Readers Write 2/24/10

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!

Imaging Decisions Demand Up to Date Information
By Michael J. Cannavo

Five years ago, I was approached by a PACS vendor to put together a presentation for IT folks at HIMSS. We did the presentation titled Everything IT Needs to Know About PACS* (but is afraid to ask) off-site and had 75 people there.

Why off-site? The vendor tried to get HIMSS to sponsor the session, but was continuously rebuffed in their attempt. Exasperated yet needing to get their potential IT clients the information they wanted, this was the only way they knew how to get their information out.

Five years later, where is PACS at HIMSS? Still ostensibly a persona non grata. Of the 300+ presentations being given at HIMSS this year, only two deal with PACS. What is most fascinating is that in spite of this seemingly ongoing denial of PACS importance in the IT community, over 200 of the 900 vendors showing at HIMSS are directly involved in PACS and imaging .

An entry level PACS at a small community hospital can cost $250-300K, while a larger facility can easily spend several million dollars. IT needs have much more information than knowing just the hardware, O/S, and potential network impact, yet has few resources for these from its own society,

The dynamics of the PACS decision making has also significantly changed in the past few years. Where radiology once stood apart from other departments in the way decisions surrounding the vendor of choice were made, now nearly half (and in some cases more) of the final decision on the PACS vendor of choice falls to the IT department. And where does IT go to gets its information? Largely from HIMSS.

With so much geared towards meeting the EHR initiative by 2014 and with it the facilities share of the $20B in ARRA dollars set aside for healthcare IT, one has to question why PACS isn’t part of the HIMSS educational equation. This is especially important since radiology is second only to cardiology in overall revenue generation.

HIMSS should be commended for its role in ongoing education through virtual conferences and expos, but PACS needs to play a much larger role in this. Vendor Neutral Archives are a hot topic not just from a PACS perspective but enterprise wide as well. PACS also plays huge role in the delivery of images both to the desktop and via the web and will play a massive role in the rollout of an EHR.

Some might say that radiology has SIIM as its show, but SIIM doesn’t attract nearly the number of IT professionals or vendors that HIMSS does. Since these IT professionals are already at HIMSS wouldn’t it make sense if SIIM were a subset of HIMSS? Both entities already work together and this way everything radiology/imaging related could be seen at one trade show and not two providing IT with access to radiology-specific educational sessions as well. It’s worth a try…

Michael J. Cannavo is the president and founder of Image Management Consultants and is a 26-year veteran in the imaging community as a PACS consultant. He has authored over 350 papers on PACS and given over 125 presentations on the subject as well.

Something Wonderful
By Mark Moffitt

In this article I’ll discuss the potential future of smart phone operating systems and the impact these changes might have on clinical healthcare IT systems.

Enhancements to Smart Phone Operating Systems

The underlying operating system of smart phones will become more robust with improved multitasking and inter app communication. This will allow developers to integrate native apps, built by others that interact with the underlying hardware of a smart phone, e.g. phone, microphone, speaker, etc., with web apps. Web apps seem best for getting and displaying data and consuming services that are unique to a healthcare system. The reason is changes to web apps can be made and pushed out to users much faster than a native app.

These enhancements will enable developers to build hybrid smart phone apps that use, for example, the device’s phone app, another vendor’s dictation app or voice to text app, and another vendor’s secure messaging app. Developers at health systems will spend most of their time writing web apps that get and display data and consume services unique to the system. Inter app communication will minimize data entry by users as they switch between native and web apps. The user experience will be similar to using a single app.

Android (Google phone OS) has these capabilities, but with limitations. The Apple iPhone/iPod Touch/iPad does not, but will, I predict, within a year. Microsoft Windows Phone 7 is similar to Apple. Make no mistake, these three vendors, Microsoft, Apple, and Google, are going to drive innovation that will benefit healthcare IT users.

From 2010, Odyssey Two:

Floyd: "What’s gonna happen?"
Bowman: “Something wonderful.”
Floyd: “What?”
Bowman:  "I understand how you feel. You see, it’s all very clear to me now.  The whole thing.  It’s wonderful.”

See: http://www.youtube.com/watch?v=OqSml40nwCE&feature=related – start at the 2:08 mark

“Something wonderful” is what physicians, nurses, and other care providers have to look forward to once the use case models of smart phone technology are fully realized.  “It’s all very clear to me now.” It will bring software with features that makes your work much easier and you more productive while automatically generating the data needed for reimbursement, decision support, and the legal record.

See: http://histalk2.com/2010/01/18/readers-write-11810/ – second article down

I predict physicians will use smart phones for 80-90% of their work with electronic medical records, versus using a computer and keyboard, to do work such as viewing clinical data, real-time waveforms, vitals, medication list, notes, and critical results notifications; dictation and order entry.

Disruptive technology (see: http://en.wikipedia.org/wiki/Disruptive_technology) is a term used in business and technology literature to describe innovations that improve a product or service in ways that the market does not expect.

Disruptive technologies are particularly threatening to the leaders of an existing market because they are competition coming from an unexpected direction. A disruptive technology can come to dominate an existing market in several ways including offering feature and price point improvements that incumbents do not match, either because they can’t or choose not to provide them. When incumbents choose not to compete it’s often because the incumbent’s business model blocks them from reacting, aka “feet in cement” syndrome.

Smart phone technology alone is not a disruptive technology in clinical healthcare IT. When you mix smart phone technology with web services for integration and messaging and a virtual database model, you get a disruptive technology.

Smart phone and web services technology will bring improvements of a near-magnitude order change in the price-to-feature relationship of clinical healthcare IT systems or, simply stated, much more features at a much lower cost.

Vendors that offer large integrated clinical systems such as Epic, Cerner, McKesson, etc. charge a large premium for an integrated system because the market will pay it. These vendors have built their business model to capture and defend that premium. That premium will shrink to zero over the next decade due to these disruptive technologies. I predict the premium won’t go down without a fight from these very same vendors.

By then the justification for large, monolithic, integrated, single-vendor systems will have vanished taking with them a number of vendors encased in obsolete business models. From the ashes of the fallen will rise a new pack of healthcare IT vendors leading the industry.

This process is called creative destruction (http://en.wikipedia.org/wiki/Creative_destruction) and is a by-product of radical innovation, something the USA does better than any other country. While painful for some caught up in the destructive wave that pain is more than offset by the gains realized by the whole of society during the creative wave of innovation.

Surfs up!: http://www.youtube.com/watch?v=1j7ID47Nng8

Mark Moffitt is CIO at Good Shepherd Health System in Longview, TX where his team is developing innovative software using the iPhone, a web services infrastructure, and a virtual clinical data repository.

EHR Adoption and Meaningful Use
By Glenn Laffel, MD, PhD

No matter how you approach the issue, it is clear to see that a serious information technology gap has been created in healthcare. From restaurant reservations to banking records, American information resides electronically across nearly every sector … except healthcare.

Where do we stand? Are the adoption reports accurate? And how will these figures be impacted by the US Government’s economic stimulus investment in health IT? Let’s take a closer look at the numbers.

First, the challenge of tracking EHR use in the US. There are currently varied and discordant definitions of what constitutes an EHR. Let’s take a closer look at the reported EHR use from a few different sources

CDC reports: The Center for Disease Control released a study in 2009 reporting that 44% of office-based physicians are using any kind of EHR system and only 6% are using a fully-functional system.

Harvard reports: A Harvard study reported that 46% of hospital Emergency Departments adopted EHRs. The figures dropped dramatically in rural and Midwestern emergency departments.

Patients report: A Practice Fusion survey conducted by GfK Roper in January 2010 found that 48% of patients reported that their doctor used a computer in the exam room during their last visit.

So where do these numbers leave us? We know from these three studies that approximately half of US doctors have started to use some kind of computer system in their practice. An indication that healthcare has taken major step toward closing the digital divide? Yes. A flawed and limited statistic? Also, yes. We don’t know exactly how these physicians are using the reported EHRs and computers. Practices may just be scheduling or billing with their electronic systems — two features that don’t contribute significantly toward improving quality of care.

Meaningful Use will set the bar high. Starting in 2011, we should be able to have a much more detailed perspective on how doctors use EHR technology. The 25 Meaningful Use criteria (currently still in draft with HHS) require demonstrated use of e-prescribing, CPOE, charting, lab connectivity, and more. As the name states, with the new HHS guidelines will help us to “Meaningfully” understand “Meaningful” EHR use.

Improving these adoption rates. EHR adoption has been slow in the past due to several factors: high upfront costs for traditional health IT programs ($50,000 or more per user), high levels of IT infrastructure needed for installation and maintenance, and concerns over changing workflows. The $44,000 stimulus for EHR adoption under ARRA removes some of the cost barrier with legacy EHR systems. It also creates a dynamic market for doctors to price compare and find affordable solutions to fit their needs.

As the start of the incentive program approaches, it will be interesting for those of us in the sector to track changing EHR adoption rates and see if the government’s hope for exponential EHR adoption growth becomes a reality.

Glenn Laffel, MD, PhD is senior VP of clinical affairs for Practice Fusion.

Readers Write 2/15/10

Data Entry and Quality Health Care
By Al Davis, MD

The enthusiasm generated for EHRs by the 2009 ARRA legislation is almost palpable and hospitals across the country are scrambling to install systems at a breakneck pace. Behind the enthusiasm, however, are two issues, related yet disparate, that have been the confounding factors of EHR adoption in the past and will continue to be so in the foreseeable future.

EHRs offer the promise of data aggregation which can be used to refine clinical treatments for both improved quality and, possibly, lower costs, but this aggregation is dependent upon standardized dictionaries and, importantly, standardized data entry. EHRs currently offer standardized data via the use of templates, boilerplates, and pre-defined order structures. But the standardized data entry model often (usually?) does not completely and precisely conform to the observed signs, symptoms, and problems displayed by patients in the physician’s office, and therein lies the rub.

Patient care, especially when dealing with complex problems, requires the clinician to differentiate subtle distinctions among less than obvious alterations from normal physiology. Shortness of breath, one of the most common problems encountered in the emergency room, can result from problems with the lungs, with the heart, with the vascular system, with the blood, from medications, or simply from pollution or toxins breathed in by the patient, and those are the direct causes. Indirect causes such as intra-abdominal pathology, skeletal deformity or muscle weakness must also be considered.

While there is a high statistical likelihood that shortness of breath will result from one of a relatively small number of potential pathologies, assuming a diagnosis based on statistical likelihood will lead to poor or even dangerous patient care. The reason a pulmonologist trains for 12 or 13 years, and a nurse practitioner for six or seven, is to allow the pulmonologist to learn not only the underlying basis of the more rare causes of disease, but also to be able to discern the subtle differences that those more unusual pathologies may display. The use of template- or boilerplate-driven clinical notes negates the benefits of the more refined knowledge and experience of the pulmonologist. Requiring the use of such standardized data inputs is antithetical to quality medicine, yet allowing free text entry is equally antithetical to the as yet unrealized potential of the EHR. It is this contradiction which has slowed adoption of EHRs and will continue to hinder their use.

The challenge is for IT designers to work out a way for experienced clinicians to be able to commit to the record the sometimes subtle thought processes and observations that lead to their diagnoses, while maintaining enough control and/or discipline over the input to allow the potential of data aggregation to be realized. Monetary issues, regulatory compliance, and usability are important as well, but the paramount concern of the EHR must be to ensure that the best quality patient care can be delivered. If the cost of the input restrictions needed to allow data aggregation is the loss of ability to place nuance and subtlety into the record, the EHR fails that most primary of tasks.

Al Davis, MD is in private practice in Elmhurst, IL.

A Meaningful Ruse?
By Frank Poggio

At the risk of being a called a Cassandra, or at best a contrarian, I will attempt to explain why the federal government’s HITECH Act and Meaningful Use (MU) incentive program is a wolf in sheep’s clothing and why the better response for a provider would be to run, don’t walk, from this wolf.

First let’s review the basics. When a hospital or physician’s practice purchases and implements an electronic medical record (EMR) or Computerized Physician Order Entry (CPOE) before 2011 and files with the federal Department of Health and Human Services (DH&HS) the yet-to-be-developed regulatory documentation to declare their meaningful use (MU), then starting in 2011 that provider will be potentially eligible for an MU bonus payment. For physician practices, that could amount to a total of $44,000 over three years. For hospitals, depending on the number of discharges, somewhere between $2million to $3.8 million total. These incentive amounts are to be paid over three stages, or years, starting in 2011.

On the other hand, if a provider does not implement an EMR or CPOE, or purchases and implements a system but cannot show meaningful use, then a penalty will be incurred on Medicare payments in years 2015 thru 2017. This penalty will be in the form of a reduction to the legislated increase in Medicare payments for that year. Note: this is not a reduction in overall Medicare payments, but a reduction on the yearly Medicare inflationary adjustment factor. The first year the penalty is a 33% reduction of the adjustment, the second 66%, the third 100% (or in effect, you will get no adjustment at all).

Before I explain why I believe there is a wolf at your door, let me say I am a believer in the benefits of EMRs and CPOEs. There can be significant benefits in both, but not unless they are incorporate a sound work flow re-engineering processes prior to installation. Unfortunately there are very few if any MUs that are workflow-focused.

There are at least four major reasons why I believe your facility will never see an MU bonus.

1) MUs are, by the DH&HS’s own admission, a moving target. As stated in the Interim Final Rule (IFR) published in the Federal Register, December 30, 2009, on page 314, “We expect to issue definitions of meaningful use on a bi-annual basis beginning in 2011”. Hence, MUs will evolve over time. That will allow DH&HS to make them as easy or as onerous as they choose. How can you predict you will hit a moving target that you can’t even describe today? And if you believe the Feds may try to make it easier to foster participation, read on.

2) If you hit all but one MU, will you get the full bonus, or 95%, or 50%? Nobody knows and the question is not addressed in any IFR or other documents. I am willing to wager you will get nothing, and my reasoning follows.

3) The federal government has stated they are funding the HITECH program with $34 billion for MU bonuses. They also have stated repeatedly they expect to save over $200 billion to help fund the new national health plan. That’s about a seven-to-one expected payback in only a few years. When was the last time you had a seven-to-one ROI on any IT project over three years? If the feds do not see the seven-to-one payback in time, how many providers do you think will get to cash an MU check?

4) Our government is under extreme pressure to cut the federal deficit. In the President’s recent State of the Union Address, he stated he will freeze the government budget for ‘non-essential’ items to save $250 billion, to alleviate the trillions of dollars in deficits predicted by the OMB. Essential is currently defined as Social Security payments, interest payments on debt, entitlement programs, Medicare benefits, and the defense budget. These taken together make up over 80% of the total government expenditures. So the freeze has to come from ‘non-essential’ departments and programs. Medicare payments to providers are not considered part of Medicare benefits, they come under the DH&HS /CMS department operating budget. So, although the benefits to the seniors will not be reduced, the payments to the providers are fair game. And therein lays our wolf.

I noted earlier that if you fail to purchase and install an EMR / CPOE, you will be penalized by a reduction in the increase in Medicare inflationary adjustment in future years. Based on the above reasons, I believe there will be little or no adjustment increase in future years. If you don’t think this will happen, look at what Congress and DH&HS had allocated for the adjustment ‘increase’ in 2010 for physician Medicare payments. DH&HS wants to apply a -21% adjustment for physician payments. Yes, that’s minus twenty-one percent. Then, to get the AMA on board with the national health initiative, the Administration and Congress was going to delay this adjustment, but now even that agreement is up in the air.

On the hospital side of the world, look at what the Medicare adjustment increases have been over the last five years. The most they have been is 2% and the average is around 1%. If you run those numbers for a typical 200-bed community hospital with a Medicare utilization percent of 50%, the one percent increase amounts to about $300,000. Hence, reduce it by a third and you will miss out on $100,000 that year. Again, and that’s assuming there is any increase at all in future years.

Lastly, let history be your guide. I have worked in the healthcare world for 35 years as a CFO, CIO and multitude of other roles. As a CFO, I saw Medicare renege on many case mix adjustments, TEFRA adjustments, and DRG adjustments,all in the name of national budget deficits and health care cost controls. At one point, they set up a Medicare Payment Advisory Committee, then disbanded it when the Committee disagreed with too many DH&HS adjustment policies. I doubt the future will be much different, in fact probably worse.

So, run the numbers again, in future years if the Medicare adjustment increase is zero – because the feds and DH&HS say we can’t afford an increase due to overall deficits and budget freezes, then reducing the zero adjustment increase by 33% will incur how many penalty dollars?

What’s a shepherd to do?

The bottom line is there is no need to “horse in” a new EMR/ CPOE regardless of what vendors say. Secondly, horsing in a system as complex and far-reaching as EMR/CPOE and while hitting the expected glitches along the way is going to cost you far more than any Medicare adjustment penalty.

My advice … take your time, do it right ,and install components that will give you the most ROI the fastest. And watch out for the wolves.

Frank L. Poggio is president of The Kelzon Group.

Accurate Patient Identification and Privacy Protection – Not an “Either/Or” Proposition
By Barry Hieb, MD

 

Whether you support federal government funding of HIT or not, it can’t be denied that healthcare is undergoing a major revolution as more and more clinical automation capability is being adopted. Funding of HIE projects, building toward the Nationwide Health Information Network (NHIN), will further these efforts. And clearly progress is being made, as noted in the recent KLAS report that verifies 89 active HIEs across the US. The ultimate vision of regional clinical information exchange crosses political, operational, and geographic boundaries using the NHIN’s network of health information exchanges.

However, we’re not addressing one of the most significant challenges that must be overcome for this scenario to work: the ability to accurately identify patients whose information may be scattered across a number of providers using disparate HIT applications and platforms.

The current state-of-the-art approach for patient identification centers on EMPIs that identify patients using demographic matching techniques. But industry experience indicates that EMPI matching techniques are only accurate 90 to 95% of the time, introducing a variety of potential errors in care delivery within and across provider organizations.

We know the answer to the problem — issue each patient a unique identifier that would be used to label their information across all participating provider locations. In fact, the 1996 HIPAA legislation mandated just such individual healthcare identifier. But, in 1998, Congress reversed itself on the patient identification issue based on valid concerns about the inability to protect the privacy of this data, and forbade the expenditure of federal funds on further pursuit of this essential component for accurate patient identification and data exchange. Since that time, there has been virtually no progress on this issue at the federal level, although recently a number of states have begun to pursue state-wide identifiers to support their HIE projects.

Since I left Gartner in 2008, I’ve been working with Global Patient Identifiers Inc. to build out the Voluntary Universal Healthcare Identifier (VUHID) system under the umbrella of a non-profit, private enterprise. The VUHID system is based on over 20 years of patient identification standards work done by the ASTM international E31 medical informatics group, and proposes a solutions that is both inexpensive and effective.

The VUHID system communicates with the EMPI system at the heart of each HIE. It issues identifiers upon request and maintains a directory indicating the sites that have information for each identifier. The VUHID system has been specifically designed to enhance the privacy of clinical information because it has no identifiable patient data — only the locations where each identifier is recognized.

VUHID identifiers are globally unique and are designed to support activities that the patient or others indicate need to be handled with privacy. The VUHID system represents a secure, cost-effective, currently available solution to enable error-free patient identification that extends across political and organizational boundaries.

Barry Hieb, MD is chief scientist for Global Patient Identifiers, Inc.

Readers Write 2/8/10

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!

First Impressions of the iPad in Healthcare
By Trey Lauderdale

I don’t think we have ever seen a piece of technology as polarizing as the recently released Apple iPad. Being vice president of innovation at a healthcare-focused iPhone development company, I have received an unbelievable amount of feedback (some solicited, some not) on the good, the bad, and the ugly of the iPad’s potential uses in healthcare.

The first potential use models are the usual suspects we have all been hearing about for the last 3-6 months: entering data into the EMR, viewing medical images, observing patient data, managing alarms and alerts, etc, etc, etc. I could go on and on, but you already know all of these because they are available right now on your iPhone.

Don’t get me wrong — all of these functions are wonderful, but nothing here is really game-changing. I consider these the foundation of what is necessary to bring this device into healthcare in a useful manner.

In my opinion, the greatest impact this platform will have on healthcare is going to be from the creative juices squeezed out of the developer’s minds who will be writing applications specifically geared for the iPad and its potential use model.

You have got to look beyond version 1.0 of the iPad and into what it will become in the second, third, and onward generations of the device / platform. Apple tends to make significant improvements to their product between the first and second generation releases (2nd Gen iPhone >> 1st Gen iPhone). The limitations that have been brought up are all valid, but will be alleviated over time or through simple physical remedies.

It won’t survive in the hospital environment?

A robust, antimicrobial case will be out by the end of 2010 – it can almost be guaranteed.

No camera for image taking?

It will be there by Gen 2 (not for healthcare, but because consumers want it).

Too big to fit in a pocket?

The workflow model should not position this as an “always carried” device.

The one limitation that had me on the verge of throwing my MacBook across the office was the lack of background processing. While potentially the greatest shortcoming of the iPad, after some thought and analysis, it needs to be viewed as a mixed blessing. This device is going to have 1GHz of processing power focused on ONE application. The user experience in the currently open application is going to be amazing, assuming developers take time to re-factor their applications to fully leverage this “limitation.”

Through appropriate use of inter-app communication and data sharing, a great deal of the concerns brought on by no backgrounding can be bridged relatively easily. The key is going to be the foundational applications leveraging and creating open-source frameworks and standards that can be leveraged across multiple vendors in a collaborative environment.

The first day the iPad is released in March, all of the technology and applications are in place to enable a caregiver to view their patient’s vital monitoring waveform (Airstrip Technology), check the data against their EMR (Epic Haiku), and then send a quick message to an appropriate staff member asking them to take action on a potential event (Voalté).

While these currently reside as three separate applications, the experience provided to the end-user should not feel as such. The real power of the iPad (and even iPhone) platform is going to be a collaborative environment between the vendors that reside on the device. This collaboration will be of even greater importance with the iPad due to the greater amount of real estate the end user has to work with.

I can envision a hospital where an iPad is placed outside every hospital room displaying relevant information about the patient and their current vitals (REALLY decentralized monitoring). Clinicians grab the iPad as they enter the room, sign in with a quick series of hand gestures (or maybe take a quick picture of their ID?), and easily enter information into the open application regarding the patient’s current status. Messages and tasks can be dispatched to the right caregiver automatically from the iPad, and the clinician places the device back into the cradle once done with the patient. All of the pieces for this experience are currently in-place and ready to be tied together.

Apple has provided the revolutionary platform we could have only dreamed of 10 years ago. It is now our responsibility as application developers and IT system administrators to turn those dreams into reality and provide the end user experience our clinicians deserve.

Trey Lauderdale is vice president of innovation of Voalté of Sarasota, FL.

Interim is not Final
By Mountain Man

I don’t know about you, but my organization is asking a lot of questions about ARRA "now that it is finalized" and what we as an organization should do. Should we change our strategic plan? 

With all the hype and media around this pseudo-event, we certainly have the the eyes and ears of our executive team and board members. We have somewhat of a bully pulpit. We should use the awareness created to advance our causes of bringing safety and efficiencies to healthcare delivery and financial visibility  into the business. If we can tilt the spending towards an appropriate amount in order to complete our strategic plan, we should do so.

Here is the problem. “Interim” is defined by Wikipedia as “a temporary pause in a line of succession or event.” This does not sound very FINAL to me. So, Interim Final Rule really makes little sense.

Quit freaking out, people. NO ONE thinks we can hit the dates provided by the IFR. We should not reallocate all our resources to cover some part of the ARRA requirements that we left out of our strategic plans two years ago.

Most of us are working towards the general direction that the IFR is leading us. Keep doing what you are doing. Trust your plan and execute.

It is your STRATEGIC plan for a reason. Hitting an INTERIM suggested state is very TACTICAL and short-sighted.

If you are not headed in that general direction by now, then you should freak out.

They’re all Synonyms!
By Deborah Kohn

I don’t know how many times I delivered a presentation / authored a published article when I had to explain why two healthcare information technology (HIT) trade organizations (one so large that it won’t be mentioned in this article and the other, federally commissioned at taxpayer expense and no longer in existence) adopted definition differences between an electronic medical record (EMR) and an electronic health record (EHR).

This only further confused my healthcare professional audience / readership who, for years, have had a complete understanding that charts, records, patient charts, patient records, medical records, health records, etc. are synonyms! Walk into any hospital or clinician office and always one will hear an assortment of such synonyms without ever questioning the meanings.

True, in the late 20th century, synonyms of adjectives, such as computer, computerized, automated, or electronic were needed to differentiate between (what is known in the greater IT world as) analog vs. digital charts, records, patient charts, patient records, medical records, health records, etc. However, still the use of the synonyms of adjectives with the synonyms of nouns made no difference to practicing healthcare professionals, except to differentiate, when necessary, between analog, digital, or hybrid.

Thankfully, we might be getting close to ending this nonsense. Recently, one HIStalk reader correctly pointed out that NOWHERE in the 2009 American Recovery and Reinvestment Act (ARRA) with its Health Information Technology for Economic and Clinical Health (HITECH) Act is there a distinction made between an EMR and an EHR. Only the term electronic health record and acronym EHR is used — for health information exchanges, for hospitals, for physician offices. That’s probably because every healthcare industry-bred author / reader / interpreter of this legislation has a complete understanding of what is being conveyed.

On the floors or in clinic rooms, let’s continue to use whatever synonyms (adjectives and nouns) come to mind, because we’ll continue to understand what is being communicated. In addition, let’s give credit to the 2009 legislation for dealing one of the final blows to this “trade organization made up EHR/EMR” definition debate and all agree to use EHR (as used in the ARRA / HITECH legislation) as the standard terminology in presentations / published articles / vendor products, etc. Only then will we be able to move on to more important discussions.

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

Licensing of EHR Systems: Contractual Considerations
By Robert Doe, JD

As a result of the incentive payments offered under the HITECH Act for implementing certain qualifying EHR systems, many healthcare entities are evaluating the various EHR systems that are available, taking into account the certification, interoperability, and meaningful use requirements. There are a number of considerations a healthcare organization should take into account during the process of choosing and contracting with an EHR vendor.

A healthcare organization should consider including certain warranties and representations in the agreement with the EHR vendor to help ensure that the system is capable of allowing the healthcare organization to receive the incentives (and avoid future penalties) associated with the adoption of an EHR on an ongoing basis for the term of the license. As a drafter and negotiator of license agreements on behalf of healthcare organizations, while some vendors claim to do so, I have seen reluctance on the part of EHR vendors to meaningfully warranty their systems with regard to these considerations.

One argument is that the criteria for receiving the incentive payments have not been clearly defined. Future requirements, the argument goes, could conceivably require significant investment in new functionality. In addition, a vendor may argue that it has no control over how the system is actually used within the healthcare organization.

With regard to the first argument, EHR vendors are receiving significant new business as a result of the HITECH Act. If they cannot warrant the functionality which is one of the main motivating factors for licensing the particular system chosen, they are in effect transferring the entire risk to the healthcare organization, which, at a minimum, should be shared by the parties. For a significant capital expenditure of this nature, care should be taken to produce the result which justifies the expenditure. As a result, this should be one of the first discussions a healthcare organization should have with the EHR vendor during contract negotiations.

Some vendors may offer warranty language that appears to address the subject matter, but from a legal perspective, doesn’t actually provide much in the way of legal rights. Some vendors may propose that the issue be addressed as part of maintenance and support. Keep in mind that the legal remedies may be significantly less for a breach of maintenance and support as opposed to a breach of warranty. The warranty language could also be crafted to take into account the situation where significant additional investment is required for the system to conform to HITECH’s requirements, allocating an agreed upon portion of the expense to the existing customer base.

With regard to the second argument, it’s true the vendor has no control over how the system is actually used by the healthcare organization, but the warranty language can be worded to ensure the system includes the necessary functionality to allow the healthcare organization to qualify for incentive payments and avoid future penalties.

In addition, many healthcare organizations are endeavoring to provide access to their EHR systems to other unrelated healthcare organization in their communities, as part of a regional health information organization, health information exchange, or otherwise. The underlying goal of many of these arrangements is to provide EHR technology to other local healthcare facilities that may not be able to afford such systems by themselves. Such arrangements may also help to lesson the financial burden. Whatever the reason, there are legal and licensing issues to consider.

Any healthcare organization that desires to provide access to a software application to another unrelated healthcare entity or clinician must be aware of the physician self referral prohibition (Section 1877 of the Social Security Act) commonly known as the Stark law, the federal anti-kickback statute, and, depending on the data being exchanged, the Health Insurance Portability and Accountability Act, commonly known as HIPAA. In addition, significant anti-trust issues could arise if the software allows the sublicensees to share financial information. These additional legal issues must be addressed with legal counsel prior to setting up such an access arrangement.

In addition, the agreement with the EHR vendor must contain specific provisions allowing the healthcare organization to provide access to the unrelated healthcare organization. Do not assume that you can provide access by simply executing the EHR vendor’s standard form license agreement. All license agreements contain a license grant section that specifies the parties and individuals that can use the software. In most instances, it is limited to employees of the legal entity that signs the contract.

In addition, most license agreements specifically prohibit the use of the software to process information for, or use the software on the behalf of, any third party. The contractual language allowing the healthcare organization to provide access to an unrelated organization can take many forms. It may be as simple as expanding the definition of an authorized software user to include any other individuals authorized to use the software. Alternatively, the license grant may specifically state that the licensee may sublicense or provide access to the software application to a third party and set forth the conditions under which it can do so. There will also need to be an agreement between the two healthcare organizations governing access to and use of the EHR system. Careful consideration should be put into the drafting of this document. There are a number of issues that could arise if not addressed in this agreement.

The HITECH Act incentives have increased demand for EHR systems. Often times the timeframe for implementing such systems is quicker than would ordinarily be the case. It has been my experience that taking the time now to address the legal and business issues will help avoid problems in the future.

Bob Doe is a founding member of BSSD, an information technology law firm located in Minneapolis, MN.

Readers Write 2/1/10

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!

Virtual Medical Devices and Vendor Liabilities
By Scot M. Silverstein, MD

I found the Jan. 20, 2010 news release on Sen. Grassley’s latest health IT industry inquiry, Sen. Grassley asks hospitals about experiences with federal health information technology program, quite interesting. Based upon direct experience in hospital IT and in Big Pharma, I believe the inquiry justified and potentially beneficial to ensure proper accountability for taxpayer money and for patient safety.

One statement in particular caught my attention. In question #9: the Senator’s letter of inquiry states “… for example, one vendor stated that it is accountable for the performance of its [clinical information technology] product as long as the client uses the product appropriately. Another vendor stated that it is not liable when harm or loss results from the client’s use of the product in diagnosing and/or treating patients.”

Denial of inclusion of explicit "hold harmless" provisions on the one hand, and statements about being "accountable for the performance of its HIT product as long as the client uses the product appropriately" and "not [being] liable when harm or loss results from the client’s use of the product in diagnosing and/or treating patients" on the other hand, are at odds.

An EMR and other clinical IT systems are virtual medical devices, that is, medical devices that happen to reside on a computer.

The first part of the quoted statement above dismisses virtual medical devices that don’t “use the client” properly, for example, through presenting a mission-hostile user experience. Human computer interaction is a science, and its quality has major effects on results. For example, the Air Force — for obvious reasons — has been concerned with HCI and long ago, even before the GUI, wrote a treatise on its importance in mission critical settings (“GUIDELINES FOR DESIGNING USER INTERFACE SOFTWARE”, August 1986, http://hcibib.org/sam/).

Some vendors have opined that they are not liable when their products are used outside their intended purpose. I am not sure how an EMR can be used for anything else other than the "intended purpose" — that is, providing information and providing some type of actionable advice or recommendation based on the information (for example, decision support). On the one hand, if non-validated changes are made by the customer that cause malfunction, a vendor is clearly not liable. On the other hand, if inherent design problems (such as in the display of information) confuse or misinform the user, these vendors seem to be excusing themselves from liability on the grounds that the user was “using the product inappropriately.”

This position will not sit well with clinicians.

On the second issue about use in diagnosing and/or treating patients, vendors may feel they are “not in the business” of diagnosing and treating patients, therefore they are not liable when their products are used for such purposes.

They may have been correct two decades ago, but are in error today. Yes, HIT vendors are in the business of diagnosing and treating patients; in fact they are in the business of practicing medicine — via machine proxy.

HIT vendors are in the business of practicing medicine in the same way my medical supervisors (when I was a trainee) or medical consultants (when I practiced) were in that business when I presented a case to them and they made an assessment and treatment recommendations on what I should do.

When errors in presentation of information or errors in advice-giving occur, a "learned intermediary" defense does not absolve the consultant unless the error is so gross as to be implausible (e.g., a male with toxemia of pregnancy, or a serum creatinine rising from 1.0 to 10.0 in 24 hours). A physician should not be expected, on the other hand, to be able to with 100% reliability detect when a computer — or consultant — is lying when they provide a falsely low INR blood-thinning value or false diagnoses of another patient.

To emphasize these points further, a small thought experiment is in order:

1. If I set up a shop where I was allowing patients to bring me records and I simply looked at the records and dispensed advice on what evaluations or treatments I thought they needed, or what was wrong with their current regimen, but did not go further than that (just being a consultant), would I be practicing medicine? (The answer is yes; I actually held this role in the performance of independent medical evaluations and required both licensure and malpractice insurance in my state to perform this function.)

2. If I were to stand in the corner of the clinic where the computer terminal is, and take its place, i.e., offering data and advice on evaluation and treatment (perhaps Maelzel’s Chess Player-style) in place of the machine, would I be practicing medicine? (The answer is yes.)

3. If the advice I offer is based simply on the advice of another, or on following to the letter the rules and algorithms provided by an HIT vendor’s code, becoming a human computer, so to speak — am I not an intermediary to the other person’s, or the HIT company’s collective practice of medicine? (The answer is yes.)

I believe today’s HIT products involve the practice of medicine by machine proxy.

Two additional points:

I’m reasonably certain the vendor(s) who claim "not being liable [for the performance of their product] when harm or loss results from the client’s use of the product in diagnosing and/or treating patients" also make claims in their P.R. or in executive speeches about how their products will transform/revolutionize medicine.

Claims of transforming or revolutionizing medicine via their products are irreconcilable to any reasonable person with their stated claim of non-liability for use of the products in diagnosing or treating patients. Unless, that is, these systems are intended only for playing games:

Furthermore — and this is perhaps the more important point — hospital executives have both a fiduciary responsibility to patients and practitioners, as well as Joint Commission safety standard obligations.

Would the executives be performing these duties in good faith if, for example, they sign a contract for a CT scanner or surgical equipment where the vendor disclaims liability when these tools are used in diagnosing and/or treating patients? I believe the very act of signing such contracts is a breach of healthcare executive responsibilities and obligations, at the very least by shifting an undue legal burden onto their own clinical staff and contractors, as well as potentially putting patients at risk with tools that vendors are not as highly motivated as they should be to make robust.

Imagine a pharmaceutical company saying "we are not liable for the performance of our products when used in the treatment of patients." Would you use their products?

Health IT should be no different, as I pointed out in my JAMA letter to the editor of July 22 2009 at http://jama.ama-assn.org/cgi/content/extract/302/4/382.

Finally, it seems a vendor claiming they are not liable when harm or loss results from the client’s use of the product in diagnosing and/or treating patients should put that disclaimer on every screen of their products. Do I hear volunteers?

Ultimately, I believe vendors would best serve themselves, their customers, their shareholders, and patients via considering and understanding these points. If a HIT vendor claims to be a partner to clinicians and clinical medicine, they should be willing to accept the responsibilities that accompany such a position.

Scot M. Silverstein, MD is with Drexel University, College of Information Science and Technology.

TPD’s Review of the Samsung N310 Netbook
By The PACS Designer

The Windows 7 Starter Edition software is the key operating system being employed for netbooks. Windows 7 Starter has all of the features of the Windows 7 system except the Aero user interface. The Aero feature primarily offers window transparency so that you can see below your current window similar to looking through a glass pane. Windows 7

Originally I was going to evaluate a Dell Windows 7 Wi-Fi Netbook, but due to some problems with their online ordering system, I decided to obtain a Samsung N310 Netbook from service provider AT&T for $199 after a mail-in rebate.

The Samsung N310 has a 10.1" WSVGA screen, 1GB of memory, and a 160GB hard drive. In its small form factor, it only weighs slightly over three pounds.

Other features of this netbook are an integrated webcam, a Samsung Recovery Solution that restores your system without a CD or DVD, and a method to download applications using Intel’s AppUp Center online service.

One other feature of the Samsung N310 is it offers a 60-day trial version of Microsoft Office Online.

I tested the download speed for Firefox, Chrome, and Internet Explorer. The following response times when downloading HIStalk were: Firefox – 12 seconds, Chrome – 18 seconds, Internet Explorer – 28 seconds. So using Firefox for your internet browser is the best choice for netbooks.

Using the N310 as a highly portable netbook makes it ideal for anyone who travels frequently and needs virtually continuous access to a network connection. However, the smaller screen form factor of 10.1" makes screen navigation more difficult thus you’ll find you are using Control + or Control – keys more often to see content better.

The AT&T network is the standard 3G cell phone system, and access is available anywhere there is cell phone connection towers. The AT&T 3G Network is a bit slower than a DSL solution, but not slow enough to deter its use by everyone.

If there is no cell phone service available, you can still access a Wi-Fi hot spot where your system indicates the possible connection opportunity.

The Windows 7 user interface is simple and easy to use as Microsoft has worked on this new software extensively to improve it over the previous Vista system.

As far as using this netbook daily, it still emulates the larger laptops because of its sizeable keyboard which can accommodate just about any size hand that would use the netbook.

Also, even with its reduced size touchpad, it still provides adequate space for all hand movements.

When it comes to healthcare, it appears to be a useable solution provided that network connectivity inside buildings is not sporadic or restricted.

Overall, the experience to date has been satisfactory, and I would highly recommend a netbook with Windows 7 Starter to anyone looking for a smaller system that is easily portable and uses a cell phone network provider for Internet access. I’m predicting that the Windows 7 netbook with its Intel Atom processor will be the hot product in the 2010 PC space! Windows 7 Popularity

Physician Reluctance to Share Data
By Joe A.

One issue that I do not believe has had enough exposure is what may be underlying the reticence of MDs sharing data. It is the 800-pound gorilla in the room that seems to be hiding behind the sheets – specifically,
malpractice reform.

There appear to be no protections for physicians that "share" data from those fishing for torts — open season for lawyers hunting for malpractice once the data is shared and available.

We are all too familiar with punitive lawsuits, from Mickey D’s coffee to asbestos to tobacco to plastic toys. Putting your clinical data in view seems to me will invite second guessing and lead inevitably to legal actions. If Obama wants HIEs to flourish, he must first work for malpractice reform — something that this current Democrat Congress has zero interest in pursuing, but which is a necessary predecessor to HIEs.

Readers Write 1/25/10

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!

Provider E-Mails — Appearance is Everything
By Mark C. Rogers, Esq.

An experienced well-known medical malpractice defense attorney once gave me a very important piece of advice: in defending a healthcare provider in a medical malpractice action, appearance is everything. Legal counsel play an important role in the appearance of a medical malpractice defendant at trial.

Specifically, through pre-trial preparation, legal counsel will advise a client as to how they dress, where they sit in the courtroom, their facial expressions, and even what kind of car they drive to the courthouse — all of which a member of the jury may see and (like it or not) take into account during jury deliberations.

One of the things that trial counsel cannot affect, which does have a substantial impact upon a provider’s appearance at trial, is the provider’s documentation related to his/her care and treatment of a patient. Consider, for example, the following scene played out in medical malpractice trials throughout the country each day.

A patient’s attorney is questioning a physician on the witness stand about a note the physician wrote in the patient’s medical record several years earlier regarding some aspect of the physician’s care and treatment. In order to assist the jury, the attorney will use a “chalk” or a cardboard blow-up of the note. Through testimony, the note is analyzed for several hours and in some instances, several days, by the parties and their respective experts. A brief entry into the patient’s medical record that is incoherent or includes incomplete phrases may, at the very least, be perceived by the jury as consistent with the actions of a careless physician, and at the worst, evidence of negligence.

What now worries me and other attorneys who represent providers is what the provider said or didn’t say in their e-mail exchange with a patient. Already physician e-mails to patients are becoming a central focus of medical malpractice trials. Although some will argue that e-mails present providers with an excellent opportunity to demonstrate to a jury their appropriate care and treatment of a patient, they can also be seen, in some instances, as evidence of the provider’s failure to clearly communicate with the patient.

Providers who communicate with patients via e-mail need to ensure that such communications are clear and appropriate. A misunderstanding or misinterpretation by the patient or subsequent treating provider can have dire consequences for the patient and in turn for the physician in a subsequent medical malpractice trial.

A provider’s e-mails to a patient can have a significant impact upon their appearance at trial. In particular, a provider’s e-mails have the potential to undermine the provider’s qualifications and overall intelligence in the eyes of a jury. Simply put, the manner in which many people write e-mails as a conscious stream of thought without any consideration for the consequences is not appropriate in terms of a provider’s e-mails to his/her patients. Providers should consider a number of actions when communicating with patients via email or electronic communication:

• Avoid acronyms and abbreviations that may not be understood by patients,
• To the extent possible, write in clear and complete sentences.
• Include a statement at the end of each e-mail that says if the patient does not understand anything within the provider’s e-mail, that he or she should contact the provider immediately.

The critical element to provider-patient e-mails is making sure that the patient understands what the provider is trying to communicate. If a provider believes that a patient will, by reason of the subject matter, not understand an e-mail communication or if it appears to a provider that the patient did not understand the previous e-mail communication, the provider should no longer communicate with the patient via e-mail regarding the subject matter. The provider should attempt to contact the patient via telephone (and should document these efforts).

Physician groups should consider maintaining a policy that addresses e-mail communications with patients. This policy should incorporate the above elements pertaining to patient comprehension of provider e-mails, and should also address such issues as encryption, informed consent, e-mail retention, confidentiality notices and e-mail use restrictions.

Furthermore, it is important to keep in mind that in many instances it may not be the physician who communicates via e-mail with a patient. Oftentimes such communications take place between the patient and a nurse practitioner, nurse, or staff member. Therefore, a provider’s patient e-mail policy should be broad enough to include non-physician staff.

A word of caution: once you issue a policy, it creates a standard. If a physician or any member of his/her staff does not follow that policy, it becomes evidence of negligence, which depending upon the circumstances, may be admissible at trial.

A provider who communicates with a patient via e-mail needs to understand that these e-mails are part of their care and treatment of the patient and, as such, can be seen as clear and convincing evidence of their appropriate, or inappropriate, actions. Appearance is everything.

Mark Rogers is an attorney with The Rogers Law Firm of Braintree, MA.

The Missing Piece: Enterprise Forms Management and the Electronic Health Record
By Chuck Demaree

  
With all the hype surrounding meaningful use and moving through the stages of the HIMSS Analytics EMR Adoption Model, many facilities overlook the integral role that an integrated forms management and content management approach plays in the successful operation of the EHR. For the sake of clarity, we’ll define a form as a paper-based or electronic tool used to capture and present information (or data) in an organized fashion.

If facilities are going to maximize the effectiveness of their EHR projects, they must understand how forms management can effectively collect information and present it in an organized and user-friendly fashion in their enterprise content management (ECM) system and EHR. An enterprise forms management (EFM) solution needs to provide the features to not only manage and control hospitals’ forms needs, but also provide strong integration of both electronic and paper forms into the EHR. Here are some things to consider as your facility evaluates your forms management strategy, alongside content management options:

Paper Forms

• Every form should be bar coded with both the Form ID and Patient Identifiers. This eliminates bar code cover sheets, addresses Positive Patient ID issues, and facilitates automatic indexing into the EHR via the ECM system.
• A forms management system should be able to auto-populate any form or forms packet with patient demographics .
• A workflow engine that is complimentary to ECM functionality can help by interfacing forms data to fax and e-mail systems.
• When bar coded forms print, there should be the capability to send a notification to the EHR so a deficiency or place holder can be created which will be resolved when the form is scanned.
• Electronic signatures (preferably with biometric capture) can be placed on electronic forms via a tablet PC, LCD signature pad, or e-clipboard as part of a paperless registration or bedside consent process consent forms
• At a basic level design, update and routing of paper forms should be in the hands of the hospital, a service of the vendor

Electronic forms

• Should provide for database (ODBC) access to populate forms, as this removes effort on the front end.
• Can leverage paper forms-focused functionality to manage printed output and routing to ECM, e-mail or fax.
• Electronic signatures (preferably with biometric capture) can be placed on electronic forms via a tablet PC, LCD signature pad or e-clipboard, as part of a paperless registration or bedside consent process consent forms.
• Need to adhere to HL7 standards for passing information back and forth to an HIS system (often provides the links the the EHR documents in the HIS system).
• Form presentation is important, not only during the data collection process, but also once the document has been moved into the EHR. Often data is “COLD” fed into the EHR from ancillary systems, but the documents remain in the hard-to-use format outputted. If the EFM system can receive these feeds, reformat the presentation into a standard look and feed it directly into the EHR, the data is more user-friendly, reducing hassle for HIM staff. In addition, if a legal health record (LHR) is printed from the EHR via the content management system, it is in a more organized and usable format.

In summary, forms management needs to be evaluated from a data collection and presentation perspective as a gateway to a hybrid record and ultimately a true EHR.

Chuck Demaree is VP of product development at Access of Sulphur Springs, TX.

Preparing for the Geriatric Tsunami of 2030
By Peter Goldstein

A certain geriatric tsunami is heading our way as the over-age 65 senior population doubles to 71.5 million by 2030. Today, our country stands as unprepared and vulnerable as a coastal city with an unprotected shoreline. If we don’t take the necessary steps soon to prepare for the massive demographic realities ahead, our healthcare and long-term care systems simply won’t be able to cope with the overwhelming challenges of caring for the swelling ranks of seniors.

There are some signs of progress. A growing number of experts are embracing the “aging in place” movement as a cost-effective, practical, and inevitable solution that will enable more seniors to live independently, safely, and comfortably in the home setting of their choice within their communities. Independence is also what most Americans want for their old age. In an AARP survey, 89 percent of all American adults said they would prefer to stay in their homes as they age. Not surprisingly, this desire only increases with age: 95 percent of those 75 years and older said they would prefer to remain at home.

Monitoring technologies that can help support seniors’ independent living are finding increasing use across the country. A new study by the National Alliance for Caregiving in collaboration with the AARP found that nearly half of caregivers reported using at least one technology to help care for an aging relative.

However, significant barriers remain. Few resources exist to help family members navigate and coordinate all of the necessary care and support services for their loved ones. The lack of widely available coordinated care in this country is not only a frustrating and bewildering experience for families, but it also threatens seniors’ health, safety and long-term independence.

Clearly, the fragmented healthcare and long-term care industries cannot continue to operate separately; they must converge, aligning coordinated care services, resources, and technology under a unified and integrated environment that will support independent living for millions of the nation’s seniors and enable providers to take care of more patients, more affordably and efficiently.

Vendors must work together to establish new HL7-like standards that facilitate interoperability across disparate technologies used in the home, such as telehealth portals, electronic sensors to prevent falling, and medication adherence monitors, and provide a comprehensive 360-degree view of the patient’s wellbeing.

In addition, new incentives must be put in place to encourage care coordination and sharing of observable and diagnostic health information between the healthcare providers who diagnose illnesses and prescribe medications and the caregivers who assist with daily living activities such as dressing, bathing, and feeding.

An independent old age is the hope of every generation. For Baby Boomers, the growing convergence of the healthcare and long-term care systems, combined with improved technology interoperability, could help move that goal within reach and reinvent what it means to be a senior in a rapidly graying America.

Peter Goldstein is an expert on aging in place and executive vice president of Univita Health of Scottsdale, AZ.

Readers Write 1/18/10

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 There Really an End In Sight? Will EHR Be the Answer?
By Pat Clark

With all of the media attention being given to the “new, improved and affordable healthcare in the US” who will actually benefit? The “real life” continuity of patient care seems to be worse now than ever. With the new federal regulations forcing healthcare providers to implement and use EHRs and physician’s being forced to track and record meaningless quality standards, you would think that the public is finally getting the “quality, affordable, well informed “ healthcare they deserve. 

In this age of unlimited access to all levels of information technology , including the ability to communicate sensitive patient information from one physician to another and/or between facilities, there is no reason for the major disconnect we still see in today’s patient care. All healthcare providers involved in a patient’s care should be completely informed about their shared patient and have access to that patient’s recent medical history and list of current medications.

Unfortunately, this is not the reality of today’s healthcare environment. The onus of healthcare and the continuation of care for each patient is still the sole responsibility of the patient and/or a family member (when possible) to battle the convoluted maze of US healthcare and “follow-up patient care”.

I have been involved in healthcare for over 30 years, both on the clinical and administrative sides. As a healthcare consultant, working with facilities to help interpret the federal guidelines, I have been a huge fan of the current push towards EHR and the true intent of HIPAA.

Recently, however, I have had the personal pleasure to experience the true disconnect between facility inpatient care and the transition to outpatient follow up care. I am totally amazed that any elderly patients survive post-hospital life. My experience is not limited to one facility or even to one state. 

My father was hospitalized in Asheville, NC after having a stroke in September 2009. He was evaluated, admitted, monitored, and released within two days. His stroke was considered minor, but he was left with memory and vision loss. 

His discharge papers were filled out accurately and he was promised a series of social and rehabilitative services, including: visiting home health, physical therapy, Meals on Wheels, and community transportation. Very few services were actually provided. Park Ridge Hospital did send a social worker to the house to assess my father’s needs. It was determined that he did indeed need home care to help with not only his physical therapy, but also his new assortment of pharmaceuticals (14 pills to be taken at different times throughout the day). 

It took five additional days to get another hospital employee to come out to the house to draw blood for his Coumadin management and then several additional phone calls to get a physician to monitor the dosage. Without  help, my father would not have survived!

Two months later, my father moved to Scranton, PA  to be closer to family. As a responsible adult, my father gathered all of his medical records and immediately made an appointment to establish a new primary care physician.

Within two weeks of his initial  visit, my father suffered a heart attack in our new house. Because my father is a diabetic, his heart attack symptoms were not classic chest pain but simply a “funny feeling”. When the “funny feeling” did not go away, we decided to go to the ER. At that point, my father began having trouble breathing and walking. The local police were wonderful and the ambulance services were quick to respond.

My father was taken to Moses Taylor Hospital, Scranton, PA, diagnosed with CHF, and then admitted to ICU for the acute MI. He was monitored and stabilized for 72 hours and then transferred to Mercy Hospital, Scranton, PA., where he had  a complete cardiac workup, including a heart catheterization and bypass surgery. Once my father was stabilized, I became terrified. How was I supposed to coordinate the care needed to allow my father to recuperate completely?

After having experienced such poorly coordinated post-hospital care in NC, I was nervous about the care required after a 20+ day hospitalization. This time, the discharge papers from Mercy Hospital were unbelievably disgraceful! There were drugs crossed out, dosage changes, and follow-up requests scribbled all over the place.  

I refused to take my father home until I personally spoke to a home health nurse that would follow up with my father upon discharge. Fortunately, my request was honored. It took the HH RN over three hours to identify what medications were active and which ones were to be discontinued. She also had to  negotiate between  physician offices to see who would monitor my father’s daily Coumadin.

After Christmas, the discharge notes stated that we needed to make three different follow-up physician appointments. Only one of three physicians even knew why we were calling.

Gotta love the new EHRs and transportation of patient information! I can’t wait to see the new “affordability” portion of healthcare in action.

Pat Clark is a healthcare consultant for a software vendor.

Future in Healthcare IT
by Mark Moffitt

Early in the morning Dr. Brimmer, chief hospitalist at Good Shepherd Medical Center, pours a cup of coffee and reaches for her iPhone. She logs into an iPhone application using a four-digit PIN, like her ATM, on a large virtual numeric keypad. Elapsed time to login: three seconds.

Dr. Brimmer is alerted that one of her patients has a critical potassium level. She taps on the icon “Contact Nurse” and the application dials her iPhone.

The nurse assigned to the patient feels her iPhone vibrate and reaches in the pocket of her lab coat, grabs her iPhone, and answers, “This is Sharon Thomas in A600 and how may I help you?” Dr. Brimmer identifies herself and instructs Sharon to give the patient potassium bolus of 40 mEq and repeat the lab test in five hours.

Sharon walks to a computer, selects an icon on her iPhone desktop, and a message is sent over Bluetooth to the computer and an application automatically logs her on and displays only those patients assigned to her. She taps the screen to select Dr. Brimmer’s patient and taps the “Order Med” icon. The application displays the top 25 meds most often ordered by Dr. Brimmer. The list is dynamically updated after every entry. Three more taps on the monitor and the med is ordered and transferred electronically to pharmacy. She repeats a similar process for the lab test. Sharon never touches a keyboard during these transactions. Elapsed time for entering both transactions: less than one minute.

Dr. Brimmer receives a text message on her iPhone notifying her she has an order waiting her approval. She selects the link and the med and lab order entered by Sharon is displayed on her iPhone browser. She approves the order. The transaction is recorded. Elapsed time for transaction: 15 seconds.

While entering the med order, Sharon is alerted that the patient’s allergy information has not been updated since 2008. She selects the “My Tasks” folder and taps the icon “Add a Task.” She selects “Update Allergy”, selects a patient, and enters “Now.” She selects “OK” to complete the task. She enters another task by tapping the icon “Lab Test,” selects a patient, Potassium lab test, and selects “5 hours.” She selects “OK” to complete the task. Elapsed time for both transactions: less than one minute.

Sharon gets distracted with other tasks and forgets to update the patient’s allergies. Five minutes later, her iPhone vibrates. She reaches for it and selects the link and it pulls up “Reminder: Update allergies on Mary Johnson” on her iPhone browser. Sharon walks to the patient’s room, obtains allergy information, and then enters allergy information on her iPhone while talking to the patient in the room. The patient shares with Sharon her grandson has “one of those gadgets” as she points to the iPhone. They both share a laugh. Sharon asks the patient the name of her grandson and discretely records the name using her iPhone. Sharon knows patient satisfaction scores can be improved by remembering important tidbits like a grandson’s name.

Ten minutes later, a pharmacist processes the patient’s med order. The pharmacist notes the recently updated allergy information and that the order was entered by Sharon and electronically approved by Dr. Brimmer. The pharmacist processes the order.

Dr. Brimmer completes her review of critical labs while she sits at her kitchen table sharing the time between preparing for work using her iPhone and talking to her kids before school. She appreciates the ease and convenience of the iPhone application that makes it easy to do both. As a result, she can spend more time at home in the morning with her kids while preparing for the day.

Sharon’s iPhone vibrates again and she reads that a patient’s med is available in Pyxis. She retrieves the med from Pyxis, gives it to the patient, and then records the administration on her iPhone. Tap, tap, tap, and she slips the iPhone into her lab coat pocket. Elapsed time for transaction on the iPhone: less than 15 seconds.

Later that day, Sharon’s iPhone vibrates and a text message is displayed with a link that takes Sharon to a Web page that alerts her to collect blood for a potassium lab test ordered earlier in the morning by Dr. Brimmer.

Note: All of these events are possible with current technology or will be possible with anticipated enhancements to the iPhone OS or with current unsupported third-party software. No $20 – $50 million healthcare IT system is required. This level of functionality is possible with legacy healthcare IT systems.

Mark Moffitt is CIO at Good Shepherd Health System in Longview, TX where his team is developing innovative software using the iPhone, a web services infrastructure, and a virtual clinical data repository.

Lessons Learned From Our Top 10 Infamous Interviewees
By Tiffany Crenshaw

You just landed an interview with a coveted hospital in the city you’ve been dreaming of for years. It would mean a significant pay increase, along with stronger job opportunities for your spouse and better schools for your kids. As you don your best suit and head with sweaty palms to what you are hoping will be your next place of employment, don’t forget to pack your common sense. This list of our favorite infamous interviewees may serve as good reminders of what can happen when you leave your common sense behind. Enjoy!

The Dawdling Responder
One job seeker sailed through the interview process and was immediately offered the job. Perhaps no one told him that it would not be prudent to respond, “Thank you so much for this opportunity! Tell you what — I’ll be getting back to you in six months with a response on your offer.” Of course it may have been worse had he demonstrated his enthusiasm at the offer by busting out break-dance moves, but common sense would have dictated that he communicate sincere interest in the opportunity by providing a timely response. Six months — not so timely. If you need a few days or even a week to consider an offer, assure the interviewer that you will get back with her or him on a specific day. And then, of course, follow through.

The Mute Criminal
Criminal background checks are standard, no surprise there except to the interviewee who underwent a lengthy interview process all the while hoping that the misdemeanors he’d accumulated through the years (one per decade) would be ignored. It wasn’t, and this particular interviewee had no skill at spinning his experiences into positive outcomes, so he began his muddled reply with a rather uncomfortable and protracted pause. The interviewer, predictably, was not impressed. The candidate’s time was wasted, as was the prospective employer’s. If you have a skeleton or two in your closet, it won’t necessarily disqualify you from a position, but anticipate that the interview process will uncover those bones. Take control of this issue by bringing it up before a background check reveals it, and address the issue in a positive light, explaining how you have grown through or acquired new skills as a result of the experience.

The Lunch Lady
A well-dressed woman with a professional demeanor and a stellar resume was demonstrating to her interviewers how she led training sessions. Normally in these sessions she would provide snacks to the trainees, so she decided to provide snacks to the interviewers as well. After all, it was lunchtime, and there may have been a few stomachs rumbling. Unfortunately, though, to her interviewers, this smacked of unprofessionalism. Perhaps they were concerned about dribbling goo on their ties or blouses, or perhaps they did not want crunching sounds to compete with conversation. Either way, her decision to incorporate a potentially charming if slightly unusual interview tactic lost her the job. So if you are ever in doubt about whether an activity is appropriate, be conservative.

The Want-to-Be Comedian
A male interviewee was asked the familiar “How do you handle work pressure?” question. He drew a pensive expression and then creatively replied: “I liken it to my experience surviving in a household of teenage daughters with PMS.” And, readers, he didn’t stop there. He made a few jokes about preventive measures and calendars. Save it for the stand-up routine. An inappropriate analogy is a great way to offend the interviewer. Creativity is great, but when it borders on the offensive, it moves into hazardous territory. Stay in the region of known safety.

The Tumultuous Telephoner
Picture this: the dog is barking to be let out, the cats are scuffling loudly in the adjacent room, the baby is howling at the top of her lungs, and you are on the most important phone interview of your career. Not a comfortable scenario. Unfortunately, a candidate recently experienced a scene similar to that. The background noise during her phone interview was so disruptive that the interviewer asked if the candidate needed to reschedule for a more convenient time. And if that weren’t bad enough, the candidate’s spouse yelled in the background, “If the hiring manager thinks this is noisy, just tell him to call back in two hours when the rest of the kids get home!” One just cannot convey professionalism from a zoo. If your interview is by phone, lock yourself in a room, keep the pets out, and bribe your family with dinner out for an hour’s total quiet. With common sense in gear you can easily create the calm, distraction-free environment you need to present yourself as the competent, focused professional that you are.

The Chemically-Enhanced Candidate
Clearly nobody with even half an ounce of common sense is ever going to consider doing cocaine during an interview. Well, that part of the cranial grey matter was apparently missing for the job candidate who took a bathroom break during an interview in order to snort a line. Apparently this little fix depleted any other common sense he might have had. When he returned to the interview, he thought it wise to explain to the hiring manager why there may be traces of chemical substances in his drug screen. Hard to believe, but that is a true story. While you certainly will not be ingesting chemical substances in between questions about your professional background and skill sets, you may want to lay off the wine at lunch. And if a seemingly harmless indulgence like a heavy meal makes you drowsy, you’ll need to avoid that prior to an interview. Your mind should be razor-sharp and your thinking, quick.

The Unsavvy Dresser
One interviewee walked into the room and before he sat down, the interviewer had already formed an opinion that was not promising. The candidate was wearing black pants, a blue blazer, and brown shoes. Certainly your mother taught you that it is the inside that counts, right? But not in an interview — this is where you are judged by how you present yourself on the outside. Your professionalism, character, personality, and competence are being assessed visually from the moment you walk into the room. This candidate did not follow the basics of dress codes, and his indiscretion was perceived as an unforgiveable breach of professionalism. Never, ever forget the basics.

The Diverted Traveler
A gentleman booked a flight online for his upcoming interview with a large, highly respected health system. The route included a relatively lengthy layover in the world’s entertainment capital. To pass the time, this job seeker decided to partake in a few of the city’s diversions. Lady Luck was apparently pleased with him, though Lady Prudence was not. As his dollars (or alcohol) accumulated, his good sense diminished, so that when he should have been boarding his plane, he was cashing in his chips. Needless to say, he missed the connecting flight, and, consequently, the interview. The moral of the story: Don’t miss a connecting flight in Vegas on your way to an interview. What stays in Vegas is your good reputation.

The Fast Friend
One sharp, talented candidate was confident that she had not only wowed her interviewer, but also had clicked with her right away. They had several common interests and similar personalities. So, in her thank you follow up note, she included a photo from a recent family trip to a mutually appreciated vacation spot. The interviewer, much as she liked the candidate, was not impressed. The little red flag that signals “What you are about to do may be slightly inappropriate” failed to rise (or it did and she ignored it), and she lost a fantastic opportunity. It’s fantastic to have immediate rapport and that can make for a more relaxed interview, but remember that in the end, business is business.

The Gnashing Professional
The final reason-challenged candidate actually demonstrated a good deal of common sense in many key ways. Unfortunately, the demonstration of professionalism she established with her timely response, favorable background check, clean drug screen, punctuality, polished appearance, and professional appropriateness was dashed to pieces by a tiny wad of gum rolling around in her mouth during her interview. The result was more redneck than executive. But we know you have more common sense than that.

It all boils down to common sense. Although you may not even be able to conceive of doing anything remotely near what these interviewees have done, we have cringed while witnessing these very real events. These examples serve as good reminders to follow the red flags of prudence along the often stressful, but in the end, gratifying, process of interviewing.

Please accept our apologies if you resemble any of these remarks. We are on a mission to create better interviewers one candidate at a time. We believe a sense of humor, dash of common sense and willingness to learn from mistakes are ingredients for career success and life in general.

Tiffany Crenshaw is CEO of Intellect Recources.

Readers Write 1/7/10

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!

Glen Tullman’s 10 for ‘10: Top 10 Healthcare IT Trends for 2010
By Glen Tullman

1. 2010 Will Be the “Year of the EHR”

We are at the beginning of the fastest transformation of a major sector of our economy in the history of the United States. The American Recovery and Reinvestment Act has provided billions in incentives to encourage adoption and “meaningful use” of Electronic Health Records. Given the time-stamped nature of the program, we can expect to see a dramatic increase in EHR adoption. Physician groups recognize the need to deploy an EHR now to be ready to demonstrate “meaningful use” by 2011, when the ARRA incentive payments kick in.

With CMS issuing the requirements for an EHR to qualify for meaningful use, many physician groups that were sitting on the sidelines will feel more comfortable getting their EHR initiative underway. It is clear that 2010 will be the “Year of the EHR”, not only because of the rapid rise in adoption rates, but more so because of the positive impact that this technology will have on how patient care is delivered.

You will continue to see two different approaches to acquiring EHRs. The first are investments by physician groups focused on creating efficiency in their practice and collecting the stimulus incentive. The second are community-based decisions where hospitals and health systems invest on behalf of their owned and affiliated physicians, with an eye toward referrals and being “easy to do business with.”

The most recent example is North Shore Long Island Jewish Health System with their program to connect approximately 7,000 affiliated physicians. In 2010, many more health systems will realize the benefit of leveraging the ARRA incentives and the Stark Safe Harbor to help build stronger connections with affiliated physicians in their communities.

2. Not “One System” . . . “One Patient Record”

The old thinking that you need the same system across your hospitals and ambulatory providers will give way to a new way of thinking. As more physicians automate and connect, the large IDNs, academic medical groups, and other integrated systems will put less emphasis on a single IT solution and more emphasis on connecting existing systems to build One Patient Record. This will enable caregivers to access a comprehensive view of all data available about a patient from any location within or outside of the system. Clearly, many physicians already have systems installed in their practices, so establishing a connection to these existing practices will be as important as the rollout and connection to new practices. Organizations that think strategically about this endpoint will find themselves better positioned to take advantage of new opportunities that will emerge in the market.

3. Communities Will Connect

Healthcare is still a local phenomenon. Depending on the estimates you use, 90 percent of all patient care is provided within 30 miles of a patient’s home. Given its local nature, the first priority must be to electronically connect caregivers across a community, leading at some point in the future to a national health IT infrastructure. In 2010 we’ll see more health systems banding together with others in their communities to create local health information exchanges as well as other approaches that enable One Patient Record across a region. A local network is easier to manage and already proving successful with HIEs like the Transforming Healthcare in Connecticut Communities (THICC), which connects that state’s top 20 hospital systems with each other and with major physician groups.

4. Service and Support Will Become Competitive Differentiators

One of the key reasons ARRA was passed was to create jobs. According the White House, over 50,000 will come from the healthcare information technology sector. Allscripts will hire hundreds of new employees, not only to help our clients deploy the technology, but also to assist them in using it in a meaningful way and optimizing the technology to deliver quality care. Clearly there will be a premium on process redesign and consulting services. Those who have the resources and can deliver these services will be rewarded.

5. Innovation Will Begin to Drive Sales and Use of EHRs

Innovation will become a differentiator and drive adoption as it has in other industries. The ability to access your EHR via your phone (iPhone, BlackBerry, Windows Mobile, etc), use a kiosk to register, check labs at home via a portal, and pay your bill via Quicken Health are all examples of physician/patient-focused innovations that deliver simplicity, customer service, and also take out cost. Using advanced technology from outside the four walls of healthcare is symbolic of the transformation of healthcare into more of a consumer-driven business.

6. Revenue Cycle Management Will Become Integrated

Given the need to focus on new EHRs, most physician groups will choose not to replace their existing practice management systems. As a result, in 2010 the larger hospital vendors and EHR/Practice Management vendors will leverage their large installed bases to aggressively move into Revenue Cycle Management. Early leaders in the standalone RCM space will see growth slow and those firms that can integrate RCM with widely-used EHR and PM will dominate.

7. Management Reporting Will Transition to Actionable, Quality Patient & Population Management

As information becomes more available across bigger networks, more emphasis will be placed on developing proactive quality feedback rather than simply reporting. The focus will be on changing caregiver behavior by driving actionable feedback to providers at the point of care, not after the fact. This is the first step toward the development of true “information systems”.

8. Payers, PBMs, and Pharmacies Will Use EHRs to Deliver Information

As the market for Electronic Health Records heats up, we’ll begin to see payers, pharmacy benefit managers, and pharmacy chains partnering with e-prescribing and EHR solutions to efficiently deliver new kinds of information on best practices, care plans, and additional clinical guidance to physicians as they begin to directly tie compensation to results. We have already seen this with current pay-for-performance programs and it is likely a preview of things to come.

Changing physician behavior at the point of care has been the Holy Grail of healthcare. Now the “cable system and set-top boxes” will finally be in place to do just that. Think of this as a formulary, but with a focus on something beyond just the cost of a medication or which one to choose .. but rather an entire plan of care for the patient.

9. Intuitive is Best

Whether it’s ease of use or ease of deployment, “easy” is a must in 2010. We’ll see the customer experience transformed in both areas with an emphasis on intuitive, easy-to-install, easy-to-learn systems (think the difference between your average cell phone and the iPhone).

10. Software as a Service

Software as a service has been advertised as “the” solution for healthcare. The reality is that SaaS is a great option and will be one of a number of solutions. The fact is that physicians don’t really care whether the Electronic Health Record and Practice Management Systems, along with other solutions, are hosted, client-server, or SAAS — they just want them to be easy to access and use. And, many physicians think software as a service is synonymous with monthly payments, like leasing a car. That is a critical and appealing element. The answer is that SaaS will need to be a part of a vendor’s solution set.

As noted, we are watching and participating in a major economic transformation, one that is being driven from all sides. What we know is that while Electronic Health Records are not sufficient by themselves to solve the healthcare crisis in America, they are a necessary component of any solution that drives safer, higher quality healthcare provided cost effectively.

2010 will be the “Year of the EHR” and our current healthcare system of disconnected silos will begin the transition into a connected system of health.

Glen Tullman is CEO of Allscripts.

Major Flaw In Claims Operations Model Found Responsible For Payer Overpayments
By Stephen Ambrose

As part of the insurance industry, subrogation has at times been a bit of a dirty word to policyholders and personal injury attorneys, but a necessity to payers. Known as “the great balancer”, the "right of subrogation" means that a (health) insurer may choose to take action to recover a calculated amount from a claim paid to a policyholder if the loss was caused by a third party.

A major flaw identified within today’s subrogation model is the inability for a payer or their outsourced vendor to accurately identify only those times when their policyholder has pursued and successfully settled a third-party claim. There exists no public database of third-party liability claim filings and the use of court records only applies to less than ten percent of all claims anyway.

Over many years, the most widely utilized method for identifying policyholders who are involved in injury claims is through an indirect identification method of data mining patient claims via diagnostic codes, billed procedures, doctor type, and accident / injury check boxes. Such flagged information generally leads to form letters sent to the patient, who is supposed to complete and return them, both timely and accurately, to the payer or their outsourced claims vendor.

This ubiquitous system of TPL claim involvement has suffered from a number of shortfalls including patient accuracy, inability of complete follow-up, use of indirect identifying factors, timeliness of detection, as well as missing claims filed for chronic illness and malpractice. These factors greatly limit a payer’s knowledge of wasteful injury claim overpayments and make identification of TPL claims more of a “good-guessing” game.  Additionally, the current system allows outsourced claims vendors to demand large collection fees from recoveries made on behalf of their payer clients.

A new model of injury claim identification offers health payers greatly increased TPL claim knowledge while addressing waste reduction and delivering more cost-effective operations to the payer community. Known as Collaborative Subrogation, or Subrogation 2.0, this Web-based technology connects patient release-of-information (ROI) requests, made of the provider with a health payers claim department.

The innovation of better identifying TPL claims stems from limitations, inherent within the use of claim forms and electronic claims data, submitted by providers in their billing. Chiefly noted and now improved upon is the understanding that injury claims are not just “accidents”, but rather any claim involving, in part, the use of medical billings to substantiate value. This opens up areas of medical malpractice, chronic illness, product liability, and other non-auto liabilities.

Collaborative Subrogation is employed as a lower-cost, Web-based operation, where health payers use an online search engine to match provider-submitted TPL data. The approach is one of layering on a new model, in conjunction with existing subrogation software and outsourced vendors. 

Stephen Ambrose is executive director of SubroShare.

Readers Write 1/05/10

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 Direction of Healthcare Industry Technology
By Steve Margolis, MD, MMed, FCS, BSIS, MBA

Regarding the recent John Gomez interview on the direction of healthcare industry technology:

“Interoperability is a huge one where the way that this industry’s worked, has been not embracing the ability to exchange or interoperate between systems. We’ve been kind of proprietary. I think that also creates a challenge and a barrier for hospitals to move.”

I agree that data system interoperability is key to moving the industry forward. The plans for standards of interoperability, privacy, and security will be finalized next year. It’s going to change the landscape and mandate exchange of “semantically interoperable” information among care providers and between providers and patients.

Beyond that, we all know many common applications in healthcare are not available from a single vendor and cannot be made to integrate easily. Supporting third-party integration is extremely helpful, allowing provider organizations access to the latest advances in knowledge and technology, especially when you consider that the fundamental focus of ARRA and other federal initiatives is to take costs out of the nation’s healthcare delivery system.

Content for evidence-based care is dynamic and federal regulations are changing too rapidly for a stagnant platform. I think our industry needs to take lessons from the iPhone app model, i.e., ease of ability to integrate new applications to meet the growing need to keep up with the latest information and technology advances in order to sustain quality and curb costs — especially when the provider’s core vendor is not ready to meet those particular needs.

In short, the right technology approach for the industry is an open technology platform that provides flexibility in both front- and back-end integration, together with the means to easily cater to constituent-specific workflow. This openness is necessary to allow for the cost-effective leveraging of existing and future technology investments.

That’s why we’ve been deeply involved with Eclipsys in developing a platform that provides a services-oriented architecture that allows for third-party integration and multiple applications in context of both the patient and the user. This app integration strategy will enable providers and other third parties to build applets that will enable easier integration between existing vendor solutions, legacy, and/or other in-house developments.

The key benefit for this design approach is that hospitals need not be concerned that prior technology investments will become obsolete if the vendor advances the platform. Conversely, it means that user innovation doesn’t have to cater to the vendor’s development timeline or direction. This type of openness will allow a hospital to integrate with any Web service with a similar open health platform for driving innovation and efficiency.

Another area of important technological development is in the area of visual workflow tools. Many healthcare workers prefer to design visually and iteratively. A visual workflow tool enables rapid prototyping. Examples of this need include the opening of new clinics or the development of a new protocol in response to a pandemic.

Working together, the clinical team can translate their thinking into a devised workflow in very short order and then upload and incorporate that workflow into the system. The beauty would be that the workflow could incorporate third-party systems, such as interacting with NIH or CDC systems and provide biosurveillance data and outcomes data that could help treat pandemics in real time across the country or globe.

This is just one example, but it exemplifies the possibilities we could leverage in open architecture design. To take the monumental steps needed to improve care delivery, we will need this type of open architecture to overcome the challenges we face in delivering quality healthcare in a rapidly changing and ever-demanding environment.

Steve Margolis, MD, MMed, FCS, BSIS, MBA is chief medical informatics officer at Orlando Health of Orlando, FL.

Interoperability 2009
By Jerry Sierra

I’m a nurse who has worked in healthcare IT for over 10 years; six (and counting) for two of the top vendors. However, I feel compelled to share a story that has absolutely nothing to do with my background.

I recently moved my family from Wisconsin to Cleveland. I know you won’t be able to concentrate on my story unless I add it was to be near family (but I also really like Cleveland). My 22-month-old decided months ago to stop the normal progression to solids and instead to stick with bottles. After extensive medical testing, I’ve come to the conclusion that he’s outgrown his reflux, and out of sheer stubbornness (inherited from my wife, of course), refuses to eat anything but M&Ms, goldfish, and yogurt. As much as I like these snacks, I have fears of having to pack these items and a bottle in his lunch box for the next 12 years. To prevent that, we took him in to see our Cleveland pediatrician for a referral to their feeding clinic.

During the visit, we filled out a records request for our Wisconsin hospital and prepared to wait a few months for our referral appointment. Being a cynic, I decided to call and make sure that the records had been sent to the Cleveland GI. They, of course, had no idea what I was talking about and suggested calling Medical Records. They, of course, assured me that the doctor had never sent the piece of paper to MR and that it was never scanned into the EMR. They promised to promptly send me out a new form.

After a few short weeks, I received the form, filled it out, and sent a copy to the hospital in Wisconsin. After waiting a few more weeks, we received a letter from the Wisconsin hospital letting us know that they would love to help us out but, because of HIPAA, they could only accept their own records request form (it’s been a while since I waded through the act, so I must have forgotten that section). So I copied the exact same information onto the form with the correct letterhead and sent it off. I called a few weeks later and was told that the records were mailed out.

We arrived at the specialist’s office and asked the doctor if he had received the records. Would anyone care to guess the response? Anyone? Anyone? Bueller? Of course, he had received nothing. So I took out my tattered copy of the Wisconsin EMR report and the doctor photocopied it so that it could be scanned and added as an attachment to the visit note in the Cleveland EMR (which coincidentally, enough is the SAME vendor). There you have it, a shining example of real-world interoperability.

Who was to blame for this mess? The hospitals, for having antiquated workflows and not turning on key features like the ability to e-mail physicians? The vendor for not making it easier to share information and not allowing patients to add to their own records? The government for not mandating the NHIN, CCD exchange, etc.?

As you can see, the interoperability bar is set depressingly low. Let’s hope 2010 is the year we start making some real progress.

A New Reality in Healthcare Systems – Automation, Agility, and Compliance
By Bruce Oliver

The ever-changing administration of healthcare, increased regulatory requirements, cost control demands, clinical quality, patient safety,and satisfaction issues challenge the US healthcare system. The volume of these challenges requires automation, agility, and compliance, plus relentless execution from healthcare organizations who expect to survive and prosper in the new US healthcare system.

The current HIPAA 5010, ICD-10, ARRA (American Recovery & Reinvestment Act), and HITECH Act of 2009 mandates, incentives, and requirements — and the penalties for noncompliance — are forcing all healthcare organizations to adopt new technologies, processes, and standards. Additionally, pending new health reform legislation will add more requirements to an already over-burdened healthcare delivery and administration system.

Making the changes necessary to achieve the mandated requirements should be viewed only as one of many steps. This first step should be a well thought out and comprehensive strategy designed to prepare healthcare administrative organizations to take full advantage of imminent changes, such as secure anytime-anywhere access to patient information and clinical data, improved patient quality, safety, and service standards and real-time processing of medical transactions and claims.

In addition to the new requirements, national healthcare reforms will require healthcare organizations to implement new business processes and workflows to be compliant while being cost effective. It requires foresight to establish corporate standards, project methodologies, and updated infrastructure to adapt to pending and future requirements for process automation, organizational agility, and operational excellence and compliance.

As healthcare provider and payer administrative organizations embark on compliance processes, they can build parallel paths toward business process improvement and operational excellence. This can happen because compliance is an organizational process that includes business process and technical reengineering for healthcare organizations. Therefore, an organization’s overall strategy should be centered on achieving operational excellence as well as implementing new regulations for compliance. This strategy would require the organization to:

• Establish standardized operational excellence as a corporate strategic priority that is parallel to the implementation of new regulatory mandates, incentives and compliance projects.
• Reassess how and why the organization conducts business to improve agility, especially in the area of manual business and clinical processing that may provide opportunities for online real-time processing and secure anytime-anywhere information availability for more effective decisions and reductions in operational costs.
• Define operational excellence as an enterprise wide initiative with measurable goals that extend beyond the regulatory compliance dates. Once initiated, this initiative should continue to scale up or down to improve, evolve and automate business processes to meet the ongoing healthcare mandates requirements as needed.
• Target compliance areas that can provide high degrees of success in shortest possible time to build momentum and demonstrate compliance. Foster the use of agile technologies and software tools for automation of processes to realize faster results and improved functionality.
• Create sustainable knowledge transfer processes, staff training infrastructure, and programs to develop the skills required for operational excellence as an extension to the HIPAA 5010, ICD-10, ARRA, and HITECH projects and new health care reform regulatory requirements.
• Link operational excellence goals to compensation and incentives to focus and reward program efforts.

Healthcare organizations that are able to accomplish this dual effort should be able to differentiate themselves in the marketplace. This differentiation will be evident not only in outcomes and operational performance, safety, and quality measures, but in financial performance as well.

An automation, agility, and compliance approach does not necessarily require an organization to do an enterprise “rip and replace” project and face the monumental risks associated with it. Instead, an operational excellence plan executed with incremental improvement in systems and infrastructures is a risk adverse and affordable approach toward the automation, agility, and compliance the organization is striving to achieve.

Bruce Oliver is the payer practice director at maxIT Healthcare, LLC.

Readers Write 12/28/09

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!

TPD’s Review of the RIS/PACS Relationship
By The PACS Designer

As hospitals try to get more efficient, it would be a good time to review what the Radiology Information System (RIS) and Picture Archiving and Communications System (PACS) can bring to the institution when it comes to efficiency.

First, let’s review the imaging piece, which is PACS. The main purpose of the PACS is to digitize image files for easier access and increased image sharing. While a PACS is a significant change, it does start to improve processes through more rapid access to image files. The PACS also encourages the sharing of image information with other departments.

Next, the acquisition of a PACS can be a significant draw on financial resources, as it will require workstations for each radiology department member, and other need-to-know individuals who require image file access privileges.

Weighing the cost against the benefits of a PACS, the institution can reduce film and chemical costs with a PACS, and also improve process flow for patients through quicker access to image files. These improved results have to be weighed against the financial outlay that has to be made to bring digital imaging to Radiology.

Now, adding a RIS to a PACS can further improve the scheduling of patients for Radiology procedures. The RIS allows efficient scheduling to take place through its automating of the scheduling software. The software can also highlight potential bottlenecks to alert staff to a looming problem.

The RIS lets everyone know what each radiologists workload is, and how fast equipment can be used to take advantage of each equipments efficiency features.

Another benefit of adding a RIS to a PACS is the bi-directional flow of patient information after procedures are completed and sent back to the RIS for staff review and planning.

In summary, a RIS/PACS configuration can bring great value to the Radiology imaging process, and help reduce costs overall after careful redesign of existing processes.

Awards For Sale?
By Randall Swearingen

KLAS recently named its “Top 20 Best in KLAS Awards: Software & Professional Services 2009” report. Before I list my concerns, you need to understand a few basic points about KLAS.

Their main award is the “Best in KLAS” award. It is supposed to be awarded to the vendor with the highest customer satisfaction scores in a given category (i.e. the best vendor). To be “Best in KLAS”, there has to be a minimum of three non-asterisked vendors in a given category. Vendors are asterisked when they have less than 15 customer surveys because KLAS doesn’t consider the data reliable. In addition to their “Best in KLAS” award, KLAS also has “Segment Leader” awards for those vendors whose categories don’t qualify for “Best in KLAS”.

It is important to note where KLAS gets their revenue because it seems to indicate a conflict of interest between serving the healthcare industry and serving the healthcare vendors. One source of their revenue is from selling their reports to hospitals, clinics, consultants, vendors, etc. Since hospitals and clinics can get free reports by completing just one vendor survey, very little revenue comes from them. The bulk of KLAS revenue comes from vendors. Vendors pay KLAS to survey enough of their customers to get the asterisks removed their products. That isn’t cheap.

KLAS further encourages vendors to pay to have the asterisks removed from at least two of their inferior competitors so that they can be eligible for “Best in KLAS”.

KLAS also charges vendors an annual fee to view KLAS data (including their own). The fee is calculated as a percentage of that vendor’s annual revenue. Thus, larger companies pay more than smaller companies to view KLAS data.

Of course most vendors elect not to pay KLAS, which is why most products are asterisked in their database. But, those who do pay and who are awarded “Best in KLAS” play the award up big time in ads, trade shows, etc.

See the conflict of interest yet? Isn’t the purpose of KLAS to identify and reward the best vendors on the basis of customer satisfaction? Not based on how much a vendor pays?

Back to this year’s report. As a radiology information system vendor, I went straight from the e-blast to review the radiology winners. The “Segment Leader” in the Radiology Ambulatory category this year went to a vendor who happens to be asterisked. Upon reviewing the report, I contacted one of my customers, who has a KLAS account, and asked them to compile some KLAS data for me. Turns out that the winning vendor had scores that were slightly better than those of Swearingen Software.

I then turned my focus to the Radiology Small category. Swearingen Software had the highest scores in the Radiology Small category in all three sections (PRIMARY INDICATORS, DETAIL INDICATORS, and BUSINESS INDICATORS) but the “Segment Leader” award was given to a vendor whose scores ranked seventh out of the10 vendors in all three sections! If you have a KLAS account, you can easily verify all of this information. In the KLAS e-blast, they did not disclose how the “Segment Leaders” were selected or that it doesn’t necessarily go to the vendor with the highest scores.

I felt compelled to dig deeper, so I asked my customer to review the “Segment Leader” section of the report and look for any clues that might explain this action. My customer informed me that upon close inspection of the Top 20 KLAS report on their Web site, a small note is shown below the “Segment Leader” chart which states: “Other solutions must have at least two products that meet the KLAS minimum for statistical confidence in order for a product to earn category leader status.” (That means having a minimum of two non-asterisked products somewhere in KLAS).

OK. So let me get this straight. It’s possible for a vendor to have two non-asterisked products (even if they are the absolute worst scores in their respective categories) AND they can have the absolute worst score in a different category AND they can still win the “Segment Leader” award for that category. Remember, vendors have to pay to get their asterisks removed. Hmmm. What happened to the concept of the award going to the vendor with the best scores?

Simple questions: who monitors KLAS? Who audits them? What independent source verifies their data to make sure it is accurate and fairly represented since they seem to have influence over some buying decisions? Answer: nobody.

I think the “Best in KLAS” award should be renamed to the “Deep Pockets” award. It would be more fitting.

Randall Swearingen is founder and CEO of Swearingen Software, Inc. of Houston, TX.

Readers Write 12/10/09

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!

Catastrophic Insurance Coverage to Reduce Healthcare Costs
By Carl Witonsky 

Expanding on Dr. Dan Fields’ point number nine in his excellent 16-point program on how to reduce healthcare costs and improve outcomes, I think there is a potential to save $100 billion a year by employers buying catastrophic insurance for their employees and giving them an HSA account funded with $5,000.

The employee would then pay for all doctor, pharmacy, and outpatient visits with their HSA credit card. NO CLAIM FORMS would be created. The doctor would update the patient’s EMR with the patient complaint, clinical findings, treatments, etc. The catastrophic insurance would kick in when the employee’s out-of-pocket hits $2,500 (above the company-funded $5,000) so insurance claims would be confined almost exclusively to inpatient stays. 

The last time I checked, there were five billion claims processed a year in these United States. I estimate that four billion are not related to an inpatient stay. If the total cost for a typical physician claim is $25 between the provider and payor to process (current studies report that a two-doctor family practice costs $70,000 per year per physician for claims-related work), that is a $100 billion cost reduction per year.

I am continuing to research this subject and would be very receptive to critical comments and suggestions.

Clearly all the payors would be up in arms against losing their lucrative administration fees and doctors might  attempt to raise the price for office visits, so we will still need insurers / government to negotiate fair fee schedules. The key is to make health care insurance like home insurance — catastrophic-only — and reduce the enormous administration cost of the paper chase to the absolute minimum.

Carl Witonsky is managing director of Falcon Capital Partners of Radnor, PA.

Any Sufficiently Advanced Technology is Indistinguishable from Magic – Remember, Clarke’s Third Law?
By Shabbir Khan

I have been reading HIStalk for couple of years. In addition to saying that your HIStalk posts have always been timely and informative, I wanted to express my kudos to you and Inga for always staying objective.

I have also been reading Dr. Gregg Alexander’s posts on HIStalk Practice with great interest. I am in total agreement with him on the need for giving the physicians and their nursing / office staff a basic tool to help them build their own apps and user interfaces for documenting and sharing patient data with each other using lightweight portable devices.

Physicians have always proven themselves pragmatically wise in adopting and using a new technology if it works for them and if they see a real value in using it. They are not averse to adopting a new technology if it helps them in treating their patients while increasing their productivity. They have enthusiastically adopted a great variety of new technologies in the past. Some examples of the technologies adopted include the use of IV drip line, medical ventilators, and medical imaging equipment. We have also witnessed rapid adoption of many other technologies by the medical community including the use of fax machines, pagers, cell phones, transcription technologies, Internet, and more recently, smart phones (with computer brains) running on 3G networks.

These technologies have made physicians and nurses more productive, improved their workflow, and enabled them to spend more time with their patients. Importantly, these technologies have given the control back to the physicians, nursing staff, and ordinary technicians to use these technologies without needing any outside or specialized help. For example, today nurses routinely use an IV drip line to administer medicine to a patient intravenously without needing any assistant from an IV drip line specialist or from an IV drip equipment vendor. A lab technician can easily fax a lab report to a physician’s office without worrying about HL-7 compatibility on the other end.

Electronic health record systems of today put physicians at the mercy of EHR vendors. Therefore, Dr. Alexander’s post regarding the need for achieving more simplicity and giving more control back to the physicians reflects a more practical approach.

Today, each EHR vendor offers you a unique, “one shoe fits all” solution. Each vendor claims that customizing their system is easy and inexpensive. However, your intuition tells you that the reality is totally different. Using existing technologies and current processes to re-configure, re-program, re-build, and re-deploy poorly designed software is an extremely arduous, expensive, and a painfully slow process as it requires an army of non-clinicians to do it correctly, e.g., programmers who speak such a wide diversity of languages it’s as if they are still living in a Migdal Bavel today.

No wonder the adoption rates for EHR systems have stayed in single digits for so many years. This has been the case despite all of the brilliant marketing tactics used by the EHR vendors. The insurance industry has also been lobbying hard for faster adoption as it eliminates its own data entry costs and gives it a very powerful tool to reduce its medical loss ratios by getting its hands on all patient charts in the entire nation for free. Then, they’ll use the data, that was provided by the physicians to begin with, against the physicians after data mining it extensively.

In addition to the massive lobbying efforts of the insurance industry, other efforts for increasing EHR adoption are also failing, including the relaxation of the Stark Law and a variety of financial incentives being offered by the Federal and state governments.

Physicians are sticking to their paper charts for now.

Building a simple, but a separate smart phone application for each little thing is also not a good solution. Juggling through multiple apps during a very short session (15-20 minutes with a patient) will prove to be too cumbersome for the physician and their nursing staff. It will slow them down. The small size of an iPhone or similar smart phone (e.g., a palm prē) is another limiting factor that will force clinicians to stare at a computer screen for too long while flipping through a myriad of small screens just to get to the right page to enter or display the required information.

An ideal solution requires two important things to happen:

a) Availability of better hardware with larger screen size for quicker access to the data in a patient’s chart and faster means of data entry.

b) Development of a brand new class of software.

I live in Silicon Valley. Better hardware is coming soon (as early as the summer of 2010). However, development of the necessary software will continue to prove to be a more daunting task as it requires a totally new kind of thinking. It requires the development of a brand new and a revolutionary software technology that will be highly disruptive to the status quo.

Both Dr. Alexander and I have been looking for a sufficiently advanced technology that is indistinguishable from magic. Although I’ve developed pretty good intellectual property to make this magic happen (e.g., making it easier for the clinicians to define and build their own apps), it is very difficult to get funded in today’s environment to build such a disruptive technology.

Who wants to fund a Robert Gaskins or Dan Bricklin in today’s economic climate?

Shabbir Khan is a Silicon Valley entrepreneur who is proud of being a nerd.

Physician-Friendly Documentation
By Chris Joyce

Thank you for posting the interview with Dr. Hau of Shareable Ink. Dr. Hau’s comments really resonate with those of us that have been evangelizing for more intuitive documentation solutions and a different approach to healthcare IT for years. Every week we get calls from frustrated docs and CIOs that have purchased a big-box EMR, yet are struggling to adapt their workflow and make the jump. 

Fortunately, the industry is finally catching onto the source of the poor adoption rates — the user experience! Many HIS/EMR vendors have adopted a web and/or SaaS architecture which solves the IT deployment, cost, and support challenges, but doesn’t address the practical usability for the providers. We’ve seen the same issues with the adoption of EDC in clinical trials. These users are often mobile and offline in spotty wireless environments such as the OR, making a Web application that’s expecting primarily keyboard input unacceptable. Not to mention the horrible bedside manner of being behind a laptop during the encounter. 

The solution must be integrated so they have real-time validation, access to previous notes, and don’t have to re-enter patient demographics/history. At the same time, the interface needs to be natural and flexible so the provider can enter structured discrete data as well and notes / annotations to encourage more complete documentation. As Dr. Hau states, if the providers aren’t using it, it is worthless and you won’t be able to address meaningful use or safeguard against RAC audits.

For these reasons, we embraced the tablet in our Logical Ink solution where can truly eliminate paper without giving up the speed/intuitiveness of a pen interface that is so patient/physician-friendly. The user can combine the power of pen, voice and keyboard input instead of choosing just one approach. It is baked into the user experience instead of the “bolt-on” approach many take. We take advantage of the powerful computing device to make the form(s) interactive: interfacing with devices, validating the data in real time, and performing calculations. And the large screen maintains the familiar paper metaphor. Finally, we can work disconnected for periods of time and sync the documentation with the HIS/EMR via industry standards like HL7, for seamless integration into the hospital workflow.

I’m hopeful the industry is moving towards us and that more vendors will renew their focus on physician-friendly documentation.

Chris Joyce is founder and president of Logical Progression of Cary, NC.

Readers Write 12/1/09

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!

Healthcare Solutions
By Dan Field, MD

1. Tort reform. Cap every state as has been done in California and Texas.
2. Medical justice panels. A jury by our peers. Medically trained arbitration panels to hear cases.
3. Eliminate doctors’ malpractice costs for patients who demand free care. If the government insists that ED docs see every patient (through EMTALA), they are de facto government employees for those patients and should receive government indemnification.
4. Limit advertising again. It was a bad move when they opened it up.
5. Research, publicize and reward best practices. The worst hospital at Kaiser today has a better record of sepsis prevention than the best Kaiser hospital two years ago. Some have had ZERO sepsis in two years. Sepsis costs $40,000 to $100,000 per patient and frequently adds to the nation’s iatrogenic death load. Replicate this through the major diseases and some of the $500 billion of savings we need to achieve becomes realizable.
6. Divest physicians of the benefit of profiting from ordering tests. A study shows a doctor who owns a scanner is seven times more likely to refer a patient for a scan.
7. Generics drugs for everybody, name brands for those who want to pay out of pocket (or from the HSAs).
8. Revamp medical reimbursement
9. Create a two-tiered medical system where everyone has catastrophic coverage and HSAs. Allow the rich and others to opt out for value-added service. This might be just enough incentive to keep some innovation moving forward. I seriously doubt most medication advances are necessary — seems to me they just add a molecule so they can extend the patent without any new, real benefit. First tier accepts all, including, pre-existing illness, with no rescission. Everyone pays same rate for basic tier, everyone gets a tax credit. Not sure how to deal with those that don’t work. Incentivize healthy behaviors — non-smokers with low cholesterol and great genetics are an attractive subgroup. Second tier insurance companies will compete for these stars with lower premiums. Veal calves with remotes and cancer sticks will be avoided like the plague and end up in the first tier or paying more.
10. Accept that disparities will continue but that they will be better and more morally acceptable disparities than before.
11. Allow true portability.
12. Give needles to addicts, along with access to treatment.
13. Strongly consider legalizing and decriminalizing drugs.
14. Realize that screening doesn’t save money for society.
15. People should have a right to unlimited end of life care … as long as they can pay for it.
16. All government officials must utilize the system they insist we follow, especially “the public option”.

Dan Field is a physician with The Permanente Medical Group.

CPOE – One Size Fits All?
By Mark Moffitt

The goal behind Computerized Physician Order Entry (CPOE) is worthy — replace handwritten physician orders using information technology to minimize translation errors and provide conflict checking at the point of entry. There’s only one problem: many physicians are not satisfied with CPOE. The reason I hear often by non-physicians is this: “Older physicians reject technology. The newer generation of physicians is more accepting.”

I admit I have voiced this sentiment in the past. But after working with physicians and having seen them embrace technology that makes them more productive, I’ve changed my view. My view now is that physicians accept technology if it helps them be more productive and they reject technology that makes them less productive — regardless of age. However, I have observed that physicians over 50 are less tolerant and more vocal than physicians under 40 when their workflow is slowed. Maybe because they have more work to do in less amount of time?

Most all in the industry know the issue. CPOE shifts work done by low-cost clerical staff on a hospital payroll to the highest-paid people working in a hospital. Compounding the problem, physicians are not always employed by a hospital. So the work is shifted from a hospital payroll to an individual physician. And time spent in front of a computer is time not spent with patients. And seeing patients equals making money.

Let me qualify my statements above with this: This discussion is restricted to CPOE in an acute care setting and does not apply to all physicians. Some physicians love the current model for CPOE. It works for them. It makes them more productive.

National adoption of CPOE is low. The 2008 KLAS CPOE Digest reports that less than 10 percent of hospitals are “doing some level of CPOE.” In only six percent of hospitals nationwide, physicians enter more than 50 percent of orders directly using the system.

CPOE adoption is affected by many factors. One factor is availability of CPOE. Another factor is ease of entering orders. Another is physician workflow.

Physician workflow is influenced by factors including specialty, size of hospital, employment model, practice size, etc. There is no one model for how physicians do their work. There are many models.

It’s possible that CPOE, once widely available, will be embraced by physicians and the nationwide adoption rate will rise quickly to near 100%. The other possibility is that the current CPOE model does not work for all physicians and CPOE adoption rate climbs slow and stalls at some level, say 50%. What outcome do you think most likely?

Given the money involved, I wonder why more research isn’t being done to find other models that provide the benefits of CPOE that doesn’t require a physician to sit at a computer and enter orders? Why, when many physicians have expressed dissatisfaction with the current model? Why, when the industry is spending BILLIONS, partially underwritten by the federal government, to implement CPOE and other technology in healthcare?

For what it’s worth I’m doing my part by researching a new model for CPOE. I call it CPOE without the “POE.” Not a replacement for CPOE, but an alternative to physicians entering orders on a keyboard. Same benefits, only a different model. I’ll write about this topic in a future article.

Mark Moffitt is CIO at Good Shepherd Medical Center in Longview, TX.

Those Who Believe in The Network Will Go Far
By Carl Byers

 As one of Mr. H’s and Inga’s biggest fans, I am lucky to have had the chance to meet them in my travels as CFO of athenahealth. It is therefore an honor to submit this post.

I soon will be far from the world of HCIT. As announced in June, in early 2010 I will step down from the job I have treasured for more than twelve years to live abroad with my family. My wife and I have dreamed of immersing ourselves in another culture before our kids (ages 11, 7 and 3) are too cool to hang out with Mom and Dad. We will be in Chile for 18 months, and we look forward to returning with new energy and a fresh perspective on the world and on our role in it.

As a finance guy, I am not a technology innovator or a clinical subject matter expert, so I can’t address the future of technology or patient care. What I can address is a question that I am often asked gingerly and respectfully: “How is athena able to achieve such a high value?” Last week, on a panel discussion in Boston, an audience member’s way of asking was far less discreet: “Everyone thinks you are overvalued. Why is that?”

There are all sorts of fancy answers from capital markets people to explain prices based on total addressable market, long term margin profiles, and Price-to-Growth ratios (in fact, a fellow panelist from Goldman Sachs gave this type of answer to the questioner). I won’t attempt to do that sort of analysis justice here. And, I certainly can’t tell you why stock prices jump around as much as they do, but I do have a clear point of view on athena.

Simply put, I think our company trades where it does because of the scope of our vision and the confidence people have in us actually accomplishing it. It was Warren Buffett who said that, in the short run, the market is a “voting machine” and in the long run it is a “weighing machine.” I have no idea what the votes will say from day to day or even year to year, but I know that the weight of our business will be extremely hefty over time.

How can I be so sure? The reason athena has done well as a public company is the same reason athena has done well in the marketplace — because we offer a better way to solve our industry’s most complex problems and the market is responding. athena is one of very few companies in our sector that is not hopelessly stuck in a software mentality, and the market understands that the days of software as we know it are limited.

From complex reimbursement processes, to clinical coordination, to patient communications, to research, the future of health care (just like the future of the rest of the world!), is not software; it is “The Network.” In 1992, I worked on the Clinton campaign staff in Little Rock. If James Carville were in HCIT, he’d put an even sharper point on it — “It’s the Network, stupid!”

The market understands this because outside of HCIT, The Network has already taken over. This shouldn’t be news. How long has it been since salesforce.com put that big “no smoking” sign on the word “SOFTWARE”?  For how many years has Sun Microsystems declared, “The Network is the Computer”? My boss and friend Jonathan Bush said it even more clearly a couple of years ago: “Software is dead… Dead. Dead. Dead.”

And yet everyone — from pundits in Washington to some of our industry’s best technologists — remains fixated on terms like “versioning,” “implementation,” and “interoperability.” Not only is client-server software fundamentally unable to succeed in this new reality (whether installed locally or hosted from a giant data center), it drives business models with much lower visibility, much weaker alignment of incentives with practitioners, much lower sustainable margins, and much lower lifetime value of a customer than does a software-enabled-service like athenahealth.

What the software mentality misses is that at its core, the problem with health care is one of supply chain coordination. Isolated practitioners typically know next to nothing about what care has occurred in a patient’s life outside of his or her own four walls. Creating software that asks practitioners to type into templates in isolated local databases will not accomplish much of anything given the broader coordination challenge. This is why EMR adoption is so incredibly low today. Only through the emergence of copious networks of information and related process-oriented services will the silos break down and will the coordination (and quality) actually improve.

In every industry (including health care), the only way such networks come about is when there are financial incentives to exchange information. PBMs, pharmacies, and manufacturers of pharmaceuticals seem to have figured out how to build networks, and they didn’t need federal interoperability standards to do it! All they needed was a strong financial incentive to get aligned and remove wasted effort from the supply chain so patients could get their meds without huge inventory write-downs or large commissions for middlemen.

Similarly, athena is focused on building real networks so that the supply chains that extend into and out of the physician office can improve — not just for the coordination of payment information with payers, but also for the coordination of physician order information with labs and pharmacies. athena is also building a network for coordinating schedule, payment, and results communications with patients and referring providers. And to do this, we don’t need to wait for federal transaction and software standards — we just need an opportunity to earn financial rent for having made it happen (and in the process having made physicians, their trading partners, and the industry better). Networks cannot be only about information, they have to relate to real work — and it is through accomplishing the work that revenue, profits, and value flow.

So, as I start a new personal chapter in the New Year, my answer to that persistent question and my message to our industry is this: those who believe in software alone will fall away; those who believe in The Network will go far. Companies that embrace this distinction and produce tangible improvements in the delivery of care as a result will help to bring about the health care vision we all seek.

Thank you for the opportunity to comment here on this very unique network of your own.

Carl Byers is senior vice president and chief financial officer of athenahealth of Watertown, MA.

Readers Write 11/23/09

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!

Our Success with EHRs in an Ambulatory Environment
By Stephen L. Badger

Hindsight. It’s the corrective lens which turns progress into a milestone. Imagine that anesthesia, antibiotics, germ theory, and x-rays each once seemed more evolution than revolution. This may be the case, too, with healthcare IT.

A few hundred healthcare institutions are exploring IT — some because the clock is ticking on a federal mandate, and some because their leadership sees value for both practice management and patient care.

The George Washington University Medical Faculty Associates entered the exploration into electronic medical records in 2004. It was a time of tremendous growth in our service capacity. That growth left us drowning in the millions of pieces of paper associated with patient charts. Costs for processing and storing that paper were mounting daily and the records themselves were, at times, unrecoverable. It was an unyielding drag on staff and led to patient dissatisfaction and frustration. For us, electronic healthcare records were like direct pressure on a bleed.

Chart room before and after


Chart room remodeled

The remedy began with a document scan which would play out over nine months and capture over four million bits of paper. It ended with elimination of chart pulls, the elimination of more than 30 full-time staff members, and the elimination of paper records storage. Initial net savings was over $1.5 million, but the dividends are still being delivered through improved accuracy in coding and the conversion of office space. Our old record rooms are now used for executive physicals, nuclear cardiology, digital x-ray, and new physician administrative offices.

The impact on patient care is equally positive on a national scale. Because each physician looks at the same central patient history, redundancy in imaging and other diagnostic orders is reduced at a great savings to the patient and the broader health care system. The prospect of prescription error is controlled, too, because the various treating physicians are working from the same record. That means they are less likely to unwittingly order a prescription which may interact adversely with medication ordered for their patient by another treating physician.

Here at the MFA, our patients can renew prescriptions through an encrypted, private network which processes refill requests typically within 60 minutes. That same system allows the MFA to deliver prompt, targeted alerts about news like FDA drug recalls.

Our records are shielded by firewalls, biometric passwords, and routine data audits which show what staffers have entered a record, what they viewed, and how long they lingered on a page.

MFA patients check in for provider visits at electronic kiosks which are much like those at the nation’s airports. Patients scan in using their unique palm print to preserve security and they answer a brief series of questions to confirm basic demographic data and insurance information. As a result, our records are more up to date and complete.

The kiosk registration will evolve as we extract targeted data which helps us improve an individual patient’s care. We envision that this data may pose tremendous advantage in transforming overall patient care, too, ensuring our patients are being treated on a proactive basis.

These data systems also may be helpful in seeking patients who would likely be helped with clinical trials and research. The potential impact for expediting the quantity and pace of research, especially longitudinal study, is exciting and just one more reason we believe we are living through a milestone in medicine.

Healthcare IT is improving patient care, practice profitability, and has considerable potential as a tool in clinical research. It is nothing short of transformational!

Stephen L. Badger is CEO of The George Washington University Medical Faculty Associates, an academic multi-group practice of world-renowned physicians affiliated with The George Washington University. The MFA consists of over 550 physicians deploying the latest advances of technology and technique through more than 41 medical/surgical specialties.

Are You Sure it’s the Software?
By Fourth Hansen Brother

There’s been a lot of focus on HIStalk lately about the customer side of HIS. Having worked on the “bandit” side of things for a few years, then as a consultant, I’d like to add to what’s been said.

There is an enormous amount of variation in the quality and culture of IT departments serving hospitals and clinics. This has a major impact on the design, quality, and implementation of HIS software. Let me explain.

Most folks on the customer side seem to think that the major vendors don’t consult with the people in the front lines of software. The thought that, “Gee, if only a doctor or hospital IT system created their own software, then we’d finally have a decent system” is common.

Folks, I assure you that every major vendor hires doctors, nurses, pharmacists, and other similar professionals to participate in design, often by the hundreds. There’s no shortage of medical folks willing to be tempted out of healthcare by software vendors. In fact, that’s part of the problem. It’s where they come from.

Your software vendors also find design partners out in the healthcare world, either with formal agreements or informal visits and shadowing. Depending on the luck of the draw, that’s either a good thing or a bad thing.

As noted in a survey that Mr. HIStalk linked to recently, most healthcare workplaces have severe problems. Politics reigns supreme and confrontation about minor issues happens frequently. Refinement or modification of workflows becomes impossible in those environments. These problems are often invisible to vendors at first. Vendors can easily choose a design partner that may have a department that’s become a personal fiefdom of a internal political heavy hitter and has done things the same way for thirty years.

The opposite happens as well — a hospital that’s run by a “thought leader” with oddball workflows in place and little sense of practicality. Vendors may not have the perspective to see that the emperors have no clothes. Hitting these problems with a design partner can cause severe problems with early adapter customers, often resulting in years of workarounds and remedial development.

Often, the vendor doesn’t have enough money to have the in-depth relationship with multiple design partners that it takes to put good software together. Healthcare has more than its fair share of egos. And there’s been more than enough research to show that health care professionals don’t keep up in their education or change their ways, at least on the clinical side.

If a vendor chooses the wrong design partner, or selects a good employee from a bad workplace, chances are that it will show up in a major way in the early versions of the product. As the product matures, these problems can get straightened out with the help of good customers and hard work from the customer-facing staff of the vendor. If the vendor is good, then all of the staff are customer-facing, including developers and testers.

The culture of healthcare customers can create some longer term issues. Many customers have major issues with trusting employees. Often certain types of employees want certain other types of employees monitored or their workflows controlled. Management wants all sorts of reporting and controls as well. The mistrust in certain healthcare organizations is pervasive, omnidirectional, and vicious. The mistrust can result in product enhancement that is weighted heavily towards these issues.

If a vendor has a design partner and early adapters with the same cultural issues, the functionality may be there from the start. Otherwise there will be a struggle to keep up. Of course, regulation (can anyone say HIPAA?) can not only force functionality into the system, but require it in a certain timeframe, causing major development schedule disruptions for the vendors.

Quality of HIT departments can severely affect implementations, or course. The early adapter customers are often the higher quality operations. They can handle implementation practices on the vendor side that are still in development, have a good grasp of the workflows in the organization, and have quality folks who can come to agreements on how to proceed in a organized fashion. Then come customers in the next wave, who may not be the bright stars, who need firm implementation processes, vendor help with workflows, etc.

Then comes the average HIT department. They may have an idea on how babies are conceived, but they often don’t know how they’re born or in which departments. Want to have fun? Ask a CIO what happens in the L&D department. Then ask the L&D department! Or ask where in the hospital babies are born. The answer may surprise you.

Vendors eventually develop lists of these customers who need special help when adding new functionality or upgrades — or when the vendor is sending out a new batch of replacement implementers on a project running several years overdue.

Decisions about configuration are either made off the cuff by top executives with little consultation with the subject matter experts in their organizations or worse yet, take months to bring together hundreds of people for a “consensus” decision. Warfare usually exists in the upper levels, with vendors and consultants often getting caught in the crossfire.

Often, a particular piece of software can go through dozens of implementations with quality healthcare organizations, only to run into problems when traversing to the next level of customer. This usually catches both the customer and vendor by surprise. Often, the vendor gets the blame (and often doesn’t dispute blame, since they shouldn’t be saying that the folks that bought their product turn out to be complete idiots).

If you hear of a product having problems at a particular site, ask at what point the vendor is in the introduction cycle and ask what kinds of problems they are having, Investigation might reveal that it’s not the vendor at all.

Concept – Hospitals that Expect People to Rely on Trust
By Healthfreak

Let us think how it would be to go to a hospital where there will no recourse to legal lawsuits, no visits to courtrooms. Patients come in and get treated quickly — no waiting for 5- 8 hours for a small surgery on a finger — and go back HAPPY.

It is possible, provided some mistakes by the hospital, doctor, or staff are considered "human" and patients do not go overboard in demanding legal action.

What can one achieve by all this ? Quite a bit. One, with legal hassles out of the way, the entire staff will be motivated to provide  better and faster service and not resent their jobs. Equipment sold to the hospital  will be economical, since the vendor does not factor legal costs in his pricing. Hospital administrators will offer economical service to the same patients. The overall insurance premium per patient will also come down and drive down healthcare costs as a whole. This is exactly what the US is looking for today.

Yes, there will be a fear that this may allow malpractice to go unchecked, vendors to sell faulty equipment, etc. A small percentage of cases may happen, as in any society. This, however, should not deter the introduction of a concept which will reduce the overall cost of healthcare.

The guru of AoL (Art of Living) has said that " the health of a society is determined by how many empty beds are there in hospitals and how many prison cells are vacant". May be we can add "and how many courtrooms do not have cases relating to hospitals".

Too farfetched? Maybe today. Let us debate this a little more openly and I am sure it will trigger some hospital into leading the way.

Readers Write 11/19/09

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!

Let’s Send Mom On A Cruise – Forever
By Peter Longo

Dear Siblings,

With all this chatter about healthcare, I started to think about Mom. It dawned on me that, at some point, Mom is going to need some sort of nursing home (that or she lives with one of you four). Either option is not cheap or an exciting alternative for her. We all know she wants to keep her independence and maintain her zest for life.

Recently reading one of the confusing healthcare articles, I deciphered that the cost of care for elderly is way up. Now, I thought “up” might mean a higher co-pay or more expensive bingo. No, we are talking big monthly costs. The article pointed out that putting an elder parent into a home in Tennessee costs, on average, $72,000 a year. Can you believe that? What possibly do you get for all that money? From my view of working in the healthcare software world, I have no idea where all that money goes. It sure does not go to buying my software.

I understand the basics you get for some of that money. For instance, it comes with medical care. Apparently there is a doctor who stops by periodically to check medications. Great. Also, there are nightly activities. I assume bingo, Pictionary, and probably crossword challenges. The money also pays for Mom’s food. Jell-O choices, Pasta Night, and caloric smart desserts. Don’t forget the occasional outings or field trips (I bet they go to see Graceland once a year). I did check and the one near me does not provide free Internet.

I love Mom just as much as you guys. She took care of us for years, so we have to take care of her. We have to be there for her and we will have to split this cost no matter how tough it will be. But wait, I found something even better! Right there in the newspaper next to the article I was pondering.

Next to the picture of several Senators claiming victory on some healthcare issue was an ad for a cruise. Think about it — the cruise can be Mom’s floating nursing home. A higher level of quality care at a lower cost. Yep, Brother Peter found the answer — send Mom on a cruise, forever.

The advertisement touted a cruise for as little as $250 a week. It you think about it, that would be $12,000 a year to live on the cruise ship, with food, Vegas-style entertainment, skeet shooting, and even slot machines included.

Yes, Mom will need some healthcare attention, but hey, these boats all have a doctor onboard. A real, live doctor. I hear they give a free trip to the doctor and their family in exchange of services. (Maybe Medicare should consider a program like this. Free trip, they give back free care for a week).

All those medications she is on … she can buy them at the ports of call! No mail order from Canada or another country. Every foreign port the ship docks in, she can refill her meds on the cheap. We all know medication is cheaper in every country other than America. The ship even keeps a supply of certain medications on board. Even surgeries are less expensive at these foreign stops.

But wait, there’s more. Food. Medicare-subsidized food or all-you-can-eat buffet. On the cruise, Mom can have her choice of restaurants each night. For lunch, she can have an outdoor barbecue by the pool or grilled salmon in the formal dining room. Breakfast of eggs the way she wants or maybe a trip to the omelet bar! If she can’t sleep, then how about a stroll pass the midnight buffet? All included in the price. (Tough decision — midnight buffet or choice of Jell-O tonight.) There is even a gym with a trainer to work off the extra calories!

I know nursing homes have magicians and comedians stop by, but think about a live, Vegas-type show. The stages on some of these cruise ships are huge. When is the last time you saw Billy Crystal stop by a nursing home to perform? Every night, Mom can get dressed up and really be entertained. Remember, all for a fraction of the cost of a nursing home.

I known we all live in different parts of the country, making it hard to visit Mom in a nursing home. But if she was on a cruise, we could make a fun trip out of it. We could bring the kids. “Hey kids, you guys want to spend a week at a hotel across from a nursing home or a week on a cruise playing with Grandma?”

This cruise idea saves us money, puts Mom in better care, better food, better entertainment, and a place to interact with friends. Now I see why so many old people are on those cruise ships. This is brilliant.

Let’s try to keep this idea a secret. We would not want the government to find out. They might choose to debate a “cruise” idea in Congress for several months. Then the next thing you know, we will see a picture of some Senators celebrating a victory for “CruiseCare” that only costs $120,000 a year. Money our taxes will pay. Let’s keep this idea low key for now!

Next stop for me; let’s see if the cruise will buy some medical software. Boss, I need to expense a couple of cruise trips …

Peter

Readers Write 11/2/09

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!

Web Services, A Real-World Example
By Mark Moffitt and Kevin Hornberger

In this article, we will give an example of the use of a “transactional” Web service to request and return clinical data.

GSMC processes about 90,000 patients per year, 1,700 per week, or 250 per day in our Emergency Department (ED). ED physicians at GSMC use MEDHOST to record each patient visit. MEDHOST is a “best-of-breed” ED application. MEDHOST is interfaced to our hospital information system (HIS), Meditech Magic, using HL-7. Meditech and MEDHOST stay in sync by way of HL-7 data transfers. In this example, think of Meditech as our HIS and clinical data repository (CDR).

GSMC developed an iPhone web application that physicians use to view clinical data. GSMC ED physicians wanted to use this application to pull up a list of patients assigned to them. Then, they can access clinical data like lab and radiology (audio dictation) on the iPhone. This information (list of patients) is not included in the HL-7 messages sent from MEDHOST to Meditech.

We could modify the HL-7 transaction from MEDHOST to Meditech to include this field. The GSMC iPhone app would then query Meditech (CDR) to get a list or patients associated with an ED physician. This effort would require modifications to MEDHOST and Meditech to process and store this data. See Figure 1.

An alternative approach is to keep the data in MEDHOST (source) and get it using a Web service when needed. See Figure 2. The advantage to this approach is:

1. Only one copy of data exists.
2. Implementing a Web service is easier than having multiple vendors modify an HL-7 message.
3. It is easier to maintain – the Web service only needs updating when changes are made to the underlying MEDHOST database.

GSMC uses a Web service developed internally using XML over HTTP. The Web service receives a physician identifier, constructs an SQL message and queries the MEDHOST database, and returns the result in a Web service. See Figure 3. The return message contains a list of patients assigned to a specific ED physician. Figure 4 is a return message (with patient identification altered to keep confidential).

Most CDRs in operation today perform two functions: 1) provide easy access to data spread across multiple systems, and 2) serve as a data store for analytics and decision support.

It is fairly easy to construct a Web service to get data from different systems. Web services with direct access to data sources eliminate the need for a CDR with respect to providing easy access to data spread across multiple systems.

New technologies in the business intelligence (BI) space may eliminate the need for a CDR for analytics and decision support. I will be writing about this topic in my next article.

I acknowledge that this is a simple example of the power of Web services. To take Web services to the next level, aka a Service-Oriented Architecture (SOA), you need interoperability and other features. Interoperability, unlike the example above, requires cooperation and coordination from vendors, something not always easy to obtain. MEDHOST is working further on its web services to provide a full SOA.

Figure 1

Figure 2

Figure 3

Figure 4

Mark Moffitt is CIO and Kevin Hornberger is a senior software developer at Good Shepherd Medical Center in Longview, TX.

Strategic IT Investments in the Operating Room: Why Now is The Time
By Kermit Randa, FACHE, CPHIMS

By now it’s obvious that the current economic downturn has not spared hospital organizations. With capital markets inaccessible to many hospitals, the financing for major investments and physical plant expansion is suddenly unavailable. Additionally, income from hospital endowments, which is often dependent on equity investments, has been dramatically reduced. The recently passed economic stimulus for healthcare and especially the $19 billion for adoption of an electronic health record may offer hospitals some funding relief in the long term, but initial funding for hospitals will not begin until 4th quarter 2010. In addition, the regulations for determining funding and eligibility are still being debated and finalized.

Long-term assistance may be on the way, yet demands on hospitals remain high for now and the foreseeable future. These demands include the need to maintain a high level of quality, operate ever more efficiently, continue with patient safety initiatives, comply with regulatory requirements and attract and retain talented clinicians. Certainly, this is not a time for “business as usual” and it offers a real opportunity for renewed leadership, strategic vision and action.

The traditional response to tough economic conditions is to put current project expenditures on hold or to implement an “across-the-board” belt-tightening budget process (“Every department needs to reduce their expenditures by 10%”). This latter approach, while appearing straight forward and fair, may have unintended consequences. But where can an organization begin to effectively navigate through these unprecedented times?

One sound approach involves a back-to-basics look at the economic underpinnings of hospital organizations and the importance of the hospital operating room (OR). According to recent HFMA studies, today’s OR is the economic engine of most hospitals – accounting for up to 60% of a hospital’s revenue and some 35%-40% of the hospital’s expense. Over 60% of the hospital’s margin typically comes from surgical patients. Based on data from DJ Sullivan Healthcare Consulting’s database of 700+ ORs, each empty but open OR suite costs a hospital an estimated average of $1,000 per hour (including pre/post op staffing and anesthesiology costs). The OR is also a primary source of up to 50% of hospital-based errors. The impact of the OR is felt well beyond the perioperative department, according to the AHA’s Quality Center, “Because the OR is a primary source of admissions, it is virtually impossible to streamline hospital-wide flow without first streamlining patient flow through the OR”.

Optimizing the performance of the perioperative department can significantly improve performance of both the perioperative department and the hospital. Through the use of new perioperative information systems coupled with improved work flow processes, hospitals can expect the following improvements in their OR:

• More accurate scheduling resulting in a more rational schedule
• Increased on-time case starts due to an effective pre-surgical screening and documentation process
• Improved quality of care and patient experience by reducing redundant data collection through an integrated digital record
• Reduced supply costs by using preference cards automatically maintained on actual usage, not “what was used last time”
• Documented cost-per-case averages to offer greater access to surgeons with higher margin case mixes
• Generated comparable metrics showing cost-per-case by surgeon by procedure so that standardization decisions can be made based on full information and not just purchasing data
• Published empirical performance outcomes to demonstrate quality and efficiency to other surgeons and the community using analytics and business intelligence tools
• Web access to create a path of least resistance for surgeons and their offices
• Consistent and predictable surgical days for which everyone can plan
• Integrated Anesthesia record driving increased efficiency, charge capture, and safety

To enable hospitals to make a perioperative IT investments now, some healthcare IT vendors have already announced special subscription pricing models that enable hospitals to fund such initiatives from operating budgets rather than capital budgets that may be currently on hold. Hospitals can begin these projects now, spreading payments over a longer time horizon, realizing a positive ROI more quickly.

Surgeon and OR Staff Recruitment and Retention

Another strategic consideration for moving forward with an investment in perioperative IT is that it can be a powerful motivator in attracting talented surgeons, residents, and OR clinicians.

According to James Pennington, Chief Information Officer, JPS Health Network, located in Ft. Worth, Texas, “Our hospital has long been a preferred institution for incoming residents due to its diverse levels of patient acuity, service lines and our use of advanced technology.  We recognize that top new residents understand the benefits of advanced IT solutions in the provision of care and expect them to be available”.

One way to increase OR revenue is to attract surgeons with high volume practices from competing hospitals.

The Centers for Medicare and Medicaid Services (CMS) reports that the average surgeon reimbursement from Medicare has decreased by some 7% over the last three years, resulting in surgeons seeking hospitals that can demonstrate efficiencies that will enable them to maximize volume and revenue for themselves and consequently the hospital. I believe that if the following key considerations are met, surgeons will be willing to consider moving their OR schedule to a different provider if:

• Surgeons’ referral patterns are not disrupted
• Surgeons can perform at least one more procedure daily
• They see an improvement in lifestyle (earlier leave times, reduced extended hours)
• They have regular access to OR time using an easy, repeatable process (e.g. guaranteed block times)
• The OR documents high satisfaction ratings from patients and staff

The use of a robust information system that is well integrated into the workflow of a perioperative department can be a key underpinning in recruiting (and retaining) talented surgeons and other perioperative staff.

Conclusion

This is a time for leadership. Recognizing the perioperative department as the economic engine of the hospital offers many opportunities for change that can result in quick economic wins. Prioritizing this area to ensure the ability to gain and maintain economic advantage is a critical step. A robust perioperative system is one of many improvements that can be made relatively quickly with significant and early ROI payback. The strategic long-term benefits can be even more significant. While such investments may seem counterintuitive in challenging economic times, they can in fact result in both tactical and strategic advantages that will lead to financial success for the organization.

To take on this initiative, support from senior management is essential. It requires focus, team work, leadership, and the final key ingredient – courage.

Kermit Randa is Senior Vice President, Surgical Information Systems.

Readers Write 10/27/09

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!

CPOE Is The Surest Route to Meaningful Use
By Linda Gleespen, RN, BSN

Few hospitals have complete EHRs, so demonstrating Meaningful Use to get government financial incentives looks like a pretty steep hill to climb. But if your institution’s strategy first begins with implementation of computerized physician order entry (CPOE) you will be on the road to success.

The 2011 Meaningful Use criteria for hospitals require the use of CPOE for at least 10 percent of orders, and many of the other requirements can be achieved with CPOE alone. For example, CPOE enables hospitals to collect data for many of the requisite quality measures because they’re related to test or medication orders. Examples include the use of high-risk medications in the elderly, the percentage of eligible surgical patients who received VTE prophylaxis, and the percentage of patients at high risk for cardiac events on aspirin prophylaxis.

Meaningful Use will also require medication reconciliation, which is much easier to do at discharge or during transfers if you have CPOE. And, each hospital will have to show it has implemented a clinical decision rule related to a high-priority hospital condition. My hospital system, Summa Health System in Akron, has created dozens of such decision support rules since we started using the Eclipsys Sunrise Clinical Manager application in 2006. For instance, for stroke care, we programmed a “hard stop” to prevent physicians from prescribing the clot-buster medication tPA if more than three hours have passed from initial onset of stroke symptoms. However, research has now defined clinical scenarios in which this three-hour window can be exceeded.

The beauty of clinical decision support rules is that the application can be altered to adhere to the most current standards of care.

I’m not minimizing the difficulty of successful CPOE adoption. At the two hospitals in my health system that have implemented CPOE, a couple of years of planning were required to prepare for CPOE, and early on, getting physician buy-in was a challenge. However, I’m proud to say that our latest statistics indicate that doctors are entering over 80 percent of their orders directly into the system. Only 8.8 percent of our orders are telephoned in, 7.3 percent are verbal, 2.3 percent are written, and under 1 percent are faxed.

Equally important, electronic order sets are used for 94 percent of hospital orders. These order sets incorporate evidence-based protocols that improve quality and safety, which is the paramount goal of Meaningful Use.

To add decision support features to the order sets, Eclipsys SCM enables us to create customized “medical logic modules” that automate key portions of orders. For example, when doctors enter orders for a patient with pneumonia, they are prompted to enter information about the type of pneumonia and other significant clinical information. The system then auto-selects the correct antibiotics. It functions like an electronic decision tree.

To measure how our order sets are affecting patient care, we compared how closely physicians were following the American Stroke Association and Joint Commission guidelines for stroke care with and without the use of order sets. We found that compliance with best practices was 40 percent higher with the order sets than without them. More important, the use of order sets in CPOE improved outcomes. When the order sets were used, 9.4 percent more patients went home directly from the hospital, and 21 percent fewer patients were readmitted.

By these demonstrations of Meaningful Use, the exceptional quality care and patient outcomes is truly what is meaningful.

Linda Gleespen, RN, BSN, is lead quality and clinical analyst for the Summa Health System of Akron, OH.

EMRs and Interoperability: HIT’s Oxymoron?
By Lynn Vogel, PhD, FHIMSS, FCHIME

ox·y·mo·ron; \äk-sē-‘mor-än\, noun, a combination of contradictory or incongruous words (as cruel kindness); broadly : something (as a concept) that is made up of contradictory or incongruous elements[1]

How odd, you say, to propose as an oxymoron two terms that politicians, IT luminaries, healthcare experts, vendor product brochures, and academic journals typically assume simply and reasonably can and must go together. But do they really go together, or are we just trying to make them fit when maybe they don’t?

Consider the fact that every EMR product on the market today started with a single purpose: to automate the workflow of clinicians within a specific organizational setting, and in the process, seek to make it more efficient and more effective. Among other features, EMRs focus on making data from previous encounters or activities easier to access, assuring that orders for tests and x-rays have the right information, or that the next shift knows what went on previously. In general, in spite of visible successes and failures for all manner of products, EMR products do a pretty good job of automating a complex workflow — of automating intra-organizational clinical processes.

But interoperability, in the sense in which the term is used in today’s discussions about Health Information Exchanges (HIEs), is not about intra-organizational workflow, but about inter-organizational work flow. Recognizing that patients often receive care in a variety of organizational settings — hospitals, multiple physician offices, rehabilitation facilities, pharmacies, etc. — the challenge is to extend the internal workflow beyond the boundaries of individual organizations so that data is available across a continuum of care. Interoperability, then, is not so much about what happens within an organization, but about what happens across organizations.

A major assertion here is that the architectural requirements for automating intra-organizational clinical workflows are very different from the architectural requirements for facilitating inter-organizational interoperability. An intra-organizational architecture focuses on facilitating real-time communications among providers, optimizing the process of collecting data at the point of care, and ensuring that clinical tasks are carried out in an appropriate sequence.

An inter-organizational architecture needs to be designed to minimize the duplicate collection of data in different care settings, to facilitate quick searches of relevant data from a variety of organizational sources, and to rank data in terms of relevance to a particular clinical question.

If these assumptions are true, then one has to wonder whether we can ever achieve true inter-organizational operability using an architecture that has focused for more than a decade on optimizing intra-organizational processes.

An appropriate analogy might be taking a bunch of cars, which were designed to accommodate small numbers of people, and somehow string them together to make a bus in order to accommodate a large number of people with the same goal of moving them from one point to another. Yes, you could make a bus out of cars — no doubt with a lot of effort — but why would you? Requirements for tires, suspension, seats, luggage storage, and even bathrooms are very different for buses than for cars and require a different architecture if you want to build a bus that works. But isn’t that what we are trying to do with current proposals for using EMR architectures to build HIEs?

Maybe it’s time to rethink this approach. Interestingly we don’t have to look very far to find a set of experiences that would make more sense for an interoperability architecture than trying to extend our current EMRs. It’s  the Internet. With millions of different data repositories around the world, an architecture that seems to work most of the time, and increasingly sophisticated search engines for locating data, it would seem that we should be looking more closely at the services-oriented architecture of this ubiquitous example of interoperability rather than trying to string EMRs together and replicate their architectures in an attempt to achieve objectives which were never in their initial designs.

So that’s why EMRs and Interoperability may be HIT’s oxymoron: the architectures may simply be too contradictory and too incongruous to fit together no matter how hard we try. If so, this would add a significant constraint to HIEs that are already being challenged by the sustainability of their business model. Bus manufacturers learned long ago that simply making cars bigger using the same underlying components wouldn’t result in a workable bus. Perhaps there is a lesson here for how we should be thinking about interoperability.

[1] Adapted from http://www.merriam-webster.com/dictionary/oxymoron, accessed on 9/19/2009.

Lynn Vogel, PhD, FHIMSS, FCHIME is vice president and chief information officer and associate professor of bioinformatics and computational biology at The University of Texas M.D. Anderson Cancer Center in Houston, TX.

Readers Write 10/12/09

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!

Health 2.0
By DrLyle

I attended the second day of Health 2.0. Although geared towards consumers and the Internet, I thought it was worthwhile for any HIT junkie. Here are a few points of interest.

It was a good review of what the big guys are doing (Google, MS, WebMD).

• Basically all three want to be the "holders" of your health data (e.g. your demographics, med list, lab values …).
• While both Google and MS want to also allow anyone else to create PHRs or apps that can use that data, WebMD wants to be the only one who can use the data they hold. 
• Business models — unsure on Google and MS, but I assume it is something about either company marketing or eyeballs. WebMD obviously does advertising, but they also can sell their system as a private label for employers to give their employees (and they said employees can access their data on the regular WebMD site if they leave the company). 
• Overall, I think Google and MS will be more successful since they seem to have more openness, but they are not mutually exclusive. You can have information in both, and then have a third party creating a PHR or apps that sucks in data from both of them. My hunch is that WebMD will eventually interoperate with them and focus more on the end user applications than on being data storage experts.

Seeing new/interesting startups in the Internet space.

• Most are consumer focused, mostly enthusiastic souls trying to build a site that provides new information, niche communities, or consolidated approaches to healthcare. 
• Some business plans rely on employer financing (e.g. wellness sites), while others seem to be just interested in getting eyeballs for now, with plans for ads or an upsell (e.g. extra functionality) later. 
• Particularly interesting ones included AccessDNA (helps a consumer pick out which company to use for gene banking and analysis). TrialReach (a nice improvement on the typical search for research trials). iGuard (give them your medication list, and they will email you if any FDA or similar warnings come out). RelateNow (focused exclusively on the niche of parents and providers taking care of autistic children). ScanAvert (you tell them your meds and dietary issues, and then use your phone to take a picture of a UPC code and it will tell you about interactions, etc. …) 

Keas.

The NYT article paints an amazing picture where a patient would bring in data (some manual, some automatically from pharmacies, payors…) and the Keas system would create personalized "Care Plans" that tell the patient how to get healthier. Furthermore, they see a world where any provider or company could create Care Plans within their system and then sell them to patients like iPhone apps (e.g. one of my patient might want to buy the Cleveland Clinic Diabetes Plan, while another might want to buy my group’s Diabetes Plan, and yet another will buy my own DrLyle’s Diabetes Plan).   

So I was excited to see Adam Bosworth launch Keas at the Health 2.0 conference. Unfortunately, I was underwhelmed (as were many others whom I spoke with about it). Basically, it looked like a fancier version of the same old stuff that eHealth wannabees have been pushing for years (providing personalized advice based on your data). Specifically, their Care plans seemed very basic — "eat better by doing ABC, and exercise more by doing this XYZ…  and we’ll send you three reminders a day!"  

In other words, they seem to be naïvely falling into the trap of thinking that patients are just looking for advice and knowledge. What they really need is motivation. They know they need to lose weight, so it is unlikely that a Web site telling them they need to lose weight will make it easier for them.  Additionally, the screen is quite cluttered. He seems to be using his MS roots rather than his Google ones.

However, I would not underestimate Adam and his company. The general concept is sound and they must know they have to figure out "patient motivation" eventually, so one to watch.  

 

Lyle Berkowitz, MD is a practicing internal medicine physician, a healthcare IT consultant (www.DrLyle.com), and founder of the Szollosi Healthcare Innovation Program (www.TheSHIPHome.org). He blogs regularly at The Change Doctor (http://drlyle.blogspot.com/).

Readers Write 10/5/09

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!

Web Services are Changing the Industry, Slowly
By Mark Moffitt

It’s an age-old argument in healthcare IT. Which is better, the single vendor or best-of-breed approach to software?

The single vendor approach has had the advantage, namely less risk from integrating systems, for a number of years.

The best-of-breed approach offers systems with better functionality and/or ease of use, but integrating systems from different vendors is a challenge. Small and innovative vendors are often the leaders in best-of-breed systems.

HL7 has not evolved past “piping” data from one system to another. Interoperability? Not using HL7. But web services offer a way to provide interoperability between systems.

This is the same technology that brought us the World Wide Web or Internet, online banking, Google, Amazon, eBay, the dotcom bubble and bust, and online communities. It is diminishing the primary benefit of the single vendor approach — ease of integration.

I predict Web services will bring more competition into the healthcare IT space and lower costs where vendors compete on functionality, innovation, and flexibility. It will open the door to smaller, more innovative vendors.

Web services have been around since the late 1990s, yet the single vendor approach still dominates the industry. Change has been slow as the sunk costs of single vendor software present a significant barrier to change. In addition, vendors of single vendor systems do not promote Web services for interoperability for obvious reasons.

But those barriers are about to be swept away by much more powerful forces.

Change is coming to healthcare regardless of the outcome of current healthcare reform efforts, in the form of 1) higher volume as baby boomers march through old age (Chart 1); and 2) lower reimbursement as healthcare cost as a percent of GDP falls. This change will be forced on the USA as a consequence of competing in a fiercely competitive global market.

The Obama administration is increasingly signaling that the United States will not continue to be the world’s consumer and importer of last resort. The clearest statements came last month from Larry Summers, White House economics director, in a speech at the Peterson Institute for International Economics and in an interview with the Financial Times. The United States, he said, must become an export-oriented rather than a consumption-based economy and must rely on real engineering rather than financial wizardry. Tim Geithner, the US Treasury secretary, and other top officials have spoken similarly of rebalancing US growth.

Healthcare costs are like a “tax” on the economy. That tax is much higher in the US than in other countries (Chart 2). Healthcare cost as a percent of GDP cannot continue at current levels if the USA is to compete against other global economic powerhouses in the 21st century. Unrelated to this discussion is the likelihood that the dollar will continue to devalue to level the playing field for USA exporters (Chart 3).

Web services are beginning to make inroads at the grass root level as healthcare IT shops are forced to find ways to provide more and more functionality in the face of stagnant or shrinking budgets. This trend will only accelerate as healthcare confronts a new reality.

It will take time to dislodge Epic, Siemens, GE, Cerner, et al, from their perch atop the healthcare IT food chain. I predict that these vendors will fight the inevitable reordering of the industry like others before them in other industries (read the book: “The Innovator’s Dilemma”). And like those before, them these vendors will not change because they are stuck in the business model that got them to the top.

But change is coming and it is unstoppable. It will bring about a leap forward in ease of use and flexibility at a much, much lower cost. The trend for the cost of healthcare IT systems is down, not up.

The primary beneficiary of these changes will be physicians and other care providers in the form of real and tangible productivity-enhancing features and functionality. They are going to need it.

It will be fun and exciting for some in the industry. For others, it will bring job losses and stress.

Fasten your seatbelts. It is going to be a thrilling ride over the next ten years.

Chart 1

Chart 2

Chart 3

Source for chart. OECD publishing. Rights and permissions. Allows websites and blogs to use excerpts of their publications with attribution and URL.

Mark Moffitt has worked in healthcare IT for 25+ years and has a BSEE, minor in computer engineering from University of Texas at Austin and an MBA from Vanderbilt. He is currently (de facto) CIO at Good Shepherd Medical Center in Longview, Texas.

Fee-Based Clearinghouses Defy 80/20 Rule
By Jim Denny

Mr. Revak raises an interesting premise about the costs associated with use of clearinghouses, based on the 80/20 principle. However, I’d like to offer some additional perspective on the value of using a Web-based clearinghouse.

I would agree that it is hard to justify paying for transactions if all you are getting is a dumb pipe to the payers. To justify the fees that clearinghouses would charge, they must deliver meaningful value beyond transaction processing. You should expect to receive some form of SLAs (Service Level Agreements) around performance, reliability, service levels and response times, first pass rates, etc.

It is also importation to remember that not all clearinghouses make money on a “per transaction” basis. Some, Navicure included, charge a flat monthly fee unrelated to claim volume — much like Internet service providers and cable television companies do. Indeed, any of these would prove to be prohibitively expensive if users were charged each and every time they used the service.

And, as noted above, Web-based clearinghouses can provide added value that goes well beyond simple claims processing. These services deliver business intelligence that can greatly enhance a practice’s business operations, such as real-time claim tracking; analysis of paid vs. contracted fees; coding and data entry error patterns; rejection and denial trends; and staff productivity reporting.

In addition, users benefit from the ever-widening scope of information available from Web-based clearinghouses. The claims engine employed by these firms get bigger and smarter with each claim processed because the “claim brain” benefits from the broader community of practices. In effect, thousands of practices could be making the same mistakes with given payers, resulting in repeated rejected claims. With online functionality, the error can be corrected automatically without each practice needing to fix its own system. And when new payer edits are applied, practices can rely upon their clearinghouse to integrate the policy change, so they don’t have to invest staff resources in keeping up with countless payers making endless modifications.

Certainly, in these difficult economic times, it makes sense for practices to take a critical look at how they invest their resources. But they must ensure they are looking not only at the price tag for any given solution, but that they also consider the overarching value they may receive.

Jim Denny is president, CEO, and director of Navicure of Duluth, GA.

Let Us Rise to the Occasion: It’s Not About the Technology We Offer; Our Value is in Changing the Way a Medical Practice Works
By Lindy Benton

Since February’s announcement of the federal stimulus package including electronic medical record incentives, the healthcare industry’s attention has focused mostly on the money: how physicians can get paid to implement an electronic medical record (EMR) — and how much vendors can make in the process.

I fear that we are neglecting one of our most unique — and critical — duties as vendors of healthcare technology, which is to align ourselves to the needs of physicians.

Let’s not forget why the federal government decided to pay for our industry to embrace automation. It wasn’t to install our technology; it was to change the way medical practices operate. Our nation needs — truly deserves — more value for what it spends on healthcare. As President Obama so bluntly put it, we’re even missing the basics:

Healthcare is the only area where you still have to fill out five different forms – when you go into a bank you don’t have to do that. You’ve got an ATM. …Sometimes you see their [healthcare] files and it’s all stuffed with papers, and nurses can’t read the doctor’s handwriting. AARP tele-town hall Tuesday July 28, 2009

The real issue at hand is changing the way a medical practice functions from the moment the patient walks into the door. Today, patients groan when they see a sign-in list teetering on a shallow window sill below a hand-written sign that declares, “Tap if you need help”. In the future, we need patients to be comforted by the precision and security of the technology and corresponding workflow that supports their physician.

There’s good evidence that the time is right for change. In these turbulent economic times, patients are anxious because money is tight, preventive care has been neglected, and long wait times for appointments just add to the frustration. Physicians are just as apprehensive. Reimbursement is down, expenses are up, and for many, the work is less and less professionally satisfying. Yet, faced with these challenges, most physicians don’t see technology as a savior. In fact, many see the stimulus package as just adding to the frustrations of the current economic environment.

It’s no surprise that physicians are fearful: EMRs haven’t had a stellar track record. In 2005, then-Arizona Governor Janet Napolitano issued an executive order for all healthcare providers to install EMRs by 2010. A May 2009 report found that as many as 20 percent of medical practices in Phoenix have or are canceling their EMR contracts as a result of training, functionality or affordability issues. Cancellations were especially prevalent among smaller medical practices, according to the HealthLeaders-InterStudy report.

As vendors, our challenge is to stop focusing exclusively on the EMR — getting physicians implemented as quickly as possible and then moving on to the next client. An EMR is a wonderful tool, but the national healthcare reform debate isn’t about tools. It’s not even about technology.

In order for physicians to not only implement an EMR, but to automate their workflow, they need us. Instead of worrying about how they are going to afford the staff training, maintenance, and continual upgrades of an EMR, physicians should be assured that the vendor they choose has the intellectual resources to be consultative to their needs so they can deliver efficient, affordable and high quality care to patients. They need vendors who can be partners — who can be experts, trainers and consultants on how to integrate technology into day-to-day operations. Physicians want a partner who can guarantee qualified information technology and be the professionals who help them navigate the complexities of an EMR.

As healthcare technology experts and as fellow Americans, it’s our calling — our responsibility — to make sure physicians get a positive return on their investment. In turn, patients will experience the value of the technology we offer.

The healthcare information technology industry should be proud of delivering on its past promises to produce cost savings, efficiencies, and even better patient outcomes. If we stay focused on truly creating value for medical practices, we’ll ensure that the stimulus package’s HITECH Act doesn’t become another Cash for Clunkers — a short-term stimulus that doesn’t get to the core problems. Instead, let it become our legacy.

Lindy Benton is chief operating officer of Sage Software Healthcare Division of Tampa, FL.