Readers Write 5/21/12

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Readers Write – National Nurses Week 5/7/12

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

Our Heroes

Captain Donna Rowe and fellow servicemen

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

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

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

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

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

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

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

Baby Kathleen

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Need For Technology

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

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

Reunion and Update

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

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

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

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

Never Forget

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

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

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

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

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

Readers Write 4/25/12

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

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

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

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

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

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

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

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

Let’s begin with discussing the Three Pillars.

The Three Pillars

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

Pillar 1: Best Knowledge Available When Needed

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

Pillar 2: High Adoption and Effective Use

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

Pillar 3: Continuous Improvement of Knowledge and CDS Methods

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

The Five Rights

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

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

The Ten Commandments

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

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

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

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

AHRQ, Approaching Clinical Decision Support in Medication Management

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Readers Write 4/16/12

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Clinical Intelligence to Improve Quality and Reduce Costs
By Michael Weintraub

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

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

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

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

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

Data Management

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

Data Quality Services

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

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

Analytic Technologies

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

Shared Learning Resources

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Readers Write 4/2/12

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ACHE Impressions
By Darkened Room Observer

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The defining quality of a tablet is touch.

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

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

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

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

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

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

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

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

Readers Write 3/26/12

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

If You Did It, Enter It in the EHR
By Mitch McClellan

I was recently asked the following by a colleague:

We know that every organization has some physicians who just will not fully use the EHR. They will have nurses, MAs, and other clinical staff do all of the data entry. They may just hand the staff a piece of paper and have them enter the problem list. A specific example would be the MU requirement for weight counseling – do you think it is acceptable for an MA to indicate in the record that the physician did the weight counseling? Clearly it makes sense to have nurses and other clinical staff enter medications and even other orders and even start notes, but where do you draw the line?

This question certainly walks the line between facilitating accurate data entry vs.what is appropriate.

If an organization is truly going to embrace this much-needed change in healthcare, they need to enforce that their clinicians do the right thing. In this case, it would be physicians taking 100% ownership of entering the documentation specific to weight counseling. They are the ones actually provided the counseling.

I understand that is a black-and-white response, but I strongly believe that if an organization’s culture accommodates physicians who choose not to do their complete EHR responsibilities (e.g. not documenting the counseling that YOU provided), then it defeats the entire purpose of what we’re doing.

The EHR revolution is strongly driven by the fact that paper is not efficient and creates too many points of failure. Not only is the medium (paper) antiquated, so are many of the policies and processes that support those paper workflows (e.g. documenting a note that you then pass on to someone else to then "document a note" on your behalf).

Unfortunately, I believe most physicians are put into a "get it done now vs. a get it done right" scenario due to the payers’ stringent reimbursement policies. I completely understand the time demands on these physicians. But the rule I try to instill with all of my groups is that, "if you did it, then you must enter it in the HER." Otherwise, the effectiveness and efficiencies of an EHR are lost if the old way of doing things is still embraced.

The groups that I’ve worked with would require the physician enter that piece of documentation themselves instead of the MA. The only groups that I’ve worked with that would allow this scenario to happen would be if it was the physician’s nurse — not an MA –entering the documentation. To me, the issue is twofold. The first is workflow (reasons already stated), the second is the lack of credentials of an MA. I know I’d want a higher-credentialed healthcare provider entering that information if it’s not the physician themselves.

Mitch McClellan is manager of implementations at MBA HealthGroup of South Burlington, VT.

Optimization
By Dave Vreeland

Cumberland brought together a select group of HIT executives from some of the nation’s leading health systems for a recent breakfast discussion The topic: optimization.

Now that many are on track for Stage 1 Meaningful Use and other compliance deadlines, the focus is beginning to shift beyond go-live toward getting the most out of HIT systems. The panel, made up of Cumberland’s Brian Junghans, HCA’s Dr. Divya Shroff, and Memorial Healthcare System’s Jeff Sturman, shared how non-profit Memorial and industry giant HCA are tackling optimization.

The takeaway: success largely hinges on solid communication and the collaboration of two very different worlds – IT and clinical. Clinicians are arguably the keystone in achieving effective system adoption and long-term optimization.

Junghans points out that IT folks tend to think in terms of projects, which have a defined beginning and end. When it comes to IT implementation projects, the end is go-live. In contrast, optimization is an ongoing effort.

Dr. Shroff points out that clinicians have more of an optimization mindset, with a continuous focus on improved quality of care, optimal patient outcomes, and best practices.

With techies and clinicians in different mindsets, speaking two different languages, communication issues are common. HCA has success placing physicians and other clinical professionals like Dr. Shroff in clinical transformation roles. Valuable insight and hands-on experience makes these clinicians effective ambassadors for both the IT and clinical teams. 

Sturman and the Memorial team have incorporated clinical aspects into their approach to optimization. The team makes regularly scheduled rounds to observe workflow, system usage patterns and identify opportunities for improvement throughout each of their six hospitals, clinics, and ambulatory practices.

The importance of a clear distinction between IT support and optimization teams was also stressed. HCA trains the IT support team to triage incoming calls, address specific break/fix issues, and refer optimization matters to the optimization team.

Both organizations have seen success with various efforts to improve clinical/IT relations and are on track with current and long-term efforts toward optimization.

In addition to a number of lessons learned and critical success factors to consider during and after the implementation process (summarized in our presentation Beyond Go-Live: Achieving HIT System Optimization), it was interesting to hear this room of executives from diverse organizations, representing both the clinical and IT fields, reinforce the significant impact collaboration between the two worlds has on the success of end-user adoption and achieving true optimization.  

Dave Vreeland is partner with Cumberland Consulting Group of Franklin, TN.

Stage 2: The Vendor View
By Frank Poggio

On March 7, 2012, a draft for comment on the new Stage 2 rules was published in the Federal Register. Actually there were two separate parts to the rules. They are:

1. The CMS part that is aimed at provider requirements necessary to meet Meaningful Use, and
2. The ONC piece that addressed proposed changes to the certification process for EHR vendors.

On the provider side, there are innumerable blogs and Web sites that are covering the provider issues, which deal mostly with a few added MU criteria such as electronic medication administration records, menu options in Stage 1 that are now mandatory in Stage 2, greater emphasis on exchanging patent care information across care levels, and greater patient access to care information.

This article will focus on the “second side” of the regulations — the elements that most impact the system suppliers, with emphasis on the impact to niche or best-of-breed (BoB) vendors.

The full text of the new ONC Certification proposed rules can be found at here.

Before we hit the high (and low) points of the rules keep in mind these are proposed rules. If there is anything you don’t like about them, have suggestions for improvements, etc. you have from now until June 7 to post comments on the federal Web site. Speak now or forever hold your price! (No that is not a typo … see the Ugly).

Here’s the Good, the Bad, and the Ugly of proposed certification changes for vendors.

The good news:

Privacy and Security — will it go away?

EHR Module certification gets a little easier for niche and best-of-breed vendors (BoB). The big change here is that Module certification no longer requires you to address any of the privacy and security criteria. In the past, there were eight P&S criteria (number nine was always optional), and in our working through many ATCB tests, if you said the right phrase, you could get a waiver on three others (Integrity, General Encryption, and HIE.) Proposed under the Stage 2 as a niche/BoB vendor, you can ignore all the P&S criteria. To get certified under Stage 2, it would seem all you will need to do is pass any one Inpatient, Ambulatory, or General criteria, just ignore the P&S criteria, and you’re home free.

ONC said they made this change because many of the smaller firms complained that the P&S criteria did not apply or were too burdensome. This may sound too good to be true. Maybe it is. Read what ONC says in other parts of the document:

Finally, we propose to require that test results used for the certification of EHR technology be available to the public in an effort to increase transparency around the certification process. We believe that there will be market pressures to have certified Complete EHRs and certified EHR Modules ready and available prior to when EPs, EHs, and CAHs must meet the proposed revised definition of CEHRT for FY/CY 2014. We assume this factor will cause a greater number of developers to prepare EHR technology for testing and certification towards the end of 2012 and throughout 2013, rather than in 2014.

This is classic ONC. They say you don’t have to get certified. There is no law that says any vendor MUST – even a full EMR vendor. They believe the market will tell you. And by the way, ONC will be publishing the details of your certification so the world can compare you against your peers.

As we tell our clients, the MU criteria you choose to test on is dictated more by your competition and clients, not by the ONC.

Gap certification for Stage 2

A question that we have heard frequently was if I was certified on 20 criteria for Stage 1, under Stage 2, would I have to be tested again for those same criteria? Under the proposed Stage 2 rules, you would not need to get re-certified on Stage 1 criteria. You will only have to be tested on new criteria you select, and tested on Stage1 criteria that has changed or been revised by ONC.

A good example is the encryption P&S test. The focus now will be on encryption for data at rest. They state:

EHR technology presented for certification must be able to encrypt the electronic health information that remains on end user devices. And, to comply with paragraph (d)(7)(i), this capability must be enabled (i.e., turned on) by default and only be permitted to be disabled (and re-enabled) by a limited set of identified users.

So if you tested out on encryption under Stage 1 and want to carry it forward into Stage 2, you’ll probably have to show how you default encryption for user devices.

Component EHR vs. Complete EHR

A typical misunderstanding we came across many times during past year taking our clients through the certification process was a CIO at a hospital would say to the vendor that he/she believed they had to install a full EMR from a single vendor to meet all the MU criteria. In the proposed regulations, ONC has clearly addressed this question. On page 104, they say:

Certified EHR technology means: 1. For any Federal fiscal year (FY) or calendar year (CY) up to and including 2013: i. A Complete EHR that meets the requirements included in the definition of a Qualified EHR and has been tested and certified in accordance with the certification program established by the National Coordinator as having met all applicable certification criteria adopted by the Secretary for the 2011 Edition EHR certification criteria or the equivalent 2014 Edition EHR certification criteria; or ii. A combination of EHR Modules in which each constituent EHR Module of the combination has been tested and certified in accordance with the certification program established by the National Coordinator as having met all applicable certification criteria adopted by the Secretary for the 2011 Edition HER certification criteria or the equivalent 2014 Edition EHR certification criteria, and the resultant combination also meets the requirements included in the definition of a Qualified EHR.

In effect, a provider could meet the MU criteria using as many suites of BoB systems as they believe necessary. They do not have to be from one or the same vendor.

Now some bad news:

Criteria components

Many BoBs struggled with the make up of the criteria for Vitals and Demographics and several other clinical criteria. On the surface, they seemed easy to pass. The problem was they contained some data elements that were not typically found in BoB systems. For vitals, the hurdle was growth charts. For demographics, the hurdle is date and time of death. To pass these criteria, some vendors would use user-defined fields or create new inputs that they knew their clients would never use. Repeatedly I was asked by niche and BoB clients, “Why would you ask a patient during a registration process, ‘When did you die?’” Now there’s a comforting dialog!

Keep in mind several or the participants in building the HITECH/MU program were academics and researchers who would find that piece of information critical to their retrospective medical data analyses. Also, vendors of full EMR systems would easily have that piece of data readily available in their medical record abstract system. But for an ancillary or niche vendor, not likely. As far as I know, there were no niche or BoB vendors represented on any of the HITECH Policy or Standard Committees.

You may wonder why any firm would go through the trouble of adding a useless data element. Again, keep in mind what ONC said above: market will require certification. It can be virtually impossible to sell an ancillary system such as surgery, ICU monitoring, therapy, anesthesia, etc. if you had to tell your prospect your product was not certified for vitals.

Unfortunately this issue is still there for BoBs. The big change is on the provider side. ONC has greatly liberalized the granting of exceptions to providers for MU attestation if the MU criteria (or element of the criteria) do not apply to their practice of facility. As an example, a psychiatrist does not have to do growth charts for his patients — an exemption will be readily available. But the vendor who sold him the system still must!

Continuing this topic, in a recent interview Dr. Mostashari chided EHR vendors who "aren’t making meaningful use of Meaningful Use." Instead of attempting to seamlessly incorporate MU standards into their interfaces, Mostashari said "vendors did what vendors do—they slammed in the criteria and got certified.”

I submit that ONC slammed these regulations into being as fast as they could due to Congressional and Executive pressure, so one good slam deserves another. Maybe if ONC took a moment to look at the impact of certification on niche and BoBs — which are mostly the smaller, more innovative developers — and adjusted the criteria, we all could stop slamming.

And now the ugly:

As I mentioned in an earlier HIStalk post, ONC wants comments on vendor product price transparency. Here’s the ONC statement:

During implementation of the temporary certification program, we have received feedback from stakeholders that some EHR technology developers do not provide clear price transparency related to the full cost of a certified Complete EHR or certified EHR Module. Instead, some EHR technology developers identify prices for multiple groupings of capabilities even though the groupings do not correlate to the capabilities of the entire certified Complete EHR or certified EHR Module. Thus, with the transparency already required by §170.523(k)(3) in mind, we believe that the EHR technology market could benefit from transparency related to the price associated with a certified Complete EHR or certified EHR Module. We believe price transparency could be achieved through a requirement that ONC ACBs ensure that EHR technology developers include clear pricing of the full cost of their certified Complete EHR and/or certified EHR Module on their websites and in all marketing materials, communications, statements, and other assertions related to a Complete EHR’s or EHR Module’s certification. Put simply, this provision would require EHR technology developers to disclose only the full cost of a certified Complete EHR or certified EHR Module.

As a former CFO, I know that the through definition of ‘full cost’ would take at least another 500 pages in the Federal Register. After the vendors in the audience come down off the ceiling, you’d probably like to share your reaction with ONC. Just click here.

Frank L. Poggio is president of The Kelzon Group.

Readers Write 3/19/12

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

Sampling the Legislative Sausage
By Civics 101

Be careful reading the proposed Meaningful Use regulations. Note the “proposed” part. As a Notice of Proposed Rulemaking, it’s unwise to ignore any part of the document.

Every word in the document – even in the preamble — has survived numerous rounds of federal vetting. Every section is important, but especially so are those areas in which public comment is invited. Objectives may be added or removed, so don’t get hung up on those to the exclusion of the preamble or the overall intention.This is not a set of business requirements that is ready to be handed off to programmers to implement.

Read the NPRM as a big picture, keep an open mind, and try to understand the intention, not just the tentative objective list. And above all, don’t forget that while Stage 1 is locked in place, Stage 2 isn’t. My organization and yours need to study the NPRM carefully and comment on what we like or don’t like about what’s been placed before us. Remember all the changes that were incorporated between the Stage 1 NPRM and the final version? Every one of those came as a result of public feedback.

Using the iPad in Surgery
By Michael B. Peterson, MD

I use the iPad every day while rounding at work and connected to the encrypted hospital wireless network, finding web information for patients and showing educational videos. I use a Bluetooth keyboard and sometimes a stylus that fit into a netbook soft case when I need to do heavy typing.

We were doing a complicated vascular surgery, an axillary femoral femoral bypass. I had dissected out the blood vessels on the right groin, but the surgeon working on the left could not locate the critical arteries and branches. The patient did not have any pulses in the groins because of severe vascular disease.

I had the nurse drop the iPad into a sterile sleeve and seal it. I used it to pull up the CT scans on the table and paged to the proper level so we could compare the right to the left. Then we knew where to go. We could place the iPad right on top of the patient and visualize what we needed.

Then while my colleague and our PA completed the left side, I checked my Lotus Notes e-mail, went into the vascular econsult program and triaged some vascular consults to the appropriate clinics, and checked my inbasket in our Epic EMR to read labs and answer messages (the iPad runs Epic very well.) When I was done, we were ready for the rest of the surgery.  

The x-ray viewing is an innovative project on which we are partnering with with Thinking Systems.

We are using the latest Citrix Receiver to host our version of Epic on the iPad and other devices as well. Since the rollout of Epic Summer ’09 across the country in all Kaisers, the old web address we used for Spring ’06 access no longer works for the iPad. In addition, there are additional video requirements for Summer ’09 that our current web servers need that the Citrix receiver cannot handle. Attempting access to the Summer ’09 environment will result in a connection failure with a “USKIN” error message.

Fortunately our Kaiser web engineers were aware of this and understood the need for iPad functionality. They created special web addresses for Kaiser iPad users in Northern and Southern California, Hawaii, and Pacific Northwest. The official term is PNAgent Site. Setting it up is complicated, but the iPad works very well.  

Of course there are ergonomic challenges with a smaller screen, and accurate tapping is critical. But it is so fast and convenient — you don’t have to wander around looking for an unoccupied keyboard and computer. If I need to look up something, I just do it where I am. It has really spoiled me.

I don’t know if there is any way to demonstrate improved outcomes with the iPad. Kaiser is starting to roll it out to other medical centers with different specialties. My general feeling is that with the EMR, there is a 20% productivity hit with data entry and typing your note. It does take longer on the generic computer, but the the iPad is so much faster and it literally puts the medical record at your fingertips… or perhaps the patient’s.  

I plop the iPad down in front of the patient and point out pictures, diagrams, and a quick graphic plot of their rising creatinine. I run the lymphedema pump movie to show them how it works, or review the online video again to remind me or others how that endovascular closure device works again before I actually do it.  

I have invested the time it took to get comfortable with the iPad and arrange it the way I want. I could not do without it. I have very little specialized software on the iPad except for the VPN and the Citrix Receiver. And my medical apps, books, and games!

Michael B. Peterson MD is a surgeon with The Permanente Medical Group in Hayward, CA. His use of the iPad in the operating room was featured in the April 2012 edition of Macworld. Since Mike is an old friend of HIStalk, I asked him for more detailed information, which he provided above.

What Do You Do Regardless? Five ICD-10 Steps To Continue
By Torrey Barnhouse

The AMA lobby is strong. US government program delays are common. The two came together on February 16, 2012 when Health and Human Services Secretary Kathleen Sebelius announced a potential delay in the October 1, 2013 deadline for ICD-10 implementation.

The announcement, made just before the start of the HIMSS12 Annual Conference, left a lot of attendees scratching their heads and asking themselves, “Now what?” Most agreed a delay of one year or less gives everyone more time to prepare, train, and test. However, a delay of greater than one year spells chaos for healthcare providers and payers.

While at HIMSS, TrustHCS had the honor of sponsoring an executive roundtable on ICD-10. During the roundtable, speakers discussed five ICD-10 projects that should continue full steam ahead despite the delay. It’s a good list and worth sharing.

In general, the panel’s advice was to identify ICD-10 tasks that have collateral benefit for ICD-9 coding. These are the tasks that should be continued until such time as HHS makes another announcement regarding their plans, intentions, and deadlines.

Vendor and Payer Assessments

Continue checking with vendors and payers to see when systems will be ready for testing. Know what the ICD-10 upgrade will cost your organization, if anything. If your vendor simply can’t accommodate, start evaluating new systems to replace them. Conduct ICD-10 testing with your payers whenever and wherever possible to help reduce backlogs and denials upon go live.

Clinical Documentation Improvement

Any improvement in clinical documentation specificity and granularity will help support better, higher quality coding and reduce time wasted querying physicians. Coders can only code what is documented. This same core principle applies in ICD-10. CDI programs must be continued regardless of a delay.

Coder Biomedical Training

While educating coders in the finer nuances of ICD-10 coding can be postponed, strengthening their knowledge of the basics can’t. Many coders graduated from programs 10, 15, or 20 years ago. Medical science and our knowledge of anatomy, physiology, and disease processes has grown exponentially. Now’s the time to make sure your coders are brilliant at the basics. Anatomy and physiology training should continue to be conducted: online through a service provider or at a local community college.

Computer Assisted Coding (CAC) Technology

Coder productivity is predicted to drop by 50% during the implementation of ICD-10 and perhaps remain 10-20% below normal output for ICD-9 coding. CAC systems help offset this productivity loss by electronically “reading” the record and suggesting codes to the human coder. While CAC systems don’t replace coders, they do make them more productive and efficient. The delay provides more time for organizations to evaluate and implement this technology.

Assess and Refine Your Work Plan

Conduct a methodical step-by-step review of your initial plan. This process will identify which tasks can be pushed out and which cannot. The review will also uncover other tasks that have collateral benefit for ICD-9. For each task in your work plan, ask yourself, “Does the delay impact this task?”

Industry experts are already predicting the cost of an ICD-10 delay. Other experts are predicting lawsuits by providers to help recoup monies already spent. This expert simply suggests that you stay the course and keep working toward ICD-10 preparedness. We will all have to get there eventually. Better to be early than late on this one!

Torrey Barnhouse is CEO of TrustHCS of Springfield, MO.

Viva la CPOE!
By Daniela Mahoney

According to the HIMSS Analytics EMR Adoption Model , CPOE adoption remains steady at a rate of 13.2% for the past two quarters. And in recent months, many hospitals achieved the first stage of Meaningful Use. Congratulations to all!

However, looking at the story behind CPOE implementations reveals that adoption struggles continue —regardless of the vendor system. Many community hospitals expend great effort and many dollars meeting Meaningful Use criteria, but additional time and money is also spent avoiding a full-blown revolution within their provider community because of CPOE implementation.

Technology is really only 15-20% of a CPOE implementation. Process, acceptance, culture, and constant transformation are the parts that truly define the difference between CPOE failure and success.

At the end of the day, technology’s golden purpose is to support the infrastructure: devices, performance, remote access, integration/interoperability, streamlined single-sign-on, and ease of navigation. But even when working flawlessly, it’s still an uphill battle capturing provider adoption on that much-needed “voluntary basis.”

I can always hear the physician protests, even when left unsaid: “Why should I use it?” “What is in it for me?” “Show me the money, Jerry.”

The question remains: why? Why won’t providers embrace new CPOE technologies and take advantage of the wonderful features, such as clinical decision support or evidence-based order sets that streamline the admission process?

Truthfully, there is nothing wrong with the providers’ feelings here. They simply know what’s at stake. And the odds are not in favor of CPOE, despite the benefits we may see through our own rose-colored glasses:  “Oh, how it benefits the patient! Why don’t you providers just snap out of it and embrace CPOE for the people, or at least for the children?”

Kidding aside, what a new CPOE system takes away from providers is TIME.

… at least for a while.

Time is a provider’s most precious commodity. A new system changes the way they work and takes time away from office hours and family. Time is irreplaceable and invaluable.

But the Meaningful Use mandates say “so what” and to just do it and accept it. CPOE is a reality and must be part of every provider’s future in the hospital or in the office. With that, I sympathize. Providers may have cause to rebel.

I spent some time researching literature while preparing this article, looking at provider efficiency with CPOE. Many studies are relatively old, done in the ‘90s or early 2000s. Not to dismiss their importance, but many issues experienced then have been since resolved with today’s systems. In retrospect, they really aren’t relevant.

But one thing overlooked then and now, to me, is the most important question: what is the right value proposition to the provider?

The answer? One that fits a provider’s community and meets their conditions to accept CPOE into their domain.

With 22 years invested helping providers through CPOE adoption , I found only one simple and effective system pitch. Be truthful and realistic. That’s what works. That’s what opens door and also ears.

For example, we can’t deny that it typically takes significant time to adopt and adjust to a new system, and that efficiency improves only with consistent use. Additionally, never overpromise that CPOE is faster than handwriting an order or checking boxes on a pre-printed order set. I can tell you, that approach doesn’t work.

Once providers are engaged, gather the value proposition’s building blocks by talking and listening to them –  eliciting their concerns, needs, and requirements — and also identify opportunities for compromise.

Usually during interview sessions, similar things are voiced. And believe it or not, it’s less about Meaningful Use (understanding the “benefit” of hospital reimbursement is typically demonstrated by only a few) and more about the direction of technologies in healthcare and reporting requirements and how it affects the way they practice medicine.

For example, for some it is important to have remote access, and not just to CPOE, but to also do other tasks, such as signing their charts. And from others, I often hear how they would prefer using their own laptops or iPads, so they do not need to compete for devices.

Here are some very telling interview quotes from providers about CPOE adoption:

• “Access from outside of the hospital, home access would be great.”
• “CPOE should be a resource for us. It should not make us work harder to accommodate it.”
• “Ease to use and quicker order entry is most important.”
• “Online view of medications administered would be a great value.”
• “Reduces errors and provides clarity of medical orders. There must be a safety net if errors are made, especially with residents. Incorrect orders need to be stopped.”
• “A quick-pick list for providers would be nice.”

In the end, the right value proposition delivers the commitment of the hospital’s leadership to respond to what providers say and need. It engages all providers and can convince them to fully adopt CPOE as part of their workflow—especially with respect to efficiency in daily operations.

Providers become very reasonable and willing to compromise if engaged and their voices heard. Realistically, you cannot fulfill every need, but it is still important to listen and respond. The hospital’s leadership must be proactive and have a solid communication plan to manage expectations at different levels before, during, and after implementation. The direction of CPOE within the organization must be clearly defined, from the adoption and training to the deployment strategy. Lastly, completing a cultural evaluation the provider community provides tremendous insight into defining the value proposition which is the foundation of your CPOE success.

Let them eat cake, because we’re having crepes …

Here is a simple but delicious nutella-banana crepe recipe enjoyed by our family. Bon appetit!

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

Readers Write 2/27/12

Why Device Connectivity Is Hot Now
By Dave Dyell

Tech-based solutions often enjoy a surge or hot period—a moment in the sun if you will. For those of us in the medical device integration (MDI) space, 2011 felt pretty sunny. For one thing, 2011 was the first year in which KLAS, an independent research organization that ranks health information technology vendors in key market segments, recognized MDI.

In an annual report titled Medical Device Integration 2012: Proven Connections, KLAS detailed the major MDI vendors and their individual strengths, as well as the overall benefit of MDI. For those of us who have worked in the MDI space for several years, recognition from KLAS represented a major milestone.

So why did KLAS add MDI to its list of relevant tech spaces in 2011? Why is the HIT spotlight on MDI now?

One reason is that MDI is a necessary component, or stepping stone, on the road toward achieving HIT initiatives such as Meaningful Use, health information exchange, ACOs, etc. In this way, the rise of MDI has been fueled to a certain extent by the passing of the HITECH Act in 2009.

But I believe that the real momentum behind MDI has another, slightly more organic explanation that is rooted in MDI’s payoff. The promises of MDI—improved clinical efficiency and quality—mirror the promises of other large, federally mandated initiatives. The difference with MDI, though, is that it is a much quicker win. The feedback loop with MDI is shorter than, say, the feedback loop with ACOs.

MDI automates the flow of data from devices directly into the hospital’s clinical information system (CIS) or electronic medical record. This automation (as opposed to handwritten transcriptions and keying) immediately improves clinician productivity as well as data accuracy and availably throughout the hospital.

The aforementioned KLAS report also notes this immediacy. When comparing the benefits of MDI to other HIT initiatives, the report states, “In a simple, more immediate way, some healthcare providers are quietly getting a bump in quality and efficiency through medical device integration systems.”

What does “bump” mean in this context? More than 65% of the study’s respondents reported that MDI saves time and provides the ability to make more informed decisions concerning patient care using the data that MDI makes available.

For the hospital trying to figure out which tech-based solutions to purchase, the KLAS report paints MDI as a solid investment with immediate and future payoffs—a synergy that those of us in this emerging industry have always stressed and will continue to. 

Dave Dyell is founder and CEO of iSirona of Panama City, FL.

Walking Through HIMSS
By Carlos Nunez, MD

Walking the aisles of the exhibit hall and participating in HIStalkapalooza at the world’s largest gathering of healthcare IT professionals and the companies that do business with them led to several interesting discoveries. 

All of the usual suspects were well represented in the exhibit hall (Epic, Cerner, GE, etc.), along with the expected collection of smaller IT vendors and specialty niche solutions (did you know that Rubbermaid makes hospital-grade computer carts?) And, of course, you found companies like IBM, Oracle, and Microsoft that also play in this space.

Coming in to the meeting, it was expected that ICD-10 would be a big topic of focus, but with the recently announced delay in the implementation requirement, that story seemed less relevant. There was also the announcement  that the Stage 2 requirements for Meaningful Use were ready to be published in the Federal Register, but likely wouldn’t be available until after HIMSS. The announcement was big news, but it came too late to have any discernible impact on the conference floor. Finally, the trend toward mobile devices and cloud-based solutions is still grabbing a great deal of attention and booth space.

The trend that was most interesting was the rise and growing prominence of companies exhibiting at HIMSS that – at first glance – may seem out of place. For example, I had a meeting with the folks from Lockheed Martin. Yes, the same Lockheed Martin that makes fighter planes and satellites also has a healthcare business and is now partnering with Johns Hopkins on a patient safety and quality initiative. One of the larger booths in the exhibit hall belonged to a collection of IT and benefits management businesses that were recently cobbled together by one of the major insurance companies. I guess it should come as no surprise that as the American healthcare system continues to grab more attention (and more dollars) than any other segment of the economy, businesses new and old would look for their place at the table.

This trend got me thinking about my own place at HIMSS, and more specifically, where CareFusion should be slotted in the spectrum of industry represented there. To the uninitiated, you might think that CareFusion belongs closer to the Rubbermaid end of the spectrum, especially if you only focus on the “things” that CareFusion makes. What do surgical instruments, infection prevention, or infusion pumps have to do with information technology? However, when you realize those “things” are key components in a portfolio of solutions, many of which are tied together by the very technology that defines HIMSS, you begin to see that CareFusion brings a unique perspective and vision to the HIT conversation.

What became vividly apparent this year at HIMSS is that Healthcare IT today, and the concept of Meaningful Use, is much more than an EMR. It is the information ecosystem that supports every patient encounter. It is the millions of clinical data points streaming from a ventilator or an infusion pump, into a server or into the cloud. It is a medication order entered in a CPOE system, tracked and secured through an automated pharmacy system, and the surveillance engine on a constant vigil for inappropriate medication dosing or signs of infection.  It is new technology designed to make devices and HIT systems talk to one another and provide critical patient data to caregivers when and where they need it, seamlessly across hospitals and systems.

Initiatives like Meaningful Use can sometimes make us forget that healthcare IT is more than just software or the systems we build to collect and store data; it’s how those systems enable us to convert data into useful information to help improve workflow, efficiency, and patient safety. As many providers begin to focus on Stage 2 Meaningful Use requirements, broader concepts like interoperability and standardization will emerge as critical objectives in achieving the desired end goal.

Or as ONC chief Farzad Mostashari, MD, asserted in his keynote speech at HIMSS, “We’re on the right track to make meaningful use of Meaningful Use.” What I saw and heard at HIMSS was a promising acknowledgement of our shared responsibility to improve healthcare. It’s a challenge that’s breaking down barriers between providers, suppliers, and companies of all industries and competencies working to make a contribution. I was proud to represent a company bringing so many meaningful solutions to the table.

Carlos Nunez MD is chief medical officer of CareFusion of San Diego, CA.

Readers Write 2/15/12

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

iPad Fatigue: Choose Your Mobile Strategy Wisely
By Chris Joyce

I get the attraction of the iPad … your own personal device that’s sexy and lean, as opposed to the standard-issue, Windows XP desktop locked down by your hospital’s IT group or the clunky computer on wheels. The simple UI and the glossy new apps let you shed the pain of those legacy systems and, most important, you get mobility.

Given the glacial pace of innovation in healthcare, who can fault people for wanting to use these beautiful devices? We are all trying to create a sea change in healthcare IT, much like the iPhone did for telecommunications. But I’m going to say something that’s wildly unpopular: the iPad is not well suited for healthcare in its current state.

I’ve been working in tablet-based mobility for seven years (yes, there were tablets before the iPad). We’ve studied clinician data collection workflow in registration, the ED, home health, cardiology, radiology, orthopedics, and clinical trials. Trust that my opinions are carefully thought out from experience.

I will concede that the Windows-based tablet manufacturers deserved to be smacked around by Apple for their lack of vision and slow progress. Years ago, I, along with my customer (one of the largest health systems in California that had been using tablets in cardiology for years) sat down with the folks at Intel and Motion Computing to tell them that the C5 was too complicated and expensive. I shared what we needed in the ideal tablet: a bright, 12” screen with stylus support that’s ideal for documents, 8-10 hours of battery life, no external ports or other gadgets, and a sub-$1,000 price tag. Our request fell on deaf ears as they paraded out the next incremental chip set improvement in their roadmap.

When the iPad hit the market, we thought we’d finally gotten our ideal tablet. The price was right, the screen was bright, the battery life was unbelievable, it ran coolly and didn’t burn your arms, it booted in seconds, and the 1.5 pound. form factor (half the current tablets) was simple and elegant. Finally, we had the perfect complement to our mobile forms software. This wasn’t just a Windows laptop with the keyboard chopped off – it was an appliance, a tablet.

But it also has some major shortcomings that our customers are now discovering:

10” display
This is subtle because I like the more portable size, but those standard consents, ABNs and Medicare forms you’ve used for years don’t fit on a 10” display without disrupting the layout. Your app has to be “touch-aware” or you’ll interact with the screen when you rest your hand to sign or add a note. Our customers are counting clicks and don’t like the iPad because they have to scroll to use the forms that once fit on their 12” Windows tablets.

No stylus
This makes capturing signatures, annotations on diagrams, and unstructured notes impossible unless you buy a third-party stylus like Pogo. But that’s like writing with a crayon and there is no place to dock your pen. Are your patients going to be comfortable signing an informed consent with their fingers?

No handwriting recognition
The soft keyboard isn’t practical for a lot of data entry because you are still holding the tablet with one hand and pecking out everything with the other. And bouncing back and forth between numeric and alpha characters drives users absolutely mad. Handwriting recognition has its place in documentation, just like voice dictation, and it can be as fast as paper. There is nothing fast about the iPad’s soft keyboard when at the bedside.

Proprietary operating system and deployment isn’t enterprise-friendly
Obviously Apple wasn’t concerned with compatibility with “legacy” apps like Meditech or MS4, but in healthcare, that eliminates about 90% of current systems. Most hospitals have compromised for “runs on iPad” versus “optimized for iPad” using Citrix or a Web interface.

That leaves the end user with an underwhelming experience. Citrix apps don’t get the intimate integration with the display, touch, or the camera for image annotation. Not many vendors were prepared to rewrite their clinical systems in iOS or HTML5. The HTML5 standard hasn’t been published yet and isn’t consistently supported by all browsers (although it is the future). I know of several major healthcare systems that are still standardized on Internet Explorer 7, so I don’t anticipate adoption of HTML5 to be as high in healthcare as Apple would like you to believe. Again, we (healthcare) are not that nimble.

Lack of rugged form factor
Eventually your iPad will come into contact with fluids or the floor and you’ll realize it’s a consumer-grade device. These devices are often in a hostile environment, very unlike the environment in most iPad commercials.

The hype of hardware
One of our best mobile forms customers is a major health system in the Northeast. They gave each clinician an iPad, only to discover that they took them home to watch Netflix versus using them on their rounds. Hardware alone isn’t the answer. You also need software that’s mobile aware.

When you’re developing your mobile strategy, keep this in mind. The iPad is a beautiful device with multiple applications (just not healthcare data collection). It isn’t going to transform your hospital systems’ user experience. But don’t compromise – there are other options to consider. Look for vendors that can fill the gaps in your EMR with mobility solutions optimized for the right tablet for your environment (iPad, Android and/or Windows) and that upgrade your user experience/productivity.

Chris Joyce is director of healthcare solutions engineering for Bottomline Technologies of Portsmouth, NH.

If you have achieved Stage 1 Meaningful Use requirements or are planning to attest in the future, you are likely aware of the required core measure for implementing and tracking at least one clinical decision support (CDS) rule. The goal of this measure — along with maintaining active problem and medication lists and recording vitals and smoking status — is to improve the quality, safety, and efficiency of patient care.

So what exactly is CDS and why is it important? 

In simple terms, CDS gives physicians the clinical information they need for decision-making tasks. For example, during a patient exam, CDS tools can provide prompting to help a doctor determine a diagnosis or select an appropriate treatment plan. Alternatively, a provider may use CDS technology to improve documentation or identify billing codes or determine the most relevant data to forward to a specialist.

CDS technologies are particularly powerful when the engine is mapped to a wide variety of medical concepts and diverse reference and billing terminologies, such as LOINC, RxNorm, SNOMET CT, ICD, and CPT. CDS tools are more robust the wider the engine’s mapping. Strong CDS engines have the ability to identify and interpret patient information from multiple sources, whether the data comes in the form of lab and test results, previous therapies, or patient histories.

It’s important to keep in mind that CDS tools don’t make the actual clinical decisions for a physician, but support a physician’s own decision-making by sifting through existing data and presenting the most relevant information. As more clinical information becomes available online from EHRs and health information exchanges (HIEs), providers will rely more heavily on CDS technologies to identify the most pertinent information for a given situation.

Many commercial EHRs and HIEs have embedded CDS tools to help providers wade through vast amounts of clinical data. CDS technologies work behind the scenes to identify the most clinically relevant information within a practice’s EMR or from a connected reference lab or from HIE records. Search engines consider additional relevant details amongst on thousands of clinical scenarios and then interpret the cumulative data. Physicians are then presented with pertinent information at the point of care and offered details to aid with diagnosis and treatment plans, as well as critical data needed for compliance and reimbursement.

Though Stage 2 Meaningful Use is not finalized, look for the ONC to add additional CDS objectives in the core measures.

Dave Lareau is chief operating officer of Medicomp Systems of Chantilly, VA.

Super-Sized Productivity Gains from Computer-Assisted Coding?
By Akhila Skiftenes

The required migration from the ICD-9 to ICD-10 has significantly increased the demand for computer-assisted coding (CAC), moving beyond its early beginnings in outpatient specialty areas. The potential benefits from using this technology to make the transition to ICD-10 can be very compelling –improved coding productivity, accuracy, consistency, transparency, and compliance.

Yet CAC products require a substantial investment, and implementing one does not a guarantee that these benefits will be realized. Therefore, it is essential for an organization to complete a thorough analysis before investing in a CAC product.

Exceptional productivity gains have been reported by vendors. However, these are based on a number of assumptions and the specific circumstances for the organizations using the system. The following are key considerations when estimating CAC benefits for your organization.

First, estimates are often based on outpatient implementation data. As more and more hospitals move toward using a CAC in their inpatient areas as well, these productivity estimates need to be adjusted accordingly. Inpatient stays are longer and have more variability, making accurate CAC translations much more complex. Vendor products have made great strides toward accurate inpatient coding, but it takes more computing power and more time, so productivity gains will be lower.

Second, CAC works best when the documentation inputs are standardized. There are four standard formats for documentation: consultation note, history and physical, operative note, and diagnostic imaging report. The more variability in documentation formats for your organization, the longer the CAC process will take and the lower the translation accuracy.

Standard medical terminology used by the electronic medical record system also impacts the effectiveness of CAC. Many EMR systems use ICD-9 verbiage rather than SNOMED-CT for physician documentation. In these situations, the CAC application will translate to a lower level of accuracy since SNOMED-CT has a more modern standard for medical terminology and greater levels of specificity.

Finally, there is a general belief built into benefits estimate that optimizing the CAC process is ongoing. Once CAC is implemented, it is vital for the Health Information Management (HIM) department to audit the output and identify any issues with the software’s documentation interpretation. A critical success factor is the working relationship between HIM and IT, with resources assigned on both sides for continued optimization.

When making a decision about CAC implementation and ongoing support, organizations need to incorporate all of these assumptions into the estimate of how much productivity can truly be realized.

Akhila Skiftenes is an associate consultant with Aspen Advisors of Denver, CO.

Virtual Patient Simulation: Strengthening Medical Decisions, Strengthening Outcomes
By James B. McGee, MD

Provide better patient care with fewer resources. Essentially, that is what healthcare reform is asking us all to do. Most providers agree that the only way to maintain the quality of patient care and decrease overall cost is to reduce errors, prevent duplicate or unnecessary tests, and discover more effective yet less expensive approaches to care.

As I see it, that is the simple reality we all have to work within. The real question is: what does it mean from a practical standpoint?

It means that the modern delivery of medical care is far more structured, more measured, and more reported on than I—or anyone—ever could have imagined. Even the most recently educated providers now have to learn new skills and processes in order to respond to federal and third-party payer demands. An entire generation of practicing physicians and physician extenders is being asked to change practice habits, yet still engage in complex decision making.

It is a tall order. However, virtual patients (VPs) offer a way to provide examples and feedback that can help train providers to work within the new constraints. Think about it: clinical decision making is a skill. Like any other skill, it needs to be practiced, refined, and updated regularly. Simulation in general offers a safe environment to assess specific skills and receive personalized, dynamic feedback. VPs can simulate a wide range of clinical decision-making scenarios without requiring dedicated space and time the way physical simulators do.

Simulators such as mannequins are a familiar way to practice clinical skills. VPs are a relatively new development best described as interactive web-based simulations used to develop, enhance and assess clinical decision-making for all types of learners (physicians, physician extenders, nurses, students, etc.). Branched narrative style VPs, in particular, do this by presenting a patient’s story and background information. They then challenge learners with multiple decision paths and show the impact of their decisions—without the risk of actually treating patients, of course.

Training with these realistic computer-based cases strikes a practical blend of simulation with the convenience of web-based delivery and centralized reporting. Think of them as “cognitive” task trainers.

Hospitals have long recognized that providers who pursue learning on a regular basis tend to have better patient outcomes at a lower cost of care. Educational programs like VPs provide a mechanism to make good clinicians better and—perhaps best of all—help novices improve the cognitive skills that lead to expertise.

One good example that I am aware of is Warwick Medical School in the UK, which created VPs to train new doctors to handle life-threatening acute medical emergencies. The doctors can practice over and over again. Through the VPs, they receive immediate, personalized feedback while responding to a rapidly evolving, life-threatening clinical challenge. This type of deliberate practice simply cannot be replicated in real life. In an actual emergency the doctors who practiced decision-making skills are more likely to perform successfully.

Given healthcare’s focus on accountability and other reform efforts, it is important to not lose sight of ways providers and nurses can improve the care and the safety of their patients. VPs provide a safe and objective way to identify variations in practice and decision-making; remediate using real-life examples; reassess until competency is demonstrated; and continually reinforce best practices.

In any given community hospital, providers with a wide range of prior knowledge, skills, and attitudes practice under one roof. Patients expect and deserve the highest level of expertise from all of their caregivers. Payers also expect a certain level of performance and have begun to reward superior performers.

Simulation provides an efficient way to assess clinician performance and provide feedback, whether in the form of clinical guidelines, performance metrics or formal educational programs. By strengthening medical decision making, virtual patients offer one way to reach everyone’s ultimate goal—better patient outcomes.

James B. McGee, MD is the scientific advisory board chairman and co-founder of Decision Simulation LLC, co-chair of the Virtual Patient Working Group at MedBiquitous, and assistant dean for medical education technology at the University of Pittsburgh School of Medicine. Additionally, he is an associate professor of medicine in the division of gastroenterology, hepatology, and nutrition and a practicing gastroenterologist.

Readers Write 2/8/12

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

HIMSS, A Golden Opportunity: Insider Tips for Maximizing Media and Analyst Interviews
By Jodi Amendola

It’s hard to believe that HIMSS is just around the corner. In addition to meetings with new business prospects and partners, networking, and reunions with friends and former colleagues, you can maximize your HIMSS experience by arranging media and analyst interviews during the show.

HIMSS is a golden opportunity to meet one on one with these key industry influencers and differentiate your company from the competition. You can also leverage these meetings to identify and secure opportunities to be included in print or online articles, blog posts, and industry reports.

These industry movers and shakers are incredibly powerful. One positive mention and your sales leads could skyrocket. One negative comment and the opposite can occur. Don’t panic. The following media training “cheat sheet” can help you achieve your goals and generate positive coverage.

• Prepare. One of my most embarrassing HIMSS moments was when a client told an analyst that he “really liked his magazine.” The client obviously hadn’t taken the time to read our prep book! Before a meeting, research the background of the editor or analyst and become familiar with his or her areas of expertise and interest. Always customize your answers to address their audiences’ needs and pain points.
• Listen. Nothing is more annoying than being interrupted. Listen to the entire question being asked and tailor your responses. Address the questions within the context of the target audience(s) and avoid dominating the conversation with a product or service pitch. Sometimes it will be appropriate to share your knowledge, vision, and thoughts on the industry rather than focus on your company.
• Body language. Be confident, enthusiastic, and friendly. Smile, lean forward, and make direct eye contact. Don’t cross your arms or fidget. Remember, how you deliver your message can be as important as the message itself.
• Get to the point. Prepare an elevator pitch, a two- to three-sentence description of your company that is easy to understand. In other words, how would you describe your company and its products and services to your mother or the person sitting next to you on an airplane? Make sure it includes the key points you want editors or analysts to remember.
• Avoid jargon. Explain your product or service in layman’s terms. It’s your responsibility to make the pitch simple, clear, and memorable.
• Power of three. Focus on three main talking points and weave them into the conversation whenever possible. Often a reporter or analyst will ask if there is anything else that you would like to add at the end of an interview. Use this opportunity to restate your three core messages.
• Tie to hot topics. Demonstrate that you are a thought leader and can address hot topics such as Meaningful Use, ACOs, and where the industry is heading, not just talk about your product or company. Share the bigger vision.
• Zen of interviewing. When asked a difficult question, maintain eye contact, control your gestures, and breathe. Listen to the question and request clarification if necessary. Give yourself time to collect your thoughts and then respond. If you don’t know, don’t make it up. Offer to get back to the reporter or analyst with the appropriate information.
• Tell a story. People remember stories. Talk about client successes and lessons learned that highlight how your products deliver real-world value. If possible, include relevant ROI data in your storytelling.
• Relationships. Last but not least, it’s all about relationships. Be yourself, be genuine, and have fun. Let editors and analysts know that you can address multiple topics and to feel free to call on you for commentary or to discuss industry trends. Offer your clients as sources for future articles. Remember, these editors and analysts can have an incredible impact on your company’s reputation and marketplace visibility. Take the time to establish and strengthen these important relationships. Your investors, board members, and employees will be glad that you did.

Jodi Amendola is CEO of Amendola Communications of Scottsdale, AZ.

Comparing CEOS – Steve Jobs and Neal Patterson
By Reflective

Interesting comparison of Neal Patterson to Steve Jobs you made. 

Neal is, like most true visionaries, a complex person. I worked directly with him for many years, and while he can be quite the PIA to put up with at times, he is also incredibly compassionate and human and generous at others. He is a great leader, but not always a great manager  – and those are two entirely different things. He would agree with this assessment and has said as much in the book he wrote – manageIT.

As a leader, he sets clear direction to where he wants the company to go and the role he wants you to play in getting there. He defines aggressive and tangible goals that can be measured – and measure them he does. But he can be an impatient manager who doesn’t like to listen to reasons why goals aren’t accomplished (he views them as excuses). He is incredibly picky about the words you select in presenting your arguments. Words are VERY important to him, nearly as important as your intent. If you use the wrong words, he will come at you ruthlessly until you are embarrassed into retreat – many times, in a public forum. 

This is not an easy thing to deal with, and some might view it as unfair. But he does get his point across, and you surely do choose your words carefully the next time. And he has a great radar for detecting bullshit, so I would advising against trying. For your area of responsibility, you better figure out how to be more prepared than him, more informed than him, and have spent more time on the strategy than him – or you will not survive.

I have worked with several truly brilliant folks over the course of my career, and none of them have been easy. The things that they see aren’t always easy for the rest of us to see. The drive that they have to achieve comes from an inner place that we may not ever understand. They are different. They are difficult to be around because they are constantly judging and evaluating everything and everyone – making split-second decisions that can change the course of people’s careers and lives. 

The decisions aren’t always fair or even right , but they aren’t afraid to make them and live with the consequences. And once made, they do not live in the past. They only move forward. Leaders have it in their DNA to do this. Many managers do not.

But I have also observed that these truly visionary, genius-type folks are also acutely aware of their own mortality. They feel that they have a lot to accomplish in the short time they are on the planet. They are afraid they will run out of time to accomplish all they want to accomplish. They hear the clock ticking and they tend to steamroller over others that they feel will impede their progress, not always choosing a path that may yield less collateral damage. 

They are not always fair, and they sometimes listen to the wrong advice and situation summaries from folks with hidden agendas  because they don’t have the time to do everything themselves. Because they are forced to delegate, they can sometimes be manipulated. They may be brilliant visionaries, but they are not always the best judge of people. 

But leaders like these accomplish things that the rest of us cannot. They probably don’t like being labeled "genius" because they just see it as working harder than others. Being more driven than others. They have tenacity and a refusal to accept failure. I don’t think that they are necessarily put here to become beloved. I don’t think that is what’s important to them. What’s important to them is achieving their goals. Making a difference, leaving their mark, changing the world. The accolades, awards, and adoration are not what drive them, no matter how big their egos might be.

They can be incredibly charismatic when they want to be. They are successful leaders because, inevitably, their followers believe in the direction they are headed. They are leading their team into battle, and the team goes – because they believe their fight is right and just and winnable.

You don’t always love being around these types of folks. They are not easy. They wear you out. But it is their difference from the average that makes them successful. We need them. And most of us are changed by being around them. We are challenged to be better than we had been. We are less average by working up to their standards. For as long as we can stand it.

Too Much Football Without a Helmet
By Mike McGuire

I’ve managed to spend the lion’s share of my career in healthcare informatics. I’m not sure if that says I’m brain damaged or that I really admire not only the industry, but also the dedicated people I’ve met over the last 30 years.

I’m choosing to believe it’s the people, even though my bride believes anyone working in healthcare is brain damaged. Her view was formed by her experiences caring for her mother when it was discovered that she had cancer. We’re all too familiar with the story. Patient has multiple providers that are treating her, each focused on their part of the care. Between the drug interactions and multiple protocols, she managed to survive almost four years before she passed. While we were grateful for the time, the quality of those years will always haunt us.

Each of us have gone through a similar scenario or have known someone that has gone through it. Some of us have been around long enough to have survived the ‘80s and the introduction of clinical information systems. In the ‘90s. electronic medical records were introduced, and in the ‘2000s we had RHIOS, then CHINs and now HIEs and ACOs with still no solution in sight.

This weekend, like millions of Americans, I watched the Super Bowl. I marveled at the athleticism of the players, the size of the spectacle, and the precision of the execution of the game. When you think about how these are games scripted beforehand and how the coaches anticipate what the other team will do under certain circumstances, you wonder how they make all those pieces come together? And when they put together the plan, how do they modify it when a new piece of data or a new formation suddenly appears?

Like any battle plan, it’s only good until the first shot is fired, and then it’s constant adjustment. What I saw was that the quarterbacks of those teams had the ability to approach the line of scrimmage, access what they saw, and then had the wherewithal to call an audible. An audible is a new or substitute play called by the quarterback or a defensive formation called by a linebacker at the line of scrimmage as an adjustment to the opposing side’s formation. The audible is communicated by a series of hand signals, numbers, or colors called out by whoever is changing the formation. The players at each position then adjust their attack accordingly.

It’s a tribute to man’s ingenuity that the game of football has figured out a way to seamlessly react to change and adapt, yet we in healthcare can’t even exchange or share basic data. Now I hear the healthcare purists shuddering that the mere thought that I had the audacity to imply that somehow the exchange of patient data is analogous and on the same level as an audible in football. No. My point is that the NFL has figured out that in order to consistently win, you have to continually adjust and be able to communicate those adjustments in real time. This is something we cannot easily do in our healthcare environment.

Our healthcare game plan needs to be built around our two quarterbacks, the patient and the provider. Sustainability can only occur when the 880,000 physician quarterbacks can audible the other members on the patients care team, including the patient. Data exchange must be real time, succinct, and cheap. What we’re building is slow, difficult to maneuver in, and expensive.

Unless we design the game plan around the quarterbacks, my grandchildren will be writing articles about why ACOs and HIEs never delivered the expected results. We are better than this.

Mike McGuire is senior VP of sales for Holon Solutions of Roswell, GA.

Readers Write 1/27/12

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

The Top 10 Mistakes Salespeople Make at the HIMSS Conference
By Beth Friedman

A vendor’s sales staff is one of the company’s most important assets. While marketing, PR, and events management put it all together, the sales staff determines whether or not the HIMSS conference is a success.

Is your sales team engaged, interacting with prospects, and busy with pre-scheduled appointments? Or are they sitting around the booth, eating dinner together, and looking like Las Vegas wallflowers?

Here’s a Top 10 list of sales staff mistakes at HIMSS derived from our 30+ years of combined experience. Avoid them and you’re golden. Make them and you’re history. It’s that simple!

Mistake #1: Sitting Around the Booth

Your booth is crowded with salespeople, but no prospects. This is the most common mistake at any trade show.

Prospects must be enticed to enter your booth. They won’t come into it willingly. It is the job of your sales team to get them in. Yes, that means standing at the edge of the carpet and greeting attendees. A simple “hello” and smile works wonders. Multiply your smiles and see how many you get back. Hey, these guys and gals are competitive – have a contest!

Secondly, ask attendees easy, friendly, open-ended questions as they pass by. Get them engaged in a friendly conversation to start. Before you know it, you’ll be giving a demo! For example:

• How are you enjoying the show so far?
• What did you think of the keynote this morning?
• How are you finding the educational sessions this year?
• Did you go to HIStalkapalooza?

Mistake #2: Smart Phone Syndrome

All year you’ve made cold calls, left messages, and begged for appointments. Guess what? The same folks you’ve been trying to reach for six months via phone are here at HIMSS, live and in person. Dump the cell phone and talk to everyone in real time.

Avoid e-mail or any other electronic-based interpersonal avoidance. This includes time spent in the booth, between exhibit hall and hotel, in the elevators, during lunch breaks, and at the roulette table. Attendees are everywhere. Be “on” and smile at all times.

Mistake #3: Selling Too Much

Keep the sales pitch in the booth. If you meet attendees at events, poolside, or at the casino, keep conversation fun, personable, and low pressure. People are people. Everyone likes to meet someone personally first, professionally second. Overselling is one sure way to drive people away.

Mistake #4: Having Dinner Alone

Even if your company is small, make the most of having all your customers and prospects in one place. Arrange a dinner. Invite customers for cocktails. Host a small reception, focus group, or breakfast.

Breaking bread with fellow employees only is an opportunity lost. Make sure every meal includes a customer or prospect. You’ll be glad you did!

Mistake #5: Assuming One Size Fits All

Sales staff often uses a “one size fits all” approach to HIMSS attendees. Take a moment to ask questions and better understand your audience. See what problems they are trying to solve. If your company can solve it, great! If you company can’t solve it, don’t waste their time. Refer them to a company that can, and remember that smile!

Mistake #6: Avoiding Sessions

HIMSS offers a huge educational opportunity. Hundreds of sessions are offered and your prospects are sitting in each one!

Take the time to attend sessions. Sit next to someone interesting. Introduce yourself. Attending educational sessions is the best investment sales teams can make at HIMSS. Plus, it might make you smarter.

Mistake #7: Negative Selling

Talk your company up, not others down. Negative selling never works. And it especially doesn’t work at HIMSS. Enough said.

Mistake #8: Keeping Your Company’s Presence a Secret

You’ve invested time, money, and effort into HIMSS. Why not shell out a few more bucks to let everyone know? Direct mail is back. E-mail campaigns and promotions help. Unless attendees know you’re there, you’ll get lost in the noise.

And remember to attach promotion to your HIMSS efforts, and some emotion to your promotion. Give attendees a reason to visit your booth. And have some fun!

Mistake #9: Confusing Signage

OK, this mistake is usually made by the marketing folks and not sales. But confusing signage is a nuisance to everyone. Your company has less than three seconds to tell HIMSS attendees what you do. Make those three seconds count! Keep signage brief and communicate in familiar industry terms.

Mistake #10: Not Making Appointments

Failing to make one-on-one appointments with customers and prospects at HIMSS is inexcusable. Even if your company doesn’t have access to the pre-show attendee list, just call them! See if they are going. If your direct contact is not going, chances are that someone from their organization is. Call and introduce yourself. Schedule a cup of coffee or have a drink.

Reach out and touch someone before the conference. Because once everyone is in Vegas, it is too late.

Good luck. Have fun. Make the most of HIMSS. It only happens once a year!

Beth Friedman, RHIT is president of The Friedman Marketing Group of Atlanta, GA.

EHR Systems Can Be “Genius” to Use
By Seth Henry

In proper accordance to government regulations, approximately 50% of doctors’ offices nationwide have implemented some form of electronic health record (EHR) system. However, of these, only 25% have adopted the technology to serve in a meaningful and useful way. Most managers understand the mandatory changes that are underway, and in many cases, have begun the critical transition to these systems. Even if users have implemented the proper technology, they may be unsure of how to effectively incorporate it into their daily protocol or how to operate them with maximum benefits.

Compounding the financial investments required to implement an EHR system, there is an average of 1,000 hours of data entry required within the first year of adoption. Doctors and their staff are already pressed for time and money and do not have the proper resources to accomplish this tedious but crucial task. Moreover, they need to be focused on their real job – providing quality healthcare to patients.

The good news is that EHR systems can become user-friendly with the addition of proper infrastructure. Comparable to personal technologies, EHRs originate as a generic platform, with the responsibility of the owner to engage with the product to create a usable, tailored system.

Compare your iPod to that of your friends. No two are exactly alike after you each have the opportunity to personalize and import desired features and applications. Electronic health record systems are similar. They start with standard capabilities and can be uniquely personalized and adapted to meet individual facility requirements. The EHR technology requires applications to make them accommodate the needs for users to engage with the system on a daily basis to further benefit patients.

The most formidable part of any technical change is the actual use of the product and gaining consensus amongst the staff to implement it accurately and consistently. EHR professionals are constantly looking for better ways to educate, counsel, and instruct their client facilities on the technology as together they identify the most meaningful way to apply the tailored applications.

Taking a bite out of Apple’s famously coined “Genius Bar,” functional, hands-on training and support is the cornerstone to the successful use and implementation of any new product integration. The “Genius Bar” adapts the concept found at global Apple retail stores: in-person assistance for product-related education. Technology providers are retaining onsite, dedicated experts equipped with the skills, solutions, and passion for information sharing to guide facility staff through the program until they are 100%autonomous.

A single-style teaching approach is not an acceptable resolution to ensuring total integration of these technical upgrades. Thoroughly educating users in a personalized method, void of time constraints, will enable them to be properly trained to engage with the systems. Not everyone responsible for use will learn in the same manner or adapt as quickly as others. Therefore, the “Genius Bar” solution allows hands-on training and a continuous resource for resolving practical issues encountered as they implement the systems.

When the facility staff and doctors are comfortable with using the products, they are more inclined to incorporate the processes into their daily routines. In-person, ongoing support from their “Genius Bar” representative will help facilitate a smooth transition and implementation process.

The real benefit of an EHR system lies in generating, analyzing, and, ultimately using patient information to directly improve overall patient care. Tailored applications that enhance the EHR technology allow facilities and users to employ the appropriate features and accommodate their needs without the high cost of in-house IT infrastructure and staffing.

With the value of applying customizable, intuitive features, internal office support, and the help of the “Genius Bar” staff, facilities can succeed in long-term implementation and meaningful use of electronic health records.

Seth Henry is founder and president of Arcadia Solutions of Burlington, MA.

Readers Write 1/18/12

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

The EHR Bubble Will Pop—To the Victor Go the Spoils
By Evan Steele

There is no question that the EHR incentives have created a frenzy of EHR purchasing and that the trend will intensify in 2012 because this is the last year to qualify for the full $44,000. As I look at what’s happening in the market, it becomes apparent that at some point in the not-too-distant future, the EHR bubble will pop and many vendors will face financial challenges that will lead to their demise.

Despite the surge in EHR purchases in 2011 and 2012, it is important to recognize that there will be some unintended consequences of the rush to meet the government’s deadlines and requirements. Many physicians will be unhappy with their newly acquired EHR because, in their haste, they made a poor product choice. Others will face a rude awakening as they are forced to use their EHR in ways they never have before, and discover that it does not support their workflows. In the rush to market, there will also be some products that, while certified, are of inferior quality—possibly developed offshore.

Vendors will be backlogged and unable to manage the surge in new purchases in a timely manner due to insufficient staffing levels. Many will come to market short of the necessary educational resources to help physicians navigate the complexities of Meaningful Use, and physicians will find themselves victims of inadequate, rushed EHR implementations by green, wet-behind-the-ears trainers. Other vendors will be so overwhelmed that they will fail to keep to their promised implementation schedules, preventing their new clients from meeting the government’s timetable entirely.

In the years following the initial boom, many physicians will become disillusioned with the EHR Incentives Program. There will be too many requirements that will seem either burdensome or irrelevant to their practice—or both. As the increasingly stringent Stage 2 demands are weighed against the drastically decreasing dollar value of the incentives, physicians will either abandon the program or trade the EHR they originally purchased for one that supports not only the government’s needs, but also the workflow needs of their practices.

To see what will happen to many of the EHR companies, it is important to understand how they are financed. In order to raise money, companies had to show investors a story anticipating significant new client acquisition. Initial funding for EHR companies was based on “hockey stick” growth projections, fueled by the availability of government incentive money. Each individual company’s projection anticipated rapid, accelerating, and long-term growth in EHR demand.

The first thing to recognize is that these projections were overly optimistic. In fact, if you add the projections of all the EHR companies together, they would grossly overstate the total potential market. To excite investors, a typical start-up EHR company seeking funding was likely to predict that it would have 5,000 customers within five years.

With a population of approximately 600,000 physicians serving the ambulatory market — 25% of whom may never adopt an EHR due either to approaching retirement age or doubting that the penalties will ever be imposed –there is a potential market of 450,000 physicians. ONC’s Certified Health IT Product List (CHPL) website currently lists 472 vendors that offer at least one “Complete EHR” product. A conservative assumption that the top 20 vendors will together secure half of the physician market leaves the other 452 vendors competing for their share of the remaining 225,000 physicians. This represents an average of 498 physicians per vendor—not even a paltry 10% of their projections.

The circumstances described above present a textbook case of a dramatic bubble followed by a dynamic shakeout. Whether at the end of 2012 or in 2013 (when the bulk of the incentives are no longer available and physicians will have to focus on the conversion to ICD-10), the bubble will pop, and the financial fallout will be significant. Missed growth projections, government money drying up, and mounting physician dissatisfaction will leave many companies unable to find investors willing to fund their future growth. Scores of companies will face a cash crunch as revenue growth slows, or revenue declines, in the face of continued and significant expenses for implementations, support, ongoing upgrades and certification requirements, etc.

As in the dot-com era, strong companies will survive. Those that generate other sources of income from a deep set of products that offer alternative growth opportunities will be around to take advantage of the second EHR bubble that will be fueled by the looming EHR penalties, the development of ACOs, and new pay-for-performance programs, among other factors. There will be a trend toward consolidation, and financially strong companies will acquire distressed companies for pennies on the dollar, reaping the benefits of their unique technologies and/or their customer bases. To the victor go the spoils!

Evan Steele is CEO of SRSsoft of Montvale, NJ.

HIMSS Prep: Get Inside the Head of Your Customer
By Rosemarie Nelson

How much is it costing you to exhibit at HIMSS? It’s all about making a connection, developing a relationship, and delivering results. That’s why you’re exhibiting. These are my tips for vendors on the trade show floor.

First, Do Your Homework

What do you know about HIMSS? How many members? How many are attending? How many physicians are in those organizations? What else is important for you to know?

Who is walking the floor? You expect to see the C-level. The significant physician. Directors, administrators, and managers. Those from the academic world of academics. And “other.” Other means influencer. Think of the impact of the media, consultants, attorneys, accountants, and spouses. They know, work, eat, and maybe even sleep with the purchasers. Smile and greet them all.

They’re smart. Chances are they are graduate level. They are ready with questions that delve deeper than your elevator pitch. Prepare your answers.

They are boomers, more than any other generation. Are you Generation X or Y? How do you relate to the boomer’s characteristics? How does the boomer relate to you? Regardless of generation, the attendees will fall into one of the following cohorts:

• Wide-eyed wonder (first-time attendee)
• Seasoned cynic (been here, done it all)
• Social butterfly (came for HIStalkapalooza)
• Loyal customer (wants to learn even more)
• “If it’s free, it’s for me” (expert flea market goer)
• Heads-down tweeting and texting (oh, that’s you, the exhibitor!)

Like a Boy Scout, be prepared. Engage the enthusiastic, be cautious with the cynic, curb the chatty, appreciate the customer, and WALK AWAY from your smart phone while you’re in the exhibit hall.

Next, Know the Buzz

• Reimbursement will continue to decrease.
• Regulation will increase.
• Business and government focus on clinical quality will intensify.
• Payers will increasingly pay for demonstrated performance.
• Hospitals will employ larger numbers of established physicians.
• New physicians will continue to seek hospital employment over private practice opportunities.
• Increased consolidation among hospitals and physicians will result in intense competition for insured patients in local markets.
• Improved technology will facilitate — and force — change in healthcare delivery.

Then, Know the Trends

• Consumerism and patient-centered care.
• Transparency and everyone knowing how much healthcare costs and how effective it is.
• Value, represented by quality and safety in relation to cost.
• Metrics and developing gold standards. 
• Information and technology that delivers real-time data on the patient, processes, and systems.

Consumerism Trend

As the population statistics change and the baby boomers age, health care costs rise. Telemedicine, smart phones, direct-to-consumer marketing and the economic constraints on organizations’ fundraising efforts are all opportunities and threats to the traditional methods for delivering health care.

Mobile Technology Trend

Reduces need for hospital admissions and physician office visits. 40% of physicians say they could eliminate 11% to 30% of office visits through the use of mobile technology (PWC Health Research Institute, Sept. 2010). Why would providers accept technology that hurts incomes?

Insurance and Coverage Trend

Medicare spends more than 25% of its budget on patients in their last year of life. As a society, we can’t keep up with the growing needs for coverage and care: state budget constraints, federal budget pressures, and unwillingness to raise taxes. By increasing the preventive services and by monitoring key measures specific to chronic diseases, payers expect to improve health outcomes and reduce overall costs based on reduced hospitalizations and additional procedures.

ICD-10 Requirement

The costs of transition are almost as much as the costs to acquire an EHR.

And Finally, The Bottom Line

Does your solution address one of these trends? Why does what you do or provide matter to the exhibit hall walker? Each buzz signals a reduction in costs to the health care system, which means reduced income to those delivering the service. Are you signing up for a reduction in your income? No one wants to do that. How can you improve that income picture for your potential client?

“How does this solution/product help me?” is running through the mind of that exhibit hall walker. Do you know enough about them and their issues to answer that question? Challenge the conventional thinking in your sales process. If you keep doing what you’ve always done, you’ll keep getting what you’ve always gotten. Is that really what you want from your investment in HIMSS 2012? 

Rosemarie Nelson, MS is principal consultant with MGMA Health Care Consulting Group of Englewood, CO.

The Biggest Mistakes Companies Make in the War for Healthcare IT Talent
By R. Gaines Baty

“War” is officially declared and the healthcare industry is the battlefield. We speak of “The War for Talent” in healthcare – the perfect storm at the intersection of ballooning demand, limited supply, and mandated urgency, with no viable solutions but to accept mediocrity or fight for the best. 

This is not a new phenomenon, nor is it unique to the healthcare industry. Similar forces were at play in the IT industry leading up to Y2K. We in healthcare, as a result, now find ourselves in a candidate-driven “seller’s market” for executives.

No organization can excel without great leadership. Most chief executives agree that for an entity to ascend to and perform at an optimal level, it must attract and retain the best leaders possible. Some, however, don’t align their own recruiting processes with this fundamental truth.

We’ve pinpointed several of the more common and detrimental mistakes potential employers make in the pursuit of great executive talent. Of course, relevant candidate flow is crucial (and the reason good search firms are in business.) This said, the following issues can derail the pursuit of excellent potential leaders.

1. “Perfect Profile” expectations. It is advisable to first seek the perfect match. However, recruiting is not pizza delivery. When a comprehensive search is producing quality candidate flow, the market will reveal the caliber of talent and credentials available to the company. If and when the elusive “perfect person” does not appear, organizations may be best served by evaluating through a different lens. Prioritization and flexibility are required in this approach, with due credit given for transferrable skills and a recurrent track record of success. The operative question must become, “Can she do the job?” Strong performers come in different packages, and may not appear perfect at first glance. One can find something lacking with anybody, even a candidate fully capable of achieving an organization’s objectives.

2. Failure to “sell” the candidate. Excellent candidates typically have multiple suitors and are not necessarily looking for a job. Therefore, everyone in the recruiting process should reinforce consistent and inspired organizational vision, importance of the role, opportunity for success, potential for recognition and reward, and future career opportunities. Undoubtedly, effective candidate evaluation is paramount. Simultaneously, however, a consistent and compelling value proposition must also be perceived by the candidate. This should be complemented by a prompt decision and an appealing compensation offer. Candidates should be treated like prospective customers. We must bring our “A” games to the interview room.

3. Poor communication, indecision and ineffective processes. Organizations frequently drag out hiring decisions nonchalantly for months; communicate inconsistent visions; utilize inconsistent or ineffective evaluation criteria; inadequately communicate with sponsors or recruiters; conduct distracted or unprepared interviews; and generally create unimpressive or sloppy candidate experiences. This same process may be a candidate’s only window into the soul of a potential employer. In contrast, competitive suitors with crisp, clean recruiting processes will quickly eclipse others for this top performer’s services.

In summary, big game hunting for high quality leadership can reap huge rewards. However, the real stars are rare and may appear differently than we first imagined. Competition is stiff. The hunter only has one shot at the target, before it disappears.

R. Gaines Baty is president of R. Gaines Baty Associates of Dallas, TX.

Readers Write 1/6/12

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

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

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

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

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

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

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

Timing: “Match timing with approach”

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

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

Authenticity: “Keep it real”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

2012 New Year’s Resolutions
By Vince Ciotti

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

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

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

Readers Write 12/19/11

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

View from the Healthcare Recruiter’s Chair
By Don Calhoun

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

The Job Market

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

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

Tips for Candidates

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

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

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

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

Tips for Those Laid Off

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

Tip #2. Network like crazy.

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

Editorial Comment Section

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

Clients

(Not ours — they already know this.)

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

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

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

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

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

Breakfast of Physician Champions!
By Daniela Mahoney

Culture eats strategy any day.

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

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

So, you ask, where are the challenges?

Unwritten Rules

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

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

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

Great Expectations

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

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

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

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

Or,

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

Constant Compromise

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

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

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

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

Personal to Us, but System Agnostic

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

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

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

Time for Breakfast!

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

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

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

iPatients?
By Vince Ciotti

An interesting week of news for our EMR world.

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

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

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

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

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

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

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

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

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

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

My Christmas Wish
By Chip Perkins

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

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

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

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

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

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

Readers Write 12/14/11

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

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

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

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

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

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

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

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

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

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

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

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

Ivo Told Me Not To Do It
By Dana Sellers

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A Cost of Doing Business

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

Empower the Analysts (Plus a Little Insurance)

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

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

Targeted and Tactical

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

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

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

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

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

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

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

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

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

Readers Write 12/5/11

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

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

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

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

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

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

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

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

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

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

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

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

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

Talk about a physician adoption challenge and patient safety!

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

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

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

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

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

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

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

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

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

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

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

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

And then there was the matter of facial hair.

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

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

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

Enter Joseph Lister.

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

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

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

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

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

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

Readers Write 11/21/11

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

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

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

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

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

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

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

So why the change of heart now?

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

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

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

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

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

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

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

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

A Response to Vince’s Epic Article
By QuietOne

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

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

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

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

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

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

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

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

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

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