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Readers Write 12/19/12

December 19, 2012 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 views and opinions expressed are those of the authors personally and are not necessarily representative of their current or former employers.

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

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

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

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

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

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

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

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

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

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

Multi-Tasking Metrics
By Anil Kottoor

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

So why not make those required metrics multi-task?

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

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

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

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

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

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

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

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

Coordinated Care and the Changing Role of Payers
By Ashish Kachru

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

However, the PCMH has two problems:

A marketing problem
A change management problem

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

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

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

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

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

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

Readers Write 12/10/12

December 10, 2012 Readers Write 7 Comments

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

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

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

Ain’t baseball something?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Questions for ONC and the Obama Administration
By John Gomez

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

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

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

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

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

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

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

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

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

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

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

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

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

An excerpt from the ONC test script describing SED follows:

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

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

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

§ 170.314(a)(6) Medication list

§ 170.314(a)(7) Medication allergy list

§ 170.314(a)(8) Clinical decision support

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

§ 170.314(b)(3) Electronic prescribing

§ 170.314(b)(4) Clinical information reconciliation

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

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

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

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

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

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

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

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

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

Identified an industry-standard QMS by name (for example, ISO 9001, IEC 62304, ISO 13485, ISO 9001, and 21 CFR, Part 820…)

Identified a modified or “home-grown” QMS and an outline and short description of the QMS, which could include identifying any industry-standard QMS upon which it was based and modifications to that standard

Indicated that no QMS was used for applicable capabilities for which certification is requested

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

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

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

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

Frank Poggio is president of The Kelzon Group.

The Jury is No Longer Out
By Nicholas Easter

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

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

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

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

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

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

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

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

Readers Write 12/5/12

December 5, 2012 Readers Write 3 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Let me offer a little perspective …

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

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

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

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

My suggestions are threefold:

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

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

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

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

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

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

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

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

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

The de-identification methods OCR has proposed are:

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

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

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

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

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

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

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

Evolution in your Data Center
By Axel Wirth

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

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

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

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

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

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

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

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

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

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

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

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

Readers Write 11/19/12

November 19, 2012 Readers Write 1 Comment

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

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

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

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

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

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

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

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

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

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

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

Defining a Complete Patient Engagement Solution
By Jordan Dolin

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Readers Write 11/14/12

November 14, 2012 Readers Write 2 Comments

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

Formal HIT Education
By Deborah Kohn

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

James Harris is president of Westside Public Relations.

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

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

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

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

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

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

The settlement included the following terms:

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

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

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

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

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

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

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

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

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

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

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

My View from the Other Side
By Vendor Nurse

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

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

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

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

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

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

Readers Write 10/29/12

October 29, 2012 Readers Write 2 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Throw MU Out the Window!
By Darius LaGrippe

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

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

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

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

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

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

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

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

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

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

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

Readers Write 10/17/12

October 17, 2012 Readers Write Comments Off

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

ONC Moves on Data at Rest
By Frank Poggio

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

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

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

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

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

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

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

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

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

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

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

Frank L. Poggio is president of The Kelzon Group.

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

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

However, other assertions simply miss the mark.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ICD-10: Time to Act
By John Pitsikoulis

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

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

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

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

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

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

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

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

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

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

Seven Things Most Important to Top Performers
By Frank Myeroff

Can you relate?

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

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

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

Readers Write 9/26/12

September 26, 2012 Readers Write Comments Off

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

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

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

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

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

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

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

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

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

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

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

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

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

What are these behavioral healthcare EMR gaps and variances?

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

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

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

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

Sources:

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

2. Disability Adjusted Life Year, DALY, Daly 2004

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

Data Virtualization Best Practices Accelerate Time to Value
By Richard Cramer

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

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

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

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

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

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

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

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

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

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

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

Coordinating Physician and Nursing Care
By David Lareau

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

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

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

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

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

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

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

Readers Write 9/10/12

September 10, 2012 Readers Write 2 Comments

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

I Am the BOSS!
By Bill Rieger

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

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

WAKE UP! The time for career oppression is over.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Patient Engagement
By Kim South, RN

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

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

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

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

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

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

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

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

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

Readers Write 9/3/12

September 3, 2012 Readers Write 1 Comment

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

Routine Killer
By Bill Rieger

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

EHR Donation and Accountable Care
By Jed Batchelder

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

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

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

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

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

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

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

Jed Batchelder is an independent healthcare IT consultant.

Readers Write 8/15/12

August 15, 2012 Readers Write 14 Comments

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

A Letter from Michael Stearns, MD

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

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

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

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

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

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

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

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

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

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

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

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

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

Michael Stearns, MD.

Response from e-MDs

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

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

Readers Write 8/8/12

August 8, 2012 Readers Write Comments Off

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

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

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

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

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

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

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

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

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

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

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

Carrying the Torch
By Guy Scalzi

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

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

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

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

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

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

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

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

Guy Scalzi is a principal with Aspen Advisors.

Four Tips for Addressing Healthcare IT Implementation Costs
By Walter Reid

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

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

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

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

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

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

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

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

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

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

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

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

Tim Kelly is vice president of Dialog Medical.

Readers Write 8/4/12

August 4, 2012 Readers Write 1 Comment

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

The Doctor Shortage Calls for Innovation
By Jonathan Bush

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

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

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

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

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

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

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

Why Device Connectivity Matters Now
By Dave Dyell

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

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

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

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

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

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

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

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

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

Dave Dyell is founder and CEO of iSirona.

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

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

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

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

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

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

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

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

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

Readers Write 7/20/12

July 20, 2012 Readers Write 1 Comment

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

How Obamacare is Driving Healthcare IT Investment
By Stewart Billings

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

Health Information Exchanges

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

New Payment Paradigms

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

ACOs Will Need Communication Support

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

Even Bigger Data Will Drive Efficiency

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

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

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

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

Actuarial Informatics: An Emerging Field?
By Digital Bean Counter

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

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

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

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

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

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

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

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

Implementing SSO Imposes Greater Pressure on Security

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

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

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

An SSO Implementation is a Long, Drawn Out Project

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

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

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

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

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

An SSO Implementation is Expensive

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

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

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

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

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

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

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

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

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

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

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

And then ONC goes on to state:

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

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

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

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

164.308 (a) Audit Procedure

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

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

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

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

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

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

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

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

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

Frank L. Poggio is president of The Kelzon Group.

Readers Write 7/2/12

July 2, 2012 Readers Write 8 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

These are not the same.

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

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

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

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

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

Healthcare Cure?
By Vince Ciotti

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

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

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

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

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

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

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

Readers Write 6/25/12

June 24, 2012 Readers Write 3 Comments

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

HIE Success: Think Google, Not Government
By Orlando Portale

In March 2010, Governor Schwarzenegger named CaleConnect as the new entity that would deploy funds from the Obama economic stimulus package to build out a statewide health information exchange. As was reported recently, the effort has been transitioned to UC Davis.

Make no mistake, this was never going to be an easy task. There are lessons learned for all of us as we plan for our own public or private HIE initiatives.

Shortly after the formation of CaleConnect, I visited with members of the board, including Jonah Frohlich, the Terminator’s right-hand man on HIT. As I indicated to the CaleConnect board back in 2010, “This could turn out to be just another Keynesian economic experiment where money is spent, but nothing tangible is ever delivered.”

Prior to the meeting, I distributed a white paper (click the link to download) to the board outlining specific strategies and potential pitfalls to avoid. Here is its introductory section:

The business sustainability strategies adopted by the California eConnect (CeC) organization are likely to be the same ones employed by other technology startup companies. Success for any startup venture is largely determined by the organization’s ability to rapidly deliver compelling solutions with clear customer value propositions. These solutions must not only meet the functional requirements of the targeted customer segment, but be efficiently delivered and effectively supported. Startup companies that succeed in capturing a given market with compelling solutions are generally rewarded with increased profits and sustained customer loyalty. The path for the successful launch for CeC will be conditional on having the right organizational framework in place, sound business strategies, an understanding of current and future customer requirements, solid solution planning capabilities, financial management expertise, and superior execution. This paper will outline high-level strategies for CeC to consider with regard to achieving a sustainable and successful organization.

When I visited with the board, I stressed the following key points:

Make sure you clearly define roles and responsibilities of the board of directors versus the CaleConnect executive team. The board should not attempt to micro-manage the effort, rather provide high-level oversight. Leave day-to-day decision-making to the organization’s CEO.
Don’t line up a burdensome schedule of periodic meetings. A solid, well-understood governance structure will avoid needless conflict later.
Run the organization like a Silicon Valley startup, not like a branch of state government. Set up shop in Palo Alto, not Sacramento. Think Google, not government. Embrace speed to market, agility, pivoting … everything you would do in a startup company.
Build out the beta version of the product ASAP. Get some early adopters to test it out ASAP. Iterate on it like crazy. Enlist the beta testers to evangelize your product.
You are building a product. Treat it like a startup product’s design, build, and delivery effort.
Your #1 priority should be on the product. Avoid the usual pitfalls of constituent outreach and conference speeches about what might be possible if California had a wired healthcare system. Don’t hype up your stuff until you can demo something.
When you do get it built, market the heck out of it.
Don’t waste your time running around the state talking about what might be possible in advance of the product release. Everyone has been pitched endless times about the potential value proposition for health information exchange.
Everyone will be skeptical, and rightfully so. They have heard it all before. Until you can demonstrate something real, you will have zero credibility.

Unfortunately, as the project unfolded, many of the pitfalls I had warned about were realized.

I continue to believe that a highly agile approach to HIE planning and deployment is greatly beneficial. Remember, think Google, not government.

Orlando Portale is chief innovation officer with a large healthcare organization in Southern California.

Why Windows 8 Might Be the Next Big Thing for Healthcare
By Anthony Hooper

We’ve been following Windows 8 since the developer beta was released at build/windows and it really excites us. Why? Microsoft has a ton of device driver support for Windows XP, Vista, and 7, and most of these drivers will work with Windows 8.

Clinicians want mobility in their day-to-day jobs and they want a device they can carry with them, but one that will also augment and make their day more efficient by allowing them to enter information on the go. Consuming data isn’t the only reason for a tablet any more.

Windows 8 brings a ton of medical device driver support to the table, powerful computing hardware, and a great touch-enabled interface. Finally, a mobile OS that allows health professionals to run their current Windows-based EHR and charting applications, and augment them with metro touch-enabled workflows.

With Windows 8, a clinician can have a single mobile tablet that can be carried during rounds and can be used for taking blood pressure readings without cumbersome dongles. Then, clinicians can return to their desk, switch into desktop mode, and complete many of the tasks they started in the mobile-optimized application.

Unlike iOS, Windows 8 will have a wide variety of hardware manufacturers. This means each hospital or clinic administrator can select the hardware profiles that meet their team’s needs. And it opens the possibility for biometrics hardware and HDP-enabled Bluetooth chipsets.

Anthony Hooper is development manager at Macadamian of Gatineau, Quebec.

Use the ICD-10 Deadline Delay to Maximum Advantage
By Deepak Sadagopan

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

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

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

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

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

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

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

Payback is a CPOE
By Daniela Mahoney

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

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

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

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

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

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

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

Examples of cost:

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

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

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

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

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

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

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

Readers Write 6/6/12

June 6, 2012 Readers Write 2 Comments

Moneyball and the Power of Data Analytics
By Gerard Livaudais

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

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

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

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

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

1. Focus on the Data that Matter

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

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

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

2. Leverage Internal and External Data

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

3. Influence Positive Patient Behavior

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

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

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

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

Gerard Livaudais is chief medical officer of Quantros.

Care in an Emerging Market
By Arvind B. Deshpande

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

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

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

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

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

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

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

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

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

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

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

Why We Do What We Do
By Dan Herman

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

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

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

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

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

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

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

Dan Herman is founder and managing principal of Aspen Advisors.

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