Readers Write: Students in the HIT Spotlight

Students in the HIT Spotlight
By Lisa Reichard RN, BSN

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

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

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

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

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

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

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

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

How will the app help kids recently diagnosed with diabetes?

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

What are the plans for the product?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Readers Write: The Transition TO Paper Record Keeping

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Original “Standard” style Wooton Desk

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

An “Extra” style Wooton desk

A pedestal-style Rotary Wooton Desk

Rare single-pedestal roll-top Wooton Desk

The Ultimate Irony

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

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

Readers Write: In Defense of Copy-Forward

In Defense of Copy-Forward
By Lyle Berkowitz, MD

I’m part of the Association of Medical Directors of Clinical Information Systems (AMDIS), a group of 2,000+ physicians who are the experts in implementing and using EMRs. We have a pretty lively listserv discussion board, and I enjoy seeing what my colleagues are thinking, as well as posting my own thoughts. I especially enjoy posting when I feel like certain studies or comments by non-clinical researchers, administrators, or politicians make us start to question common sense.

One of my favorite topics recently came up — the fear and horror associated with actually reusing some of a previous note. This usually falls into the concept of "Copy-Forward" (when you copy forward the whole note and then edit for today’s visit), or "Copy-Paste" (when you select certain parts of a past note and just copy that part of it. I posted my reply and thought I’d share and expand a bit.

So as not to bury the lead, I think Copy-Forward of a note is a great tool and supports both efficiency and quality, when used appropriately. Turning it off is a classic throwing the baby out with the bathwater analogy. To clarify my biases, my thoughts and ideas are mainly from the perspective of an outpatient physician using Copy-Forward over the past decade, but much of this certainly can be applied to the inpatient world in various ways.

Also, the use of Copy-Paste has some similarities to Copy-Forward, but I agree Copy-Paste is not nearly as efficient and poses more quality issues since it does not have the automatic updating features you might see with Copy-Forward. Here are the points I would suggest we consider.

First, I am sick of these reports which say that things like, "We used plagiarism software to show that 60-80 percent of a doctor’s note is the same as their last one." Um, of course! Since when did progress notes become creative writing endeavors about coming up with different ways to document diabetes, hypertension, and obesity in the same patient visit after visit?

The creative parts of doctoring should involve being "House": figuring out the diagnosis, figuring out the best treatment plan, and artfully explaining it all to the patient. It should not be writing Edgar Allen Poe-like short stories to amuse our auditors or confuse our colleagues. Although, it could be fun, hmmm… what if I described a diabetic’s problems with hypoglycemia in Poe’s style: "Arousing from the most profound of slumbers (due to a glucose of 45), the patient states he feels as if he was in a gossamer web of some dream. Yet in a second afterward, so frail may that web have been, he claims to not remember that which he was dreaming."

Second, there are obvious efficiency benefits to Copy-Forward, but there are very real quality benefits as well. The most obvious is that this type of workflow makes it less likely that important diagnoses will be missed or forgotten over time. Additionally, many systems update certain pieces of data during the Copy-Forward process, so that you can see the most recent results (discussed more below). Obviously incorrect information can be duplicated, especially when a note is being authored by multiple providers over time, but this is where good training and leadership are needed to ensure every provider feels fully responsible for everything in their notes.

Third, getting rid of Copy-Forward or even Copy-Paste is certainly overkill, but we do need to use some common sense in designing technology, workflows, and processes that make it easy to do the right thing when documenting. In the ideal system, much of the critical data would either be updated automatically (e.g. the most recent lab would appear when a note is copied forward), or the system would date entries so it is clear what was done in the past versus today. To clarify, let me break down how an ideal progress note might look like when Copy-Forward is used:

Allergies, Meds, Problems

These update automatically, which is great, and means the note has the most recent data. I would hope all EMRs have this functionality already.

Past Histories (Social, Surgical, Family)

These copy forward and allow for easy editing in the note. Ideally, they could be managed in a widget external to the note and have them update from those profiles as well.

Physical Exam

Want to ideally be able to view old physical exams, and even reuse them when desired (except for vitals). In my current system, the full exam (sans vitals) does copy forward. So I usually just delete it and drop in a new macro and edit that. However, some patients have findings I want to compare from last time (e.g. size of a rash), or consistent findings (e.g. murmur) which I want to be reminded about

Labs/Studies

For labs (e.g. CBC, chem, chol profile) and certain studies (e.g. mammogram results, last ECG), we use macros which "auto-updatem" so when a note is copied forward, they update automatically to the most recent dates and values.

HPI/Impression/Plan

As some have heard me detail before, I use a form of "problem-oriented charting" in which I type out the history, impression, and plan for a diagnosis (e.g. diabetes) or system/problem area (e.g. "GI issues") all on one line. I also use a macro which includes the date of the entry and my initials.

• Example for a diabetic patient. "01/19/13(LLB): Stable on Metformin 500bid, CS 100-120s before meals, no med side effects or other complaints. Impr: Stable DM, PLAN: CPM, labs, rtc 4 mos". No flourish is needed. The result is that when copied forward I can see the last time I addressed the DM and if I made any changes. In the same "area" for the problem, I would also have a list of relevant meds, labs, and testing results (e.g. ECGs and ECHOs for hypertension). This way I can see everything I need about a problem all in once place – which means I can make quicker and more accurate decisions.
• Summarizing old entries over time. I will either retain the old entry, or can summarize over time (e.g. I might take four entries from 2012 and summarize into one line such as, "2012: Dx with DM 4/12, added Metformin 500qd, 6/12 incr to 500 bid and did well").
• Multiple issues. Since I often address multiple issues in a given visit, I created a line which reads, "Problems below not addressed this visit" so that I can clearly demarcate what I did and did not address on a certain day. I think this method is extremely efficient and higher quality than the method of trying to document all the HPI about multiple issues at the top of a note, and then separating out the Impr/Plan at the bottom.
• What is a SOAP note? Larry Weed, MD devised the concept of problem-oriented charting 50 years ago, but I think it’s fair to say we have over-complicated it over time. The SOAP note is supposed to be based around a problem. In other words, each problem should have a documentation area for Subjective, Objective, Assessment and Plan. Instead, we create one large SOAP note where we break away all the Subjectives into their own paragraph ("HPI"), thereby distancing your thinking about the complaint and what we are going to do about it. I hope we will soon see more EMRs going "back to the future" by embracing the true problem oriented charting philosophy.

Fourth, the outpatient world is different from inpatient, but there are similarities. I understand that inpatient notes can be more difficult to manage due to quickly changing problems, and especially multiple authors. Personally, I hope we put some more thought into the concept of an "Inpatient Wiki," a single type of inpatient note that can automatically pull in the relevant information for each specialty (e.g. different for medicine, OB, and various types of surgery). Then each author could see what they need to see – it would pull in the labs, tests, consult suggestions, or a nursing note – why make the doctor repeat this themselves every time?

The care provider would then be prompted to write what they are supposed to add, and the note would be a living document which flexes to the individual, but can be time-stamped for medico-legal purposes as well. It could have clear sections (similar to above), as well as an organ or system based areas (e.g. Cardiology issues, GI Issues, Neuro Issues, F/E/N issues) for documenting the SOAP note .

In summary, I would go as far as to say that we need to change our paradigm to "The Note is the Chart." The chart should no longer be a collection of distinct and incomplete notes, but rather the last note can really be the complete chart which contains everything a provider needs. If we do this, then we can reframe our expected workflow from, "You need to read every note ever written to understand the full patient" to, "You just need to read the last note".

The result: when a patient goes to the ER or sees another doc, those providers will find that the most recent note in the system will have all the info they need, so they won’t need to try and dig through 48 notes over 10 years (and let’s face it, they never do that anyway). Granted, the paper record allowed for a much easier way to flip thru past notes, but sooner or later we have to acknowledge that computerized systems have different attributes than paper. We can either keep trying to force the computer to act like paper, which never works out well, or we can start embracing the differences and truly take advantage of them.

Lyle Berkowitz, MD, FACP, FHIMSS is associate chief medical officer of innovation for Northwestern Memorial Hospital; medical director of IT and innovation for Northwestern Memorial Physicians Group; and co-founder and chairman of healthfinch.

Readers Write: New HIPAA Rule Overview

New HIPAA Rule Overview
By Brian Ahier

Four years ago, the HITECH Act introduced major revisions to HIPAA. Now everyone is all atwitter since the Office for Civil Rights (OCR) of the Department of Health and Human Services (HHS) has published the omnibus final rule modifying the HIPAA Privacy, Security, Breach and Enforcement Rules as well as additional changes required under the Genetic Information Nondiscrimination Act of 2008 (GINA).

"Much has changed in healthcare since HIPAA was enacted over 15 years ago," HHS Secretary Kathleen Sebelius said in a statement. "The new rule will help protect patient privacy and safeguard patients’ health information in an ever expanding digital age." This rule also creates a lot of work for healthcare organizations.

First off, organizations will need to amend notices of privacy practices and make sure the revised notices are properly posted and distributed. This means creating new forms and posters as well as allocating resources for legal review. There will likely be other forms, such as requests for access, that should also be updated or created. There will also be a need for workforce training to promote more ongoing awareness among staff. This is a good opportunity to take advantage of the safe harbor provision by encrypting PHI according to HHS guidance.

The rule has significantly expanded the scope and impact of the Privacy and Security Rules on business associates. Anyone providing services to a health plan or healthcare providers who receives or generates PHI may be subject to these expanded provisions. Previously, most business associates were subject to the Privacy and Security Rules only through a business associate agreement with the covered entity. Now, even if there is no BAA, if you are simply acting as a business associate, you are liable under HIPAA. The rule specifically identifies as business associates subcontractors, patient safety organizations, health information organizations (and similar organizations), e-prescribing gateways, and vendors of personal health records that provide services on behalf of a covered entity.

Another interesting development is that the rule revises the definition of a “breach,” which will serve to make breach notification much more likely. The HITECH Act requires covered entities and business associates to provide notification following discovery of a breach of unsecured PHI. Breach means the acquisition, access, use, or disclosure of PHI in a manner not permitted under the HIPAA privacy rule that “compromises the security or privacy” of the PHI unless an exception applies.

The rule amends the definition of breach to clarify that the impermissible acquisition, access, use, or disclosure of PHI is presumed to be a breach and breach notification is necessary unless a covered entity or business associate can demonstrate, through a documented risk assessment, that there is a low probability that the PHI has been compromised.

Previously under the interim final breach notification rule, the privacy or security of PHI was deemed to be compromised if there was a significant risk of financial, harm to reputation, or some other harm to the individual as a result of the impermissible use or disclosure of PHI (commonly referred to as the “harm standard”). In other words, if you could demonstrate no significant risk of harm, then the incident did not rise to a reportable breach.

The new rule replaces this "harm standard" with what HHS calls a more objective process for assessing whether PHI has been compromised. The new standard, however, still appears to leave covered entities and business associates with a lot of questions. The rule has deleted the definition of “compromises the privacy or security” of PHI (which was the harm threshold), and declined to adopt a clear standard requiring notification of all impermissible uses and disclosures without any assessment of risk.

The rule expands what uses and disclosures of PHI are considered marketing thus requiring an individual’s authorization; however, the new marketing restrictions do not impact a covered entity’s face-to-face communications with individuals. For example, prior to this new rule, an authorization would not be required for a hospital to send a brochure to its patients about a new imaging device being used by the hospital, even if the communication was paid for by the manufacturer of the imaging device.

Now the hospital would no longer be permitted to send communications about its new imaging device if the manufacturer of the device pays the hospital for the communications unless the hospital first gets authorizations from its patients. The rule provides an exception for communications about drugs that are currently is prescribed to an individual as long as any payment is reasonably related to the covered entity’s cost of making the communications. For example a drug manufacturer would be able to subsidize a physician’s cost for sending out refill reminders.

The rule has also implemented a new tiered penalty structure. Depending on the degree of knowledge that the covered entity had or should have had regarding the violation, penalties for each violation range between $100 (did not know or have reason to know) and $50,000 (willful neglect without correction), with a maximum penalty for a given year of $1,500,000 for any violations of the same requirement or prohibition. It will be very interesting to see how aggressive enforcement is over the next few years.

One of the significant changes in the rule is the expanded rights for patient access to electronically-stored PHI. The rule extends beyond those promulgated under Meaningful Use and provides the right to obtain an electronic copy of PHI stored electronically in a designated record set (e.g., medical records, billing records, and other records relied upon to make decisions about the individual) rather than simply and electronic health record.

If the covered entity can’t readily produce the form and format requested, then it must offer other electronic formats that it can provide. If the patient doesn’t agree to any alternate electronic formats offered by the covered entity, then the covered entity must provide a hard copy as an option to fulfill the access request. Also, if an individual requests that a copy of his or her PHI be sent via unencrypted email, then after advising the individual of the risks a covered entity is permitted to do so.

Another notable requirement is that  covered entities now have 30 days to fulfill a request with the possibility for a singular 30-day extension allowed. Electronic and hard copy PHI, no matter where the data are located, must be provided within the timeframe.

The rule also clarifies the fees that may be charged. For example rule adopts the proposed amendment at § 164.524(c)(4)(i) to identify separately the labor for copying protected health information, whether in paper or electronic form, as one factor that may be included in a reasonable cost-based fee. However fees associated with maintaining systems and recouping capital for data access, storage and infrastructure are not considered reasonable, cost-based fees, and are not permissible to include. The rule also  rule we clarifies that a covered entity may not charge a retrieval fee (whether it be a standard retrieval fee or one based on actual retrieval costs).

Even with some of the protections in the Affordable Care Act, the rule still provides that a covered entity must comply with an individual’s request to restrict disclosure to a health plan (or the plan’s business associate) of PHI that pertains solely to a health care item or service for which the health care provider has been paid out-of-pocket and in full. This right extends to situations where a family member or other person, including another health plan, pays for the service on behalf of the individual.

Last week I joined Deven McGraw and David Harlow for a Google Hangout where we discussed the new HIPAA rules. It was a lively discussion and is well worth taking the time to see, so grab some popcorn and watch the video for some great insights.

Brian Ahier is health IT evangelist at Mid-Columbia Medical Center of The Dalles, Oregon and president of Gorge Health Connect, Inc.

Readers Write: Dueling Myths: Interoperability and Bending the Cost Curve 1/23/13

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

Dueling Myths: Interoperability and Bending the Cost Curve
By David Lareau

We’ve been hearing for so long about how interoperability is going to do wonderful things that we may have lost sight of the fact that it isn’t actually real yet.

Just look at the sharing of patient clinical information between systems. HHS has just come out with a press release in which they highlight that the penalty per incident for HIPAA violations can be as high as $1.5M. Healthcare executives are being told, “Make your system interoperable, but if you make a mistake, you’ll pay.” Is it any wonder vendors have put clinical data in silos with massive protections around it?

Maybe a bit of reality is getting through. At least they removed the requirement to process incoming clinical quality measure data from MU stage 2, although that seems like a moot point since no one is sending it out except to the government.

But even with these mixed messages in our industry, there is hope. Within the next year or so, new companies will enter the market with systems that are being designed from the ground up to share and distribute clinical information using some of the same methods as social networks. One of the key factors in getting to market quickly for these new entrants is that they don’t have to build upon 15 or more years of “already poured concrete.”

A front-page article in the Washington Post this week said that healthcare is driving job growth in the Washington, DC, area. Read a bit further and you get to these tidbits:

• “Northern Virginia’s Inova Health System added about 1,000 positions in 2012”
• “The growth at Inova last year was largely a result of a major initiative to overhaul its medical records program”

OK, I love it that people are gearing up to update their systems and that jobs are being created, but someone please tell me how that helps us bend the cost curve down? I’m not hearing much about clinician productivity increasing, and I seem to remember from Econ 101 that there is an inverse relationship between cost and productivity. Productivity goes down, cost goes up, and vice versa.

Meanwhile, we hear rumors about Meaningful Use Stage 4 when we’re trying to read the crystal ball about Stage 3 and gear up for ICD-10-CM. I must tell you, I don’t know about the cost curve bending down any time soon, but I sure can tell you that my anxiety curve is going up.

David Lareau is chief executive officer of Medicomp Systems of Chantilly, VA.

Readers Write: Mandating Physician Data Entry 1/23/13

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

Mandating Physician Data Entry

We constantly hear about how EMRs slow physicians down in clinic. I’m on the IT side, and while I agree that every EMR needs to work on usability, it seems that part of the problem is physicians have to use the computer in cases when they would hardly touch paper.

Example: the physician used to just dictate his note and tell his nurses about any tests he was ordering. The note goes to a transcriptionist, and later comes back and is filed to the paper chart. The nurses grab whatever paper forms were needed for the tests, which the MD signs so it can be faxed over.

An analogous workflow in the EMR would be: physician dictates his note (not using Dragon, still using a transcriptionist) and the note is interfaced back into the EMR to be signed. The nurses queue up the orders and the MD signs them (or the nurse just places the order and they’re sent to the MD for signing later). This is all technically possible in Epic and I imagine in other EMRs too.

This workflow seems ideal and maintains the original division of labor. Or you could even hire a scribe to write the note and queue up the orders instead of relying on transcription interfaces and forcing nurses to deal with order entry. But it seems that hospital leadership has an assumption that physicians’ hands need to be on the computer constantly. Is there a reason for this, besides health systems not wanting to pay for the extra staff?

In an ideal world I can see mandating that physicians enter data to ensure accuracy, but maybe that’s a goal for later when EMR usability improves.

The author has chosen to remain anonymous.

Readers Write: Vendor Lessons Learned 1/23/13

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

Vendor Lessons Learned

After 10+ years working for a few HIT vendors, here are a few lessons learned:

1. Stop trying to sell half-baked products: new products, upgrades, and old products remarketed. Litmus test: if you wouldn’t sell it to your mom or best friend, it ain’t ready. No amount of sales talent will overcome poor quality.
2. Hiring a strategy firm for a lengthy assignment is a red flag that shows a lack of confidence in the direction of the company. Litmus test: validating information or evaluating a new market is one thing, hiring someone to tell you how to run your business is another.
3. Buying a business at a premium and then inflating prices to customers and prospects to cover the cost of the acquisition is not wise. Litmus test: if your pricing strategy is based on creating value for you rather than your customer, you have it backwards.
4. The best sales talent in the world can’t fix bad products, bad service, and bad strategy. Those problems need to be first addressed at the top before anyone is going to sell anything of value over time. Litmus test: silver bullets don’t work despite the temptation to believe they do.
5. Stop establishing sales quotas that have no basis in reality. Spreadsheets don’t sell deals and prospects don’t care about your budgets, business plans, or quotas. Did you hear Nick Saban talk about winning? He doesn’t focus on results, he focuses on the keys that create the results. Litmus test: if you are not clear on exactly how you expect to generate the leads required to hit your sales targets and/or your plan is solely contingent upon your reps figuring this out you have a problem. Hope is not a strategy.
6. Companies that achieve consistent growth follow basic principles. At the core, they have passionate leaders who have a cause, are committed to being the best, and are dedicated to truly helping their customers (internal and external) win. This is much easier said than done. Litmus test: you know when you have something special. You cannot really explain it, but you have Mojo – Energy, Confidence, and Focus.

The author has chosen to remain anonymous.

Readers Write 1/16/13

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

Lessons Learned from My First HIMSS in 2007
By Bern Werner

Six years ago I set out on a journey from Pittsburgh, flying to Baltimore to be picked up by my young boss (Todd Johnson, the 25-year-old head of our six-person software company, Salar Inc) in his 140,000 mile-worn Toyota Forerunner for a trip to New Orleans. The truck was loaded with precious cargo and our booth for HIMSS07, packaged neatly in three plastic containers. 

On our first day of the journey, we mused over where the healthcare IT industry was headed and whether there was a future in it for our small company.

When I joined Salar a year earlier, we had begun implementing our physician documentation software at 20-hospital system that already had a major EMR (I’m not saying who the vendor was, but the company name has six letters and I met the owner by chance at HIMSS  before I knew that his booth was worth more than our company). I figured the big fish would just look at our success, then “ borrow” our IP and we’d be out of business in a couple of years. 

We made it safely to New Orleans, and I was excited to be on the floor. I was admittedly green, and knowing the value that we could provide, I was eager to sell it to anything that came within two feet of our booth. 

My favorite memory is of one visitor that walked up to our booth just after the convention hall had cleared for morning session. I was tending the booth on my own. He was accompanied by two booth bunnies. I was alone in front of our 10×10 booth with our slick, new, cloth marketing extravaganza. I asked him if he was interested in seeing a physician documentation tool that is better than anything on the market and drives physician adoption, etc. He was very kind and let me finish before saying, “No, thanks. I was looking for that booth that has a treadmill. Know where that is?” I did not.

As he walked away, my boss was just returning to the booth. He said to me, “Do you know who that was?” I said no. He said, “That was Neal Patterson.” Thus began my real HIMSS education.

I now find myself preparing for HIMSS 13 with the same company, but with two million completed forms and over six million captured charges behind me. Though I’m flying to New Orleans this time, there are many parallels to the 2007 road trip (which included driving through tornadoes on the way home and roaches in the non HIMSS-approved hotel) and events of the past year, with our company changing hands three times. 

One thing for sure is that I’m no longer worried about the big guys getting ahead of us when it comes to innovation. They can steal our ideas and they can try to pilfer our content, but they move like the QE2 we’re still zipping around in our speedboat, changing direction as fast as our customers demand.  

If I find HIMSS 13 to be a sales bust, no biggie. Not only will I be able to recognize some of the industry’s biggest icons, I know I’ll have a good time at the HIStalk party.

Bern Werner is VP of implementation with Salar of Baltimore, MD. 

Ambulatory EHR Adoption: Success vs. Failure
By Justin Scambray, MBA

In a New York Times article, In Second Look, Few Savings From Digital Health Records, David Blumenthal, MD expresses his thoughts on the current struggles the US health care system is facing with the successful adoption of the EHR. Technology “is only a tool,” said Blumenthal. “Like any tool, it can be used well or poorly.”

While there is strong evidence that electronic records can contribute to better care and more efficiency, the systems in place do not always work in ways that help achieve those benefits.

Technology is only a tool, and it is true that it’s all in how you use it. However, it’s not just good use of the technology that will yield results. Physicians need to understand that current processes and the way their practice has run for the last 15-20 years must change.

To put a tool like an EHR in place and expect that it will conform to existing systems and workflow is like changing all the rules in a game, but not changing how the player plays it. This is what many practices end up doing, and the very tools put in place that are supposed to help the practice begin to work against it.

After working in the ambulatory EHR market for seven years, selling and being a part of hundreds of implementations, there is one common attribute that I have seen that separates success from failure: the ability to change and adapt systems and processes to the right tools and right people.

The EHR market has been plagued with the thought that this tool — the EHR — will change the medical practice. The fact of the matter is that it is the practice that needs to change for the EHR to work properly. Careful business process mapping and systems redesign needs to take place prior to implementation of any new tool into a business, and it is no different for a medical practice.

If you have ever sat in on a physician EHR demo, they all want to see the same thing. "Show me how I would see a patient in your system from check-in to check-out." All too often, vendors will immediately start to fumble through a canned patient scenario that really has nothing to do with the current office workflow. The physician will watch, ask a few questions in between taking phone calls and signing off on charts, and never really get a good idea of how the EHR will work in their office.

Is it any wonder that a recent survey conducted by KLAS shows that the number of practices shopping for a replacement EHR jumped from 30 percent in 2011 to 50 percent in 2012? Among the top reasons for switching: decreased productivity.

The EHR is only a tool. It is a tool that requires careful integration and mapping between a current state and desired future state design. If the EHR is going to live up to expectations, it’s a focus on change in workflow, processes, and systems that’s going to get it there.

Justin Scambray is VP ofsSales and marketing for Pacific Medical Data Solutions of Paso Robles, CA

Argument for Healthcare Enterprise Project Management Office
By Joe Crandall

Every hospital project is an IT project.

How many times have you heard that in the past few years? A quick look at the evidence and there is little room for argument:

• Hospital budgets remain stagnant while healthcare IT projects grow. Eight of ten providers expect organizational HIE budgets to significantly increase by 2014 (2012 Black Book State of the Enterprise HIE Industry report).
• Unprecedented HIT spending. $40b investment in all IT related services, $8.2b in software services alone (RNCO study).
• The rise of health data analytics (HDA). Almost every aspect of healthcare can be improved through the use of HDA. Terabytes of healthcare data … terabytes!

As the American healthcare industry moves into its own Information Age, the existing IT infrastructure supporting the projects of today must be realigned strategically across the entire organization to support the projects of tomorrow.

The function of a healthcare Enterprise Project Management Office (EPMO) is pretty simple. The EPMO would be the single source of information related to all strategically aligned projects for the entire organization. This creates more accountability, better communication, and data governance.

Along with implementing an EPMO, an organization must look at the portfolio management process. You can’t have one without the other. The EPMO ensures the projects are done right, but the portfolio management process ensures that the right projects are chosen.

With each IT project being considered a major strategic project, the EPMO becomes the communication hub for the organization. It provides timely and effective mitigation of issues, risks, and budgets. The EPMO makes sure communications are the right message at the right level at the right time. The EPMO also standardizes the best practices of project management across the organization so all projects run smoother.

The other byproduct of elevating the PMO to an EPMO is that the CIO and team become true partners within the organization. The IT staff is already involved in the majority of projects already. Why not leverage their skills to benefit the entire organization?

The benefits to implementing an EPMO are clear:

1. Project alignment. All projects introduced are managed through a central resource and aligned with organizational goals
2. Project capacity. More projects in less time. Long-term planning is simpler and efficient.
3. Project focus. Projects are focused on the strategic goals of the institution and embrace lasting change, not the “flavor of the month.”
4. Project execution. Projects are executed with industry-standard processes resulting in project done right, on time, and completely.
5. Project redundancy. One central location has the knowledge to ensure projects are not duplicative or redundant.

One example. In 2008, Catholic Health Initiatives (CHI) established an IT EPMO with the goal of standardizing best practices and improving project success rates across all hospital IT departments within the health system. Since being established, the EPMO has reached its goals and then some. Due to its success, the EPMO was repositioned to support all enterprise-wide projects in 2012. 

Every hospital project is an IT project.

Joe Crandall is director of client engagement solutions of Greencastle Associates Consulting of Malvern, PA.

Readers Write 1/9/13

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

Why Medical Practices Must Manage A/R Better … Now
By Tom Furr

“I didn’t go to med school to be an accountant.” How many times have we heard those words being muttered from a physician’s mouth?

Until now, that’s been an acceptable sentiment for any doctor. Today such thinking is financially dangerous if not downright disastrous. Even doctors in practice for as little as 10 years kept their focus on the insurance company, the source of 85 to 95 percent of their income. That almost predictable cash flow made reviewing accounts receivable reports — universally known as A/R — barely necessary.

Today, looking at A/R is an absolute requirement because of four letters that are having a huge impact on medical practices of all sizes and types – HDHP, which stands for High Deductible Health Plans.

These insurance plans have sent a loud and clear message to doctors across the United States: the game has changed. Simply stated, those practices that adjust quickly and wisely will be better able to survive. Those that don’t will be at risk of needing to sell out to hospitals or suffer serious issues with cash flow that could threaten the survival of their practices.

According to the annual report of America’s Health Plans, the number of U.S. residents using HDHPs rose nearly 20 percent in the past year. In 2013, 70 percent of larger employers will offer HDHPs, noted a Tower and the National Business Group of Health study. While the growth rate of this type of plan varies from region to region, no practice can think it won’t affect them soon.

The new reality is deductibles as a percent of contracted rates are about 50 percent. The days of the $25 co-pay are gone. Now practices are tasked with securing half the service bill’s balance from the patient. Unfortunately, physicians today don’t know the amount due until weeks after service, making it a priority to get the patient bill out as soon as the claim is adjudicated by the insurance company. That’s especially the case at the start of a calendar or plan year.

No one is suggesting doctors turn in their white coats and stethoscopes for green eye shades and a handful of sharpened pencils. However, they must become more attuned to the state of their practices’ financial condition. If a system is not embedded in their practice management software to manage patient bills and balances as well as produce insightful A/R reports, the doctor and his/her office manager should identify one and put it into place. Even if a new practice management system has just been deployed, that doesn’t mean you don’t need to ask the questions immediately of how to capture patient balances and post them automatically.

In the HDHP environment, everyone in the practice has a role to play, from front desk personnel to physicians. Each member of a practice should be educated on the new reality of HDHPs and how patients understand this new reality. However, it is also the responsibility of the practice to provide patients a simpler way to meet their financial obligations to the practice and continue to keep their healthcare relationships sound. If patients understand and have easy ways to remit payments, the physician keeps a sharp focus on the practice of medicine, secure in the fact that the A/R is being managed.

However, make no mistake, there is a limit on how much delegation a doctor or his/her office manager can allow. The tough calls need to be made by those individuals leading the practice. Decisions of the sort that most medical professionals could never have conceived of during their internships, like “firing” a patient.

Think about it:  with HDHPs, the shift from patient to deadbeat can occur in a matter of weeks if close attention is not paid to A/R.

Tom Furr  is CEO of PatientPay of Durham, NC.

NLP and Physician Workflow: An End to Physician Resistance?
By Chris Tackaberry, MB, ChB

“I hate all the EMRs out there, including the one our practice just bought. Notes that come from an EMR have so much extra stuffing in them that it takes me forever to figure out what you guys really had to say about the patient I referred to you. I have to wade through lines and lines of empty verbiage to finally find a meaningful sentence or two that tells me what I need to know.”

While the promise of the EHR/EMR remains as great as ever for healthcare providers, so too does the issue of physician resistance, as evidenced by this doctor’s comment, part of a conversation highlighted in a MedPageToday online article. Since EHRs came on the scene decades ago, physicians have remained slow to adopt the technology, even with the promise of improved workflow automation, enhanced care quality, rapid data exchange, and increased efficiencies. While the issue of physician resistance is certainly not new, it becomes an ever-more important concern as many hospitals continue to struggle to achieve Meaningful Use requirements.

There may be several reasons why physicians remain slow to come on board, but the most obvious is simply that doctors want to spend their time caring for patients, not struggling to use technology that introduces foreign, cumbersome tasks into their workflow. The truth is, even with today’s best systems, EHR data remains, on the whole, insufficiently descriptive or lacking in clinical context. Complete patient details often reside within historical notes embedded deep inside the EHR, and manually reviewing them for each and every patient, if a physician can access them, is incredibly time consuming and cumbersome.

Even with the technological advancements EHRs have seen over the years, physicians still have to spend tremendous amounts of time describing patient problems, medications, allergies, etc., in cumbersome forms or templates. As my colleague Tielman Van Vleck, PhD, Clinithink’s director of language processing, recently stated: “There is an intrinsic inefficiency in this process because so much of this information must be documented in the clinical notes repeatedly. As a result, there has been significant physician pushback against EHRs, despite their potential to improve both the quality and efficiency of physician-delivered care.”

NLP effectively embedded into an EHR has shown remarkable promise when it comes to minimizing the negative impact EHRs have on physician workflow. Rather than burdening physicians, NLP delivers more efficient and intuitive documentation of patient information in a manner already natural to the traditional physician workflow.

This is an important concern for providers dealing with Meaningful Use requirements, particularly Stage 2 and ICD-10, where capturing patient problem lists with unfamiliar coding terminology is another big deterrent to physicians. The good news is that NLP within an EHR can automatically tag all the problems referenced in a patient note, which in addition to facilitating analytics and clinical decision support not previously possible, can also support the capture of medications and allergies, saving physicians time associated with filling and maintaining these lists.

Physician resistance to EHRs won’t end tomorrow. But with the advent of Natural Language Processing and the manner in which this technology compliments physician workflow and will ultimately improve care quality, the light at the end of the tunnel may be considerably closer. Dr. Van Vleck recently noted, “NLP isn’t just a bigger hammer to build better widgets. If we do this right, we can improve medicine, helping people lead healthier, longer lives; we can simplify healthcare delivery and involve patients more; we can even help researchers make medical discoveries or respond to new diseases. There are a million ways that NLP can be leveraged in healthcare.”

It would seem tough to find a physician who could resist that scenario.

Chris Tackaberry, MB, ChB is CEO of Clinithink of London, England.

Vendor Resolutions for 2013
By Vince Ciotti

I tried to go to the gym today, but couldn’t get in. Too many people making New Year’s resolutions to exercise! So I went back to the office early and wrote this piece on New Year’s resolutions for our top 13 vendors, listed in order of their annual revenue.

1. McKesson. So big (over $3B in annual revenue) that they made two: (a) find jobs for the 200+ well-paid Horizon veterans they laid off last year, all with 15+ years experience in healthcare, programming, etc., and (b) hire 200+ new employees for the expanded Paragon line, following the Epic model of young, inexperienced, and cheap.
2. Cerner. Kick Paul Black’s butt.
3. Siemens. Use the excellent marketing materials and RFP responses for Soarian financials to start the design and programming soon.
4. Allscripts. Make Neal Patterson sorry he ever let Paul get away.
5. Epic. Find a NYC bank with a high interest rate on CDs.
6. GE. Sell something to somebody, somewhere, sometime, somehow …
7. Meditech. Start the design work on Release 7.
8. NextGen. Integrate the brochures, proposals, and PowerPoints for Opus, Sphere, and IntraNexus.
9. CPSI. Sell a large hospital (over 25 beds).
10. QuadraMed. Take a Quantim leap backwards.
11. NTT/Keane. Optimize their disparate product lines.
12. HMS. Get ready for Primus time.
13. Healthland. Rearrange their various products in Concentriq circles.

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

Readers Write 1/2/13

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

Don’t Exclude Existing CDS Tools from Conversations on Eliminating Diagnostic Error
By Peter Bonis, MD

Diagnostic error is a pervasive and potentially deadly problem. The New York Times article, “For Second Opinion, Consult a Computer?” underscored the significant potential health information technology holds for reducing harm related to an incorrect diagnosis. Several tools have already been developed and ongoing advances in computational science may ultimately produce approaches that surpass the best of human cognitive skills.

Significant challenges remain in achieving such a vision. At present, commercially available tools that can assist in generating a differential diagnosis have not yet proven to be highly effective in reducing the burden of diagnostic error in clinical practice. There are a number of limitations to existing technology and the way in which it can be used into the workflow. In fact, many of these systems received a barely passing grade in “A Follow-Up Report Card on Computer-Assisted Diagnosis—the C+ Grade,” published in December 2011 by the Journal of General Internal Medicine.

Furthermore, helping clinicians achieve a comprehensive differential diagnosis (and ultimately a correct diagnosis) represents only a subset of the opportunity that health information technology has to offer to reduce cognitive errors. Multiple studies have demonstrated that two out of every three clinical encounters generates a question that, if answered, would change five to eight care management decisions each day. Unfortunately, only 40 percent of questions are routinely answered, and sometimes not with the best contemporary medical knowledge. Existing clinical decision support (CDS) tools not only assist clinicians in generating a differential diagnosis, but they also address the broader need for cognitive support in diagnosis and management-related decisions.

CDS allows clinicians to answer approximately 90 percent of their questions. Dozens of studies have demonstrated a link between CDS and clinically substantial changes in diagnosis, management, and acquisition of medical knowledge. CDS has also been directly linked to improved health outcomes, including hospital length of stay and mortality. It has a proven impact on increased quality, safety, and efficiency of care by providing actionable, detailed, evidence-based answers to clinical questions at the point of care.

Proper care cannot be achieved without a correct diagnosis. Better tools and changes to workflow will continue evolving to reduce potentially tragic outcomes associated with diagnostic error. However, the dialogue surrounding what is still evolving – differential diagnosis software – should not overshadow the larger canvas of what is already here – CDS at the point of care.

Peter Bonis, MD is chief medical officer of UpToDate, part of Wolters Kluwer Health.

The Seven Deadly Sins of EMR Success
By Frank Poggio

After some 40-plus years in the healthcare IT world and after reading Vince Ciotti’s extensive history of HIT published in HIStalk during the past year, I asked myself, “What have we learned? What does it tell us?” Or is it just the ramblings of old war horses that can’t stop running down the history trail? 

From my years in the trenches coupled with Vince’s extensive anthology, I’ve distilled it down to two simple rules:

1. HIT/EMR buyers just love the fair-haired boy or new glamour model.
2. Like all glamour models, they have a runway life of about a decade.

Just look at the history, decade by decade (my apologies to Vince for being so brief).

These vendors were or are the dominant top-tier vendors in each decade. Not necessarily in terms of the largest number of installs, but when a major vendor selection was made during that decade, it usually went their way.

Then after about a decade, they start to stumble. Not collapse, but stumble, and it was downhill from there. Maybe in some cases preceded by a long plateau, but soon enough they hit the down slope. Some hit it faster and harder than others, such as HBOC. Others have a very long and slow downhill run, like Siemens (SMS).

Glamour models don’t blossom overnight. It took SMS maybe 10 years to hit their stride and HBOC at least 20 when you include the life cycle of the companies they acquired. Cerner and our new darling Epic started in the 1980s. Not surprising, it takes at least 10-15 years to blossom.

Of course there were and are many second- and third-place vendors such as McAuto, Saint, Baxter, and the various mini system vendors. And there were ones that stayed away from the top tier of the market and focused on smaller facilities, like Meditech and CPSI.

Now why is it that the top-tier glamour model always seems to fatten, then fade? Why couldn’t IBM, SMS, Technicon, and McKesson hang on to the brass ring for more than a decade?

My theory is their demise is in the DNA of HIT/EMR. Nothing lasts forever, least of all top-tier HIT companies. Along with their chosen industry, they are destined to sow the seven seeds of their own destruction. Those are:

1. Constantly changing regulations

The plethora of health care regulations is innumerable. It all started with Medicare and its complex billing and reporting in 1967. Then TEFRA, Price Controls, DRGs, CHINS, RIOs, JCAHO, FDA, CLIA, HIPAA, FLSA, and on and on. Today it’s MU, ARRA, P4P, ACO, HIE, ACA, EBM, Outcomes, and more to come. And that’s not to mention the many state and local regulations starting with Medicaid.

All these mean more software modifications and updates. Every update will generate at least a dozen bugs that will come back to bite you when you are least prepared.

2. Moore’s Law

The law has been great for hardware, maybe not so great for software developers. Just about the time our glamour model has everything together, out comes a new style (technology).

Remember mainframes, minis, micros, dumb terminals, lunch box computers, notebooks, client-server, peer-to-peer, thin clients, fat clients, chubby clients, Internet, Web-based, PDAs, and so it goes? That’s just the hardware. Now add to that a tsunami of software languages and tools. IBM promoted at least 20 languages and core development tools during its healthcare reign. Oracle and Microsoft are not far behind.

3. More installs equals more costly support

As the successful company grows, its geographical footprint grows, and meanwhile it extends its application portfolio. All this success makes for more complex and costly support. Things are bound to go wrong, and the market will hear about it. It starts with small pimple, then some wrinkles, and then grows into lesions.

The only way to slow or stop the pox is to significantly invest more in support, fix code problems before they fester, increase quality control, or maybe do a full rewrite. That can take tens of millions of dollars and decades of years as witnessed by Siemens (Soarian) and McKesson (Paragon). And all are non-revenue generating (see Seed # 6).

4. Medicine – science or art or both?

Information technology to automate the science piece can be complex, yet it’s more straightforward than applying IT to the art component. Then add to that the ever-changing nature of medicine. The majority of today’s protocols, procedures, and medications did not exist 10 or 15 years ago. Medicine is a moving target and the information it generates is orders of magnitude beyond 1980. Changing medicine also means more enhancements, more support, and more fixes.

5. Pursuit of the perfect design becomes no design

Some firms get mesmerized by the latest tools, then get caught up in the perfect design syndrome. While they are immersed in designing the perfect evening gown, the glamour model is sent down the runway half naked. Technology perfection becomes the enemy of good. Then after missing too many delivery dates, their back is against the wall and they fall into the next trap: “Code now, ask questions later.” At that point, the downside has arrived.

6. Need for capital, or who’s in charge here?

You need capital to keep your systems up to speed and address all the mammoth medical, regulatory, operational, and technological changes. There are only two ways to get it.

From profits (via installs- see Seed # 3). That gets more difficult as you grow and deal with size and industry changes. 

From investors, either private or public. If you prefer private investors, there may not be enough sources. The public stock route has its own unique problems. To keep feeding this monster, you’ll need more and more investments. But after your outside investors are on board, it’s not uncommon for them to have a change of vision, plan, or agenda. It’s a marriage, and like some marriages, you don’t know your real partner until the honeymoon is long over.

7. Pride before the fall

As the glamour model nears the end of the runway, her eyes are blinded by the light and her head is in the clouds (no pun intended). So much so she loses her footing and falls off the stage. In the HIT world, this is usually described as “marketing got way ahead of development.” As an old friend once told me, “When you start eating your own marketing BS, death can’t be far away.”

Any one of the preceding can be assigned to any of our past leading models. In most cases, to more than one. Any one seed can be the beginning of the end, with some more deadly than others. Usually it’s a combination of several that cause our glamour model to fall off the runway.

At this point you may ask, “Who will be the glamour model of 2020?” Stay tuned for the next chapter. You may be surprised.

(Vince’s full HIS-tory series covering over 50 HIT vendors is at http://HISPros.com.)

Frank Poggio is president of The Kelzon Group.

One More Time, With Meaning
By Jonathan Bush

The federal government’s Meaningful Use (MU) incentive program has been getting plenty of ink lately – and not the good kind. I enjoyed reading Reed Abelson’s article in The New York Times a few weeks back, “Medicare Is Faulted on Shift to Electronic Records,” which outed the program’s “vulnerability” to fraud and abuse. It cited the OIG’s report blasting the government for failing to properly police payouts to doctors and hospitals. It got me thinking again about this program – one that’s had doctors lining up to buy EMRs like its Black Friday at Best Buy.

First, let me say that I honestly believe the government’s Keynesian efforts through the HITECH Act to stimulate adoption of the EMR have been noble. I don’t blame them. There was nothing going on. Even if they were just paying doctors to collect data and never send it anywhere (like paying farmers to pour milk out on the side of the road) they’d still have accomplished the desired effect of getting things rolling. I get it.

But as currently conceived, MU is moving providers backwards, investing big money to make caregivers less able to move information across the health system. Billions are being spent by health systems to put doctors on pre-Internet software that doesn’t actually lay the groundwork for sustainable information exchange. As Abelson suggests, the OIG is right to be alarmed. But not just because of the risk of fraud. They should be alarmed because even when obeying the rules, caregivers don’t need to actually connect and send data. They just have to “attest” to having the capacity to do it… someday … hypothetically.

Why is CMS asking for “attestation” rather than actual data? Because they don’t have the sophistication to receive the data. When our service teams attest on behalf of our clients, they have to manually enter data into a CMS website because CMS doesn’t have the technology to receive an electronic download of data from our cloud-based network. The fact that the government can’t implement the very technology that it is demanding of healthcare providers is … awkward.

So what needs to happen? Let’s pay for the fruits of MU rather than for the “attestation” of it. If MU stays as toothless as it is now, then yes, the only way to avoid fraud is to send out thousands of OIG inspectors. But a far cheaper and cleaner way to solve this problem is to pay only for flows of useful data. If they can’t give you the data, they can’t get paid. If the government can’t receive the data, then they shouldn’t be asking for it in the first place. This will quickly stem the flow of wasted dollars into closed pre-Internet systems that will never realize important goals for health information exchange.

It’s time to graduate from well-meaning Keynesian approaches – where the committee decides the test and whoever passes the test can have the money – to a true market-based approach. Receivers who need patient information can define what they need and pay a nominal fee to anyone who sends it to them electronically for the favor of efficiently sending clean, relevant, and meaningful data. Just like it works in banking and every industry other than healthcare. The fees can then come right out of administrative savings, not out of taxpayers’ pockets. The result will be a dynamic, sustainable market for the exchange of clinical data which will help drive down costs and improve outcomes. Now that would be meaningful.

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

The Department of Duh
By Robert D. Lafsky, MD

We have an elderly couple living at my house now. Oh, right, that’s me and my wife, come to think of it. But because we’re old, we still read the daily paper. And we sometimes amuse each other by writing red pen comments in the paper for the other one to see.  (This is kinda like Twitter for you younger readers out there.)  

Anyhow, one of my favorite comments is written above something that’s particularly obvious or overdue:  the heading “Department of Duh.”

My wife is a civilian, though, so I can’t do that with medical journals. But the elite New England Journal of Medicine sure gave me an opportunity in the December 27 issue with a “perspective” article called “Higher-Complexity ED Billing Codes—Sicker Patients, More Intensive Practice, or Improper Payments?”

Now don’t get me wrong, this is a serious academic piece, based on the recent OIG report on reimbursement categories. It has its own statistical analysis of a representative sample of Medicare ED visits, confirming more use of higher CPT codes in recent years. And it goes through a lot of potential causes, including sicker patients and “an increasingly interventionist ED practice style.”(I can confirm that one—it seems any symptom in the Major League strike zone in my ER here gets an abdominal CT.)

But further on the author talks about the influence of electronic records and the effect of “clickable check-boxes that easily satisfy coding-complexity criteria.” And later, “The EHR may also facilitate improper behavior, such as clicking multiple items in the ‘review of systems’ that patients were not directly asked about.” 

As one of my favorite colleagues would often respond, “Gosh, d’ya think?” 

We don’t need to or have the space to reargue this and all related points here. But what’s really fascinating to me as a regular reader of NEJM and Annals of Internal Medicine is how little they’ve been dealing with a process that’s been fundamentally changing the practice of medicine at the ground level over the last half decade or so. 

NEJM presents the most up-to-date scientific information, but very little about how the applecart of diagnostic thinking is being overturned by the EMR process. Especially in their renowned “Case Records of the Massachusetts General Hospital,” which present a mystery case to the senior expert in the exact same traditional format they used when I started reading them in the 1970s. (OK, they did start using tables for labs sometime in the late 1980s, I think). 

The real issue here is the passivity that elite medical thinkers have shown toward the radical transformation of medical records and consequent changes of medical thought processes that have been taking place. There’s a lot more to say about this, but I’d sure like to see that visiting expert professor try to unravel a difficult case using nothing but the printed output from a typical EMR. 

File that under Department of Duh. 

Robert D. Lafsky, MD is a gastroenterologist and internist in Lansdowne, VA.

Readers Write 12/19/12

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

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

Epic’s “Rules of the Road”
By Frank Myeroff

Are you aware of the hiring guidelines from Epic entitled “Rules of the Road?” These rules are in place to protect Epic clients by ensuring that staff members do not negatively impact their implementation projects by leaving them.

The rules state that you are not able to recruit or hire any employee from an Epic customer until four months after the go-live, unless the individual is hired for a position that is not related to Epic. You are also not able to place or hire any individual who left employment from a customer’s Epic project before critical go-lives or rollouts are complete until one year after the individual’s last day at the customer.

The “Rules of the Road” no longer permit recruiters to acquire employees from an active install or rollout. With rollouts at hospitals continuing well into 2014, the Epic contracting staff are essentially locked in and prohibited from leaving and consulting before completion. Before these rules, recruiters were able to acquire HIT talent already working at hospitals but interested in entering the job market as an Epic consultant.

As a result, the demand will continue to grow, but the consulting pool will shrink. This increased competition for Epic consultants could increase hourly rates over 2013.

From time to time, I speak with Epic candidates who have quit their jobs in order to consult prior to knowing about the “Rules of the Road.” Unfortunately, these candidates are not eligible to consult on any Epic project for one year.

Please ask the question: is the Epic contractor I’m about to hire eligible to consult? Don’t find yourself in the situation where you’ve filled an open Epic consulting position with an ineligible candidate.

Infractions to Epic’s “Rules of the Road” will result in the loss of the consultant’s access to the Epic User-Web. Eligibility of the candidate to consult should be the first question you should ask any staffing firm submitting a candidate for consideration in order to avoid this costly situation.

To be sure that you are meeting Epic’s “Rules of the Road”, only work with firms that have a relationship with Epic and its consulting relations department. Reputable firms will work closely with that department to validate that your candidate(s) is eligible to consult.

Frank Myeroff is managing partner of Direct Consulting Associates of Solon, OH.

Multi-Tasking Metrics
By Anil Kottoor

An Accountable Care Organization (ACO) is only as successful as the sum of its fundamental parts. Failure by just one participating provider to achieve a successful outcome on any of the 33 required quality measures could ultimately stand between the ACO and its eligibility for incentives under the Medicare Fee-for-Service Shared Savings Program.

So why not make those required metrics multi-task?

Every provider involved in an ACO should be leveraging the quality metrics they must already track to monitor internal performance and identify areas in need of improvement. From improved documentation to streamline care transitions to compliant coding and billing for more appropriate reimbursement levels to better utilization of resources for efficient patient throughput and reduced overhead costs, every aspect of a provider organization can be improved with internal benchmarking.

By repurposing data already collected to comply with reporting requirements, ACOs can easily perform effective internal benchmarking across the organization to identify gaps in care or areas of exposure before they affect the organization as a whole.

In particular, the metrics collected under the care coordination/patient safety and preventive care domains can reveal clinical outliers that may necessitate education, outreach, or process improvements. For example, by tracking the average HbA1c level across its diabetic population, an ACO can identify which if any patients run consistently higher than average after a one-year period. This could trigger a closer look at how individual physicians engage their diabetic patients to determine whether the outliers are a result of the treatment plan or the patient’s non-adherence to that plan.

Tracking and monitoring utilization rates and medical costs can also be useful to identify those providers who are managing care and costs more effectively compared to their peers. This information can then be leveraged to identify best practices which can be shared to align all providers within the ACO.

Further, by monitoring claims data, ACOs can identify the frequency of returned and rejected claims or missed filing deadlines. From there, the ACO can take a closer look at individual practice workflows and processes to determine how the situation can best be remedied.

The full benefits of ACO participation will only be realized when all providers are efficiently managing care and costs within the organization. One provider or practice can impact overall ACO performance. By utilizing the real-time information necessary to comply with external benchmarks for internal benchmarking purposes, providers can ensure that they are contributing to the good of the ACO and the organization is on track to meet the quality outcomes necessary to qualify for shared savings.

The successful ACO will partner with a technology company that can present data both retrospectively and in a real-time actionable manner to improve workflow and care outcomes. By focusing efforts on real-time reporting, ACOs will be more likely to demonstrate improvements in care and quality outcomes, thereby improving the likelihood of receiving financial incentives under the Shared Savings Program.

Anil Kottoor is president and CEO of MedHOK of Tampa, Fla.

Coordinated Care and the Changing Role of Payers
By Ashish Kachru

The result of the recent presidential election did more than return President Obama to the White House. His signature policy victory, the Affordable Care Act (ACA), looks like it’s here to stay as well.

Whether or not you agree with this policy politically, the ACA will introduce substantial changes to the US healthcare system. Millions more Americans will have an opportunity to purchase health insurance. The nature of that insurance is also changing. Lifetime limits on benefits and coverage of pre-existing conditions will be lifted.

One of the most significant systemic shifts introduced by the ACA is the expansion of integrated care delivery models. With millions more Americans now eligible to receive healthcare, hospitals and primary-care practitioners simply do not have the capacity to handle this new volume of patients. For RNs and other clinicians in a variety of care settings to effectively pick up the slack, patients must be assured they will receive seamless, consistent, high-quality care.

Of course, bringing millions of new patients into the healthcare system is unsustainable without to reducing the cost of care delivery. The ACA includes a host of cost containment and quality improvement initiatives that, collectively, are helping us migrate from a reactive, quantity-driven healthcare system to one that’s driven by quality, patient satisfaction and coordination among patients, physicians, providers, and payers.

It’s hard to overstate the importance of this migration. A reactive approach to care is one in which patients present symptoms to their healthcare providers. Treatment is focused on identifying the illness as presented and mitigating its effects on the overall health of the patient. Proactive care hinges on communication initiated by healthcare providers. The focus is not on treatment but prevention – identifying potentially negative health outcomes (and their associated costs) before they occur.

In a proactive care environment, physicians, hospitals, and other healthcare providers coordinate care for a population to improve the health of individual patients. With the right data, analytics tools, and workflow technology, coordinating population care can be streamlined, cost effective, and powerful.

The Center for Medicare and Medicaid Services (CMS) has taken a lead role in our migration to a proactive care environment by initiating and funding a variety of new payment and delivery models. At the federal level, more than 150 Accountable Care Organizations (ACO) have been launched since 2011. The CMS State Innovation Models Initiative provides competitive funding opportunities for states to implement and test their own payment and delivery improvement models.

Many safety-net health plans have existing population care management platforms that already enable them to coordinate care proactively with their provider community. These systems dovetail nicely with both the ACO mission and many state-specific care coordination initiatives. Many payers, in other words, are already up to speed on leveraging data – both internally-generated claims data as well as clinical data from provider EMR systems – to identify high-risk patients and actively engage them in their health.

The next few years will be crucial to ensuring our proactive, quality-driven healthcare system becomes successful. It’s a huge shift for everyone involved. But with the right technology solutions, widespread implementation of best practices and the removal of data barriers between patients, providers, and payers, the US healthcare system can successfully delivery higher-quality care to more people at a lower cost.

Ashish Kachru is CEO of Altruista Health of Reston, VA.

The Patient’s Point of View: Patient Centered Medical Homes (PCMH)
By Joe Crandall

About 10 years ago, I was hospitalized a few times for colon cancer. Because of this experience, I pursued a professional career in healthcare.

Most recently, I have seen a care provider about 10 times for myself or my kids. You could say I am an educated consumer of healthcare. I would like to offer a patient’s perspective on the PCMH being adopted as a new care delivery model for the primary care physicians (PCP) office.

First, the PCMH has a lot to offer patients and caregivers:            

• Better access to healthcare
• Utilizing the right healthcare provider for the right problem
• Electronic medical records being shared to reduce tests and exams
• Better coordination for preventative medicine and long-term disease management

However, the PCMH has two problems:

• A marketing problem
• A change management problem

The term Patient Centered Medical Home is confusing to patients. The confusion arises because the name implies a physical location versus what is a change in the care process. For organizations implementing this solution, they should change the name to better reflect what they want to accomplish. A title suggestive of “centralized care coordination” would be better understood and adopted by all. Patients will be pleasantly surprised by the changes if they get past the poor naming convention.

The second problem the PCMH will have to overcome is resistance to change. Most organizations are slow to change because they don’t know where to start and/or they don’t know what they need to do to get certified. Luckily, the NCQA has specific guidelines on attaining designation as a PCMH along with some great tools to help with certification. Organizations are left on their own to conduct a comprehensive, unbiased, and objective assessment of their current capabilities. A good assessment will not only tell the organization where they are, but also why they are at that state of readiness.

With the starting point clearly identified and the 2011 NCQA standards as the goal, the organization can develop detailed courses of action. Even with excellent courses of action that clearly outline the steps to certification, organizations are reluctant to change. Each and every office worker needs to be educated on the PCMH model so they can articulate a clear message to each patient that visits the office. By involving and education everyone, the chances of success increase dramatically.

My PCP adopted the PCMH last year. His office appeared to run smoother. I got an appointment immediately and I waited less. Since then I have been treated, diagnosed, prescribed medications, had x-rays, and got the results all without seeing my PCP.

I didn’t feel like I received lesser treatment. I felt I received better, more focused care because the people I saw were available when I needed them and qualified for the level of care provided – all because of a centralized care model based out of my PCP’s office (not a home).

Joe Crandall is director of client engagement solutions of Greencastle Associates Consulting of Malvern, PA.

Readers Write 12/10/12

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

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

Baseball Traditionalists: Whose “Use” was More Meaningful?
By Robert D. Lafsky, MD

Isn’t it fascinating to follow the daily progress of a battle that pits traditionalists against digitally-armed insurgents? On the one side are deeply-entrenched practitioners of an ancient art dependent on subjective judgment calls that, in their view, can only be described in descriptive natural language. On the other side are advocates of a granular hard data approach that, although tedious and opaque to the untrained, reveals insight into previously unseen trends and realities.  

Ain’t baseball something?  

You do have to admit, if you’ve read the sports pages lately, that the battles in the sport eerily reflect arguments that run through the pages and comment sections of this blog. I cite as the crowning example the brouhaha over the naming of Miguel Cabrera as this year’s National League Most Valuable Player.

The traditionalists have a powerful argument for Cabrera. For one thing, his Detroit Tigers won their division and went to the World Series, while second place Mike Trout’s LA Angels finished third in their division. And Cabrera was the first Triple Crown winner (highest batting average, most homers, and runs batted in) in 45 years. He had a knack for hitting when it really counted, and he selflessly agreed to move to third base from first when the Tigers acquired the powerful but slow Prince Fielder. The traditionalists say it’s obvious he’s the MVP.

But the “Moneyball” guys have their points about Trout. Using highly sophisticated and detailed data, they determined using a measure called “wins over replacement,” — using not only batting statistics, but defensive and even individual ballpark factors to compare Trout to an average replacement player — he accounted for 10.7 additional wins for the Angels over 6.9 Tiger wins for Cabrera. And that, to them, is what matters. All that other stuff is dismissed by these “Sabermetricians” as mere “narrative.”

But the traditionalists could ask, I suppose, the following cogent question:  whose “use” during the season was more “meaningful”? 

That’s an obvious parallel  to current trends in medical computing, right? Well, let’s not forget an obvious point. Baseball has always been a thing entirely made up by humans. Before these high-end statistics were developed, it had a clear-cut set of rules and a clear-cut goal–scoring the most runs in the most games.  

Medicine’s rules, on the other hand, are essentially defined by nature, and after more than 40 years in the field, I still wonder what the goals of practice really are. Fewer deaths, of course, but that’s really hard to count. And we know that people focus on a lot of other things that don’t affect critical outcomes like death and disability.

So, no — it’s way more complicated.  And advocates of evidence-based practice make valid points. We won’t settle any arguments here. But I know that obtaining and analyzing data is hard.  

Which is why we need baseball.  Go ahead and break for home, Bryce Harper. When that happens, we don’t need no stinkin’ statistics.

Robert D. Lafsky, MD is a gastroenterologist and internist in Lansdowne, VA.

The EHR Conversion Staffing Dilemma: Cost vs. Go-Live Disaster
By Don Sonck

With the window to initiate participation in the Medicare EHR Incentive Program expiring in 2014, the next two calendar years are certain to be chaotic within the EHR arena. With an ever-increasing number of hospitals and physician groups already scheduled to implement an EHR and still others in the final selection stage, internal and external resources necessary to staff these critical and expensive projects are already at a premium.

Particularly on the acute support side of these projects, professional consultants (internal and external) who possess clinical experience and know firsthand the inner workings of a hospital or ambulatory environment should be utilized. Ratios of one acute EHR professional for every four to five core clinical staff members is optimal. Any ratio greater typically results in frustration and morale decline, extended end user adoption, residual training, and of course, increased expense.

Far too often I’ve encountered healthcare systems of all sizes (as well as physician practices) that underestimate the importance of clinical support staff. During EHR post-mortem discussions, leadership rues the fact they overlooked or underappreciated the skill and expertise that clinical resources bring to the table, particularly during the critical 4-6 weeks just prior and subsequent to go-live. Too often, the main focus and budget allocation is on the EHR build and associated infrastructure costs. IT consultants are justifiably a majority slice of the overall project budget pie, but these same resources are ill prepared for and lack the “soft” skills to prosper as super users with core clinical staff during that chaotic go-live window.

My advice? Do not rely solely on overtime utilization of existing staff, the float pool, or seasonal staff. Make sure you pay for the ala mode on top of that budget pie in the form of nurses, therapists, and physicians who are seasoned in both go-live experience and the particular EHR vendor software to which you are migrating. When blended with existing core staff, these clinicians can assist in both patient care and technical guidance on the electronic charting process, easing your clinical team’s anxiety, reducing overtime, minimizing the need for additional EMR training consultants, and accelerating the adoption and knowledge of the EHR software.

When considering the employment of third-party clinical support staff, avoid the pitfall of waiting until the eleventh hour to pull the trigger. Human resources and nurse recruiting teams have enough on their plate without the added burden of answering these questions for themselves:

• How will nurses and physicians learn the system and treat their patients at the same time?
• What scheduling challenges will we experience due to the temporary decrease in productivity?
• Who will handle my core employees’ technology aversion?
• Will overtime compensate for coverage during classroom training time?
• What will be our electronic charting standards be day one, week two, and month one?
• Who will be taking care of orientation, credentialing, and my other duties during implementation?
• What will my patients experience be during go-live?

Be an early adopter of the clinical staffing question, at least six months prior to go-live. Your CFO, CIO, and CNO will all thank you.

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

Questions for ONC and the Obama Administration
By John Gomez

The Meaningful Use program requires technology to be adopted and utilized by healthcare providers and payers throughout the United States. The funding for these programs is coming from federal tax dollars  All that is well and good. In the long term, we will hopefully see a good return on these investments through standardized care, lowered administrative overhead, and a reduction in medical errors that affect patients.

The technology that is designed, developed, tested, and deployed to support Meaningful Use requires literally thousands and thousands of engineers, consultants, product and program managers, not to mention all the system administrators, network managers, and others. It is perplexing to me though, that in these times of economic hardships, many healthcare software vendors and secondary software service providers offshore these positions. 

For instance, companies like Allscripts have huge staffs in India and smaller presence in Canada. Some companies are offshoring to Israel, China, and Europe. Given that we as taxpayers are funding the Meaningful Use program, shouldn’t there be a provision requiring that those companies benefiting from these programs only utilize US-based resources? 

There is potentially a silly argument that could be made that if were to require these companies to use US resources, they would need to charge more for their products and services and that would ultimately cause a deeper burden to the taxpayer. That is an accurate knee-jerk response based on lack of information and research.

We could keep these jobs here in the United States and not increase the cost of operations for these companies if these companies fill these positions in areas of the United States that are hardest hit by the current state of our economy. The level of talent, required training, and other factors would be similar if not better then that which is encountered outside our borders.

I realize that this is not a simple problem. Wall Street and private equity firms are more interested in margin improvement then really considering the long-term benefit to our country. But in my eyes, I think that creating jobs here is a priority. 

We should do what we can to get more Americans working, even if it impacts the margins of healthcare software companies or slightly raises the cost of software or services. When you have a program as big as Meaningful Use, the benefit should be well beyond that of its primary objective.

John Gomez is CEO of JGo Labs of Asbury Park, NJ.

Stage 2: You Ain’t Finished ‘till the Paperwork is Done
By Frank Poggio

Many years ago I saw a cute little cartoon that pictured a three-year-old climbing off a commode. Standing next to him was his mother, instructing him that he wasn’t finished until his paperwork was done. Well now, the characters in that cute cartoon can be replaced by a vendor and the ONC, respectively.

Two new Stage 2 test scripts for certification will require vendors to supply documentation previously not needed under Stage 1. They are:

1. Safety Enhanced Design – 170.314(g)(3), and
2. Quality Management System – 170.314(g)(4)

Safety Enhanced Design (SED). In early drafts of Stage 2, this criterion was referred to as User-Centered Design. The primary impetus for SED came from the November 2011 IOM report (Health IT and Patient Safety: Building Safer Systems for Better Care) that lamented the lack of built-in safety elements in many clinical software products.

An excerpt from the ONC test script describing SED follows:

This test evaluates the capability for a Complete EHR or EHR Module to apply user-centered design for each EHR technology capability submitted for testing and specified in the following certification criteria:

§ 170.314(a)(1) Computerized provider order entry

§ 170.314(a)(2) Drug-drug, drug-allergy interaction checks

§ 170.314(a)(6) Medication list

§ 170.314(a)(7) Medication allergy list

§ 170.314(a)(8) Clinical decision support

§ 170.314(a)(16) Inpatient only – electronic medication administration record

§ 170.314(b)(3) Electronic prescribing

§ 170.314(b)(4) Clinical information reconciliation

The Tester shall verify that for each EHR technology capability submitted for testing and specified in the above-listed certification criteria, the Vendor has chosen a user-centered design (UCD) process that is either:

A) UCD industry standard (e.g.; ISO 9241-11, ISO 9241-210, ISO 13407, ISO 16982, and ISO/IEC 62366); and submitted the name, description, and citation or,

B) Not considered an industry standard (i.e. may be based upon one or more industry standard processes); and submitted the named the process(es) and provided an outline and description of the process(es)

The Tester shall examine each Vendor-provided report to ensure the existence and adequacy of the test report(s) submitted by the manufacturer. The Tester shall verify that the report(s) conform to the information specified in NISTIR 7742 Customized Common Industry Format Template for Electronic Health Record Usability Testing.

Full EHR vendors must address this new requirement, while EHR Module vendors can skip it if your certification request does not include any of the above criteria. On the other hand, if your EHR Module includes even one of the above, you then must address the SED for that criteria.

The second new criterion questions the use of a Quality Management System 170.314(g)(4). The ONC-published test script states the following:

For each capability that an EHR technology includes and for which that capability’s certification is sought, the use of a Quality Management System (QMS) in the development, testing, implementation and maintenance of that capability must be identified.

– The Vendor identifies the QMS used or indicates that no QMS was used in the development, testing, implementation and maintenance of each capability being certified

– The Tester verifies that for each capability for which certification is sought, the Vendor has

1. Identified an industry-standard QMS by name (for example, ISO 9001, IEC 62304, ISO 13485, ISO 9001, and 21 CFR, Part 820…)
2. Identified a modified or “home-grown” QMS and an outline and short description of the QMS, which could include identifying any industry-standard QMS upon which it was based and modifications to that standard
3. Indicated that no QMS was used for applicable capabilities for which certification is requested

Clearly ONC is interested in learning more about what QA tools vendor use (if any) for each of the submitted Stage 2 criteria. Under Stage 2, per step 3 above, you do not have to have a formal (or any) QA process available. No QMS is an acceptable answer. But, you can easily guess what will happen in Stage 3. Words to the wise: if today you do not incorporate in your systems development a formal and documented QA process, better get one soon.

Last year in a previous HIStalk post I referred to the FDA coming to EMR systems through the back door. SED is a big step in. I fully expect the criteria covered to expand in Stage 3, and expect the depth and extent of the documentation submission to expand as the test agencies (ACB) gain more experience in 2013.

Lastly, if your staff is not familiar with the ISO and IEC standards, better do some homework. I suspect that the best of breed /specialty and new HIT startup firms would have a more difficult time in addressing SED than the large legacy firms. Documentation and QA are typically not their strongest suits.

All the new Stage 2 criteria and test scripts can be found here.

Frank Poggio is president of The Kelzon Group.

The Jury is No Longer Out
By Nicholas Easter

Very recently, I was a summoned to District Court for my civic responsibility of jury duty. Unlike many Americans, I relish the opportunity to sit for a jury trial, as it affords me the great opportunity to assist in the beautiful process of democracy. Unfortunately, the attorneys did not choose me this time around. But there is always next week, when I will be summoned to return.

Due to my freedom from this specific trial, I can comment on some of the particulars, but the important message from this trial comes from the other panelists as the voir dire was conducted.

In short, the case was/is an inmate at a federal detention facility (prison) attempting to sue members of the healthcare team at the facility for negligence in treating his life-threatening illness. A mix of guards, nurses, PAs, and a doctor being sued by an inmate for violation of the 8th Amendment to the US Constitution, since it is a constitutional question, was remanded to Federal District Court.

Eighteen lucky people were selected to move from the pews to the comfy seats in the jury panel. Each was interviewed by the judge and asked a series of questions to whittle the number down to 10 jurors.

Among the questions was a seemingly innocuous one: “What is your opinion on the healthcare provided to inmates?” Each of the 18 responded that they believed it was a right for each and every prisoner to receive fair and adequate medical attention. Of the panelists, there were teachers, engineers, consultants, unemployed persons, and the director of a local emergency room’s nursing team. I repeat, every single one thought it was the duty of the Federal Department of Corrections to provide ample and adequate healthcare to its inmates.

I believe it is time to formally reaffirm that a majority of this country believes that access to quality healthcare is a right afforded to each and every citizen, even felons. It is this basic comment on the structure of our society that gives a full and formal mandate to our leaders in Washington DC to complete the process of unifying the delivery of healthcare in America to make it accessible and affordable for all Americans.

If 18 randomly selected Americans above the age of 18 without any prior convictions for felonies can confirm that this basic right is required for criminals, then it ought to signal that it is high time to continue to find ways to make this an affordable reality for the remainder of Americans.

Social scientists agree that the “Social Strain Theory” is accurate. The greatest impetus to criminal behavior is poverty. America’s healthcare system can easily push even the most well-heeled patients into poverty. Hopefully the healthcare system of tomorrow will recognize the sharpness of its sword as it begins to eradicate a lot of ills that befall our society.

Readers Write 12/5/12

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

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

Hey Healthcare, ‘I Dare You to Do Better’
By Nick van Terheyden, MD

I was reading “Dream Big, Start Small: NYU Startups Disrupt Big Industries” when a quote from Mana Health caught my attention: “We want to make the job as easy as possible for doctors … We want to be Apple in [the] health industry.”

This quote got me thinking about the role of simplicity in healthcare. Part of what makes Apple unique is its simple approach to consumer technology. While bells and whistles are buried beneath the surface, what the user experiences is the ability to pick up a piece of Apple technology and interact with it without reading a verbose manual or watching a “How-To” YouTube video.

Clearly, a team has already taken the time to anticipate how people will use this technology, what questions they might have, where they might get hung up, and what’s really going to “wow” consumers and keep them engaged. There’s something mystical and awe-inspiring about this type of simplicity, particularly if you compare it to what clinicians have to do in order to get up to speed on the most basic healthcare technologies.

Maybe it’s because The Official Star Trek Convention was recently held in San Francisco, or the fact that I just recently heard that a nine-minute teaser for the latest Star Trek movie, “Star Trek Into Darkness” will be available in 3D IMAX theaters on December 14, but in addition to “simplicity,” I’ve also been thinking a great deal about how advancements in technology can help the healthcare industry “boldly go where no one has gone before.” And more importantly, to get “there” without asking clinicians to fight Klingons.

Over the past year, there has been an array of studies and stories pointing to frustrations associated with electronic health records and Meaningful Use. This is compounded by additional pressures putting the heat on the healthcare industry — a looming physician shortage, an aging population with increased care demands, and changes in the reimbursement model.

Still, for every problem, there’s a solution. What keeps me up at night, though, is the fact that all too often we try to slap a new coat of paint on a problem in an effort to mask the issue as quickly and efficiently as we can. More often than not, we approach problems — especially in healthcare — with a fast and furious desire to make things right in the moment instead of aiming to make things right for the long term.

The fast fix in healthcare is often not the real solution to the problem. Take the transition to ICD-10, for example. At first, some healthcare providers wanted to keep doctors as far from the transition as possible. And at first glance, I can understand why. No one wants to take the focus off of the patient. Still, the transition to ICD-10 can’t be simplified without having doctors on board as part of this massive personnel and technological overhaul.

See, the problem with simplicity is that to get to that type of Apple approach in healthcare, you have to take into consideration the myriad of players that will be affected. You have to take the time to test and tweak, test and tweak in an iterative process that while challenging and time intensive, will ultimately be rewarding. In other words, to get to “simple,” you have to trudge through the difficult for quite some time.

As we head into the holiday season and take a look back at the accomplishments and failures from the past year, let’s agree to remain focused on integrating a new sense of simplicity into the complexity of all things healthcare in 2013 – whether it’s technology, health insurance, or patient communication. One particular “Star Trek” quote mapping back to the simplicity theme that seems like a fitting request for all healthcare players in the coming year is this: I dare you to do better.

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

Humble Suggestions from an Allscripts Pro Client to Ease Transition Pain for MyWay Clients
By Cathy Boyle, RN, BSN

By now, I’m sure everyone who uses Allscripts MyWay is aware that the company is transitioning customers to the Professional Suite. You’re probably overwhelmed sorting through options as you decide whether to upgrade to the new product or to jump ship and start over with another EHR company. 

Starting over with another company may be painful, but it’s also somewhat vindicating. On the other hand, agreeing to upgrade to the Professional product may be the easier road because you’re exhausted and don’t want to start over with someone new. 

Let me offer a little perspective …

Three years ago, our practice learned Misys was merging with Allscripts and we would need to move to the Allscripts product. No choice.

We were miffed, to say the least, and jumped ship to a competing product. Within three months, we realized it was a serious mistake. We ate a little crow and made the decision to return to Allscripts. 

We implemented the Allscripts Pro EHR/PM system and came to the conclusion that even though not all of our experiences with Allscripts have been perfect, it was the right choice. Like it or not, Allscripts is the leader in the EHR world for a reason. They haven’t always gotten it right. Unfortunately, no one does. 

I will not pretend to understand how any of you feel as a MyWay client. The only thing I can offer is my perspective from moving to another product and realizing the grass is not always greener on the other side. 

My suggestions are threefold:

1. If you haven’t already, sign up for Allscripts Client Connect and check out the resources available for people upgrading to the Pro EHR and for those considering other options. You’ll find links to webinars, product demos. and lots of other info. Can’t hurt, right?
2. Go to the Pro ARUG (Allscripts Regional User Group) page for your state and start asking questions of Pro users in your area. They’ll answer you honestly. They are not paid by Allscripts and have real-life, in-the-trenches perspectives on the Pro product.
3. Find out who in your local community has the Pro product and go take a look at it. See it for yourself firsthand as you make the best decision for your practice.  

Then, if you don’t like what you see and hear, feel free to explore other options.

I wish you the best in this world of healthcare changes – I really do!  But if you come to realize, as we did, that the Pro solution is right, I would personally like to welcome you to the Pro family! We will help you, support you, cry with you, teach you, bang our heads (at times) with you, and celebrate the victories that come with finding a system and a family of users from which you can benefit. It’s not always easy going, but you will be heard and you will not be alone.

I am not paid by Allscripts and do not reap any personal benefit from writing this post. Just concerned with what is happening to fellow clinicians in the Allscripts community. Feel free to contact me directly if you have questions. I will not mince words and am happy to help in any way I can. 

Cathy Boyle, RN, BSN  is clinical director at Heiskell King Burns & Tallman Surgical Associates, Inc. of Morgantown, WV.

OCR’s Guidance for De-Identifying Health Data
By Deborah Peel, MD

The federal Office of Civil Rights (OCR), charged with protecting the privacy of nation’s health data, has released guidance for “de-identifying” health data. Government agencies and corporations want to de-identify, release, and sell health data for many uses. There are no penalties for not following the guidance.

Releasing large data bases with the de-identified health data of thousands or millions of people could enable breakthrough research to improve health, lower costs, and improve quality of care — if de-identification actually protected our privacy so no one knows it’s our personal data. But it doesn’t. 

The guidance allows easy re-identification of health data. Publicly available databases of other personal information can be quickly compared electronically with de-identified health data bases to reattach names, creating valuable, identifiable health data sets.

The de-identification methods OCR has proposed are:

• The HIPAA Safe Harbor method. If 18 specific identifiers are removed (such as name, address, and age), data can be released without patient consent. Still, 0.04 percent of the data can still be re-identified.
• Certification by a statistical expert that the re-identification risk is small allows release of databases without patient consent. There are no requirements to being called an expert. There is no definition of small risk.

Inadequate de-identification of health data makes it a big target for re-identification. Health data is so valuable because it can be used for job and credit discrimination and for targeted product marketing of drugs and expensive treatment. The collection and sale of intimately detailed profiles of every person in the US is a major model for online businesses.

The OCR guidance ignores computer science, which has demonstrated that de-identification methods can’t prevent re-identification. No single method or approach can work because more and more personally identifiable information is becoming publicly available, making it easier and easier to re-identify health data. See Myths and Fallacies of Personally Identifiable Information by Narayanan and Shmatikov, June 2010. Key quotes from the article:

• “Powerful re-identification algorithms demonstrate not just a flaw in a specific anonymization technique(s), but the fundamental inadequacy of the entire privacy protection paradigm based on ‘de-identifying’ the data.”
• “Any information that distinguishes one person from another can be used for re-identifying data.”
• “Privacy protection has to be built and reasoned about on a case-by-case basis.”  

OCR should have recommended what Shmatikov and Narayanan proposed: case-by-case “adversarial testing” in which a de-identified health database is compared to multiple publicly available databases to determine which data fields must be removed to prevent re-identification. See PPR’s paper on adversarial testing.

Simplest, cheapest, and best of all would be to use the stimulus billions to build electronic systems so patients can electronically consent to data use for research and other uses they approve of. Complex, expensive contracts and difficult workarounds (like adversarial testing) are needed to protect patient privacy because institutions — not patients — control who can use health data. This is not what the public expects and prevents us from exercising our individual rights to decide who can see and use personal health information.

Deborah C. Peel, MD is founder and chair of Patient Privacy Rights Foundation of Austin, TX.

Evolution in your Data Center
By Axel Wirth

The change of a biological organism through a combination of mutation and natural selection over a number of generations was first articulated as the Theory of Evolution by Charles Darwin. In short (and with my apologies to the great scientist), if a change occurs and the next generation is more successful, it will have a higher probability of passing on its characteristics to future generations.

Survival of the fittest, survival of the smartest, or plainly a strategy to adapt to a changing environment. Whichever way you look at it, it has enabled the human race to populate the earth from our origins in Africa to the icy north.

But evolution works in both directions. Think, for example, of the problems caused by antibiotic-resistant infections like MRSA. We can also apply a similar thought model outside of biology. Let’s have a look at the scary and complex world of computer viruses and malware.

A recent example. In mid-2009, W32.Changeup, a polymorphic worm written in Visual Basic, was first discovered, but was not really anything special. It wasn’t harmless, but in general, it was classified as a medium damage, medium distribution, and easy to contain worm.

But then evolution came to play (granted, this was not evolution by mutation, but evolution by design). As of recently, we have seen over 1,000 variants of W32.Changeup, some of which much more aggressive and successful than the original. Some variants recently showed an increase in activity of over 3,000 percent in a single week.

What is even more concerning is that based on some of the characteristics of this worm, it is especially dangerous for the typical healthcare infrastructure. We have already seen several hospitals hit hard over the past weeks.

Why now and not back in 2009? Just like MRSA, W32.Changeup evolved and became more resistant and dangerous.

There are a number of malware threats which, due to the way there are designed, are affecting healthcare IT more than others. Downadup, also known as Conficker, was one of them. It looks like Changeup is joining the club. Here is why:

• It spreads through removable drives. Devices and subnets which are perceived to be protected through isolation and may not have sufficient malware protection and resilience are at risk.
• It infects old and new versions of Windows on workstation and server platforms. Certain devices on hospital networks with older or unpatched operating systems (e.g. medical devices, dedicated workstations, and servers) may be especially vulnerable.
• It uses multiple propagation methods through removable drives and shared network drives. Once a system is compromised, Changeup’s main purpose is to download various additional malware. Among it is a Downloader Trojan, which in turn will download even more malware.
• Changeup is polymorphic in nature. As it copies itself to other devices, it maintains its function, but changes it look. This makes it difficult to detect with traditional signature-based antivirus software. Modern anti-malware software provides more functionality than signature-based protection, but proper configuration of your endpoint protection combined with a layered security approach are required to detect and protect against a sophisticated worm like Changeup.
• Changeup copies itself to removable and mapped drives by taking advantage of the AutoRun feature in Windows, which should therefore be prevented for all users and devices, including network shares.

This brings us back to the initial point made about evolution. We now have diseases which are resistant to a single antibiotic and require a complex, multi-pronged approach. Similarly, with computer malware like Changeup, a single approach (e.g. relying on signature-based antivirus alone) is not sufficient any more. At a time where we are seeing well over 10 new viruses and variants being created per second, we need to take a strategic “defense in depth” approach.

Of course, traditional and signature-based antivirus is still part of that picture, but it needs to be complemented by system and network intrusion detection, peripheral security (firewalls), system configuration and controls, security event monitoring, and URL filtering to prevent connection to known C&C (command and control) URLs.

Axel Wirth is national healthcare architect for Symantec Corp. of Mountain View, CA.

Readers Write 11/19/12

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

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

Paying Attention to How NLP Can Impact Healthcare
By Chris Tackaberry, MB, ChB

Unstructured clinical narrative is increasingly being seen as the primary source of sharable, reusable, and continually accessible knowledge, essential in helping providers make informed decisions, reduce costs, and ultimately improve patient care. While form-driven EHRs readily leverage and share captured structured data, the richest patient information remains locked inside EHR databases as unstructured notes.

Natural Language Processing (NLP) technology is becoming increasingly recognized in healthcare as a powerful tool to unlock this vital clinical data and turn it into analyzable, actionable information. While many have heard of NLP, there is significant confusion about what it actually means for healthcare.

In short, NLP means recovering computable data from free text. Even though most of the world’s knowledge is documented in some form of written narrative, we increasingly rely heavily on computers to analyze the world around us, and computers work better with well-defined, structured data rather than unstructured text.

Google has clearly proven that simple text search allows us access to vast amounts of information, but it still requires humans to determine meaning in the results. NLP is the science and art of teaching computers to understand the meaning in written text in order to extract data from narrative for reporting, analysis, etc.

NLP, typically embedded within other solutions, can help deliver significant benefit to providers and their patients by:

• Improved reporting and monitoring. Many administrative tasks in healthcare depend on structured data, including the submission of billing codes that describe diagnoses and procedures to insurance companies. The identification of billable concepts in clinical narrative is probably the most common application of clinical NLP because it is the most direct path to delivering financial benefits.
• Improving utilization of clinician time, resulting in more efficient care delivery. Doctors and nurses are accustomed to carefully documenting the condition and care of each patient in clinical notes. Without computable data, however, hospital operations, physician reimbursement, and patient care are all compromised. By pulling data directly from notes with NLP, even in real time at the point of care, we can save clinician time and frustration while identifying more data and detail to support clinical decision making, efficient care delivery, better public monitoring, and more.
• Improved physician understanding of patients. NLP provides the level of clinical detail necessary to provide quicker access and review of patient histories. Revealing key information in existing notes that would be invaluable for more timely, better-informed clinical decisions.
• Better research and monitoring. Existing studies have looked for correlations between patient genes or proteins and characteristics identified in the patient’s medical record. Conducting similar studies with the greater volumes of so-called phenotypic data, which can be pulled from patient records using NLP, will reveal far more about what makes our species tick – or sick.
• More efficient clinical workflow. There is an intrinsic inefficiency in EHRs because so much of the information must be documented repeatedly. As a result, there has been significant physician pushback against EHRs, despite their acknowledged advantages.
• Embedded NLP tools can facilitate EHR redesign for more efficient and intuitive documentation of patient information in a manner already natural to the traditional physician workflow.

Done well, there are countless ways NLP can be leveraged in healthcare to deliver benefit by improving efficiency, driving outcome-based performance, promoting access, facilitating research, and supporting population-based healthcare delivery models.

The application of NLP technology to healthcare will transform what we know about disease, wellness, and healthcare performance, enabling major improvement in efficiency and outcome. At the heart of this data-driven transformation is clinical narrative, a powerful and valuable asset. We need to recognize that.

Chris Tackaberry, MB, ChB is CEO of Clinithink of London, England.

Defining a Complete Patient Engagement Solution
By Jordan Dolin

A few years ago it was somewhat rare for a technology vendor to pitch the benefits of patient engagement. Today it seems that everyone is claiming to be a “leader in patient engagement technology.” This has led to a good deal of confusion in the marketplace. 

Patient engagement can deliver significant financial and clinical results, but to actually achieve these benefits, organizations need to select a "complete" solution.  A complete solution is one that addresses the needs of all constituents. It engages patients on their terms and also contains the content, technology, and regulatory considerations sought by providers to support care in every setting across the continuum. 

Simply stated, a solution that satisfies these eight critical elements has the ability to improve clinical and financial outcomes.

1. Understands how to synthesize and deliver actionable information to patients. An effective solution must impart information to a patient in a manner that will actually change behaviors and improve outcomes. Addressing a spectrum of learning styles, literacy levels, and cultural relevance requires a tremendous amount of expertise across multiple communication methodologies.
2. Facilitates engagement along settings across the continuum of care. A complete solution must support the needs of the patient and the provider in care settings across the continuum as well as the transitions between them. This includes addressing clinical, operational, and regulatory needs of providers in addition to supporting new models of care such as ACOs and PCMH.
3. Engages patients at their convenience. Historically, healthcare technology solutions have always targeted the convenience for the provider, not the patient. Patients must have the ability to receive information when they want, where they want, and on the devices they already own.
4. Seamlessly integrates into IT systems and workflow. Organizations are no longer willing to accept disruptions to their infrastructure or existing processes. To be successful, solutions must be complementary and additive, not disruptive or distracting.
5. Results measured down to the individual patient. The single unifying goal that now pervades healthcare is accountability. A solution must contain tools that allow providers to measure their impact from multiple perspectives. The ability to confirm that a patient received and reviewed information prescribed by their clinician is a fundamental measure needed to quantify impact.
6. Measures and delivers an economic return. Healthcare organizations are accountable for outcomes and their partners should be as well. Clients should expect hard dollar ROI studies and vendors should impartially fund and conduct them.
7. Backed by an organization with the requisite knowledge and experience. Investing in an engagement solution to support key business objectives is a critical decision. The vendor selected should have the appropriate experience and staff to support the success of their clients and their clients’ employees and patients.
8. Effectively supports the near-term and long-term objectives of the organization. The partner selected must understand the challenges of health systems and have a track record of delivering solutions that effectively address them. In addition, it should be clear that investments are being made in new solutions and innovations that will continue to address the needs of an ever-changing market.

Jordan Dolin is co-founder and vice chairman of Emmi Solutions of Chicago, IL. This article contains an abbreviated list due to space limitations; the complete list is available by download. 

Physician Compensation: The Accountable Care Challenge
By John C. Roy

As healthcare systems and physician groups across the country grapple with definitions and implications of “accountable health care” and “value-driven contracting,” physician compensation based on a fee-for-service model is irrational. Pioneering institutions have already incorporated quality and outcomes into their compensation plans. Similarly, payment for health care services is shifting into fee-for-value models.

As these models evolve, compensation plans must reward physicians for meaningful quality improvement and patient outcomes. Key questions emerge. How can clinical and other data help providers enhance value in the most strategic ways? What measurement strategies, and which data, can be used to reward provider teams that contribute the highest value?

In a fee-for-value world, physicians and hospitals will have to focus on quality, outcomes, and cost (or efficiency) requiring a true culture of quality improvement. Physician engagement is critical in shaping that culture. Physicians will have to assess and agree upon outcome measures and practice standards and change practice based upon valid, practice-specific data.

Today, many health systems struggle with the absence of such data. Essential data supporting such a transformation is often stored in disparate clinical and financial databases, including multiple electronic medical record systems and homegrown software solutions.

One universally challenging example is accurately attributing patients to individual physicians. Accurate attribution is central to reporting outcomes, but all too often proves extremely difficult. If physicians don’t trust that the data accurately reflect their practice, they cannot invest adequate time and energy in improving quality of care.

On the other hand, when physicians trust data that truly does reflect their practice, the data spur meaningful conversations around quality and outcomes. They see improvements in real time. The ability to correctly assimilate, align, and attribute patient data to individual physicians is a fundamental issue today and a cornerstone of reimbursement and compensation tomorrow.

As payment for health care shifts from “caring for sick” to “maintaining health,” providers will need extremely effective, efficient care management strategies for chronic disease patients. They will rely on patient data that is strategically aggregated to identify interventions around priority patient populations. They will direct sophisticated, well-coordinated management plans to help insure appropriate patient management, appropriate testing, control complications, and improve direct attention to that patient. They will have the ability to report improvements in quality, demonstrating the value of their work over time. All of these efforts deliver significant value that needs to be monitored and rewarded when achieved.

In a fee-for-value world, the provider groups who use population-level data to create and implement successful strategies for effectively managing their chronic disease patients will command higher compensation, regardless of their RVUs. Successful systems and groups will design physician compensation models around elements that matter most in a new, risk-based health care environment. To do this, patient data needs to be more physician-centric, with improving population health as the primary goal.

John Roy is vice president of Forward Health Group of Madison, WI.

Six Facts You Should Know About Stage 2 Meaningful Use and Data Interoperability
By Ali Rana, MBA, MCITP, CISSP

In the world of care delivery, having access to the right information at the right time can be a matter of life or death. Anyone who has been a patient or cared for one understands that the transfer of medical information – whether current or historical – among providers is not readily happening today.

The Stage 2 Meaningful Use requirements, which begin as early as fiscal year 2014, call on eligible providers and hospitals to increase the interoperability of clinical data and adopt standardized data formats to ensure disparate EHR systems are capable of information sharing.

The following are six high-level areas of the Stage 2 rules to consider during your preparations. These areas underscore how clinical data interoperability will change and impact IT infrastructure:

1. Interoperability of clinical data is no longer optional. Hospitals are required to connect with disparate EHR systems and send clinical information electronically for at least 10 percent of its discharges.
2. Vendor software certified for 2014 clinical data interoperability criteria will produce and consume a consolidated CDA (C-CDA) document (one specification). The C-CDA document must contain medications, allergies, and problem list elements as well as many other clinical data elements. The majority of the clinical data elements in the C-CDA have single, well-defined coding system requirements. For example, the SNOMED CT July 2012 release for a problem list. Thus, all vendors will speak the same language.
3. Transmission specifications to other systems for Stage 2 include only “e-mail” (SMTP) and cross-domain sharing format (XDS). These do not require costly and complex HL7 interfaces and instead just configuration to make connections for data flow.
4. Vendor software certified for 2014 clinical data reconciliation criteria will be able to import and reconcile home medications, allergies, and problem list elements as discrete, codified data. The ability to reconcile discrete, codified data in conjunction with the C-CDA and transmission standards nearly eliminates vendor and technical obstacles to clinical data sharing. The coding standards also eliminate some of the complexities. Vendors will likely have to map the data into their systems to support drug-to-drug and drug-to-allergy checking.
5. Hospitals must have ongoing submission of reportable labs, syndromic surveillance, and immunization information unless there is no entity present that can accept and exchange this data. This bi-directional information sharing is largely at the local level, meaning the abilities on hand to perform this function in a production state will vary. The requirement of these three submission measures is a significant change from Stage1, which only required one data sharing test and failure of that was an acceptable option.
6. Patients must have electronic access to their records within 36 hours of discharge. Eligible entities must provide a patient portal that enables the patient to view, download, and transmit information. This Stage 2 criteria now mandate providers to encourage patients to make behavioral changes accessing their own data. The information that feeds these patient portals must be available within 36 hours of discharge. Therefore, key workflow modifications ensuring appropriate timing are a top priority.

Ali Rana, MBA, MCITP, CISSP is manager of implementation and integration services and client services for T-System, Inc. of Dallas, TX.

Readers Write 11/14/12

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

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

Formal HIT Education
By Deborah Kohn

I read with interest HIStalk’s news regarding Georgia Tech’s free online health informatics class in the cloud and Mr.HIStalk’s comment, "This looks really good, especially for folks who don’t have a lot of formal healthcare IT education on their resume."

This led me to research four-year baccalaureate degree programs in health information technology (HIT), where I expected students in such programs to earn a BS degree, a Health Information Technologist title, and, perhaps be ready to sit for a rigorous certification exam.

No such programs exist in US colleges and universities – online, on-campus, or combination – as far as I know, except perhaps one at Miami (Ohio) University’s regional campuses. (note: I am not referring to four-year baccalaureate degree programs in health information management or HIM, which are complementary to but different from four-year baccalaureate degree programs in HIT.)

Largely due to 2009 ARRA/HITECH dollars (workforce training), many two-year, community college-based HIT programs exist (before the dollars run out), where students earn an AA degree (or similar), a Health Information Technician title, and are ready to sit for the Department of Health and Human Resources’ HITPro exam. (A certification is not conferred upon successfully passing the HITPro exam.) Unfortunately, contrary to expectations and because of lack of experience, most of these students cannot find jobs.

Many excellent one-to-two-year, post-baccalaureate degree programs exist in health informatics (e.g., Georgia Tech), whereby graduate students (typically clinical) earn either a MS degree or similar or a certificate, allowing the student to officially wear the Health Informaticist title (Nurse Informaticist, MD Informaticist, etc.).

As a college undergrad, I earned a BS degree in medical record science (today, health information management). My program in medical record administration was part of the university’s Allied Health Professionals Division. General Arts and Sciences Division requirements (English composition, sociology, chemistry, biology, etc.) plus anatomy and physiology consumed our freshman and sophomore years. Many of our junior and senior year courses were shared with the Allied Health Professionals Division’s undergrad nurses, pharmacists, lab technologists, dieticians, etc. The remaining courses were specific to HIM (ICD coding, records management, etc.). All Allied Health Professionals Division students experienced a minimum of four months practice in a hospital in the nursing, lab, pharmacy, dietary, and medical records departments.  

I graduated the university with a Medical Record Administrator title and was prepared to sit for a rigorous exam that, upon passing, allowed me to be certified as a Registered Record Administrator (today, Registered Health Information Administrator – RHIA). Similarly, my fellow student nurses, pharmacists, lab technologists, dieticians,etc., became RNs, RPhs, RDs, etc.  In general, we went directly into good-paying jobs as entry-level — but at least semi-experienced — healthcare professionals.

As a graduate student, I had few options except to pursue a masters degree in Health Services and Hospital Administration (or similar), which I do not regret. However, today, those with BS degrees in the healthcare professions can pursue advanced degrees in health informatics, highlighting advanced skills, knowledge, and experience in healthcare and in IT. 

Consequently, I am proposing that four-year colleges and universities, working with or without existing two-year college HIT programs promoting Health Information Technicians, consider offering sorely-needed, workforce HIT programs promoting Health Information Technologists (like lab technologists). Subsequently, graduating students could sit for certification exams and become registered. (This is a subject for another article that would address those associations that would be able and willing to manage the testing.)  

These healthcare information technologist programs would allow the BS-degreed, graduating Health Information Technologist (registered or not) to gain required experience in the HIT industry and, if interested, to choose an HIT advancement and graduate path in health informatics.

In addition, I propose that these four-year, baccalaureate degree programs be incorporated into universities’ existing four-year, Allied Health Professional Divisions. Unfortunately, I learned from one public university with such a division that it is difficult to get the right parties to agree to offer new degree programs at the undergraduate level. I learned from one private university with such a division that undergraduate programs do not generate enough revenue to justify adding new programs, and only post-graduate programs do. Perhaps an accredited online university that is willing to keep the cost reasonable and can quickly establish a program also should be proposed, although program quality might be a concern.

Who or what entity is willing to take me up on my proposal? 

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

Value of Meaningful Use Funds Debated at IHT2 Conference
By James Harris

“History will not look positively on how the meaningful use funds were spent,” said Dale Sanders, senior vice president, Healthcare Quality Catalyst, at a November 7 IHT2 Conference in Los Angeles.

The panel was discussing the current status of healthcare analytics. Several panelists, including Sanders, said the $30 billion federal program had erred by not including more incentives for providers to use analytics.

Sanders said a “substantial” proportion of the EHR Meaningful Use fund had gone to large hospitals which had already purchased or planned to purchase an EHR system. “The program has served to further entrench Epic and Cerner” as the dominant systems in the hospital industry, Sanders said. This is unfortunate because neither company has shown a willingness to “opening their API” to outside vendors with analytic programs.

All of the panelists agreed that analytic programs held significant potential to reduce both clinical and administrative costs in hospitals.

According to Steve Margolis, MD, MBA, chief medical informatics officer of Adventist Health Systems, the newest types of analytic programs will offer “visual discovery tools,” which he described as being like Amazon’s system of suggesting additional purchase items based upon the consumer’s buying habits.

Margolis said in the future analytic programs will give “each individual provider, whether she’s in the ER, kitchen, or NICU, will get her own individual ‘dashboard.’” This dashboard would contain specific KPIs for the individual position to help in decision making.

Sanders noted that the most significant barrier to widespread adoption of analytics was the current economic model in healthcare. “Until we move to paying for quality, not quantity,” there is little incentive for hospitals to use analytics.

He added that the “I” in CIO should stand for “analytics.” Margolis countered that many CIOs felt the “I” stood for “insecure.”

In the conference’s opening keynote speech, Brent James MD, chief quality officer and executive director of  Institute for Health Care Delivery Research of Intermountain Healthcare, noted the vast amount of waste in the US healthcare system.

James said $2.83 trillion was spent on healthcare in one recent year and about 50 percent, or some $1.5 trillion, was “wasted.”

He said studies showed that 32 percent of all clinical care was “inappropriate,” meaning unnecessary or without proven clinical benefit.

James said “nobody in healthcare believes we will not be seeing major payments cuts” in the future. He urged healthcare executives to study the principles of W. Edward Deming, the famed engineer and management theoretician.

James said the old advice to American manufacturers, “Do Deming or Die,” takes on new meaning in US healthcare. He said the retail and auto industries have shown that “quality drives down costs.”

James Harris is president of Westside Public Relations.

It Takes One Bad Apple…
By Fernando Martinez, PhD, FHIMSS

I recently hosted an information assurance webinar that focused on security and audit and control functions that are frequently overlooked by healthcare organizations. In order to establish the appropriate context for the discussion, I began by reviewing notable trends and statistics regarding experiences around data security in the industry.

For example, in recent years, almost 21 million patient records have been implicated in reported breaches of electronic protected health information (ePHI). The statistics included a brief review of civil and criminal penalties for HIPAA-related violations which apply to covered entities and business associates alike.

Although the primary industry and regulatory focus has been on covered entities such as providers and healthcare organizations, compliance expectations have also matured and expanded to now include business associates. While business associate agreements are by design typically an affirmation that the business associate agrees to comply with some degree of security and related controls, not until recently have audits been directed specifically to business associates. The expectation is that the business associate has the same level of accountability as the covered entity when it comes to safeguarding ePHI.

Although it seems that some of the impetus for the heightened focus on business associates is related to consumer complaints about HIPAA violations or perceived violations, it is safe to conclude that regulators recognize the need to audit business associates simply because a relationship exists with one or more covered entities. Business associates are expected to conform to the same level of HIPAA compliance as covered entities where applicable, which in turn suggests that a properly designed, executed, and monitored management program must be in place by the business associate.

At the annual NIST/OCR conference held in June 2012, several presentations reinforced the point that a dedicated focus is going to be directed toward business associates. Evidence of this heightened focus is demonstrated in a Wall Street Journal article which appeared late July 2012. A complaint was initiated by the Attorney General of Minnesota directed at a service provider that was implicated in a security breach associated with patients from two local hospitals. The article reported that without admitting to any of the allegations, the service provider agreed to settle out of court. The terms of the settlement speak to the significant risk of not adequately managing compliance with security and privacy standards.

The settlement included the following terms:

1. The provider will pay $2.5 million to the state of Minnesota as part of a restitution fund to compensate patients
2. The provider must cease operations within Minnesota for a two-year period (the company voluntarily decided to cease operations in the state)
3. If the provider wants to do business within Minnesota after the two-year exclusion period, it must first obtain the consent of the state’s Attorney General

The fallout from the incident also resulted in the resignations of several of the provider’s executives, the loss of an estimated $20-$25 million in projected annual revenue, and a 56 percent drop in the stock price of the company.

Fernando Martinez, PhD, FHIMSS is national practice director, enterprise information assurance at Beacon Partners of Weymouth, MA.

The Seven Most Important Soft Skills for Healthcare IT Consultants
By Frank Myeroff

Google “soft skills” and you’ll find that they are defined as the cluster of personality traits, social graces, communication, language, personal habits, friendliness, and optimism that characterize relationships with other people.

While soft skills are a fairly new emphasis in healthcare IT, today’s job candidates and project consultants are either landing or losing positions based on them. Healthcare IT hiring managers regularly ask me about our consultants’ soft skills and consider them as important as their occupational and technological skills.

Therefore, in the event you are interviewing people or even currently seeking a new healthcare IT position yourself, you will need to understand or even demonstrate that there are a number of the soft skills required to be successful on the job. So my best advice to you — get in touch with your soft side and hone these skills quickly!

With that in mind, here are seven top soft skills considered vital for healthcare IT consultants:

1. Excellent communication skills. Emphasis is being placed on IT professionals who are not only articulate, but who are also active listeners and can communicate with any audience. Good communicators are able to build bridges with colleagues, customers, and vendors.
2. Strong work ethic. Organizations benefit greatly when their people are reliable, have initiative, work hard, and are diligent. Workers exhibiting a good work ethic are usually selected for more responsibility and promotions.
3. Positive work attitude. Wanting to do a good job and willing to work extra hours is highly valued. In general, a person having a positive work attitude is more productive and is always thinking how to make things easier and more enjoyable. Plus a positive attitude is catchy.
4. Problem-solving skills. Today’s businesses want IT professionals who can adapt to new situations and demonstrate that they can creatively solve problems when they arise. To be considered for a management or leadership role, problem-solving skills are a must.
5. Acting as a team player. Clearly a worker who knows how to cooperate with others is an asset. They understand the importance of everyone being on the same page in order to achieve organizational goals.
6. Dealing with difficult personalities. Businesses want people who are capable of handling all types of difficult people and situations. Healthcare IT workers who succeed in this area are in great demand.
7. Flexibility and adaptability. The business and IT climates change quickly. Job descriptions are becoming more fluid. Therefore, professionals who are able to adapt to changing environments and take on new duties are becoming more valued in the workplace. Those who rely on technical skills alone limit how much they can contribute.

The importance of soft skills in a healthcare IT environment cannot be stressed enough. Healthcare organizations link them to job performance and career success. Having the right soft skills mean the difference between people who can do the job and those who can actually get the job done.

Frank Myeroff is managing partner of Direct Consulting Associates of Solon, OH.

My View from the Other Side
By Vendor Nurse

I have worked in and around the vendor world for about 13 years now. But last month was my first experience as a patient in a practice just going live on an EMR (Greenway). In one day, I experienced two doctor visits. Both had recently adopted an EHR.

The first was a dermatologist using Greenway. My appointment was at 1:00 p.m. I arrived a bit early, was asked to fill out several pages of forms, including patient registration forms, PMH, ROS, etc. I was called back to the front desk window four times to answer questions about race and ethnicity, insurance, and I forget what else.

My nurse (MA, really) finally took me back to the exam room at 1:35 p.m. and started to ask me all the questions I had just filled out. When I said, "It’s all on the forms," she said, "I know, but I have to ask you anyway." As she typed into the laptop, she sat at a diagonal but did not face me or make much eye contact and seemed more interested in entering the documentation than me. Of course, I get that, but geez it didn’t feel good.

The second appointment was with my PCP for URI symptoms. They are a major academic healthcare center and are going live on Epic (who isn’t?)…their third EMR! This doc was a little more fluent with an EMR, but sat with her back to me the whole time. She handed me a patient care summary and e-prescribed my medications, but forgot to print the referral for a mammogram.

Somewhere during that visit I was given information about the patient portal, which I had been waiting for a long time. As it happened, I had a couple of questions come up within the week and absolutely loved being able to send a message and get a response within an hour or two. This rocks! No more automated phone messages that go on so long I can’t even remember why or who I called.

Anyway, just thought I’d share my personal experience with EHRs. I have to say it will help me as I work with other physicians going live on their EHR.