Oops! No, no. You’re killing “me” again. You and Tim are now the object of a verb (to take), and you have to use the objective case. “Inga’s taking Tim and me to the ER.” We use the same criterion for the case of that pronoun that we used when it was the object of a preposition: take “Tim and” out of the sentence. In your most ungrammatical of moments you wouldn’t say “Inga’s gonna take I to the ER.”

Keep thinking about objective case (and quit killing “me”).

Joy Goodspeed is a senior integration analyst with Sarasota Memorial Healthcare of Sarasota, FL.


Passionate People Perform
By Peter Longo

Another day, another conference call. “OK, we have everyone on the line and we are ready to review our ACO strategy that will affect v5.5 and the ICD 10 but we can’t forget the FFS model or the FQHC needs as we build the HL7 exchange. With the eMPI not ready, the focus should still stay on the CSI program and promote the current CCD standards that hopefully won’t affect the DR on the COF for client CPHR or the CPQs …” (do we use too many acronyms?)

With all this work selling software that enables physicians and nurses to deliver high-quality healthcare, we still can feel removed from the impact on a patient’s life. Yearning to be reminded, a group of dedicated sales professionals felt the need to get directly involved with delivering care and service to people in need, volunteering at Wheels For Humanity.

Wheels For Humanity (I guess that is WFH) is an organization that is dedicated to supplying wheelchairs to incredible people who are unable to walk for many reasons and who can’t afford mobility. Generally, they spent their young lives being carried from place to place. Painfully, the time comes when they no longer can be carried, and they are left to stay in their rooms. Recipients of these chairs are given the joy of mobility, but equally importantly, they are given dignity.

We work in an industry that is focused on the patient. This live experience stands as a pivotal reminder that the patient should be the center of everything we do. Many of the wheelchairs will be sent to places like El Salvador, Indonesia, and beyond. This whole operation is possible through donations and volunteers wanting to make a difference. Volunteers with a passion to help others.

The one thing our industry is not short on is passion. It is incredible to see so many individuals passionate about improving healthcare. I don’t think anyone can find an industry with a rivaled passion toward helping others. I am pretty sure there is no acronym for passion.

Please take a moment to read more on Wheels For Humanity.

Peter Longo is vice president of sales with Allscripts.

Readers Write 10/17/11

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!

Video to Smart Device Technology Improves Patient Care in Rural Areas
By Kevin Lasser

Innovative technologies are connecting doctors to experts around the globe, instantly and in real time. These innovations, including video to smart device technology, address the significant gap that rural patients experience compared to their urban peers. By improving access to expert medical care, innovations that can connect physicians to specialists are improving the quality of patient care and the outcomes of that care.

Access to specialty care is a challenge that rural Americans must tackle daily; according to a study published by the American Hospital Association, more than half of Americans in rural areas travel more than 20 miles for specialty care, with an average reported distance of 60 miles.

The plain fact is that rural Americas do not have access to adequate health care.

• 50 million Americans live in rural areas, yet there are only 65 primary care physicians per 100,000 rural Americans. By comparison, there are 105 physicians for every 100,000 urban and suburban Americans.
• Rural areas have less than half the number of surgeons and other specialists than urban and suburban areas.
• Saving lives means changing the status quo.

In emergencies, these rural patients can be in the fight of their lives against the clock. The current status quo for doctors in rural areas is to transport patients who need emergency specialty care to another physician. In life threatening emergencies, this delay in care can cause serious and irreparable harm.

Video to smart device technology is bridging the gap between physical location and access to expert care. By allowing a doctor to broadcast video over a secure network, a specialty physician can see the patient’s condition and advise on appropriate care.

“Video to smart device technology allows physicians immediate access to a patient via the mobile phone that they already carry,” said Dr. David Wang, director of the INI Stroke Network. “Other solutions, including personal computers or laptops, are cumbersome and impractical.”

Since the technology is real-time, diagnoses and recommendations can be made and implemented quickly; this real-time technology can save a life in settings where access to immediate expert care is required. The INI Stroke Network recently produced a video on how its use of video to hand-held device technology is saving lives in critical situations.

For the expert, including the stroke specialists in Dr. Wang’s practice as well as cardiologists, neurologists and specialty internists, video to smart device technology allows easy consultation with emergency room doctors and rural health care providers. Combined, these physicians deliver best in class health care to patients, regardless of their physical location.

Using technology to connect rural physicians to specialists in urban areas allows the patient to stay with a doctor that they know and trust while still receiving the best medical care. Real-time, real expertise leads to real care that can save a life.

Leveraging the power of innovation can change the outcome of care for rural patients. When access to expertise is critical, the phone in a doctor’s pocket might be more important than any other tool in their medical bag.

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

Imaging’s Test: The Balance of Cost and Quality
By Steven Gerst, MD, MBA, MPH, CHE

Providers will be put to the test as they deal with President Barack Obama’s recent proposal to trim trillions from the deficit and hundreds of billions from Medicare. Specifically, radiology professionals should take note. 

The proposal calls for nearly $1.3 billion in savings by raising the assumed utilization rate on some imaging equipment and by requiring referring doctors to get prior authorization when ordering scans. It is still unclear if this authorization process will be managed via the now dominant radiology benefit management (RBM) model. Yet a better model exists.

Today, more than 150 million patients are at the mercy of RBM companies. Health Affairs reported in their May 14, 2009 issue that, on average, telephonic utilization review protocols, denials, and appeals processes costs the average physician $68,274 per practice. This wasted time and cost totals between $23 and $31 billion, annually. This tremendous cost is unnecessary, especially based upon the availability of new electronic, point-of-order, appropriateness criteria-driven clinical decision support (CDS) systems.

Evidence-based medical imaging CDS systems are proving their value. According to a recent study published in the Journal of the American College of Radiology, physicians at Seattle-based Virginia Mason Medical Center saved the institution 23% to 26% on selected imaging procedures by using a CDS. At the Everett Clinic, also in the Seattle area, from January of 2009 to November 2010, the number of CT and MRIs dropped by 39% (from nearly 210 to 128 images/ per 1000) following implementation of an evidence-based, point-of-order CDS solution.

These solutions will become increasingly important under newer “pre-funding” models which reward the most appropriate utilization for the lowest possible cost and the highest possible quality of patient care. With bundled payments, growth in capitation, and the pressures for DRG cost containment, providers, payers and blended ACO organizations will face pressure for both quality improvement and cost containment. Decision support delivers value on both fronts. In the next few years, CDS systems will likely replace the current contentious, inefficient telephonic utilization review protocols by leveraging point-of-order technology, authorization, and payment mechanisms. CDS is destined to become mainstream tools for physicians under healthcare reform.

It is estimated that more than one third of all medical imaging tests may be medically unnecessary and 20% may be unnecessarily duplicative. There is significant merit in attempts to curb unnecessary testing and duplicate tests that are contributing to cost increases. As the Virginia Mason and Everett Clinic Studies indicate, when ordering physicians are provided with evidenced–based criteria at the point of ordering, a physician appears more likely to order the most appropriate test for the patient resulting in the highest quality of service and potentially at the lowest possible cost.  Health reform and ACO development create financial incentives to rapidly adopt this new technology.

In the RBM model, a UR nurse or medical director reads criteria off a utilization review screen during call center discussions, and the burden of that call falls upon the ordering physician, even though that physician is not reimbursed for the study that is being ordered. It is much more efficient to make criteria available to physicians directly at the point of care. Technology can replace an inefficient and costly middleman model.

Most RBMs and carriers develop their protocols around the American College of Radiology appropriateness criteria. With a CDS, these criteria can be loaded directly into the CDS system as an integrated application within the hospital and physician’s EMR. In this scenario, the most appropriate physician imaging orders (ranked levels 7, 8 and 9 on the ACR criteria) could automatically bypass the UM or RBM process electronically and receive an instantaneous authorization for approval and payment. This is known as “Gold Carding.” 

For tests that are clearly inappropriate (ranked 1, 2, or 3), the ordering physician could be given the clinical evidence electronically at the point of ordering  through a decision support system to select a more appropriate test (without having to step out of the normal ordering workflow). In some instances, physicians may want to override the system. Here, the doctor should be able to enter free text to include the reasons for not following the ACR criteria. This is an important part of the audit trail.

Decision support systems allow the hospital to carefully monitor ordering trends by individual practitioners. Those with inconsistencies may be reviewed in conjunction with the medical director to determine causes and to discuss potential resolutions going forward.

Depending on the business needs of the hospital or ACO, if deemed inappropriate, the test may be programmatically blocked electronically from ordering. For proposed studies which score in the 4, 5, and 6 range of the ACR rankings, the CDS system itself may suggest an alternative, more appropriate test. CDS systems should easily allow physicians to select this better test without exiting the workflow. 

What about Meaningful Use? While Stages 2 and 3 are yet to be solidified, it is believed that Meaningful Use Stage 2 will require 60% of all radiology orders to go through the hospital’s EMR CPOE function. Stage 3 has proposed 80%.  A medical imaging clinical decision support solution will, therefore, become a powerful tool in the hands of a conscientious hospital or ACO medical director.

In the past 10 years, the use of advanced imaging procedures (CT, MRI, etc.) has more than doubled in some large health systems. In these systems, clinician decisions drive roughly 84% of cost of care. While estimates vary, a conservative average for an advanced imaging procedure cost is $429 per study. On average, assume a typical hospital performs 230 procedures per day, or 84,000 studies per year. For a hospital at risk under a DRG, bundled payment model, ACO shared savings scenario, Medicare Advantage, Managed Medicaid, or their own employee plan, if just 10% of duplicate studies were avoided, nearly $3.6 million could be saved. 

Why wouldn’t an organization use a medical imaging clinical decision support system?

Steven Gerst, MD, MBA, MPH, CHE is vice president of medical affairs for MedCurrent of Los Angeles, CA.

The Perfect Storm:  All the Buzz from the Healthcare Business Intelligence Summit
By Laura Madsen, MS

Earlier this month at its annual Medical Innovations Summit, the Cleveland Clinic released a listing of the Top 10 medical innovations for 2012. While most would expect many of the items on the list, such as a novel diabetes treatment and new discoveries with gene sequencing, one of the list’s items took many by surprise. Specifically, according to the list, “harnessing big data to improve healthcare” will be a forthcoming medical innovation.

In May 2011, the McKinsey Global Institute published findings after studying “big data” in five domains. According to their research, “If US health care were to use big data creatively and effectively to drive efficiency and quality, the sector could create more than $300 billion in value every year. Two-thirds of that would be in the form of reducing US health care expenditure by about eight percent.”

Last week, nearly 200 people from provider and payer settings gathered at the Healthcare Business Intelligence Summit offered in its third year in Minneapolis. This year’s speakers represented a myriad of organizations including Northeast Georgia Health System, Hennepin County Medical Center, BlueCross BlueShield of Kansas City, and the Winnipeg Regional Health Authority.

As one of the event’s lead organizers, I give credit to my colleagues who served on planning and organizing committees, and also to those who presented and those who attended.

The day was full of sharing information, observations, and insights around business intelligence (BI) in healthcare. In debriefing with colleagues and pondering my own experiences from the day, the following key themes emerged.

The Perfect Storm For Healthcare BI
Many folks told me they are buckling under the pressure of increasing volumes of data, increasing regulatory requirements, and increasing exposure to data and reports by people across and outside of their organizations. Especially with the HITECH Act and Meaningful Use, we have the perfect storm for investment in healthcare data capture, storage, and analytics. Today’s organizations must leverage a new and distinct approach to data, one configured specifically for an ever-changing landscape. Yet caution is necessary. Healthcare is a different animal than retail, manufacturing, and finance.

What About Quality?
Concerns exist about the value associated with data. Healthcare data, especially clinical data, can be subjective. It is fragmented and often incomplete, making analysis and knowledge distillation an ongoing issue. While most know that data quality is critically important, most folks don’t know how to tackle it. Some have decided that they are better off exposing bad data to end users as a way to demonstrate the impact that these end users themselves can have on the quality of data. This, of course, is not recommended. 

Where’s the Value?
When talking about data value, a shift is underway. A few years ago at the conference, the question was “Is there value in our data?” Today the question is “How do we determine where there’s the most value?”

Data, Data Everywhere
As data volume increases, so, too do the challenges of data disparity. Data integration is becoming a hot topic. Everyone knows they need to bring disparate sets of data together. Some have done it successfully.Others are just embarking on the adventure. Yet we all know that as data sources and volumes increase, so does the reliance on “Extract, Transform and Load.” ETL is a fundamental practice in business intelligence, yet it is often misunderstood. This seems to be weighing on people’s minds.   

ACOs, MU, Etc.
Data reliance is becoming a mainstay in healthcare and increasingly important as Meaningful Use continues to evolve and as the new shared risk model of accountable care is adopted. Most people at this year’s event agree that the industry needs a higher degree of sophistication associated with data management, reporting, and analytics. When discussing MU, ACOs and the like, most organizations reported feeling ill-prepared.

Representatives from CMS led a heavily-attended breakout, with significant discussion on data warehouses to support Meaningful Use. One attendee, a vendor working with MU in ambulatory care, indicated that nearly 50% of the groups he’s worked with in the past few years have more than one EHR and are struggling to determine how to move forward with these multiple environments. One individual from a provider environment said he felt they were being penalized for being an early adopter of EHRs because they had more than one, and as a result, were not sure how to proceed. At this point, they are leaning toward dumping everything and starting over. Even though they will miss some incentives, they will make the final deadline.

The discussion of data EHR and data consolidation raised a major question that’s seemingly on most people’s minds:  will there be a time that ONC/CMS will recognize the need and/or value of a traditional data warehouse for healthcare organizations striving to meet MU? If this happens, how will they handle will certification of processes including data integration, data modeling, and reporting? 

Perhaps next year at this time I’ll be writing about the ONC’s response to this very question. Until then, best wishes with the unique healthcare challenges and opportunities of big data and business intelligence.

Laura Madsen, MS is healthcare practice lead at Lancet Software of Burnsville, MN.

Readers Write 9/21/11

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!

EMR Usability and the Struggle to Improve Physician Adoption
By Todd Johnson

Now that Meaningful Use money is up for grabs, almost every US hospital is somewhere down the pathway to deploying at least a Stage 1-certified EMR. Once installed, the tab on many of these systems can run as high as nine figures. For that kind of coin, every user in every department should see their daily workflow improve dramatically. Yet industry-wide physician adoption of hospital EMR systems continues to fall short of expectations.

For many users, the source of frustration is the clinical documentation system they’re asked to use. In theory, these tools are designed to make physicians’ lives easier. But too many documentation systems compromise the usability of the EMR for its most important users.

Not surprisingly, physicians resist changing the way they work to use tools that don’t solve their daily challenges. They stick with familiar workflows – even cumbersome tools such as pen and paper – to capture the details of patient encounters. And they leave it to the hospital to figure out how to extract the data they need.

The net result: physicians end up engaging with the EMR as minimally as possible. Without timely and comprehensive involvement from a significant percentage of physicians, an EMR system cannot help hospitals achieve their clinical, financial and operational improvement goals.

Determining the “usability” of an EMR is less subjective than it sounds. Here’s how usability is defined in the HIMSS Guide to EHR Usability:

• Usability is the effectiveness, efficiency, and satisfaction with which specific users can achieve a specific set of tasks in a particular environment.
• Efficiency is generally the speed with which users can complete their tasks. Which tasks and clinic processes must be most efficient for success? Can you establish targets for acceptable completion times of these tasks?
• Effectiveness is the accuracy and completeness with which users can complete tasks. This includes how easy it is for the system to cause users to make errors. User errors can lead to inaccurate or incomplete patient records, can alter clinical decision-making, and can compromise patient safety.
• User satisfaction is usually the first concept people think of in relation to “usability.” Satisfaction in the context of usability refers to the subjective satisfaction a user may have with a process or outcome.

Each of these components is measurable. Even user satisfaction, while highly subjective, can be measured through user queries. Yet even with an objective framework of EMR usability, physicians continue to suffer through documentation tools that often fail to meet any of these criteria.

Clinical documentation has become a victim of its own exploding popularity. Thanks to Meaningful Use and other technology-driven initiatives, the value of the data found in clinical notes has skyrocketed. Hospitals now have more incentive than ever to deploy systems that capture, aggregate and transfer data as efficiently as possible.

As the point of entry for a majority of patient information found in the EMR, electronic physician documentation has the added burden of converting notes into usable data. But too often, HIS solutions attempt to solve this problem by delivering electronic documentation that migrates all users to a single, inflexible workflow. Rather than accommodate multiple data entry methods and adapt to user preferences, physicians must instead learn to navigate drop-down menus, check boxes, and other pre-defined selections to complete their documentation.

A one-size-fits-all approach to documentation is shortsighted for two reasons. First, “narrative” shouldn’t be a dirty word in the electronic documentation workflow. A comprehensive patient record is much easier to achieve through a blend of structured and unstructured data input. Certain types of notes, such as H&Ps, benefit from the physician’s ability to capture all details of the patient encounter in his or her own words. Elements with repetitive values, such as lab results and vitals, benefit from structured input – even better if these values automatically carry forward daily.

Second and more important, we can’t lose sight of the fact that we’re asking physicians to alter a very important – and very personal – part of their jobs by asking them to use new clinical documentation solutions. Workflow flexibility is crucial to achieving user satisfaction. Narrative-based capture methods such as dictation remain popular because they’re easy to use. Forcing users to modify their behavior and abandon familiar workflows – to “document to the system” – is a recipe for continued lackluster physician engagement with the EMR.

Ultimately, a truly user-friendly advanced electronic clinical documentation system should empower users to document however they’re comfortable without compromising speed, accuracy, data availability, and overall productivity. The specialized technology solutions are in place to make that possible.

Modern speech recognition and transcription systems can convert dictated narrative to structured data. Universal interoperability standards such as HL7 Clinical Document Architecture (CDA) enable that data to integrate seamlessly into the EMR, regardless of which best-of-breed physician documentation solution you’re using.

The only way to know we’re achieving the right balance of structure and narrative is to let the end users guide the design of the finished product. By achieving high rates of physician adoption, hospital CIOs and other stakeholders can finally focus attention on other priorities.

Todd Johnson is president and co-founder of Salar of Baltimore, MD.

Is ONCHIT About to Chase the Clouds Away?
By Frank Poggio

My sincere apologies to Chuck Mangione. For our younger readers, Chuck is a great French horn jazz musician from the 70s. His signature song was Chase the Clouds Away. Now back to ONCHIT.

Cloud computing is the latest systems deployment panacea. In the recent past, it was referred to as SaaS (Software as a Service), and before that, remote hosting. The word ‘cloud’ clearly has a better visual impact. Cloud computing runs all your data and applications at a remote facility, giving the user many advantages such as built-in redundancy, reduced capital investment, effortless backups, better integration with many other Web services, and faster and simpler delivery of updates and fixes.

One of the core elements of the ONCHIT certification process and the Meaningful Use attestation requirements is that a provider must run certified software. The certification must tie back to a vendor’s specific version and build. Directives from two of the current ATCBs state:

CCHIT: If you modify or update your CCHIT Certified product in a manner that carries a significant risk of affecting compliance, you must follow this procedure. Before marketing the modified or updated product as CCHIT Certified, you must apply for re-testing of the product to verify continued compliance with all published criteria and Test Scripts.

Drummond: If changes are made to the Drummond Certified EHR product, you must submit to Drummond Group an attestation indicating the changes that were made, the reasons for those changes, and a statement from your development team as to whether these changes do or do not affect your previous certification and other such information and supporting documentation that would be necessary to properly assess the potential effects the new version would have on previously certified capabilities.

If you sell and install a certified full EHR or EHR module, you must at minimum notify the ATCB with each new version or build so that your previous certification gets inherited to your new update or release, preferably before you send it out to your client base.

Turnkey system vendors (do they really fly above the Cloud?) would send out two or three updates during the year, with perhaps one being a major release. If there was an emergency fix needed for a specific client, they might send that out separately. Clearly the update notice to the ATCB should happen before you would send the fix out, but in an emergency situation if the impact was to only one or a few clients, you could send it out just to them and notify and re-certify later.

The same would be true for any special enhancements. Say a new customer requires a specific enhancement as part of a new install contract. For the period your client is running the enhanced software, that version or build would not be deemed certified. This means they could not use your package to attest to MU. But it’s only one client, and if you are a best-of-breed or niche vendor, it may not matter to that client since they might be able to cover the MU criteria with other vendor-certified products. A good example is with the ONCHIT demographic criteria. This requirement could be covered by several EHR modules.

Lastly and most importantly, the assumption is that your updates or fixes do not impact any certification criteria. At this time, how ‘no significant impact’ is defined and determined is left to our imagination, but starting next year it will be a question that must be tackled by the ONCHIT AA surveillance auditors.

Meanwhile, back in the Cloud, it gets little more complicated. As noted before, one of the real advantages of the SaaS approach is that the user never has to load updates. They are handled centrally. One load and all clients are running the new code. Back to our example where a new client contracts for a special enhancement or a fix is needed — you code them, load them, and go. Everybody has access to the new enhancement and everybody is now running a non-certified system. Ouch!

The simple solution, of course, is to make your new customer wait for a full version release, or in the case of a fix, require a workaround until you get re-certified. Either way, ONCHIT has succeeded in turning the clock back to those Neanderthal days of legacy and turnkey system releases.

Cloud vendors who are ONCHIT certified will really need to rethink that load-and-go approach.

Frank L. Poggio is president of The Kelzon Group.

Interoperability? But of Course!
By Cheryl Whitaker, MD

An HIStalk reader, Rusty Weiss, recently wrote about interoperability (Is Healthcare Interoperability Possible With a Conflicted Federal Committee?, 9/14/11.)

I am not writing to comment on the appointment of Epic’s Judy Faulkner to the Health Information Technology Policy Committee. I am writing to endorse the concept of interoperability. 

In his article, Weiss states, “Democrats, Republicans, and industry experts alike recognize the importance of interoperability.”

Amen. It’s logical that we move to a model in which health information systems talk with each other. I concur that by “tapping into ‘big data,’ there will be opportunity to learn more from existing information – and to make healthcare more effective and less expensive.”

Weiss also states, “By allowing patients to carry their health information across provider lines as easily as we want them to carry their health insurance across state lines, we will empower patients. In fact, one of the stated goals written into the Recovery Act was the development of ‘software that improves interoperability and connectivity among health information systems.”

Weiss goes on to quote Otech president Herman Oosterwijk,  who says, “The entire industry is 15 years behind in interoperability compared with PACS systems.”

PACS solutions were early in the landscape of healthcare’s adoption of electronic information exchange. However, let’s be clear. Diagnostic imaging is far from superior in the context of interoperability. Visit a doctor’s office and you’re likely to see a patient carrying his or her own images burned onto a CD. Ride in a ambulance with a trauma transfer and you’re likely to see a CD strapped to the patient or the stretcher. 

When it comes to exchange of diagnostic images, the inefficiencies are horrific. The room for error is frightening.

Weiss quotes Andrew Needleman, president of Claricode Inc., who says, “Due to the amount and complexity of data being transmitted between systems, even systems that attempt to be interoperable run into issues when they send data to other systems. For healthcare data, even the demographic data to determine if you are talking about the same patient is complex.” 

Consider the realities of diagnostic imaging: 

• Healthcare organizations generate nearly 600 million diagnostic imaging procedures annually.
• Based on a study of data from 1995 to 2007, the number of visits in which a CT scan was performed increased six-fold, from 2.7 million to 16.2 million, representing an annual growth rate of 16%.
• One CT scan exposes a patient to the same amount of radiation as 100 chest x-rays.
• $100 billion of annual healthcare costs are related to diagnostic imaging tests – but an estimated 35% ($35 billion) represents unnecessary costs for US patients and insurance providers.

PACS solutions facilitate electronic image management. But these are proprietary, closed systems that do not allow providers to easily share information between departments and entities, and also across "ologies." Exchanging images outside of a "system" is difficult if the two facilities have different PACS vendors.

To solve this challenge, some entities have added solutions to morph imaging studies so they can be viewed on a receiving system. Until recently, this has required the implementation of specialized hardware and software and costs that were not sustainable.

We continue to see patients carrying their images around on CDs. Yet according to a January 2011 article in the Journal of the American College of Radiology, Johns Hopkins researchers found that approximately 60% of respondents said most images provided by patients on digital media were unreadable or not importable.

With today’s movement toward ACOs and medical homes, new approaches are needed. An enterprise imaging strategy must focus on providing access to any type of image, anywhere, any time, by anyone – provider, referring physician, radiologist, patient, etc. – across the continuum of care. This vision goes beyond PACS to make image sharing truly interoperable and accessible in real time on any device, without having to load and support additional software and without complicated and unnecessary movement of data. Image-enabling the EHR is also critical.

Three components are required for the move to a truly interoperable imaging environment: a standardized vendor-neutral archive (VNA), an intelligent digital image communication in medicine (DICOM) gateway, and a universal viewer that can be accessed via an embedded link or a standalone portal that enables viewing of images on any browser-based electronic device.

This technology exists. An organization can readily start with just one of the components, then build toward a more robust enterprise solution. There is no wrong door for entry.

Today’s most progressive organizations are embracing enterprise imaging, saving time and money, reducing unnecessary radiation exposure, and improving quality of care.

Healthcare data is voluminous and complex. Regulatory demands seem daunting.  Other industries, however, have adapted to a multitude of “data pressures.” Banking, for example, has been successful with leveraging federated data models to enable cross-organizational transactions via ATMs. 

The time is now for healthcare to create exchanges that allow EMRs, HIEs, and PHRs to access content and results from any location without moving data. We should empower patients, providers, and payers to manage the total healthcare experience from computers, mobile devices, and new types of access points, including kiosks.

Cheryl Whitaker, MD is chief medical officer of Merge Healthcare of Chicago, IL.

Readers Write 9/14/11

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!

Is Healthcare Interoperability Possible With a Conflicted Federal Committee?
By Rusty Weiss

Interoperability – the ability of health information systems in different organizations to “talk” with each other – is crucial to the future of healthcare. By tapping into “big data” to learn more from existing information, we will make healthcare more effective and less expensive. By allowing patients to carry their health information across provider lines as easily as we want them to carry their health insurance across state lines, we will empower patients. In fact, one of the stated goals written into the Recovery Act was the development of “software that improves interoperability and connectivity among health information systems.”

But one politically connected left-wing company, Epic Systems, could destroy this healthcare progress.

With over $19 billion in stimulus money being dedicated to health IT, the selection of members to occupy the Health Information Technology Policy Committee was a crucial one for the Obama administration. And a platform of interoperability isn’t exclusive to the Obama camp. Democrats, Republicans, and industry experts alike recognize the importance of interoperability.

So why, despite their public support for interoperability, did the administration appoint to the HHS board Epic Systems CEO Judy Faulkner, who opposes the broad consensus position on interoperability?

As Lachlan Markey pointed out in the Washington Examiner, “Epic employees are massive Democratic donors.”

Unfortunately, those political donations may have caused the administration to overlook things like Faulkner’s 2009 comments to Bloomberg News claiming that sharing electronic health records (EHR) “doesn’t work when you mix and match vendors.” She added, “It has to be one system, or it can be dangerous for patients.”

Tariq Chaudhry, a consultant for American Soft Solutions Corp. says, “Judith Faulkner’s version of interoperability reveals a clear effort to establish (a) monopoly for Epic.”

He also believes that after working with Epic for a couple of years, there is little to indicate that their software is unique in the industry.

“I have not seen anything specific to Epic, not found elsewhere that could set (them) apart from other competing EHR/EMR systems,” Chaudhry explains.

In fairness, the entire industry is, according to Otech President Herman Oosterwijk, “15 years behind in interoperability compared with PACS systems”. PACS (Picture Archiving and Communication System) is a technology that allows medical images and reports to be stored and transferred electronically.

Oosterwijk, who has worked with the US Department of Veterans Affairs and the US Department of Defense, believes that “none of the EHR systems are truly open.” He adds, “I can connect a PACS workstation to pretty much any PACS system and query and retrieve images. Compare this with an EMR where we, at best, can get a HL7 feed and/or CDA summary documents out.”

Andrew Needleman, president of Claricode Inc., acknowledges difficulty with the implementation of interoperable EHR systems.

“Due to the amount and complexity of data being transmitted between systems, even systems that attempt to be interoperable run into issues when they send data to other systems.”

Expanding on the complexity problem, Needleman says:

“For healthcare data, even the demographic data to determine if you are talking about the same patient is complex. Then, you add things like medications with dosages, different forms, such as capsules, liquid suspensions for injections, tablets, inhalers, etc. And then you need to include observations, doctor’s orders, lab requests and results, admissions and discharges, billing information, vital signs, etc.”

“Despite the existing standards,” he says, “It’s not an easy task.”

Rob Quinn, a partner at APP Design, a software development company, says the office of Health and Human Services “is trying hard to get vendors to communicate via standards,” though he doubts many health IT companies like Epic will comply.

“There’s simply too much money to be made in locking in their clients,” Quinn admits.

In the end, Needleman isn’t sure if the appointment of Faulkner crosses ethics boundaries, but says a conflict of interest may be unavoidable.

“I think that it would be extremely difficult to appoint someone who was knowledgeable enough about the industry, was willing to serve, and didn’t have an interest in the outcome of the regulations.”

Needleman has a point about the difficulty of finding somebody without any conflict of interest. But it seems like the administration, at a minimum, should have appointed somebody whose business was not antithetical to an interoperable future. Unfortunately, as an iWatchNews investigation pointed out in Politico, the administration has appointed hundreds of big donors to “plum government jobs and advisory posts …”

The appointment of Faulkner poses a significant challenge for the Obama administration. Her opposition to interoperability creates difficulty for the advancement of the health IT industry. The market should decide whether the Epic Systems approach to health IT should be rewarded or deprecated, but – in the interests of interoperability and political integrity – HHS should immediately ask Judy Faulkner to step down from her role on the HHS Health IT Policy Committee.

Rusty Weiss is a freelance journalist focusing on the conservative movement and its political agenda.

Is Meaningful Use Enough When Disaster Strikes?
By Eric Mueller

Within the last 12 months, natural disasters have taught the health IT community the necessity of preparation. We’ve seen tsunamis threaten nuclear disaster; tornados wipe out entire communities and hospitals; earthquakes damage national monuments; and hurricanes effect remote coastal towns. In the wake of Hurricane Irene’s flooding and billions in damage, I truly wonder what we can learn from this experience in an effort to make the next disaster … less of a disaster.

When I think of disasters, I think of recovery. In health IT, how do we clean up and recover from the unexpected? How do we recoup data, tests, records, history, systems, schedules, hardware, software, and all the technical things that make our facilities run? Katrina occurred six years ago, yet some areas of New Orleans are still cleaning up. Virginians can tell you all about the unexpected now that they’ve experienced an earthquake in their back yard.

And who can forget the tragic images of Joplin, Missouri, where St. John’s Regional Medical Center stood directly in the path of the monster EF-5 tornado? Thankfully, St. John’s had just switched to an electronic medical record system, though it reportedly sustained some permanent paper record loss. We’ve already heard reports of IT-related problems stemming from Irene with offsite centers and backup generators failing along with general logistical and access issues. Unfortunately, after the dust settles, we’ll likely hear of communication outages, lost patient records, and failed technology – a story that is become a bit too familiar.

Having learned from past disasters, many large facilities have business continuity plans in place to restore their operations quickly. They have online data storage backups and cloud-based hosting facilities to mitigate minimal interruption and risk. But what about those that don’t? Many physicians and hospitals across the country continue to lack capital and access to advance to technology typically afforded to large hospitals. Many find it challenging to meet the noble intentions of Meaningful Use, which is designed to do just that. Reach the communities that don’t have the funds or access.

Long-timers in health IT know that implementation and adoption of new technology can be S-L-O-W. So when exactly is the appropriate time to hold ourselves and our vendors to a higher standard of safety, data recovery, and connectivity over finances? What measures do we enact to safeguard our IT investment before a catastrophic event strikes? Moreover and most importantly, how do we help those caregivers in need RIGHT NOW of information technology?

For example, cloud technologies are words that scare us. We think liability and compliance obstacles instead of opportunity and solutions. Flexibility is paramount. Many organizations are in critical risk positions because archaic and poorly funded IT processes and architecture are wrapped around one very inflexible platform. In allowing the unknown to stop us from proactively seeking out sustainable solutions, will we allow history to repeat itself the next time a natural disaster crosses our path?

Creating flexible and efficient solutions provides the foundation for innovation and problem solving. Remember, if your vendor doesn’t play well with others, Mother Nature will force you to figure this out. Patients rely on the entire continuum of healthcare to do one thing – deliver great care. Doctors, nurses, and administrators can’t deliver great care without depending on their arsenal of tools and technology in their greatest time of need. Let’s challenge ourselves to be innovative and redefine Meaningful Use in ways to help all providers regardless of size and limits, both at work and in our communities. I believe it’s worth the effort.

Eric Mueller is president of WPC Services of Seattle, WA.

Is It Only CPOE, or Is There More?
By Daniela Mahoney, RN

We’ve got to think about what is ahead of us more holistically. CPOE is no longer a standalone project. If there is one common denominator amongst any size hospital that is embarking on this journey, it is the fact that the effort is considerably underestimated. Unless you have directly experienced projects of such magnitude, it is natural to treat and plan for this project as you would for any other.

What makes CPOE so different? It is often a multi-year process, especially for larger organizations. It has clear beginning, but not an end. It impacts every operational aspect of a hospital’s business. Above all, it leads to significant clinical transformation efforts that are not welcomed by providers and clinical staff.

Adding to the complexity of delivering CPOE within the Meaningful Use timeline is that all of the clinical components targeted for Stage 1 interrelate. We have two significant integration points: (a) the integration of the CPOE application with the appropriate modules and technologies (lab, radiology, pharmacy, documentation, ED, medication reconciliation, discharge instructions, etc.) and, (b) integration of clinical workflows. The latter is more challenging.

The easier question that organizations should ask is not what CPOE impacts in a hospital, but what it does not impact. That answer is by far shorter. To drive successful CPOE implementation, we know that the leaders have to be involved to “pave” the road and set direction.

To achieve Meaningful Use Stage 1, a cadre of leaders — including the CEO — need a working knowledge of the requirements and organizational changes necessary to succeed. An IT strategic plan aligned with the vision of the organization should be in place at the time Meaningful Use projects are executed. For successful organizations, their strategic plan is centered on the patient and how to maximize clinical performance, the need for increased transparency, pay for performance, provider engagement, and building and expanding business intelligence capabilities, to name a few. This calls for resources, innovative technologies, and infrastructure, as well as a strong leadership team that is able to drive such a vision.

The CIO’s role in the execution of the vision is essential. To successfully attain these goals, the infrastructure must support all these clinical and revenue-generating applications and the new tools that optimize the care delivery process. Someone made the analogy that the infrastructure is like a garden — cultivate it and it will produce expected results, but ignore it and the weeds will take over. As we plan the budgets for these initiatives, although we lead with saying that these are clinical applications and we need to focus on clinicians, we cannot minimize the importance of reliable infrastructure.

In the big scheme of things, what does CPOE impact? Putting it simply, it will impact everything that a provider order does today. Moreover, if what happens today is not functioning at the most optimum levels, then CPOE will accentuate all inefficiencies, resulting in potential barriers towards its adoption. Even processes such as the timely assignment of the appropriate provider to a case will impact CPOE, as any delays or inaccurate information will cause disruptions in communication, delays in care, inaccurate physician performance reporting, billing, etc.

Another critical factor is the fluency of clinical processes related to patient flow, especially at the points of entry through ED or PAT/surgery. As an example, take the efforts of trying to integrate CPOE with a disparate ED system while fine-tuning the medication reconciliation processes. In most cases, the result is a mixture of new processes that could still place patients at risks, unhappy providers if they have to use multiple systems, and budget overruns. Time is a precious commodity – neither the patients nor providers want to waste it.

How do we plan for CPOE? It is by beginning with the end in mind and creating a patient-centric implementation. CPOE has to be safe, should optimize our clinical performance, and improve organizational efficiency. It is complex, but we can simplify it by always asking the question: will the patient and provider/clinicians benefit from it? If the answer is yes, then we are on the right track.

I mapped a visual diagram on how to think about the Meaningful Use components in parallel with what is happening to a patient when admitted to the hospital. This will provide a reference of thinking about what we do in a different way.

And of course, I did not forget about another delicious recipe you could try as we are approaching the end of the summer. I know this has nothing to do with CPOE other than finding a way to relax after a long day at work. And next time, we will talk more about provider adoption, organizational culture, and how to look for that value proposition.

Daniela Mahoney RN is vice president of Healthcare Innovative Solutions of Seville, OH, A Beacon Partners Company.

PHR: the Unicorn of HIT
By Ryan Parker

The Personal Health Record (PHR), in theory, is one of the best ideas in healthcare. Not only in terms of value (think of Facebook and Twitter’s skyrocketing valuations), but also in terms of patient care. As a depository of information, medical records would be easily accessible by patient and provider alike, with medications, procedures, and diagnoses always being accurate and up to date.

Unfortunately, the PHR is the unicorn of healthcare IT.

There have been some valiant efforts, but everyone seems to miss the key reasons why this fantastical PHR will remain just that, a fantasy.

1. PHR interoperability would be an issue. For a viable PHR, it would need to link with every practice and hospital, not only to ensure that providers can view information, but to also make sure that patient data is recorded properly. However, a direct EMR/PHR link would be costly and resource heavy. It would essentially be more effective to create a national HIE (which I won’t get started on why that will never happen). Since we all know that is not an option for the near future, the best option would be to give patients the responsibility of filling out the information themselves. This brings me to my next point …
2. People don’t want to take the time to fill out a PHR. Unless they are made to, most people won’t take the time to find a PHR online and then take the necessary time to fill out all of the information accurately to really make it a worthwhile source of information. In order for this to work, you would need almost a social networking/PHR option that draws people in and then allows them to fill out their medical information, essentially a “Facebook for your health.” However …
3. There will never be a “Facebook for your health.” I’ve heard this idea thrown around quite a bit, and again, it would only work in theory. Most people only use one social networking site. Although Google+ has seen some initial success, I think it will soon bow down to the Facebook beast. The only way we can guarantee a majority of the population has access and comes into daily contact with a PHR would be for Facebook to add a PHR section, which leads to my final point …
4. Facebook will never step into the healthcare arena. Sorry, folks, it is just not going to happen. Facebook is fun, exciting, and laid back. Unless you feel reviewing friends’ home medication list and procedure history is really something that most people would enjoy doing (and if you do, I think you might be in the minority on that one) venturing into healthcare IT would be an extreme departure from Facebook’s prior success strategy.

I, for one, am interested in seeing what the next few years bring in terms of PHR strategy. I think there is an option out there that will work, but it definitely has not been created yet.

Ryan Parker is implementation practice director of Preceptor Consulting Corporation of Fort Myers, FL.

Readers Write 8/24/11

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!

“Installing IT” Understates the Organizational Change that IT Can Bring
By Mike Quinto

Our organization recently underwent an $18 million turnaround in 24 months. We are very proud of this accomplishment and have no intention of stopping there. 

In a recent financial periodical, our CFO was quoted as saying, “Considerable attention has also been given to IT. In the past, top-of-the-line software products purchased for the radiology, pharmacy, lab and other areas were highly functional in their own spheres, but didn’t integrate well. Now, new integrated software is being deployed to improve communication among departments.”

Well, he said it was IT. In reality, we in IT focus on getting cross-functional teams working together to solve business challenges. IT has been the facilitator of organizational change through process redesign, not new fancy software that adds, subtracts, multiplies, or divides better. 

Software, for the most part, does not “…improve communication among departments.” Governance, change management, and cross-functional teams do. 

We implemented Lawson’s ERP suite, but the largest benefit was not gained from the new splash screen or the logo in the corner of the screen. Vendors tend to think that they have solved the same old problem with new fancy software. It is rare that there is disruptive technology that actually changes the way we do things. For the most part, software is a commodity. The real benefit is the implementation and process redesign that takes place during a system rollout.

The opportunity was the chance to focus on charge capture and develop a policy, process, and strategy around it. We could have used a spreadsheet — the technology was not a magic bullet. The focus on business strategy was.

Don’t get me wrong, we like Lawson as a vendor. However, the software had little to do with our transformation. It was the implementation process that allowed open dialogue about the way we do things, and the way we should do things. That opportunity allowed us to evaluate broken process, identify areas that there was poor or no communication, and establish governance around important operational metrics. Just getting HR and Finance in a room monthly has done wonders to find financial opportunity and redefine policies and process. 

In one case, we had two vendors blaming each other for an outrageous claims denial rate. QuadraMed and McKesson couldn’t get on the same page, and that was creating a claim that had fields transposed. This created a denial rate that was almost 100%. I don’t blame the vendors. At the end of the day, we had a department that was not communicating and working with a broken process. 

Once we “re-implemented” the software, we were able to have open, honest conversations about who needed what and how the billing office should be run. Yes, there was an interface issue; however, IT and the business office were not talking. That was the larger issue.

We put in place weekly change management meetings, assigned application owners for each operational department that has an IT counterpart, and implemented basic project management. These changes had more to do with the performance improvement than any single piece of software, hardware, or vaporware we could install.

To say we purchased IT and installed it is underestimating the organizational change that “IT” can bring.

As a CIO, I spend most of my time helping business units redefine their goals, processes, and governance. Very little of my time is spent with bits and bytes.

Mike Quinto is VP/CIO of Appalachian Regional Healthcare System, Boone, NC.

PDF Healthcare: Why PDF is the "Currency" of Health Information 
by Tom Lang, MD

Health information technology faces challenges from many different quarters and for many different reasons. It’s time for a major dose of simplicity. PDF Healthcare (in both static and dynamic modes) is this major dose of simplicity.

Here are two compelling reasons that PDF Healthcare lives up to its billing as a "secure container for the exchange of healthcare information."

PDF is easily viewed/printed from virtually any computer. With the ubiquity of PDF readers, this is a reality. This fact can be thought of as another approach to interoperability. That is, if we can simply turn healthcare information into PDF, that information is available in a human readable form. Last time I checked, humans were still taking care of patients.

Image and other unstructured data files are easily converted to PDF. Clinical medicine is a world of image files and unstructured data, and that will never change. For example, our universe is filled with EKGs, X-ray images, video clips, audio files, and text-based reports  Equally important are those medication and allergy lists that are scrawled on scraps of paper (yes, paper!) that are so important at the point of care. The fact that PDF supports image files and almost any type of file format is very important in this environment.  ​

PDF (Portable Document Format) was originally developed by Adobe Systems Incorporated, but released as an open ISO standard in 2008. This has been an important step to stimulate innovation and competition, making PDF more capable, affordable, and available for our use in health IT as well as other industries.

As an ER physician, let me give you one example of how PDF can jump over the top of interoperability problems.  

I do quite a bit of locums ER work in many settings and frequently find myself in small rural hospitals trying to communicate with specialists that I need to refer patients to over a distance. Probably the biggest slam dunk for HIT has been PACS, which even in the smallest hospitals is almost universally present.  

One weekend, working in very small rural hospital, I faced the same problem twice: I saw patients with complex fractures, and the question was, "Does this patient need surgery immediately, or is this something that can be splinted and taken care of in a day or two?” Orthopedics is not available at this small hospital, and these patients requested orthopedic care in different directions.  

I was easily able to contact the orthopods by phone, but they needed to view the films to make a decision about what needed to be done and how urgently it needed to be done. This hospital has PACS, but despite this, neither of these orthopods could view the images. In this case, which is the most common arrangement I see, the only person who had remote access to view the images was the radiologist who was contracted to officially interpret the study ("Dr X not credentialed, hospital not on this image sharing network … blah … blah … blah").  

Because the radiology tech for the day was a hacker of sorts, he had some screen capture and turn-to-PDF programs on one of the radiology monitors. In both cases, we brought the images we needed on the screen, took a screen shot, turned the file to PDF, and e-mailed to the orthopedist. Also in both cases, not only were the orthopedists delighted we could provide this to them, but we determined that both patients could be splinted and dealt with in 1-2 days rather than immediately, saving many parties much trouble.

In order to raise the level of awareness of PDF Healthcare, colleagues from the PDF Healthcare working group have arranged, for a limited time, to give away a simple little app that will help HIE in the trenches. We are doing this for the solo / small doctor office. As a special for HIStalk readers, we will give away 50 copies.

Here is a short video that outlines the functionality of this app.

For your free copy, be one of the first 50 to go to the PDF Healthcare site and scroll down to Health Information Aggregator (under the heading of Resources.)

Tom Lang is an ER physician and a member of the PDF Healthcare working group.  

This Way to a Better Patient Experience
By Jeff Kao

Everyone’s been lost at one time or another. Whether you’re far from home or just around the corner, the experience is universally the same, with plenty of stress, aggravation, and wasted time.

Thankfully, the advent of navigation systems and smart phones means most of us get lost much less frequently these days, and that’s a good thing. But what about when you’re off the grid, say trying to find a family member’s hospital room or a lab for a blood draw?

Few places are as massive and confusing as a medical campus. With countless floors, departments, and even buildings to navigate, locating the desired destination can be a daunting task. On top of these logistical challenges, patients often arrive at a medical office or hospital feeling rushed, unwell, or anxious about their visit, only compounding the situation and causing them to be late or to miss appointments altogether.

Wayfinding systems offer a viable solution and pick up where navigation systems leave off. From the moment a patient or visitor walks in the door, these self-service kiosks virtually map paths to and from multiple points in a facility, resulting in a more pleasant and personalized experience. Leading healthcare organizations like Chicago-based Northwestern Memorial Hospital have placed wayfinding kiosks near entrances and other common areas, making it easy for patients and visitors to quickly locate a specific room or department and print a customized map with step-by-step directions.

At a time when consumerism is on the rise and patients have greater flexibility in their choice of healthcare provider, such systems are fast becoming a valuable strategic asset. According to a survey conducted by The Beryl Institute, hospital executives list the patient experience as one of the top three priorities they will focus on over the next three years. Wayfinding systems directly impact the experience patients and visitors have by enhancing the level of service that’s provided and eliminating the hassle of being late or lost.

Beyond guiding patients to the correct destination, wayfinding systems can also reduce demands on staff time, both in terms of time spent giving directions and updating software. While some wayfinding systems once required users to manually re-create maps on each kiosk every time an office or department was moved, today’s dynamic, data-driven applications are extremely scalable and allow technical and non-technical staff alike to quickly recalculate routes on the fly.

When not in use for wayfinding, these systems provide an effective venue for displaying video or text-based messages and marketing medically-related services and events. Patients can also use kiosks to register for promotions or request additional information. And, once in place, wayfinding systems establish a platform for future expansion and growth, eventually allowing healthcare providers to add new self-service capabilities from the same screen.

So, what is the path to a better patient experience? The answer may be inside your own front door.

Jeff Kao is vice president and general manager of NCR Healthcare.

Specificity to the Extreme: As ICD-10 deadlines Draw Closer, Is Your Organization Ready for the Good, the Bad … and the Offbeat?
By Sean Benson

Chances are that most healthcare organizations will be able to raise the bar on current documentation practices high enough to support coding for suture of an artery under ICD-10—even though the possible codes expand from just one under ICD-9 to more than 180 under the new code set. But what if a patient walked into a lamp post (W22.02xA) or was bitten by a sea lion (W56.11xA)? What if the patient was burned by a flaming jet ski (V91.07 xA) or suffers from inadequate sleep hygiene (Z72.821)?

If your organization’s clinical documentation and coding processes can’t support that level of specificity, you need to act fast to get it up to speed. Because rest assured, no matter how weird the diagnosis, ICD-10 includes a code that accurately defines the patient’s status to a T.

The authors behind ICD-10 covered all the bases in an effort to capture the full patient picture—sometimes to the extreme and offbeat. With approximately 68,000 diagnosis codes compared to just 13,000 under ICD-9, it’s clear that documentation approaches that work fine today simply won’t cut it under ICD-10.

It will be complex enough to ensure coding staffs are adequately trained on ICD-10. Finding the resources necessary to advance clinical documentation improvement programs to meet the ICD-10 challenge is simply out of the question for many organizations. Nor are most clinicians interested in spending the amount of time required to become fully proficient on the new system, especially when it takes them away from patient care.

That is why many hospitals and healthcare facilities are looking to software vendors to help them make the transition. Software that automates the documentation and coding process can ease the transition to the expanded code set and shorten the learning curve for physicians, especially if they are faced with the ever-so-common encounter of a patient who has been struck by a bird (W61.92).

Not all coding and documentation software is created equal. The best ones will drive comprehensive documentation to capture the high level of detail required under ICD-10. The software should guide physicians through the process of documenting with enough specificity and granularity to ensure appropriate coding. Otherwise, the code that would accurately identify an embarrassing fall on the local airport’s escalator (W10.0xxA) might be missed.

Healthcare organizations will want to focus on the software’s ability to provide prompts relevant to the documentation needs of ICD-10. That is why it’s important that the evaluation be done by someone who is well-versed in ICD-10 to ensure the right questions are asked.

There are multiple initiatives competing for the attention and resources of healthcare organizations, including 5010 and Meaningful Use, in addition to ICD-10. Because it will affect every aspect of operations, the transition to ICD-10 needs to be placed at the forefront.

For many organizations, leveraging the efficiencies inherent in technological solutions to drive documentation improvement is the best strategy for meeting the ICD-10 challenge head-on.

Sean Benson is co-founder and vice president of consulting with ProVation Medical, part of Wolters Kluwer Health.

Readers Write 8/3/11

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 Pressures of EHR Adoption and a Market Trend of Converged Services and Technology
By Janet Dillione

Recent mergers and acquisitions in the healthcare information technology (HIT) industry bring to light many facets of electronic health record (EHR) implementation that often go overlooked. As many in the medical industry know, implementing an EHR system so it works seamlessly with clinical workflow is more complicated than downloading and installing software with the click of a mouse. There is not an EHR switch that can simply be turned on.

Healthcare organizations that have successfully implemented EHR systems, along with those currently navigating the process, can attest to the need for a scalable system wide approach. To achieve improvements in the quality, safety and efficiency of patient care special attention should be paid to services and technologies that foster EHR adoption across the clinician population.

Recent strategic alliances in the healthcare IT space signify a movement toward a promising future of EHRs, a future with a genesis in advanced clinical documentation. A successful, long-term EHR strategy, one that will position healthcare organizations to overcome the many pressures of the healthcare industry in the years to come – Meaningful Use, ICD-10, Accountable Healthcare – begins with effective data capture. The reality is that an EHR is only as good as the information captured within it, and as the saying goes, it takes a village …

I have no doubt that the industry will continue to see more strategic partnerships. These alliances establish greater resources for the healthcare industry, leading to more streamlined workflows, greater cost savings, satisfied physicians, and improved quality of patient care. However, none of this happens overnight and healthcare organizations should see this as an evolutionary process, not one of instantaneous change. By this I mean, every provider setting has a clinical documentation workflow in place, and pursuing an approach that is diametrically opposed to the status quo can prove counterproductive to the effort.

Despite the enthusiasm for employing state of the art technologies, healthcare organizations should not feel pressured to immediately make all data capture mobile, to put all applications in the cloud tomorrow, or to force doctors to use an EHR without a safety net out of the gate. In time, the increased amount of service and technology convergence across the industry will help healthcare organizations to better address the pressure of EHR adoption, and more importantly, will help them better manage their robust collections of clinical data.

It is becoming increasingly clear that in healthcare, data is knowledge. It drives care decisions, billing and reimbursement, compliance with federal regulations, and is key to overall health system improvement. Today, there is no one solution, no one vendor, and no magic potion that can address all of these issues and capitalize on all opportunities. However, by strategically bringing together the best in technology with the best in services, healthcare organizations will be better positioned to make the transition from traditional workflows to the EHR in a thoughtful, natural way.

An impressive amount of progress has been made over the last several years, particularly in light of EHR adoption pressures. Innovation and automation is transforming the processes and outputs of clinical documentation. What once was scribbled on a notepad, created on a typewriter, or passed from caregiver to caregiver in the hallway, is captured and transferred more efficiently and effectively than ever before. Such effective clinical documentation establishes an important foundation for EHRs.

By leveraging and contributing to technology collaborations, healthcare organizations can access the best in services and technology. This means a transition from handwritten records stored in manila folders to digital information stored within EHRs captured through natural clinical workflows. Moving forward, there will be multiple ways to capture the patient story including keyboard input and speech-to-text technologies.

Once clinical information is captured, we’ll see the application of highly intelligence clinical language understanding (CLU) technologies, often referred to as natural language processing or NLP in other industries. These highly sophisticated technologies will turn our vast amounts of clinical data into knowledge to be leveraged across the healthcare ecosystem.

The convergence going on across the healthcare industry amongst healthcare IT vendors, academic centers, service-oriented businesses, and other organizations is promising, but should be scrutinized by healthcare organizations.  There are many promises amongst the recent M&As and partnership activity, but only few proven results and long-term plans.  As you work to tackle EHRs as a strategic initiative, enlist supportive guidance and build a nimble infrastructure where the EHR can become a launching pad for better use of data.

Janet Dillione is EVP/GM of the healthcare division of Nuance of Burlington, MA.

Meaningful Use and Innovation
By Ryan Parker

All human development, no matter what form it takes, must be outside the rules; otherwise we would never have anything new. – Charles Kettering.

I have recently finished up some consulting work for a startup HIT company (which for non-solicitation reasons I will refer to as Company X.) I was working with them to help develop their EMR. 

When Company X first showed me their product, I was amazed. In just over a year, they had developed an almost fully functioning EMR. Using more advanced coding language than what you would find in most legacy systems (i.e. C#, Silverlight) they came as close to mimicking the clinical workflow as I have seen with an information system.

Everything was looking up. Their product was becoming more and more complete and becoming more and more advanced. But then they ran into an issue. If anyone has worked with or been a part of a start-up, momentum is key to success, and in this company’s case, the Innovation truck slammed head first into the Meaningful Use wall.

To be completely honest, forcing Company X to get their product Meaningful Use certified did have some benefits. There were some system needs they hadn’t thought of previously. In terms of HIE and interoperability, the requirements will have a positive impact as a whole as we move to a more ‘data-sharing’ driven information system structure. However, the innovation, creating a system different from anything else, which, to keep the truck metaphor rolling, was sitting in the driver’s seat of the company, dissipated as executives and engineers dived deeper and deeper into the ONC requirements.

Weeks turned into months of working on the Meaningful Use requirements. Although Company X was making progress, the focus slowly turned from creativity and ingenuity to one of conclusion, as in, “How soon can we meet these requirements and be done with this product?”

Soon, the executives starting turning their attention to other products, focusing on solutions that fall outside of the ONC/Meaningful Use umbrella.

I have no doubts that after they complete their Meaningful Use certification in the near future, and hospitals and health systems get a good view of their product, Company X will receive accolades on their HIT advancements from the healthcare community. Personally, I will be wondering what progress could have been made without standardization. What advancements could Company X have made without the rigors and requirements forced upon EMR vendors?

Ryan Parker is implementation practice director of Preceptor Consulting Corporation of Fort Myers, FL.

HIEs: High Performers Will Be Around for the Long Term
By John Haughton

Improved patient care outcomes, lower administrative costs, fewer medication errors, improved ability to manage chronic conditions, reduced unpaid re-admissions, greater efficiency, fewer ER visits …

There is no question about the benefits that a highly effective health information exchange (HIE) brings. By highly effective, I mean a healthcare ecosystem grounded in evidence-based medicine, clinical guidelines, and performance reporting.

For providers hoping to achieve Meaningful Use (MU) or to become Accountable Care Organizations (ACOs), performance-based HIEs hold the promise of pulling together data from myriad sources — medical staff and community physicians, insurers, labs, imaging centers, behavioral health and home health providers, employers, consumers, retail pharmacies — to finally deliver truly coordinated care.

But there is also no question about the challenges facing fledgling HIEs, the primary one being a sustainable business model. It turns out that, if you build it, they won’t necessarily come. And once the grant money runs out, the organization rapidly runs out of steam.

The only way to build an HIE with enduring power to transform the health of a community is to have providers pay for it. And the only way to do that is to provide high value — quickly. This means demonstrating value from Day One by raising the bar on clinical quality for their customers, namely, patients.

In response to the MU requirement for value-based purchasing and market realities pushing margins into negative territory for about half of all hospitals, HIEs must help hospitals survive and thrive in the new patient-centric business model to garner lasting provider support.

The HIEs that have done this successfully have something in common: they pretty much all have their heads in the cloud, which is to say, they use platform-as-a-service (PaaS) cloud computing technology that offers authorized users easy, but extremely secure access to centrally stored, actionable information for an affordable price.

Here are the seven technology elements needed to play in the high-performance league:

1. Maximum functionality and flexibility. Since around three-quarters of healthcare in this country remains paper-based, technology is needed that supports hospitals and physicians regardless of their technology sophistication. This favors best-of-breed EHR modules that can meet a wide variety of needs, budgets and timetables, rather than a comprehensive, enterprise-wide approach.
2. A full range of value-added tools and services. Think of the app store on an iPhone. That type of flexibility and customization are what is wanted from HIEs, only instead of YouTube, GPS, and Fandango, apps that provide clinical decision support, performance management, quality reporting and analytics, clinician messaging, shared guideline dictionaries, and disease registries are valued.
3. On-the-fly translation. As long as stakeholders continue to speak different electronic languages — all of which are upgraded and updated almost constantly — mapping and translation services are needed for interoperability.
4. Scalability. An HIE is a dynamic entity; it needs a platform that continually accommodates more of everything: providers, users, technologies, regulations… Collaborating across town is great. Collaborating anywhere is the ultimate goal, however.
5. Ease of use. An identity federation service means providers need just one user name and password to interact with each other, health plans, regulators and patients — and just one point of access for all clinical and administrative data held by the HIE.
6. A 360-degree, real-time view. A single, comprehensive view of a patient’s status, including all information submitted by all authorized sources from five decades ago to five minutes ago, will help eliminate redundant tests and procedures.
7. Sharing of best practices. The best HIEs aren’t merely repositories. They must be able to analyze input, generate point-of-care solutions, and disseminate data that draws on documented successes.

So the future is bright for those high-performance HIEs that “bring it” — clinically speaking. HIEs and other data exchange organizations that figure just having the data will have hospitals and physicians beating a path to their door are being naïve and are putting their long-term survival at risk.

Like it or not, healthcare is a business as well as a service, and organizations need to deliver ongoing value to ensure their long-term relevance and sustainability.

John Haughton MD, MS is CMIO of Covisint of Detroit, MI.

Readers Write 7/25/11

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!

Walter Reed Medical Center to be Decommissioned this Week
By Orlando Portale

As part of the Base Realignment and Closure announcement on May 13, 2005, the Department of Defense proposed replacing Walter Reed Medical Center with a new Walter Reed National Military Medical Center (WRNMMC). The new center would be on the grounds of the National Naval Medical Center in Bethesda, Maryland, seven miles from its current location in Washington, DC. The proposal was part of a program to transform medical facilities into joint facilities, with staff including Army, Navy, and Air Force medical personnel.

At the same time, my own organization was in the design phase of our $1B “hospital of the future,” which is scheduled for a 2012 opening (our construction webcam is here.)

In the fall of 2007, I was asked by Congress and the Department of Defense to participate in an independent review of the design plans for the Walter Reed Replacement Project. My role was to identify potential technology and design shortcomings in the Walter Reed replacement facilities.

In May of 2008, our committee submitted a report, noting design and operational deficiencies, but nonetheless advising that the project proceed on schedule.

On Wednesday July 27, the Walter Reed Army Medical Center is closing its doors after more than a century. Hundreds of thousands have received treatment at Walter Reed, spanning World War I, World War II, Vietnam, and the Iraq and Afghanistan conflicts. The move to the new facilities is scheduled for the weekends of August 12 and August 19.

In case you have not been to the old Walter Reed Campus, there are many important pieces of history there. The original red brick hospital was named to honor Major Walter Reed, an Army physician who treated troops and American Indians on the frontier. Dr. Reed had numerous medical achievements, but his most important work involved research that proved yellow fever was spread by the mosquito. He died in 1902 at the age 51 of complications related to appendicitis.

There is a memorial chapel on campus where President Harry S Truman visited after taking office. General Pershing had his own suite on campus for many years. Vice President Richard Nixon was treated for a staph infection over a few days, and received an unexpected visitor one day, then-Senator Lyndon B. Johnson. President Calvin Coolidge’s teenage son died in the hospital from an infected blister he received while playing tennis at the White House. President Dwight Eisenhower and Generals John Pershing and Douglas MacArthur died at Walter Reed.

In 1977, a new addition to Walter Reed was dedicated. The new hospital was as tall as a 10-story building. There were 5,500 rooms covering some 28 acres of floor space. The distance around the top three floors stretched the length of six football fields.

As you can see, the new Walter Reed National Military Medical Center is a beautiful facility. My hope is that it brings comfort and healing to those who have put their lives on the line for this country for us every day.

While our report identified a number of shortcomings with the design plans for the Walter Reed replacement facilities, many of these have been addressed. In fact, recently the new hospital was granted LEED Gold certification, which was an area addressed in our report. Very few hospitals in the US have achieved this status.

More important than the design of the new facility, however, are the extraordinary and dedicated people there who care for our wounded warriors every day. Congratulations to the great team at Walter Reed for all of their hard work and continued dedication.

Orlando Portale is chief innovation officer at Palomar Pomerado Health, San Diego, CA.

Over the past year, we’ve been helping a hospital in New Orleans augment their data center operations to avoid a disaster when the next major hurricane grows out the Gulf of Mexico. Doing this work in the midst of other recent natural disasters across the Midwest and South has helped to reinforce my thoughts about the importance of detailed and actionable plans for disaster recovery and business continuity.

When catastrophic events occur, the concept of business continuity (BC) is really focused on continuity of patient care. This is the ability to continue to attend to those in immediate need and also assist patients who rely on their caregivers on a regular basis.

You would be amazed to know about the number of healthcare organizations with EMRs that have minimal disaster recovery (DR) and care continuity plans. Some hospitals do well in this regard; however, many others have inadequate DR plans that are infrequently revised or tested. Manual care processes for long-term systems outage also suffer from lack of definition or practice. When an organization without good plans faces a major disaster, they quickly learn about their planning deficiencies at the worst possible time.

St. John’s Regional Medical Center in Joplin, Missouri was damaged so badly by an EF-5 tornado on May 22, 2011 that all patients had to be evacuated to other hospitals in the area. When a catastrophic event occurs, the provision of care for patients can be easier and many adverse event risks avoided if some portion of the medical record is available. Recent procedures, conditions, medications, orders, lab results, and radiology reports are extremely helpful in care continuity.

Hospitals can prepare for many types of disasters. We have advance warning for hurricanes, tornadoes, and even floods. Of course, some of the less-frequent disasters such as earthquakes and fire are not preannounced. With knowledge of an impending disaster, the hospitals with an EMR can have a process for the IT department to take steps to assure that current pertinent patient information is available.

Simply printing information at each nurse station in the hospital for the admitted patients is not sufficient. The hard copy reports can be misplaced or damaged. Writing these reports to an encrypted file on a CD, DVD, and even a USB flash drive (a.k.a. memory stick or thumb drive) will assure that important patient data is immediately available after the disaster causing event has passed. When the risk of a disaster is high, write the reports to the disks and flash drive, and along with a laptop PC and spare laptop battery, seal them in a waterproof bag and lock them in a fireproof safe that is anchored to the floor, typically in the data center. If practical and time permitting, prepare a second flash drive with another copy of the data delivered to a key person as identified by the DR/BC plan.

These few simple steps can help you to continue delivering appropriate care for your patients and potentially even save lives in the aftermath of a major disaster.

Jeff White is a principal at Aspen Advisors of Pittsburgh, PA.

Readers Write 7/6/11

Readers Write 6/27/11

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!

Will Meaningful Use and EMRs Help Jump the ACO Hurdle?
By Frank Poggio

The Accountable Care Organization (ACO) is the government’s latest attempt to improve quality of patient care and control the ever-escalating growth in healthcare costs. The Affordable Care Act (commonly known as the health reform law) encourages, via financial incentives and penalties, the formation of ACOs by organizing healthcare teams, technology, and knowledge around patient needs. 

As might be expected, there are many complex organizational, monetary, and other significant policy issues surrounding the ACO model of care delivery.

The ACO concept is not new to the healthcare world. In past decades, we called them PHOs (Physician Hospital Organizations) or HMOs (Health Maintenance Organizations).  Both of these in the 1980s and 1990s had only a small impact on healthcare costs. Many PHOs and some HMOs are still in existence today.

In fact, we have always had some form of ACO going as far back as 1939. For example, the Kaiser Health Plan, The Cleveland Clinic, Sharp HealthCare, Geisinger Clinic, and many others are basically ACOs. If they include an insurance component, they are more like an HMO.

The simplest definition of an ACO is a health care delivery system where the physicians and hospitals work under one corporation, have one set of synchronized patient objectives, and share in the profits  and losses from normal operations. Medicare wants doctors and hospitals to work together and accept one payment for all levels of care and accept the responsibility for coordinating the care of the patient across all modalities of care. 

Where ACOs work and why

The concept has worked at Mayo, Kaiser, and Cleveland Clinic because the attending docs are part owners of the hospital. They get paid a salary and bonus based on both the performance of their practice and the performance of the hospital and other health services.

For example, the physicians readily accept that fewer support staff will save the hospital money, which in turn could result in a year-end monetary bonus while hopefully improving patient care. That, in turn, can lead to more patient referrals and more revenues. The same is true for ordering fewer tests or procedures. Fewer tests equal less costs, and under a fixed payment system like Medicare DRGs, that means more profit.
 
But today, the independent physician makes his or her money seeing as many patients in his or her office as possible. The hospital is just a cost-neutral and convenient place for physicians to perform complex procedures. If an ACO is that simple and beneficial, why are there so few of them?

How did we get here?

Today and for the past half century, we have been in a situation where the person most responsible for “product definition” and most responsible for “bringing in the business” is not an employee of the hospital. That person is the attending physician, or sometimes called the independent practitioner.

It goes back to the establishment of the AMA and the AHA in the early 20th century. Both of these groups were focused on increasing utilization of hospital and medical services. Even at that time, just as today, medical care was relatively expensive. To drum up business, they both came up with the idea to sell a medical insurance policy.

Rather than work together, around 1940, the AMA founded Blue Shield and the AHA started Blue Cross. Each had similar, yet different objectives. Keep in mind that almost all doctors in the early part of the 20th century were independent practitioners and hospitals were places to be avoided.

In 1966, along came Medicare. If you go back and study the legislation of the day, you will find that physicians fought Medicare with a vengeance and wanted no part of the government or the institutional side of the package. Of course today, if you tried to take Medicare away, you’d have a rebellion — and not just from seniors. Medicare in 1966 solidified the doctor-hospital split via separate payment systems by creating Medicare Part A for hospital payments and Part B for physician payments.

Then in 1972, as the health insurance industry matured, the Federal Trade Commission became concerned that doctors and hospitals selling insurance was a little to cozy. The AMA had to spin off Blue Shield and AHA split with Blue Cross. Later, as the Blues saw themselves more as insurance companies than part of the medical establishment, many of the Blues merged and eventually morphed into today’s United Health, Wellpoint, etc.

To drive the hospital-physician wedge deeper, in 1993, Congress passed OBRA, which contained the infamous Stark amendment. The Stark amendment made it a crime for doctors to refer patients to a hospital in which they had a financial interest. The feds saw this as a conflict of interest that would drive up healthcare costs. 

The structure we have today — full physician independence — has been around a very long time. It has been repeatedly fortified through separate provider and piecework-based payment systems.

That raises today’s big question: who is accountable for all the care a patient receives? 
 
How can we create more ACOs?

Now, after more than a half century, the government has come to the conclusion that doctors working separately from hospitals with separate payment systems and different incentives is a counterproductive operating model. (too bad we didn’t see that coming when we initiated the Medicare-Medicaid systems.)

Under the duress of a very large federal deficit (in part, a result of healthcare costs), we are trying to reverse 70 years of misdirected legal and financial incentives. Under an ACO, the feds want both parties to work together, share the payments, and share the risks.

The ACO statute of April 2011 lists the following provider combinations as potentially eligible ACOs:

1. ACO professionals in formal group practice arrangements.
2. Networks of individual practices of ACO professionals.
3. Partnerships or joint venture arrangements between hospitals and ACO professionals.
4. Hospitals employing ACO professionals.
5. Such other groups of providers of services and suppliers as the Secretary determines appropriate.

Combinations 2 and 3 are what I call the “virtual’”ACO. Combinations 1 and 4 are more like the PHO/HMO of the past, or the Mayo model.

As stated by CMS, ACO compliance with the requirement to reduce costs and improve care may involve a range of strategies, which they state includes the following examples:

• A capability to use predictive modeling to anticipate likely care needs.
• Utilization of case managers in primary care offices.
• Having a specific transition of care program that includes clear guidance and instructions for patients, their families, and their caregivers.
• Remote monitoring.
• Telehealth.
• The establishment and use of health information technology, including electronic health records and an electronic health information exchange, to enable the provision of a beneficiary’s summary of care record during transitions of care both within and outside of the ACO.

Promote the virtual ACO

As can be seen from the compliance strategies, CMS is leaning heavily on HIT and EMR to help avoid some very difficult political battles. As an interim step, they are encouraging hospitals and physician groups to use EMR systems to build and support a virtual ACO.

In this scenario, the physician and the hospital would remain corporately separate, but the patient information and the payment would be shared. This dovetails with the new federal HITECH Act that promotes EMRs and stronger coordination of care via interoperability.

CMS has defined the five levels of ACOs and has set target dates for providers to achieve one of the levels. If a provider organization achieves an ACO level during the next five years, they will get a financial bonus. If they don’t, their Medicare payments will be reduced. Sounds like MU all over again.

Initially, the AMA was indifferent towards the ACO concept. AHA gave it mild support. But after CMS issued draft regulations in April noting the bonus-penalty provisions and the shared payment component, both associations came out strongly against it.

Of course, the 800-pound gorilla is who should run the ACOs, physicians or hospital executives? If there’s to be a single payment for Medicare patient services to the ACO, how do you split that payment?

CMS is staying out of this battle and leaving it to the docs and hospitals to fight it out. To say the least, AMA probably views it as the death knell for the independent physician practice, and AHA may see it as the surrendering of institutional autonomy to physicians.

I think it will be a long arduous road getting to real ACOs. Remember, the overall objective is to reduce the costs of healthcare. According to a CMS analysis of the proposed regulation, Medicare could potentially save as much as $2 billion over the first three years, so somebody’s ox has to get gored.

But as we stumble down this long and very bumpy road, I believe in the early years, the focus will be on the virtual ACO. The CIO’s office will be right in the middle of it. If you look at the Meaningful Use criteria for CCR, CCD, and interoperability, the first hurdle is staring us in the face.

Frank Poggio is president of The Kelzon Group.

During the first quarter of 2011 alone, there were media reports of inappropriate access to electronic Personal Health Information (e-PHI) of four sizeable healthcare organizations. This is damaging in terms of public relations, patient confidence, possible revenue loss, and increased costs to protect patients with exposed identifying details. It seems that many organizations are overlooking or delaying the need to perform a security risk assessment.

Yet under the HITECH Act, one of the core Meaningful Use measures is the requirement to “Conduct or review a security risk analysis … and implement security updates as necessary, and correct identified security deficiencies prior to or during the EHR reporting period to meet this measure.”

This measure is, therefore, a key task healthcare providers must conduct before attesting to their ability to meet Stage 1 requirements. Additionally, the risk analysis requirement in the HIPAA Security Rule is not only an integral part of meeting Meaningful Use for HITECH, but also for being in compliance with the law.

A risk analysis is the very foundation from which to build your information security compliance program. A security risk analysis should be conducted with active participation of internal auditors, IT leadership, and IT subject matter experts.

The Office for Civil Rights (OCR), the security watchdog for the Department of Health and Human Services (HHS), suggests that a covered entity use the National Institute of Standards and Technology (NIST) risk-based approach for doing a risk analysis, which encompasses nine primary steps:

1. System characterization to fully understand key technology components in your infrastructure.
2. Threat identification.
3. Vulnerability identification.
4. Controls analysis to assess the capabilities of your existing set of controls to meet your environment’s needs
5. Likelihood determination to assign likelihoods, considering the threat motivation and ability, the nature of the vulnerability, and current and planned controls
6. Impact analysis to analyze that impact, considering for each system the effects of lost confidentiality, integrity, or availability, and the effect of any current or planned mitigating controls
7. Risk determination, a combination of the impact rating and the likelihood determination
8. Control recommendations, a roadmap for planning controls for future implementation
9. Results documentation.

To prepare for Meaningful Use attestation, it is recommended to conduct the security risk analysis at both the technical design and system build phase when implementing a new EHR system. Additionally, it will be important to update the risk analysis further on in the MU Roadmap approximately four months prior to go-live.

As ongoing changes happen, new risk occurs. An annual risk assessment should become part of the compliance process; that is, the risk assessment can be merely updated as an addendum and not as an overbearing intrusion that competes with other organizational needs. A regular review of your risk posture is what is required to protect e-PHI. Too many new threat vectors and vulnerabilities are introduced into information environments each day. A reasoned, systematic, and consistent approach will help to achieve your organizational goals.

Spurred by the HITECH Act, the healthcare industry is embracing EHRs at an accelerating rate. This move carries with it a need for heightened responsibility since digital information can be copied, transmitted, or used so easily. As such, the risk accruing from this transition to electronic records must be well understood.

In its passage of HITECH, the US Congress took special consideration to note that security and privacy of patient records should be a paramount concern. In essence, HHS recognizes that the very success of the HITECH program rests in part on patients’ ability to trust provider information systems with sensitive information.

Jeff White is a principal with Aspen Advisors of Pittsburgh, PA.

Readers Write 6/22/11

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!

Epic Ponderings
By Cam O’Flage

Epic is a marvelous marketing machine, from initially establishing themselves as a boutique firm with a certain mystique since they were able to tell clients whether they were the right customer (rather than the customer telling Epic that they were the right vendor).  And it continues to be a superlative marketing machine.  They tell a good story, present a great vision, and manage customer expectations nonpareil.  They’re superb business people.

Epic doesn’t do everything right, but who does?

Epic makes many good decisions, but they make some bad ones.

Epic releases aren’t always so bug free.

Now, I know that I speak from a biased perspective since I currently am involved with provision of implementation consulting (staff augmentation) services.  But I’ve been around a long time and seen lots of successes and failures across multiple delivery systems using multiple vendor applications.

Epic’s current implementation methodology, however, is circumspect.  While it’s partially in response to ONC’s mandated MU timetable (another source of discussion), Epic does believe that it knows the best way to install its product.  But a tight timetable with little time to consider workflow needs or optimizations or deferral of vital function simply to make a deadline is so wrong.

We’re told time after time, plan and engineer correctly in advance to maximize return on investment and minimize production problems.  It’s in our business school case studies.  It’s in our re-engineering process improvement literature.  It’s in our quality theories.  Yet, Epic – and ONC – have embraced a slam dunk implementation methodology.  Get it in, optimize later.

There are so many choices.  So many informatics considerations (one of my biggest fears since so many of Epic’s designers and installers simply don’t have a good basis in understanding clinical informatics needs – or revenue cycle considerations, for that matter).  So many process issues.  So many opportunities to improve, to ensure that clinical documentation is complete, that patient safety is maximized, that budget is truly aligned with needs and expectations, that appropriate governance has been put into place, that risks are adequately mitigated, that expectations are properly established, that work/life balance is dealt with, etc.

There are too many customers that go apoplectic when there are budget overruns, even if scope has changed.  While that’s not an Epic problem per se, the perception that their plan is comprehensive and constitutes the safest way to attain MU is contributory.  CIOs and COOs and CFOs and VPs simply need to get real.  An EHR implementation is an immensely complex organizational change, fraught with unknowns and potential failure points.

There are too many customers who wish that they had done their implementation differently. There are too many times that customers realize that optimization entails rebuilding the foundation.  There are too many customers who find themselves a year later not where they wanted to be. HIStalk pages certainly document such things.

However, all of that said, I can’t say enough good things about Epic.  Epic truly focuses on improving the patient experience. Their culture is one of excellence, of passion, of dedication and commitment.  Their employees are smart and industrious.  And they continue to deliver what they promise.  I can’t say that about many IT vendors.

Why Are We Still Struggling with CPOE?
By Daniela Mahoney

I often ask CIOs a simple question: what keeps you awake at night? Over the years I have received many different answers. Lately I have been thinking about my work and my experiences from previous days and could not stop asking myself, “Why, after more than 30 years, are we still struggling with getting CPOE going?” What other industry has tried implementing technologies and three decades later they are still in their infancies with the results?

I was excited about the idea of writing an article each month for HIStalk to share some of my insights about what to do with this entire CPOE business and how to best prepare for its challenges. Then I was wondering about our colleagues in the industry, and who wants to keep reading about CPOE? Mine would be just one more article of something you read somewhere, else because “theoretically,” we know what we need to do and there is already a lot of information about it. And that is the exactly the key — we know the “whats” but we oftentimes miss the “hows”.

But, one would ask, why should anyone listen to Daniela? Well, you don’t have to. I am only going to share what I have learned by doing CPOE for over 20 years. I am going to keep it simple because I find that we can achieve much more when we present information in a way that we can relate to and it makes sense to most of us. It is like baking a molten chocolate cake –  it has only six basic ingredients, but the outcome is divine! You can add the raspberries on top if you wish. Simple is good, and we can achieve exceptional results.

Did you know that CPOE has been talked about since the 70s? In June 1971, the National Center for Health Services selected El Camino Hospital, CA, to evaluate and implement the Technicon Medical Information Management System (TDS) to be used by nurses, physicians, and others. The main goal was to expedite the overall patient care processes.

By 1974, 45% of all orders were entered directly by physicians into their CPOE system. Yes, we had it then, and unfortunately at that time in the 70s and 80s, some of the institutions and vendors who attempted had varying degrees of failures, with some limited successes. It was not until the late 80s and early 90s that we experienced a renewed effort and interest in CPOE. I started my journey on this path in 1990, so I can say that we have learned a lot. Or did we?

I am going to begin with the end in mind, assuming that we are not just doing CPOE to meet the political timelines, but also to do the right thing for the patients and give our clinicians a tool they can appreciate and incorporate into their everyday workflow. Based on this assumption, we will work backwards and talk about the right things to do as we prepare for this CPOE journey. Almost three decades later, it is about time that we get it right the first time around! Here is the roadmap we will talk about in the next 12 months:

1. Is it only CPOE, or there is more? We have to think about what is ahead of us more holistically because CPOE is no longer a standalone project.
2. What support we need from our leaders to pave the road for us and why?
3. Why should I (physician) use it? What’s in it for me? How do we create a value proposition?
4. How much will it cost?
5. How do we create the teams (who steers the wheel vs. who shifts the gears)?
6. Don’t let perfection get in the way of good. Setting the scope of what CPOE is and what it is not.
7. Clinical process transformation. How to manage and not get crushed by the magnitude of change.
8. How about the vendor? Where do they fit into this?
9. Did we get it right? How do you know? (aka, success factors).
10. What is going to make us fail? If 30% of CPOE installs have historically failed, how do we rise above this? (aka, risk factors).
11. Large or small hospital, we need to roll out somehow. What are the options and their respective pros and cons?
12. No, I did not forget about training and support. I will address this as well.

And if there are any other readers who enjoy cooking as much as I do, here is the link to the molten chocolate cake. 30 minutes to prepare, six minutes to cook, and 10 minutes to savor your work of art. And while you are enjoying this superbly rich chocolate delicacy, please try not to think of CPOE!

Daniela Mahoney RN is president and CEO of Healthcare Innovative Solutions of Seville, OH.

Thoughts on Lazar Greenfield Stepping Down
By Tiffany Carroca

On Sunday April 17, renowned surgeon Lazar Greenfield MD resigned from his position as president-elect of the American College of Surgeons (ACS). The resignation came just over two months after he had written a controversial article that caught the attention of nearly everyone in the healthcare community, including those in medical coding, and has achieved a level of infamy nationwide as the Valentine’s Day editorial. The controversy of the article stems from a statement made in which Dr. Greenfield suggests giving women semen for Valentine’s Day instead of chocolates.

The editorial was originally published in the February 2011 issue of the American College of Surgeons affiliated newspaper, Surgery News. The paper, made available free to the public online, was pulled from the Web site when the controversy erupted soon after the story ran. Interestingly, Dr. Greenfield was also editor-in-chief of the publication, but was subsequently removed from the position due to the content of his article.

Although Dr. Greenfield apologized for the editorial and reaffirmed his belief in the rights of women in health care, these actions did not end the controversy. Besides offending many female surgeons who have had to put up with sexual harassment for decades in this male-dominated field, Dr. Greenfield managed to dig himself in deeper when he sent an e-mail to several media outlets defending his claims. However, Dr. Greenfield did ultimately determine that resigning would be the best way to put an end to the uproar over his article. In a statement given to ABC News, Dr. Greenfield said, “My personal and written apologies were ignored, and my suggestion to use my experience to educate others rejected. Therefore, rather than have this remain a disruptive issue, I resigned.”

The comments made by Dr. Greenfield on Valentine’s Day seemed like a joke to some and the crass opinion of a womanizer to others. However, the statement does have a basis in scientific and medical fact. Dr. Greenfield was referring to a study published in the Archives of Sexual Behavior in 2002. The study was performed by psychologist Gordon G. Gallup, PhD at the State University of New York in Albany, and gained widespread attention when it was reported in the article Crying Over Spilled Semen by Tiffany Kary for Psychology Today.

The study was conducted on 293 college women who were sexually active. The results showed that women experienced less depression after having unprotected sex, and the depression slowly returned as the time progressed after their last sexual encounter. Women who used condoms did not experience any reduced or heightened rates of depression.

The conclusion reached by Dr. Gallup was that the hormones contained in semen are absorbed through the walls of the vagina and elevate the mood of the woman after intercourse. Other variables that could have caused the reduced depression, such as birth control and behavior patterns, were also taken into account.

The group most outraged by the editorial was women in the healthcare field, most notably women surgeons. Colleen Brophy MD, a prominent professor of surgery at Vanderbilt University School of Medicine and chairwoman of the ACS’s surgical research, explained to Pauline W. Chen MD who reported on the story that she was “aghast” at the editorial. However, when the ACS refused to stand by her response, Brophy resigned from the College in response, claiming, “The editorial was just a symptom of a much larger problem. The way the College is set up right now is for the sake of the leadership instead of the patients.”

Many women in the healthcare field voiced their outrage over Dr. Greenfield’s editorial, but he was not without his supporters. Dr. Greenfield, a professor emeritus at the University of Michigan, had always been highly regarded and was presented with the Jacobson Innovation Award just last year, according to NPR’s Health blog.

A colleague at the University of Michigan, Diane M. Simeone MD, came out in his defense, saying that she has witnessed several accounts of gender bias among surgeons, but never from Dr. Greenfield. Similarly, Dr. Gallup, who conducted the initial study, also came to the defense of Greenfield, noting that what he said may not have been tasteful, but does have “some basis in available science.”

Undoubtedly, Dr. Greenfield’s remarks caused a public outrage even though they were based on science. However, a lewd and womanizing comment based on science is no less offensive that one based on fiction. If Dr. Greenfield was trying to be humorous or otherwise non-offensive with his comments, he failed miserably, as public opinion has shown. Even an esteemed doctor and scientist can fall from grace when injecting personal opinions into the science. As most scientists will agree, it is best to keep the science pure.

Readers Write 6/8/11

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: today’s first article was written by the CIO of an academic medical center that will move to Epic once the necessary approvals are in place (not yet announced). I suggested drafting some thoughts about why Epic is so successful in that market, even with hospitals that had no plans to replace their existing systems. I thought the perspective of a CIO in the middle of that decision would be interesting since it’s hard for the rest of us to understand how Epic can be so consistently successful, and therefore tend to blame unspecified “Epic Kool-Aid drinking” rather than the real differences between Epic and its competitors.

Why Epic? Why So Many Decisions to Deploy Epic?
By Thoughtful CIO

As a nation of healthcare delivery systems, we seem to be selecting Epic in record numbers. I’m told that nine of every 10 decision-makers are selecting Epic.

It is astounding, but it is also rather obvious. Epic has become the market choice for many of us. And like many market swings, the causes are many.

I’ve given it some thought. I fully expect that many will disagree. This is just one person’s opinion.

In some ways (I hope you can forgive the melodramatic root cause), I think our focus on Epic and the need for tight integration and simplification of our environments might relate to the upcoming 10th anniversary of September 11. We are longing for a return to a simpler time.

It has been ten years since the “world stopped turning.” I think many of us are carefully revisiting where we have been and what we have accomplished since that September day. It might not be deliberate, but I think it is real, nonetheless.

We all refocused on the “main thing” back in 2001. It may have been different for different industries, but in healthcare, we decided we were going to make a difference. And I think we meant it.

Sadly, in spite of much hard work, and many system deployments, we are not yet achieving safe, efficient, and effective healthcare to the degree we all had hoped.

Here is some thinking out loud. 

1. In a world where healthcare decisions and information flows are growing increasingly complicated and are conflicting, our care providers are overwhelmed with complexity, burdened by too much not-always-relevant information, and are often interrupt-driven as they attempt to make decisions. It feels like chaos because it is. It’s a difficult balancing act. Many of us are longing for a simpler and safer approach to the management of information. We haven’t yet found it, and we worry that it is hurting our patients and making it more difficult to be a care provider.
2. Patient- and family-centered care is going to become even more critical in the world of individualized health and personalized medicine. This will require improved access to longitudinal patient records. It will necessarily involve and empower the patient to be an active member of the care team. It will soon be the only way to effectively and efficiently manage and allocate scarce resources. Targeted interventions and therapies will be the future of medicine, and information technology will be a critical component of the deal. But we are not yet delivering on the promise, in spite of many millions of dollars of investment.
3. To deal with this complexity, chaos, and the critical focus on the patient-centeredness, we are focused on minimizing the burden on our care providers and our patients. We want to collect data once, at the source, in the most user-friendly way possible. We want our data collection to be the by-product of care, not an added responsibility. And we want it to be easy to do. We have not yet found a way to achieve these goals in a meaningful way, at least not consistently.
4. Some current vendor-supplied solutions offer choices and options. They promise to be all things to all people. They rely heavily upon a provider-based organization to make wise decisions and “perfect decisions” in the midst of a very imperfect world. The decisions that must be made expect that there is clarity, when in fact there is not. We are not realizing increased productivity, lower costs, and more efficient care. In fact, many of our healthcare delivery systems are questioning the investments we have made and are not yet able to clearly define the benefits we had hoped to achieve.
5. Many of us have experienced implementations that over-promised and under-delivered. We trusted our vendor partners and some of them failed us. We then we failed our user partners. The systems didn’t perform well, the vendor was unable to deliver the rich functionality that was promised, the product didn’t scale, the developer didn’t listen, etc. Everyone loses, and we were parties to the losses.
6. Enter Judy Faulkner and Epic. There is no ambiguity! For more than 30 years, she has been crystal clear about her strategy and the strategy of Epic. The patient is at the center. The business of healthcare is about saving lives and managing information to support life-saving activities. No ambiguity. It’s about the basics, and she gets the basics right! From the beginning, what you see is what you get. No ambiguity.
7. Judy Faulkner and Carl Dvorak treat everyone the same. No deep discounts, no development partners. We’re all in this together. There is no ambiguity.
8. Judy and Carl have a healthy optimism about the future. They believe there are many opportunities we can leverage, but they never make a promise they can’t keep. They tell the truth. They do what they say they will do.
9. Judy doesn’t offer to solve problems she can’t solve. She is completely transparent and tells the truth, both when it is popular and when it isn’t. No pretense. She doesn’t need to be liked. She has a product that works, that scales, and is fully integrated. There is no ambiguity.
10. Judy also sells a product that works well. She provides the rules for how it must be implemented. Again, she eliminates the ambiguity. Follow the rules and everybody wins.

I’m not sure I’ve captured what I was hoping to capture. In summary, when I think of Epic, I think of a few words:

• Honesty
• Integrity
• Candor
• Trust
• Transparency
• Consistency
• Focus
• Commitment
• Patient-centered

These are words I hope folks will use to describe the work we all do in healthcare IT.

What Providers Need to Know about Patient Engagement
By Donna Scott

Given all the talk these days about patient-centeredness, is there really change afoot? Will the US healthcare system of the future really be built around the needs of patients? Or is “patient-centered” just another buzzword which won’t quite survive the complexities, the political realities, and the multi-faceted stakeholders in the great healthcare reform debate?

Well, I have been called an “optimist,” so you can probably guess my opinion on the subject. Yes, I believe that we are truly at the crossroads of change in the healthcare system in the United States. In spite of the complexities and difficulties ahead of us, the desire to implement new ways of managing healthcare in this country has never been stronger.

Regardless of what you think about the future success of Accountable Care Organizations or Patient-centered Medical Homes, there appears to be widespread agreement that US healthcare delivery needs to shift from a quantity orientation to quality of care and better outcomes. And better patient outcomes will be enabled by a much higher level of patient engagement across the healthcare industry. This shift toward quality outcomes and patient engagement represents both an opportunity and a challenge for providers.

Because of this shift, a small group of patient engagement enthusiasts and industry pundits were recently asked by The Institute of Technology Transformation to write a paper for providers about the current state of patient engagement. The objective was to offer healthcare providers a summary of the latest research that exists about patient engagement and provide some key points for their consideration as they embark on the healthcare reform journey. The Top Ten Things You Need to Know about Engaging Patients is the result of our efforts. The paper can be accessed here.

In summary: there is a lot of good patient research out there that our group has synthesized into the following key ten considerations for providers:

1. Providing Patient Education Online
2. Interactive Online Dialogue
3. Patient Segmentation
4. Role of Caregivers
5. Trust in Physicians
6. Consumer Mobility
7. Security and Privacy Concerns
8. Leveraging Inexpensive Tools
9. ROI of Patient Engagement
10. Changing Care Models

In each of these ten areas, we briefly discuss the research and the key learnings which are relevant to providers. In addition, we include four key recommendations for practical action:

• Walk the talk: set specific patient engagement objectives and measure them
• Champion your hospital’s social media strategy and assure mobility as a key component
• Pay attention to caregivers and do your homework on patient demographics
• Consider HIT solutions that already incorporate patient access and engagement capabilities

For some progressive hospital administrators, this information will simply affirm what they are already doing. For the others, we hope it will spark ideas on how to take their patient engagement strategy to the next level. Because the need for more patient engagement in the U.S. healthcare system will impact all of us, sooner or later.

Donna Scott is leader of the Patient Engagement Action Group for the Institute of Health Technology Transformation and executive director of marketing strategy for RelayHealth.

Twitter, Dogs, and Healthcare
By Ronnie James Dio

I see a lot of dogs out in public these days. They’re everywhere. People bring them to Home Depot and into Starbucks. Sometimes they’re peeking out of purses. 

I love dogs. I’d even go so far as to say I consider most dogs excellent judges of character. But I’m not wild about sharing my coffee and oatmeal at Starbucks with somebody’s dog right next to me. When I go to the grocery store, I don’t want to see a dog riding in the basket of the grocery cart. 

I went to the dentist the other day. Guess who’s hanging out by the reception desk? You got it — a big black Lab. Named Elliot, by the way, which I consider to be a decidedly un-dogly name. The look in his eyes said, “I’m begging you, call me Fetcher.”

I want some boundaries is my point. Just give me a shopping experience without dogs. 

Same goes for ubiquitous talk about social media. More specifically, Twitter. I really don’t care that Anderson Cooper of CNN on-air wants to tell me he’ll be tweeting during the broadcast. (I especially don’t like the word “tweeting,” while we’re coming clean with each other.)

Also, I don’t need software I use in my healthcare IT business to update Twitter with what I’m doing, as a contract management tool I have is dying to do for me. Just sent a contract out! Third one today!

I don’t say this thinking trade secrets could be disclosed. It’s much simpler: I’m just not that interesting.

And now that we have these two things on the table (too many dogs in public; I’m largely boring) I need to cover one more thing. I don’t find Twitter interesting or helpful for healthcare except, I’m sad to say, in a catastrophe such as an earthquake or tornado, where we actually learn things we couldn’t know otherwise. 

When tornadoes strike or a tsunami hits, Twitter can be indispensable. It can become a strikingly important tool for healthcare, if only to inform others where help is needed. When we least expect it, a hula hoop becomes a vital messaging tool.

Otherwise, it’s the dog in Starbucks, the thing I can’t escape that I actually don’t dislike, but I want to pick and choose my interaction with it. 

And just because there’s a tool that lets us share 140 characters of text with the world doesn’t mean it’s valuable. In the real world of healthcare, when things are not catastrophic, I’m arguing that Twitter is rarely helpful, and as parents can attest (via the attestation process) in the breezy “real” world teenagers move in, few have the slightest interest in Twitter. It interferes with their texting.

I have a very high professional focus on healthcare IT, so I typed in “healthcare IT” from the main Twitter screen. This popped up: 

We r letting d Tfare issue overshadow d aim of the damn lunch. It was a forum where issues of light, good healthcare / education were discussed.

Besides the fact that I find the phrase “damn lunch” funny, I have no idea what the post means, but I’ll bet a quarter it’s right at 140 characters. I’m also pretty sure there is no such thing as “light, good healthcare,” and I’m positive that you should be able to find “healthcare IT” in context when using an ever-present tool for social media.

So I put to you a simple question. Outside of emergencies or catastrophes, when does Twitter actually benefit healthcare? Who is helped, and how? 

I’m wide open to learning something here, but please answer in 140 characters or less. I’ll be back in touch after I take my dog to church, then out for a damn lunch.