Readers Write 10/29/12

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.

It’s Only One Extra Click
By Jonathan A. Handler, MD

Clinicians swear an oath to put patients first, so why is it so difficult to get them to adopt new processes and technologies designed to improve care? Perhaps my experience during the SARS outbreak can provide some insights.

In the middle of the SARS outbreak, I was the director of emergency medicine informatics at a large hospital in the heart of a major city. A tourist with SARS would likely come to our ED. SARS disproportionately affects caregivers, and our ED nurses serve as our first line of defense when working in triage. Since I had written our ED’s tracking system, they begged me to add a SARS screening tool. I refused, saying it would add work and they wouldn’t use it.

Persistent, they mounted a campaign to convince me. The screening required only a few questions. Only the first question needed to be answered if the patient had no fever. I could build it right into their existing workflow. It might save patient and caregiver lives. A compelling argument.

So I did it. We added just a single click to the workflow in the vast majority of cases.

Of the thousands of patients triaged the next week, on what percentage did the nurses do the single click needed to answer that first question on fever? One percent. What was the click rate for patients with a chief complaint of fever? Zero.

In a world of increasing patient volumes and decreasing staffing, time spent on health information technology (HIT) is largely an “unfunded mandate.” Many caregivers are overwhelmed, with literally not a second left to spare. Each second spent on an additional click must be stolen from something else. Faced with the choice of clicking a button to note that the current patient does not have a rare disease versus triaging the next acutely ill patient, the extra click loses almost every time. And rightly so.

Early HIT efforts (e.g. digital labs and EKGs, PACS) dramatically improved care and saved time for caregivers. More recent HIT (e.g. electronic documentation) has largely stolen time from caregivers without improving outcomes. Our hubris has been our belief that all HIT offers enough value to justify encroaching on direct care activities such as talking to patients, administering medications, and performing life-saving procedures.

Despite clearly proven benefit, for 150 years we’ve been unable to get clinicians to consistently wash their hands. Now we take away fast and easy paper and dictation, replace them with electronic health records (EHRs) driven by slow and clunky keyboard and mouse, ask clinicians to document more than ever, and we expect rapid adoption?

Not going to happen. When asked, clinicians will agree to anything that might improve care. When time is short, they will prioritize tasks in order of perceived importance. Care will supersede documentation and quality initiatives that are not relevant to the immediate need.

One therapeutic prescription: things that save time for clinicians – such as badge and biometric login, single sign-on, context management, transcription services, speech recognition with natural language understanding, analytics, mobile access, and seamless integration with the local health information exchange – must be considered “mandatory pre-requisites.”

Right now, most consider these “nice to have some day.” The issue is much more than clinician resistance: patients are suffering from delays in care due to EHRs, and too often the promise of HIT is not being realized. When we recognize that one extra click is nearly always one too many, we (and our patients!) will have taken the first step on the road to recovery.

Jonathan Handler, MD is chief medical information officer at MModal.

Prepare Now for More Patient Requests for Medicare’s Annual Wellness Visit
By Averel B. Snyder, MD

Medicare records show that less than seven percent of people aged 65 and older have taken advantage of the Medicare Annual Wellness Visit (AWV). While it’s surprising that so few patients are receiving this important benefit, what’s even more alarming is that many seniors don’t know the AWV is even available. In fact, another study conducted by the John A. Hartford Foundation found only 32 percent of seniors are even aware of the benefit.

As more seniors become aware of the AWV and its benefits, these statistics will undoubtedly rise—and quickly. There’s no better time to prepare than now, as Medicare’s Open Enrollment period is now underway, and more than 49 million Medicare beneficiaries are being inundated with literature about all Medicare benefits, including the AWV. Physicians must be prepared not only to answer patient questions about the AWV, but also to provide the service efficiently and effectively.

The AWV includes specific components that address all aspects of a senior’s health status—physical and mental. A comprehensive AWV involves not only a review of a patient’s medical history and medications, but also a conversation about his or her functional ability and lifestyle issues that impact health. A list of risk factors, conditions, and treatment options must be established. Cognitive function must be assessed, and a 5-10 year preventive screening schedule created.

Until now, many physicians have been hesitant to offer the time-intensive AWV. That’s certainly understandable, given the challenge the hour-long visit poses to physicians who have limited time to visit with patients, especially when ongoing acute care visits are a priority. Fortunately, there are steps that can be taken now to get ready to accommodate a growing number of patient requests for this benefit.

• Step 1: Use a non-physician practitioner (NPP) to conduct the AWV. The Affordable Care Act allows NPPs to deliver the service—which in turn enables physicians to focus on problem-oriented visits.
• Step 2: Automate the process as much as possible with an electronic solution that identifies age- and gender-appropriate health screenings based on the patient’s health risk assessment (HRA). This solution can also dynamically generate a personalized prevention plan, order screenings or tests indicated during the AWV and make necessary referrals. If you have an electronic medical record (EHR) system, the solution should be integrated. This reduces documentation time, ensures an accurate patient health record, and prompts physicians to ask questions at follow-up visits based on the wellness visit recommendations.

Because a key component of the AWV is a personalized preventive health plan that’s updated each year, it’s also important to use a solution that provides recommendations for areas such as nutrition and exercise that are based on accepted guidelines and protocols. That way, you don’t have to have a number of staff members on hand who are trained to address those specialty areas.

Every year, the government spends $500 billion to treat Medicare patients impacted by chronic conditions. Many of the most costly chronic conditions — including heart failure, coronary heart disease, and diabetes — can be easily prevented with routine screening, which is what the AWV is designed to ensure. NPPs and technology can help physician practices offer this valuable benefit to patients in an efficient and cost-effective manner, and as a result, improve the quality of patient care and the level of patient satisfaction.

Averel B. Snyder, MD is co-founder and chief medical officer of Senior Wellness Solutions

Throw MU Out the Window!
By Darius LaGrippe

I don’t watch the presidential debates because they are irrelevant. I already know who I am voting for, and I’m certain the adorable concerns of swing voters are of no interest to me.

On the other hand, I sure do like to start a debate from time to time. Like right now.

It could be argued that the introduction of MU has destroyed more jobs than it has created. MU might be the cause of incredible amounts of lost patient information. MU might even be taking technology backwards.

Let’s face it. Smaller vendors with tighter budgets don’t have the free cash flow like that of larger corporations for development and marketing expenses, which denies startups and small vendors competitive resources for meeting the newest regulatory mandates, not to mention the Meaningless Use requirements that reimburse physicians for adopting electronic health records.

Unfortunately, those small, down-to-earth, client-focused private vendors ultimately dissolve or are absorbed. In my opinion, the products being acquired often are better than the larger companies’ product offerings, but when you answer to the stockholders, the
clients are there for your benefit. So who cares about the product?

Adopting electronic health records is very costly. Especially when the chief benefactors are ultimately the larger EHR vendors sucking up the stimulus milk shake through the government straw. With all these EHR products on the outs, who is responsible for maintaining that software and database you paid eleventy-thousand dollars for three years ago?

Not the vendor, because they are off the hook when your maintenance agreement expires, and they are not offering a renewal for your product. What kind of crappy loophole is this? During this realization, you might scream out loud like me, exclaiming, “This should be unlawful!”

The vendors are bound by the same HIPAA requirements as doctors and can be held accountable for HIPAA breaches. Last I knew, HIPAA had a six-year retention requirement, which follows federal statute for limitations for civil penalties(42 CFR Part 1003). If the physicians are required to maintain those records, shouldn’t the vendors be held to the same standard? Of course they should. Vendors should be required to either support and maintain those records for six years from when the product is shelved during “end of life cycle” or provide a comprehensive migration path for those clients at very little cost.

However, being a victim of an acquisition shouldn’t automatically force the physicians into a product they don’t want. The physicians shouldn’t be pigeonholed into a downgrade, upgrade, or migration. They should have the option to refuse the new product and seek a new one. Physicians should be able to demand their patients’ data from the vendor in a reasonable amount of time. Vendors should relinquish ownership of the patient data to the clients so they can at least explore their own migration path.

We’re talking about people’s health. Their lives. The records shouldn’t suffer the same attrition as the employees of the acquisitions, and the demise of the EHR shouldn’t be an albatross around physicians’ necks.

If the intentions of the HIT stimulus were to engage patients in their healthcare, provide physicians means to better electronic systems, and possibly even boost the economy, they are doing it wrong. That $19 billion should have been invested into the smaller companies to help produce better, cheaper technology at a faster pace and to keep the industry competitive. Instead we see attrition, poorly integrated products with no better standards than we had four years ago, and innumerable amounts of lost patient records.

Readers Write 10/17/12

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.

ONC Moves on Data at Rest
By Frank Poggio

ONC recently published the draft of the new Stage 2 certification criteria for data at rest — or as they call it, End User Device Encryption Test Procedure 170.314(d)(7). With the almost weekly stories about stolen notebooks, lost thumb drives, and missing data CDs while the new HIPAA audits get underway, this new criteria are no surprise. But as understandable as the ONC goals are, the implementation of 170.314(d)(7) may give system vendors fits.

Per the published ONC test script, there are two ways for a vendor to meet this criteria:

1. If, while your Complete EHR or EHR Module is active you allow data to be moved to external devices, then your system must do it using a FIPS 140-2 (AES 256) encryption algorithm. The data on the device must stay encrypted and only be allowed to be de-encrypted by authorized personnel. Encryption must be the default setting.
2. Or, your system must prohibit any movement of PHI data to external devices.

To pass the new Device Encryption test procedure, you must have either one of the above capabilities embedded in your system.

Here are just a few possible problems you might encounter from a vendor’s perspective under Scenario 1.

If you are currently using a full system encryption tool such as BitLocker under Windows, this will not work for external devices, so you’ll have to move to other third party products such as TruCrypt or 7Zip.

If within your application you support user-generated SQL searches and tools like Crystal Reports, then the reports that the user generates will only be allowed to be copied to external devices (thumb drives, note books, tablets, etc.) if the reports are properly encrypted. The same is true for images, care notes, instructions, etc.

It can get more complicated if you have a patient portal and allow me to download my personal info to my personnel tablet. Will you encrypt the download? And then give me the key to allow me to view my information after I have signed off from your portal? Will my tablet support your encryption tool? If on the other hand you (the vendor) do not support downloads, yet I undertake that step on my own (e.g. use screen print), then per ONC the vendor is not responsible.

If all that seems too complicated to deal with, as noted earlier, you could go for Option 2 and prohibit any movement of PHI to external devices. You allow clients to see reports on screen but not move /copy them. No transfers to Excel or Crystal and no screen dumps. Already I can hear the roar of client complaints.

On a positive note, ONC does say that the vendor must supply the provider with this capability, but it is up to the provider to use it. This new criteria also state if a provider manages to accesses your application data outside your application, you are not responsible.

Finally, included in the last set of Stage 2 test criteria there was a another new one called ‘Safety Enhanced Design’ (170.314(g)(3). I’ll cover that one next time. You can see all the new Stage 2 test criteria here.

Frank L. Poggio is president of The Kelzon Group.

RTLS Offers Value Beyond Asset Tracking to Healthcare Facilities of All Sizes
By Barry Cobbley

HIMSS Analytics Vice President John Hoyt was recently interviewed regarding Real-time Locating Systems (RTLS) for an article that appeared at mhimss.org and healthcareitnews.com. The premise of the article is true enough—that RTLS offers significant ROI as well as improvements to patient safety, yet adoption among hospitals is lower than it should be.

However, other assertions simply miss the mark.

First and foremost, RTLS is discussed primarily in terms of asset tracking. It’s a common use, but forward-thinking healthcare organizations use it for so much more. Mr. Hoyt does mention “patient tracking,” but only as a way to relay completed stages of a patient’s visit to family. The article even goes so far to state that “RFID/RTLS has a lot to offer—but primarily only to hospitals—big ones, at that.”

This couldn’t be further from the truth. Large facilities like The Johns Hopkins Hospital will reap huge value from RTLS, but there’s plenty of evidence that small- and medium-size facilities benefit as well, and the value goes far beyond simple asset tracking.

What Mr. Hoyt seems to miss is that RTLS is not just about tracking. It’s about making healthcare more efficient through workflow automation. In this way, RTLS addresses a fundamental challenge that all healthcare organizations are facing: how to do more with less.

Large and small emergency departments, hospital operating rooms, outpatient clinics, ambulatory surgery centers (ASCs), long-term care facilities, and others successfully use RTLS to improve processes, giving providers more time with patients while increasing volume. They’ve reduced patient wait times and increased patient satisfaction. They’ve nearly eliminated phone calls and search times for patients, assets, and other staff members, allowing more time to focus on the patient. And in one of the most impressive use cases, they’ve automated EMRs, relieving skilled clinicians of tedious data entry.

I agree with Mr. Hoyt that the rate of RTLS adoption would certainly be higher in a healthcare landscape not focused on regulatory compliance. But the fact of the matter is that nearly one in five hospitals have already adopted this technology without a mandate. In other words, based strictly on merit. Those organizations that are truly internalizing the need to operate more efficiently are at the head of the adoption curve.

Take for example Memorial Hospital Miramar, a 178-bed facility in Florida, the first to automate Epic EMR with RTLS. Thanks to their work, RTLS was highlighted as a hot technology recently at Epic UGM. The integration automates the entry of important patient data normally typed manually into Epic (patient arrival, nurse/doc assignment, room/bed assignment, nurse/doc assessment complete, discharge time, etc.)

EMR automation is just one of several ways Memorial Miramar leverages RTLS. This community hospital is one of many who see the big picture of healthcare IT, where technology like RTLS improves efficiency and enhances patient care—far beyond finding assets.

Barry Cobbley is director of location solutions of Versus Technology of Traverse City, MI.

Strategies for Healthcare’s Successful Transition into the BYOD Era
By Brent Lang

Bring Your Own Device (BYOD) is a hot topic as companies across all industries are increasingly faced with allowing employees to use their own smartphones, tablets, and other mobile devices for work purposes. Within the healthcare industry, there continues to be a rise in the number of busy physicians, nurses, and other healthcare professionals who have consolidated their mobile devices to streamline the use for both work and personal into one. In fact, a recent survey of mobile device usage indicates that 84 percent of individuals across all industries use the same smartphone for personal and work issues.[i]

Despite this demand, security concerns have led hospitals and health systems to embrace BYOD in varying degrees. Some organizations permit employees within designated departments to use personal devices, while requiring other employees to use company devices designed specifically for unique healthcare settings. For instance, purpose-built devices or in-building wireless phones are relatively easy to manage, secure, and clean. Conversely, there can be great variation in employee personal devices and operating systems. This lack of uniformity will place an increased burden on IT departments as they seek to configure, manage, and implement both security and network changes on a plethora of devices.

Fortunately, various strategies exist to mitigate the risk caused by this rich diversity of mobile devices entering the healthcare work environment. For example, the use of Mobile Device Management (MDM) software, which can include password protection, software control, version management, remote wiping, inventory, and other security controls. MDM tools can also be used to create “enterprise partitions” in personal devices. This allows for an individual’s work-related applications and data to reside on a secured partition within the device, easily managed by the hospital or health system. Organizations may also consider storing patient information on a centralized enterprise server rather than on the individual device, or creating wireless local area networks (WLANs) specifically for personal devices to help limit network access.

Additionally, executives tasked with health IT purchasing decisions should only partner with healthcare communications vendors that make their applications “BYOD ready.” In certain circumstances, this will include encrypting all data while “at rest” and “in motion” and providing remote wipe capabilities. Vendors should also have the ability to monitor the security of their corporate data.

By and large, BYOD is having an impact on companies across all industries. Its evolution has unique meaning in healthcare, where a generation of internet savvy physicians, nurses, and other clinicians are bringing the promise of mobile technology to the bedside. To ensure the successful transition of the healthcare industry into the BYOD era, hospitals and health systems must carefully consider and adopt policy, software and infrastructure controls, and educational initiatives.

[i]Weber, M. (2012, August 14). BYOD Survey Results: Employees are not playing it safe with company data. 

Brent Lang is president and COO of Vocera Communications of San Jose, CA.

 ICD-10: Time to Act
By John Pitsikoulis

Now that the ICD-10 implementation deadline has been extended to October 1, 2014, time is ticking away as we move closer to the date. The extension was a reaction to intense pressure from the American Medical Association (AMA), hospitals, and others who reported that they need more time to implement the extensive changes. As the deadline loomed, many hospital leaders admitted that their organizations weren’t prepared for the ICD-10 transition.

Now that we have an extension, how can providers use the time wisely, especially as they are contending with other competing and conflicting priorities such as electronic health records projects, Meaningful Use deadlines, and IT system replacements that impact the abilities of organizations to stay on task with their ICD-10 activities? Now is the time for hospitals to go into overdrive and concentrate on their planning, strategic decisions and implementation activities.

Developing the ICD-10 project plan for complying with the deadline is the first step many organizations have accomplished. While there are some great resources for organizations to utilize for managing the assessment and implementation key remediation components, many organizations are relying on a “check the box” methodology for readiness and mitigating the risks associated with the conversion to ICD-10. While this is a good framework for project managing the global tasks associated with ICD-10 initiatives, this approach will not provide the organization with alternative strategic considerations or the content expertise that will complement the organization’s portfolio of strategic initiatives. The average organization’s resources are stretched so thin, they just do not have the bandwidth of personnel to manage all of the activities required to mitigate the risks.

Managing a multi-year enterprise-wide initiative is a monumental initiative that requires planning, preparation, collaboration, progress evaluations, and alternative decisions throughout the project’s life cycle. With any multi-year enterprise project, periodic evaluations of the plan, progress, and timelines are critical success factors for achieving the desired end goals. But how are you measuring the end goals?

For example; there is an industry shortage of medical record coders. The simple answer to meet the demands of the industry would be to train more coders. This might be a solution for the productivity issues associated with ICD-10, but how many CFOs would be comfortable with entry-level coders determining the organization’s reimbursement? Coding is more complex than simply assigning a code from a coding book – it takes years of education, training, and mentoring to be a seasoned coding resource. You may have met the goal of providing education and training, but do you have the confidence that after the coders, physicians, and other contributors are educated they will achieve the same level of proficiency they obtained with the ICD-9 system? Managing the clinical documentation specificity and coding quality requirements will be a continuous process that will require dedicated resources focused on clinical documentation improvement, operational process improvement, and financial analysis to ensure the organization is receiving the appropriate reimbursement under ICD-10.

How will your organization test for ICD-10? We know the testing focus for ICD-10 will be fundamentally different than 5010 testing. Even with the 5010 experience, the industry learned that validating the end result was not sufficient and a significant amount of content modification was required. ICD-10 will require changes to the IT infrastructure, which is the foundation for the organization’s business processes. More importantly, the content of the business transactions that are the core of the healthcare delivery, reimbursement, and data outcome models is being replaced with a new set of coding standards.

Standard testing for compliance with format and content will not be enough for a seamless transition. End-to-end testing with payors and trading partners will require a detailed inspection of the claims submission and adjudication transaction process, both from an internal and external methodology, to ensure that business intent and reimbursement requirements meet the anticipated results.

Testing functionality and content with payors will be a challenge that will be costly from a dollars and resources perspective. Close enough is not good enough when talking about revenue neutrality and compliance with billing guidelines. ICD-10 testing will certainly need to include end-to-end, cross-functional, bi-directional, internal and external testing activities. Additionally, ICD-10 will require coupling testing analytics with ICD-10 coding expertise to validate the results of the test transactions and expected revenue outcomes.

Hospitals must also take a hard look at their strategic approach when it comes to the ICD-10 transformation of the organization’s processes and technology. Emphasis must be placed on the tactical approach for education, clinical documentation improvement, testing, and data outcomes, etc. Organizations that focus on content and desired outcomes and not merely the steps to complete a task will achieve the benefit s of a highly trained workforce and a strategic and comprehensive ICD-10 business transition that covers every major impact area.

John Pitsikoulis is ICD-10 practice leader for CTG Health Solutions of Buffalo, NY.

Seven Things Most Important to Top Performers
By Frank Myeroff

Can you relate?

Recently, a leading HR organization conducted a survey of top performing professionals at a wide variety of organizations in order to understand what they find most important to them on their jobs. Overall top performers ranked the following seven as the most important things to them (industry or practice area did not matter):

1. Challenging and meaningful work. Top performers want to be engaged and energized by their work and organization. In addition, people generally want to feel a sense of achievement, responsibility, and to know that what they’re doing on a daily basis has some purpose behind it.
2. Compensation. Top performers want to make top dollar, and salaries that include bonuses and benefits ranked as very important. Also, regular performance reviews and salary reviews were included as part of compensation.
3. Job security. While job security is hard to come by these days, it is important for workers to avoid layoffs and declining salaries. Therefore, top performers found it important to have up-to-date skills, follow industry trends, and keep pace with their industry in order to bolster their job security.
4. Work-life balance. Top performers are looking for synergy between their personal and professional lives. The 8 a.m. to 5 p.m. schedule isn’t for everyone. They appreciate having a say over when they work and sometimes even where they work, including from home.
5. Career development. Technology innovations and fast-changing trends in any field are hard to keep up with. That’s why top performers value ongoing career development and training. It enhances their capabilities and sharpens their skills.
6. Leadership style. A manager’s leadership style is critical to a satisfactory work environment and production levels. To keep the best and brightest engaged in their jobs and performing at high levels, managers need to provide support, resources, and opportunities.
7. Advancement. A promotion is viewed as important and desirable because of the impact it has on pay, authority, responsibility, and the ability to influence broader organizational decision making. In addition, a promotion raises the status of an employee because it is a visible sign of esteem from the employer.

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

Readers Write 9/26/12

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

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

Weaknesses Revealed:  Secrets Exposed by Data Integrity Summary Reports
By Beth Haenke Just

The data integrity summary report is one of the most powerful – yet underutilized – tools hospitals have at their disposal for maintaining the integrity of the data within their MPI. Digging deeper into the statistics provided in these reports reveals far more than the volume of overlaid or duplicate records within the system. It can also reveal areas of weaknesses that, left unchecked, could threaten the long-term integrity of the MPI, limit its usefulness in achieving quality and safety goals and Meaningful Use, and hamper participation in ACOs and HIEs.

In addition to pinpointing the root cause of data integrity issues, summary reports can identify specific areas upon which hospitals should focus corrective efforts. These may include improved education and training, policy clarification, enhanced communication, and other steps that result in fewer duplicates and overlays for a more accurate MPI and improved data integrity.

Regular reviews of summary reports can also reveal patterns of errors. For example, too many null or empty fields in certain records can signal problems with registration processes. Drilling down deeper, data integrity statistics can be used to track errors with greater specificity, such as identification of incorrect patients, transposed Social Security numbers, or non-compliance with naming conventions. Data integrity reports can even provide detailed insight into the specific types of errors that are happening most frequently within individual departments or facilities and even enterprise-wide.

Once patterns are identified, individual cases can be closely examined to pinpoint where additional training or policy refreshers might be required. Coupling the data integrity summary report with advanced analytics tools allows hospitals to determine precisely where errors are entering the system and the specific types of mistakes being made. This, in turn, allows education programs to be customized to strengthen specific areas of weakness.

For example, if the summary report reveals an unusually large number of registration errors being made within a short period of time, a hospital can drill down into the data to determine the department where the mistakes are originating, as well as who is making them, why, and how. Often the culprit is an individual who is unfamiliar with the registration process and who is attempting to save time by creating new records for every patient versus first searching the MPI for existing ones. Additional training and education will significantly reduce, and in some cases eliminate, these types of registration errors.

The integrity of patient identity data is critical to achieving care quality and safety goals and plays an integral role in the success of HIEs and ACOs. By taking advantage of the wealth of information found within summary reports, hospitals and health systems can ensure the long-term integrity of their data.

Beth Haenke Just, MBA, RHIA, FAHIMA is CEO and president of Just Associates of Centennial, CO.

Round Peg in a Square Hole: Behavioral Health and EMRs
By Kathy Krypel

Implementing an EMR for behavioral health is like putting a round peg in a square hole. Yes, you read that right: a round peg in a square hole (the opposite of the traditional analogy). The EMR (round peg) can fit, but unless certain steps are taken, it won’t fill the behavioral health (square hole) need entirely. Those steps that need to be taken include:collecting the appropriate data and offering the behavioral specific tools and care plans for optimal diagnosis and care delivery.

Why does it matter? Since many large hospital systems offer behavioral health services as part of their continuum of care, it is important to fill in the gaps and variances around the EMR. The following are just a few examples of why it is important to offer behavioral care services that are supported by a robust EMR:

• One in eight (or nearly 12 million) ER visits in the US are due to mental health and/or substance use problems in adults.¹ This is the most costly venue for care delivery.
• Major depression is considered equivalent, in terms of its burden on society, to blindness or paraplegia. Schizophrenia is equivalent to quadriplegia.²

What are these behavioral healthcare EMR gaps and variances?

1. Providers. Most behavioral health providers are not MDs. In fact, primary care physicians spend limited time with patients and are often hesitant to diagnose and treat behavioral concerns. Most behavioral health providers are clinicians with Masters or Doctorate degrees who have been licensed by their state(s) to diagnose and treat behavioral health disorders.
2. The diagnostic process and tools. Behavioral health disorders are the only serious, chronic illnesses that are diagnosed based solely on self report. The tools used to assess the behavioral health patient’s mental status and substance abuse patterns are very different than the traditional medical diagnostic tools of imaging and lab work. Behavioral health diagnostic tools are most often elaborate question and answer tools that are can be both clinician-administered and self-administered. Behavioral health clinicians use tools such as the Beck Depression Inventory (BDI), Generalized Anxiety Disorder scale (GAD 7), and the Diagnostic and Statistical Manual (DSM IV). These tools need to be incorporated into the data capture and workflow built into an EMR. Additionally, behavioral health providers are required to develop elaborate treatment plans with the patient’s participation. Non-behaviorally focused EMRs typically don’t have tools built in for this and must be built (or ignored). If ignored, the EMR becomes nothing more than a word processor.
3. Customization will always be required. While there are multiple behavioral health specific EMR vendors in the marketplace and enterprise-wide EMRs that can be configured to cover behavioral health, customization will be required to meet multiple state-specific mandates, practitioner specialty requirements, and federal privacy rules that apply to behavioral health.

Although there are challenges, successes are growing. The following recommendations help to ensure a positive implementation outcome:

• Create a small but specific implementation team that aligns with your behavioral health leadership during the build and test period, so all build and testing work is completed in a collaborative manner.
• Build using the most commonly used diagnoses and their DSM IV criteria into the EMR to make it easy for providers and therapists to use drop-down lists to create the diagnostic picture of the patient.
• Build using ASAM criteria, so chemical dependency staffs can more easily complete treatment planning.
• Design within the “tighter than HIPAA” federal constraints that govern confidentiality of patient information for patients receiving chemical dependency treatment (i.e., CFR 42).
• Involve trainers and testers in the workflow discussions.

In order to avoid putting a round peg in a square hole, it’s essential to understand the variances in the behavioral health setting and address them in workflow, data capture, information exchange, provider engagement, and administrative requirements and incorporate them into the EMR project plan, design, and implementation.

Sources:

1. Mental Disorders and/or Substance Abuse Related to One of Every Eight Emergency Department Cases. AHRQ News and Numbers, July 8, 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/nn/nn070810.htm

2. Disability Adjusted Life Year, DALY, Daly 2004

Kathy Krypel is master advisor at Aspen Advisors of Pittsburgh, PA.

Data Virtualization Best Practices Accelerate Time to Value
By Richard Cramer

Data virtualization offers a value proposition that quickly excites business leaders and technologists alike. Business executives are enthusiastic because data virtualization enables IT departments to more quickly respond to new requirements – often in days or weeks rather than months or quarters. Information technologists are similarly excited about being able to get more done, more quickly, and deliver higher value to their business customers.

However, unless we’re careful, this same enthusiasm can lead to organizations trying to use data visualization where it’s not appropriate and results in a classic “square peg in a round hole” situation. It is important to keep in mind that while data virtualization is an important part of the data management tool kit, it is not the right tool for every purpose, and doesn’t eliminate the need for a traditional data warehouse.

Successful deployments of data virtualization share some common characteristics. First is that data virtualization is most successful when it complements a mature data management infrastructure, development standards, and implementation processes. Best practice in these organizations is to use data virtualization as a part of an overall data management life-cycle where data mapping logic that had been built in the virtual solution is seamlessly reused in the physicalized data integration solution.

Second, there are specific use cases where data virtualization is most appropriate. Best practice is to vet candidate uses of data virtualization against these use cases. Just because data virtualization can be used does not mean it should be used.

This is particularly true in the early stages of adopting data virtualization technology, since missteps in using data virtualization for inappropriate use cases in the first project or two can give the technology a black eye that is hard to overcome later.

Good use cases for data virtualization share the following characteristics: (a) data needs are of a short duration; (b) business requirements are unclear or evolving; and (c) situations where quickly prototyping a view of integrated data is required.

Situations where data virtualization is not a good fit include: (a) complex join logic is required; (b) high performance query response is a driving requirement; or (c) source system availability is unreliable or unpredictable.

In this context of best practices, it is exciting to see the healthcare industry providing many opportunities where data virtualization can be a key enabler of organizations looking to maximize their return on data. There are a large number of healthcare organizations with traditional enterprise data warehouse solutions in place, and that can most benefit from the addition of data virtualization to their architecture.

There are also many examples of use cases that are appropriate for data virtualization and can quickly deliver high value. For example, data virtualization can be used to accelerate drug research by providing scientists with integrated views of internal and external information to aid in the drug discovery process. The unpredictable nature of discovery can be enabled by virtualized data integration solutions—quickly combining lesser-known external data with well-known internal data speeds up the decision-making process and ultimately reduces the time to bring new drugs to market.

For healthcare providers, the ability to respond to ambiguous and frequently changing data requirements in a rapidly changing regulatory and business environment is a must. The rapid prototyping enabled by data virtualization can be invaluable in meeting fleeting reporting and data needs today that may be gone or completely different tomorrow. 

Richard Cramer is chief healthcare strategist of Informatica Corporation of Redwood City, CA.

Coordinating Physician and Nursing Care
By David Lareau

Historically, physician and nursing systems and workflow have often been parallel, but independent of each other. Physicians and nurses must be able to share information to provide coordination of care.

For example, physicians must comply with standards such as ICD-10, ICD-9, SNOMED CT, RxNorm, LOINC, DSM-IV, and CPT, while nurses employ terminology like NANDA, NIC, NOC, ICNP, PNDS, and CCC. With so many different standards in place, creating an integrated picture of patient care can be difficult at best.

Fortunately, all of these standards have already been mapped to link physician and nursing information. The capability now exists to integrate physician and nursing documentation and care capabilities as well as provide links between a patient’s clinical diagnoses and nursing care.

To create this functionality, all existing nursing standards were evaluated to identify the best candidate for use at the point of care in computerized systems. The Clinical Care Classification (CCC) system was selected and 182 CCC Nursing Diagnoses were linked to the more than 55,000 clinical diagnoses. Linking the CCC and clinical diagnoses makes it possible for all members of the care team to generate a list of nursing diagnoses based on the physician’s clinical diagnoses for that patient.

In addition, CCC Nursing Diagnoses are linked to CCC Nursing Interventions and to more than 1,760 specific nursing actions. Also, a starter set of customizable documentation protocols has been developed for each of the nursing actions.

One of the most significant aspects of this work is that the same concepts in the nursing protocols are linked to the physician content where appropriate. Coordination of care has arrived.

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

Readers Write 9/10/12

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.

I Am the BOSS!
By Bill Rieger

There is no question who the boss is around here. I earned the office with two — count ’em, two — windows.  My paycheck is at the top of the pile and serves as a paperweight for the rest of them. The CEO and I swap stories about how great we are. I am the one in front of the board every month reviewing IT strategy and direction. Make no mistake about it, I am the man!

Ever work for anyone like this? Maybe you still do, although it may not be this obvious. Or, are you yourself like this?  

WAKE UP! The time for career oppression is over.

Change is happening faster than ever. We no longer have the luxury of centuries, decades, months, weeks, days, or even hours to adapt. While back in the day it took just about 2,000 years to invent the stethoscope after discovering that heartbeats do actually have clinical meaning, today a discovery can reach millions of scientists around the globe in seconds.

Have you seen some of the "Did you know" videos that illustrate the rapid pace of change today? Certainly not all of them are validated, but it makes you think, doesn’t it? One of the statistics I like is about text messages. The first commercial text message was sent in December 1992. Today the number of text messages sent and received every day exceeds the total population of the planet. 

The point? As stated before, change is here and it is coming faster every day. If you think you can manage the change of this generation alone, you will cut short yourself, your organization, your community, and all of those you influence.

At our hospital, a member of the IS leadership team had previously been exposed to the Clifton Strength Finders book. Their idea was to purchase it for all IS staff members to help them find their strengths. This led to a whole mindset shift of the IS leadership team, including me. Instead of focusing on what we don’t have, let’s determine what we do have and capitalize on it.  

What a difference it has made. All staff members who participated have proudly tacked their list of strengths to their cubicle or office. The entire IS leadership team from supervisors on up have gone on to read Go Put Your Strengths To Work to help align staff member roles with their strengths.

From here, it is a work in progress. I am fully confident that many more ideas will come from this and we will continue to focus on and better use the strengths of the team. What if I would have said, "Great, Chris, now go back to your office and get me the budget report?" or something else insignificant in comparison? Where would the department be? Where would the organization be, as this concept is certainly leaking out of the IS department?  

Healthcare is in the beginning of great change and healthcare IT is in the middle of frantic change. As the stethoscope example indicated, healthcare changes slowly. After all, change in healthcare is risky. My response to that is that indeed change can be risky. In order to mitigate that risk, you cannot — I cannot — be the big shot in the corner office. 

You have to — I have to — seek out who can best help manage the seemingly unmanageable change that is coming. The talent exists. It is up to leadership to draw out those strengths that will be needed.  Leadership should be seen as a springboard, not as a ceiling.

When Abraham Lincoln worked hard to free the slaves, his original idea was to "free" them from their oppressors and then send them to Jamaica or Cuba where they could be "free." When some of the slaves were freed, they asked to be able to fight for and with the Union. That was great, and in response, they were given shovels and uniforms. When they asked for weapons, they were originally told that they could not have them. It literally took an act of Congress to get weapons in the hands of the newly freed slaves. The fear was that they would turn on their oppressors. What actually happened is that they fought with honor and courage and played a vital role in the final defeat of the Confederate army.

That is exactly what I believe some leaders are like: afraid to empower their teams, afraid they will turn on them when they lose control of them. If you want to see an empowered employee, bring them to the CEO’s office, the next board meeting, or the next department meeting and give them credit for a great idea. Watch their world change as they grow in front of your eyes.  

How many more ideas will be born of that one? How many light bulbs and stethoscopes will be created from simply giving credit where it is due? As a result of our Strength Finders journey, the IS org chart changed. The CIO and the directors are at the bottom, supporting those who are above. The ceilings are gone. Fly, people, fly! 

Bill Rieger is CIO of Flagler Hospital of St. Augustine, FL.

Moving from Care Following Technology to Technology Following Care
By John Haughton MD, MS

How is it the feds have paid out $5.7 billion for Meaningful Use Stage 1 incentives and we are still missing community-wide patient views and shared care plans accessible across EHRs and mobile devices for acute providers or across providers and payers working to enhance coordination of care or across acute and post-acute providers engaged in streamlining health delivery effectiveness?

The answer is threefold, but simple. Standards-based interoperability using discrete data is hard. Available EMRs, at their core, were designed with an encounter and billing perspective rather than a discrete patient level portable data and shared care focus due to business and legal needs. Technology in the standalone, client-server / web screen-sharing world is not designed for moving data across systems.

Integration and processing of discrete data across populations requires dynamic community views of information coming from multiple sources to realize the true value of shared care – better coordination, pre-crisis intervention, and decreased redundant care delivery. To date, incentives and needs haven’t requested the collaborative care technology infrastructure. That’s changing.

Enter the cloud and native Internet applications integrated with secure cloud information brokers, cloud consumers, and cloud providers. Cloud coordination is front and center in general federal IT acquisition activities. These systems are designed for collaboration and to share information across organizations, systems, and technologies from different vendors in different formats.

True and complete interoperability requires standards that are useful and usable, which are still hard to come by in general and certainly in healthcare. Heck, even a simple one – Medications and RxNorm didn’t allow for the prescription of birth control pills (two in one box) or prenatal vitamins (more than three ingredients in one) until recently. Fortunately, there are ways to use modern security, data, and analytic processes to move information now. Methods that are proven from other industries to work in environments without perfect standards are available to healthcare.

MU 1.0 was a good first step: $2 million or more for hospitals and $18K to start for providers. Money flowed into the system to purchase IT. Even so, the electronic health records purchased by and large don’t talk to each other yet. Even the Beacon Communities are into their third year without real interoperable clinical data from various EMRs (fingers crossed — we should see data movement starting this fall. Lots of folks have been working hard to make it happen.)

Now with MU 2.0 out, the money for change won’t come so much from the same ONC carrot. The majority of incentive dollars will have been earned during MU 1.0. Instead, there’s a new carrot — shared savings rewards in ACOs and other value purchasing — and now a stick in penalties for fee-for-service Medicare payments for a lack of reporting and performing on various quality of care metrics. Additionally, rewards and penalties from commercial insurers are creating narrow networks with less revenue and access for providers at the lower end of the cost-quality matrix.

What is the right design for EHR and community care systems in the evolving world? At a minimum, systems must make sure the data collected is secure, accessible, portable, and interoperable. To make this happen, EHR systems must include the perspective of being part of a network — part of a data fabric — at their core.

Newly emphasized functions from MU 2 for collaborative care include: data formatting; content normalization; patient-level information aggregation – in discrete, standardized elements – attributable to sources; population analytics for opportunity identification and effectiveness measurement; workflow that includes access to information at a place where it can be used; and collaborative communication across teams. Expanded decision support rules are useful for clinical care, financial management, and measurement and reporting for payment based on value.

As we move forward, the biggest change will be a change in design mindset for electronic health records, from one of monolithic, vendor-specific islands of technology to a connected ecosystem of secure data collection, portability, display, aggregation, and access across the community, across payers and providers, across patients and their caregivers , across healthcare and the general community.

Change is unstoppable as we move to networked healthcare. That’s good, but it’s tiring. In the new world, providers will no longer be dependent on singular big IT infrastructure as secure, clean, portable data and identity coupled with lighter-weight modules, interoperable widgets and applets solve real problems. Vendors will open communication channels as a strategic asset rather than “wall the garden.” Monolithic HIE umbrellas will fade as government initiatives — such as Direct for the patient and Query Health for the population — continue to gain traction as front and center techniques for simplifying interoperability and shared care tasks.

What will be needed? Outside of healthcare, the federal government has a framework. It’s moving into the cloud – a framework that includes cloud suppliers and cloud brokers – to ensure a secure, reliable interoperability experience. In fact, it is the cornerstone of the federal strategic plan for technology and information management: increasing usability and access to information while decreasing the complexity and cost of information technology. Why should healthcare be any different?

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

Patient Engagement
By Kim South, RN

With the new Stage 2 Meaningful Use rules finalized and released, patient engagement is becoming a major focus. Can providers control that their patients are logging in online to view their medical information? Can providers control their patients to the point of sending secure messages? Everywhere I turn, these are the questions I am hearing. 

The short, quick answer is, “Of course we can’t control them.” That’s also the answer the people who are asking the questions are searching for. 

On the surface, it’s an accurate answer. We can’t control our patients. We can’t make them engage in their care. We can’t make them be interested in losing weight or quitting smoking. But we do have the potential to influence their behaviors and encourage them to be our partners in their health.

As an oncology nurse, I spent hours every day talking with my patients and their family members about what was discussed in the recent office visit. It’s so much foreign information to take in, remember, and explain to others. Online access to this information has the potential to seriously reduce office time spent in this role, which translates directly into the nurse’s ability to focus on other tasks. 

I’m no longer a practicing oncology nurse, but it’s where my heart lives. Being on the vendor side now, my patients are always in the back of mind: what would benefit them, what would make their burden less, what would make them feel more in control of this disease process? Patients with chronic diseases are hungry for information. What better information to supply them with than their own? It makes perfect sense to me. 

I’m sure I’m in the minority, but I actually see this transparency with medical records as a benefit to both the patients and the medical personnel who care for them. Fewer phone calls about what was said, secure messaging to answer questions that would be a phone call interrupting a clinic, the ability for patients to visually see their health. It’s very powerful stuff and why I stay in the healthcare field — to make a difference for the patients.

Can we control patients? No, but we sure can influence them. I could sell online access to my cancer patients in a heartbeat. Online access to their office visit information, online access to their lab results, online access to send me a question as they think of it regardless of the time. 

The 5% threshold to meet these measures is very attainable. Having the right tool to enable your patients to participate in their health is core, but those tools already exist. As a medical community we need to embrace patient engagement and give our patients the tools to be intelligent about their health.

Kim South, RN is product manager of Jardogs, LLC of Springfield, IL.

Readers Write 9/3/12

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.

Routine Killer
By Bill Rieger

I was at a conference recently. Before I left, I was looking forward to getting away and enjoying the sights, sounds, and energy of Chicago. The first few days were awesome, filled with several miles on foot experiencing the Magnificent Mile, Navy Pier, Lake Michigan waterfront, and several good restaurants. 

By the third day, I started to feel “it.” I wasn’t sure what "it" was, but I knew it was uncomfortable and it was starting to impact my trip. By Friday, I was drop-dead ready to return home. You know that feeling. Tired, "problems" because of way too much restaurant food (OK, maybe that’s too much information, but it’s true), and sorely missing my wife and kids. 

The weekend was great and very busy. The weekend before the first day back to school is always crazy, but compound that with the fact that I had been gone all week and still hadn’t resolved what "it" was, I could have been a better husband and father.  

I got up Monday at 5:00, hit the shower, made the coffee, read for 30 minutes, prayed, got the kids up, made breakfast, got dressed, and walked out the door headed to my drive (which always includes a podcast of something educational or uplifting). It hit me. I figured out what "it" was. My routine had got way out of whack.  

As I started to consider this more, books I have read that speak to the significance of routine started running through my squirrel cage.  Podcasts I listened to and personal conversations I have had that reinforced purposefully creating a schedule started reverberating through my head.

One of the best books I have ever read relating to personal growth and development is The Compound Effect by Darren Hardy. He reveals a formula that I have adopted as a way to manage my own growth: 

Choice + Behavior + Habit + Compounded (over time) = Goals

The funny thing about this formula is that if you remove one of the addends, the sum could be reduced dramatically. The lack of routine in my trip, I believe, decreased my effectiveness on the trip. As a result, I didn’t get as much out of it or pour as much into it as I could have.  

As I continued to reflect on this, I started looking around me at who I influence: my wife, my kids, my co-workers, my team. The trip I took, at least to some degree or another, impacted their ability to achieve those goals that I’m helping them with. I am not saying here that the world revolves around me (or any one of us specifically), but we do have an impact on those around us. Even if you cancel the weekly meeting ahead of time, the routine is broken when you aren’t there. According to the formula, there is an impact.

This reflection has been a good one for me. The next time I travel, I will develop a schedule and routine for the trip. The next time I have to cancel a standing meeting with a staff member, I will try to think about how that is impacting the routine that is built into that relationship.

Routines and habits make up who you are. Our lives are defined by how we spend out time, talents, and treasures, I want to be as responsible and accountable as possible for all of these areas of life.

The takeaway: Routines have impact.  If you do not have habits or routines, take the time to make up daily routines and you will experience growth. The people around you will benefit immensely. I have a schedule I use as a template that I would be glad to share. E-mail me at bieger@gmail.com.

Bill Rieger is CIO of Flagler Hospital of St. Augustine, FL.

It Doesn’t Matter if Allscripts is “Open” – Their API is a Game-Changer
By Jonathan Baran

More and more vendors are thinking about going "open" — turning their EMR into a platform for third-party application developers. Allscripts is the first major EMR vendor to the party. Because of it, they are taking criticism for whether they are truly "open."

I’m here to say that it doesn’t matter if you call Allscripts open or not. Their API will create an ecosystem of innovation that will both solve provider needs and increase vendor revenue.

My company has first-hand experience with their API. This is what we’ve learned:

The Allscripts API removes the burden of integration away from the health system IT staff

For an EMR app to be truly useful, it will require data. In a pre-API world, you can use HL7 or a Web client to get some data, but what does it cost? It seems like regardless of how simple the project is, it will take three months of IT time. When tacked onto a list that is already 12 months long, there is a lot of waiting for an innovation to reach the light of day.

Compare this with an Allscripts world. Want to get an application integrated? Call your Allscripts sales rep and the app will be integrated that afternoon. The integration has been completed once with Allscripts API, which means it can scale to all their users on that single product. This simple elimination of IT time could have a profound impact on the pace of new technology adoption.

By using an API, applications can work in the background, minimizing the training and go-live time

Now that you have gotten the application integrated, it’s time to train the users. But of course that will not be easy, because HL7/Web client are a good source of clinical data, but demand a disjointed experience for the user. This requires awkward steps like seeing websites “embedded” in the EMR, having to click a button to transfer data, requiring users to copy and paste text, or needing to have a completely separate application. Even the simplest process becomes difficult when you’re asking users to take these pseudo-integration steps. I know this because we did it. Ugly.

Compare that with Allscripts. Everything can be done in the background. Want to pull tasks out of a task list and read the patient’s medication list? Want to have everything happen automatically in the background with no clicks? Done. It is easy to see how this could impact training and go-live. In the first example, every staff member in the organization needs to be trained on the "new system.” In the second, they don’t even need to know it is happening.

API level access means that your product can fit within the end users existing workflows

Workflow change is hard – really hard. The only easy way to change a workflow is to get rid of it. Eliminate steps. Remove clicks. How can you do this when by definition you are adding something? The answer is "addition by subtraction.” By getting deeper levels of integration, workflows can actually be made better.

This is only a small sample of the benefits that come to mind. Others include piloting (“Dr. CMIO, would you like to try the solution out this afternoon?”) and the App Store (find new apps in a single marketplace).

Jonathan Baran is co-founder and CEO of Healthfinch of Madison, WI.

EHR Donation and Accountable Care
By Jed Batchelder

I’m working with a healthcare system that is in the process of developing an EHR subsidy for the independent affiliated physicians in their community. They’ve just made a large IT investment, including EHR and HIE, and have started building a platform to help deliver accountable care.

Right now the challenge is how to structure the subsidy so it is attractive enough to entice physician adoption while remaining fiscally responsible for the sponsoring entity.

Much of industry is still living in the fee-for-service world, which is perfectly understandable given that’s how we get paid today. But we need to imagine and prepare for how that is all going to change in the coming years and make the right decisions now to prepare for it. We have the unenviable task of having to live and pay the bills in the fee-for-service world while investing in an infrastructure for the next value-based world.

Imagine you own a large retail store in the year 1997 and are trying to decide how much money to spend on web sites, computers, e-commerce solutions, and Internet connectivity. You can already hear the disagreement in the budget meetings and smell the fear in the room. You can’t yet see how the web is going to transform how you conduct your business, how sales transactions will occur, and how you’ll get paid.  

All of your revenue comes from customers who walk in the door of your stores, but you keep hearing about this thing called the World Wide Web and e-commerce that is supposed to be the next big thing. You could take a wait and see approach, possibly allowing a disruptive innovator like Amazon or Zappos to take your market share. Or you could pause and notice the ways that the world is already changing. (Best Buy just reported a 90% drop in earnings last quarter.) In a bricks and mortar retail model, large IT investments can initially look reckless, but once that new world arrives, you’re relieved that you took the risk.

When viewed solely from the view of the numbers, the EHR subsidy doesn’t make a ton of sense in the fee-for-service model. In fact, it looks more like a charity. But what happens when you look at it through a value-based ACO model, where providers will be compensated based on how well they jointly take care of patients, how well they coordinate the care, and how healthy their patients are? Just as it was difficult to predict the extent that the Internet would transform commerce, it is difficult to imagine what care will look like in a post fee-for-service world.

These points support both the idea that the hospital should take on more of the cost and the idea that independent docs should put more skin in the game, lessening the financial burden on the sponsoring hospital system. How far should we move the slider? How much skin should both sides put in? Who is more at risk by not having the connectivity and common platform? Who stands to gain the most and lose the most? These are perhaps the most pressing questions.

Jed Batchelder is an independent healthcare IT consultant.

Readers Write 8/15/12

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

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

A Letter from Michael Stearns, MD

As many of you know, I was until recently the president and CEO of e-MDs, Inc. an ambulatory EHR vendor. I joined e-MDs in 2006 as their CMO and was promoted to president and then president and CEO in 2007 and 2008. Through 2011, my tenure at e-MDs was marked by significant increases in revenue.

On July 2, 2012, I was abruptly removed from my position with e-MDs for reasons undisclosed, other than a vague inference to company policy violations. e-MDs has refused several requests to disclose the details of these alleged infractions or the names of those involved, making it impossible to respond or to provide essential information that would allow me to clear my name. 

Unfortunately, e-MDs took the unusual step of publishing a press release that contained information based on false allegations that have not been subject to basic tenets of due process. The rationale for taking such action is difficult to discern. Regardless, I will be relentless in my pursuit of the facts. I remain confident that information will eventually emerge that will exonerate me completely. 

Due to a very unfortunate situation that occurred while I was a Navy medical officer roughly two decades ago, I have learned to be particularly sensitive to my conduct in the workplace. In summary, I found myself caught up in the fallout from the Tailhook scandal of 1991 that resulted in hundreds of naval officers having their careers damaged or destroyed, as detailed in this Duke Law Journal article.

Staffing shortages in the Navy resulted in a lack of available female chaperones, and female patients made a number of complaints. One of my patients, a female seeking disability for unexplained loss of genito-rectal sensation, bladder dysfunction, and lower extremity weakness, complained that my examinations had been overly detailed on two separate occasions. An investigation of my conduct with female patients over a four-year period led to two other complaints emerging, but the overwhelming majority of patients reported that I was “one of the most caring and thorough physicians they had ever known.” 

During the investigation, a number of facts emerged that shed doubt on the validity of the claims made by these individuals. Given the post-Tailhook atmosphere, there was a great deal of pressure on the commanding officer not to demonstrate leniency in any matter of this nature. I was given the option of either fighting the allegations in court or submitting my resignation in lieu of charges. However, under a subsequent threat of media attention, they reneged on the resignation offer and filed indecent assault changes.

My military counsel, after a cursory fact-finding effort, informed me that given the hysterical climate created by Tailhook — regardless of my guilt or innocence — I would be found guilty and could spend up to 15 years in prison. I was told my only realistic option was to accept a time-sensitive plea offer that reduced the charges to the misdemeanor equivalents of simple assault and battery. In return, I would also be found formally not guilty of the indecent assault charges, including any reference to inappropriate sexual touching. I was also informed by my attorney that the plea bargain would not result in a loss of my medical license, based on direct communication she had with the Maryland Board of Physician Quality Assurance (MBPQA).

A MBPQA review body recommended that my license be suspended for six months and the suspension stayed. However, after a protracted and acrimonious process, the MBPQA removed my license to practice medicine for a minimum of one year. Perhaps most disappointing to me, especially in light of the fallout from the Tailhook scandal, was that, despite my pleadings, the MBPQA did not perform an independent investigation that would have revealed a number of exculpatory findings of fact. Making matters worse, the published MBPQA order contains false information that has never been corrected. I was found formally not guilty of indecent assault and all language to that effect was removed from the guilty pleas. Despite this, the MBPQA order states that my guilty pleas arose from inappropriate sexual touching, something for which I was actually found innocent.  

My former employer, to their credit, conducted their own independent investigation in 2010 to address the facts surrounding the MBPQA orders. e-MDs went so far as to speak with a physician who served alongside me in the Navy and who corroborated the information I provided to them. They concluded that the process had been unfair and biased and published their findings on their website for over a year. HIStalk republished their findings in this article. 

Due to the age of information and easy availability of this erroneous MBPQA order, a number of individuals have drawn incorrect conclusions regarding the facts and actual findings of law based on the MBPQA orders. I appreciate HIStalk giving me the opportunity to address this in a public forum and I am hopeful that the MBPQA successor, the Maryland Medical Board, will correct the errors in these documents.

While always conducting myself in a respectful way, I have learned to be cautious and somewhat guarded in my professional interactions over the 18 years that have passed since this situation arose. Thus, I was stunned to hear of the vague allegations brought forth by e-MDs. 

During my leadership, e-MDs was increasingly seen as a company willing to contribute substantially to core informatics efforts driving advances in healthcare and clinical research. In addition to running a company that saw a roughly 15-20% annual increase in revenue during my tenure, I represented e-MDs on multiple boards and played a direct role in informatics, policy, standards, interoperability, genomics, coding, patient safety, patient privacy, compliance, and educational efforts related to HIT initiatives; gave over 100 educations presentations; provided five testimonies to various work groups of the ONC; and was invited to a private White House town hall meeting on HIT in June of this year.

It is disheartening to believe that a company to which I dedicated more than five years to would publish something so vague as to invite innuendo and speculation. The unusual step e-MDs took in publishing conclusions based on a hastily conducted and inexplicably incomplete fact-finding process was highly unfortunate and damaging to my reputation. Knowing that inaction in the face of defamation can cause long-term damage, I have no other choice than to provide corrections through public forums while I work diligently to clear my name.

Michael Stearns, MD.

Response from e-MDs

e-MDs, Inc. removed all the material and information that comprised the web posting “The Truth About Michael Q. Stearns” that had been posted in March of 2010, and this removal occurred immediately following the action taken on July 2, 2012 by e-MDs that completely terminated its affiliation with Michael Q. Stearns.

Both e-MDs, Inc., and Dr. David Winn, each formally retract that entire prior posting statement and want to be very clear that statement should not be relied upon as the current position of e-MDs, Inc. or of Dr. David Winn.

Readers Write 8/8/12

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

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

RTLS: A No Brainer to Enhance Top-Line Revenue and Drive Clinical and Financial Improvements
By Deborah Tuke Bahlman RN

Real-time location systems (RTLS) are underutilized in the health care domain. I consider myself and my organization fortunate to have access to this technology and can’t imagine what life would be like without it.

Just a little over a decade ago, our periop staff, surgeons, and anesthesia teams spent considerable time using the phone to determine the patient’s physical location and stage of care. Communicating this information by phone is inefficient and a waste of precious patient care time, resulting in numerous phone calls, potential delays to surgery, and an environment not conducive to healing and quiet.

At our two large flagship facilities in Oregon, we have more than 75 operating rooms. We have been able to accommodate growth by eliminating inefficiencies — like multiple phone calls — and can now find equipment quickly at the click of a mouse.

To accomplish this, we installed a real-time tracking system. We spent 18 months analyzing workflow and working with the vendor to design the application. We piloted the system in 2002, starting with asset tracking and then expanding it to track patients. This gave us the ability to locate people and equipment in real time and improve workflow, communication, patient throughput, and care delivery efficiency. The ability to instantly locate needed equipment also had a positive impact on the bottom line by reducing unnecessary purchases and rentals.

The benefits have been impressive. There are three key ways a hospital can optimize clinical performance, workflow, revenue, operations, and patient safety with RTLS:

1. Tracking. Being able to quickly identify and track any tagged equipment, staff, or patients anywhere within a facility equates to on-time procedures and efficient use of nurses’ valuable time. It helps staff easily locate assets, maintain an accurate inventory, and adhere to regulatory requirements. RNs typically spend about one hour per shift looking for missing equipment, additional staff, or the actual patient. This unnecessary time contributes to delays in 30% of all scheduled surgeries.
2. Rentals. The average US hospital owns or rents at least twice as many mobile medical devices (pumps, vents, wheelchairs, etc.) than it actually needs. RTLS provides visibility into inventory which enables facilities to better match supply with occupancy and acuity needs, which can eliminate excess inventory and result in significant cost savings.
3. Preventive maintenance. RTLS improves the timeliness of preventive maintenance by providing data that helps hospitals identify process inefficiencies in equipment management including cleaning and sterilization. Up to 25% of mobile assets are not properly cleaned between patients, resulting in hospital-acquired infections that can adversely affect a hospital’s bottom line now that insurers have stopped coverage for those conditions.

It is astounding that only 10% of hospitals have implemented RTLS, which can quickly boost top-line revenue. With health systems wrestling with declining reimbursement rates and increased regulatory mandates and quality improvement initiatives, the pressure to improve operational efficiency and care has never been greater.

For Providence St. Vincent Medical Center and Providence Portland Medical Center, RTLS has been a true asset. We plan to further maximize our RTLS investment by integrating it with our new EMR. The integration will streamline access to lab results, medication lists, and other critical data, positioning us to meet the challenges of the rapidly changing health system.

Deborah Tuke Bahlman RN is system manager of surgery information systems at Providence Health & Services of Renton, WA.

Carrying the Torch
By Guy Scalzi

As part of the Olympic coverage, I’ve learned more about the significance of the Olympic Flame and the journey it takes through the host country before the last torchbearer lights the cauldron at the opening ceremony in the Olympic Stadium, marking the official start of the Games.

As you know, the Olympic Flame stands for peace, unity, and friendship. As part of the London 2012 Games, 8,000 inspirational torchbearers carried the Olympic Flame through more than 1,000 cities, towns, and villages in the UK over a 70-day journey delivering that message: peace, unity, and friendship.

The stories of the torchbearers are inspiring, and the images of the 70-day relay journey are truly breathtaking. I encourage you to read their stories watch some of the relay footage.

You and I both know that it took many more than the 8,000 torchbearers to make this accomplishment possible. Day in and day out, all of us in the HIT field support our torchbearers – the nurses, physicians, and other clinicians at the bedside delivering care. And yes, our flame represents patients and their care quality and outcomes. We all play a part in carrying the torch, and it’s essential to keep our eye on the flame — the patient. The more the human element is kept at the forefront by all of us, the better healthcare will get.

I was invited to the Yale Medical School graduation in 2010 and heard Don Berwick MD speak to the class. He emphasized that the person-to-person, clinician-patient relationship and interactions are possibly the most important part of care giving. Two points he shared struck me:

• “All that matters is the person. The individual. The patient. The poet. The lover. The adventurer. The frightened soul. The wandering mind. The learned mind. The Husband. The Wife. The Son. The Daughter …”
• “Those that suffer need you to be something more than a doctor; they need you to be a healer. And to become a healer, you must do something even more difficult than putting your white coat on. You must take your white coat off. You must recover, embrace and treasure the memory of your shared, frail humanity …”

We in the IT realm don’t interact with patients for the most part, but we do interact a lot with the clinicians who treat the patients. If we listen to them, respect them and their work, and relate on a human level, I think this will translate to a better use of technology and perhaps have a ripple effect.  

As I shared earlier, the more the human element is kept at the forefront by all of us, the better healthcare will get.

Guy Scalzi is a principal with Aspen Advisors.

Four Tips for Addressing Healthcare IT Implementation Costs
By Walter Reid

A recent KPMG poll confirms that hospitals continue to struggle with managing implementation costs of healthcare IT systems, including electronic health records (EHRs). However, hospitals would do well to take a broader look at their entire IT agenda and make a long-term commitment to maximizing value from those investments.  Below are a few ways to better address the healthcare IT implementation challenge. 

1. Get more from the core. It’s been estimated that most providers only use about 50% to 80% of their IT system’s core clinical and revenue cycle features, and many routinely under-invest in learning about new releases. By re-evaluating your core system capabilities, you can analyze whether or not you are fully leveraging existing resources. Such steps will go a long way toward making the most of the technology you already have.
2. Promote from within. If you work with your HR team to develop your own internal “champions of change,” you can drive adoption of clinical informatics and reduce the expense of costly external consultants. That’s not all, as internal champions also can help you further generate – and sustain — system uptake to achieve long-term value. In addition, ensure your systems are readily accessible with easy-to-use applications, based on a familiar industry standard such as Microsoft Windows, as that can further encourage ongoing use of IT.
3. Keep it simple. Select an HIS with fully integrated applications and a single-database design. This will help your organization streamline current solutions, retire dormant third-party applications, and consolidate IT providers. Doing so provides opportunities to reduce acquisition costs, system complexity, and maintenance by requiring less hardware and fewer servers. In addition, systems with a faster deployment period and a lower total cost of ownership help ensure that hospitals achieve cost savings over both the short and long term.
4. Collaborate. Hospitals should expect greater flexibility and collaboration from those entrusted to develop, deliver, and deploy their critical HIS technology. Move beyond just demanding discounts and suggest collaborative win-win solutions that work for both you and your vendor. This includes offering flexible delivery options, new implementation alternatives, and more efficient and effective methods of system training, including using Skype or other web-based methods.

Ultimately, reducing healthcare IT implementation costs starts with IT vendors themselves. Those that demonstrate a willingness to truly partner with you and provide simple, flexible, cost-effective options are best positioned to help you achieve better business and better care.

Walter Reid is vice president of product strategy and marketing with McKesson.

Consumer Reports Points to Opportunity to Improve Patient Communications
By Tim Kelly

I used it before I purchased my last car, digital camera, and just a month ago when I purchased virus protection software. The “it,” of course, is Consumer Reports (CR) magazine. If you are nodding in understanding, you and I are like eight million other Americans who reference that publication to evaluate automobile tires and scrutinize models of the latest electronic gadgets.

It is thus intriguing that CR has, for the first time, introduced hospital ratings in its August issue. Until now, there were few well-known resources to compare one hospital to another. Arguably, both The Leapfrog Group’s Hospital Safety Score program and Health & Human Services’ Hospital Compare website are readily available to prospective patients. However, neither is “mainstream” and familiar to the readers of CNET, Yelp and TripAdvisor.

Consumer Reports readers will immediately recognize the standardized format with which hospitals are ranked. Safety scores are presented as horizontal bars with a numerical value, while the other key rating categories contain familiar red and black blobs. Both metrics are characteristic of CR ratings for hundreds of products and services.

Unlike the cleaning performance of a laundry detergent, the quality of care offered by a hospital is extremely difficult to summarize with only a number and a few shaded circles. Critics will argue that the historical data employed for the CR rankings is by default out of date when presented, imprecise, and limited in scope, failing to provide a complete picture of the organization. Ironically, those same concerns apply to the just-released U.S. News & World Report rankings of Best Hospitals. Yet for 23 years, hospitals have proudly cited their top U.S. News rankings on their organizations’ websites and in their press releases.

Clearly, the difference between the U.S. News approach and the Consumer Reports approach is that as an independent, non-profit organization, the publishers of CR do not hesitate to be critical – even to the extent of identifying the “Bottom 10 Hospitals” in their rankings. CR is also quite comfortable copiously assigning black blobs – its “worst” rating. Nowhere are the black blobs more abundant within the hospital ratings than in the “Communication” category. The CR article reports that not a single hospital earned its top score for communications.

This glaring weakness will have many in the HIT community scratching their heads. Conceivably, patient communications can be improved with proportionally less effort than might be required for other categories, such as rates of hospital-acquired infections or readmissions. A three-year study of 394,000 Kaiser Permanente members, published in the July issue of The American Journal of Managed Care, found that use of Kaiser’s online personal health record tools made patients 2.6 times more likely to remain members of Kaiser. The Kaiser experience demonstrates how technology can easily be deployed to assist patients with better understanding their procedures, how to prepare for surgery, what to do when discharged, and how to take new medications.

Consumer Reports has introduced a new ratings system, one that provides easy-to-understand comparison data on 1,159 hospitals. The ratings are from a recognized, trusted source, and they are presented in a familiar, digestible format. The impact, if any, of CR ratings on consumers’ choice of hospitals is unknown. The opportunity to redouble efforts to deploy HIT initiatives to improve patient communications should be clear to all of us.

Tim Kelly is vice president of Dialog Medical.

Readers Write 8/4/12

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

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

The Doctor Shortage Calls for Innovation
By Jonathan Bush

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

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

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

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

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

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

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

Why Device Connectivity Matters Now
By Dave Dyell

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

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

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

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

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

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

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

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

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

Dave Dyell is founder and CEO of iSirona.

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

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

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

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

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

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

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

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

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

Readers Write 7/20/12

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

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

How Obamacare is Driving Healthcare IT Investment
By Stewart Billings

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

Health Information Exchanges

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

New Payment Paradigms

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

ACOs Will Need Communication Support

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

Even Bigger Data Will Drive Efficiency

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

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

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

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

Actuarial Informatics: An Emerging Field?
By Digital Bean Counter

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

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

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

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

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

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

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

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

Implementing SSO Imposes Greater Pressure on Security

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

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

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

An SSO Implementation is a Long, Drawn Out Project

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

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

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

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

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

An SSO Implementation is Expensive

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

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

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

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

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

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

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

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

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

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

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

And then ONC goes on to state:

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

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

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

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

164.308 (a) Audit Procedure

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

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

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

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

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

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

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

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

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

Frank L. Poggio is president of The Kelzon Group.

Readers Write 7/2/12

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

These are not the same.

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

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

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

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

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

Healthcare Cure?
By Vince Ciotti

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

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

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

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

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

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

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

Readers Write 6/25/12

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

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

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

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

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

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

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

Payback is a CPOE
By Daniela Mahoney

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

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

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

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

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

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

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

Examples of cost:

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

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

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

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

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

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

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

Readers Write 6/6/12

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

Moneyball and the Power of Data Analytics
By Gerard Livaudais

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

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

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

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

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

1. Focus on the Data that Matter

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

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

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

2. Leverage Internal and External Data

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

3. Influence Positive Patient Behavior

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

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

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

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

Gerard Livaudais is chief medical officer of Quantros.

Care in an Emerging Market
By Arvind B. Deshpande

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

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

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

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

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

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

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

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

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

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

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

Why We Do What We Do
By Dan Herman

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

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

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

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

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

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

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

Dan Herman is founder and managing principal of Aspen Advisors.

Readers Write 5/21/12

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Readers Write – National Nurses Week 5/7/12

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

Our Heroes

Captain Donna Rowe and fellow servicemen

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

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

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

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

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

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

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

Baby Kathleen

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Need For Technology

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

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

Reunion and Update

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

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

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

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

Never Forget

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

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

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

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

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

Readers Write 4/25/12

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

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

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

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

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

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

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

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

Let’s begin with discussing the Three Pillars.

The Three Pillars

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

Pillar 1: Best Knowledge Available When Needed

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

Pillar 2: High Adoption and Effective Use

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

Pillar 3: Continuous Improvement of Knowledge and CDS Methods

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

The Five Rights

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

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

The Ten Commandments

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

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

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

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

AHRQ, Approaching Clinical Decision Support in Medication Management

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Readers Write 4/16/12

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Clinical Intelligence to Improve Quality and Reduce Costs
By Michael Weintraub

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

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

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

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

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

Data Management

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

Data Quality Services

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

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

Analytic Technologies

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

Shared Learning Resources

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Readers Write 4/2/12

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ACHE Impressions
By Darkened Room Observer

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The defining quality of a tablet is touch.

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

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

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

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

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

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

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

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