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Readers Write 5/16/11

May 16, 2011 Readers Write Comments Off

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 Four Principles of Getting Things Done Well
By Mark Johnston

There are thousands of self-help and business books out there, each promising to change your life with the author’s “new” and “revolutionary” ideas. But when it really comes down to it, most of these books are based on fads or the repackaging of old knowledge, and are not worth the cover price.

In my experience, someone who’s looking to get more done in their professional and personal lives (and to do it better) can do so by practicing four simple things until they become habit: organization, prioritization, execution and discipline. Let’s take a quick look at each one:

Organization

Is your desk a mess? What about your car? If you answer yes to either of these, chances are your work life is messy, too. To be effective, you must become more organized. My advice? Go clean your desk. Tomorrow, clean your car. The next day, clear out your garage (or, if it’s really that bad, this next weekend).

Then start on your paper-based and electronic documents. Create a logical file structure so that you can find any piece of information you need within seconds. Do you travel a lot? Then keep a pre-packed bag of travel-sized toiletries in your carry-on bag.

Indentify other areas of your business and personal life that are disordered, and do the necessary! Sounds simple, but you’ll be amazed at how much productivity you’ll gain by weeding out disorganization.

Prioritization

In business, particularly at a small company where everyone wears a lot of hats, there are always 101 things to get done. If you think every one is of equal importance, you’ll never get anything done, let alone to the best of your ability.

Instead, write weekly and daily to do lists, with the most crucial things at the top. This crosses over into organization, showing how these principles are closely connected. Again, this may sound patronizing, but to make an impact, you need to get your daily activities in order.

Execution

All the organization and prioritization in the world is useless if you don’t follow through. Know you’ve got to finish writing a report? Block off two hours on your calendar and set your IM status to “busy” so you won’t be disturbed. Create a distraction-free work environment that lends itself to focusing on your priorities, and start checking items off your to-do list.

Procrastination will kill your productivity and decrease your effectiveness in business and in your personal responsibilities. As Nike ads say, “Just do it!”

Discipline

To regain control — over your workspace, your documents, your to dos, your life — takes discipline. Is it fun to reorder every file on your computer and put them in logical folders and subfolders? Is it fun to write detailed lists of your daily and weekly priorities? What about cleaning your desk, garage and car?

No, no and no, but such tasks are effective because they remove mental and physical clutter.

Discipline is the daily practice of doing what needs to be done, and is the umbrella that overarches organization, prioritization, and execution. Discipline doesn’t just apply to work, but also to eating right, working out, and making time for your family. If practiced for a few weeks, discipline becomes a habit that will apply to most situations for the rest of your career and lifetime.

It is all too easy to confine the combination of organization, prioritization, and execution to your office, and to focus so much on work that it becomes the only thing in your world – to the detriment of your family, friendships, and other non-work commitments. Equally, it is possible to let the many responsibilities of your personal life (particularly when you have kids) minimize your efforts in your job.

Both scenarios are examples of imbalances that prevent us from being all we can be. That’s why discipline is so crucial. It enables us to regulate each aspect of our lives so we’re living out a commitment to excellence in everything we do.

The first time I shared these principles with a younger team member I was mentoring, his wife came up to me at a company event and said, “I don’t know what you did to him, but he picks up after himself, our car is clean, and he cleared out the garage for the first time in 10 years!” So, even beyond what they will do for your work life, these principles can make you more popular in your home. And that’s got to be worth something!

Mark Johnston is president of Access of Sulphur Springs, TX.

Building a Healthcare Storage Archive
by Charles Mallio, Jr.

The healthcare storage archive is a centralized repository managed by IT, but made available to all departments throughout the organization. It is home to the approximately 80% of hospital data that is static, unchanging, and best managed in a centralized repository that provides the appropriate protection based on the profile of the data.

This healthcare archive should have the ability to store the data intelligently and to leverage the mix of media assets available in the organization. This includes reserving the highest cost storage assets — typically fiber-channel disk in a storage area network — for the dynamic data and managing static data on more cost-effective media, such as lower-cost disk, optical, tape, or even cloud.

With its storage archive in place, an organization can eliminate storage silos, optimize existing storage assets, facilitate data interoperability, and provide a level of data protection that enhances its disaster recovery strategy. And it does all this while delivering a strong return on investment in existing and future storage infrastructure.

Data Interoperability

With a truly healthcare-aware archive in place, the CIO can collaborate with peer department heads to facilitate enhanced data interoperability of systems. To do this effectively, the archiving solution must leverage healthcare standards by which these systems can interact and fully exploit the benefits of shared data. These standards include:

HL7 (Health Level 7), for the exchange, integration, sharing and retrieval of electronic health information.
DICOM (Digital Imaging and Communications in Medicine), for the storage and transmission of medical images and medical imaging data.
XDS/XDS-I (Cross Enterprise Document Sharing / for Imaging), for the sharing of clinical documents, images, diagnostic reports, and related data.

In addition to the above, the archive should have the ability to index both metadata and content to make that data easily searchable, by both applications and end users.

Data Protection

The healthcare archiving solution must provide safeguards against data loss and security breaches. It may do this by methods inherent to the solution, by leveraging the features of specific storage devices, or by a combination of both. However it achieves these objectives, it should accommodate the following features:

Multiple copies of data, stored on disparate media types in separate locations, will ensure survivability of data in the event of a disaster. The healthcare archive should employ a user-configurable, intelligent policy engine to determine the optimal number of copies and locations
Data replication complements the multi-copy strategy by facilitating mass duplication of entire repositories of data to a secondary location.
Encryption prevents unauthorized access to data in the archive. This is critical for Protected Health Information (PHI), as well as financial records and sensitive communications.
Digital fingerprinting technology ensures that data retrieved from the archive is identical to data committed to the archive, safeguarding against deliberate or accidental data tampering.

The data protection characteristics of the healthcare archive also complement IT’s disaster recovery strategy. While backup is necessary for whole-system retrieval, it is not optimal for the more granular recovery allowed by an archive. Furthermore, backups do not protect against file corruption, whereas an intelligent archive ensures the integrity of the data committed to it.

Return on Investment

By investing in a healthcare archive, hospitals not only gain the aforementioned benefits, but can also realize substantial cost savings. By eliminating storage silos and consolidating expensive primary storage, tier-1 storage assets are no longer underutilized. Thus, hospitals do not pay for expensive storage that sits idle.

Organizations also have more flexibility to employ cheaper storage where the data access profile or data value supports that decision. And by employing intelligent data management policies to move infrequently accessed data to lower-performing, but more energy-efficient devices, they can be more “green” with their storage strategy, which translates into costs saved on power and cooling.

Charles Mallio, Jr. is vice president, product strategy and business development, of BridgeHead Software of Surrey, UK.

IT Governance Remains a Top Organizational Challenge
By Dan Herman

IT governance has been topic of interest for many years. Even though the concept has been embraced within the healthcare industry, the reality is that it’s still not operationally working well within most healthcare organizations.

According to the 22nd Annual HIMSS Leadership Survey released in March 2011, the metrics regarding IT governance look strong at first glance. The majority of respondents (87%) reported that there is a strong level of integration between the IT strategic plan and the organization’s overall strategic plan. In addition, nearly three-quarters of senior IT executives reported that they sit on the executive committee at their organization.

The HIMSS Leadership Survey does a good job of tracking the pulse of the industry, but our industry needs to reevaluate how we measure the effectiveness of IT governance. IT governance should be looked at holistically and not merely whether the IT plan is integrated with the organization’s business plan and whether the CIO sits on the executive team.

Strategic alignment is definitely an important element of IT governance, but having effective committee structures, well-defined roles and responsibilities, specific processes and workflows, and a project portfolio management structure to drive value delivery, measure performance, and manage risk and resources are critical success factors for IT to help the organization achieve its objectives.

In the past three years, we have assisted over 30 clients with their IT strategic planning efforts. In 80% of the cases, enhancing existing IT governance, decision-making, executive sponsorship, and project prioritization processes have been a key focus of the planning effort.

There is a finite set of variables to control: funding, resources, and scope. It’s important to focus on a limited set of major projects that support the organization’s strategic goals. Appropriate alignment of IT resources ensures that IT is spending the organization’s money prudently, and effective IT governance is essential to making that a reality.

Critical success factors for effective IT governance include the careful definition of who is responsible and accountable for decisions. Executive involvement is critically important for holding the clinical and business sponsors, as well as IT leaders, accountable for project success. Executive involvement is also vital for assuring that resources are actually available until projects are completed.

IT should not be the primary sponsors of projects, so clinical and management sponsors must be involved from the beginning as well as the clinicians who will actually use the systems implemented. Executives must also assure adherence to the governance process, so that the benefits of governance are received.

While executive and board involvement is always cited as important in IT governance, translating that into specific roles and responsibilities isn’t easy or obvious. The task is to define roles and responsibilities that result in the effective allocation of resources and in successful projects.

There are a number of considerations in determining committee structure. Authority, time, and expertise are important considerations.

IT governance requires the definition of a process for project proposal, consideration, approval, and management. This process is often closely related to or integrated with the capital budgeting process, especially in terms of the timeline for project approval.

IT governance will not result in successful projects unless effective project management is in place.

In conclusion, governance remains one of the biggest challenges of healthcare IT. Organizations continue to battle with the dilemma of having much more demand for IT services than supply and budget to service. Requests for new projects arrive with typically no effective mechanism to control how projects get prioritized, funded, and resources allocated. IT then gets put in the position where they’re overwhelmed, under-budgeted, and under-delivering.

With the number of competing initiatives on the priority lists of hospital executive teams such as Meaningful Use, ICD-10, and Accountable Care Organization structures and their IT implications, it’s even more essential that a strong governance model be deployed to prioritize initiatives, align projects and capital spend with key organizational priorities, establish the appropriate champions and sponsors to successfully drive the top priorities forward, and define ways to measure results.

Dan Herman is founder and managing principal with Aspen Advisors of Pittsburgh, PA.

Readers Write 5/9/11

May 9, 2011 Readers Write 4 Comments

Nurse Buy-In Essential to ACO Success
By Lisa Reichard, RN, BSN

Though the healthcare technology landscape has changed greatly over the last 10 years, what the clinical nurse cares about most has not: delivering the best care possible to the patient. As National Nurses Week celebrates the caregivers that most would agree form the backbone of healthcare, it is interesting — as an RN who now works on the vendor side of things — to watch the leadership role of nurses evolve, especially in light of the policies behind accountable care. The ACO model will directly affect a nurse’s role at the bedside, or, as mobile technologies may have it, over the phone, via text, or by Skype.

The pending ACO model will be physician driven, true, but it must also include nurses and other providers to improve the quality of healthcare services and reduce costs. Regardless of whether an organization pilots an ACO, gets ready for the Medicare Shared Savings Program, or even chooses to wait and see how ACOs develop, the main cornerstones of ACOs — assumption of clinical risk, improvements in quality care measures, and decreasing costs — will be required of all organizations as the healthcare industry moves through reform. Therefore, nurses will be required to enhance their overall accountability and embrace the role of patient advocates in the ACO model, especially with regard to management of patients’ chronic conditions.

As CMS statistics show, 75-80% of healthcare costs are related to chronic conditions. The impact of the clinical nurse on continuity of care, from emergency room to clinic or physician office to home care, will be crucial to accountable care’s success. So how will this need for greater accountability work its way into a nurse’s already pressure-filled shift? How can administrators, doctors, payers, and even vendors get a nurse to buy in to an ACO?

Vendors tend to emphasize new technology and cost containment surrounding ACO policy as the biggest pieces of the pie when going into a clinical setting. It is important to understand, however, that at first glance, the clinical nurse may be inclined to view ACOs as roadblocks to patient care since they are used to the “treat the illness and hope that patients will comply at home” model now in place. This is where vendors and policy makers can point out and emphasize the benefits of the ACO model – improved patient outcomes and higher quality patient care, which, after all, are what nurses value most.

The time is ripe for nurses to take the lead in defining the way ACOs will deliver. Opportunities abound, including:

Identifying patients at risk for 30-day and multiple readmissions;
Assisting in developing clinical criteria and benchmarks around “The Right Care At The Right Time,” which is central to ACOs;
Increasing the usage and compliance with regards to home monitoring devices;
Ensuring timely care coordination between hospital and community-based providers;
Involving nurses as change agents to improve quality indicator scores;
Taking an active role in delivery models that focus on ongoing care coordination and resultant evaluations of clinical and financial effectiveness;
Developing nurse peer groups and support around new technologies like EMRs and PHRs; and
Helping with the development of quality measures not currently being tracked by CMS. These could include measures for the treatment of cancer, arthritis, osteoporosis, or chronic pain. It will be challenging to create outcome measures that capture all key attributes of successful treatments.

Vendors can assist in this process by walking in the nurses’ shoes, understanding their world and what is at the heart of their work — helping patients to get well and stay well. Coming from this angle of understanding and cooperation, friends will be made, and yes, care will even become accountable.

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

Meaningful Use: A Case for Choosing Cloud-Based Technology
By Russ Keene

On Monday, April 18, a moment that was once among the most hyped in recent health IT memory passed almost unnoticed. That day, the Department of Health and Human Services opened the process for physicians to attest to demonstrating Meaningful Use of an EHR system so they could qualify to receive Medicare incentive payments.

Of the estimated 95,000 physicians now using an EHR system, just 150 stepped forward to attest to achieving Phase 1 Meaningful Use measures.

What gives?

As Douglas Foreman, DO, one of those 150 physicians learned, demonstrating Meaningful Use isn’t difficult. In fact, he exceeded the requirements, and did so within the first 90-day eligibility period.

Foreman’s (and his staff’s) commitment to his patients and to meeting the Core and Menu Set requirements cannot be discounted. But a decision he made in 1997 to use a cloud-based practice management and EHR system gave him a head start.

The term cloud computing is a recent entry to the IT lexicon, but the technology has been around for a while. Cloud-based health IT systems don’t require client-server hardware or for physicians to install special software on each computer. They deliver advanced health IT capabilities through a simple Web browser. System maintenance and upgrades are included in a monthly subscription rate, and delivered seamlessly.

Foreman’s example offers a clear case for physicians to consider cloud-based technologies for their health IT systems and to rid themselves of the archaic client server-based systems which are difficult to upgrade and costly to support.

Foreman received his Meaningful Use upgrade one weekend in May 2010, along with thousands of other doctors. Within days, he said he could see how well-designed technology contributes to his ability to improve patient care while also making it easier to demonstrate Meaningful Use.

However, as Foreman told Physicians Practice, the EHR vendor needs to support physicians’ efforts to demonstrate Meaningful Use. “Your vendor should have a support team. They need to be familiar with the process and support you,” he said.

He’s right. Health IT providers owe it to their clients to help them be successful at demonstrating Meaningful Use, to make using health IT simple and affordable, and to ensure the technology really delivers when it comes to supporting better patient care.

Dr. Foreman was successful because of his commitment to make technology work for his practice and because of the technology that he chose. As a result, he will receive his first payments soon. Meanwhile, tens of thousands of other EHR users are still waiting for their health IT vendor to get around to upgrading the systems in their offices. As those companies know, scaling to meet that demand is exceptionally difficult.

Physicians shopping for an EHR system should ask a couple of questions. If it’s this difficult for the old technology companies to enable their current clients to meet Phase 1 Meaningful Use requirements, how will they fare in preparing even more users for Phases 2 and 3? And, can they realistically support ICD-10 and future regulatory changes that require updates to their software?

Meaningful Use is just one stop on a long ride of technology advancement. As such, the case for “the cloud” is clear.

Minimum upfront investment, lower total cost of ownership, and rapid ROI
Cumulative value and simple interoperability with a wealth of systems and health industry partners
Adaptability to future demands, from ICD-10 to new Meaningful Use rules to additional performance and quality measurement capabilities

It’s time to focus on the needs of the end user. The cloud offers the easiest, fastest, and most economical means for many physicians to implement and use an EHR system.

Russ Keene is vice president of Ingenix CareTracker.

The Power to Fail
By RJ Dio

As good as the fine novel Spooner is by Pete Dexter, it’s Dexter’s bio on the back jacket that pleases me more. Dexter wrote the bio himself and it states:

Pete Dexter began his working life with a US Post office in New Orleans, Louisiana. He wasn’t very good at mail and quit, then caught on as a newspaper reporter in Florida, which he was not very good at, got married, and was not very good at that. In Philadelphia he became a newspaper columnist, which he was pretty good at, and got divorced, which you would have to say he was good at because it only cost $300. Dexter remarried, won the National Book Award, and built a house in the desert so remote that there is no postal service. He’s out there six months a year, pecking away at the typewriter, living proof of the adage “What goes around comes around” –that is, you quit the post office, pal, and the post office quits you.

What can we learn from this (besides using a sense of humor when we can)? Courage. Not many people admit their mistakes, and few of us would be candid in our assessments of ourselves or our efforts.

It takes courage, for example, to admit an HIT project was a disaster, and to candidly discuss how it went wrong, lessons learned, and what can be done to avoid this again. The typical post-mortem that all thoughtful projects (even unsuccessful ones) should use at their conclusion.

Where’s the story on the eight-year Cerner rollout that wasn’t intentionally slotted for eight years, for example? The lowdown on why a vendor would explain poor business intelligence reporting by suggesting the hospital spend close to another million dollars to add CPUs in a database server so the reports will run faster? The honest facts on a clinical workflow software solution that’s a glorified Intranet?

As the woman in the Wendy’s commercial in the 1980s demanded, “Where’s the beef?”

We live in a world where everyone has a raving recommendation on LinkedIn — or maybe 30 — and most of us have written them, too. Meanwhile, we could use a few people to step up courageously with constructive feedback on HIT efforts that lost their way, without permanently judging (or misjudging) those who didn’t succeed. Some great leaders (but not enough) readily say to others, “Let me share some of my mistakes with you so you don’t have to make them, too.”

After all, failure serves a purpose in life, and business, and sometimes it makes us far better than we ever could have been otherwise. It just takes time to know. “A lot of good things in my life came from half my mistakes,” says the songwriter Radney Foster, and I’m right on board with him, (even if I did use too many parentheses in this piece).

Readers Write 4/27/11

April 27, 2011 Readers Write 3 Comments

There is Nothing Normal about the “New Normal”
By Tom Carson

I recently had a conversation with a physician friend of mine. He shared the experience of their hospital system’s EMR implementation for their ambulatory practices, which is, so far, an 18-month project and counting.

This project has resulted in a 12% decrease in physician-generated revenue, 75% of which is attributable to reduced physician productivity. Fewer patient visits, in other words. When I asked what they intended to do about what sounded like a serious problem, he told me, “Nothing. Our administrators are calling this the ‘New Normal’ for production.”

If this had been the first time I heard this explanation, my jaw would have dropped. I mean, really, whoever heard of implementing technology to decrease the productivity of the most expensive resource in the healthcare delivery chain?

As it is, the “New Normal” mantra is being repeated often. Vendors of these products (and their customers) must be hoping it catches on as truth, preserving the reputations of both.

Here is my problem with reduced productivity as a “New Normal.” Management doesn’t really believe it. If they did, hospital administrators in these provider organizations would be reassuring all the physicians involved that to make up for their productivity losses, they would all be given 12% raises and their visit quotas would be reduced accordingly.

No longer would doctors be spending 2-4 hours each day off the clock to catch up on documentation responsibilities made more burdensome by their new system requirements. Instead, the dark side of the “New Normal” is the implied expectation that doctors will suck it up and find a way to return to former levels of productivity, regardless of personal cost. That is simply not sustainable.

Every business leader I know understands the correlation between happy employees and satisfied customers. An unhappy work environment creates stress in all parts of our lives. it is destructively unsustainable for both individuals and the companies that employ them. When doctors are free to practice medicine on their terms, the organizations that employ them can attract better doctors. The result is satisfied patients and better outcomes. This is a positive feedback loop that is sustainable.

I don’t know when this breakdown of honest communication and respect occurred, but it would be in the best interests of patients, physicians, and provider management to fix it. Here are my ideas.

Management, you do not have to settle for a “New Normal” that reduces your economic performance and crushes the enthusiasm of your staff. Ask yourself if you would have made the system purchase under the terms you did if the vendor had explained up front that you should factor in a 12% revenue reduction. If the answer is no, then do your fellow administrators and the industry at large a huge service and start raising Cain. Eventually, your vendor, or his replacement, will honestly address the problems.

I have never seen a documented case in which average physician productivity in an ambulatory setting did not decline following implementation of an EMR system. There are ways to recover productivity outside of the vendor’s design, including the use of virtual scribes, physical scribes, and speech recognition for some physicians. These won’t be free, but they will cost much less than what good physicians cost.

Physicians, you owe it to yourselves to not fall into the trap of believing that you can overcome long-term limitations through the short-term measure of working more hours. You owe it to your management group to provide fact-based feedback on the realities of what is going on at the patient encounter level.

I am not anti-EMR. Far from it. My company has been committed to moving physicians to electronic records for 11 years. However, we have always believed that the transition will work best when working with and for the physicians — not around them.

Tom Carson is president and CEO of MD-IT of Boulder, CO.

Build IT Right
By Guy Scalzi

According to Modern Healthcare’s 32nd annual Construction and Design Survey published March 14, the healthcare construction industry continues to show signs of rebounding. There’s pent-up demand from years of capital freezes that will soon explode, so it’s more important than ever to get the information services right the first time when designing and building any new facility.

Timing is Everything. IT professionals need to be involved as soon as possible in the planning or design specification stage and stay actively plugged in throughout the project.

IT – A Critical Element of Design. IT must be involved before the design specification is generated to define what applications and technology will be used in the space. It’s important that as soon as required work space is estimated, the space needs of the hardware to support the activities are included and the plans reflect those needs. This is the time to get it right, so the workflow will be enhanced by the space, not compromised.

The overall project budget should incorporate IT requirements. Many times, the square footage needs to be reduced or the planned services have to be scaled back to fit within the amount of available dollars. Don’t try to retrofit old IT equipment into the space to save on budget because this technology is often at the end of its life cycle or not powerful enough to run the current software.

Best Practices and Next Practices. The new space should make optimal use of the next release of major software applications and functionality. iPhones and iPads are already being incorporated into new releases of HIS software. This means fewer requirements for viewing data on workstations, but a heightened need for docking stations and additional places to enter data. New space will most likely take advantage of RFID tags and generally richer user interfaces requiring powerful hardware.

Not a Night and Weekend Job. Depending on project size, there needs to be one or more IT staff dedicated from design to opening. Questions will arise on a daily basis, and bad decisions are made when there’s a lack of knowledgeable IT input.

New Sandbox for Strategic IT Direction. This is an opportunity to pilot new processes, systems, and technology. There’s no reason to move workflow, applications, or hardware that are only marginally acceptable, or failing. While beta testing of applications should be avoided, technology that’s proven elsewhere but still new to your organization can be piloted.

Test, Test, and Test Again. A few weeks before the opening, fully staff for two or three days with test patients cycling through the systems, at about half of what’s expected at peak volume. Data can be entered in a test database, so it’s easy to review but won’t interfere with production. Necessary changes can be implemented quickly and be ready for the next test session.

Blanket with Support. On opening day, have as many IT people and vendor staff as possible on site during all hours of operation. While the staff is in a learning mode, they’ll be receptive to new ideas and skills. A lot of progress can be made quickly.

By applying these and other industry best practices, IT can be strong partners in ensuring healthcare facilities meet the needs of patients and practitioners alike.

Guy Scalzi is a principal with Aspen Advisors of Pittsburgh, PA.

Summary of the ONC EHR Usability Meeting 4/21/11
By Vicente Fernandez

”A computer makes it possible to do, in half an hour, tasks which were completely unnecessary to do before.” Larry Wolf, Health IT strategist, Kindred Healthcare (original author unknown)

”Cumbersome system design is the biggest threat to the ARRA investment.” Kamal (Bill) Hashmat, CEO, CureMD

“Every industry believes it’s ‘special’ and doesn’t want to deal with the issue of standards. Variability of design and display of common and necessary information is not creativity, it’s chaos.” Ben Shneiderman, PhD, University of Maryland, CureMD

Synopsis

Most of the discussion seemed to pivot around the pleas from the provider community to standardize usability measures by either making them a part of certification, creating a Consumer Reports-like system of reporting and comparing EHRs and/or mandating a common user interface.

There was also a call for EHRs to be held to accessibility standards, to support system-wide interoperability for the wholesale migration of data from one product to another, and to be more transparent with their internal usability and accessibility guidelines.

Probably the most intriguing testimonies were from Ben Shneiderman from the University of Maryland, Stanley Wainapel MD of Montefiore Medical Center, Eva Powell from the National Partnership for Women and Families, Mary Kate Foley of AthenaHealth, Carl Dvorak from Epic, and Doug Solomon of IDEO.

Cerner was also represented by David McCallie, who contributed this interesting insight: “The tools [EHRs] are designed for the volume of documentation instead of the value of the information.”

Executive Summary

Although the conference title specifically stated EHR (Electronic Health Record) Usability, the presentations and discussions were applicable to all types of electronic and Web applications across all healthcare environments. The resulting work and recommendations from the Health IT Policy Committee will have far-reaching effects, and are likely to impact all forms of future human-computer interaction in healthcare settings.

The EHR Usability Conference presented fresh and insightful perspectives from five separate panels: Care Provider, Patient/Consumer, Vendor/Technology Developer, Measurement and Improvement, and Options Around Usability.

The most important items addressed were:

The current state of usability in healthcare applications
Accessibility standards in healthcare applications
How usability affects the well-being and lives of patients/consumers
How usability should be included in health technology certification
The roles of vendors, providers and organizations in developing usability standards and guidelines
The role of the Federal Government in producing and enforcing usability standards and guidelines
The roles of vendors, providers and patients in ensuring that delivered products are usable

Dominant opinions and recommendations from providers, consumers, developers and experts included the following.

Current usability in healthcare applications is atrocious

Difficult to navigate.
Time consuming.
Frustrating.
Cluttered and disorganized.
Unsearchable.
Leads to fatigue and ultimately burnout.
Does not adequately support disabled community.
Does not adequately support clinical workflows.
Critical information is dispersed & buried.

Recommendations to vendors

Develop streamlined methods of entering, retrieving and displaying complex data sets.
Display data from disparate sources in fewer, simpler views.
Create navigation pathways that match the workflow and thought flow of clinical work.
Design and build applications within accessibility guidelines and enable integration with accessibility hardware and software.
Support patient-centered information flow.
Provide a mechanism or process for the customer to submit feedback for rapid changes and fixes.
Allow for customizable views of varied information from multiple sources.
Modularize and increase interoperability of product offerings.
Publicize internal usability guidelines and standards.
Work closely with the clinical community to develop best practices and appropriate workflows.
Limit or change the use of structured data capture for specific workflows.
Incorporate usability personnel and best practices in product development.
Design and build products to support effective partnerships between providers across care settings, and between patients and providers.
Design and build products to support a patient-centered healthcare system.
Work with regulators to develop standards and tests to measure usability.

Recommendations to HIT professional associations and certification agencies

Develop usability standards and metrics.
Work with regulators to develop standards and tests to measure usability.
Publicly report usability comparisons across healthcare applications.
Create reporting mechanisms for the healthcare community to voice their opinions and relate their experiences with healthcare applications.
Develop methods of measuring and relating usability to “effectiveness.”
Educate and provide guidance to vendors on a user-centered design process.
Educate providers on what to look for in a user-centered design vendor.

Recommendations to provider institutions

Allocate the appropriate personnel and resources for effective application implementation.
People, systems, processes, and hardware.
“Vote with your wallets” – create the demand and pay for products with high usability standards.

Recommendations to government agencies/regulators

Work with providers and vendors to develop standards and testing as a part of certification.
Require public reporting of comparative vendor performance of usability.
Foster an innovative vendor environment by requiring interoperability at the enterprise level to allow the wholesale migration of an organization’s data from one vendor to another and requiring interoperability at the modular level so that providers can select the best combination of applications that will work together seamlessly.
Require healthcare applications to meet accessibility guidelines.
Mandate consistency in the presentation of standard data types.
Mandate a common user interface.
Promote the wealth of usability science and resources already available.
Allocate resources to get feedback on usability from providers.
Develop simple, best practice guidelines for providers to follow in selecting, customizing and implementing healthcare applications.
Garner best practice workflows for safety.
Develop usability quality measures that coincide with the specific practices.
Increase transparency and discussions around usability efforts.

Vicente Fernandez is “just a dude trying to make a difference in healthcare with my skills as an interaction designer.”

Readers Write 4/13/11

April 13, 2011 Readers Write Comments Off

Thoughts on the Department of Defense/VA
By Arturo

Back in the 1980s, Congress, responding to the clamor for greater productivity and using the private sector should the private sector be more efficient (hence leading to such things as outsourced waste pickup and selling of municipal-owned utilities), mandated a competition for selection of the information system to be used by the VA. And so there was a competition involving EDS, McDonnell Douglas, SMS, and the VA (if I recall properly).

At that time, the VA VistA system was, in many respects, kludgy, somewhat proprietary (after all, what OS or application isn’t somewhat proprietary in one way or the other for the general population?), had a user interface not particularly friendly to many end users, and quite disjointed.

By disjointed, I mean that various modules were written at different locations, sometimes with different standards and feels, and that was simply not a standard or uniform implementation of the system throughout the system. There was no such thing as a general release of the system.

The competition ended up with the selection of the VA system. Now, I’ll never really know if it was the right decision, but I suspect that it really wasn’t.

Shift forward a couple more years and we had another competition for the Department of Defense TRIMIS system – CHCS (Composite Health Care System). The selection didn’t compare apples to apples in the beta implementations (a single site installed by each competing vendors). The winner in this one was SAIC, which had used the VA system as its basis.

The SAIC bid for the five-year deployment came out about a half billion dollars lower than its nearest competitor. Interestingly enough, SAIC required another $500KK to complete its implementation and the DoD had a system that really wasn’t ready for the future — a database that wasn’t SQL compliant, a more or less command-driven system (MUMPS at work) that wasn’t ready to meet the demanding needs of clinicians, etc.

Eventually, sometime in the first half of the 1990s, as I recall, there was a DoD RFP for a clinical workstation. I believe that this ultimately led to the 3M proposal for a clinical workstation and clinical data repository which was to become the foundation for DoD’s computer-based patient record system. (3M continues to support the DoD repository – a good thing, I suspect.)

Then came CHCSII. Now I guess that it’s AHLTA.

And throughout all of this, we just don’t have a tight linking of DoD and VA EHRs.

Now we could talk about some of the inflexibility of VistA, its inability to provide workflows and screens tightly linked with different disciplines, the need for a more robust database manager, or the fact that VistA (and the VA) just didn’t know how to deal with female veterans. Or why the VA delivery system was perceived as being substandard for so long before emerging as a leader in preventative healthcare (although why did we have the disaster with veterans returning from Iraq not so long ago?)

Is it time to use a commercial product for the DoD and VA? Or should the DoD and the VA have taken the lead long ago in providing a robust EHR for deployment throughout our healthcare delivery system? Or if VistA was so good, why didn’t more provider organizations deploy it sooner?

Something for thought. And, Epic, despite all of its success — is it really the right product or is it really any better?

Filling in the Holes in Your EMR/EHR
By Tim Elliott

With all the hype about electronic medical/health records (EMRs/EHRs) and pressure from internal folks (everyone from the executive team to various committees), hospitals often rush into their EMR projects without seeing holes between their systems, people, and departments. These typically get filled in later, often with inefficient manual processes. This approach reduces the productivity gains delivered by the EMR and frustrates the IT/IS team, clinicians, and administrative staff members who thought they’d be leaving paper pushing behind.

It’s a good idea to get people from each department that’ll be using the EMR to analyze the potential gaps in their areas well before vendors come on site instead of waiting to find and address these gaps later. Involving experts from outside your organization in the process is often beneficial, because they have the objectivity that it can be difficult to get when you’re running through processes you’re involved in. They’re also not going to be worried about hurting anyone’s feelings, which can be a concern when analyzing your colleagues’ daily tasks.

If you didn’t do this before going live with your EMR, it’s not too late. A good place to start a post-deployment review is to ask yourself and your team the same questions that you posed during project planning. By getting feedback from multiple departments (patient registration, HIM, clinical areas, etc), you’ll figure out how the EMR system is working well in some ways, and how can it can do better in others.

Again, consider why you’re doing what you’re doing. What are your goals for people, processes, and systems? How do these impact your overall initiatives, such as patient safety and disaster planning?

Don’t accept a process that isn’t working just because of a vendor’s limitations. If something’s not working right, call them and tell them exactly what the challenge is and what you need to achieve. Chances are they’ve heard a similar question before and will get right on it. Maybe you need a custom workaround, additional functionality in a newer release you didn’t know about, or a couple of extra training sessions for your staff.

We vendors spend lots of dollars on building products that solve problems. It pains us to see customers not using all of the tools we created to make their facility run smoother. Maybe you don’t want all of it, but if you need additional functionality, please ask. If your vendor is worth their salt, they have it, can build it, or will include it in a future release if several facilities share that same challenge.

We want to help you to cut your costs, enable your staff do their jobs better, and improve your patients’ care and safety. Often, the first step is you picking up the phone.

Tim Elliott is founder and CEO of Access.

Readers Write 3/28/11

March 28, 2011 Readers Write 1 Comment

The Status Quo: Profitability’s Biggest Enemy
By Tom Stampiglia

In just a few short years, the financial situation for healthcare providers has changed drastically. While patients only represented 12% of a provider’s revenue sources in 2007, they now account for almost a third of overall revenue, according to a Celent report. Between the rapid growth of high-deductible, consumer-directed care plans and a burgeoning self-pay population, patients are now responsible for a significant portion of both their medical expenses and a healthcare organization’s bottom line.

Despite these changing dynamics, many healthcare providers still employ the same conventional, long-standing approaches to revenue cycle management that were designed strictly with payers in mind. Even if these strategies are precisely what’s needed to capture quick and accurate reimbursement, they are unable to adequately address the unique challenges that come along with patient collections.

Why? Consider the industry standard for capturing patient fees. More often than not, patients are billed for their portion long after services have been rendered because providers are unable to determine exactly what the insurance company will allow for each procedure — the key variable in calculating a patient’s out-of-pocket obligations.

Unfortunately, this approach not only forces providers to postpone patient collections, but it also puts them at serious risk for payment delays and patient bad debt. In fact, more than half of patients’ healthcare obligations are never collected, adding up to more than $65 billion in lost revenues last year alone, according to McKinsey Quarterly reports.

By instituting practices designed to capture these funds at the time of service, healthcare providers can increase the odds that patients will fulfill their financial responsibilities. With recent technology advances, healthcare providers now have the ability to verify a patient’s eligibility and benefits status in real time and then pair it with the relevant CPT codes to determine insurance allowables.

Once allowables are determined, providers can apply patient responsibilities, including co-insurance and deductibles, to calculate precisely what the patient owes. Certainly this process could have been done before. However, using manual processes to examine each of these items for every patient would be cumbersome and unrealistic.

Beyond helping to accelerate cash flow, this upfront approach to patient collections brings greater transparency to payment processes and establishes a platform to conduct more effective patient financial counseling programs. With these initiatives underway, healthcare providers are well positioned to adopt a number of additional retail-based strategies proven to further enhance collections processes, such as introducing more patient-friendly billing statements, offering flexible payment plan options, and accepting credit or debit payments.

Another emerging trend that’s being met with great success is performing soft credit checks prior to the time of service. This approach, which acts like a form of financial triage, generates a rating of a patient’s likelihood to pay medical bills and gives providers the information needed to evaluate any associated financial risks. Once this information is in hand, providers can customize collection policies based on the unique circumstances of each patient.

Looking ahead, healthcare providers that implement these retail-based strategies and embrace their role as patient financial counselors will be well equipped to thrive in this new, patient-centered world. As consumers shoulder greater financial responsibility for care, it’s clear that change is critical to a healthcare organization’s survival, especially when it comes to capturing patient payments both at the point of service and beyond.

Tom Stampiglia is CEO of MPV of Austin, Texas.

Longitudinal Patient Record Systems – A Necessity for Accountable and Collaborative Care
By Alan Gilbert

In response to Dr. Jayne’s inaugural Curbside Consult regarding the lack of longitudinal care systems and the focus on episodic care, our experience has shown that a longitudinal patient record system is critical to realizing a goal of a more effective and efficient healthcare system that results in improved outcomes for patients. We believe that healthcare needs to be delivered at the point of need and not at the point of care.

One example of a longitudinal patient record is the National Clinical Network for Cleft Lip and Palate Services in Scotland. This project was established in 2000 to deliver interdisciplinary care between health professionals providing care for cleft lip and palate patients between birth and 20 years old. The objective was to provide a single record for a patient, creating a virtual multi-disciplinary care team for that patient including dentists, orthodontists, oral surgeons, speech pathologists, ENTs, audiologists, as well as the patients themselves, who were active participants in their own care. The platform accommodated clinical imaging, generated email,and letter alerts to remind clinicians and patient alike of their particular responsibility at specific times, and supported and facilitated audit and outcome assessments.

Benefits realized included:

Improved communication – sharing of information across care providers
Improved standards of care — a single source of patient information to monitor and analyze outcomes
Improved coordinated care — interdisciplinary treatment planning and care has improved due to use of the platform
Improved efficiencies — more effective use of clinicians’ time as well as the patients, their parents, and caregivers
Improved data access — minimized risk of data fragmentation over multiple sites, reduced cost, time and effort incurred by offline data entry and replication
Better patient satisfaction — through improvement in the organization of clinics and coordination among specialties
Improved reporting — reports and analysis on a national basis

Another example of a longitudinal patient record is the National Sexual Health System in Scotland (NaSH) that was started in 2005. This strategy set out a framework for improving sexual health by enhancing access to information and services while enabling flexibility for local services to respond to local requirements. It also highlighted the need to be able to review existing data and develop a data collection framework to provide a more accurate picture of sexual health and wellbeing, in terms of both sexual conditions (chlamydia, AIDS, etc) and behaviors and attitudes.

Benefits realized included:

Ability to produce and aggregate national sexual population and public health data
Improved clinical care and access to patient clinical information by introducing more patient focused processes and the ability to communicate directly with patients through patient portals, secure email and text
Streamlining of services enabling improved throughput and availability
Increased ability to share clinical data across services nationally
Removal of multiple manual record keeping systems
Ability to address some clinical governance issues more effectively
Reduced requirement for duplicate entry of patient data and better quality of data
More efficient and increased integration of systems

These examples, as well as others in diabetes, cancer care, COPD, and infection control, all focus on the need for a technology platform that can create a consolidated clinical view of the patient, no matter their care setting.

Alan Gilbert is VP of business development for AxSys Health of New York, NY.

Playing the Percentages with EHR Uptime Will Not Pay Off
By Nelson Hsu

Playing with the percentages is risky for the many healthcare organizations on the electronic healthcare record (EHR) adoption curve. The percentages in question are EHR systems’ uptime – how often the applications are available and working at sufficient performance to meet healthcare providers’ needs. Industry standards, vendor claims, and assorted misconceptions about uptime conspire to make this critical area of EHR implementation a footnote where it needs to be near the top of the priority list.

EHR’s success depends as much on application availability as it does on functionality. According to a February 2011 report by AC Group Inc., system speed and availability was critical in physicians’ decisions to use an ambulatory EHR application. That’s a good start. Their perceptions of what constitutes acceptable levels of speed and availability, however, leave open the door to punishing financial and productivity costs.

A panel of physicians surveyed at a recent Medical Group Management Association Conference said if the system was not available a minimum of 99% of the time, then they would not consider the application reliable enough to use in the future. While that may sound reasonable, 99% is unacceptable for healthcare applications. System availability at that level roughly translates into an average of more than 87 hours of downtime annually — almost four days. And 99% isn’t even the minimum industry standard. The same AC Group report that included the physicians’ survey polled 37 EHR vendors and found that they don’t guarantee any better than 96% uptime.

That number of hours of downtime costs time and money. AC Group determined that for every minute an EHR application is down, the average physician practice spends 2.15 minutes to perform the required tasks manually plus the time required to update the computer systems once the system is back up and operating. The average cost of downtime, the survey analysis determined, was $8.13 per minute per provider, which equates to a median across all practice sizes and specialties of almost $488 per hour.

Nevertheless, most EHR software vendors will not even include uptime SLAs in their contracts unless specifically required to do so. When they are, almost every vendor AC Group talked to said that the cost of the system would increase from 5-20% for each 1% increase in uptime guaranteed beyond the standard 96%. With the products available today specifically designed for uptime assurance, there is no justification for levying such price premiums.

To gain the full value of their EHR implementations, physicians and healthcare managers must become their own uptime advocates. Eighty-seven percent of medical practices spend no time evaluating their EHR implementation’s uptime and service levels, instead leaving it to software providers who have little interest in it. Neglecting the amount of system downtime that a practice might experience could cost the average five-physician practice nearly $25,000 if the product is down just 10 hours during the course of a year.

Software providers may or may not recommend or provide a high-availability platform solution (either hardware or software) for their applications. Regardless, practices and clinicians must make this a requirement for the critical applications they depend on to run their practices and care for patients. The medical profession always tells patients to take responsibility for their own health. Now it’s time for the profession to take its own advice on this important issue.

Nelson Hsu is senior director at Stratus Technologies of Maynard, MA.

Readers Write 3/16/11

March 16, 2011 Readers Write 6 Comments

Privacy and Security
By Glen F. Marshall

The primary issue with healthcare privacy and security is the lack of ongoing risk management as a routine business practice, plus the failure to share data from existing risk analysis in a form that the general public can understand. For example, while anecdotal evidence says that provider employee snooping is the largest threat to privacy, real data are harder to find.

The evidence I have of this is anecdotal. I continually get questions from HIT people about what technology to implement or whether the latest gadget is a good thing to buy. If there was a body of risk analysis information to draw upon, the selection and implementation of mitigating technologies would more often be an informed business process. So would the selection and implementation of physical and administrative controls, e.g., locks on doors, privacy training for employees, or privacy-enhancing advisories for health care consumers.

It is more convenient for the general and HIT press to focus on sound-byte instances of breaches, versus the actual threats and outcomes in comparison to other threats to privacy. It is more readable to assess blame for breaches than identify and celebrate good privacy and security practices that provably prevent, detect, limit, and disclose breaches before damage occurs. The eagerness of the general public, provider community, and political leaders to consume this lazy news reporting amplifies the problem and crowds out the solutions.

Glen F. Marshall is the principal of Grok-A-Lot, LLC of Berwyn, PA.

Patient Privacy and Information Accessibility: A Necessary Balance
By John Tempesco

In the original HHS privacy rule, a core component of HIPAA’s purpose was the ability to protect patient privacy while at the same time allowing the sharing of personal health information to facilitate patient care. And while healthcare has finally been dragged, kicking and screaming, to a more comprehensive use of technology, a serious divide has emerged between advocates of patient privacy versus the free flow of data needed to improve patient care.

As EHRs become more widely used by physicians and health information exchanges (HIEs) become more commonplace, the debate between privacy and the sharing of information for the purpose of enhancing patient care and lowering the costs of care delivery will only intensify.

As guidelines continue to be developed, it will be important to consider the mechanisms of how patients will determine the exchange of their health information. If restrictions are too severe, the goals of ARRA and HITECH will be in jeopardy. Patients will be driven by policy to “sit on” their data which will nullify the ability of the healthcare system to achieve its goals of improving patient care and safety, and reduce costs. But if data is exchanged too readily, patient privacy will certainly be in jeopardy. This dichotomy is the essential conundrum.

Opt-Out most closely resembles the state of fair and controlled information exchange as it exists today. Opt-Out protects patient privacy and enables the sharing of health records unless the patient specifically opts out. The Opt-Out provision requires that the patient is given an adequate amount of time to make a decision about consent, including urgent need of care. It also requires a clear explanation of consent choice that must be provided by the physician or hospital as well as the consequences of opting out.

Opt-In, on the other hand, would stop the sharing of patient information unless the patient opts in to the system enabling the transmission of health data. This option not only severely restricts health information exchange, and limits the ability of health information technology to improve patient care and reduce costs, it demolishes many of the core benefits of health information technology, particularly the multi-organizational and multi-community benefits of HIEs.

The ONC is still deliberating a final ruling on information exchange. While patient privacy must be attended to, clearly the critical exchange of patient information through HIEs is a central and key component to achieving the reforms of ARRA and the HITECH Act. There are numerous studies that point to health information technology as providing the necessary tools which enable improved patient safety and the improved efficiencies desperately needed to lower healthcare costs.

Let’s not throw out the baby with the bath water. Let’s move forward with a rational, forward-thinking approach that will ultimately get us to where we want and need to be.

John Tempesco is chief marketing officer of Informatics Corporation of America of Nashville, TN.

HIStalk Written on an EMR
By Robert D. Lafsky, MD

Given the mixed feedback regarding the recent HIStalk format change, it occurs to me that all available options have not been explored. The following sample report represents a modest proposal, which if adopted would allow Mr. HIStalk to enjoy the same efficiencies utilized by most EMR users. Apologies to 1960s-era MAD magazine and the late Jonathan Swift.

SUBJECT
Goniff Group

CHIEF COMPLAINT
“Cash flow problems”

HPI
The COMPANY is complaining of INSUFFICIENT INCOME. DATE OF ONSET: 1/15/2010. DURATION OF PROBLEM: 14 months. The problem is made worse by LOWER SALES. The problem is made better by HIGHER SALES. The problem is aggravated by EMR WORKFLOW ISSUES. The EMR WORKFLOW is felt to be SLOW. The EMR WORKFLOW is felt to be TEDIOUS. The problem is aggravated by EMR DESIGN ISSUES. The DESIGN is felt to be AWKWARD. The DESIGN is felt to be UGLY. The problem is aggravated by LEADERSHIP ISSUES. The LEADERSHIP is felt to be INCOMPETENT. The LEADERSHIP is felt to be INDIFFERENT TO USER COMPLAINTS. The LEADERSHIP is felt to be INDIFFERENT TO USER FEEDBACK.

PAST HISTORY
Problem List
1. Insufficient capitalization
2. Insufficient programmer staffing
3. History of SEC sanctions

MEDICATIONS
1. Bank loans
2. Penny stock
3. Overdue payroll

FAMILY HISTORY
CEO’s brother doing 3-5 in Allenwood for stock fraud

ALLERGIES
Revealing stories in HIStalk

REVIEW OF SYSTEMS
Obfuscatory logorrhea (last stockholder’s meeting)
Bilateral buttock pain (participants last board meeting)
Spastic torticollis (CFO explaining financial picture)
Chronic corporate latrocinosis

PHYSICAL EXAMINATION
Blood pressure: 60/30
Pulse: Undetectable
Head: Spinning
Neck: Horizontally positioned
Chest: Heaving
Heart: Absent
Abdomen: Distended and firm along course of colon
Extremities: Erythematous from red ink stains
Genitalia: Numerous, especially CEO and CFO

DIAGNOSTIC IMPRESSION
537926 Corioliform Hydrodynamic Gravitational Descent (“Circling the Drain”)
872035 DDI: Database Design Defects, Congenital
472653 Ugly Interface Syndrome

PLAN OF TREATMENT
First class ticket purchases to BRAZIL for CEO, CFO
Cash transfers to OFFSHORE BANK ACCOUNT in CAYMAN ISLANDS
Urgent resume production by employees
Reduce thermostat settings in office during cold weather
Discontinue free coffee in break room

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

Readers Write 3/7/11

March 7, 2011 Readers Write 10 Comments

Meaningful Use Does Not Have to Burden Physicians
By Evan Steele

As the CEO of an EHR technology company, I am driven by an unwavering dedication to physician productivity. As readers no doubt recall, the preliminary version of Meaningful Use generated an outcry from physicians — specialists in particular — regarding the burden they would have to shoulder to qualify for the government’s EHR incentives and the resulting effect on their productivity. Many physicians decided that they would not comply, and would simply forgo the incentives.

In response to significant lobbying efforts and to the more than 2,000 comments the government received last summer regarding the Proposed Rule on Meaningful Use, the Final Rule included considerable easing of the requirements for physicians in general, and significant accommodations for specialists in particular.

I want to share with HIStalk readers my view of Meaningful Use from a workflow perspective. The pie chart above illustrates how Meaningful Use is achievable without negatively impacting physician productivity, taking advantage of the exclusions available (to most specialists) and shifting the bulk of the burden away from the physician to the staff.

The implications of demonstrating Meaningful Use vary by specialty. For most specialists, the available exclusions make it relatively easy for a physician to comply. For primary care physicians, there is more to do to meet the requirements.

However, the pie chart illustrates how everyone can achieve Meaningful Use through a practical and efficient use of staff resources, combined with a productivity-focused EHR. This chart is for a typical orthopaedist, but similar charts for other specialties and primary care are also available.

The physician him/herself has four areas of responsibility. The act of ePrescribing alone addresses five of the Meaningful Use measures, and good ePrescribing software increases physician productivity. For example, we have documented that it takes to 23 seconds for a physician to prescribe on paper and a mere fraction of that time using our ePrescribing module.

Maintaining a problem list could be done by the nurse or MA, but we recommend that the physician at least review it, so he/she can view the clinical decision support alert at the point of care.

For some specialties, there are no (or few) relevant clinical quality measures, but where there are relevant measures, most of the work is done in the normal course of the visit: documenting the problem and ordering tests and/or medications.

As illustrated, the rest of the Meaningful Use measures can be handled by clinical and support staff, and some measures are excludable. So, with the right EHR and the right workflow, Meaningful Use is definitely achievable by specialists and primary care physicians alike.

Evan Steele is CEO of SRSsoft of Montvale, NJ.

Usability = Adoptability: What if Facebook and Amazon Built an EMR?
By Dale Sanders

Below are screen mock-ups based on Facebook’s and Amazon’s user interfaces. Borrowing ideas from them is comfortable because they parallel healthcare processes quite nicely, but also because the user interfaces on today’s EMRs are abominable, and adoption rates are terrible (without financial coercion) as a result. People flock to Facebook and Amazon by the millions, without financial incentives. Why? Because:

Total Value of Software Applications = Functional Value x Usability

If either Functional Value or Usability drop to zero, the overall value of the application drops to zero as well. EMRs might be functional, but they are not user friendly, so their Total Value to healthcare is very low.

In Facebook, we have a perfect framework for longitudinal documentation, collaboration, messaging, and scheduling between a patient and members of their entire care team, including family and friends. We also have a framework for easily integrating data from other sources to enhance the value to the patient’s healthcare — there’s no equivalent of HL7 interchange going on in Facebook. It references data located in other sources and systems. Can you imagine Facebook surviving if it required itself to house all the data that it presents? Facebook takes great advantage of referencing and pointing to data in the source systems to build rich content.

In Amazon, we have a perfect and familiar metaphor for ordering tests and procedures; tracking them; assessing their costs; rating them and seeing how other clinicians rated those orderables and referrals; and adjusting orders based on the behaviors and ratings of other clinicians, etc.

Here are the screen shots. Let’s start building these, eh? Think Mark Zuckerman or Jeff Bezos would help? 🙂

(Note: click the pictures to enlarge them).

Dale Sanders is CIO of the Cayman Islands National Health System. He writes about healthcare IT on his blog.

Readers Write 2/9/11

February 9, 2011 Readers Write 5 Comments

Comments on the PCAST Report
By HITworker

You don’t have to look very far to see evidence of just how much this PCAST report is a sophisticated marketing piece for Microsoft’s ailing Health Solutions Group.

The committee co-chair (note – not just a member, a full co-chair so presumably he had a lot of control over input and direction) is Craig Mundie. The Health Solutions Group was set up by Craig Mundie and the Peter Neupert, who leads the Health Solutions Group and reports to Craig.

Listed under expert input at appendix A are a list of 47 ‘experts’ who contributed to the report. Thirteen of those experts are from vendor companies, the rest coming predominantly from federal departments and health providers. Of the 13 experts, three of them are from Microsoft including:

Craig Feied – Microsoft Health Solutions Group’s chief strategy officer, who joined Microsoft after selling the Azyxxi product he built to Microsoft, which later became Amalga UIS (which just happens to be a clinical data aggregation technology – so favored in the PCAST report).
Sean Nolan – Microsoft Health Solutions Group’s chief architect, who admits to having no experience in health IT before he led the development team that designed Microsoft HealthVault (which is a personal health record, also so favored in PCAST).
Peter Cullen – Microsoft’s chief privacy officer, who has a significant role around advocating in relation to Microsoft’s approach to privacy in cloud computing, (the third and final favored technology in PCAST).

Then of course, there’s Craig Mundie.

I got to looking into this after reading a blog posting on John Halamka’s blog (Life as a Healthcare CIO), where Sean Nolan of Microsoft illustrated how he believed Microsoft had all the answers for a Universal Exchange Language for health using their products Amalga and HealthVault. This was only a couple of weeks after the PCAST report was published in which he was a named ‘expert’.

So curious, I dove a little deeper into the other 10 ‘experts’ and found that seven of them work for three companies (Ingenix, athena, Sage, and Medicity) who all have partnership relationships with Microsoft.

Now I’m not opposed at all to vendors contributing to these kinds of reports – industry often has expertise and insight that is not readily available within government — but something didn’t seem right. These just aren’t the companies that would leap to mind at all when I think of the leading vendors in health IT with the most expertise and insights to contribute. Something’s amiss.

We’re being asked to believe a committee chaired by someone who runs Microsoft Health Solutions group, independently and without bias sought input from experts, and that three of the 11 experts from industry consulted just happened to work for the chair of the committee within Microsoft. And that these three had direct responsibility for products that just happened to address the three key technologies called out as enablers of the PCAST recommendations. Furthermore, seven of the other industry contributors work for companies that are Microsoft partners.

Something is most definitely wrong with this picture.

Bill Bria for ONC
By Ann Farrell

Note from Mr. H: industry long-timer and consultant Ann Farrell is mounting a campaign to have Bill Bria, MD (CMIO of Shriners Hospitals for Children) considered for David Blumenthal’s replacement at ONC. Her reasons: he’s an industry thought leader, he is regarded for his work with AMDIS, he is not self-promoting, and he recognizes the value of informatics in areas other than those involving physicians. Ann believes that his appointment would unit the industry and signal an HHS commitment to patient-centric, benefits-driven, interdisciplinary, and workflow-friendly technology strategies. Her letter is below.

Greetings,

I am a career-long champion of EMRs as end-user at first US commercial implementation, EHR vendor VP and now Principal of Strategic HIT consulting firm. The news of Dr. Blumenthal’s departure while not totally surprising is nonetheless of concern with now third hand off of leadership in high impact initiative that is advantaged by continuity. Nevertheless, this is an opportunity to look carefully at the character, characteristics and capabilities of the new leader so we can align the next set of challenges to the appropriate candidate and perhaps overcome flaws with current approach.

We recognize value of the next leader having directly supported ONC in HITECH initiatives. We also appreciate value of someone who has successfully supported change management with “hands on” experience in implementing EHRs in several diverse organizations who’ve achieved goals of HITECH in real world settings. The person ideally would be universally respected by vendors, hospitals, colleagues and the market – without political baggage and not part of “old boy network”.

In this regard, we think Dr. Bill Bria would make an exceptional candidate. His knowledge, passion and track record well position him for success. Perhaps most importantly, Dr. Bria recognizes that healthcare does not equal “MDs“ alone but requires a care team who execute MD orders as well as plans of care that together drive efficiencies and outcomes. All caregivers contribute to EHRs and patient care. Till this time, a clear MD-centric bias is reflected in Meaningful Use content, phasing of criteria and messaging. Ironically, this approach has had unexpected negative consequence for MDs as well as the program.

Dr. Bria has played a critical role in the “visioning” and design of several lead EMR/EHRs since the early days and played key leadership roles at diverse prestigious healthcare organizations and AMDIS. Bill is a hero to those of us who worked with him. Dr. Blumenthal’s departure provides a chance to “reboot” HITECH – Dr. Bria could bring a new more realistic and a-political, patient-centric, interdisciplinary approach needed to optimize this once on a lifetime opportunity for HIT.

Regards,

Ann
Ann Farrell
Principal, Farrell Associates
San Francisco , CA 94114

Five Things Hospitals Should Know About Backing Up Virtual Machines
By Charles Mallio

As more hospitals introduce virtualization to their data centers, they must incorporate virtual machines (VMs) into their backup and recovery strategies. How is backing up VMs in a hospital environment different? There are five things that hospitals should think about as they incorporate VMs into their overall DR program.

Don’t assume agentless backup. One of the most common misconceptions about VMs is that you will be able to perform backups on any machine without an agent. VMware does help in this regard, but it is often the case that you will need a backup client – virtual or physical – especially when you consider how you are going to recover applications.
VMware doesn’t reduce the importance of good DR planning. For example, virtualizing your server environment does not negate the need to fully optimize your backup routines. In every hospital, approximately 20% of data is dynamic (i.e. current, active content that is highly likely to be accessed and or changed), which should be given the highest priority in your DR cycle. Yet, around 80% of a hospital’s data is static (such as DICOM images from PACS, which will never change and are highly unlikely to be recalled again). Whether this static data is in a physical or VM is irrelevant – the fact is, if you don’t move it out of the primary backup stream, you will end up making unnecessary copies of copies, place a considerable, additional burden on your infrastructure and dramatically delay your backup processes.
VM sprawl will require more thorough DR planning. As VMs multiply within the data center, each hospital must align each VM with their overall DR strategy and assign policies for restoring mission-critical applications and data so that business continuity criteria are met.
VMware has produced some new features in vSphere, but these do not provide a DR silver bullet. vStorage APIs for Data Protection (VADP) offers great new facilities, such as changed Block Tracking, that may be applied in a VMware environment to enhance data protection and disaster recovery. These tools are ideal when protecting file and print servers, but you should always ensure they offer adequate facilities to RECOVER applications in your environment.
Choose backup hardware that meets your business needs. Although migrating from physical to VMs will bring new economies to the data center, it does not mean that you are restricted to disk-based backup. VMs can just as easily be protected on more affordable, portable tape media. Hospitals should choose the backup media that best meet their budgets and business processes.

Charles Mallio is vice president of product strategy and business development at BridgeHead Software.

Capitalizing on PQRI’s Financial and Quality Improvement Learning Opportunities
By John Nelson

It is not often that the Centers for Medicare and Medicaid Services (CMS) offers an initiative or mandate that allows doctors to receive extra money, deliver better care, and attract and retain patients without inflicting enormous pain and extra work on a practice. However, after a false start, CMS’s Physician Quality Reporting Initiative (PQRI) has become such a program, enabling us to easily collect a bonus while positioning us to learn what we need to do to further enhance quality and prepare for an era where payments will be based on outcomes rather than visit or procedure volume.

This was not always the case. When the program began in 2007, the Heart Center of North Texas, a nine-doctor cardiology practice in Fort Worth, Texas, found that collecting and reporting PQRI quality measures was so burdensome and expensive that we did not want any part of the program. But we changed our minds in 2009 after CMS, acting on physician complaints and feedback, not only made it easier for doctors to participate in the program but also enabled them to report quality measures through registries.

Another reason we participated in PQRI is that the Texas Medical Association offered a coupon covering nearly the entire cost of the fee we had to pay CMS to register our participating physicians.

It took a clerk only a month to collect the information from our electronic health record and clinicians, which she then forwarded to our registry. Her effort had no impact on clinician workflow but had a huge impact on our bottom line: CMS paid us $87,000 for the 2009 reporting year.

Collecting data for 2010 turned out to be even easier than in 2009 in part because CMS changed the definition of consecutively seen patients. Now, the reporting physician did not have to see 30 patients consecutively which allowed them to go back and gather the data. This plus the fact that we stand to receive another substantial bonus led us to participate in PQRI again. We urge our colleagues follow our example, as they still have plenty of time to meet the March 15, 2011 deadline for the 2010 reporting period.

Another reason to file for 2010 PQRI incentives is that the bonus will be at its highest level. CMS will reduce the 2 percent bonus to 1 percent in 2011. From 2012 through 2014, the bonus will drop to 0.5 percent. In 2015, the carrot changes to a stick: reimbursement for non-participating physicians will drop by 1.5 percent and by 2 percent in 2016. Why pass up the bonus when it’s so easy to participate now?

Additionally, we believe PRQI enables us to identify areas where we are strong and where we can improve, giving us a head-start on accountable care, bundled payment, pay-for-performance and other care models that CMS and other insurers are rolling out. It is my job to ensure my group is clinically, financially and administratively efficient. The bonus, information and electronic reporting help me achieve these goals.

John Nelson is practice administrator of Heart Center of North Texas, a nine-physician cardiology practice in Fort Worth, Texas.

Readers Write 1/24/11

January 24, 2011 Readers Write 3 Comments

Connecting Performance Measurement and Clinical Decision Support to Improve Patient Care
By Gregory Steinberg, MD

In late 2009, the National Quality Forum (NQF) convened a panel of experts from across the health care industry to lay the foundation for promoting clinical decision support (CDS) to enhance performance measurement and help improve patient care. The Health Information Technology for Economic and Clinical Health (HITECH) Act had standardized the information needed for quality measurement.

However, it did not address the lack of standardization when it comes to the information and algorithms for measuring clinical performance, or the importance of linking clinical performance measurement with CDS to help improve it.

Over the past year, a panel of CDS experts, including Dr. Madhavi Vemireddy (our chief medical officer at ActiveHealth), worked to create a “taxonomy,” or classification of the information that connects quality measurement and CDS in clinical information systems. The result – the first step in defining the data sets needed to ultimately drive performance improvement. The panel’s new taxonomy is described in the report Driving Quality and Performance Measurement – A Foundation for Clinical Decision Support, announced this month by the NQF.

This new taxonomy has the potential to significantly improve health care. Today, many health care providers’ and organizations’ systems do not automatically capture the necessary information to drive CDS and performance measurement reporting. Having a common language for CDS and performance measurement is essential to improve quality with every patient.

All too frequently, at the individual practice level, performance measurement data has to be manually collected at the end of each performance year to create static reports that are not linked to CDS. The new CDS taxonomy will not only automate and standardize the data sets within electronic health records (EHRs), but also create the foundation to transform CDS into a dynamic workflow tool that is tightly linked with performance measurement improvement and supports performance measurement reporting as a byproduct of everyday practice. It is this connection that will improve performance and, ultimately, improve patient care and reduce health care costs.

The NQF’s report is only the first step in standardizing CDS datasets and in synergistically linking clinical performance measurement with CDS. Now, it will be up to health care vendors and organizations to begin using the taxonomy, building CDS and performance measurement alignment into their IT infrastructures. The hope is that this alignment will soon become standard practice in hospitals, physician practices, and other provider organizations across the country.

Gregory Steinberg, MD is CEO and president of ActiveHealth Management.

The “One” Thing HIT Vendors Need to Know
By Cynthia Porter

Reading the Web’s recent prognosis for Meditech strongly reinforced this simple truth: the customer is at the heart of the healthcare IT industry. This can sometimes get lost in the marketing, sales, and product development shuffle, with a company none the wiser until a valued client is no longer a returning client.

Recent blogger opinions beg several questions. What can an HIT company do to make sure it holds onto customers? Why is it so hard at times to better understand clients’ needs? It all comes down to the simple skill of listening. HIT vendors need to listen to what their clients are saying — and they’re saying a lot right now, to be sure.

Market research services fill this listening need. The HIT market is now more than ever in need of an unbiased third party to assist them in listening to their customers. Someone that will derive true opinions from a vendor’s clients — so valuable in continuing to meet clients’ needs when considering future product development.

The third-party solution provides an outlet for HIT customers to compliment or vent to. No selling, no marketing — just an ear that cares.

It is this skill of listening that will enable seasoned (some may say complacent) HIT companies like Meditech to survive. Meditech has been the “one” market leader for years – in the 200-bed market. What HIT vendors like Meditech need to realize is that the market is moving beyond the four walls of the hospital. HITECH, HIE, and ACOs are changing the game and expanding the walls.

Vendors need to listen to their customers and better understand the impetus behind their growing need for new HIT solutions. EHR integration, as mentioned in connection with Meditech’s issues, is just one part of this.

As Curly says in the movie City Slickers, there is just “one” thing and that is all there is to know. But the “one” has gotten bigger. One hospital is now one community. One state is now multiple states or regions. One patient is now the e-patient who demands access to his or her data any time, anywhere.

Meditech will need to adapt to this new way of thinking to remain the “one” vendor its customers have traditionally turned to. Luckily, it has one of the best and most active user groups on hand to help navigate this new course.

Cynthia Porter is president of Porter Research.

Steps to Take Against Medical Snooping
By Pete Niner

Medical snooping is in the news again, with the firing of four workers for looking at Congresswoman Giffords’ hospital records after the Jan. 8 shooting. While this instance was swiftly detected and punished, most instances of snooping will not make headlines, and are thus more difficult to detect.

Few care providers will ever have a patient whose treatment will be front page news (thankfully). But lower-profile patients are victims of snooping as well. For every case that makes the tabloids, there are doubtless many more cases involving less-newsworthy victims. A concerned father looking at his daughter’s suitor’s records, an irritated neighbor looking for malicious gossip, or a bitter ex-spouse seeking ammunition in a custody battle are much more difficult to catch.

Technology, alas, isn’t too much help here. Information security products have historically been focused on stopping unauthorized access, not the misuse of authorized access. Though there are a few products on the market that purport to detect and stop medical snooping, they are both expensive and cumbersome, beyond the financial and technical resources of many organizations. Those who can’t afford to spend six figures on a sleek, high tech product need to use other means to detect medical snooping.

Assuming your security fundamentals are in place, below are some additional ideas we’ve seen work.

Implement thorough segregation of duties. Many organizations default to an "all access" or an "all clinical access" policy for information. While this aids in staff flexibility, it is worth asking whether all staff need access to all information and judiciously trimming unneeded access.

Periodic review of access entitlements. Most organizations have solid processes to grant access; far fewer have good procedures to modify or remove access once it’s no longer necessary. An annual or bi-annual review of entitlements can clean up obsolete permissions and prevent surprises from lurking in dusty corners.

Spot checks of access, This can be done two ways: patient-centered or personnel-centered. Either review all access used to a particular patient’s records or review all access used by a particular employee. These can be done either randomly or for cause — an employee who steals medication is probably more likely to have misused his access as well.

VIP monitoring. Should a VIP enter your doors, closely monitor who accesses his or her information and why. We know of one organization that, when a VIP checked in, created half-a-dozen null records of non-existent persons with identical demographic and treatment information to that of the real VIP (security types call this a honeypot — stage actors recall 1 Henry IV, Act 5, Scene 3: "The king hath many marching in his coats".) All those who viewed the record of the dummy VIP were terminated.

Once the misuse is detected, of course, there should be clear, HR-approved procedures in place to very publicly discipline the offender.

Medical snooping can be tough to detect, but you’re not helpless. There are steps to take that will increase your ability to detect and deter such misuse.

Pete is a director at Techumen.

Readers Write 1/17/11

January 17, 2011 Readers Write 10 Comments

Remote Access Is Not Mobile Access
By Cameron Powell, MD

Healthcare organizations are quickly learning that both remote and mobile access strategies are required. See Table 1.

Remote access lets providers work in the hospital computing environment when they are not on location. This includes accessing the EMR and clinical applications via a PC or laptop from office or home. Secure the session with something like VPN, add the necessary authentication and encryption, and clinicians can use their Windows desktop and a browser to interact with hospital applications.

Offer mobile access when you need to empower providers to perform specific tasks anytime, anywhere. This would include visual assessment of images and waveforms, checking lab values, reconciling medication lists, checking allergy status – all while on the go. Providers want the data transformed into meaningful chunks; they don’t want to navigate the medical record from their Droid in order to make timely treatment decisions. Mobile data should be provided via native applications, built to run securely on a specific device and operating system.

Some organizations have considered using Citrix to provide interpreted or emulated application access to the EHR or CIS via a mobile device. Accessing patient monitoring data via a non-native solution is discouraged, because visual distortion is almost certain when things like medical aspect ratios cannot be controlled. [1] Further, the FDA is mandated to regulate mobile devices. [2], [3]

Mobile versus Remote Access

Consideration	Mobile Access	Remote Access
Accessibility	Single, personal mobile device Anytime, anywhere cellular or Wi-Fi access	PC, laptop, or workstation-based, even if it’s a workstation on wheels
Interface	Native Application – Designed to run in the computer environment (machine language and OS) being referenced (i.e.: Android, iPhone, Blackberry, etc.)	Citrix or web access to desktop applications
Data Transformation	Improves clinical decision making at the point of care through data transformation – does something with the data. Adds meaning with graphing, trending, colors, visuals cues, etc.	Looks and functions like the desktop electronic health record (EHR). Presents data in the same fashion as the computer program being accessed.
Added Value	Works with clinician workflow by delivering in meaningful ways. Incorporates evidence based medicine and knowledge-based prompting.	Supports office- or home-based access via computer.
Meaningful Use	Physician usage quickly ramps up, is sustained over time.	Initial usage spike, unsustained; often drops off after weeks/months. Physicians will seldom help organizations achieve data access/sharing objectives when they have to go to the data.

References

[1] http://ahealthydoseofmobility.com

[2] http://www.ebglaw.com/showarticle.aspx?Show=12184

[3] http://www.law.uh.edu/healthlaw/perspectives/2010/kumar-fdamobile.pdf.

Cameron Powell, MD is president, chief medical officer, and co-founder of AirStrip Technologies of San Antonio, TX.

Transcription Today
By Diligent Monk

Transcription is back.

As EMR adoption picks up in response to Meaningful Use, it is worth noting that lurking in the shadows is a familiar enemy to EMR companies: transcription. The age-old practice of dictating for capturing clinical observation is the most efficient, accurate, and preferred method for physicians to document a patient encounter.

Over the past few months, announcements from large organizations have signaled a return to relevancy for the transcription industry. IBM, Nuance, 3M, HealthStory Project, major universities from around the globe, and many other dominant players in the transcription service industry have made significant strides in utilizing technology to create more value from transcripts.

Enter the transcription technology revolution.

Partnering the skilled labor of transcriptionists with technology produces a rich and accurate dataset from a traditional transcript. Whether labeled natural language processing (NLP) or discrete reportable transcription (DRT), the concept is quick, simple to understand, and the value is just now being seen by the industry at large.

Using extensible mark-up language (XML), data is pulled from transcripts and provided in common transport standards (CCR, CCD, CDA) to be used in EMR systems and reports. A physician can dictate his/her notes and collect all of the data required for meeting the objectives and measures for incentive payment per the HITECH Act without purchasing an EMR.

Historically, the EMR sale was built on an ROI derived from transcription savings. Looking at a practice or hospital balance sheet, the transcription bill seemed to be the easiest to pick on, and with the point-and-click interface promoted by EMR vendors, it was a straight replacement for clinical documentation. EMR adoption would eliminate transcription costs. As an industry, the transcript was losing its relevancy in an age of electronic records, but physicians and practices weren’t thrilled with the results. And back to the revolution.

Permitting a physician to dictate in their preferred and normal manner, coupled with the ability to ‘tag’ the data elements of importance from the note, provides the best of both worlds.

Unfortunately, this does nothing to eliminate that pesky transcription charge, which is still the focal point of many EMR pitches. The transcription industry, however, counters that the prevention of productivity loss will more than cover the cost of their services and therefore be a win-win for all involved. As well, the risk of errors in reports is significantly decreased by the medical language specialists that review documents for clinical quality and integrity before submitting back for approval from the physicians.

As crazy as this sounds, and as hard to believe as it may be, transcribing may be the best way for practitioners to achieve Meaningful Use and the most cost-effective for their practice. The technology continues to improve and adoption continues to be strong, so yes, transcription doesn’t appear to be going away, and that may be a good thing.

FDA Comes to HIT… But Through the Back Door
By Frank L. Poggio

For several decades, there has been a raging debate as to whether HIT systems should be regulated by the FDA. A search of HISTalk on ‘FDA’ brings up hundreds of mentions. Some clinicians believe FDA oversight is desperately needed; others feel it would be a major detriment to new development.

Now the debate is over. It came earlier this month through a back door called ONCHIT, probably while you were sleeping.

On January 7, ONCHIT issued the Permanent Certification Program Final Rules PCPFR. These are the rules that will transfer the testing activities from the ‘temporary’ agencies to ‘permanent’ ones as of January 2012. On the surface, you would think these rules would impact only the companies like CCHIT, Drummond, InfoGard, etc. But our creative friends at CMS–ONCHIT went many steps beyond that.

Here are some highlights from a vendor perspective.

A new entity was created called the ONC-AA called the Approved Accreditor agency. The current ATCB will be changed to ACB, or Authorized Certification Body.

In a nutshell, the ACB administers the test and the AA oversees the ACB. Today under the temporary rule, the ATCB does both. What is now a one-step process will become in 2012 a two-step process for software firms seeking certification. The AA will also be the agency that selects and contracts with the ACBs for testing services (such as CCHIT, Drummond, etc.)

The new ONC-AA is required to insure that the ACBs conduct ‘surveillance’ of certified vendor products. Surveillance is CMS’s way of saying ‘audit’.

Here’s how the surveillance will work. The AA can walk unannounced into an ACB office and review all certification documentation, or can randomly sit in on tests. More importantly, the AA or ACB can audit at will, unannounced, the MU criteria out in the field at the providers shop to ensure the certified system really does what it was certified to do.

And it doesn’t stop there. Similar to the FDA processes, any user of a certified system (provider clients or their employees) can file a complaint directly with the ONC-AA or ACB stating that the vendor’s installed certified system DOES NOT MEET the certification criteria. At that point, the AA will conduct an investigation at the site and make a determination whether the vendor’s certification should be pulled.

If so, as with the FDA, press releases to that effect will be circulated. OUCH! Better start thinking about stronger client support in the future and set up internal channels to catch the gripes before they get so bad a user wants to scream ‘ONCHIT’.

On of my friends called this the ‘HIT Whistle Blower Act’, a good description. It’s just like the FDA: if a device or drug has an unexpected adverse impact, anyone can file a complaint. I hear a train a coming …

Frank L. Poggio is president of The Kelzon Group.

Readers Write 12/29/10

December 29, 2010 Readers Write 13 Comments

The Role of Automation in Reconciling Patient Records
By Beth Just

Duplicate patient records have long been a serious problem for hospitals, creating the potential for missing or inaccurate patient information that can lead to life-threatening care situations. They are also a substantial drain on financial, health information management (HIM), and IT resources.

Industry estimates are that 3-15 percent of patient records at a typical hospital are duplicates. That number skyrockets to 30 percent or higher for facilities that have been acquired or merged or are part of an integrated network. Exacerbating the sense of urgency surrounding the elimination of duplicates is the impact they can have on a hospital’s ability to qualify for incentive payments under HITECH. In particular, duplicates artificially inflate the number of unique patient records, which are the basis for several Stage One criteria.

That is why eliminating existing duplicates and preventing the creation of new ones must be an integral part of any facility’s data management strategy. In addition to easing the burden of achieving Meaningful Use, doing so also eliminates significant cost drain. One three-hospital system determined that the duplicate volume for its health system was more than 17,000 records.

The estimated annual cost of those duplicates? Anywhere from $554,000 to more than $1.2 million for repeated tests and treatment delays, as well as incremental costs related to longer registration times and correcting duplicate records.

The challenge is that reconciling and eliminating duplicates is a cumbersome, manual process that requires staffing resources most hospitals cannot spare. What’s more, these processes do nothing to prevent future issues.

Traditionally, the reconciliation process is executed entirely on paper. Potential duplicate records are identified as patient charts are pulled. They are then assigned to the HIM staff, which must analyze previous charts and other information to verify whether they are actual duplicates before they can be eliminated.

Even if a hospital’s information system provides reports of duplicate records, the data they contain typically is limited to key identifiers, such as name and date of birth. More research is generally required once potential duplicates are identified.

Progress on reconciliations is also typically tracked on paper, leaving room for error and duplication of work.

By automating portions of the reconciliation workflow, hospitals are able to quickly and efficiently weed out existing duplicates and prevent new ones. By allowing multiple duplicates to be reviewed in a single view, automated processes also heighten user control over the merge process, lessen the time required to complete the process and enable more effective quality assurance before records are merged. High-level process will also support merging records in downstream systems while reducing manual steps and associated costs.

Automation can also reduce the time and resources required for reconciliation. The best systems will also automatically document decision validity, track productivity and generate comprehensive, user-friendly reports that provide a complete view of efforts and insights into problem origination points.

After six months of manually analyzing duplicates records, the previously mentioned hospital system chose to leverage the efficiencies of an automated reconciliation process to eliminate duplicates prior to its transition to a new clinical information system. Today, it relies on the software to maintain clean, high-quality patient records. The automated solution resolves upwards of 500 duplicate records monthly at each of its three hospitals – and it does so with fewer resources than had previously been dedicated to the process.

Beth Just is CEO and president of Just Associates.

How Healthcare Is Different
By Rambling Man

Healthcare is unlike any other industry for a ton of reasons, a few I found the time to ruminate upon this morning.

What industry does not know its costs? There are examples of providers performing this analysis, but most community hospitals, ambulatory care centers, and primary physician offices operate from ignorance of this information. How can providers negotiate payer contracts without this knowledge? This information will become increasingly important as the industry evolves from traditional payment models with ones based on quality of care and outcomes. This begs the question: how will we measure quality care and outcomes? The answer will inevitably involve more consumer involvement.

How will the industry respond to the increasing demands upon the primary physician? Today’s reimbursement models force physicians to fit more patients into their daily routine, while still making the same amount of income. This model will eventually change the face of healthcare, and perhaps for the better. Demands on physicians to stay current with new clinical data, juggle a schedule of seeing 36 patients a day, and “practicing the art” seems super-human and may be outdated.

These demands, combined with an alarming decrease in physician ranks, will create a new layer between the patient and the science. This new layer may be satisfied with Nurse Practitioners or Physician Assistants, or a skill-set not yet defined that focuses on data gathering and psychological insight.

How can patients do to better the system? Medicine addresses our physical vulnerability and fear of death, which are the darkest of human emotions. Physicians must have a serious sensitivity towards the emotional needs of patients, and one could argue society’s reaction towards death has worsened in the last fifty years.

For many, years of pain or confinement to bed are better alternatives to accepting the inevitable. We expect our physicians to be the best scientist and psychologist all wrapped up into one package, but how have we changed as consumers? We need to bear a larger portion in the direction of medical care, and the systems that provide medical information to the consumers must be simplified for all. Health data banks, where consumers store health information and pay for data analysis, will emerge and become the centers of our data.

And finally, and arguably more difficult, is that we require a change in attitude regarding death. Fear of death is the motivation behind the largest portion of healthcare expenditures. Has our consumer psychology foregone quality of life in favor of quantity? Changing these attitudes will not happen overnight and will not be easy. Each of us facing our ultimate demise need to do so with dignity and faith that death is a beginning to a larger chapter in our existence.

As I Stand With Nozzle In Hand
By Mr. HIStalk

Pumping gas is boring. There’s nothing you can except fidget and enjoy the fumes (which I do). The high point for me is spotting a squeegee in a nicely full container so I can at least pretend that my windshield is dirty and entertain myself for a few seconds by cleaning it (or curse the lazy clerks who’ve left the squeegee in a desert-dry container because they just don’t care).

Sometimes I read the stickers on the pump, like the last inspection date or how to find the emergency shut-off valve (daydreaming of heroically saving an entire neighborhood by stopping a spreading ocean of flame as I sprint confidently to shut down the pumps like John Wayne in Hellfighters). While scanning for those exciting tidbits the other day when I was in another state, a sticker on the pump caught my attention. Under a picture of a scowling, R. Lee Ermey-lookalike state trooper, it said Drive Off, Lose Your License.

I marveled at the political clout of the gas station owners. Shoplifting, walking out on a restaurant tab, or any kind of petty theft are all subject to a ponderous legal system with generally light penalties for first-time offenders. The punishment, if it ever comes, is generic and disjointed from the crime. But somehow the gas guys used their political grease to get politicians to approve a very specific (and severe) penalty for a specific type of theft affecting only them.

Obviously the R. Lee sticker was designed to get your attention. The Lose Your License part is a lot more dramatic than, Drive Off, You Will Probably Not Be Arrested and At Worst Will Get a Slap On the Wrist Months From Now Even If You Are Arrested, and That’s Assuming the Unmotivated Dry-Squeegee Clerk Cares Enough to Chase You Down the Street To Get Your License Number.

I was appalled. What does skipping out on a gas station tab have to do with the privilege of driving? That makes about as much sense as … uh oh … penalizing doctors for not using electronic medical records.

Gas stations could have eliminated their problem without judicial favoritism by simply requiring cash customers (are there really any left?) to pay before pumping. Just like EMR vendors could have boosted use of their products beyond the pathetically tiny percentage of busy, pre-HITECH doctors willing to use them by making them easier to use and designing them to increase doctor efficiency rather than accumulating interesting but not always clinically helpful data for insurance companies and the increasingly intrusive Uncle Sam to poke around in to find reasons not to pay for services already rendered.

Even though I’d paid at the pump, I decided to go into the C-store for a soda and some nutritionally devastating snacks (anybody for an jelly orange slice or a pack of those mini-donuts slathered with coconut gunk?) On the wall beside the “deli” (where the commissary-made sandwiches encased in their nitrogen-filled coffins are moved from totes to the refrigerator in a form of “cooking”) was the C-store’s health inspection sign.

I read those. If I’m going to a strange restaurant (especially if it’s Asian or Mexican), I’m going to seek it out right away to make sure the cooks at least occasionally wash their hands and don’t store the goat carcass designated for employee lunches in the same refrigerator as the desserts, at least during the inspector’s surprise visit. (As a second-level review, I always check out the customer restrooms since whatever disgusting state those are in is ten times cleaner than the areas customers can’t see, like the kitchen).

I want to see those health inspection signs on hospital and practice doors. Give me a letter or number score of how well they adhere to quality measures, as measured by a totally independent and fear-inspiring government bureaucracy (not the chummy Joint Commission, which has given hospitals glowing scores right before the state inspectors came down on them like the wrath of God for running shockingly lax operations). I would turn tail just as quickly from an impressively ornate medical provider’s facility with a C-minus score as I would from a $5.39 all-day Chinese buffet restaurant that doesn’t even own a trash can (but with illegal immigrant employees who probably wash their hands more than the average doc even though they’re deboning chicken thighs instead of probing people).

So thumbs-down for making up new penalties to encourage whatever behaviors the politicians and those who influence them have decided are desirable. Thumbs-up for letting businesses run their own affairs, but with mandatory full disclosure to their customers. Let the market decide whether and EMR-wielding C-minus practice is preferable to an A-grade practice using an IBM Selectric and one of those, “Sara, this is Sheriff Taylor” telephones that look like the far end of a clarinet.

But in the mean time, I’m thinking about applying a for a few paltry million of the HITECH bonanza to create an EMR awareness program for the paper-clinging providers. I’m calling up R. Lee Ermey, posing him in a government-looking suit and power tie, and putting him on stickers for manila folders that read Write Order? Lose Income.

Readers Write 12/15/10

December 15, 2010 Readers Write 4 Comments

The Elephant in the Room
By Dana Sellers

I spend most of my time with provider organizations. Recently, though, I spent a day with a company that focuses on payers. As we discussed the many challenges our industry faces in today’s tough economic and regulatory climate, it hit me that we appeared to be coming at the problem from different angles.

One side of the room talked about patients, clinical data, and quality measures. The other side talked about members, population management, and risk reduction. It reminded me of the old story about the blind men who touch the same elephant, but describe it very differently. We were all talking about the same elephant, but we saw it and described it in our own terms.

There’s one thing both providers and payers have in common, though. Everyone’s trying to figure out how to play in a changing world that’s moving toward pay-for-performance, value-based purchasing, and ACOs. Providers are jockeying for position — buying physician practices, networking with community docs, and starting to think a lot more like payers.

Provider CIOs, who are just fully realizing how hard it is to capture the discrete data needed for the first 15 quality measures within their own walls, are facing the challenge of aggregating discrete clinical data over extended provider communities that include a hodgepodge of physician practices, specialty clinics, long-term care facilities, and home care settings.

Key payers are jockeying for position, too. Last week Aetna bought Medicity. Earlier this year, Ingenix, a subsidiary of UnitedHealth Group, purchased Axolotl and Picis. It makes sense that payers want into the HIE world. They need a way to gather clinical data, but more importantly, they want a framework that will allow them to influence the behavior of care providers to drive best practices back out to the point of care. These moves may really complicate things from a provider’s perspective, though.

How all of this will play out isn’t clear by any means, but there are a few things I’d be willing to bet on.

The 15 quality measures in Stage 1 are just the tip of the iceberg. Over the next five years, reimbursement will be increasingly based on data that must be captured, aggregated, and reported electronically, rather than through abstracting.
Physicians are key. To enhance the health of a population in a substantial way, you need to be able to connect with community-based care providers, manage handoffs, and influence decisions at the point of care. Whether it’s through acquisition or networking, healthcare organizations need to include physicians in their IT strategies.
The lines are blurring. Providers are starting to look and talk a lot more like payers, and payers are starting to move into areas long thought to be the domain of providers. We’ll see providers assuming risk and managing populations of members. Interesting alliances and new business models will emerge, and CIOs will need new information systems to support this new world.
Data will be the new gold in whatever finally emerges out of healthcare reform. Not just clinical data or financial data, but both combined … and lots of it. Payers have known this for years, and have invested heavily in systems to capture and report on member data. The organizations that come out on top will be the ones that figure out how to capture data, how to aggregate it, and how to apply the insights they derive from it to bring about real changes in quality. This doesn’t happen overnight. CIOs who don’t take the time to develop an analytics strategy will struggle to keep up.

So maybe at the end of the day, it doesn’t matter so much that we all have the same pachyderm perspective … as long as we can get it to do the heavy lifting.

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

I Have an ONC-Certified EHR and Vendor Meaningful Use Guarantee, Why Do I Need Anything Else?
By James O’Connor

Software is a tool. An ONC-certified EHR captures and reports data, but an EHR system cannot characterize the gaps in your workflow and processes, initiate change within your practice, or foster teamwork to meet a common goal. These activities can be supported by a good software tool, but cannot be enacted by one. Here’s an illustration.

Recording demographics is a core requirement. To an EHR vendor, "readiness" means there is a form somewhere in the system that collects the information and there is a report that calculates the ratio.

To a medical practice, "readiness" means something else entirely. Certainly demographics are being recorded to some extent now, but one of the Meaningful Use requirements is to record a patient’s preferred language. To comply, practices must update forms (if patients still register on paper) and train staff to ask established patients the question (to fill in the gaps).

There is no partial payment for partial compliance. If the ratio doesn’t hit the minimum 50%, there will be no incentive payment. There are a number of requirements that depend on staff, not clinicians, to fulfill. These must be understood and incorporated into the workflow.

It is no great secret that Meaningful Use (at least Phase I) is not rocket science. The steps to prepare do require organization and a certain depth of knowledge. A small- to medium-sized practice willing to dedicate a competent individual to undertake this task can reasonably expect the person to succeed.

It might take a little longer. There may be a few bumps in the road dealing with the HIPAA security assessment. There could be some resistance to change if the individual selected to head the effort has a "regular" job that does not ordinarily have the power to influence senior members. But surely it can be done.

On the other hand, there are benefits to bringing in an outsider: no subtraction from practice productivity, no power struggles, no learning curve, greater objectivity, expertise with security assessments. Also, you can fire a bad consultant, but dealing with a staff member who isn’t performing can be touchy.

Regardless of the path chosen, be sure to read the EHR vendors’ guarantees closely. They generally offer to credit the monthly usage or maintenance fees for a limited period of time if the practice doesn’t receive the incentive payment. Practically speaking, how will that work?

The incentive is paid to individuals, but fees are typically paid by the practice. Does that mean if one physician does not qualify, then there are no fees for the entire practice that month? Does it mean that a portion of the fee will be credited?When you really think about it, what is a monthly maintenance fee compared to $44,000?

Yes, you need an ONC-certified EHR system, but don’t depend on an EHR vendor’s guarantee to get you ready.

James O’Connor, MD is CEO of MDcohort of Ashburn, VA.

Electronic Medical Records, HITECH, and Your Health Information: Does Bureaucracy Inhibit Innovation?
By Doug Wallace

In case you have not heard, the economic stimulus program that passed in 2009 includes a little something called the Healthcare Information Technology for Economic and Clinical Health (HITECH) act, funded in excess of 20 billion dollars.

Your doctor is now required to computerize your personal health records. All of them. Boom!

Gone will be your current paper medical charts. But where will they go? Scanned and computerized for easy access and review. And why?

The current administration has claimed that, “To improve the quality of our healthcare while lowering its costs, we will make the immediate investments necessary to ensure that all of America’s medical records are computerized”.

While productivity and efficiency is a necessary goal, who is to decide how to accomplish such an initiative?

Much as the Transportation and Security Administration (TSA) claims that upon purchasing a ticket for air travel, you may well than “give up a lot of rights”. Will this hold true for your medical information?

In the move to enforce compliance of HITECH and physician adoption of electronic medical records, some immediate barriers to this initiative have become evident. Among them: doctors are not moving as fast as the money is flowing; the healthcare market already is positioned to deliver on what HITECH demands; any “preferred EMR systems” in good favor of Health Information Exchanges (HIEs) would hinder free market choices.

Is it fair to use regulation as a way to bypass legislation? Or just let bureaucrats decide? The US healthcare system is approximately 2.5 TRILLION dollars, or 18% of the GDP. Should measures such as our personal medical information be placed on a relative fast track whose journey has just begun, for an outcome that is uncertain?

Doug Wallace is executive VP, business development solutions for My EMR Choice of Doylestown, PA.

Readers Write 12/1/10

December 1, 2010 Readers Write 4 Comments

To Be or Not To Be — Certified; That is the Question
By Frank L. Poggio

The ONCHIT Certification process is in full swing. There are three interim firms designated as Authorized Testing and Certification Bodies (ATCB). Over 100 products and about 70 firms have been approved. The key question is this: should you, as a vendor or in-house system developer, get certified?

I think we all can agree that if you sell a full EMR or EHR system to health providers, certification is a must. If you do not get certified, it is unlikely you will install another new client. Worse, your existing clients will start leaving in droves.

But what if you are a niche vendor? What if you sell a best-of-breed (BoB) package, such as a lab system or a therapy or a dietary system? And what about vendors that sell smart medical devices?

For these situations, according to a strict interpretation of the rules, you do not have to get certified (unless, of course, your clients and prospective clients request that you do). And therein is the rub. ONCHIT is not telling vendors they must get certified before they can sell systems (as does the FDA for blood bank software). ONCHIT is going to let the market tell you.

The potential impact of the Meaningful Use bonus / penalties can add up to millions of dollars over the next five years for a given health facility. The responsibility for realizing bonuses and avoiding penalties will fall on the CIO (or maybe COO) of the health facility. If the facility misses out on a bonus or gets hit with a penalty, it is likely that the responsible executive’s job is on the line.

Given that real personal concern, it is fair to assume the CIO /COO will purchase only certified systems and de-install ones that are not.

Even in situations where a niche product does not directly deal with certification “modules”, it could put meeting MU approval at risk. In a recent discussion about certification by the HITECH Policy Committee, it was explained that if you have a ONCHIT-certified clinical data warehouse and use it to generate quality and MU performance measures, if a non-certified system accesses the warehouse and/or places data into the warehouse, the warehouse could be deemed non-certified. I call it “contamination through association”.

Considering the vast amount of PHI and clinical data that moves daily to and from interface engines while finding its way into, and passing through, multiple systems, you can see where a CIO/COO would not want to take a chance on a non-certified product, regardless of how insignificant the application may be to the overall facility’s operation.

This “contamination” issue is not unique to facilities that favor best-of-breed solutions. It cannot be avoided by purchasing an EMR from a single vendor since no single vendor covers the complete waterfront for all applications needed by a provider.

In fact, many medical device vendors will be faced with the same challenge. For example, if a device such as an IV pump, drug dispensing cabinet, or digital imaging equipment is considered “smart” (that is, receiving and communicating patient information and communicating the data over the core hospital infrastructure), then if the device is not ONCHIT-certified, it could be deemed as a potential “contaminator”, thereby rendering the entire EMR as non-compliant and not eligible for MU. Remember: fail just one criterion and you don’t get a bonus.

Unfortunately (or fortunately, depending on your view), there is a now a new cost of doing business in the health systems marketplace: ONCHIT certification. The unfortunate outcome may be that this is a new barrier to entry and will scare off new HIT startups while further embedding the current ones.

The second challenge for a niche IT vendor or device manufacturer is navigating your way through the MU “module” tests. There are 44 certification criteria today. Additional ones are promised for Years Two and Three that will increase the list by orders of magnitude. As a niche player, your product(s) is considered an “EMR Module” and does not have to meet all test criteria. You are required to meet eight privacy and security tests and just one of the remaining 35.

But this may create a real competitive concern. What if you are a BoB vendor or have a smart medical device and none of the 35 criteria apply to your application? From a regulatory standpoint, you do not need to go through certification. Yet your arch-competitor’s application touches just one module criteria and they submit on that one along with the eight P&S criteria and get certified. Whose product or software will the CIO be most comfortable with?

On the surface, you may think it best to try to meet as many criteria as you can, but there are real risks and costs in doing that. Selecting which to pursue, and which to pass on, must be both a strategic marketing and critical development decision.

In summary, it’s hard to see how a niche player can avoid diving into this pool. The more important question is — how deep?

Frank L. Poggio is president of The Kelzon Group.

Is Your Vendor About to Deflate?
By Alan Jack

One of the problems in HITland is the inability of many vendors to hire and keep talented staff, especially in the R&D area. Compared to other sectors , healthcare software companies pay lower salaries, need folks to stay on call 24 hours a day, have long hours, etc. Many vendors do not have great internal cultures, either. The result is that many companies have a reputation problem.

When demand for software developers is good, HIT companies start having problems recruiting, while at the same time, headhunters are targeting their employees. Added to the normally high turnover in the software industry, the losses can start snowballing as workloads go up and more folks bail. Developer numbers will start shrinking despite efforts to recruit more. Software will be delayed just at the time when it is needed most.

Do not think that the vendor will willingly disclose issues with customers. The total headcount at companies experiencing issues will likely be going up, in fact, as other roles are hired: project managers, sales and marketing, and other folks in the easier-to-recruit categories. Employees will often switch roles in those time periods, requiring backfill.

As the economy comes out of the Great Recession, this will become an increasingly difficult problem to deal with. Several companies I’m familiar with are already having issues recruiting.

Given that software developer degrees area unpopular with college students at the moment and the reputation problem companies are having have spread overseas to areas where H1B visa people are recruited, don’t look for things to change soon.

Back to School For a Master of Biomedical Informatics Degree – Part II
By Jeremy Harper

Many HIStalk readers are past the career stage where education adds life-changing value. In fact, they are the men and women who will be interviewing and hiring students in the upcoming years.

This post will discuss the differences students will offer from someone who has experience, but no formal education. It will also discuss some of the general education required for a MBI. Lastly, it will briefly mention internships and how a proactive company could interact with students who would be more inclined towards working at their company upon graduation.

As you saw in my introductory post, I am at the beginning of my career. While I have seen a rapid progression in my career, having entered the full-time healthcare work force in 2007, it would probably take an additional 20 years of experience and luck before I could become a CIO without higher education.

What this degree shows for me — and every other student — is that the person receiving it has a passion for the industry. It shows that that the student is willing to take years out of their life to receive a breadth and depth of knowledge that cannot be equaled solely by work experience. It shows they can determine a long-term goal and marshal the necessary resources to achieve it. These are valuable skills to consider when hiring these students to senior team member and management positions.

As someone with experience at both a vendor and a hospital system, I know the value that real-world experience offers. However, that same experience has a narrow focus. A formal educational setting is changing my perspective on past work to look beyond the scope of the project to see how it fits into the overall arena.

This quarter in pathophysiology, for example, we’re doing clinical reviews every week with a physician. We learn how to do the same types of HX&PE medical students perform (lacking their expertise, of course). We will also shadow a healthcare provider with the specific goal of observing their workflows and reporting them to our fellow students.

The people leaving these degree programs will educated in a variety of different methods, but they will have the ability to adjust and learn to use any system necessary to accomplish a goal. Students learn about disparate topics like database structure, biostatistics, and report writing. This provides a confidence to accomplish more than a work force operating solely on experience.

As a real-world example, I have interacted with two separate interface teams closely in my career. One had exceptionally practical experience, having learned via the school of hard knocks. The other also had practical experience, but also formal clinical education prior to working with the interfaces.

The former team would not modify any data pushed through the interfaces. The closest to modification they would come was translation tables. The latter used their specialized knowledge and depth of understanding to successfully accomplish a stronger interface between two systems that did not inherently talk to one another or have data that could be simply translated with a table.

To close, the OHSU program requires two quarters of real-world internship in whatever specialized field the master’s degree student chooses. In general, the other programs I investigated also required some type of internship and capstone.

These programs had a wide variety in what they were looking to accomplish with the internship. Many past projects from my research were evaluations of an EMR implementation, assisting with EMR implementations, working for software vendors on improving their product, or doing general research for scientific endeavors.

If you have a school in your area (check here)or an internship that can be done remotely, you can start forming professional relationships with these schools and students that will enrich your work force.

Jeremy Harper is a student at Oregon Health & Science University of Portland, OR.

Readers Write 11/12/10

November 12, 2010 Readers Write 16 Comments

On the Largest Medicare Fraud Case in History – $100 Million
By Deborah Peel, MD

Key points:

This case is “the largest single Medicare fraud case” in history.
“There were no real medical clinics behind the fraudulent billings, just stolen doctors’ identities," says Janice Fedarcyk, FBI assistant director-in-charge. "There were no colluding patients signing in at clinics for unneeded treatments, just stolen patient identities."
The organization stole the identities of doctors and filed applications to bill Medicare in their names, often providing a clinic address on the application that was, in fact, the location of a mailbox, according to the indictment. The organization then obtained the stolen identities of thousands of Medicare beneficiaries, including the identities of about 2,900 patients treated at the Orange Regional Medical Center in Orange County, NY.
Members of the organized crime ring also are charged with operating a multi-million dollar scheme to defraud health insurance companies in the New York area by submitting claims for medically unnecessary treatments.
In some cases, defendants allegedly staged auto accidents to generate fake patients who would then undergo unnecessary and expensive treatments that would be billed and reimbursed.

What I still do not get is the inability of very smart people in government, healthcare, and HIT to miss the REALLY big picture.

Privacy isn’t about preventing tomorrow’s profits or blocking meaningful use of data. It’s about the fact that if Americans lose ALL control over personal information in healthcare, we will lose all our privacy rights in the Digital Age. Period. All of them. For every kind of information / data about us. Our strongest rights to control personal information are our rights to control health information.

If we lose the war over control of personal information in health, the US will become a total surveillance state and we will have lost the most precious right individuals have in Democracies: the right to be let alone. Do you think that we can remain a Democracy if everyone — government and private corporations — knows everything about us? There is a reason for the saying “information is power.”

By the way, I am not in the Tea Party or a radical. Standing up for medical ethics, the law, and the right to privacy is a very conservative position!

The big take-away is that as long as patients’ sensitive electronic health information and demographics are so poorly protected, millions of employees of hospitals, clinics, insurers, pharmacies, and health IT vendors will have open access to steal it. We will continue to see an explosion of multi-million dollar healthcare fraud, identity theft, and medical identity theft, unless we radically redesign our health IT systems, protect health data wherever it flows, and restore the right of consent.

The high-profile of this case is supposed to discourage criminals and potential criminals, but when millions of employees in healthcare, government, and health technology corporations have open access to all patient health data, the likelihood of getting away with data theft is high. The innumerable outside hackers and criminals whose business is stealing valuable health data will never stop.

The only solution is to require comprehensive and meaningful privacy and security for all health data, wherever it flows:

1) Restoring patients’ rights to control electronic health information would end open to the nation’s health data by millions of employees of the healthcare system, insurance, government agencies, and technology industry. Requiring informed consent before ANYONE can see our records is simple, cheap, and easy if we require robust electronic patient consent for all data use or exchange.

2) Requiring and enforcing ironclad, state-of-the-art security for all health IT systems and health data wherever it is held online is essential.

If we don’t require and build trusted systems now, before ‘wiring’ all health data systems together, before systems are ‘interoperable’ and before every American is required to have an electronic health record, we will destroy privacy for generations. Once our sensitive data is ‘out’, like Paris Hilton’s sex video, it can never be made private again. And when healthcare systems cannot be trusted, people refuse to get needed treatment, fearing their jobs and futures will be endangered. Creating a healthcare system that people are afraid to use is a national disaster. Trust takes a long time and is very expensive to rebuild.

The implications for Democracy if we lose the right to privacy in healthcare are dire.

Deborah C. Peel, MD is the founder of Patient Privacy Rights.

Before Extending Software Support Contracts, Consider Alternatives
By Tony Paparella

It’s common for a healthcare organization to become unnecessarily tied to an extended support contract when it retires an HIS in favor of a new system. The old system is not an ideal data storage solution. Although patient accounting and clinical data sets still require some functionality and real-time user access, the legacy application is expensive overkill for what is needed.

Support contracts typically run a year or more in length, meaning they’re oftentimes paid for longer than necessary. Furthermore, it may be difficult to negotiate favorable rates and terms with a vendor facing long-term loss of revenue.

Other times, purchasing a contract isn’t an option; the system may be so outdated that the company that owns the software no longer offers support. This places the organization in a precarious position, facing potential loss of vital data. Furthermore, IT staff may become burdened with legacy system upkeep, deflecting efforts away from the new HIS.

“Doing nothing” or opting for an inadequate option invites serious compliance and financial risks. Millions of dollars (and the jobs of CIOs and department directors!) can be lost to: interruption to account billing/cash flow; inability to respond to a payer audit (such as RAC and commercial insurance audits); noncompliance with Federal and State data retention requirements; loss of access to the legal medical record and; increased hardware/software expenditures.

Additionally, fines for non-compliance with Federal employment record, HIPAA and other retention requirements can be significant. Depending on the statute, data retention requirements range from three to 28 years – meaning a short term, one-dimensional solution won’t do.

Fortunately, signing an extended support contract isn’t the only option for organizations that must access and manage legacy data.

Internal warehousing may be considered as an alternative – metaphorically, a home for data, albeit largely unfurnished. Though data access and management is inherently restrictive, this option is typically the most time- and cost-efficient to implement.

In a full detail conversion, all legacy account data is converted into the new system. If precisely executed, compliance and cash flow are maintained. Often, however, the vendor will decline to bring old data into the new HIS. Hence, the risk of cash flow interruption. A high degree of planning and analysis is required before implementation.

Legacy data can also be migrated to a healthcare active archive specifically designed to allow end users to access and update accounts, run reports and, in some cases, post payments and bill accounts. Advance preparation is essential. In some instances, an organization may need to specifically task an IT team member with helping coordinate the migration of data.

Proper planning and preparation will help your organization sidestep a burdensome legacy system support contract. Understand the risks and investigate your options many months in advance.

Tony Paparella is president of MediQuant Inc.

The Quest for Price and Quality Transparency
By Colin Konschak

What one hospital charges for a particular procedure varies widely based on a host of factors. Understandably, many providers who are otherwise all for transparency when it comes to patient outcomes are reticent to disclose cost data. There are real reasons for concerns on the globalization of medicine. However, health care is largely a local phenomenon.

What are the compelling reasons for being as transparent with prices as with anything else? For one, increasingly, consumers are armed with price information today that exceeds anything they could have assembled even just a few years back. Also, in the mind of many consumers, price equals quality. Logical or not, this notion has become ingrained as a result of their consumer experience in other industries.

Wine under one label is deemed more expensive than wine under another label, even in the case where the wine has proved to be exactly the same, from the same source, processed and delivered in exactly the same manner.

Reputation Enhances Price

At the supermarket, branded merchandise still sells at a premium compared to store or generic brands that offer the same ingredients, molecule by molecule. Your hospital’s reputation could prove to be the deciding factor in whether or not a patient will plunk down more money to be treated by you over others who, based on all comparison measures, offer exactly the same care and service.

Suppose a consumer does his homework and finds that you and a competitor have entirely equal success rates for particular procedure, and you charge 15% more. Is this a reason to fear price transparency? No, because with all the data available for a consumer to peruse to his heart’s content, the decision to choose one provider over another is multifaceted. Price is one factor, albeit an important one, among several.

Many consumers will go with the lowest price. Many will choose the best value – a blend of price and quality. Short term, there is not much you can do about the prices for some of the procedures you charge. In the long run, everything is up for grabs.

More Business, Lower Prices

The more often a hospital performs a particular procedure, and the more experience its doctors accrue, the better it is able to offer that procedure at a lower price. Even in health care, greater business volumes contribute to economies of scale. In the short run, you can’t do that much about the volume you handle for any particular procedure. In the long run, you could seek dominance in your local or regional area by publicizing your experience in a given procedure. Thus economies of scale could result and price transparency would work to your favor.

At Alegent Health, based in Omaha NE, the prevailing attitude is that consumers have a right and ought to be able to easily know how much a provider charges. Three years ago, Alegent launched My Cost, found at www.alegent.com, a consumer-friendly feature that offers cost estimates for a variety of tests, procedures, appointments, and services.

So, You Want Cost Data

Visitors can simply enter the name of their insurance providers and any co-payment or deductible information. The system then presents a cost estimate that is useful in personal health care decisions.http://www.alegent.com, The visitor is also treated to financial assistance information via links provided, and a phone number in case their anticipated procedure is not listed on the site. Now up and running for nearly three years, more than 50,000 cost estimates have been generated at My Cost.

Alegent’s experience in promoting price transparency has been that consumers appreciate the honesty and openness of the organization. Instead of price transparency scaring away potential business, in this case it has led to stronger provider-patient relationships. Alegent’s CEO says transparency “isn’t necessarily easy, and it does take courage, but in the end it is the right thing to do for consumers and the community.”

Make the Commitment

Commitment to transparency takes guts. Yet, what other choice is there? Fortunately, as we’ll see, there is room for creativity and initiative.

Providing information on the results that your hospital achieves for patients, at the medical condition level, is vital. Your data needs to include patient outcomes with an adjustment for risk based on prior conditions, the overall cost of care, and measurements for both extending through the care cycle.

Transparency also encompasses offering the experience your hospital has in treating specific medical conditions, by volume of patients, coupled with delineation of such treatments based on methods of care offered. Your processes, in the long run, can be improved only by understanding how results are achieved, which methods are most effective, how they might be refined to make critical differences, and what the actual outcome of such refinements have been.

Details Count

Outcomes for a specific medical condition can and should be expressed many ways. For, say, shoulder surgery several validated measures exist such as range of movement, reduction of pain, and ability to function. Still other outcome measures for shoulder surgery include the interval between the initiation of care and return to normal activity such returning to work or playing tennis again.

Data related to the particulars of patients, known as patient attributes, such as gender, age, genetic factors, and prevailing conditions, are vital elements of transparency and are essential for assessing risk. Accurate diagnoses are vital for both the patient and the provider. A transparent provider will publish measures of diagnostic accuracy including cost, timeliness, and completeness.

Outcome measures that only address episodic interventions fall short because they fail to yield results meaningful to the patient. Such short-sighted reporting and consequence scoring can be counterproductive and lead to the publication of misleading data.

Failure is not pretty and human beings instinctively want to avoid reporting their own shortcomings, much like organizations. Still, ineffective treatments – errors in procedure, medication, or treatment – and complications following a procedure need to be identified and scored. As unpleasant as this task may be, it is a step on the path to improved levels of treatment and overall service. You cannot fix a problem that you refuse to acknowledge.

Expand Your Measures

A traditional core measure, “the 30-day readmission rate,” tracked by the government, is of course a potential indicator of poor quality. Who wants too many patients are readmitted within 30 days for the same problem.

You may be able to devise your own kind of data measures by tinkering with traditional data measures. For example, you could align your total quality management efforts, such as your Six Sigma Performance Improvement initiatives, around improving the 30-day readmission rate and devote resources to that. In turn, for each of the core measures which need to be fully transparent, you may wish to devise two, three, four or more strategies to ensure that your scores improve over time. Rest assured, other providers will be doing the same.

Costs Mysteries No More

Unlike most businesses, many hospitals, to this day, don’t know what their actual charges ought to be. They charge for this procedure or that based on tradition, competition, payer contracts, or whatever cost data they can scrape together. A comprehensive understanding of true cost is often lacking. If and when the government mandates that hospitals publish price and quality information, they will need the technical ability to do so.

In almost all cases, some web restructuring proves to be vital. There needs to be a huge consumer section that is highly inviting. Take the bull by the horns and invite the consumer to go patrolling through your data. Just as industrial companies publish annual reports with a profit and loss statement, balance sheet, and cash flow analyses, you might choose to offer a five-year projection as to the life cycle cost of a procedure and its follow up.

Implications for Your Hospital

Is transparency part of your agenda for your weekly and monthly meetings?
Has your hospital developed policies and procedures in relation to transparency?
Within your own office or division, are top officers involved in the transparency discussion?
Have you attended any conferences and symposiums on transparency?
Are you monitoring other providers who have already made the conversion to transparency?
Are you devising plans to capitalize on the inherent opportunities in offering transparent data?

Colin Konschak is the managing partner of DIVURGENT, a management consulting firm. His book on this topic was just released.

Readers Write 11/1/10

November 1, 2010 Readers Write 6 Comments

A Step Towards the Cloud
By Mark Moffitt

People tend to use the terms SaaS and cloud interchangeably, when in fact, they are two different things.

Software as a Service (SaaS) delivers software as a service over the Internet, eliminating the need to install and run the application on the customer’s own computers and simplifying maintenance and support.

Cloud computing is about using economies of scale and sharing cheap, commoditized computing resources to lower overall costs. To realize these economies of scale large data centers are built and managed to protect and secure customer data at the lowest possible cost. These data centers are huge (see photo below).

Cloud software takes full advantage of the cloud paradigm by being service-oriented with a focus on statelessness, low coupling, modularity, and semantic interoperability. Cloud storage uses shared-nothing, distributed data stores so that low-cost, commodity storage technology can be utilized. Traditional RDBMS don’t fit into these new storage models. The reason is RDBMS need to join data from multiple tables. This requirement is incompatible with the distributed storage configuration found in cloud storage services.

Google’s Dalles, OR data center on the Columbia River

On the banks of the windswept Columbia River, Google is working on a secret weapon in its quest to dominate the next generation of Internet computing. But it is hard to keep a secret when it is a computing center as big as two football fields, with twin cooling plants protruding four stories into the sky. New York Times, June 8, 2006

Few HCIT vendors have architected their system for the cloud. The good news is that healthcare systems don’t have to wait for HCIT vendors. They can take advantage of cloud computing today by storing and archiving clinical results such as lab results, transcribed reports, images, and waveforms in the cloud.

Clinical results are well suited to take advantage of cloud storage for reasons such as:

Results do not require a schema or other features of a RDBMS to store and access data. Yes, that includes lab results.
Key-value (object) stores are better suited for storing results than RDBMS.
Key-value data stores can use cloud storage technologies that are less expensive than the cost of using a vendor’s RDBMS to store and archive data.
Clinical results often need to be shared beyond the walls of an organization and, therefore, ideally suited to being stored in the cloud.

Amazon’s S3 cloud storage prices run about $18,000 per year for 10 terabytes of data. These prices include storage, archiving, and security. 500 terabytes is priced around $800,000 per year. There are additional fees related to access, but this number gives the reader a ballpark estimate of the price for the service. Other vendors such as Google and Rackspace offer a similar service at about the same price.

Other potential costs include deploying a system to provide local caching of often-used data in the cloud. This is accomplished by deploying a hybrid cloud to include local storage as depicted in the diagram below.

Savings are real and immediate when an organization pursues the cloud storage strategy for clinical results when replacing hardware such as moving from MEDITECH Magic to 6.0 or MEDITECH Magic to Cerner; or upgrading an image archive system. Cloud storage can eliminate the need for hardware and software that would otherwise be needed to store and archive existing and future clinical results.

It seems to me that cloud storage is a better model for an HIE than reposing clinical results into yet another fixed-schema RDBMS. The reasons are:

Providers are obligated to maintain a copy of results for legal and reimbursement obligations.
Providers save money by storing and archiving clinical results in the cloud.
HIE organizations can use clinical results stored in the cloud and focus their efforts on providing services unique to an HIE such as electronic opt-in/opt-out functionality, security, and record locator services for clinical results as a way to offer personalized EHRs to patients.

The transition to cloud computing in HCIT will take years as the business case for the approach becomes financially and operationally attractive as compared to alternatives and customers understand and accept the new paradigm of cloud computing and cloud storage. The transition to cloud computing will not be a waterfall event, but rather a gradual diffusion of the technology into HCIT. Storing, archiving, sharing, and securing clinical results in the cloud may be the first step in moving HCIT to the cloud.

Mark Moffitt, MBA, BSEE, is a former CIO and is working as a consultant while looking for his next opportunity.

Why IT Can Never Be Irrelevant
By Shubho Chatterjee

Over the last few years, journals, trade magazine articles, editorials, and even a textbook (Does IT Matter by Nicholas Carr) have prognosticated the irrelevance and strategic demise of IT. Many thought-provoking articles and blogs have debated the pros and cons of this prognostication.

I am going to add one more and argue that IT can never be irrelevant in organization, strategically or operationally. Here is my argument.

Firstly, IT is a discipline, much like engineering, finance, marketing, and others. Within engineering and finance exist multiple disciplines. As long as the world exists, both disciplines will exist. IT is similarly an assembly of different disciplines providing a very important outcome. Do we come across arguments that engineering or finance is irrelevant? No. Similar rationality will negate the IT “demise” thought leadership.

Secondly, following from the first argument, can we imagine today any organization operating without technology and IT? Take out IT — ERP, EMR, CRM, data networks, Web sites, ad infinitum — from any organization and the entire organization will collapse. Who plans for this, who should strategically plan for this, and who operates these systems? IT. IT is probably the most critical component of a functioning organization.

Thirdly, let’s examine IT functions and how it provides context to this debate. At the lowest level, Tier 1, is the basic infrastructure support, such as, help desk, network management, telecommunications support, and others. These activities are very commoditized and often outsourced, on-shore or off-shore. Outsourcing has also provided a rationality support for the “IT irrelevance” thought camp. But let us examine what happens and who does it.

Even when such functions are outsourced, somebody in IT has to do it, even though it is done by another organization. Often the outsourced employees are absorbed in the outsourcing organization. Therefore, in this case, we cannot say that IT is irrelevant — the function and activity has shifted organizationally and is also managed by IT of the vendor. The outsourced vendor relationship is also managed by the customer IT organization. Similar arguments hold for application development and support activities. For off-shored activities, the job losses are a fact, but it does not make IT irrelevant.

At the middle level (Tier 2) of IT operations, let’s say, at the business analyst, project management, vendor management, or network operations management levels, the IT aspects are critical. For example, the business analysts are key to developing IT product or service development and delivery requirements and pipelines, the IT vendor managers are key to selecting, evaluating, and managing vendor relationships. Can any other disciplines perform these functions? No. Why? Because these activities require domain knowledge and experience. For example, who other than IT can plan how a wireless network will integrate with a wired network to provide a point-of-service usage of EMR for medication management at a patient’s bedside?

Finally, no other function can be responsible for, perform, and meet the strategic technology requirements. Here, IT leadership is key in determining and ensuring the alignment of organization business strategies with technology strategies.

Consider the following example of Miami Jewish Health Systems operating the EMR, HR, Enterprise Content Management, and other applications operating in a cloud (SaaS) environment. The strategic planning and business case for moving to a cloud environment was completed by IT leadership, in collaboration with executive management, as were the tactical and operational aspects.

IT is uniquely positioned to provide results-oriented technology and process leadership to an organization. The future also holds enormous significance for IT, not only in healthcare, but in all industries. Let’s think about the healthcare landscape and the technology leadership requirements. For example, how will Accountable Care Organizations (ACO) function, who will plan and implement the strategic ACO technology requirements, how will cloud computing change service delivery and how will data security be impacted at all levels? These are some of the many very strategic questions that require deep IT involvement.

I believe IT can never be irrelevant. The discussion, while sensational, is moot.

These opinions are mine and do not reflect current or previous employer views.

Shubho Chatterjee, PhD, PE was formerly chief information officer of Miami Jewish Health Systems of Miami, FL.

What Tom Munnecke Is Thinking About Today

I exchanged e-mails with Tom Munnecke after mentioning his VistA-related Congressional testimony. I was fascinated with his 1998 HealthSpace concept paper and asked him if he had updated it or what he was thinking about twelve years later. Here is his reply.

My thinking now largely deals with the deeper implications of time. Here’s a talk I gave at the International Society for the Study of Time and some more in this interview from 2005 for the Pew Internet Visionaries.

I’ve been also very interested in the physics of anticipation. As this relates to health IT: a deeper understanding of what is sometimes called the placebo effect, but in a broader sense is the self-referential feedback loop between our anticipation of the system and its net effect on us. Also, the need to support the notion of flow or state in our communication systems.

The Web was built on a stateless protocol, but health information is very stateful, linking things over time. So, I think a "diachronic" model (flow of things over time) is a critical addition to our current "synchronic" (everybody synchronize their transactions, protocols, interfaces, and standards to current).

VistA was designed to be an evolutionary approach from the git-go. We created a "good enough" seed system, and planted it to see it grow. As I’ve learned in my studies of complex adaptive system (Stu Kauffman in particular), the most critical factor shaping evolution is the fitness function, the metric by which "survival of the fittest" is determined.

In VistA, this fitness function was user acceptance. If people didn’t like or use a module, then it wasn’t fit and fell off the evolutionary path. The finer the granularity of these experiments and the quicker you can get a lot of feedback, the faster you can accomplish the error-making and error-correcting evolutionary process. When you try to do a $100 million centrally-planned change, you lose this graceful process and end up in front of a Senate panel asking what happened when it inevitably crashes.

I think we need to come to grips with the notion of personalization (see my 1999 "personalizing health" paper) beyond just today’s FaceBook craze. While the HHS/ONC focus is weighted to the enterprise-centric (aka the Disease Industrial Complex), turning patients into "consumers," I think we need to turn the healthcare system upside down, putting the patient at the top and the providers as supporting elements. I talked about this a bit in the Opening Chapter (co-authored with Rob Kolodner) in Person-Centered Health Records: Toward HealthePeople.

What we are seeing now is a heroic battle between rigid, hierarchical top-down control (Blumenthal telling vendors, for example, that it is "imperative" that vendors support less insured populations) and grassroots, peer-to-peer, Net-based activities (FaceBook, Patients Like Me, Cure Together). Looking at the evolutionary fitness functions, I think that the grassroots will eventually win out, but only if the proper constraints can be applied (Tim Berners-Lee constrained the evolution of the web to TCP/IP, for example, a "good fence" that made "good neighbors").

So, I think we need to rethink health IT as a "space" rather than a "system." Perhaps people think that we can keep adding thousands of pages of legislation per year to the 125,000 we already have to end up with a "more perfect" health care system, but sooner or later we are going to have to declare a complexity crisis and admit that our intellectual paraphernalia with dealing with health care is inadequate.

It’s a bit like if Tim Berners-Lee tried to create the Web by going to the UN and asking for the UN High Commission on Innovation to create a Web subcommittee, who would then create global subcommittees and standards for specific applications. The sub-subcommittee of the high commission would meet with all the auction houses to collect all the stakeholders (Christies, Sothebys, etc) to create an integrated approach respectful of all parties and complying with all international regulations, UN regulations, etc. The very thought that Pierre Omidyar would write a simple program to auction off a broken laser pointer and turn it into eBay would be totally beyond belief 🙂

Yes, I’ve been doing a lot of thinking about the future of health and health care IT and dropping notes into my blog. Try the tags for VistA and AHLTA. You can read some of my early thinking at the bottom of this page. And here is some of my early thinking on the personal health record.

Tom Munnecke is a leading expert on healthcare IT, having been involved in the creation of both the VA’s VistA and the DoD’s CHCS and served as VP and chief scientist of SAIC. He is a consultant, entrepreneur, and board member of several health IT startups. He holds frequent workshops, salons, and networking events in a cabana at his home in Encinitas, CA.

Dreaming IT to Reality
By Ron Olsen

For years as a hospital IS manager, I had the tag-line of ‘Dream It To Reality’ in my e-mail signature. I meant that. You dream it and I, the humble IT guy, will do my best to bring it to reality.

Einstein once said, “Innovation is not the product of logical thought, although the result is tied to logical structure.” Thinking about that quote, I realized that to truly innovate, you must not necessarily think illogically, but you must think outside the sandbox you play in every day.

To meet the ever-changing needs of your organization, you have to empower your IS/IT team to approach problems from different angles — every day — and to not be afraid of failing once in a while. The logical structure is all around us, so when looking at processes, give everyone the freedom to question what you’re doing, at all levels.

With the many masters a hospital IT staff serves, what was once good enough for yesterday will never be good enough for tomorrow.

Ron Olsen is a product specialist at Access.

Readers Write 10/20/10

October 20, 2010 Readers Write 7 Comments

Note: we asked two consulting company executives to respond to a reader’s question: “Most physician offices say they are waiting for their EMR vendor to let them know how their systems will handle ICD-10 before they do any of their own prep work. Is this common? Vendors seem to be quiet on the subject.”

Preparation for ICD-10
By Peter Butler

From what we are seeing and hearing from healthcare organizations we work with, in general, the larger IDNs and healthcare organizations are addressing ICD-10 readiness through appointed committees to head up the planning for ICD-10. It is the smaller physician medical groups that are taking a “wait and see approach” to ICD-10 and vendor readiness.

In one conversion with a medical group CEO who is also a practicing pediatrician, I was told that his concerns as it relates to ICD-10 were minimal. His view was it was mostly an IT issue. There is a small subset set of ICD-9 codes he uses regularly today and with ICD-10 that list will grow slightly, but nothing that will require a major amount of education or training.

We’ve seen many of the major IT vendors saying they are investing in ICD-10 readiness today. They are still doing their own due diligence internally before communicating details and specific plans with their customers which is why your reader may not be hearing much from the vendors.

I was recently visiting with a vendor who has made ICD-10 and Meaningful Use their top priorities and slowed other R&D efforts to focus more resources on these two initiatives. We believe that the majority of vendors will deliver ICD-10 compliant upgrades in reasonable timeframes.

For providers, taking a “wait and see” position is dangerous, as ICD-10 codes will affect all services in all settings; and therefore all reimbursement. Providers must begin to inventory all of their vendor systems to determine their ability to be able to accommodate the EDI v5010 enhancements and expanded character sets. Workflows need to be inventoried so organizations can understand where testing and mitigation need to be planned. There are many constituents (i.e., insurance companies, labs, etc.) that also need to be managed and contracts reviewed to minimize the impact to provider reimbursement.

ICD-10 needs to be viewed more broadly than just complying with government regulations. The ICD-10 code set provides organizations with new opportunities to enhance their revenue stream. The key is to begin now and prepare a clearly defined transition plan.

Peter Butler is president of Hayes Management Consulting of Newton Center, MA.

Preparation for ICD-10
By David Vreeland

I’d say that the burden of implementing CMS V5010 and ICD-10 is largely going to be borne by the vendors, but it’s always the responsibility of the organization’s leaders to ensure that the organization is compliant with such regulations.

In a hospital, there are typically many more information systems in production and so the burden on the organization is larger because they need to responsibly ensure that they have a handle on all those vendors and determine what the plan is for accommodating the change to these new code sets across the various IT providers. They also will likely need to have a testing plan in place for interfaces, downstream system compatibility, etc.

On the ambulatory / physician practice side, I’d say that the approach is the same, but the complexity is likely significantly lower. But simply waiting until the vendor takes action is ill-advised.

As a physician, I’d be requesting information from my vendors about the development plan and timeline for these enhancements, and if the practice operates a practice management system that is provided by a different vendor than the EMR solution, I’d be looking at moving to an integrated solution. Most vendors we work with have a plan and timeline either in mind or on paper by this point, and it’s appropriate to ask for it.

David Vreeland is a partner with Cumberland Consulting Group of Brentwood, TN.

Back to School – For a Master of Biomedical Informatics Degree
By Jeremy Harper

With the recent influx of government funding in healthcare, educational opportunities abound. I have been lucky enough to receive a scholarship to Oregon Health & Science University’s (OHSU) Healthcare Informatics program. My passion is to work with healthcare organizations to ensure patient safety and innovative technologies. This article will cover how I found the OHSU opportunity and why I decided to attend a program that required moving to the other side of the country.

An elevator story about my personal background is that I attended The Ohio State University’s business degree program from August 2003 to December 2006, receiving a BS in General Business. I worked at Epic Systems from February 2007 to April 2009 and discovered a passion for healthcare IT.

After I left that company, I took my GRE, where I scored well but not brilliantly. I applied and was accepted to three graduate schools for healthcare informatics (Capella, UIC, UW Milwaukee) but I failed to procure funding, so I accepted a full-time position at an amazing hospital as a systems analyst. A month after starting, I transitioned to being the secondary interface engineer and over the past year spanned both positions.

While I found my work environment to be an amazing experience, I had a passion for education and furthering my career. To do this, I needed either to gain further professional experience or consider specific degree programs. I made the decision that I would find an online program that would allow me to continue to gain real world experience while furthering my education and qualifications.

To this end, I researched available programs online and sent a letter to Mr. HIStalk to ask which programs he could recommend. He came back with a number of programs, among them OHSU as one of the leading online programs. I went to their website (along with the others) and found that OHSU had received a grant that would fully fund a one-year online certificate program and a few masters’ degree students. I applied and was accepted to the master’s degree program.

That application was not instantaneous nor was it free. However, spending $358.72, (Including the A&P online course I took to be eligible for the program, not including the sunk cost of my GRE from 2009) was a small price to pay to have a fully funded degree program with stipend. The program itself will take six quarters, two of which will include an internship. This fall, I am taking courses in Java, scientific writing, and introductions to biomedical informatics, biostatistics, and healthcare. This scholarship provides me the freedom to focus solely on my education rather than needing to balance it with work.

There have been opportunity costs. Nothing is free, even on a scholarship. The highest costs are the same anyone attempting a work/life balance will have to face. My personal situation means I have a fiancé 2,800 miles away in Ohio. I will have limited time to see her until we are married next year. I left a position where I enjoyed my co-workers and found the work itself exciting and fun. I moved with only what could fit in my Toyota Corolla (far more and far less than you’d expect). I have needed to find a roommate because of my budget. I have needed to budget my funds closely to assure I will be able to attend school. All the type of sacrificed anyone going back to school will have to consider.

If you are considering further education, now is the time to look into opportunities. OHSU, for example, will be funding hundreds of more certificate program students, leaving those students half way to receiving a MBI degree from the program. If you visit the ONC website, you can research and find additional schools that have been funded. The ONC has also funded community colleges around the nation for a workforce re-education model that will put folks through approximately a nine-month program educating them on healthcare informatics.

Jeremy Harper is a student at Oregon Health & Science University of Portland, OR.

Note: the following original article exceeds the usual word limit, but was valuable enough for its content and citations that I thought it was worth running intact.

Customer Relationship Management in Healthcare
By Lindsey P. Jarrell

Consumerism is playing an increasingly important role in healthcare, one that hospitals need to address in order to deliver the level of service that patients are starting to expect. In fact, according to a 2009 survey of healthcare consumers by the Deloitte Center for Health Solutions, consumerism is such a powerful force in healthcare that it is a “defining characteristic between its past and its future that will impact every stakeholder’s value proposition and business models. Consumerism is not a fad; it is a trend of enormous significance.”[1]

Today’s consumers are highly attuned to the level of service in healthcare and their attitudes and behavior reflect this. Roughly one in four has switched or has considered switching hospitals, clinics, or doctors because of a negative customer service experience.[2] Slightly more than half of customers report that they choose hospitals “based on whether they believe employees understand their needs.”[3]

Consumers have many choices when selecting their healthcare providers and they are beginning to exercise their options. Almost one-third report comparing doctors before choosing one and 15% compared hospitals.[4] Unfortunately, healthcare consumers believe the system is performing poorly: 76% percent grade the system as “C” or below.[5]

Customer relationship management (CRM) is an approach used in many industries that focuses on addressing the unique needs of customers to increase value for both the customers and the organization.[6] CRM software is currently used in only about 15% of hospitals, but it is a growing trend.[7] It can help streamline operations to handle the multi-headed juggernaut of attempting to compete for lucrative customers, control costs, improve profitability, and foster a customer-focused cultural climate.

Today’s Healthcare Consumer

A growing number of consumers want to be actively engaged in their health. They compare doctors, hospitals, medications, devices, and health plans; explore alternatives to conventional approaches; and spend money to achieve their health goals.[8] They want to control their health information and prefer providers who use Internet-based tools to augment care.

The 2009 Deloitte survey showed that 57% want a secure Internet site that would enable them to access their medical records, schedule office visits, refill prescriptions, and pay medical bills. Forty-two percent of health care consumers want access to an online personal health record connected to their doctor’s office, one in five would switch physicians to obtain such access, and consumers are less concerned about privacy and security issues than in the past,.[9],[10] Many (62%) believe that hospitals vary with respect to quality.

Because they are increasingly sensitive to errors, poor service, and lack of useful tools that would enable them to navigate the system more effectively, they are receptive to innovations that offer greater value, better service, higher quality, and lower costs. What’s more, they embrace innovations that enhance convenience, personalization, and control of their personal health information. Consumers, especially those who are younger, are willing to try new service and change providers in order to obtain better value. They are highly receptive to technology that eliminates redundant paperwork and unnecessary tests and saves time and money.[11]

Why CRM?

It’s not surprising that consumers are often dissatisfied with their healthcare experience. Today’s healthcare environment is fragmented and complex, with numerous entities controlling access to information that exists, yet is inaccessible to both providers and patients. A lack of integration and workflow impedes the ability to deliver complete, accurate patient information, which has a negative impact on patient satisfaction and quality of care.
In seeking better tools to manage patients across the continuum of care, healthcare providers are turning to CRM software because it offers several components to address these issues. It provides integrated business systems that serve the medical staff, the administrative staff, and hospital stakeholders while also directly serving customers, giving them easy access to their healthcare history and on-demand knowledge of potential remedies.

Effective CRM systems are starting to integrate personal health records with the hospital’s data to provide a system for managing care-related activities, costs, and benefits, and enabling patients to have better online access to enhance the management of their healthcare. The benefits of this approach include:

The ability to analyze the performance of routine processes over time (such as admissions, discharges, transfers and referrals) in order to eliminate unnecessary steps and increase patient satisfaction.[12]
Developing customized workflows to automate care coordination activities between provider organizations (e.g. physician office, hospital and home health) which can lead to improved patient outcomes, increased operational efficiency, and reduced costs.[13]
Proactively managing chronically ill patients (e.g., diabetes and congestive heart failure) to target them with communications about educational offerings and remind them of ways to manage their illness.[14]
The ability to improve care coordination and reduce the risk of patient readmission.
Reducing costs by consolidating systems and pooling resources to obtain economies of scale, improving utilization of appropriate healthcare resources and understanding the cost of treatments to drive business planning
Preventing and mitigating medical errors by integrating CRM data with medical history and clinical data.[15]
Generating marketing campaigns targeted at specific patient types by combining a knowledge base with scientific analytics and feedback mechanisms.[16]

With the advent of electronic medical records and the infusion of federal stimulus money that is helping to drive the widespread adoption of technology, CRM software may well be the next logical step in the increasing reliance and utilization of IT in healthcare.

CRM Components for Healthcare

Companies such as Siebel Systems, Salesforce, HealthForce and SalesBoom offer CRM solutions that are tailored to the needs of large and small providers. These systems often include the following components:

Integrated Data

In many industries, the majority of revenue comes from existing customers and healthcare is no different: about 80% of annual revenue comes from patients who have previously used the system.[17] Integrating enterprise-wide data is therefore a key component to improving customer service.

An integrated database allows hospitals to collect data, analyze individual needs and preferences, develop relevant messages based on these needs and preferences, and deliver communication through preferred channels (e.g., text messages, e-mails and phone calls). It requires an integrated combination of data and application programs to support analysis, opportunity identification, data mining, and communications management.[18]

Such a system is equipped, for example, to determine which patients are at greatest risk for disease or complications, allowing the hospital to provide appropriate interventions and communications at the right time. It can also help track and improve other processes, such as check-in procedures. The result is a more personalized relationship between providers and patients that increases patient satisfaction.

Customer Care and Recovery

The trend toward consumerism in healthcare means that patients expect to be treated as customers. One in four patients say poor experiences at hospitals or clinics have caused them to use or think about using walk-in centers as an alternative.[19] In its 2008 Hospital Pulse Report, Press Ganey found that the larger the hospital, the lower the overall patient satisfaction rate.[20] Coupled with the fact that the majority of hospital revenue is from repeat business, this means that hospitals need to find ways of increasing customer satisfaction — including rectifying mistakes — so that revenue is not lost.

CRM software solutions can facilitate the collection of patient-related information from a consumer perspective, facilitate complaint management by allowing hospitals to capture, review, approve, and access information about solutions to existing and past problems, and collect feedback data that can be used to improve operations. Feedback also helps mitigates risk in an environment in which government agencies are continually monitoring hospital performance. [21]

Predictive Modeling

CRM software can allow hospitals to predict patients who are at risk for developing certain conditions and identify those already diagnosed who are likely to develop complications, creating an opportunity for preventive interventions instead of more expensive treatments that may otherwise be required for acute episodes or chronic disease.[22] For example, predictive modeling can take into account co-morbidity, severity, frequency, physician, and specialty data to predict the likelihood of a patient with diabetes developing heart disease or the chance of a patient with hypertension developing glaucoma. This translates to earlier disease discovery, better management, improved intervention, and more relevant communications.[23]

Marketing

CRM-driven marketing can allow hospitals to deliver the right message to the right person at the right time. A comprehensive CRM database and analytical software can predict the likelihood of patients to require specific preventive interventions or develop certain health conditions. By leveraging CRM data, hospitals can implement customer-specific outreach to educate both diagnosed and undiagnosed patients.

For example, one hospital implemented a campaign targeted at diabetes patients. This involved mailings that included offers for free glucose screening and nutrition classes, as well as discounted diabetes and cholesterol screenings. The campaign resulted in incremental patients in three categories: patients with a first-ever diabetes diagnosis, patients who used services who had been undiagnosed, and patients who used services who had been previously diagnosed.[24]

CRM software is complimentary to both revenue cycle applications and electronic medical records within physicians’ offices and hospitals. One has only to think of the type and frequency of e-mails from retailers (e.g. hotel chains announcing special deals at exotic locations) that are carefully placed marketing campaigns based on a specific customer’s previous buying experience and profile. The power of using CRM lies in combining data collection, information management and market targeting vehicles to creating a proactive marketing approach that can increase the customer base.[25]

CRM Making a Difference

CRM has been successfully used to help hospitals capitalize on their data to increase patient satisfaction and boost earnings. Today, many hospitals are demonstrating a substantial ROI from implementing a CRM program. Below are a few examples of CRM at work:

Children’s Hospital and Research Center at Oakland faced declining referrals and revenue stream, incomplete process follow-through, and decreased patient satisfaction. Using a contact center CRM strategy, the hospital saw a 22% increase in overall referrals and a 50% improvement in both patient and referring physician satisfaction levels.[26]
A group of six Florida hospitals used CRM tools to launch a direct mail campaign that generated $1.9 million in new revenue in three months.[27]
CRC Health required a platform to manage patient intake, track Web entities, and streamline operations to increase revenue. A CRM system enabled the company’s Web-generated revenue to jump from 4% to 26%. The company can now tie revenue to referral performance, boosting its growth potential. A tool to track web marketing effectiveness indicates to the dollar what is performing and what is not and the system even provides patients with available beds faster. As a result, CRC Health can serve a larger population.[28]
Cedars-Sinai Medical Center wanted to improve low call-to-appointment conversion rates and patient satisfaction. The hospital designed a comprehensive contact center-based CRM strategy that improved appointment conversion rates from 22% to 48% and patient satisfaction by 42% over the first year. During that time, more than $3 million was generated in incremental revenue.[29]

Challenges, Tips and Insights

Implementing CRM software can be challenging. It needs to incorporate a variety of security safeguards including patient confidentiality and privacy issues as well as HIPAA compliance. A CRM systems can be costly and time-consuming to get up and running.

Naysayers may point to past efforts of hospitals to implement CRM systems that have failed. But the landscape of healthcare is changing, and CRM can be a valuable tool to help hospitals adapt to the trend toward consumerism and transparency. IT capabilities and technological advances have paved the way for more sophisticated second-generation software-as-a-service platforms and CRM has become both more affordable and more user-friendly.[30]

As with any widespread organizational change, enterprise-wide system compliance can be difficult to achieve. Internal resistance can be significant from top executives and administrators at the outset and from medical staff once implementation begins and the system is in place. It is important to develop strategies to assist team members at all levels in the organization in adopting a new CRM program.

When considering the implementation of a CRM program, hospitals should keep in mind that:

Converting from a patient orientation to a customer orientation requires a cultural re-orientation.
CRM is not a campaign or a one-time event, but rather an all-out approach to dealing with customers.
Modifications in the language used in all customer encounters — even billing — can have a profound impact on the perceived quality of services.
Quality is defined by the customer, not the provider.

Conclusion

Information is the fuel on which hospitals run and they must harness it to both continually improve performance and measure their record against competitors. During the next decade, the healthcare environment is likely to see an emphasis on improving, measuring, and reporting the quality and safety of care, link provider reimbursement to care performance, and demand greater levels of patient service.[31]

CRM technology gives hospitals the tools they need to thrive in today’s increasingly consumer-oriented healthcare market, while improving outcomes and reducing costs. While its implementation poses a number of challenges, installing CRM programs is an undertaking worth pursuing.

Lindsey P. Jarrell, FACHE is co-founder of Source88.

References

[1] Deloitte Center for Health Solutions. 2009 Survey of health care consumers. http://www.deloitte.com/view/en_US/us/industries/US-federal-government/center-for-health-solutions/60ea5a1264001210VgnVCM100000ba42f00aRCRD.htm. Accessed April 13, 2010

[2]Datamonitor. Addressing the challenges of consumer-driven healthcare. Published January 26, 2007.

[3] Datamonitor. ibid.

[4] Deloitte Center for Health Solutions. ibid.

[5] Deloitte Center for Health Solutions. 2010 U.S. healthcare consumerism survey. http://www.deloitte.com/view/en_US/us/Insights/centers/center-for-health-solutions/consumerism/2010-survey-health-consumers/index.htm?id=USGoogle%20Consumerism%20_HC_510&gclid=CO6Premo3qECFYNd5Qod9DjKIw Accessed May 17, 2010.

[6] Glaser J, Foley, T. The future of healthcare IT. Healthcare Financial Management. November 2008.

[7] Higgins, JK. Rx for hospitals: a big dose of CRM. CRM Buyer. http://www.crmbuyer.com/story/healthcare/68758.html?wlc=1274277431. Published November 20, 2009. Accessed April 8, 2010.

[8] Deloitte Center for Health Solutions. 2009 Survey of health care consumers. ibid.

[9] Deloitte Center for Health Solutions. 2009 Survey of health care consumers. ibid.

[10] Deloitte Center for Health Solutions. 2010 U.S. healthcare consumerism survey. ibid.

[11] Deloitte Center for Health Solutions. 2009 Survey of health care consumers. ibid.

[12] Smolke P, Virmani S. Why customer relationship management in healthcare? Presented at: Healthcare Information and Management Systems Society annual conference; February 24, 2008; Orlando, FL. http://www.mshug.org/docs/techforumOrlando2008/Smolke_P_Vimani_S_Closing.pdf

Accessed April 13, 2010.

[13] Smolke P, Virmani S. ibid.

[14] Smolke P, Virmani S. ibid.

[15] Healthcare industry CRM software solutions. www.crm.forecast.com.

http://www.crmforecast.com/healthcare.htm. Accessed April 13, 2010.

[16] Higgins, JK. ibid.

[17] Healthcare relationship management depends on tailored database. www.healthcareitnews.com. http://www.healthcareitnews.com/news/healthcare-relationship-management-depends-tailored-database. Published May 13, 2004. Accessed April 8, 2010.

[18] Healthcare relationship management depends on tailored database. ibid.

[19] Healthcare industry CRM software solutions. ibid.

[20] McKay L. Healing the sick. www.destinationcrm.com. http://www.destinationcrm.com/Articles/Editorial/Magazine-Features/Healing-the-Sick-55461.aspx . Published August 1, 2009. Accessed April 7, 2010.

[21] McKay L. ibid.

[22] Schumacher S. Patient relationship management: streamlined approaches for defragmenting healthcare. Health Management Technology. June 2001; 22(6).

[23] Healthcare relationship management depends on tailored database. ibid.

[24] Hallick J. CRM saves lives. www.destinationcrm.com. http://www.destinationcrm.com/Articles/Web-Exclusives/Viewpoints/CRM-Saves-Lives-60149.aspx. Published January 25, 2010. Accessed April 7, 2010.

[25] Higgins, JK. ibid.

[26] Young T. Hospital CRM: unexplored frontier of revenue growth? Healthcare Financial Management. October 1, 2007.

[27] Higgins, JK. ibid.

[28] CRC health builds custom solutions on force.com to streamline intake process and increase web-generated revenue. www.salesforce.com. http://www.salesforce.com/customers/healthcare/crchealth.jsp. Accessed May 18, 2010.

[29] Young T. ibid.

[30] Young T. ibid.

[31] Glaser J, Foley, T. ibid.

Readers Write 10/6/10

October 6, 2010 Readers Write 13 Comments

EMR: One Size Does Not Fit All
By Evan Steele

A recent comment on HIStalk, by a hospital CIO about what he identified as the best EMRs for enterprise systems and their physicians, highlights a problematic and all-too-prevalent misconception. The fact is, it is impossible to satisfy both hospitals and community ambulatory physicians with the same EMR product. Furthermore, even the ambulatory market cannot be looked at as a whole. EMRs designed for primary-care physicians respond to a set of needs that are very different from those of specialists.

Enterprise EMRs simply do not work in high-volume ambulatory practices. This is particularly true for specialists’ practices. Many hospitals have had some success with Epic and other hospital-focused EMRs, but success has been limited when these same hospitals ask physicians — again, particularly the specialists — to implement these systems in their practices. A monolithic enterprise product cannot possibly support equally well such different workflows, patient care scenarios, and providers’ needs.

Within the ambulatory market itself, it is time to bifurcate the EMR discussion into two groups: EMRs for primary care physicians and those for specialists.

Industry analysts typically lump all EMRs into one category, which does not adequately differentiate the market segments or their distinct needs. The major EMR vendors have massive footprints in the marketplace, yet a small company like SRSsoft has the lion’s share of referenceable high-volume, prominent specialty practices in areas like orthopaedics and ophthalmology. Why? Because one size does not fit all, and it is impossible to satisfy the needs of both groups without compromising the needs of one.

The American Academy of Orthopaedic Surgeons (AAOS) acknowledged this issue in its recently released EMR Position Statement, pointing out that “Many systems are geared toward primary care medical practice, which can limit the utility of EHRs for specialty surgical practice.” It correctly suggests that “the different needs and uses of EHR by disparate medical specialties should be recognized.”

Specialists represent approximately 50% of the physician market, a sizeable segment that is largely being ignored. How are specialists to determine which EMRs are designed for their needs?

KLAS, the closest our industry has to a JD Powers–type of rating source, does not break out its ratings by specialty. This means that if an EMR vendor does well in the ambulatory primary care market and has high KLAS ratings, an unsuspecting specialty practice might purchase their product based on those ratings, only to find out that the product does not fit their unique needs.

Exacerbating the situation is the fact that KLAS only surveys practices that have actually installed the EMRs. It does not survey practices with failed implementations. Since specialists represent a disproportionate number of the failures, the information is even further biased.

The result is that there are thousands of specialists who purchase EMRs from highly rated and/or household name vendors, but who end up with failed implementations and significant financial loss.

One size does not fit all. There are good EMR solutions available for every type of physician. It is incumbent upon the individual physician to research and identify the product that best suits his/her practice’s needs.

Evan Steele is CEO of SRSsoft of Montvale, NJ.

ClickFreeMD Comment Response
By Bob Gordon

Note: Mr. H here. I’m breaking my “no commercial pitch” rule this one time because Inga had questioned the business model of ClickFreeMD, which offers practice systems including billing for a flat monthly fee rather than the traditional model of a percentage of collections. Inga’s point was that the percentage model encourages the billing company to collect. CEO Bob Gordon was nice enough to e-mail Inga an explanation and we thought his response might interest some readers even though it is hardly unbiased. I’m not endorsing their product and I have no connection to ClickFreeMD.

ClickFreeMD leapfrogs the percentage-based provider business model. Consider the following:

No start-up, implementation or training charges.
The flat fee is lower on an equivalent percentage basis than most practices would pay for outsource medical billing alone and far less than in-source options.
If the practice improves its revenue or we boost it (which we often can do), the equivalent percentage drops through the floor.
The breadth, quality, and integrated end-to-end nature of our software, services, and support are unrivaled. Physicians are paying twice as much elsewhere for much less elegant solutions today.
The flat fee sticks. If encounter or charge values increase, the flat fee stays the same and the practice captures cost free revenue. If it drops outside ordinary seasonality range, the rate is adjusted down pro-rata so our physicians’ earning power is fully protected.
Importantly, the flat fee is backed by a performance guarantee that makes sure we work every claim or we rebate half of the flat fee. There is no equivalent protection in a percentage-based model. In fact, any claim that takes more than 15 minutes to resolve in a percentage system is probably costing them more than they are making, and hence billing company profitability is at some point in the collection continuum inversely correlated to increasing practice collections.
Our contracts all have 90-day outs and low price match guarantees for comparable services.

You may ask how we do this. We have deep domain expertise from running billing companies, back offices, and technology companies for decades and have organized a Southwest Air-like discount fee, high-result business model that is very scalable. We expect that ongoing volume will feed a virtuous cycle for all, continuing to allow us to offer more for less while achieving top results.

One of the most striking things we are doing is the least recognized — giving the practice their flat-fee price, online and instantly, as well as their included services, without asking them to give us any information. Try this anywhere else like Athena and what we do in 30 seconds becomes a multi-day process that involves e-mail / telephone / online discussions and/or meetings and requires the practice undressing for the vendor. We are completely ONE-WAY transparent. That’s because we want the practice to decide if they want to contact us — after they are satisfied that this is a superior value for them and only then. We aren’t interested in lead nurturing them to death.

This is about "more dollars for doctors" and great news in the group practice fight to sustain their independence. We are doing our part to create a reversal of fortune in the group practice community with a unique business model that raises revenues faster than costs, delivers immediate and ongoing savings, and provides the tools and support that allow them to be ready for tomorrow.

Like the boiled frogs of lore, physicians have been nickel and dimed by payers, billing companies, and others, overpaying to under-produce for so long, they find themselves working much, much harder for less and less. We’re changing that and we’re passionate about it! Thank you for your consideration.

Bob Gordon is CEO of Click4Free of Chevy Chase, MD.

It’s Official: The Rush for Talent Has Begun
By Tiffany Crenshaw

In recent weeks, a number of existing and prospective clients have called me for a pulse on the healthcare IT recruitment marketplace and thoughts on how to attract quality resources. After a number of such calls, I decided to put my thoughts in writing and share.

Let’s start with the good news. Industry hiring is definitely picking up and employed candidates are now less afraid to make a career change then they were three to six months ago.

As for hot products, it’s no secret that Epic is hot, hot, hot. Hospitals are purchasing Epic left and right. Honestly, there are simply not enough Epic resources, especially Epic-certified resources, to go around, so the talent war is raging. Cerner recruitment remains modest but steady, while McKesson needs are starting to rebound after quite a lull.

In the ambulatory market, we are seeing more and more requests for eClinicalWorks and Allscripts. New names like Sage and Greenway are coming to light. And occasional needs for Meditech, Siemens, IDX/GE and Eclipsys are surfacing.

On the integration side, Cloverleaf and e-Gate skills are still in demand, but we are seeing more requests for Web-based and lesser known products like Ensemble, Symphony, and Rhapsody.

The hiring demand is highest by far for hands-on resources to design, build, and install EMR applications. However, there is a fair amount of activity for sales, project management, and training professionals, including go-live support.

CPOE, clin doc, pharmacy, oncology, and HIM are generating the most recruitment activity within the applications. Based on new client requests, we foresee growing needs for business intelligence, security, and report-writing resources.

In addition to employers’ desire for one or more of the skill sets mentioned above, most are adding clinical designation to the requirements. Over 50% of our job requisitions right now require clinicians. Pharmacists, nurses, and physicians with healthcare IT experience are in great demand.

However, post-recession hiring is creating challenges previously unheard of in my 12-year history recruiting in this industry. The process is now wrought with excruciatingly slow interview scheduling, shrinking employee benefits packages, little to no relocation assistance, and financially conservative offers resulting in more and more frustrated candidates.

Things have changed drastically since the lowest points of the recession. After the release of Meaningful Use requirements, recruiting mania has taken off. Everyone seems to have hiring needs. Candidates are getting called left and right by internal and external recruiters. Just check out a few of the job boards if you don’t believe me — you’ll see countless job postings. Furthermore, check out all of the recruiting firms with no previous healthcare IT experience trying to break into this market as experts claim abundant need for resources.

If your organization is currently or will be in the market soon for these in-demand resources, you may want to evaluate your hiring process, recognize that your competition is fierce, and take note of a few trends our candidates and clients have shared with us quite candidly over recent months.

New car syndrome. Candidates are migrating to new implementations. Who can blame them? It’s more exciting to be on the ground level and see a project through from A to Z.
Red carpet treatment. Employers who roll out the red carpet win. When weighing decisions between job offers, candidates almost always choose the employer who provided quickest response time and showed sincere interest in them. (Both response time and sincerity are simple and no-cost ways to roll out that red carpet.)
Relocation blues. Relocation is a HUGE issue right now. Even if candidates want to move, they can’t do so because of the housing market. Kudos to all of the organizations willing to work around this by providing remote work, commuting, or coverage of interim living expenses.
Communicate. Many, many candidates are feeling jerked around by potential employers because of lack of communication in the interview process. Here’s what they are thinking: “If I don’t feel valued as a candidate, how are they going to treat me as an employee?” On the flip side, these candidates are communicating with plenty of their peers. Too many hospitals and consulting firms are getting bad reputations as being lousy places to interview and to work.
Too much is not always a good thing. In the quest for resources, too many organizations are panicking and calling in all of the troops — internal recruiters, employee recruiting bonuses, dozens of external recruiters and advertisements. Candidates get called multiple times by different sources all looking to fill the same positions. Not only do they end up confused, but all the activity makes candidates suspicious. They wonder what’s wrong with an organization that has such a hard time attracting and retaining talent?
Get on board. We are hearing more and more horror stories about candidates showing up on the first day only to find their new employer is not ready for them. This gets them off to a bad start from the get-go. Employees stay longer and perform better when they feel welcomed and the transition process is smooth. The period of time between offer acceptance and start date can also be a black hole, when candidates are most vulnerable. Employers are losing candidates this far into the game because they aren’t communicating with them. If you don’t have a formal on-boarding program, now is probably a good time to look into it.
Disconnect between human resources and hiring managers. As an outside firm, we work with both HR representatives and hiring managers. We hear complaints on both sides about the other on a regular basis — namely due to lack of response. The hiring managers want candidates fast. And HR wants answers fast. Throw candidates in the mix who get frustrated as well and it’s a nasty situation. However, we find that employers who really engage the final decision-maker in the process from beginning to end and set response expectations up front have the least amount of frustrations and the most successful outcomes.

In summary, you can safely say that the industry is quickly changing to a candidate-driven market and that the market is impacted heavily by post-recession recovery and Meaningful Use. It is official. The rush for talent really has begun.

Tiffany Crenshaw is president and CEO of Intellect Resources of Greensboro, NC.

The Coming Speed Bump in the EMR Market
By Jon Shoemaker

It’s no secret that there is currently a mad rush occurring, not unlike The Oklahoma Land Rush of the 1800s, where hundreds of companies both new and old are getting into the business of healthcare information technology. Some come with industry expertise. Others come to take advantage of the financial opportunity. Consider Best Buy, the consumer electronics giant, that will install your EMR using their Geek Squad. So much for needing clinical expertise!

I believe this climate of frenetic activity will cause the EMR market to encounter a large, steep speed bump in the next 10 years. It won’t be from all of the EMR installations or supporting all of these systems, as this will create thousands of jobs and supporting infrastructure that currently does not exist. The bump in the road will come when all of these new digital silos must talk to each other as required in Phase II of Meaningful Use (MU). It is the very selling point of these systems — simple communication and usability — which become the Achilles heel of these EMRs.

EMR’s to date are not installed with a common code structure for identifying exams, studies, or services, all of which will need to be exchanged outside of the office in Phase II of MU. The reason for this lack of standardization has nothing to do with EMR functionality or capability — it is that everyone is still thinking locally not globally.

To ensure true interoperability and exchange of patient health information, EMRs must be installed to satisfy the local requirements, but also with the forethought that they will integrate to larger systems. This requires standards and standardization. The absence of a standard will require the use of translation services so that HIE repositories use the same codes for exams performed across the region.

Translation services, while a viable alternative to standardization, require one-off knowledge for the database structure and logic for each customized local EMR as well as that of the destination repository. This level of granularity creates layers of complexity for maintenance and mapping. Any changes to local system will mandate updates to the translation engine. The support nightmare of constant mapping modifications to assure the proper codes are sent outbound or received inbound will be effectively unsustainable.

Once all of the paper silos are replaced by digital silos, there will be enlightenment of EMRs that were installed incorrectly, don’t address the clinical workflows of the office, and don’t communicate outside of the office with a standard communication protocol using standard coding methods. This will lead to a second phase of the EMR revolution will include translation services and reinstallation of EMRs to address workflow and data gaps. This will have to be resolved before integration to a larger HIE repository can take place.

If we begin now with standardization of workflow and codes and ensure they are addressed with current EMR installations, we will be in a better place in five years and users will see the true benefits of these systems. With our current strategy of “every man for himself,” we risk losing users’ confidence once these systems are installed and address workflow and physician concerns. Once we lose the users’ confidence, they will stop using the system and re-adoption efforts will prove Herculean.

As you begin planning your EMR implementation, there are hundreds of questions to ask. When it comes to meeting the long-term requirements of MU as well as realization of the true benefits of an EMR, here are a few to begin with:

Have we reviewed and documented our office workflow?
Are we using the new SNOMED codes?
Are we following standardized codes for services rendered?
Does the installation team understand clinical workflow or do they look glassy-eyed when we discuss medical terms?
Is our vendor of choice an IT company trying to cash in on the HIT initiative without clinical experience and knowledge which could place our business at risk?
How will this EMR connect us in the future to larger integrated systems?

Jon Shoemaker is senior consultant with Ascendian Healthcare Consulting of Sacramento, CA.

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