Readers Write 11/14/11

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!

Structured and Unstructured Data, I Adore You Both
By Deborah Kohn

Calling all electronic patient record systems (EPRS) structured data! Yes, all you electronic health / medical, administrative, and financial systems’ data elements that are binary, discrete, computer-readable, and, typically, are stored in relational databases with predefined fields … you tidy, typically core, transactional and mined elements. Hello? I’m talking about all you digital, patient demographic, financial, and clinical health data that are sitting in master patient indices, insurance claims, clinical histories, problem lists, orders, test results, care plans, and business intelligence reports — to mention just a few.

Meet unstructured data! Yes, all you EPRS data that are non-binary, non-discrete, sometimes only human-readable, and sometimes not stored in relational databases. This means all you digital, bit-mapped images, text, videos, audios, and vector graphics that are harnessed in word-processed summary reports, electronic forms, diagnostic radiology images, scanned document images, electrocardiograms, medical devices, and web pages – again, to mention just a few.

I know this might be an awkward introduction. However, I’m really happy to finally get you two data formats together. And, while this might be jumping the gun a bit, I really hope one day you two will get married! I know, I know. That is, after you’ve carefully sorted out all your differences and learned how to live together in peace and harmony for the betterment of patient care.

After all, I’m certain you heard the rumor that the “adoption” and “Meaningful Use” of “certified” diagnostic image-generation and management systems, such as a PACS for one or more of the “ologies”, might be included in Stage 2. In addition, heaven help if, given the revised Federal Rules of Civil Procedure Governing Electronic Discovery that became effective December 1, 2006, a patient’s electronic health/medical, administrative and financial episode-of-care records (I mean x-rays, bills, ECGs, orders, progress notes – the works!) are subpoenaed for that Weird News Andy case we recently read on Mr.HIStalk! So, don’t you think it’s time at least to begin acknowledging one another in public?

Who am I, you ask, to be so bold to introduce you to the other? I’m just one, frustrated HIT professional who specializes in most of the EPRS unstructured data and who observes that these data are rarely considered in EPRS strategies and purchases … until after the fact. Once considered, they divide provider organization departments right down the middle; those working with you, structured data, vs. those working with you, unstructured data. Don’t even get me started about integration and usability issues!

Come close, structured data, so I can tell you that I do adore you – especially when I search a database for one or more of you, and, quickly and easily, the search engine finds, retrieves, and even manipulates parts or all of you. On the other hand, what often makes me want to delete you is when you insist on snubbing unstructured data. I’ve even watched you try to convert some unstructured data, such as rich-text or video data, to your popular religion, using pretty-good-but-not-perfect artificial intelligence and recognition tools … just so that you can brag about how you were able to generate the complete health story with your qualities.

Unstructured data? After so many years working with you, you know that I love being able to retrieve your gorgeous, bit-mapped, raster images generated by that digital chest x-ray or computed tomography (CT) scan stored in a diagnostic image management system; or, listen over and over to your brilliant sound bytes generated by that digital stethoscope; or, fast forward your streaming videos / frames generated by that important cardiac catheterization study; or, admire the perfect lines connecting the series of points plotted by that fetal trace recording. On the other hand, what I can’t tolerate is when I am required to search, for example, a valuable narrative text for one or more of you, and after hours I still can’t find you!

Today there is no complete electronic patient health / medical, administrative or financial record system without both of you. Let me see a hand shake.

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

Problem Lists:  Avoiding the Tragedy of the (Coded) Commons
By Dr. Jim

If we want to take better care of patients, we have to know what we did. To know what we did across a whole group, we need computers to crunch concepts that computers understand.  

But here lies a paradox. While we need structured data entry to enable useful analysis, too much structure complicates both data entry and analysis. The splitters (and payors) among us can create use cases that force the lumpers to accede to ever finer divisions until, for instance, a single ICD-10-PCS procedure code represents nearly an entire chart summary: “ICD-10-PCS 027334Z Dilation of Coronary Artery, Four or More Sites with Drug-eluting Intraluminal Device, Percutaneous Approach” e.g. There are upwards of 1,000 more angioplasty codes within ICD-10-PCS, all with a General Equivalence Mapping to a lesser number of ICD-9-CM Volume 3 codes.

Are my fellow clinicians napping off yet? If so, put on a hazmat suit before you do. What is hitting the fan now will be splattering you shortly if it is not doing so already. In the interest of being able to use our electronic records meaningfully, the movement is toward collaborative problem lists with structured entries documented by clinicians. This would be a good thing—an excellent thing—were it not for the concomitant explosion of  “structure” detail, the de facto  requirement that clinicians do the structured entry as part of their workflow, and the variety of workflow places and coded sources that potentially populate the “Problem List.” 

These sources include the SNOMED-CT and ICD-9/10-CM libraries for diagnoses. I won’t be surprised if a typical Problem List ends up including Procedural Codes as well from the  ICD-10-PCS and CPT/HCPCS libraries. While these procedural codes are not technically “problems,” and not currently Meaningfully Used (the current standard is for “ICD-9 and SNOMED-CT” pending the swap to ICD-10), it does not take a Workflow Scientist to predict that a clinician who documents a percutaneous angioplasty as a CPT code will have an expectation that the Problem List is automatically populated with that (coded) “diagnosis.” 

We are about to see electronic record-generated collaborative Problem Lists that are essentially a repository for the “workflow” output of every clinician who touched the patient. Diagnoses attached to ordered tests; diagnoses entered during a Hospital stay; ED diagnoses; prescription diagnoses; ambulatory diagnoses; imported diagnoses carried by CCDs … perhaps even diagnoses entered by billing services after discharge. It will be the plethora, and not the dearth, of finely-split coded data, which renders the Problem List less functional and the analytics related to it problematic. 

The challenge is to find ways to get to Meaningful Use without letting it prevent the record from being used meaningfully. It’s a great idea to have a collaborative Problem List from which every workflow can read and to which every workflow can write. But we must also focus on finding ways to preserve a Problem List which readily communicates a plain-English problems summary for all caregivers so that Meaningful Use does not morph it into an unnecessarily long and noisy collection of all the code-speak entered on a patient.

There is a need in the electronic record for good, coded, structured data. This does not mean it should replace clear communication.

Real-World Epic from the Ground-Level View
By Informaticist RN

I have worked as a nurse with Siemens Invision, Cerner, and Meditech and an implementation consultant for a leading HIS vendor (not Epic). I’ve also worked as an IT analyst at a major medical center implementing Epic ambulatory.

We had two Epic employees assigned to the ambulatory application, an application coordinator (AC) and an application manager (AM). Both were fresh out of college and obviously green to healthcare.

Our AC/AM would come out for a week at a time, with no agenda given in advance. When they were here, it was disorganized. Whether this was the hospital’s fault or Epic’s, I’m not sure.

Usually, the two Epic people would be typing away on their laptops and not meeting with anyone from the hospital. When I did have one-to-one meetings with them regarding the build we were working on, they were constantly on "Epigoogle" (Epic’s search engine) because they did not know answers to what seemed to me like basic questions.

After their visits, we received no follow-up on outstanding issues or status reports of things they were working on for us. Reaching them was always a challenge. Either by voice mail or e-mail, it could take days or weeks to get questions answered. Generally, it took escalating issues through our project manager just to get a response. We didn’t even get, "Saw your e-mail, working on issue, will get back to you." Nothing! Very poor customer service from them.

During what Epic calls validation sessions, we ran into many problems where scripts weren’t sent ahead of time for our review. Some sessions ended up with last-minute cancellations because Epic wasn’t prepared or hadn’t shared the necessary info with us. Very frustrating.

When build questions arose, the Epic AM preferred to fix the problem in our system herself rather than explain the answer to us so we could learn the system. Frustrating again!

These same AC/AM were also responsible for grading projects for certification. When clarification was needed for me to understand what I got wrong, they were unable to. That was actually a final answer I received from our AC — "I don’t know," and no offer to find who might know more or send on my project to someone more senior for grading.

It was really very disappointing because I was a better IC at the vendor I worked for than either of these two, but everyone at the hospital acted like they were so great because they come from Epic.

Readers Write 11/7/11

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!

The Other Side of Epic
By Vince Ciotti

It’s almost gotten boring to read about another large hospital or multi-IDN picking Epic. It’s as if they have no competitors in the high-end market, which is silly. Mckesson Horizon, Siemens Soarian, Cerner Millennium, GEs Centricty, and Allscripts / Eclipsys Sunrise all have equal or better functionality. What they don’t seem to have is a back door to sell a hospital’s C-Suite through the medical staff, an insurmountable advantage Epic has due to its ambulatory roots.

Having assessed a number of Epic hospitals and having several CIO friends relay their Epic experiences recently, I think it’s about time someone listed the many weaknesses of Epic instead of just more glowing testimonials (to be sure, every vendor has their strengths and weaknesses: one could list many things wrong with other vendor systems too.) This “other side” is intended to open the eyes of those who are considering Epic just because everyone else is.

• Rookie implementers. Epic hires fresh college graduates for their implementation consultants (IC), a practice that saves them a fortune in salaries and gives them malleable candidates to learn “the Epic way.” Unfortunately, these ICs are terribly naïve when it comes to hospitals and do poor work on site, mainly sitting in their offices and looking up questions in “Epigoogle,” their search engine. A hospital would be far better off with veterans that have many installs under their belt, plus several years working in healthcare, to know the many challenges that make hospitals one of the most difficult industries to automate.
• “Epic” costs. Epic charges huge sums for their software and implementation services, just like most other vendors — equal to or greater than license fees. However, there are internal costs that make an Epic budget just that: dozens of hospital FTEs from IT and every user department who need to travel to Verona for many weeks/months of training and testing. Factor in their salaries and the cost for replacement temps and the re-training for inevitable turnover and you can understand why clients like Kaiser and Sutter reported budget overruns of 2-3 times their initial cost estimates.
• The “Epic Way.” Time and again I have heard from CIOs who have gone through an epic install (lower case intended) that the only way to make an Epic implementation successful is to not change the system, but rather adopt your workflow to EpicCare. This is silly in light of the mega-bucks Epic charges. Vendors like Cerner and Siemens pride themselves in adopting their system to their clients’ workflow through screen painting and workflow engines. How can Epic dare charge so much, yet be so inflexible?
• What hardware? Like Meditech (which Epic seems to have copied many bad ideas from, like all employees having to live near headquarters, running up hospital travel costs), Epic does not sell hardware. It is your responsibility and good luck that you buy enough to achieve decent response times. Any problems, just call Dell or IBM and buy more servers. Contrast that with more sensible vendors like Eclipsys and GE that sell hardware and negotiate reasonable system response time guarantees where they will buy more servers if needed. And Epic’s proprietary Cache’ database does take many minutes to run even simple reports.
• Interfaces. What, you thought Epic was integrated? Well that’s true, except for “minor” applications like ERP (AP, GL, PR, HR and Materials). Even the smallest vendors in the industry — such as CPSI, Healthland and HMS — include functional, totally integrated ERP suites, let alone leaders like Meditech and Paragon. CPSI even offers totally integrated PACS and time and attendance modules. Many of Epic’s ancillary department systems are relatively weak compared to specialty vendors. For example, their Beaker LIS can’t hold a candle to SCC Soft Computing or Sunquest, and their ED suite pales in comparison to A4 or MedHost. So, you better add an interface engine, servers, and analysts to that bloated budget.
• Physician training. Physicians love the fact that they see the same Epic EHR in their practice as they see in the hospital, but for two minor problems. First, the Epic build is different for ambulatory versus inpatient order screens, so physicians have to learn two ways of entering orders, responding to alerts, etc. Second, they have to sit through 12 to 18 hours of training classes – factor those hourly expenses into your budget (physicians are not exactly low paid!) At least they don’t have to fly to Verona for weeks of indoctrination like your poor users and IT staff.
• High ratings. Epic has the highest ratings KLAS has ever seen, but think back to all the dozens of IT and user department staff who spend weeks and weeks getting brainwashed on the Epic way. How do you think QuadraMed or Keane’s scores would look if they required their clients to send dozens of FTEs to their headquarters for months of training or testing? And it they didn’t cooperate, they wouldn’t qualify for “good” software maintenance rates, running up their budgets even more. Is it cause or effect?

Well, I could go on, but I doubt Mr. HIStalk will publish much more heresy. Indeed, if he even publishes this, I’ll admire him even more than I do today, as no one in HIS circles seem to challenge Epic these days.

Again, every HIS vendor has their strengths and weaknesses. I could go on for pages of weaknesses about any vendor, not just Epic. It is just sad that everyone seems to conform to only praising Epic while ignoring these and other weaknesses. Anyone else have the nerve to join me in calling for more rationality when dealing with the Epic “cult?”

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

They’re Killin’ “Me”
by Richard E. and Joy Goodspeed

My colleagues present themselves with an air of professionalism both in dress and in conduct. However, they look sloppy when they forget some grammar basics in speech and emails. My biggest pet peeve is that they are killing “me.”

They don’t understand what happens to the first person singular personal pronoun (“I”) when it follows a preposition. If the pronoun is alone behind that preposition, they get it right, but when it is part of a group of two or more, it is usually wrong.

Grammar rules may be a little hard to understand, so I’ll illustrate with some examples.

Say I invite Tim to go to HIMSS with me. I tell you, “I invited Tim to go to HIMSS with me.” Good. Inga decides to come along to keep us out of trouble. I say: “Inga went to HIMSS with Tim and me.” My colleagues would say “Inga went to HIMSS with Tim and I,” and that’s bad grammar (killing “me,” . . . get it?). How do I know it’s bad? Take Tim out of that last sentence. Are you going to say “Inga went to HIMSS with I”? Of course not. “Inga went to HIMSS with me.” Sticking Tim into the middle of the action doesn’t change the need for “me.” The pronoun is the object of “with” (a preposition), so it’s got to be “me.”

Now you’re on a project, and you’re telling your partner about a physician who came to a project meeting to make a complaint. “The radiologist complained to the project team and me.” Right! Now you’re catching on. It’s not “the project team and I,” as it would not be “to I” if you were the only one there. “To me” and “to the project team and me” are both correct.

This discussion is all about the “objective case.” It makes sense that you use the objective case for the object of a preposition. However, “I” also changes to “me” when it is the object of a verb.

Suppose you are going to take Tim to the new ER. “I’m taking Tim to the ER.” There’s nothing hard about that. Along comes Inga. She’s going to take Tim to the ER, and you can come along. You tell Jane about it. “Inga’s taking Tim and I to the ER” Oops! No, no. You’re killing “me” again. You and Tim are now the object of a verb (to take), and you have to use the objective case. “Inga’s taking Tim and me to the ER.” We use the same criterion for the case of that pronoun that we used when it was the object of a preposition: take “Tim and” out of the sentence. In your most ungrammatical of moments you wouldn’t say “Inga’s gonna take I to the ER.”

Keep thinking about objective case (and quit killing “me”).

Joy Goodspeed is a senior integration analyst with Sarasota Memorial Healthcare of Sarasota, FL.


Passionate People Perform
By Peter Longo

Another day, another conference call. “OK, we have everyone on the line and we are ready to review our ACO strategy that will affect v5.5 and the ICD 10 but we can’t forget the FFS model or the FQHC needs as we build the HL7 exchange. With the eMPI not ready, the focus should still stay on the CSI program and promote the current CCD standards that hopefully won’t affect the DR on the COF for client CPHR or the CPQs …” (do we use too many acronyms?)

With all this work selling software that enables physicians and nurses to deliver high-quality healthcare, we still can feel removed from the impact on a patient’s life. Yearning to be reminded, a group of dedicated sales professionals felt the need to get directly involved with delivering care and service to people in need, volunteering at Wheels For Humanity.

Wheels For Humanity (I guess that is WFH) is an organization that is dedicated to supplying wheelchairs to incredible people who are unable to walk for many reasons and who can’t afford mobility. Generally, they spent their young lives being carried from place to place. Painfully, the time comes when they no longer can be carried, and they are left to stay in their rooms. Recipients of these chairs are given the joy of mobility, but equally importantly, they are given dignity.

We work in an industry that is focused on the patient. This live experience stands as a pivotal reminder that the patient should be the center of everything we do. Many of the wheelchairs will be sent to places like El Salvador, Indonesia, and beyond. This whole operation is possible through donations and volunteers wanting to make a difference. Volunteers with a passion to help others.

The one thing our industry is not short on is passion. It is incredible to see so many individuals passionate about improving healthcare. I don’t think anyone can find an industry with a rivaled passion toward helping others. I am pretty sure there is no acronym for passion.

Please take a moment to read more on Wheels For Humanity.

Peter Longo is vice president of sales with Allscripts.

Readers Write 10/17/11

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!

Video to Smart Device Technology Improves Patient Care in Rural Areas
By Kevin Lasser

Innovative technologies are connecting doctors to experts around the globe, instantly and in real time. These innovations, including video to smart device technology, address the significant gap that rural patients experience compared to their urban peers. By improving access to expert medical care, innovations that can connect physicians to specialists are improving the quality of patient care and the outcomes of that care.

Access to specialty care is a challenge that rural Americans must tackle daily; according to a study published by the American Hospital Association, more than half of Americans in rural areas travel more than 20 miles for specialty care, with an average reported distance of 60 miles.

The plain fact is that rural Americas do not have access to adequate health care.

• 50 million Americans live in rural areas, yet there are only 65 primary care physicians per 100,000 rural Americans. By comparison, there are 105 physicians for every 100,000 urban and suburban Americans.
• Rural areas have less than half the number of surgeons and other specialists than urban and suburban areas.
• Saving lives means changing the status quo.

In emergencies, these rural patients can be in the fight of their lives against the clock. The current status quo for doctors in rural areas is to transport patients who need emergency specialty care to another physician. In life threatening emergencies, this delay in care can cause serious and irreparable harm.

Video to smart device technology is bridging the gap between physical location and access to expert care. By allowing a doctor to broadcast video over a secure network, a specialty physician can see the patient’s condition and advise on appropriate care.

“Video to smart device technology allows physicians immediate access to a patient via the mobile phone that they already carry,” said Dr. David Wang, director of the INI Stroke Network. “Other solutions, including personal computers or laptops, are cumbersome and impractical.”

Since the technology is real-time, diagnoses and recommendations can be made and implemented quickly; this real-time technology can save a life in settings where access to immediate expert care is required. The INI Stroke Network recently produced a video on how its use of video to hand-held device technology is saving lives in critical situations.

For the expert, including the stroke specialists in Dr. Wang’s practice as well as cardiologists, neurologists and specialty internists, video to smart device technology allows easy consultation with emergency room doctors and rural health care providers. Combined, these physicians deliver best in class health care to patients, regardless of their physical location.

Using technology to connect rural physicians to specialists in urban areas allows the patient to stay with a doctor that they know and trust while still receiving the best medical care. Real-time, real expertise leads to real care that can save a life.

Leveraging the power of innovation can change the outcome of care for rural patients. When access to expertise is critical, the phone in a doctor’s pocket might be more important than any other tool in their medical bag.

Kevin Lasser is president of JEMS Technology of Orion, MI.

Imaging’s Test: The Balance of Cost and Quality
By Steven Gerst, MD, MBA, MPH, CHE

Providers will be put to the test as they deal with President Barack Obama’s recent proposal to trim trillions from the deficit and hundreds of billions from Medicare. Specifically, radiology professionals should take note. 

The proposal calls for nearly $1.3 billion in savings by raising the assumed utilization rate on some imaging equipment and by requiring referring doctors to get prior authorization when ordering scans. It is still unclear if this authorization process will be managed via the now dominant radiology benefit management (RBM) model. Yet a better model exists.

Today, more than 150 million patients are at the mercy of RBM companies. Health Affairs reported in their May 14, 2009 issue that, on average, telephonic utilization review protocols, denials, and appeals processes costs the average physician $68,274 per practice. This wasted time and cost totals between $23 and $31 billion, annually. This tremendous cost is unnecessary, especially based upon the availability of new electronic, point-of-order, appropriateness criteria-driven clinical decision support (CDS) systems.

Evidence-based medical imaging CDS systems are proving their value. According to a recent study published in the Journal of the American College of Radiology, physicians at Seattle-based Virginia Mason Medical Center saved the institution 23% to 26% on selected imaging procedures by using a CDS. At the Everett Clinic, also in the Seattle area, from January of 2009 to November 2010, the number of CT and MRIs dropped by 39% (from nearly 210 to 128 images/ per 1000) following implementation of an evidence-based, point-of-order CDS solution.

These solutions will become increasingly important under newer “pre-funding” models which reward the most appropriate utilization for the lowest possible cost and the highest possible quality of patient care. With bundled payments, growth in capitation, and the pressures for DRG cost containment, providers, payers and blended ACO organizations will face pressure for both quality improvement and cost containment. Decision support delivers value on both fronts. In the next few years, CDS systems will likely replace the current contentious, inefficient telephonic utilization review protocols by leveraging point-of-order technology, authorization, and payment mechanisms. CDS is destined to become mainstream tools for physicians under healthcare reform.

It is estimated that more than one third of all medical imaging tests may be medically unnecessary and 20% may be unnecessarily duplicative. There is significant merit in attempts to curb unnecessary testing and duplicate tests that are contributing to cost increases. As the Virginia Mason and Everett Clinic Studies indicate, when ordering physicians are provided with evidenced–based criteria at the point of ordering, a physician appears more likely to order the most appropriate test for the patient resulting in the highest quality of service and potentially at the lowest possible cost.  Health reform and ACO development create financial incentives to rapidly adopt this new technology.

In the RBM model, a UR nurse or medical director reads criteria off a utilization review screen during call center discussions, and the burden of that call falls upon the ordering physician, even though that physician is not reimbursed for the study that is being ordered. It is much more efficient to make criteria available to physicians directly at the point of care. Technology can replace an inefficient and costly middleman model.

Most RBMs and carriers develop their protocols around the American College of Radiology appropriateness criteria. With a CDS, these criteria can be loaded directly into the CDS system as an integrated application within the hospital and physician’s EMR. In this scenario, the most appropriate physician imaging orders (ranked levels 7, 8 and 9 on the ACR criteria) could automatically bypass the UM or RBM process electronically and receive an instantaneous authorization for approval and payment. This is known as “Gold Carding.” 

For tests that are clearly inappropriate (ranked 1, 2, or 3), the ordering physician could be given the clinical evidence electronically at the point of ordering  through a decision support system to select a more appropriate test (without having to step out of the normal ordering workflow). In some instances, physicians may want to override the system. Here, the doctor should be able to enter free text to include the reasons for not following the ACR criteria. This is an important part of the audit trail.

Decision support systems allow the hospital to carefully monitor ordering trends by individual practitioners. Those with inconsistencies may be reviewed in conjunction with the medical director to determine causes and to discuss potential resolutions going forward.

Depending on the business needs of the hospital or ACO, if deemed inappropriate, the test may be programmatically blocked electronically from ordering. For proposed studies which score in the 4, 5, and 6 range of the ACR rankings, the CDS system itself may suggest an alternative, more appropriate test. CDS systems should easily allow physicians to select this better test without exiting the workflow. 

What about Meaningful Use? While Stages 2 and 3 are yet to be solidified, it is believed that Meaningful Use Stage 2 will require 60% of all radiology orders to go through the hospital’s EMR CPOE function. Stage 3 has proposed 80%.  A medical imaging clinical decision support solution will, therefore, become a powerful tool in the hands of a conscientious hospital or ACO medical director.

In the past 10 years, the use of advanced imaging procedures (CT, MRI, etc.) has more than doubled in some large health systems. In these systems, clinician decisions drive roughly 84% of cost of care. While estimates vary, a conservative average for an advanced imaging procedure cost is $429 per study. On average, assume a typical hospital performs 230 procedures per day, or 84,000 studies per year. For a hospital at risk under a DRG, bundled payment model, ACO shared savings scenario, Medicare Advantage, Managed Medicaid, or their own employee plan, if just 10% of duplicate studies were avoided, nearly $3.6 million could be saved. 

Why wouldn’t an organization use a medical imaging clinical decision support system?

Steven Gerst, MD, MBA, MPH, CHE is vice president of medical affairs for MedCurrent of Los Angeles, CA.

The Perfect Storm:  All the Buzz from the Healthcare Business Intelligence Summit
By Laura Madsen, MS

Earlier this month at its annual Medical Innovations Summit, the Cleveland Clinic released a listing of the Top 10 medical innovations for 2012. While most would expect many of the items on the list, such as a novel diabetes treatment and new discoveries with gene sequencing, one of the list’s items took many by surprise. Specifically, according to the list, “harnessing big data to improve healthcare” will be a forthcoming medical innovation.

In May 2011, the McKinsey Global Institute published findings after studying “big data” in five domains. According to their research, “If US health care were to use big data creatively and effectively to drive efficiency and quality, the sector could create more than $300 billion in value every year. Two-thirds of that would be in the form of reducing US health care expenditure by about eight percent.”

Last week, nearly 200 people from provider and payer settings gathered at the Healthcare Business Intelligence Summit offered in its third year in Minneapolis. This year’s speakers represented a myriad of organizations including Northeast Georgia Health System, Hennepin County Medical Center, BlueCross BlueShield of Kansas City, and the Winnipeg Regional Health Authority.

As one of the event’s lead organizers, I give credit to my colleagues who served on planning and organizing committees, and also to those who presented and those who attended.

The day was full of sharing information, observations, and insights around business intelligence (BI) in healthcare. In debriefing with colleagues and pondering my own experiences from the day, the following key themes emerged.

The Perfect Storm For Healthcare BI
Many folks told me they are buckling under the pressure of increasing volumes of data, increasing regulatory requirements, and increasing exposure to data and reports by people across and outside of their organizations. Especially with the HITECH Act and Meaningful Use, we have the perfect storm for investment in healthcare data capture, storage, and analytics. Today’s organizations must leverage a new and distinct approach to data, one configured specifically for an ever-changing landscape. Yet caution is necessary. Healthcare is a different animal than retail, manufacturing, and finance.

What About Quality?
Concerns exist about the value associated with data. Healthcare data, especially clinical data, can be subjective. It is fragmented and often incomplete, making analysis and knowledge distillation an ongoing issue. While most know that data quality is critically important, most folks don’t know how to tackle it. Some have decided that they are better off exposing bad data to end users as a way to demonstrate the impact that these end users themselves can have on the quality of data. This, of course, is not recommended. 

Where’s the Value?
When talking about data value, a shift is underway. A few years ago at the conference, the question was “Is there value in our data?” Today the question is “How do we determine where there’s the most value?”

Data, Data Everywhere
As data volume increases, so, too do the challenges of data disparity. Data integration is becoming a hot topic. Everyone knows they need to bring disparate sets of data together. Some have done it successfully.Others are just embarking on the adventure. Yet we all know that as data sources and volumes increase, so does the reliance on “Extract, Transform and Load.” ETL is a fundamental practice in business intelligence, yet it is often misunderstood. This seems to be weighing on people’s minds.   

ACOs, MU, Etc.
Data reliance is becoming a mainstay in healthcare and increasingly important as Meaningful Use continues to evolve and as the new shared risk model of accountable care is adopted. Most people at this year’s event agree that the industry needs a higher degree of sophistication associated with data management, reporting, and analytics. When discussing MU, ACOs and the like, most organizations reported feeling ill-prepared.

Representatives from CMS led a heavily-attended breakout, with significant discussion on data warehouses to support Meaningful Use. One attendee, a vendor working with MU in ambulatory care, indicated that nearly 50% of the groups he’s worked with in the past few years have more than one EHR and are struggling to determine how to move forward with these multiple environments. One individual from a provider environment said he felt they were being penalized for being an early adopter of EHRs because they had more than one, and as a result, were not sure how to proceed. At this point, they are leaning toward dumping everything and starting over. Even though they will miss some incentives, they will make the final deadline.

The discussion of data EHR and data consolidation raised a major question that’s seemingly on most people’s minds:  will there be a time that ONC/CMS will recognize the need and/or value of a traditional data warehouse for healthcare organizations striving to meet MU? If this happens, how will they handle will certification of processes including data integration, data modeling, and reporting? 

Perhaps next year at this time I’ll be writing about the ONC’s response to this very question. Until then, best wishes with the unique healthcare challenges and opportunities of big data and business intelligence.

Laura Madsen, MS is healthcare practice lead at Lancet Software of Burnsville, MN.

Readers Write 9/21/11

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!

EMR Usability and the Struggle to Improve Physician Adoption
By Todd Johnson

Now that Meaningful Use money is up for grabs, almost every US hospital is somewhere down the pathway to deploying at least a Stage 1-certified EMR. Once installed, the tab on many of these systems can run as high as nine figures. For that kind of coin, every user in every department should see their daily workflow improve dramatically. Yet industry-wide physician adoption of hospital EMR systems continues to fall short of expectations.

For many users, the source of frustration is the clinical documentation system they’re asked to use. In theory, these tools are designed to make physicians’ lives easier. But too many documentation systems compromise the usability of the EMR for its most important users.

Not surprisingly, physicians resist changing the way they work to use tools that don’t solve their daily challenges. They stick with familiar workflows – even cumbersome tools such as pen and paper – to capture the details of patient encounters. And they leave it to the hospital to figure out how to extract the data they need.

The net result: physicians end up engaging with the EMR as minimally as possible. Without timely and comprehensive involvement from a significant percentage of physicians, an EMR system cannot help hospitals achieve their clinical, financial and operational improvement goals.

Determining the “usability” of an EMR is less subjective than it sounds. Here’s how usability is defined in the HIMSS Guide to EHR Usability:

• Usability is the effectiveness, efficiency, and satisfaction with which specific users can achieve a specific set of tasks in a particular environment.
• Efficiency is generally the speed with which users can complete their tasks. Which tasks and clinic processes must be most efficient for success? Can you establish targets for acceptable completion times of these tasks?
• Effectiveness is the accuracy and completeness with which users can complete tasks. This includes how easy it is for the system to cause users to make errors. User errors can lead to inaccurate or incomplete patient records, can alter clinical decision-making, and can compromise patient safety.
• User satisfaction is usually the first concept people think of in relation to “usability.” Satisfaction in the context of usability refers to the subjective satisfaction a user may have with a process or outcome.

Each of these components is measurable. Even user satisfaction, while highly subjective, can be measured through user queries. Yet even with an objective framework of EMR usability, physicians continue to suffer through documentation tools that often fail to meet any of these criteria.

Clinical documentation has become a victim of its own exploding popularity. Thanks to Meaningful Use and other technology-driven initiatives, the value of the data found in clinical notes has skyrocketed. Hospitals now have more incentive than ever to deploy systems that capture, aggregate and transfer data as efficiently as possible.

As the point of entry for a majority of patient information found in the EMR, electronic physician documentation has the added burden of converting notes into usable data. But too often, HIS solutions attempt to solve this problem by delivering electronic documentation that migrates all users to a single, inflexible workflow. Rather than accommodate multiple data entry methods and adapt to user preferences, physicians must instead learn to navigate drop-down menus, check boxes, and other pre-defined selections to complete their documentation.

A one-size-fits-all approach to documentation is shortsighted for two reasons. First, “narrative” shouldn’t be a dirty word in the electronic documentation workflow. A comprehensive patient record is much easier to achieve through a blend of structured and unstructured data input. Certain types of notes, such as H&Ps, benefit from the physician’s ability to capture all details of the patient encounter in his or her own words. Elements with repetitive values, such as lab results and vitals, benefit from structured input – even better if these values automatically carry forward daily.

Second and more important, we can’t lose sight of the fact that we’re asking physicians to alter a very important – and very personal – part of their jobs by asking them to use new clinical documentation solutions. Workflow flexibility is crucial to achieving user satisfaction. Narrative-based capture methods such as dictation remain popular because they’re easy to use. Forcing users to modify their behavior and abandon familiar workflows – to “document to the system” – is a recipe for continued lackluster physician engagement with the EMR.

Ultimately, a truly user-friendly advanced electronic clinical documentation system should empower users to document however they’re comfortable without compromising speed, accuracy, data availability, and overall productivity. The specialized technology solutions are in place to make that possible.

Modern speech recognition and transcription systems can convert dictated narrative to structured data. Universal interoperability standards such as HL7 Clinical Document Architecture (CDA) enable that data to integrate seamlessly into the EMR, regardless of which best-of-breed physician documentation solution you’re using.

The only way to know we’re achieving the right balance of structure and narrative is to let the end users guide the design of the finished product. By achieving high rates of physician adoption, hospital CIOs and other stakeholders can finally focus attention on other priorities.

Todd Johnson is president and co-founder of Salar of Baltimore, MD.

Is ONCHIT About to Chase the Clouds Away?
By Frank Poggio

My sincere apologies to Chuck Mangione. For our younger readers, Chuck is a great French horn jazz musician from the 70s. His signature song was Chase the Clouds Away. Now back to ONCHIT.

Cloud computing is the latest systems deployment panacea. In the recent past, it was referred to as SaaS (Software as a Service), and before that, remote hosting. The word ‘cloud’ clearly has a better visual impact. Cloud computing runs all your data and applications at a remote facility, giving the user many advantages such as built-in redundancy, reduced capital investment, effortless backups, better integration with many other Web services, and faster and simpler delivery of updates and fixes.

One of the core elements of the ONCHIT certification process and the Meaningful Use attestation requirements is that a provider must run certified software. The certification must tie back to a vendor’s specific version and build. Directives from two of the current ATCBs state:

CCHIT: If you modify or update your CCHIT Certified product in a manner that carries a significant risk of affecting compliance, you must follow this procedure. Before marketing the modified or updated product as CCHIT Certified, you must apply for re-testing of the product to verify continued compliance with all published criteria and Test Scripts.

Drummond: If changes are made to the Drummond Certified EHR product, you must submit to Drummond Group an attestation indicating the changes that were made, the reasons for those changes, and a statement from your development team as to whether these changes do or do not affect your previous certification and other such information and supporting documentation that would be necessary to properly assess the potential effects the new version would have on previously certified capabilities.

If you sell and install a certified full EHR or EHR module, you must at minimum notify the ATCB with each new version or build so that your previous certification gets inherited to your new update or release, preferably before you send it out to your client base.

Turnkey system vendors (do they really fly above the Cloud?) would send out two or three updates during the year, with perhaps one being a major release. If there was an emergency fix needed for a specific client, they might send that out separately. Clearly the update notice to the ATCB should happen before you would send the fix out, but in an emergency situation if the impact was to only one or a few clients, you could send it out just to them and notify and re-certify later.

The same would be true for any special enhancements. Say a new customer requires a specific enhancement as part of a new install contract. For the period your client is running the enhanced software, that version or build would not be deemed certified. This means they could not use your package to attest to MU. But it’s only one client, and if you are a best-of-breed or niche vendor, it may not matter to that client since they might be able to cover the MU criteria with other vendor-certified products. A good example is with the ONCHIT demographic criteria. This requirement could be covered by several EHR modules.

Lastly and most importantly, the assumption is that your updates or fixes do not impact any certification criteria. At this time, how ‘no significant impact’ is defined and determined is left to our imagination, but starting next year it will be a question that must be tackled by the ONCHIT AA surveillance auditors.

Meanwhile, back in the Cloud, it gets little more complicated. As noted before, one of the real advantages of the SaaS approach is that the user never has to load updates. They are handled centrally. One load and all clients are running the new code. Back to our example where a new client contracts for a special enhancement or a fix is needed — you code them, load them, and go. Everybody has access to the new enhancement and everybody is now running a non-certified system. Ouch!

The simple solution, of course, is to make your new customer wait for a full version release, or in the case of a fix, require a workaround until you get re-certified. Either way, ONCHIT has succeeded in turning the clock back to those Neanderthal days of legacy and turnkey system releases.

Cloud vendors who are ONCHIT certified will really need to rethink that load-and-go approach.

Frank L. Poggio is president of The Kelzon Group.

Interoperability? But of Course!
By Cheryl Whitaker, MD

An HIStalk reader, Rusty Weiss, recently wrote about interoperability (Is Healthcare Interoperability Possible With a Conflicted Federal Committee?, 9/14/11.)

I am not writing to comment on the appointment of Epic’s Judy Faulkner to the Health Information Technology Policy Committee. I am writing to endorse the concept of interoperability. 

In his article, Weiss states, “Democrats, Republicans, and industry experts alike recognize the importance of interoperability.”

Amen. It’s logical that we move to a model in which health information systems talk with each other. I concur that by “tapping into ‘big data,’ there will be opportunity to learn more from existing information – and to make healthcare more effective and less expensive.”

Weiss also states, “By allowing patients to carry their health information across provider lines as easily as we want them to carry their health insurance across state lines, we will empower patients. In fact, one of the stated goals written into the Recovery Act was the development of ‘software that improves interoperability and connectivity among health information systems.”

Weiss goes on to quote Otech president Herman Oosterwijk,  who says, “The entire industry is 15 years behind in interoperability compared with PACS systems.”

PACS solutions were early in the landscape of healthcare’s adoption of electronic information exchange. However, let’s be clear. Diagnostic imaging is far from superior in the context of interoperability. Visit a doctor’s office and you’re likely to see a patient carrying his or her own images burned onto a CD. Ride in a ambulance with a trauma transfer and you’re likely to see a CD strapped to the patient or the stretcher. 

When it comes to exchange of diagnostic images, the inefficiencies are horrific. The room for error is frightening.

Weiss quotes Andrew Needleman, president of Claricode Inc., who says, “Due to the amount and complexity of data being transmitted between systems, even systems that attempt to be interoperable run into issues when they send data to other systems. For healthcare data, even the demographic data to determine if you are talking about the same patient is complex.” 

Consider the realities of diagnostic imaging: 

• Healthcare organizations generate nearly 600 million diagnostic imaging procedures annually.
• Based on a study of data from 1995 to 2007, the number of visits in which a CT scan was performed increased six-fold, from 2.7 million to 16.2 million, representing an annual growth rate of 16%.
• One CT scan exposes a patient to the same amount of radiation as 100 chest x-rays.
• $100 billion of annual healthcare costs are related to diagnostic imaging tests – but an estimated 35% ($35 billion) represents unnecessary costs for US patients and insurance providers.

PACS solutions facilitate electronic image management. But these are proprietary, closed systems that do not allow providers to easily share information between departments and entities, and also across "ologies." Exchanging images outside of a "system" is difficult if the two facilities have different PACS vendors.

To solve this challenge, some entities have added solutions to morph imaging studies so they can be viewed on a receiving system. Until recently, this has required the implementation of specialized hardware and software and costs that were not sustainable.

We continue to see patients carrying their images around on CDs. Yet according to a January 2011 article in the Journal of the American College of Radiology, Johns Hopkins researchers found that approximately 60% of respondents said most images provided by patients on digital media were unreadable or not importable.

With today’s movement toward ACOs and medical homes, new approaches are needed. An enterprise imaging strategy must focus on providing access to any type of image, anywhere, any time, by anyone – provider, referring physician, radiologist, patient, etc. – across the continuum of care. This vision goes beyond PACS to make image sharing truly interoperable and accessible in real time on any device, without having to load and support additional software and without complicated and unnecessary movement of data. Image-enabling the EHR is also critical.

Three components are required for the move to a truly interoperable imaging environment: a standardized vendor-neutral archive (VNA), an intelligent digital image communication in medicine (DICOM) gateway, and a universal viewer that can be accessed via an embedded link or a standalone portal that enables viewing of images on any browser-based electronic device.

This technology exists. An organization can readily start with just one of the components, then build toward a more robust enterprise solution. There is no wrong door for entry.

Today’s most progressive organizations are embracing enterprise imaging, saving time and money, reducing unnecessary radiation exposure, and improving quality of care.

Healthcare data is voluminous and complex. Regulatory demands seem daunting.  Other industries, however, have adapted to a multitude of “data pressures.” Banking, for example, has been successful with leveraging federated data models to enable cross-organizational transactions via ATMs. 

The time is now for healthcare to create exchanges that allow EMRs, HIEs, and PHRs to access content and results from any location without moving data. We should empower patients, providers, and payers to manage the total healthcare experience from computers, mobile devices, and new types of access points, including kiosks.

Cheryl Whitaker, MD is chief medical officer of Merge Healthcare of Chicago, IL.

Readers Write 9/14/11

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!

Is Healthcare Interoperability Possible With a Conflicted Federal Committee?
By Rusty Weiss

Interoperability – the ability of health information systems in different organizations to “talk” with each other – is crucial to the future of healthcare. By tapping into “big data” to learn more from existing information, we will make healthcare more effective and less expensive. By allowing patients to carry their health information across provider lines as easily as we want them to carry their health insurance across state lines, we will empower patients. In fact, one of the stated goals written into the Recovery Act was the development of “software that improves interoperability and connectivity among health information systems.”

But one politically connected left-wing company, Epic Systems, could destroy this healthcare progress.

With over $19 billion in stimulus money being dedicated to health IT, the selection of members to occupy the Health Information Technology Policy Committee was a crucial one for the Obama administration. And a platform of interoperability isn’t exclusive to the Obama camp. Democrats, Republicans, and industry experts alike recognize the importance of interoperability.

So why, despite their public support for interoperability, did the administration appoint to the HHS board Epic Systems CEO Judy Faulkner, who opposes the broad consensus position on interoperability?

As Lachlan Markey pointed out in the Washington Examiner, “Epic employees are massive Democratic donors.”

Unfortunately, those political donations may have caused the administration to overlook things like Faulkner’s 2009 comments to Bloomberg News claiming that sharing electronic health records (EHR) “doesn’t work when you mix and match vendors.” She added, “It has to be one system, or it can be dangerous for patients.”

Tariq Chaudhry, a consultant for American Soft Solutions Corp. says, “Judith Faulkner’s version of interoperability reveals a clear effort to establish (a) monopoly for Epic.”

He also believes that after working with Epic for a couple of years, there is little to indicate that their software is unique in the industry.

“I have not seen anything specific to Epic, not found elsewhere that could set (them) apart from other competing EHR/EMR systems,” Chaudhry explains.

In fairness, the entire industry is, according to Otech President Herman Oosterwijk, “15 years behind in interoperability compared with PACS systems”. PACS (Picture Archiving and Communication System) is a technology that allows medical images and reports to be stored and transferred electronically.

Oosterwijk, who has worked with the US Department of Veterans Affairs and the US Department of Defense, believes that “none of the EHR systems are truly open.” He adds, “I can connect a PACS workstation to pretty much any PACS system and query and retrieve images. Compare this with an EMR where we, at best, can get a HL7 feed and/or CDA summary documents out.”

Andrew Needleman, president of Claricode Inc., acknowledges difficulty with the implementation of interoperable EHR systems.

“Due to the amount and complexity of data being transmitted between systems, even systems that attempt to be interoperable run into issues when they send data to other systems.”

Expanding on the complexity problem, Needleman says:

“For healthcare data, even the demographic data to determine if you are talking about the same patient is complex. Then, you add things like medications with dosages, different forms, such as capsules, liquid suspensions for injections, tablets, inhalers, etc. And then you need to include observations, doctor’s orders, lab requests and results, admissions and discharges, billing information, vital signs, etc.”

“Despite the existing standards,” he says, “It’s not an easy task.”

Rob Quinn, a partner at APP Design, a software development company, says the office of Health and Human Services “is trying hard to get vendors to communicate via standards,” though he doubts many health IT companies like Epic will comply.

“There’s simply too much money to be made in locking in their clients,” Quinn admits.

In the end, Needleman isn’t sure if the appointment of Faulkner crosses ethics boundaries, but says a conflict of interest may be unavoidable.

“I think that it would be extremely difficult to appoint someone who was knowledgeable enough about the industry, was willing to serve, and didn’t have an interest in the outcome of the regulations.”

Needleman has a point about the difficulty of finding somebody without any conflict of interest. But it seems like the administration, at a minimum, should have appointed somebody whose business was not antithetical to an interoperable future. Unfortunately, as an iWatchNews investigation pointed out in Politico, the administration has appointed hundreds of big donors to “plum government jobs and advisory posts …”

The appointment of Faulkner poses a significant challenge for the Obama administration. Her opposition to interoperability creates difficulty for the advancement of the health IT industry. The market should decide whether the Epic Systems approach to health IT should be rewarded or deprecated, but – in the interests of interoperability and political integrity – HHS should immediately ask Judy Faulkner to step down from her role on the HHS Health IT Policy Committee.

Rusty Weiss is a freelance journalist focusing on the conservative movement and its political agenda.

Is Meaningful Use Enough When Disaster Strikes?
By Eric Mueller

Within the last 12 months, natural disasters have taught the health IT community the necessity of preparation. We’ve seen tsunamis threaten nuclear disaster; tornados wipe out entire communities and hospitals; earthquakes damage national monuments; and hurricanes effect remote coastal towns. In the wake of Hurricane Irene’s flooding and billions in damage, I truly wonder what we can learn from this experience in an effort to make the next disaster … less of a disaster.

When I think of disasters, I think of recovery. In health IT, how do we clean up and recover from the unexpected? How do we recoup data, tests, records, history, systems, schedules, hardware, software, and all the technical things that make our facilities run? Katrina occurred six years ago, yet some areas of New Orleans are still cleaning up. Virginians can tell you all about the unexpected now that they’ve experienced an earthquake in their back yard.

And who can forget the tragic images of Joplin, Missouri, where St. John’s Regional Medical Center stood directly in the path of the monster EF-5 tornado? Thankfully, St. John’s had just switched to an electronic medical record system, though it reportedly sustained some permanent paper record loss. We’ve already heard reports of IT-related problems stemming from Irene with offsite centers and backup generators failing along with general logistical and access issues. Unfortunately, after the dust settles, we’ll likely hear of communication outages, lost patient records, and failed technology – a story that is become a bit too familiar.

Having learned from past disasters, many large facilities have business continuity plans in place to restore their operations quickly. They have online data storage backups and cloud-based hosting facilities to mitigate minimal interruption and risk. But what about those that don’t? Many physicians and hospitals across the country continue to lack capital and access to advance to technology typically afforded to large hospitals. Many find it challenging to meet the noble intentions of Meaningful Use, which is designed to do just that. Reach the communities that don’t have the funds or access.

Long-timers in health IT know that implementation and adoption of new technology can be S-L-O-W. So when exactly is the appropriate time to hold ourselves and our vendors to a higher standard of safety, data recovery, and connectivity over finances? What measures do we enact to safeguard our IT investment before a catastrophic event strikes? Moreover and most importantly, how do we help those caregivers in need RIGHT NOW of information technology?

For example, cloud technologies are words that scare us. We think liability and compliance obstacles instead of opportunity and solutions. Flexibility is paramount. Many organizations are in critical risk positions because archaic and poorly funded IT processes and architecture are wrapped around one very inflexible platform. In allowing the unknown to stop us from proactively seeking out sustainable solutions, will we allow history to repeat itself the next time a natural disaster crosses our path?

Creating flexible and efficient solutions provides the foundation for innovation and problem solving. Remember, if your vendor doesn’t play well with others, Mother Nature will force you to figure this out. Patients rely on the entire continuum of healthcare to do one thing – deliver great care. Doctors, nurses, and administrators can’t deliver great care without depending on their arsenal of tools and technology in their greatest time of need. Let’s challenge ourselves to be innovative and redefine Meaningful Use in ways to help all providers regardless of size and limits, both at work and in our communities. I believe it’s worth the effort.

Eric Mueller is president of WPC Services of Seattle, WA.

Is It Only CPOE, or Is There More?
By Daniela Mahoney, RN

We’ve got to think about what is ahead of us more holistically. CPOE is no longer a standalone project. If there is one common denominator amongst any size hospital that is embarking on this journey, it is the fact that the effort is considerably underestimated. Unless you have directly experienced projects of such magnitude, it is natural to treat and plan for this project as you would for any other.

What makes CPOE so different? It is often a multi-year process, especially for larger organizations. It has clear beginning, but not an end. It impacts every operational aspect of a hospital’s business. Above all, it leads to significant clinical transformation efforts that are not welcomed by providers and clinical staff.

Adding to the complexity of delivering CPOE within the Meaningful Use timeline is that all of the clinical components targeted for Stage 1 interrelate. We have two significant integration points: (a) the integration of the CPOE application with the appropriate modules and technologies (lab, radiology, pharmacy, documentation, ED, medication reconciliation, discharge instructions, etc.) and, (b) integration of clinical workflows. The latter is more challenging.

The easier question that organizations should ask is not what CPOE impacts in a hospital, but what it does not impact. That answer is by far shorter. To drive successful CPOE implementation, we know that the leaders have to be involved to “pave” the road and set direction.

To achieve Meaningful Use Stage 1, a cadre of leaders — including the CEO — need a working knowledge of the requirements and organizational changes necessary to succeed. An IT strategic plan aligned with the vision of the organization should be in place at the time Meaningful Use projects are executed. For successful organizations, their strategic plan is centered on the patient and how to maximize clinical performance, the need for increased transparency, pay for performance, provider engagement, and building and expanding business intelligence capabilities, to name a few. This calls for resources, innovative technologies, and infrastructure, as well as a strong leadership team that is able to drive such a vision.

The CIO’s role in the execution of the vision is essential. To successfully attain these goals, the infrastructure must support all these clinical and revenue-generating applications and the new tools that optimize the care delivery process. Someone made the analogy that the infrastructure is like a garden — cultivate it and it will produce expected results, but ignore it and the weeds will take over. As we plan the budgets for these initiatives, although we lead with saying that these are clinical applications and we need to focus on clinicians, we cannot minimize the importance of reliable infrastructure.

In the big scheme of things, what does CPOE impact? Putting it simply, it will impact everything that a provider order does today. Moreover, if what happens today is not functioning at the most optimum levels, then CPOE will accentuate all inefficiencies, resulting in potential barriers towards its adoption. Even processes such as the timely assignment of the appropriate provider to a case will impact CPOE, as any delays or inaccurate information will cause disruptions in communication, delays in care, inaccurate physician performance reporting, billing, etc.

Another critical factor is the fluency of clinical processes related to patient flow, especially at the points of entry through ED or PAT/surgery. As an example, take the efforts of trying to integrate CPOE with a disparate ED system while fine-tuning the medication reconciliation processes. In most cases, the result is a mixture of new processes that could still place patients at risks, unhappy providers if they have to use multiple systems, and budget overruns. Time is a precious commodity – neither the patients nor providers want to waste it.

How do we plan for CPOE? It is by beginning with the end in mind and creating a patient-centric implementation. CPOE has to be safe, should optimize our clinical performance, and improve organizational efficiency. It is complex, but we can simplify it by always asking the question: will the patient and provider/clinicians benefit from it? If the answer is yes, then we are on the right track.

I mapped a visual diagram on how to think about the Meaningful Use components in parallel with what is happening to a patient when admitted to the hospital. This will provide a reference of thinking about what we do in a different way.

And of course, I did not forget about another delicious recipe you could try as we are approaching the end of the summer. I know this has nothing to do with CPOE other than finding a way to relax after a long day at work. And next time, we will talk more about provider adoption, organizational culture, and how to look for that value proposition.

Daniela Mahoney RN is vice president of Healthcare Innovative Solutions of Seville, OH, A Beacon Partners Company.

PHR: the Unicorn of HIT
By Ryan Parker

The Personal Health Record (PHR), in theory, is one of the best ideas in healthcare. Not only in terms of value (think of Facebook and Twitter’s skyrocketing valuations), but also in terms of patient care. As a depository of information, medical records would be easily accessible by patient and provider alike, with medications, procedures, and diagnoses always being accurate and up to date.

Unfortunately, the PHR is the unicorn of healthcare IT.

There have been some valiant efforts, but everyone seems to miss the key reasons why this fantastical PHR will remain just that, a fantasy.

1. PHR interoperability would be an issue. For a viable PHR, it would need to link with every practice and hospital, not only to ensure that providers can view information, but to also make sure that patient data is recorded properly. However, a direct EMR/PHR link would be costly and resource heavy. It would essentially be more effective to create a national HIE (which I won’t get started on why that will never happen). Since we all know that is not an option for the near future, the best option would be to give patients the responsibility of filling out the information themselves. This brings me to my next point …
2. People don’t want to take the time to fill out a PHR. Unless they are made to, most people won’t take the time to find a PHR online and then take the necessary time to fill out all of the information accurately to really make it a worthwhile source of information. In order for this to work, you would need almost a social networking/PHR option that draws people in and then allows them to fill out their medical information, essentially a “Facebook for your health.” However …
3. There will never be a “Facebook for your health.” I’ve heard this idea thrown around quite a bit, and again, it would only work in theory. Most people only use one social networking site. Although Google+ has seen some initial success, I think it will soon bow down to the Facebook beast. The only way we can guarantee a majority of the population has access and comes into daily contact with a PHR would be for Facebook to add a PHR section, which leads to my final point …
4. Facebook will never step into the healthcare arena. Sorry, folks, it is just not going to happen. Facebook is fun, exciting, and laid back. Unless you feel reviewing friends’ home medication list and procedure history is really something that most people would enjoy doing (and if you do, I think you might be in the minority on that one) venturing into healthcare IT would be an extreme departure from Facebook’s prior success strategy.

I, for one, am interested in seeing what the next few years bring in terms of PHR strategy. I think there is an option out there that will work, but it definitely has not been created yet.

Ryan Parker is implementation practice director of Preceptor Consulting Corporation of Fort Myers, FL.

Readers Write 8/24/11

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!

“Installing IT” Understates the Organizational Change that IT Can Bring
By Mike Quinto

Our organization recently underwent an $18 million turnaround in 24 months. We are very proud of this accomplishment and have no intention of stopping there. 

In a recent financial periodical, our CFO was quoted as saying, “Considerable attention has also been given to IT. In the past, top-of-the-line software products purchased for the radiology, pharmacy, lab and other areas were highly functional in their own spheres, but didn’t integrate well. Now, new integrated software is being deployed to improve communication among departments.”

Well, he said it was IT. In reality, we in IT focus on getting cross-functional teams working together to solve business challenges. IT has been the facilitator of organizational change through process redesign, not new fancy software that adds, subtracts, multiplies, or divides better. 

Software, for the most part, does not “…improve communication among departments.” Governance, change management, and cross-functional teams do. 

We implemented Lawson’s ERP suite, but the largest benefit was not gained from the new splash screen or the logo in the corner of the screen. Vendors tend to think that they have solved the same old problem with new fancy software. It is rare that there is disruptive technology that actually changes the way we do things. For the most part, software is a commodity. The real benefit is the implementation and process redesign that takes place during a system rollout.

The opportunity was the chance to focus on charge capture and develop a policy, process, and strategy around it. We could have used a spreadsheet — the technology was not a magic bullet. The focus on business strategy was.

Don’t get me wrong, we like Lawson as a vendor. However, the software had little to do with our transformation. It was the implementation process that allowed open dialogue about the way we do things, and the way we should do things. That opportunity allowed us to evaluate broken process, identify areas that there was poor or no communication, and establish governance around important operational metrics. Just getting HR and Finance in a room monthly has done wonders to find financial opportunity and redefine policies and process. 

In one case, we had two vendors blaming each other for an outrageous claims denial rate. QuadraMed and McKesson couldn’t get on the same page, and that was creating a claim that had fields transposed. This created a denial rate that was almost 100%. I don’t blame the vendors. At the end of the day, we had a department that was not communicating and working with a broken process. 

Once we “re-implemented” the software, we were able to have open, honest conversations about who needed what and how the billing office should be run. Yes, there was an interface issue; however, IT and the business office were not talking. That was the larger issue.

We put in place weekly change management meetings, assigned application owners for each operational department that has an IT counterpart, and implemented basic project management. These changes had more to do with the performance improvement than any single piece of software, hardware, or vaporware we could install.

To say we purchased IT and installed it is underestimating the organizational change that “IT” can bring.

As a CIO, I spend most of my time helping business units redefine their goals, processes, and governance. Very little of my time is spent with bits and bytes.

Mike Quinto is VP/CIO of Appalachian Regional Healthcare System, Boone, NC.

PDF Healthcare: Why PDF is the "Currency" of Health Information 
by Tom Lang, MD

Health information technology faces challenges from many different quarters and for many different reasons. It’s time for a major dose of simplicity. PDF Healthcare (in both static and dynamic modes) is this major dose of simplicity.

Here are two compelling reasons that PDF Healthcare lives up to its billing as a "secure container for the exchange of healthcare information."

PDF is easily viewed/printed from virtually any computer. With the ubiquity of PDF readers, this is a reality. This fact can be thought of as another approach to interoperability. That is, if we can simply turn healthcare information into PDF, that information is available in a human readable form. Last time I checked, humans were still taking care of patients.

Image and other unstructured data files are easily converted to PDF. Clinical medicine is a world of image files and unstructured data, and that will never change. For example, our universe is filled with EKGs, X-ray images, video clips, audio files, and text-based reports  Equally important are those medication and allergy lists that are scrawled on scraps of paper (yes, paper!) that are so important at the point of care. The fact that PDF supports image files and almost any type of file format is very important in this environment.  ​

PDF (Portable Document Format) was originally developed by Adobe Systems Incorporated, but released as an open ISO standard in 2008. This has been an important step to stimulate innovation and competition, making PDF more capable, affordable, and available for our use in health IT as well as other industries.

As an ER physician, let me give you one example of how PDF can jump over the top of interoperability problems.  

I do quite a bit of locums ER work in many settings and frequently find myself in small rural hospitals trying to communicate with specialists that I need to refer patients to over a distance. Probably the biggest slam dunk for HIT has been PACS, which even in the smallest hospitals is almost universally present.  

One weekend, working in very small rural hospital, I faced the same problem twice: I saw patients with complex fractures, and the question was, "Does this patient need surgery immediately, or is this something that can be splinted and taken care of in a day or two?” Orthopedics is not available at this small hospital, and these patients requested orthopedic care in different directions.  

I was easily able to contact the orthopods by phone, but they needed to view the films to make a decision about what needed to be done and how urgently it needed to be done. This hospital has PACS, but despite this, neither of these orthopods could view the images. In this case, which is the most common arrangement I see, the only person who had remote access to view the images was the radiologist who was contracted to officially interpret the study ("Dr X not credentialed, hospital not on this image sharing network … blah … blah … blah").  

Because the radiology tech for the day was a hacker of sorts, he had some screen capture and turn-to-PDF programs on one of the radiology monitors. In both cases, we brought the images we needed on the screen, took a screen shot, turned the file to PDF, and e-mailed to the orthopedist. Also in both cases, not only were the orthopedists delighted we could provide this to them, but we determined that both patients could be splinted and dealt with in 1-2 days rather than immediately, saving many parties much trouble.

In order to raise the level of awareness of PDF Healthcare, colleagues from the PDF Healthcare working group have arranged, for a limited time, to give away a simple little app that will help HIE in the trenches. We are doing this for the solo / small doctor office. As a special for HIStalk readers, we will give away 50 copies.

Here is a short video that outlines the functionality of this app.

For your free copy, be one of the first 50 to go to the PDF Healthcare site and scroll down to Health Information Aggregator (under the heading of Resources.)

Tom Lang is an ER physician and a member of the PDF Healthcare working group.  

This Way to a Better Patient Experience
By Jeff Kao

Everyone’s been lost at one time or another. Whether you’re far from home or just around the corner, the experience is universally the same, with plenty of stress, aggravation, and wasted time.

Thankfully, the advent of navigation systems and smart phones means most of us get lost much less frequently these days, and that’s a good thing. But what about when you’re off the grid, say trying to find a family member’s hospital room or a lab for a blood draw?

Few places are as massive and confusing as a medical campus. With countless floors, departments, and even buildings to navigate, locating the desired destination can be a daunting task. On top of these logistical challenges, patients often arrive at a medical office or hospital feeling rushed, unwell, or anxious about their visit, only compounding the situation and causing them to be late or to miss appointments altogether.

Wayfinding systems offer a viable solution and pick up where navigation systems leave off. From the moment a patient or visitor walks in the door, these self-service kiosks virtually map paths to and from multiple points in a facility, resulting in a more pleasant and personalized experience. Leading healthcare organizations like Chicago-based Northwestern Memorial Hospital have placed wayfinding kiosks near entrances and other common areas, making it easy for patients and visitors to quickly locate a specific room or department and print a customized map with step-by-step directions.

At a time when consumerism is on the rise and patients have greater flexibility in their choice of healthcare provider, such systems are fast becoming a valuable strategic asset. According to a survey conducted by The Beryl Institute, hospital executives list the patient experience as one of the top three priorities they will focus on over the next three years. Wayfinding systems directly impact the experience patients and visitors have by enhancing the level of service that’s provided and eliminating the hassle of being late or lost.

Beyond guiding patients to the correct destination, wayfinding systems can also reduce demands on staff time, both in terms of time spent giving directions and updating software. While some wayfinding systems once required users to manually re-create maps on each kiosk every time an office or department was moved, today’s dynamic, data-driven applications are extremely scalable and allow technical and non-technical staff alike to quickly recalculate routes on the fly.

When not in use for wayfinding, these systems provide an effective venue for displaying video or text-based messages and marketing medically-related services and events. Patients can also use kiosks to register for promotions or request additional information. And, once in place, wayfinding systems establish a platform for future expansion and growth, eventually allowing healthcare providers to add new self-service capabilities from the same screen.

So, what is the path to a better patient experience? The answer may be inside your own front door.

Jeff Kao is vice president and general manager of NCR Healthcare.

Specificity to the Extreme: As ICD-10 deadlines Draw Closer, Is Your Organization Ready for the Good, the Bad … and the Offbeat?
By Sean Benson

Chances are that most healthcare organizations will be able to raise the bar on current documentation practices high enough to support coding for suture of an artery under ICD-10—even though the possible codes expand from just one under ICD-9 to more than 180 under the new code set. But what if a patient walked into a lamp post (W22.02xA) or was bitten by a sea lion (W56.11xA)? What if the patient was burned by a flaming jet ski (V91.07 xA) or suffers from inadequate sleep hygiene (Z72.821)?

If your organization’s clinical documentation and coding processes can’t support that level of specificity, you need to act fast to get it up to speed. Because rest assured, no matter how weird the diagnosis, ICD-10 includes a code that accurately defines the patient’s status to a T.

The authors behind ICD-10 covered all the bases in an effort to capture the full patient picture—sometimes to the extreme and offbeat. With approximately 68,000 diagnosis codes compared to just 13,000 under ICD-9, it’s clear that documentation approaches that work fine today simply won’t cut it under ICD-10.

It will be complex enough to ensure coding staffs are adequately trained on ICD-10. Finding the resources necessary to advance clinical documentation improvement programs to meet the ICD-10 challenge is simply out of the question for many organizations. Nor are most clinicians interested in spending the amount of time required to become fully proficient on the new system, especially when it takes them away from patient care.

That is why many hospitals and healthcare facilities are looking to software vendors to help them make the transition. Software that automates the documentation and coding process can ease the transition to the expanded code set and shorten the learning curve for physicians, especially if they are faced with the ever-so-common encounter of a patient who has been struck by a bird (W61.92).

Not all coding and documentation software is created equal. The best ones will drive comprehensive documentation to capture the high level of detail required under ICD-10. The software should guide physicians through the process of documenting with enough specificity and granularity to ensure appropriate coding. Otherwise, the code that would accurately identify an embarrassing fall on the local airport’s escalator (W10.0xxA) might be missed.

Healthcare organizations will want to focus on the software’s ability to provide prompts relevant to the documentation needs of ICD-10. That is why it’s important that the evaluation be done by someone who is well-versed in ICD-10 to ensure the right questions are asked.

There are multiple initiatives competing for the attention and resources of healthcare organizations, including 5010 and Meaningful Use, in addition to ICD-10. Because it will affect every aspect of operations, the transition to ICD-10 needs to be placed at the forefront.

For many organizations, leveraging the efficiencies inherent in technological solutions to drive documentation improvement is the best strategy for meeting the ICD-10 challenge head-on.

Sean Benson is co-founder and vice president of consulting with ProVation Medical, part of Wolters Kluwer Health.

Readers Write 8/3/11

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!

The Pressures of EHR Adoption and a Market Trend of Converged Services and Technology
By Janet Dillione

Recent mergers and acquisitions in the healthcare information technology (HIT) industry bring to light many facets of electronic health record (EHR) implementation that often go overlooked. As many in the medical industry know, implementing an EHR system so it works seamlessly with clinical workflow is more complicated than downloading and installing software with the click of a mouse. There is not an EHR switch that can simply be turned on.

Healthcare organizations that have successfully implemented EHR systems, along with those currently navigating the process, can attest to the need for a scalable system wide approach. To achieve improvements in the quality, safety and efficiency of patient care special attention should be paid to services and technologies that foster EHR adoption across the clinician population.

Recent strategic alliances in the healthcare IT space signify a movement toward a promising future of EHRs, a future with a genesis in advanced clinical documentation. A successful, long-term EHR strategy, one that will position healthcare organizations to overcome the many pressures of the healthcare industry in the years to come – Meaningful Use, ICD-10, Accountable Healthcare – begins with effective data capture. The reality is that an EHR is only as good as the information captured within it, and as the saying goes, it takes a village …

I have no doubt that the industry will continue to see more strategic partnerships. These alliances establish greater resources for the healthcare industry, leading to more streamlined workflows, greater cost savings, satisfied physicians, and improved quality of patient care. However, none of this happens overnight and healthcare organizations should see this as an evolutionary process, not one of instantaneous change. By this I mean, every provider setting has a clinical documentation workflow in place, and pursuing an approach that is diametrically opposed to the status quo can prove counterproductive to the effort.

Despite the enthusiasm for employing state of the art technologies, healthcare organizations should not feel pressured to immediately make all data capture mobile, to put all applications in the cloud tomorrow, or to force doctors to use an EHR without a safety net out of the gate. In time, the increased amount of service and technology convergence across the industry will help healthcare organizations to better address the pressure of EHR adoption, and more importantly, will help them better manage their robust collections of clinical data.

It is becoming increasingly clear that in healthcare, data is knowledge. It drives care decisions, billing and reimbursement, compliance with federal regulations, and is key to overall health system improvement. Today, there is no one solution, no one vendor, and no magic potion that can address all of these issues and capitalize on all opportunities. However, by strategically bringing together the best in technology with the best in services, healthcare organizations will be better positioned to make the transition from traditional workflows to the EHR in a thoughtful, natural way.

An impressive amount of progress has been made over the last several years, particularly in light of EHR adoption pressures. Innovation and automation is transforming the processes and outputs of clinical documentation. What once was scribbled on a notepad, created on a typewriter, or passed from caregiver to caregiver in the hallway, is captured and transferred more efficiently and effectively than ever before. Such effective clinical documentation establishes an important foundation for EHRs.

By leveraging and contributing to technology collaborations, healthcare organizations can access the best in services and technology. This means a transition from handwritten records stored in manila folders to digital information stored within EHRs captured through natural clinical workflows. Moving forward, there will be multiple ways to capture the patient story including keyboard input and speech-to-text technologies.

Once clinical information is captured, we’ll see the application of highly intelligence clinical language understanding (CLU) technologies, often referred to as natural language processing or NLP in other industries. These highly sophisticated technologies will turn our vast amounts of clinical data into knowledge to be leveraged across the healthcare ecosystem.

The convergence going on across the healthcare industry amongst healthcare IT vendors, academic centers, service-oriented businesses, and other organizations is promising, but should be scrutinized by healthcare organizations.  There are many promises amongst the recent M&As and partnership activity, but only few proven results and long-term plans.  As you work to tackle EHRs as a strategic initiative, enlist supportive guidance and build a nimble infrastructure where the EHR can become a launching pad for better use of data.

Janet Dillione is EVP/GM of the healthcare division of Nuance of Burlington, MA.

Meaningful Use and Innovation
By Ryan Parker

All human development, no matter what form it takes, must be outside the rules; otherwise we would never have anything new. – Charles Kettering.

I have recently finished up some consulting work for a startup HIT company (which for non-solicitation reasons I will refer to as Company X.) I was working with them to help develop their EMR. 

When Company X first showed me their product, I was amazed. In just over a year, they had developed an almost fully functioning EMR. Using more advanced coding language than what you would find in most legacy systems (i.e. C#, Silverlight) they came as close to mimicking the clinical workflow as I have seen with an information system.

Everything was looking up. Their product was becoming more and more complete and becoming more and more advanced. But then they ran into an issue. If anyone has worked with or been a part of a start-up, momentum is key to success, and in this company’s case, the Innovation truck slammed head first into the Meaningful Use wall.

To be completely honest, forcing Company X to get their product Meaningful Use certified did have some benefits. There were some system needs they hadn’t thought of previously. In terms of HIE and interoperability, the requirements will have a positive impact as a whole as we move to a more ‘data-sharing’ driven information system structure. However, the innovation, creating a system different from anything else, which, to keep the truck metaphor rolling, was sitting in the driver’s seat of the company, dissipated as executives and engineers dived deeper and deeper into the ONC requirements.

Weeks turned into months of working on the Meaningful Use requirements. Although Company X was making progress, the focus slowly turned from creativity and ingenuity to one of conclusion, as in, “How soon can we meet these requirements and be done with this product?”

Soon, the executives starting turning their attention to other products, focusing on solutions that fall outside of the ONC/Meaningful Use umbrella.

I have no doubts that after they complete their Meaningful Use certification in the near future, and hospitals and health systems get a good view of their product, Company X will receive accolades on their HIT advancements from the healthcare community. Personally, I will be wondering what progress could have been made without standardization. What advancements could Company X have made without the rigors and requirements forced upon EMR vendors?

Ryan Parker is implementation practice director of Preceptor Consulting Corporation of Fort Myers, FL.

HIEs: High Performers Will Be Around for the Long Term
By John Haughton

Improved patient care outcomes, lower administrative costs, fewer medication errors, improved ability to manage chronic conditions, reduced unpaid re-admissions, greater efficiency, fewer ER visits …

There is no question about the benefits that a highly effective health information exchange (HIE) brings. By highly effective, I mean a healthcare ecosystem grounded in evidence-based medicine, clinical guidelines, and performance reporting.

For providers hoping to achieve Meaningful Use (MU) or to become Accountable Care Organizations (ACOs), performance-based HIEs hold the promise of pulling together data from myriad sources — medical staff and community physicians, insurers, labs, imaging centers, behavioral health and home health providers, employers, consumers, retail pharmacies — to finally deliver truly coordinated care.

But there is also no question about the challenges facing fledgling HIEs, the primary one being a sustainable business model. It turns out that, if you build it, they won’t necessarily come. And once the grant money runs out, the organization rapidly runs out of steam.

The only way to build an HIE with enduring power to transform the health of a community is to have providers pay for it. And the only way to do that is to provide high value — quickly. This means demonstrating value from Day One by raising the bar on clinical quality for their customers, namely, patients.

In response to the MU requirement for value-based purchasing and market realities pushing margins into negative territory for about half of all hospitals, HIEs must help hospitals survive and thrive in the new patient-centric business model to garner lasting provider support.

The HIEs that have done this successfully have something in common: they pretty much all have their heads in the cloud, which is to say, they use platform-as-a-service (PaaS) cloud computing technology that offers authorized users easy, but extremely secure access to centrally stored, actionable information for an affordable price.

Here are the seven technology elements needed to play in the high-performance league:

1. Maximum functionality and flexibility. Since around three-quarters of healthcare in this country remains paper-based, technology is needed that supports hospitals and physicians regardless of their technology sophistication. This favors best-of-breed EHR modules that can meet a wide variety of needs, budgets and timetables, rather than a comprehensive, enterprise-wide approach.
2. A full range of value-added tools and services. Think of the app store on an iPhone. That type of flexibility and customization are what is wanted from HIEs, only instead of YouTube, GPS, and Fandango, apps that provide clinical decision support, performance management, quality reporting and analytics, clinician messaging, shared guideline dictionaries, and disease registries are valued.
3. On-the-fly translation. As long as stakeholders continue to speak different electronic languages — all of which are upgraded and updated almost constantly — mapping and translation services are needed for interoperability.
4. Scalability. An HIE is a dynamic entity; it needs a platform that continually accommodates more of everything: providers, users, technologies, regulations… Collaborating across town is great. Collaborating anywhere is the ultimate goal, however.
5. Ease of use. An identity federation service means providers need just one user name and password to interact with each other, health plans, regulators and patients — and just one point of access for all clinical and administrative data held by the HIE.
6. A 360-degree, real-time view. A single, comprehensive view of a patient’s status, including all information submitted by all authorized sources from five decades ago to five minutes ago, will help eliminate redundant tests and procedures.
7. Sharing of best practices. The best HIEs aren’t merely repositories. They must be able to analyze input, generate point-of-care solutions, and disseminate data that draws on documented successes.

So the future is bright for those high-performance HIEs that “bring it” — clinically speaking. HIEs and other data exchange organizations that figure just having the data will have hospitals and physicians beating a path to their door are being naïve and are putting their long-term survival at risk.

Like it or not, healthcare is a business as well as a service, and organizations need to deliver ongoing value to ensure their long-term relevance and sustainability.

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

Readers Write 7/25/11

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!

Walter Reed Medical Center to be Decommissioned this Week
By Orlando Portale

As part of the Base Realignment and Closure announcement on May 13, 2005, the Department of Defense proposed replacing Walter Reed Medical Center with a new Walter Reed National Military Medical Center (WRNMMC). The new center would be on the grounds of the National Naval Medical Center in Bethesda, Maryland, seven miles from its current location in Washington, DC. The proposal was part of a program to transform medical facilities into joint facilities, with staff including Army, Navy, and Air Force medical personnel.

At the same time, my own organization was in the design phase of our $1B “hospital of the future,” which is scheduled for a 2012 opening (our construction webcam is here.)

In the fall of 2007, I was asked by Congress and the Department of Defense to participate in an independent review of the design plans for the Walter Reed Replacement Project. My role was to identify potential technology and design shortcomings in the Walter Reed replacement facilities.

In May of 2008, our committee submitted a report, noting design and operational deficiencies, but nonetheless advising that the project proceed on schedule.

On Wednesday July 27, the Walter Reed Army Medical Center is closing its doors after more than a century. Hundreds of thousands have received treatment at Walter Reed, spanning World War I, World War II, Vietnam, and the Iraq and Afghanistan conflicts. The move to the new facilities is scheduled for the weekends of August 12 and August 19.

In case you have not been to the old Walter Reed Campus, there are many important pieces of history there. The original red brick hospital was named to honor Major Walter Reed, an Army physician who treated troops and American Indians on the frontier. Dr. Reed had numerous medical achievements, but his most important work involved research that proved yellow fever was spread by the mosquito. He died in 1902 at the age 51 of complications related to appendicitis.

There is a memorial chapel on campus where President Harry S Truman visited after taking office. General Pershing had his own suite on campus for many years. Vice President Richard Nixon was treated for a staph infection over a few days, and received an unexpected visitor one day, then-Senator Lyndon B. Johnson. President Calvin Coolidge’s teenage son died in the hospital from an infected blister he received while playing tennis at the White House. President Dwight Eisenhower and Generals John Pershing and Douglas MacArthur died at Walter Reed.

In 1977, a new addition to Walter Reed was dedicated. The new hospital was as tall as a 10-story building. There were 5,500 rooms covering some 28 acres of floor space. The distance around the top three floors stretched the length of six football fields.

As you can see, the new Walter Reed National Military Medical Center is a beautiful facility. My hope is that it brings comfort and healing to those who have put their lives on the line for this country for us every day.

While our report identified a number of shortcomings with the design plans for the Walter Reed replacement facilities, many of these have been addressed. In fact, recently the new hospital was granted LEED Gold certification, which was an area addressed in our report. Very few hospitals in the US have achieved this status.

More important than the design of the new facility, however, are the extraordinary and dedicated people there who care for our wounded warriors every day. Congratulations to the great team at Walter Reed for all of their hard work and continued dedication.

Orlando Portale is chief innovation officer at Palomar Pomerado Health, San Diego, CA.

Over the past year, we’ve been helping a hospital in New Orleans augment their data center operations to avoid a disaster when the next major hurricane grows out the Gulf of Mexico. Doing this work in the midst of other recent natural disasters across the Midwest and South has helped to reinforce my thoughts about the importance of detailed and actionable plans for disaster recovery and business continuity.

When catastrophic events occur, the concept of business continuity (BC) is really focused on continuity of patient care. This is the ability to continue to attend to those in immediate need and also assist patients who rely on their caregivers on a regular basis.

You would be amazed to know about the number of healthcare organizations with EMRs that have minimal disaster recovery (DR) and care continuity plans. Some hospitals do well in this regard; however, many others have inadequate DR plans that are infrequently revised or tested. Manual care processes for long-term systems outage also suffer from lack of definition or practice. When an organization without good plans faces a major disaster, they quickly learn about their planning deficiencies at the worst possible time.

St. John’s Regional Medical Center in Joplin, Missouri was damaged so badly by an EF-5 tornado on May 22, 2011 that all patients had to be evacuated to other hospitals in the area. When a catastrophic event occurs, the provision of care for patients can be easier and many adverse event risks avoided if some portion of the medical record is available. Recent procedures, conditions, medications, orders, lab results, and radiology reports are extremely helpful in care continuity.

Hospitals can prepare for many types of disasters. We have advance warning for hurricanes, tornadoes, and even floods. Of course, some of the less-frequent disasters such as earthquakes and fire are not preannounced. With knowledge of an impending disaster, the hospitals with an EMR can have a process for the IT department to take steps to assure that current pertinent patient information is available.

Simply printing information at each nurse station in the hospital for the admitted patients is not sufficient. The hard copy reports can be misplaced or damaged. Writing these reports to an encrypted file on a CD, DVD, and even a USB flash drive (a.k.a. memory stick or thumb drive) will assure that important patient data is immediately available after the disaster causing event has passed. When the risk of a disaster is high, write the reports to the disks and flash drive, and along with a laptop PC and spare laptop battery, seal them in a waterproof bag and lock them in a fireproof safe that is anchored to the floor, typically in the data center. If practical and time permitting, prepare a second flash drive with another copy of the data delivered to a key person as identified by the DR/BC plan.

These few simple steps can help you to continue delivering appropriate care for your patients and potentially even save lives in the aftermath of a major disaster.

Jeff White is a principal at Aspen Advisors of Pittsburgh, PA.

Readers Write 7/6/11

Readers Write 6/27/11

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!

Will Meaningful Use and EMRs Help Jump the ACO Hurdle?
By Frank Poggio

The Accountable Care Organization (ACO) is the government’s latest attempt to improve quality of patient care and control the ever-escalating growth in healthcare costs. The Affordable Care Act (commonly known as the health reform law) encourages, via financial incentives and penalties, the formation of ACOs by organizing healthcare teams, technology, and knowledge around patient needs. 

As might be expected, there are many complex organizational, monetary, and other significant policy issues surrounding the ACO model of care delivery.

The ACO concept is not new to the healthcare world. In past decades, we called them PHOs (Physician Hospital Organizations) or HMOs (Health Maintenance Organizations).  Both of these in the 1980s and 1990s had only a small impact on healthcare costs. Many PHOs and some HMOs are still in existence today.

In fact, we have always had some form of ACO going as far back as 1939. For example, the Kaiser Health Plan, The Cleveland Clinic, Sharp HealthCare, Geisinger Clinic, and many others are basically ACOs. If they include an insurance component, they are more like an HMO.

The simplest definition of an ACO is a health care delivery system where the physicians and hospitals work under one corporation, have one set of synchronized patient objectives, and share in the profits  and losses from normal operations. Medicare wants doctors and hospitals to work together and accept one payment for all levels of care and accept the responsibility for coordinating the care of the patient across all modalities of care. 

Where ACOs work and why

The concept has worked at Mayo, Kaiser, and Cleveland Clinic because the attending docs are part owners of the hospital. They get paid a salary and bonus based on both the performance of their practice and the performance of the hospital and other health services.

For example, the physicians readily accept that fewer support staff will save the hospital money, which in turn could result in a year-end monetary bonus while hopefully improving patient care. That, in turn, can lead to more patient referrals and more revenues. The same is true for ordering fewer tests or procedures. Fewer tests equal less costs, and under a fixed payment system like Medicare DRGs, that means more profit.
 
But today, the independent physician makes his or her money seeing as many patients in his or her office as possible. The hospital is just a cost-neutral and convenient place for physicians to perform complex procedures. If an ACO is that simple and beneficial, why are there so few of them?

How did we get here?

Today and for the past half century, we have been in a situation where the person most responsible for “product definition” and most responsible for “bringing in the business” is not an employee of the hospital. That person is the attending physician, or sometimes called the independent practitioner.

It goes back to the establishment of the AMA and the AHA in the early 20th century. Both of these groups were focused on increasing utilization of hospital and medical services. Even at that time, just as today, medical care was relatively expensive. To drum up business, they both came up with the idea to sell a medical insurance policy.

Rather than work together, around 1940, the AMA founded Blue Shield and the AHA started Blue Cross. Each had similar, yet different objectives. Keep in mind that almost all doctors in the early part of the 20th century were independent practitioners and hospitals were places to be avoided.

In 1966, along came Medicare. If you go back and study the legislation of the day, you will find that physicians fought Medicare with a vengeance and wanted no part of the government or the institutional side of the package. Of course today, if you tried to take Medicare away, you’d have a rebellion — and not just from seniors. Medicare in 1966 solidified the doctor-hospital split via separate payment systems by creating Medicare Part A for hospital payments and Part B for physician payments.

Then in 1972, as the health insurance industry matured, the Federal Trade Commission became concerned that doctors and hospitals selling insurance was a little to cozy. The AMA had to spin off Blue Shield and AHA split with Blue Cross. Later, as the Blues saw themselves more as insurance companies than part of the medical establishment, many of the Blues merged and eventually morphed into today’s United Health, Wellpoint, etc.

To drive the hospital-physician wedge deeper, in 1993, Congress passed OBRA, which contained the infamous Stark amendment. The Stark amendment made it a crime for doctors to refer patients to a hospital in which they had a financial interest. The feds saw this as a conflict of interest that would drive up healthcare costs. 

The structure we have today — full physician independence — has been around a very long time. It has been repeatedly fortified through separate provider and piecework-based payment systems.

That raises today’s big question: who is accountable for all the care a patient receives? 
 
How can we create more ACOs?

Now, after more than a half century, the government has come to the conclusion that doctors working separately from hospitals with separate payment systems and different incentives is a counterproductive operating model. (too bad we didn’t see that coming when we initiated the Medicare-Medicaid systems.)

Under the duress of a very large federal deficit (in part, a result of healthcare costs), we are trying to reverse 70 years of misdirected legal and financial incentives. Under an ACO, the feds want both parties to work together, share the payments, and share the risks.

The ACO statute of April 2011 lists the following provider combinations as potentially eligible ACOs:

1. ACO professionals in formal group practice arrangements.
2. Networks of individual practices of ACO professionals.
3. Partnerships or joint venture arrangements between hospitals and ACO professionals.
4. Hospitals employing ACO professionals.
5. Such other groups of providers of services and suppliers as the Secretary determines appropriate.

Combinations 2 and 3 are what I call the “virtual’”ACO. Combinations 1 and 4 are more like the PHO/HMO of the past, or the Mayo model.

As stated by CMS, ACO compliance with the requirement to reduce costs and improve care may involve a range of strategies, which they state includes the following examples:

• A capability to use predictive modeling to anticipate likely care needs.
• Utilization of case managers in primary care offices.
• Having a specific transition of care program that includes clear guidance and instructions for patients, their families, and their caregivers.
• Remote monitoring.
• Telehealth.
• The establishment and use of health information technology, including electronic health records and an electronic health information exchange, to enable the provision of a beneficiary’s summary of care record during transitions of care both within and outside of the ACO.

Promote the virtual ACO

As can be seen from the compliance strategies, CMS is leaning heavily on HIT and EMR to help avoid some very difficult political battles. As an interim step, they are encouraging hospitals and physician groups to use EMR systems to build and support a virtual ACO.

In this scenario, the physician and the hospital would remain corporately separate, but the patient information and the payment would be shared. This dovetails with the new federal HITECH Act that promotes EMRs and stronger coordination of care via interoperability.

CMS has defined the five levels of ACOs and has set target dates for providers to achieve one of the levels. If a provider organization achieves an ACO level during the next five years, they will get a financial bonus. If they don’t, their Medicare payments will be reduced. Sounds like MU all over again.

Initially, the AMA was indifferent towards the ACO concept. AHA gave it mild support. But after CMS issued draft regulations in April noting the bonus-penalty provisions and the shared payment component, both associations came out strongly against it.

Of course, the 800-pound gorilla is who should run the ACOs, physicians or hospital executives? If there’s to be a single payment for Medicare patient services to the ACO, how do you split that payment?

CMS is staying out of this battle and leaving it to the docs and hospitals to fight it out. To say the least, AMA probably views it as the death knell for the independent physician practice, and AHA may see it as the surrendering of institutional autonomy to physicians.

I think it will be a long arduous road getting to real ACOs. Remember, the overall objective is to reduce the costs of healthcare. According to a CMS analysis of the proposed regulation, Medicare could potentially save as much as $2 billion over the first three years, so somebody’s ox has to get gored.

But as we stumble down this long and very bumpy road, I believe in the early years, the focus will be on the virtual ACO. The CIO’s office will be right in the middle of it. If you look at the Meaningful Use criteria for CCR, CCD, and interoperability, the first hurdle is staring us in the face.

Frank Poggio is president of The Kelzon Group.

During the first quarter of 2011 alone, there were media reports of inappropriate access to electronic Personal Health Information (e-PHI) of four sizeable healthcare organizations. This is damaging in terms of public relations, patient confidence, possible revenue loss, and increased costs to protect patients with exposed identifying details. It seems that many organizations are overlooking or delaying the need to perform a security risk assessment.

Yet under the HITECH Act, one of the core Meaningful Use measures is the requirement to “Conduct or review a security risk analysis … and implement security updates as necessary, and correct identified security deficiencies prior to or during the EHR reporting period to meet this measure.”

This measure is, therefore, a key task healthcare providers must conduct before attesting to their ability to meet Stage 1 requirements. Additionally, the risk analysis requirement in the HIPAA Security Rule is not only an integral part of meeting Meaningful Use for HITECH, but also for being in compliance with the law.

A risk analysis is the very foundation from which to build your information security compliance program. A security risk analysis should be conducted with active participation of internal auditors, IT leadership, and IT subject matter experts.

The Office for Civil Rights (OCR), the security watchdog for the Department of Health and Human Services (HHS), suggests that a covered entity use the National Institute of Standards and Technology (NIST) risk-based approach for doing a risk analysis, which encompasses nine primary steps:

1. System characterization to fully understand key technology components in your infrastructure.
2. Threat identification.
3. Vulnerability identification.
4. Controls analysis to assess the capabilities of your existing set of controls to meet your environment’s needs
5. Likelihood determination to assign likelihoods, considering the threat motivation and ability, the nature of the vulnerability, and current and planned controls
6. Impact analysis to analyze that impact, considering for each system the effects of lost confidentiality, integrity, or availability, and the effect of any current or planned mitigating controls
7. Risk determination, a combination of the impact rating and the likelihood determination
8. Control recommendations, a roadmap for planning controls for future implementation
9. Results documentation.

To prepare for Meaningful Use attestation, it is recommended to conduct the security risk analysis at both the technical design and system build phase when implementing a new EHR system. Additionally, it will be important to update the risk analysis further on in the MU Roadmap approximately four months prior to go-live.

As ongoing changes happen, new risk occurs. An annual risk assessment should become part of the compliance process; that is, the risk assessment can be merely updated as an addendum and not as an overbearing intrusion that competes with other organizational needs. A regular review of your risk posture is what is required to protect e-PHI. Too many new threat vectors and vulnerabilities are introduced into information environments each day. A reasoned, systematic, and consistent approach will help to achieve your organizational goals.

Spurred by the HITECH Act, the healthcare industry is embracing EHRs at an accelerating rate. This move carries with it a need for heightened responsibility since digital information can be copied, transmitted, or used so easily. As such, the risk accruing from this transition to electronic records must be well understood.

In its passage of HITECH, the US Congress took special consideration to note that security and privacy of patient records should be a paramount concern. In essence, HHS recognizes that the very success of the HITECH program rests in part on patients’ ability to trust provider information systems with sensitive information.

Jeff White is a principal with Aspen Advisors of Pittsburgh, PA.

Readers Write 6/22/11

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!

Epic Ponderings
By Cam O’Flage

Epic is a marvelous marketing machine, from initially establishing themselves as a boutique firm with a certain mystique since they were able to tell clients whether they were the right customer (rather than the customer telling Epic that they were the right vendor).  And it continues to be a superlative marketing machine.  They tell a good story, present a great vision, and manage customer expectations nonpareil.  They’re superb business people.

Epic doesn’t do everything right, but who does?

Epic makes many good decisions, but they make some bad ones.

Epic releases aren’t always so bug free.

Now, I know that I speak from a biased perspective since I currently am involved with provision of implementation consulting (staff augmentation) services.  But I’ve been around a long time and seen lots of successes and failures across multiple delivery systems using multiple vendor applications.

Epic’s current implementation methodology, however, is circumspect.  While it’s partially in response to ONC’s mandated MU timetable (another source of discussion), Epic does believe that it knows the best way to install its product.  But a tight timetable with little time to consider workflow needs or optimizations or deferral of vital function simply to make a deadline is so wrong.

We’re told time after time, plan and engineer correctly in advance to maximize return on investment and minimize production problems.  It’s in our business school case studies.  It’s in our re-engineering process improvement literature.  It’s in our quality theories.  Yet, Epic – and ONC – have embraced a slam dunk implementation methodology.  Get it in, optimize later.

There are so many choices.  So many informatics considerations (one of my biggest fears since so many of Epic’s designers and installers simply don’t have a good basis in understanding clinical informatics needs – or revenue cycle considerations, for that matter).  So many process issues.  So many opportunities to improve, to ensure that clinical documentation is complete, that patient safety is maximized, that budget is truly aligned with needs and expectations, that appropriate governance has been put into place, that risks are adequately mitigated, that expectations are properly established, that work/life balance is dealt with, etc.

There are too many customers that go apoplectic when there are budget overruns, even if scope has changed.  While that’s not an Epic problem per se, the perception that their plan is comprehensive and constitutes the safest way to attain MU is contributory.  CIOs and COOs and CFOs and VPs simply need to get real.  An EHR implementation is an immensely complex organizational change, fraught with unknowns and potential failure points.

There are too many customers who wish that they had done their implementation differently. There are too many times that customers realize that optimization entails rebuilding the foundation.  There are too many customers who find themselves a year later not where they wanted to be. HIStalk pages certainly document such things.

However, all of that said, I can’t say enough good things about Epic.  Epic truly focuses on improving the patient experience. Their culture is one of excellence, of passion, of dedication and commitment.  Their employees are smart and industrious.  And they continue to deliver what they promise.  I can’t say that about many IT vendors.

Why Are We Still Struggling with CPOE?
By Daniela Mahoney

I often ask CIOs a simple question: what keeps you awake at night? Over the years I have received many different answers. Lately I have been thinking about my work and my experiences from previous days and could not stop asking myself, “Why, after more than 30 years, are we still struggling with getting CPOE going?” What other industry has tried implementing technologies and three decades later they are still in their infancies with the results?

I was excited about the idea of writing an article each month for HIStalk to share some of my insights about what to do with this entire CPOE business and how to best prepare for its challenges. Then I was wondering about our colleagues in the industry, and who wants to keep reading about CPOE? Mine would be just one more article of something you read somewhere, else because “theoretically,” we know what we need to do and there is already a lot of information about it. And that is the exactly the key — we know the “whats” but we oftentimes miss the “hows”.

But, one would ask, why should anyone listen to Daniela? Well, you don’t have to. I am only going to share what I have learned by doing CPOE for over 20 years. I am going to keep it simple because I find that we can achieve much more when we present information in a way that we can relate to and it makes sense to most of us. It is like baking a molten chocolate cake –  it has only six basic ingredients, but the outcome is divine! You can add the raspberries on top if you wish. Simple is good, and we can achieve exceptional results.

Did you know that CPOE has been talked about since the 70s? In June 1971, the National Center for Health Services selected El Camino Hospital, CA, to evaluate and implement the Technicon Medical Information Management System (TDS) to be used by nurses, physicians, and others. The main goal was to expedite the overall patient care processes.

By 1974, 45% of all orders were entered directly by physicians into their CPOE system. Yes, we had it then, and unfortunately at that time in the 70s and 80s, some of the institutions and vendors who attempted had varying degrees of failures, with some limited successes. It was not until the late 80s and early 90s that we experienced a renewed effort and interest in CPOE. I started my journey on this path in 1990, so I can say that we have learned a lot. Or did we?

I am going to begin with the end in mind, assuming that we are not just doing CPOE to meet the political timelines, but also to do the right thing for the patients and give our clinicians a tool they can appreciate and incorporate into their everyday workflow. Based on this assumption, we will work backwards and talk about the right things to do as we prepare for this CPOE journey. Almost three decades later, it is about time that we get it right the first time around! Here is the roadmap we will talk about in the next 12 months:

1. Is it only CPOE, or there is more? We have to think about what is ahead of us more holistically because CPOE is no longer a standalone project.
2. What support we need from our leaders to pave the road for us and why?
3. Why should I (physician) use it? What’s in it for me? How do we create a value proposition?
4. How much will it cost?
5. How do we create the teams (who steers the wheel vs. who shifts the gears)?
6. Don’t let perfection get in the way of good. Setting the scope of what CPOE is and what it is not.
7. Clinical process transformation. How to manage and not get crushed by the magnitude of change.
8. How about the vendor? Where do they fit into this?
9. Did we get it right? How do you know? (aka, success factors).
10. What is going to make us fail? If 30% of CPOE installs have historically failed, how do we rise above this? (aka, risk factors).
11. Large or small hospital, we need to roll out somehow. What are the options and their respective pros and cons?
12. No, I did not forget about training and support. I will address this as well.

And if there are any other readers who enjoy cooking as much as I do, here is the link to the molten chocolate cake. 30 minutes to prepare, six minutes to cook, and 10 minutes to savor your work of art. And while you are enjoying this superbly rich chocolate delicacy, please try not to think of CPOE!

Daniela Mahoney RN is president and CEO of Healthcare Innovative Solutions of Seville, OH.

Thoughts on Lazar Greenfield Stepping Down
By Tiffany Carroca

On Sunday April 17, renowned surgeon Lazar Greenfield MD resigned from his position as president-elect of the American College of Surgeons (ACS). The resignation came just over two months after he had written a controversial article that caught the attention of nearly everyone in the healthcare community, including those in medical coding, and has achieved a level of infamy nationwide as the Valentine’s Day editorial. The controversy of the article stems from a statement made in which Dr. Greenfield suggests giving women semen for Valentine’s Day instead of chocolates.

The editorial was originally published in the February 2011 issue of the American College of Surgeons affiliated newspaper, Surgery News. The paper, made available free to the public online, was pulled from the Web site when the controversy erupted soon after the story ran. Interestingly, Dr. Greenfield was also editor-in-chief of the publication, but was subsequently removed from the position due to the content of his article.

Although Dr. Greenfield apologized for the editorial and reaffirmed his belief in the rights of women in health care, these actions did not end the controversy. Besides offending many female surgeons who have had to put up with sexual harassment for decades in this male-dominated field, Dr. Greenfield managed to dig himself in deeper when he sent an e-mail to several media outlets defending his claims. However, Dr. Greenfield did ultimately determine that resigning would be the best way to put an end to the uproar over his article. In a statement given to ABC News, Dr. Greenfield said, “My personal and written apologies were ignored, and my suggestion to use my experience to educate others rejected. Therefore, rather than have this remain a disruptive issue, I resigned.”

The comments made by Dr. Greenfield on Valentine’s Day seemed like a joke to some and the crass opinion of a womanizer to others. However, the statement does have a basis in scientific and medical fact. Dr. Greenfield was referring to a study published in the Archives of Sexual Behavior in 2002. The study was performed by psychologist Gordon G. Gallup, PhD at the State University of New York in Albany, and gained widespread attention when it was reported in the article Crying Over Spilled Semen by Tiffany Kary for Psychology Today.

The study was conducted on 293 college women who were sexually active. The results showed that women experienced less depression after having unprotected sex, and the depression slowly returned as the time progressed after their last sexual encounter. Women who used condoms did not experience any reduced or heightened rates of depression.

The conclusion reached by Dr. Gallup was that the hormones contained in semen are absorbed through the walls of the vagina and elevate the mood of the woman after intercourse. Other variables that could have caused the reduced depression, such as birth control and behavior patterns, were also taken into account.

The group most outraged by the editorial was women in the healthcare field, most notably women surgeons. Colleen Brophy MD, a prominent professor of surgery at Vanderbilt University School of Medicine and chairwoman of the ACS’s surgical research, explained to Pauline W. Chen MD who reported on the story that she was “aghast” at the editorial. However, when the ACS refused to stand by her response, Brophy resigned from the College in response, claiming, “The editorial was just a symptom of a much larger problem. The way the College is set up right now is for the sake of the leadership instead of the patients.”

Many women in the healthcare field voiced their outrage over Dr. Greenfield’s editorial, but he was not without his supporters. Dr. Greenfield, a professor emeritus at the University of Michigan, had always been highly regarded and was presented with the Jacobson Innovation Award just last year, according to NPR’s Health blog.

A colleague at the University of Michigan, Diane M. Simeone MD, came out in his defense, saying that she has witnessed several accounts of gender bias among surgeons, but never from Dr. Greenfield. Similarly, Dr. Gallup, who conducted the initial study, also came to the defense of Greenfield, noting that what he said may not have been tasteful, but does have “some basis in available science.”

Undoubtedly, Dr. Greenfield’s remarks caused a public outrage even though they were based on science. However, a lewd and womanizing comment based on science is no less offensive that one based on fiction. If Dr. Greenfield was trying to be humorous or otherwise non-offensive with his comments, he failed miserably, as public opinion has shown. Even an esteemed doctor and scientist can fall from grace when injecting personal opinions into the science. As most scientists will agree, it is best to keep the science pure.

Readers Write 6/8/11

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: today’s first article was written by the CIO of an academic medical center that will move to Epic once the necessary approvals are in place (not yet announced). I suggested drafting some thoughts about why Epic is so successful in that market, even with hospitals that had no plans to replace their existing systems. I thought the perspective of a CIO in the middle of that decision would be interesting since it’s hard for the rest of us to understand how Epic can be so consistently successful, and therefore tend to blame unspecified “Epic Kool-Aid drinking” rather than the real differences between Epic and its competitors.

Why Epic? Why So Many Decisions to Deploy Epic?
By Thoughtful CIO

As a nation of healthcare delivery systems, we seem to be selecting Epic in record numbers. I’m told that nine of every 10 decision-makers are selecting Epic.

It is astounding, but it is also rather obvious. Epic has become the market choice for many of us. And like many market swings, the causes are many.

I’ve given it some thought. I fully expect that many will disagree. This is just one person’s opinion.

In some ways (I hope you can forgive the melodramatic root cause), I think our focus on Epic and the need for tight integration and simplification of our environments might relate to the upcoming 10th anniversary of September 11. We are longing for a return to a simpler time.

It has been ten years since the “world stopped turning.” I think many of us are carefully revisiting where we have been and what we have accomplished since that September day. It might not be deliberate, but I think it is real, nonetheless.

We all refocused on the “main thing” back in 2001. It may have been different for different industries, but in healthcare, we decided we were going to make a difference. And I think we meant it.

Sadly, in spite of much hard work, and many system deployments, we are not yet achieving safe, efficient, and effective healthcare to the degree we all had hoped.

Here is some thinking out loud. 

1. In a world where healthcare decisions and information flows are growing increasingly complicated and are conflicting, our care providers are overwhelmed with complexity, burdened by too much not-always-relevant information, and are often interrupt-driven as they attempt to make decisions. It feels like chaos because it is. It’s a difficult balancing act. Many of us are longing for a simpler and safer approach to the management of information. We haven’t yet found it, and we worry that it is hurting our patients and making it more difficult to be a care provider.
2. Patient- and family-centered care is going to become even more critical in the world of individualized health and personalized medicine. This will require improved access to longitudinal patient records. It will necessarily involve and empower the patient to be an active member of the care team. It will soon be the only way to effectively and efficiently manage and allocate scarce resources. Targeted interventions and therapies will be the future of medicine, and information technology will be a critical component of the deal. But we are not yet delivering on the promise, in spite of many millions of dollars of investment.
3. To deal with this complexity, chaos, and the critical focus on the patient-centeredness, we are focused on minimizing the burden on our care providers and our patients. We want to collect data once, at the source, in the most user-friendly way possible. We want our data collection to be the by-product of care, not an added responsibility. And we want it to be easy to do. We have not yet found a way to achieve these goals in a meaningful way, at least not consistently.
4. Some current vendor-supplied solutions offer choices and options. They promise to be all things to all people. They rely heavily upon a provider-based organization to make wise decisions and “perfect decisions” in the midst of a very imperfect world. The decisions that must be made expect that there is clarity, when in fact there is not. We are not realizing increased productivity, lower costs, and more efficient care. In fact, many of our healthcare delivery systems are questioning the investments we have made and are not yet able to clearly define the benefits we had hoped to achieve.
5. Many of us have experienced implementations that over-promised and under-delivered. We trusted our vendor partners and some of them failed us. We then we failed our user partners. The systems didn’t perform well, the vendor was unable to deliver the rich functionality that was promised, the product didn’t scale, the developer didn’t listen, etc. Everyone loses, and we were parties to the losses.
6. Enter Judy Faulkner and Epic. There is no ambiguity! For more than 30 years, she has been crystal clear about her strategy and the strategy of Epic. The patient is at the center. The business of healthcare is about saving lives and managing information to support life-saving activities. No ambiguity. It’s about the basics, and she gets the basics right! From the beginning, what you see is what you get. No ambiguity.
7. Judy Faulkner and Carl Dvorak treat everyone the same. No deep discounts, no development partners. We’re all in this together. There is no ambiguity.
8. Judy and Carl have a healthy optimism about the future. They believe there are many opportunities we can leverage, but they never make a promise they can’t keep. They tell the truth. They do what they say they will do.
9. Judy doesn’t offer to solve problems she can’t solve. She is completely transparent and tells the truth, both when it is popular and when it isn’t. No pretense. She doesn’t need to be liked. She has a product that works, that scales, and is fully integrated. There is no ambiguity.
10. Judy also sells a product that works well. She provides the rules for how it must be implemented. Again, she eliminates the ambiguity. Follow the rules and everybody wins.

I’m not sure I’ve captured what I was hoping to capture. In summary, when I think of Epic, I think of a few words:

• Honesty
• Integrity
• Candor
• Trust
• Transparency
• Consistency
• Focus
• Commitment
• Patient-centered

These are words I hope folks will use to describe the work we all do in healthcare IT.

What Providers Need to Know about Patient Engagement
By Donna Scott

Given all the talk these days about patient-centeredness, is there really change afoot? Will the US healthcare system of the future really be built around the needs of patients? Or is “patient-centered” just another buzzword which won’t quite survive the complexities, the political realities, and the multi-faceted stakeholders in the great healthcare reform debate?

Well, I have been called an “optimist,” so you can probably guess my opinion on the subject. Yes, I believe that we are truly at the crossroads of change in the healthcare system in the United States. In spite of the complexities and difficulties ahead of us, the desire to implement new ways of managing healthcare in this country has never been stronger.

Regardless of what you think about the future success of Accountable Care Organizations or Patient-centered Medical Homes, there appears to be widespread agreement that US healthcare delivery needs to shift from a quantity orientation to quality of care and better outcomes. And better patient outcomes will be enabled by a much higher level of patient engagement across the healthcare industry. This shift toward quality outcomes and patient engagement represents both an opportunity and a challenge for providers.

Because of this shift, a small group of patient engagement enthusiasts and industry pundits were recently asked by The Institute of Technology Transformation to write a paper for providers about the current state of patient engagement. The objective was to offer healthcare providers a summary of the latest research that exists about patient engagement and provide some key points for their consideration as they embark on the healthcare reform journey. The Top Ten Things You Need to Know about Engaging Patients is the result of our efforts. The paper can be accessed here.

In summary: there is a lot of good patient research out there that our group has synthesized into the following key ten considerations for providers:

1. Providing Patient Education Online
2. Interactive Online Dialogue
3. Patient Segmentation
4. Role of Caregivers
5. Trust in Physicians
6. Consumer Mobility
7. Security and Privacy Concerns
8. Leveraging Inexpensive Tools
9. ROI of Patient Engagement
10. Changing Care Models

In each of these ten areas, we briefly discuss the research and the key learnings which are relevant to providers. In addition, we include four key recommendations for practical action:

• Walk the talk: set specific patient engagement objectives and measure them
• Champion your hospital’s social media strategy and assure mobility as a key component
• Pay attention to caregivers and do your homework on patient demographics
• Consider HIT solutions that already incorporate patient access and engagement capabilities

For some progressive hospital administrators, this information will simply affirm what they are already doing. For the others, we hope it will spark ideas on how to take their patient engagement strategy to the next level. Because the need for more patient engagement in the U.S. healthcare system will impact all of us, sooner or later.

Donna Scott is leader of the Patient Engagement Action Group for the Institute of Health Technology Transformation and executive director of marketing strategy for RelayHealth.

Twitter, Dogs, and Healthcare
By Ronnie James Dio

I see a lot of dogs out in public these days. They’re everywhere. People bring them to Home Depot and into Starbucks. Sometimes they’re peeking out of purses. 

I love dogs. I’d even go so far as to say I consider most dogs excellent judges of character. But I’m not wild about sharing my coffee and oatmeal at Starbucks with somebody’s dog right next to me. When I go to the grocery store, I don’t want to see a dog riding in the basket of the grocery cart. 

I went to the dentist the other day. Guess who’s hanging out by the reception desk? You got it — a big black Lab. Named Elliot, by the way, which I consider to be a decidedly un-dogly name. The look in his eyes said, “I’m begging you, call me Fetcher.”

I want some boundaries is my point. Just give me a shopping experience without dogs. 

Same goes for ubiquitous talk about social media. More specifically, Twitter. I really don’t care that Anderson Cooper of CNN on-air wants to tell me he’ll be tweeting during the broadcast. (I especially don’t like the word “tweeting,” while we’re coming clean with each other.)

Also, I don’t need software I use in my healthcare IT business to update Twitter with what I’m doing, as a contract management tool I have is dying to do for me. Just sent a contract out! Third one today!

I don’t say this thinking trade secrets could be disclosed. It’s much simpler: I’m just not that interesting.

And now that we have these two things on the table (too many dogs in public; I’m largely boring) I need to cover one more thing. I don’t find Twitter interesting or helpful for healthcare except, I’m sad to say, in a catastrophe such as an earthquake or tornado, where we actually learn things we couldn’t know otherwise. 

When tornadoes strike or a tsunami hits, Twitter can be indispensable. It can become a strikingly important tool for healthcare, if only to inform others where help is needed. When we least expect it, a hula hoop becomes a vital messaging tool.

Otherwise, it’s the dog in Starbucks, the thing I can’t escape that I actually don’t dislike, but I want to pick and choose my interaction with it. 

And just because there’s a tool that lets us share 140 characters of text with the world doesn’t mean it’s valuable. In the real world of healthcare, when things are not catastrophic, I’m arguing that Twitter is rarely helpful, and as parents can attest (via the attestation process) in the breezy “real” world teenagers move in, few have the slightest interest in Twitter. It interferes with their texting.

I have a very high professional focus on healthcare IT, so I typed in “healthcare IT” from the main Twitter screen. This popped up: 

We r letting d Tfare issue overshadow d aim of the damn lunch. It was a forum where issues of light, good healthcare / education were discussed.

Besides the fact that I find the phrase “damn lunch” funny, I have no idea what the post means, but I’ll bet a quarter it’s right at 140 characters. I’m also pretty sure there is no such thing as “light, good healthcare,” and I’m positive that you should be able to find “healthcare IT” in context when using an ever-present tool for social media.

So I put to you a simple question. Outside of emergencies or catastrophes, when does Twitter actually benefit healthcare? Who is helped, and how? 

I’m wide open to learning something here, but please answer in 140 characters or less. I’ll be back in touch after I take my dog to church, then out for a damn lunch.

Readers Write 5/16/11

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!

The Four Principles of Getting Things Done Well
By Mark Johnston

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

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

Organization

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

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

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

Prioritization

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

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

Execution

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

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

Discipline

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

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

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

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

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

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

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

Building a Healthcare Storage Archive
by Charles Mallio, Jr.

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

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

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

Data Interoperability

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

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

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

Data Protection 

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

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

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

Return on Investment

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

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

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

IT Governance Remains a Top Organizational Challenge
By Dan Herman

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Readers Write 5/9/11

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!

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

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

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

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

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

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

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

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

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

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

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

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

What gives?

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

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

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

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

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

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

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

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

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

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

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

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

Russ Keene is vice president of Ingenix CareTracker.

The Power to Fail
By RJ Dio

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

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

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

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

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

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

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

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

Readers Write 4/27/11

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!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Build IT Right
By Guy Scalzi

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Synopsis

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

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

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

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

Executive Summary

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

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

The most important items addressed were:

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

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

Current usability in healthcare applications is atrocious

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

Recommendations to vendors

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

Recommendations to HIT professional associations and certification agencies

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

Recommendations to provider institutions

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

Recommendations to government agencies/regulators

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

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

Readers Write 4/13/11

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!

Thoughts on the Department of Defense/VA
By Arturo

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tim Elliott is founder and CEO of Access.

Readers Write 3/28/11

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 Status Quo: Profitability’s Biggest Enemy
By Tom Stampiglia

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

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

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

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

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

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

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

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

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

Tom Stampiglia is CEO of MPV of Austin, Texas.

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

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

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

Benefits realized included:

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

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

Benefits realized included:

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

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

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

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

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

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

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

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

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

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

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

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