Home » Readers Write » Recent Articles:

Readers Write 7/28/10

July 28, 2010 Readers Write 3 Comments

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!

How to Use Meaningful Use Measures to Improve Internal Processes
By Shubho Chatterjee, PhD, PE

The final ruling on Meaningful Use was released by the Centers for Medicare and Medicaid Services in July of this year after a year of comment period and revisions. According to the final ruling, to be eligible for incentive payments, Eligible Professionals (EPs) are required to submit to the CMS, starting October 2011, 20 objective measures for 15 core objectives and an additional five from a menu of 10. For hospitals and Critical Access Hospitals (CAHs) the corresponding measures are from 14 core objectives and five from a menu of 10.

There are various efforts, dialogues, and debates underway regarding the ability of EPs, hospitals, and CAHs to meet the reporting requirements, whether the cost justifies the incentives, and the sheer human and technical capacity needed. I will not further add to the discussions but will rather focus on how the MU criteria can be used to further improve care delivery process, make it more efficient, and positively impact the operating margin. After all, a measure is related to the output of a process, and while a measure can be met, it can also be used to hone into the process and sub-processes for improvement.

Let us consider some of these Stage 1 measures and how the underlying processes supporting the reporting of the measure can be identified and improved to further improve the measure, the care delivery, and the operating margin.

Stage 1 Measure
More than 30% of unique patients with at least one medication in their list seen by the EP or admitted to eligible hospital’s or CAH’s ED have at least one medication order entered using CPOE.

Implication
Let’s assume that the provider meets the 30% threshold for the reporting period. A logical follow-through is to examine why the remainder are not CPOE and what were some barriers overcome to reach this threshold. Is it because for the remainder unique patient population, data entry is manual because other providing locations are not CPOE enabled, CPOE is available but under-utilized, or are there manual data entry requirements into and between various systems and consolidate the data to one final measure?

Each of these barriers point to a different challenge. The first is system unavailability (a business decision). The second is a change management (a people challenge). The third is a technical and process automation challenge requiring an interface or other electronic inputs, such as document management and integration.

Stage 2 and Stage 3 measures will increase the threshold. Thus the underlying process or system gaps should be identified not only to meet later Stage measures, but to improve process efficiencies as well.

Stage 1 Measure
More than 40% of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology.

Implication
Assuming the 40% threshold is met, what is necessary to increase the measure? Is it because of volume of data entry from single or multiple locations, or system not fully utilized, or could it be because the receiving pharmacy or is unable to manage additional increases to their receiving capacity from their customers? Again, the barriers are similar to the above and need to be analyzed and overcome.

Stage 1 Measure
More than 10% of all unique patients seen by the EP are provided timely (available to the patient within four business days of being updated in the certified EHR technology) electronic access to health information subject to EP’s discretion to withhold certain information.

Implication
This requirement has procedural, technical, and operational implications. The procedural requirements are in providing HIPAA compliant health information, while the technical requirements are in the mode of providing the information. For example, will a secure patient portal be created, will the information be provided in memory sticks or other portable devices, and if so, what is the encryption or data protection policy?

Note that, depending on the technical solution selected, there are supply chain and purchasing requirements as well, to maintain and increase the measure threshold.

Summary
While the MU provides financial incentives for healthcare organizations, it ends in 2015. It is important for healthcare organizations to use this opportunity, not only to prepare, apply for, and receive the incentives, but to examine their organizations deeply from People, Process, and Systems perspective to utilize and enhance the measures.

Only when these three supports are robust and reliable will the Meaningful Use be truly meaningful to the healthcare system, where the improvement of quality of care is the most important objective and operational improvements and business growth will likely follow.

Shubho Chatterjee is chief information officer of Miami Jewish Health Systems of Miami, FL.

Bringing Medical Terminology Management into the 21st Century — Just in Time for ICD-10
By George Schwend

ICD-10 promises to improve patient safety, the granularity of diagnosis codes, and diagnostic and treatment workflows as well as billing processes. Sounds like a dream, right? But close to three years from the mandated switch on October 1, 2013, most hospitals and health systems are still thinking of it as a nightmare, dreading the massive amount of time, effort, and money the transition will require.

What many fail to grasp is that ICD-10 is just one step on an endless road. There are already dozens of code sets that will probably eventually need to be integrated with each other — from SNOMED-CT and LOINC to RxNorm to local terminologies and proprietary knowledge bases — and all of them are constantly evolving. Look down the road and you can see ICD-11, already in alpha phase in Europe.

Instead of tackling each new iteration as if they were setting off on a major road trip through uncharted territory, providers, payers, and IT vendors need to ditch the proverbial roadmaps and get themselves a GPS unit. That way, they can simply enter each new destination as it comes along and travel there automatically.

And automation is what true semantic interoperability requires. Our metaphorical GPS could either be embedded in proprietary HIT software or plugged into a hospital’s or payer’s information system and triggered by specific events such as an update or the need to create new maps. It would allow users to automatically:

update, map, search, browse, localize, and extend content
incorporate and map local content to standards
update standard terminologies and local content
generate easy-to-use content sets to meet the needs of patients, physicians, and customer support professionals
reference the latest terminology in all IT applications
codify free text
set the stage for converting data into actionable intelligence

Happily, software that fits the bill is already available, in use today at more than 4,000 sites on five continents. It provides mapping and terminology for leading HIT vendors, for health ministries like the UK National Health Service, and for standards organizations such as the IHTSDO, owner of SNOMED-CT., allowing them to not only implement new codes but synchronize codes throughout an enterprise, be it a physician practice or a country.

If you are still having nightmares about ICD-10, this your wake-up call. The ability to merge and manage diverse content from multiple sources — including free text from physician dictation — is what will turn ICD-10 from a frantic, one-off billing upgrade to one in a series of opportunities seized: to move clinical diagnosis to a new level, for example, to optimize EMRs, to meet meaningful use requirements, to satisfy quality initiatives such as the Physician Quality Reporting Initiative and to support robust analytics and reporting.

Can a roadmap do all that? Hardly.

George Schwend is president and CEO of Health Language, Inc. of Denver, CO.

HIE Market, A Shot in the Arm
By Tim Remke

The HIE market finally got a shot in the arm with the passage of the federal stimulus. This and other tailwinds sent hundreds of millions of dollars over the next few years toward the HIE market. From this point on, the HIE market gets muddled. Questions such as who is marketing their solutions to which markets, what deployed-use cases are functional or even operate at a high level, and what differences exist between multi-stakeholder, state, and private HIEs are mixed among many other multi-faceted questions.

The definition of a health information exchange has diluted the significance of surveys and results, particularly when they seek to understand what types of data are exchanged, the number of HIEs in the market and their respective operational capacity, and technological and governance structures. Simply, too many results are ‘self-reported’ and produce statistically insignificant, inaccurate, or misleading data points.

Of particular concern, several market surveys and reports related to the HIE market have commingled data by combining statistics from provider organizations that use solutions developed for basic hospital portals — a far cry from a broader HIE platform. Finally, HIEs may be private, multi-stakeholder, or statewide entities. In addition, payer system and public health play a role of delineation. The idea of ‘community HIE’ is limiting, and does not tier appropriately the HIE market.

With this perspective and understanding, we assess a few basic aspects of the current state of the HIE market.

Target Markets
A tremendous amount of friction exists over what specific HIE markets are accelerating at a pace greater than others, and which companies target each market. For example, a few vendors are persistent in their belief that the private HIE market is really the first ‘go-to-market strategy’ place. They look for localized geographies or a few hospitals to install an HIE platform as an overlay solution to act as a ‘buffer’ to a larger regional or statewide exchange.

Within the same HIE market, but more counter to this strategy, are the vendors who seek larger contracts from statewide or vast regional, multi-stakeholder exchanges. Two different approaches that produce some small and other more significant variation in solution focus and offerings. However, the data indicates a consistency that is expected. A

ll vendors will market to almost any market. However, slicing through the data, we see vendors that are targeted. All focus on hospital to hospital environments. Approximately 85 percent focus on providing an acute to ambulatory framework, also; and less than 40 percent offer a platform that readily integrates physician groups.

In addition, and somewhat paradoxically, many solutions are simply not designed to operate as platforms for vast geographic or state exchanges. Therefore, for the multi-stakeholder market, HIE solutions are discriminating. Contrast arises between target markets and the ability of the solution to match the specific market. Unlike other segments, HIEs seem as equally conflicting in details as they are syncopated — characteristics of a nascent market (relative to the past few years).

Critical Minimal Requirements
In recent months, we have seen a number of RFPs that contain a significant number of demands. However, they mask a serious issue in the HIE market. The reality is most HIEs are ill-equipped to take on sophisticated and complex solutions, use-cases, and technical architectures they greatly desire. Furthermore, over 65 percent stated the minimal exchange of data from information systems were posing “mission critical problems” with their respective exchange, and will succumb to “serious delays”. The table below looks at minimum versus preferred requirements for an exchange structure.

Conclusion
Finally, the HIE market is dynamic and has hit full stride. Companies that have weathered the storm seek potential exits (i.e. merger and acquisitions) while others are ramping their solution for the future. The market will likely extend an abnormal growth rate for the next one to two years.

However, many unanswered questions will remain. Business models, measured quality improvements, and funding, among other items persist into the future as open question marks. For example, initial stimulus funds will jump start statewide HIEs. However, after these funds have been depleted, real concerns about long-term viability and funding sources will endure.

Tim Remke is vice president of business development for HealthcareCIO, which produced the Health Information Exchange (HIE) Comprehensive Analysis & Insight report from which aspects of the above article were taken.

Readers Write 7/15/10

July 14, 2010 Readers Write 8 Comments

Achieving EMR Usability in Today’s Complex Technology Market
By Odell Tuttle

As HIMSS began recognizing the importance of human/computer interaction, its EHR Usability Task Force developed the 11 principles of usability — a framework which provides methods of usability evaluation to measure efficiency and effectiveness, including patient safety. This framework is invaluable as many of today’s clinical systems do not provide adequate support due to poor interface design.

From multiple data interchange and reporting standards, to formatting and encoding standards, to clinical processes and procedures — not to mention the government organizations and legislation — the EMR domain is vast and complex. For hospitals looking to implement an EMR, it is important they choose a technology partner experienced with proven, tested, and used systems. For rural community hospitals, it becomes critical, because their needs are so unique.

The HIMSS 11 principles of usability is a valuable tool in the EMR selection process. A summary of the HIMSS usability principles include:

Simplicity
Everything from lack of visual clutter and concise information display to inclusion of only functionality that is needed to effectively accomplish tasks.

Naturalness
This refers to how automatically “familiar” and easy to use the application feels to the user.

Consistency
External consistency primarily has to do with how much an application’s structure, interactions, and behaviors match a user’s experience with other software applications. An internally consistent application uses concepts, behavior, appearance, and layout consistently throughout.

Minimizing Cognitive Load
Clinicians in particular are almost always performing under significant time pressure and in environments bursting with multiple demands for their attention. Presenting all the information needed for the task at hand reduces cognitive load.

Efficient Interactions
One of the most direct ways to facilitate efficient user interactions is to minimize the number of steps it takes to complete tasks and to provide shortcuts for use by frequent and/or experienced users.

Forgiveness and Feedback
Forgiveness means that a design allows the user to discover it through exploration without fear of disastrous results. Good feedback to the user supports this goal by informing them about the effects of the actions they are about to take.

Effective Use of Language
All language used in an EMR should be concise and unambiguous.

Effective Information Presentation – Appropriate Density
While density of information on a screen is not commonly measured (though it can be), it is a very important concept to be cognizant of when designing EMR screens.

Meaningful Use of Color
Color is one of several attributes of visual communication. First and foremost, color should be used to convey meaning to the user.

Readability
Screen readability also is a key factor in objectives of efficiency and safety. Clinical users must be able to scan information quickly with high comprehension.

Preservation of Context
This is a very important aspect of designing a “transparent” application. In practical terms, this means keeping screen changes and visual interruptions to a minimum during completion of a particular task.

Reliable usability rating schemes offer product purchasers a tool for comparing products before purchase or implementation.

Making complex things appear simple is a very difficult job. However, by utilizing the HIMSS 11 usability principles, healthcare providers are armed with a powerful tool in the EMR selection process.

Odell Tuttle is chief technology officer at Healthland.

Tech Talk and Market Strategy – Smart Phones
Mark Moffitt and Chris Reed

Tech Talk – Dictating Reports within an iPhone App

Good Shepherd Medical Center developed an iPhone app that has achieved a very high rate of adoption by physicians (95%) by providing a high degree of customization. The second most popular feature of the app is accessing and playing radiology dictation when a report has not been transcribed and is not available for viewing. Viewing lab data is first.

One reason this feature is popular is that it eliminates the need for a physician to call a dictation system and enter an ID, medical record number, etc., on a telephone keypad. Using the iPhone app. they simply press a virtual button to play a dictation on the iPhone. One less gadget a physician has to futz with.

It seemed logical that physicians would appreciate being able to record a dictation and view clinical results on the iPhone simultaneously without calling a dictation system and entering information on a telephone keypad.

Initially, we planned to integrate our iPhone app with a native dictation app. Unfortunately, this configuration requires multitasking to dictate while viewing clinical information on the iPhone. About one-half of the physicians using the app have the 3G phone. iPhone OS4 (operating system) supports multitasking but runs slow on 3G phones.

iPhone OS3.1.3, the latest OS designed for the 3G and 3GS, supports viewing Web pages while talking on the phone. We used this configuration to provide for the ability to dictate reports and view clinical results from an iPhone. Our iPhone web app uses the URL scheme “tel” to send commands to the iPhone phone app.

tel: <1>, <2>, <3>, <4>, <5> # note: “,” instructs phone to pause

Where:

1. Telephone number for the dictation system.

2. Physician id.

3. Site id (hospital).

4. Job type (H&P, discharge summary, progress note, etc.).

5. Medical record number.

The shortcoming of this approach is that the iPhone dials slowly the entries after the initial phone number. However, it is a big improvement over having a physician call the dictation system and enter information manually.

This is not our final solution. Sometime late this year or early next year when most physicians are using a 3GS or iPhone 4, we will switch to using a native app to dictate a report. If we had more resources, we would provide a version for iPhone OS3.1.3 and one for OS4.

Market Strategy – Smart Phones and EMRs

If the battlefield for winning the hearts and minds of physicians using electronic medical record (EMR) systems is shifting to smart phones and iPad-like devices, and I think it is, this trend may open the door for vendors like Meditech, Cerner, etc. to derail the Epic juggernaut.

Newer systems like Epic hold an advantage over older systems in terms of usability and user interface design. Software written for smart phones that operate over an underlying system can hide these flaws. It is possible, I contend, to neutralize Epic’s usability advantage over older systems among physicians using an “agile” smart phone software model. An agile model is one that puts in the hands of the customer the ability to rapidly modify and deploy smart phone software to fit the specific needs of an organization. This approach does not change the functionality of the underlying system.

Customers using agile smart phone software can:

1. Configure the app in different ways to greatly improve flow for different kinds of users, e.g. hospitalists, specialists, and surgeons; and for different types of smart phones.

2. Add data to the user interface to guide users toward a specific objective. For example, display house census, length of stay, observation patients and hours since admission, pending discharge, one touch icon for pending discharge alert, etc.

3. Add features that make the physicians work easier. Examples include one touch icon to call patient’s unit or nurse, play recording or dictate on the smart phone while viewing clinical results; access medication list directly from a PPM EMR without a patient master index between systems; receive clinical alerts; etc.

To compete, smart phone software must be core to your business. Give credit to Epic for recognizing the strategic value of their smart phone software. However, Epic’s smart phone software is “rigid” and that leaves them vulnerable to smart phone software that is agile.

Mark Moffitt is CIO and Chris Reed is Manager at Good Shepherd Medical Center in Longview, Texas.

Readers Write 6/14/10

June 14, 2010 Readers Write 20 Comments

The EHR Manifesto
By Recently RIFed

A spectre is haunting America — the spectre of Meaningful Use. All the powers of traditional vendors have entered into a holy alliance to exorcise this spectre: Executive Office and ONC, Allscripts and Eclipsys, Epic, Cerner, McKesson, and Meditech.

Where is the software vendor that has not been decried as unusable by its opponents in power? Where is the software vendor that has not hurled back the branding reproach of unusable software, against the more integrated vendors, as well as against its reactionary adversaries? (My apologies to Karl and Friedrich).

10 Point Program to Improve EHR software

Less configurable. The Demotivators® said it best “When people are free to do as they please, they usually imitate each other”. Every hospital or physician practice is unique — they uniquely solve the exact same problems everyone else is facing.
Better designed. End-user input and UI design should be part of the specs, not the pilot.
Customer-prioritized enhancements. Fifty percent vendor-driven (sales and demo feedback, regulatory requirements, infrastructure, etc.), 50% prioritized by customers. Yearly process, projects grouped to be equal number of hours, one vote per licensed bed, top x projects will be roadmapped to fill 50% time.
Consensus-driven standard content and configuration. Vendor designed, large group customer editing — majority rules, everyone uses.
Remote hosted. 99.999% uptime, capacity and response time are key requirements.
Rapid install. If you’ve followed 1-5, training the end-users should be the most time-intensive phase of the implementation.
Qualified buyers. We’ll sell to you if you agree to: follow our standard workflows, use our standard build and participate (end-user input, content design, and prioritization). Must agree to mandate adoption! Better to support 50 involved, committed customers than 100 unhappy, non-standard, partially-implemented, low-adoption targets.
Equitable pricing. Low upfront, subscription-based. Every customer pays the same, scaled by size or volume.
Play nice with other vendors. Integration > Interfacing > Interoperating.
Record portability. Remove vendor lock-in. The intersection of the NHIN and CCDs with the market transitioning to replacement will make this a necessity. You know it will be mandated eventually.

I can’t think of a single vendor that would get a passing grade on my 10-point scale (even the industry darling would only receive a 40%). But please, prove me wrong and post comments. As I review my RIF package and dust off my resume, I’d love to be proven wrong (and find out they’re hiring) …

Personally, I’d love to see a new breed of vendors emerge. Maybe someone will submit a FOIA request and hire a team of developers and clinicians to polish and fill in missing functionality. Maybe even someone willing to follow my manifesto and explore a co-op or non-profit corporate structure. Forget the socialization of medicine, let’s socialize the vendors. Until that happens, I’ll continue to remain anonymous and try to work from within.

Jump-Start HIEs with Integrated Health Records
By Ravi Sharma

One of the challenges that most EHR systems will have in satisfying the government’s Meaningful Use requirements will be to establish connectivity and interoperability with other providers’ systems and ancillary services. Disparate data from multiple providers must come together as a more complete patient-centric record to achieve this goal, and not all providers are ready for it. These and other business and logistical issues are some of the challenges that health information exchanges (HIEs) have encountered.

One solution is to use technology to leverage data generated through existing business relationships. This can be done through a Web-based, patient-centric “Integrated Health Record” (IHR) that integrates data from multiple sources and institutions. An IHR provides up-to-date, community-wide, patient-centric data such as lab and imaging orders and results, incorporating both hospital and reference labs.

It also can be used for ordering prescription drugs and leverage the patient’s allergies, drug history, and even lab data to prevent adverse events. Physicians can even follow the inpatient encounters for patients admitted in connected hospitals, along with outpatient data, from anywhere over the Web.

IHRs also improve the ability for patient care teams — physicians who must collaborate to provide comprehensive care — to coordinate care and share patient records. Today, such clinical information between referring physicians is shared via fax, mail, or phone. Even when practices have EHRs, they’re often unable to send key patient data electronically to other physicians who may be using different EHR systems.

The Meaningful Use criteria require such exchanges to occur using standards such as Continuity of Care Document (CCD) and the Continuity of Care Record (CCR), but few systems are capable of using such standards. That’s partly because EHRs aren’t designed for information exchange and also because, in the absence of HIEs, the transmittal of CCDs requires point-to-point interfaces. An IHR that already can create connections to multiple EHRs can act as a link to exchange CCDs or CCRs.

The IHR is not designed to replace EHRs or CPOE systems, but rather to collaborate with them to connect them with other information sources. In that sense, the IHR unifies and facilitates the patient-centric data exchange between various entities to realize the formation of HIEs. The IHR further facilitates the integration of data from multiple sources by normalizing data from disparate sources using standards specified in Meaningful Use, criteria such as LOINC for discrete lab data.

Rather than upfront investments in MPI and other expensive technologies, HIE pilots can greatly benefit from the use of technologies like the IHR. The IHR can not only serve as basic HIE, but facilitate HIE participation by providing key information where and when it’s needed on the front lines of patient care.

Ravi Sharma is president and CEO of 4medica.

Thoughts on Eclipsys-Allscripts
By Tim Elliott

The coming together of two heavyweights in the healthcare IT industry, Allscripts and Eclipsys, has the potential to open doors for their existing and future customers, third-party developers, and patients. There will be some challenges, too — including helping current customers integrate legacy Allscripts and Eclipsys systems alongside new modules — but this can be considered another opportunity for outside vendors whose technologies bridge the gaps between Eclipsys and Allscripts applications.

Detractors may be lampooning the Allscripts / Eclipsys “One network, one platform, one patient” slogan, but in truth, the merger does create a cohesive, cradle-to-grave care solution by uniting pre-acute, acute, and post-acute care information, as well as simplifying financial and performance management with non-clinical data.

The use of a common .NET technology stack offers the possibility of seamless integration and increased usability for clinicians and administrative staff. It also makes it easier for third-party software providers to deliver bolt-on solutions that further enhance Allscripts / Eclipsys offerings in physician practices, hospitals, home health, and other care environments. These external vendors will be crucial if Allscripts / Eclipsys is to succeed in bringing together previously disparate patient populations, which will require capturing and managing data from multiple sources in a centralized manner.

Tim Elliott is CEO of Access.

Readers Write 5/17/10

May 17, 2010 Readers Write 6 Comments

Medical Image Sharing: The Future is In the Cloud
By Eric Maki

Is the world coming to an end — the healthcare IT world of proprietary silos, that is? When it comes to the sharing of radiology images and report files, the answer appears to be an emphatic YES.

My facility, the Great Falls Clinic in Great Falls, Montana is just one of dozens I know about that now share full-resolution images and reports via cloud-based technology.

The approach works seamlessly. Both uploading and downloading aren’t much more complicated than sending an e-mail with an attachment. No one needs to babysit the process, which at a leanly staffed rural clinic like ours, is a big advantage. And there are no requirements to establish and maintain the link, unlike the VPNs that were our workaround until recently.

There are advantages to proprietary healthcare IT technology. But when it comes to sharing images, proprietary IT has posed challenges throughout my entire state. Because nearly all of Montana’s medical facilities are less than full-service, we often have to transport patients with major issues to a large hospital in the nearest big city. The docs there, of course, want to see whatever imaging studies and accompanying info we generated at our facility. Proprietary IT forced us to use VPNs or other workarounds like burning and sending CDs.

There was also a major expense involved in all the time we spent to maintain our VPNs every time we installed an IT upgrade such as a beefier firewall. Some of my colleagues in Montana who relied on CDs for file sharing were having other frustrations. Sometimes the CDs couldn’t be read on the recipient hospital’s computers. Sometimes the CDs were damaged, couldn’t be read anywhere, or worse, were lost and never found.

We were fed up with this situation in our state, so 30 of our facilities formed an organization to search for a better solution. We called it Image Movement of Montana, or IMOM. We asked several PACs vendors for ideas and, fortunately, one had just developed a cloud-based service that met our needs. It required no new capital acquisition of hardware or software and bypassed all the proprietary hurdles that had plagued us to this point.

The Great Falls Clinic was one of the six facilities that tested the system on behalf of all 30 IMOM members. It worked pretty much without a hitch. A problem that vexed us for many years was suddenly solved, just like that.

The system we use is called eMix, but there are other players in this game — LifeImage and SeeMyRadiology, for example. From what I’m reading, there may soon be more cloud-based image-sharing services available. It’s clear to me that the medical image sharing’s future is in the clouds.

Eric Maki is manager of information technology at the Great Falls Clinic, Great Falls, MT.

NHIN CONNECT Code-a-thon
By iReporter

ONC sponsored what it called an NHIN CONNECT code<a>thon held in Miami a few weeks back. Like the IHE Connect-a-thon held earlier this year in Chicago, this forum’s attendees were primarily hands-on senior software architects and engineers who are refreshingly working together to tackle our industry connectivity woes.

This meeting had three components. The main one was two days of in-depth collaborative sessions to discuss a variety of technical topics regarding the current CONNECT version as well as group planning for future version features. The second was the CCD template competition won by Georgia Tech that you highlighted here.

The third and most important component in terms of potential long-term impact on the industry was the creation of the Electronic Health Record Interoperability Special Interest Group (EHRI-SIG). To a standing room only audience (and 60 online participants), the CONNECT team presented their ideas and reached out to the private sector for help in establishing a group committed to advancing the state of practice involving medical record interoperability.

One unique idea presented involved the use of XMPP, a protocol underneath applications like Skype and instant messaging. The idea presented was to exploit this protocol for implementing new communication and exchanges between doctors, patients, personal health records, laboratories, and pharmacies. Another interesting discussion revolved around the CONNECT teams’ desire to implement no-click solutions and to stop the phone from ringing in the doctor’s office.

The meeting video/audio and presentation and audio can be found here.

This modest event could very well signal the beginning of how health information exchange will fundamentally be changed and accelerated in this country. By combining the best of the NHIN CONNECT industrial strength “trust fabric” with the some of the same concepts being considered within NHIN Direct, this effort is positioned to provide a “sweet spot” that likely will appeal broadly to health care industry stakeholders as they tackle meaningful use under Stages 2 & 3.

EHRI-SIG will be making specific decisions on how to move forward at its second meeting in DC on June 2. As a true working meeting, attendees are required to submit short use case descriptions and be representatives of EHR, lab, pharmacy, PHR, etc. vendors so that the outcome of the discussion can potentially translate into enhancing their own product capabilities. Information can be found here.

This initiative is an open challenge to the healthcare industry vendor community to demonstrate true leadership at a critical time in order to improve outcomes by getting the right information to the right person at the right time. It will be interesting indeed to see who steps up and who does not.

Creating Efficiencies through Enhanced Communications: Alerts and Notifications
By Jenny Kakasuleff

With the recent passage of health care reform and the 30 million newly insured individuals estimated to enter the marketplace, providers are under increasing pressure to improve productivity and efficiencies to meet increasing demand. These challenges must be met while simultaneously improving the quality of care patients receive.

Historically, providers of health care services have taken a piecemeal approach to implementing health information technologies. This has resulted in a number of disparate systems that do not communicate with one another, and contribute to a growing army of devices that health care providers must haul around with them, or have at their disposal in a largely mobile environment.

The alerting and notification systems still in use at many hospitals today are a conglomeration of proprietary systems and devices utilized to perform one particular function — a bedside monitor that sends an alert to the central nursing station to report a change in a patient’s vitals; a tracking system that allows any provider with computer access to locate a device; or a lab information system that sends an e-mail to indicate an abnormal lab result.

While this approach provides many individual solutions to overcome past inefficiencies, it has been uncoordinated, and as a result, creates its own set of problems. The responding provider is saddled with a number of different communication devices to perform a range of non-standardized tasks.

Most professionals today have the ability to perform all of their business-related (and personal) activities via a single mobile device. We make phone calls, check our e-mail, manage our calendar, pay our bills, locate people and places using GPS, listen to music, connect with friends and family through SMS text and instant messaging, or through social media networking — all through one multi-functional device. It is amazing that the same demand is not pervasive in the medical sector.

Health IT solutions now exist that not only address the problems of the past, but work to streamline the disparate systems currently in use into a single, standardized messaging system that delivers a range of alerts and notifications of varying importance to the appropriate recipient. Also, with the integration of an enterprise-class communication solution, providers now have the ability to receive alerts from each proprietary system — electronic medical record (EMR), hospital information system (HIS), nurse assignment, lab information system, etc. — via a single device powered through a unified communications system.

Different messages are delivered based upon their level of importance and escalated until its receipt is acknowledged. The HIS is then updated and auditing trails create a measure of quality tracking and control. The recipient can then respond to the relevant options generated without locating a phone, computer, or other staff member.

As the American Recovery and Reinvestment Act (ARRA) forces health care professionals to evaluate how best to implement and utilize their EMR systems to qualify for meaningful use incentives, their approach should be holistic; cognizant of current and future challenges; and focused on gaining as much mileage as possible from the investment.

Jenny Kakasuleff is government liaison with Extension, Inc. of Fort Wayne, IN.

Readers Write 5/10/10

May 10, 2010 Readers Write 12 Comments

Thoughts About athenahealth
By Deborah Peel, MD

Another misguided, uninformed EHR vendor will discount the price of EHR software for doctors willing to sell their patients’ data!

How is it possible to be so unaware of what the public wants? The public doesn’t want anything new or earth-shattering, just the restoration of the right to control who can see and use their medical records in electronic systems.

Not only is the practice of selling your patient’s data illegal and unethical, but the new protections in the stimulus bill require that patients give informed consent before their protected health information can be sold. So selling patient data without consent is now a federal crime.

Quotes from the story:

athena’s EHR customers who opt to share their patients’ data with other providers would pay a discounted rate to use athena’s health record software.
athena would be able to make money with the patient data by charging, say, a hospital a small fee to access a patient’s insurance and medical information from athena’s network.
Caritas Christi [Health Care] initially launched athena’s billing software and service in October and then revealed in January that it decided to offer the company’s EHR to physicians.
How many patients would agree to sell their health records to help their doctor’s bottom line AND at the same time put their jobs, credit, and insurability at risk?

Health information is an extremely valuable commodity, so people are always thinking of new ways to use it.

What will athena’s informed consent for the sale of health patients health data looks like? Will athena lay out all the risks of harm? Will athena lay out the fact that once the personal health data is sold, the buyer can resell it endless to even more users? Will athena caution patients that once privacy is lost or SOLD, it can never be restored?

I guess some people are so out of it they do not realize what a barrier the lack of privacy and lack of trust is to healthcare. HHS reports 600,000 people a year refuse to get early diagnosis and treatment for cancer because they know the information won’t stay private. Another 2,000,000 refuse early diagnosis and treatment for mental illness for the same reasons.

Check out slides from a recent conference at the UT McCombs Business School on the subject of patient expectations, privacy and consent.

Deborah C. Peel, MD is a practicing physician and the founder of Patient Privacy Rights.

Thoughts About athenahealth
By Truth Seeker

Um, I think we need to settle down here, folks. I may be wrong, but I believe when athena refers to athenaCommunity and the exchange of information, they are referring to the following hypothetical scenario:

A patient whose primary physician is an athena customer needs to be admitted to the hospital. athena delivers to that hospital a clean, clinically accurate, and up-to-date record of that patient’s medical history and charges the hospital a few bucks. athena is able to charge the primary care physician a lower fee for their EMR service because they are shifting some of the financial burden to the hospital. And intuitively, this make sense for a couple reasons:

The push towards electronic medical records is to enable greater exchange of information and better coordination of care, etc So when athena talks about athenaCommunity, I’m fairly certain that they’re not talking about a sinister plot to share info with hospitals so they can refuse to admit high-risk or expensive patients. (Seriously, the conclusions people draw from articles like this without doing their homework can be completely ridiculous, but I suppose that casting baseless aspersions is just the nature of informed discussion in the Internet era.)

They’re just talking about handing the patient over to another provider and making sure that the new provider has a completely accurate and up-to-date record of that patient’s medical history, and of shifting the financial burden from the handover away from the primary care physician. What a "privacy disaster" … a sheer outrage!

And second, I’m no healthcare economist, but I’m pretty sure that a) the hospital really wants and needs that patient’s medical history and that athena is probably better positioned to deliver it in a more useful format than a lot of their competitors; and b) it’s probably worth a lot more to the hospital than a few bucks.

I’m not an athena employee or other stakeholder, but I do think that they continue to think of innovative new solutions to problems, bottlenecks, and inefficiencies in the healthcare system. Unfortunately, they seem to have a bulls eye on their backs right now. I for one am happy that we have smart people like Jonathan Bush out there coming up with creative new solutions.

Why Emergency Physicians Prefer Best-of-Breed IT Systems
By John Fontanetta, MD, FACEP

According to a recent report from KLAS, some hospitals are replacing standalone, best-of-breed (BoB) emergency department information systems (EDIS) with enterprise solutions that are leaving ED clinicians — and often their patients — unsatisfied. Why unsatisfied? Because the clinical functionality in enterprise solutions is both less comprehensive and less efficient for the ED environment and they are just so hard to use.

This report has re-energized the debate over the benefits of the two kinds of systems. IT professionals prefer the seamless interoperability supposedly offered by single systems, but the fact is that many large vendors have simply bought and shoehorned in a separate ED system. The resulting systems have their own interface issues.

Like many of my fellow ED physicians, I have found that a first-class BoB system tailored specifically to the needs of the ED, in our case EDIMS, offers a number of advantages. For example:

Workflow in the ED is measured in seconds and minutes rather than hours or days. The fewer clicks required, the faster the care. At Clara Maass Medical Center, we can issue complete sets of orders in as few as three clicks, enabling our physicians to be more productive.
Trying to retrofit an inpatient IT system to the ED is difficult because the ED is just so different from the floors. Customized ED order sets with a linked charge capture system means less delay between treatment and billing, not to mention a more accurate capture of charges, which has dramatically increased our per-patient revenue.
In the same way, customized alerts that tell the ED staff what they’re forgetting to document cuts back on the number of claims denied due to missing or inaccurate information. At Clara Maass, we have slashed such denials by 75%.

One of the most important things about a good ED system vendor is responsiveness. The vendor should be able to quickly accommodate the ongoing changes in standards and regulations. For example, at Clara Maass, when the H1N1 virus first appeared in 2009, we had templates for recommended care and discharge instructions built into our system by our BoB vendor within 24 hours. And when we decided to create an observation area, they promptly responded with observation-specific templates and order sets and created a secondary note option for the observation physicians.

The EMR system has enabled us to make a number of other improvements in our ED. For example, we have reduced the average patient turnaround time by over 30%. We have boosted the number of EKGs we perform within five minutes of a patient coming through the door from 46% to more than 90%.

Overall, my specialty has been slow to adopt EHRs, not because we don’t see their importance, but because they have a reputation for being unwieldy and unresponsive to the requirements of the ED. With more and more EDs adopting BoB systems that are designed to support ED clinicians’ intricate and demanding workflows, physicians are starting to realize that an EHR can actually be an advantage in our fast-paced environment, rather than a burden.

CIOs are finding that these BoB systems can offer the same, if not better, integration capabilities than a single, enterprise solution. While many of the HIS vendors are inflexible when it comes to working with other systems, BoB systems have always had to offer integration solutions and many pride themselves on their ability to integrate with almost any system.

John Fontanetta MD, FACEP, is chairman of the department of emergency medicine at Clara Maass Medical Center, Belleville, NJ and chief medical officer of EDIMS.

Digging for Gold in your HIT Applications
By Ron Olsen

Over the past few years, hospitals have focused IT budgets and resources on purchasing applications to enhance their HIS. Many facilities have spent tens or hundreds of thousands — millions for the larger hospitals — on licensing, maintenance, and ongoing professional services.

In the feeding frenzy to continually acquire and implement the latest healthcare information technology, most IT/IS teams are neglecting to ask basic but important questions about their existing applications, such as:

Are we using the software to its fullest extent?
Have we turned on every feature we’re currently licensed for?
Are HIT products meeting the needs we identified when planning the deployment?
Have we asked users what they’d like to see added to the product, and if so, has that been communicated to the vendor so they can include it in a future version?

Asking questions does not cost anything and end users are usually very vocal about what they’d really like to see software do for them. Their invaluable real-world input is useless if there’s no feedback mechanism, or if your team refuses to incorporate it into product roadmap discussions with vendors.

In a time in which hospitals’ funds are tighter and IT budgets frozen or cut, it’s time to double back and review what products you have purchased and their capabilities. Maybe re-present the product to different areas of the facility explaining existing functionality again, and introducing new features that have been added since the initial implementation. Now that the users have gotten a refresher, they may identify functionality that was not implemented initially and would now prove useful.

Healthcare technology vendors are always eager to showcase new features and theoretical uses for these at sales presentations, but IT/IS admins often overlook “hidden gems” in the software that other hospitals are actually using. If the vendor has a user group, listservs, or an online forum, these are great places to start, not to mention that they cost nothing and consume very little time.

These collaborative tools may enable your team to discover other use cases that even your vendors have not thought of. There are a lot of people in the healthcare IT trenches creating workarounds every day. There may be capabilities within current products to join with other systems within your tool bag to create a new or improved process that is, again, a freebie.

One of the most over-used buzz words in healthcare IT is “interoperability,” a is really a big word that self-important people use to describe data transfer. When thinking about data transfer at a basic level, almost every HIT product can output to a printer. A printer can be easily set up to print to a file. So now you have data in a file format.

Scripting tools can manipulate those files, turning them into almost any format imaginable. With the correct format, data can be transferred to disparate systems, individually or concurrently, via a data stream. This could be a raw text file, compressed zip file, encrypted e-mail file, FTP, or an HL7 file.

This method is easily applied to an enterprise forms management system. If it has a decision engine, you could print a form set from it and then have the engine input the data to a database for audit trails (you should be able to choose the data points). Next, the engine sends the data to a file and launches an application to text the ordering physician that the patient just presented, based on the data in the text file.

If you’re a budget-conscious healthcare IT professional who wants to better meet the needs of your user community, I implore you to take another look at the systems you’re already working with. In my many years as a system admin at a community hospital, getting more out of the tools available to me (instead of just relying on new purchases) helped me deliver more effective tech solutions to my users, positively impact patient service, and keep decision makers happy by saving money.

You, too, have gold nuggets hidden in your existing software. It’s up to you to find and use them.

Ron Olsen is a product specialist with Access.

Readers Write 5/3/10

May 3, 2010 Readers Write 3 Comments

Goodbye Data Warehouse and Cubes, Hello AQL
By Mark Moffitt

For the last two years, I have been researching systems to replace the data warehouse used for report-writing in our organization. This effort has been driven by the desire to provide better service to other departments that rely heavily on data reporting for day-to-day operations.

The idea is to push data to users so they can perform in-memory analysis and display of large amounts of data, a system that would replace the current process of requesting custom reports and spreadsheets from the information services (IS) department. The current process requires considerable resources in the IS department and requests can take several days if the number of requests for reports in the queue becomes large.

The requirements for a new system are straightforward, but somewhat daunting:

1. Put data into users’ hands so they can perform business intelligence.

2. The cost of the system, including license, hardware, and consulting, must be offset by the direct costs of shutting down existing systems.

At GSMC we operate Meditech Magic and use a data warehouse for analytics and business intelligence. The data warehouse stores about nine years of financial data in about 650 GB. The data in the warehouse is updated nightly. SQL reports have been developed to provide reporting across the organization.

IS at GSMC is bombarded with requests for new reports. These requests come in the form of specialized requests for data that often require modifying an existing SQL query or writing a new query. The process is iterative that starts with gathering requirements for a report, modifying or writing new SQL queries, generating a report and sending it to the customer.

Typical turnaround times are variable and are highly dependent on the number of reports in the queue to be developed. Best case scenario is four hours, typical is two to four days. Often the customer will, upon review of the report, ask to include or exclude specific data. This back-and-forth typically occurs several times until the report meets the customer’s needs.

The IS department at GSMC has several analysts who spend a good part of their time responding to requests for data. It is a never-ending demand.

We researched the use of OLAP (online analytical processing) cubes to provide data to users. The advantages of cubes is well documented and includes the ability to drill down to details and analyze data in ways simply not possible with reports or spreadsheets. The disadvantage to cubes is that data must first be aggregated. If a user needs data not included in the cube, then the cube must be rebuilt. Also, a data warehouse is required. Finally, building and maintaining cubes require personnel with specialized skills.

About seven months ago, I read on HIStalk about a new company named QlikView. I researched the software and it sounded too good to be true. However, I was intrigued that QlikView doubled revenues in 2008, not an especially good year for selling enterprise software as the national economy was in a major recession.

On the surface, QlikView is a business intelligence solution that consists of a data source integration module, analytics engine, and user interface. QlikView is based on AQL and is completely different from other OLAP tools.

Through AQL, QlikView eliminates the need for OLAP cubes and a data warehouse, replacing the cube structure with a Data Cloud. A Data Cloud does not contain any pre-aggregated data but instead builds non-redundant tables and keeps them in memory at all times. Queries are then created on the fly and are run against the Data Cloud’s in-memory data store.

Under AQL, all data is stored only once, and all data associations are stored as pointers, so a Data Cloud database becomes more efficient at retrieving records than do OLAP databases. A Data Cloud database is also much smaller since records are not repeated through aggregation and its structure never has to change. The architecture allows for a flexible end-user experience because it doesn’t require aggregation or pre-canned queries that try to cover every possible analytical scenario a user can create, unlike data cubes that require both. (1)

Data Clouds run in memory and AQL reduces in-memory storage requirements by about 75% as compared to source data. In-memory Data Clouds can be stored as AQL files for archiving. AQL disk files are 90% smaller than source data. Think of an AQL file like an Excel file where data can be added and deleted and the file saved with different names for archiving purposes.

The price point for the software is about $150,000 (one-time fee) for our health system. Hardware costs are about $15,000 for a server with 98 GB of memory. We expect consulting fees to total $150,000 for a SME in hospital financial data with QlikView experience. We worked with RSM McGladrey on a consulting proposal as they have well-qualified personnel in this space.

If you know much about the BI/Analytics space, you may question the low cost of the software and consulting services. This has everything to do with the AQL model. RSM McGladrey quoted a revenue cycle effort at eight weeks and includes:

Transfer data from existing systems to QlikView
Data validation
Census analysis
AR analysis
Insurance contract analysis
Hindsight analysis
Train IS staff on data extraction

The revenue cycle statement of work is only one component of the $150,000 quote for consulting services from RSM McGladrey for implementing QlikView at our organization.

The total cost for QlikView at GSMC is $315,000. That will be directly offset by shutting down a data warehouse, savings from using QlikView for analytics versus another system where the cost of consulting services had already been quoted and budgeted, and other savings. We expect additional direct benefits from having deep analytic capabilities with our revenue cycle data.

QlikView has a number or healthcare customers. I believe you will be hearing more about the company in healthcare in the years ahead as they achieve market awareness of QlikView software’s capabilities and price point.

We have not yet purchased the package. If we do, I’ll write a follow-up article on our experience.

1 “Qliktech, IBM Provide New View Of OLAP”, Mario Morejon, Technical writer for ChannelWeb, July 18, 2003, http://www.crn.com/software/18839582

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

Humpty Dumpty Leaves Wonderland to Visit Health Information Technology
By Jim Kretz

Suppose I told you that “voting” henceforth would mean you would only be shown a ballot, period. No more selecting your preferred candidate.

Now suppose I told you that your consent to disseminating clinical information did not mean your granting permission, but only your acknowledgement that you saw my information policy — take or leave it. This may remind you of Humpty Dumpty’s scornful assertion, “When I use a word it means just what I choose it to mean — neither more nor less.”

Surprisingly, the insanity of “…use the term ‘Consent’ to mean the acknowledgement of a privacy policy, also known as an information access policy. In this context the privacy policy may include constraints and obligations.” comes from an IHE (Integrating the Healthcare Enterprise) policy paper “IHE IT Infrastructure Supplement 2009” that was taken up (line 157) by the IT Standards Advisory Committee Privacy Workgroup, April 23, 2010.

The authors of this paper — the American College of Cardiology, the Healthcare Information and Management Systems Society, and the Radiological Society of North America — are not mean-spirited, uninformed, or confused. What could result in their clearly having tumbled into a conceptual rabbit hole?

Jim Kretz is project officer at the Substance Abuse and Mental Health Services Administration of the Department of Health and Human Services. His comments should not be construed to reflect the official position of SAMHSA.

Massachusetts HIT Conference Thoughts
By Bill O’ Toole

I had the pleasure of attending a National Conference hosted by Massachusetts Governor Deval Patrick in Boston last week. The conference was billed as Health Information Technology: Creating Jobs, Reducing Costs and Improving Quality.

Keynote addresses were provided by David Blumenthal, MD, National Coordinator for HIT and Vice Admiral Regina M. Benjamin, MD, MBA, Surgeon General of the United States. Health IT Policies and Standards were addressed by a panel that included John Halamka, MD (CIO, CareGroup and Harvard Medical School), Marc Overhage, MD (CEO, Indiana Health Information Exchange), Paul Tang, MD (CMIO, Palo Alto Medical Foundation), Micky Tripathi, Ph.D (CEO Massachusetts eHealth Collaborative) with Tim O’Reilly (President, O’Reilly Communications) moderating.

Another panel discussion on Health IT, Business Opportunities and Job Creation featured leading Massachusetts vendor executives Girish Kumar Navani (eClinicalWorks), Howard Messing (Meditech), Richard Reese (Iron Mountain), Bradley J. Waugh (NaviNet) moderated by Chris Gabrieli (Bessemer Venture Partners).

I could go on and on, but the list would be too long. I mentioned those above to give readers a sense of magnitude and to perhaps share in this small article the profound comfort I felt that "we" are doing this right. Many other highly qualified participants shared their knowledge on all things HIT- and ARRA-related.

What impressed me most was the overwhelming sense of momentum. The stimulus package and its future incentives have so far done exactly what was intended, serving as the spark that has set this massive project in motion. Remaining at the forefront of it all, though, is the goal of better medical care for all. That theme was never lost and was frequently repeated.

As one who until now has found certain parts of most conferences to be extraneous (ok, boring), I felt obliged to inform the far-flung readership of HIStalk that I was extremely impressed with every minute of this two-day conference. If the energy, knowledge, and sincere interest and enthusiasm expressed by those involved in this conference are carried forward to the project at large, then we are truly in for a remarkable change in our industry.

Congratulations to the Massachusetts Technology Collaborative and its Massachusetts eHealth Institute, the Massachusetts Health Data Consortium, and Governor Patrick for organizing this special event. It should serve as the model and be repeated whenever possible throughout the country.

William O’Toole is the founder of O’Toole Law Group of Duxbury, MA.

Readers Write 4/22/10

April 22, 2010 Readers Write 2 Comments

License Rights in Your Software License Agreements
By Robert Doe, JD

Each software license agreement contains a provision which grants specific use rights with regard to the software you are licensing. However, software manufacturers’ standard contract documents may not take into account your organization’s specific use requirements.

As a result, unless your organization has a relatively simple legal structure, you should pay particular attention to this language to ensure the software can be used as you intend it to be used. The extra effort is well worth the time when you consider that without the proper license grant, you may be asked to pay additional, unanticipated fees down the road.

If you don’t alter the standard contract language, typically, the license grant is given only to the legal entity signing the contract. For example, a typical software vendor’s license grant provision might read as follows: “Licensor grants Customer a perpetual, nontransferable, nonexclusive license for the number of concurrent users set forth in Exhibit A to use the computer program listed in Exhibit A (the "Software") at the installation site set forth in Exhibit A for Customer’s internal business purposes.”

In this example, the license grant is given to “Customer,” which is typically defined as the legal entity signing the agreement, which may not encompass all the actual individuals that will use the software. Getting the license rights correct in your contract requires that you know how your organization is structured and who the individuals are that you want to be able to access and use the software, both at the current time and in the future.

If your organization has a parent corporation, or has one or more legal entities that are owned or controlled by your organization or are under common control with your organization, the typical vendor license grant provision will technically not allow any use by the employees of these “affiliate” organizations.

Another example of a situation that is not technically covered in most license agreements is use by contracted providers that are not employees of your organization. In addition, some organizations may have other independent contractors that will need access to the software at various times, such as computer consultants.

With more and more frequency, healthcare organizations are licensing software not only for their own use, but to use on behalf of other smaller healthcare organizations in the community. Similarly, some healthcare organizations are considering re-licensing their systems to smaller organizations at a reduced rate.

In the example license grant language above, use of the software is limited to the “internal business purposes of the Customer.” If the software is to be used, in part, for the benefit of an affiliated or unrelated organization, or re-licensed to such an organization, the license grant will need to be significantly modified to allow for such actions.

When licensing software, it may be worth the extra time to put some thought into how you intend to use the software, both internally within your organization and, if applicable, externally. As part of your analysis, you will need to understand the legal structure of your organization. This information will help you to make sure you have the appropriate license grant in your software license agreements to allow for the use rights you require.

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

Readers Write 04/05/10

April 5, 2010 Readers Write 14 Comments

Has Meaningful Use Already Lost All Meaning?
By Cynthia Porter

The release earlier this year of expanded meaningful use requirements has gotten the healthcare IT community in quite a tizzy. The phrase was on everyone’s lips before, during, and after HIMSS. It was obvious to me
that:

Everyone has a strong opinion about it;
Not everyone understands it; and
The recent passing of healthcare reform has left providers extremely anxious about how they and the vendors they do business with will comply with “it”, depending on what “it” ultimately turns out to be.

I know for a fact that hospital executives’ concerns about their institutions’ abilities to meet requirements and the overly aggressive timetables released as part of the expanded meaningful use requirements has increased exponentially since 2009, when the HITECH Act was initially released.

Nearly 80 percent of 150 hospital executives recently surveyed by Porter Research noted an increased rate of adoption for e-prescribing, patient portals, and EHRs. That’s a 20% increase from 2009, before the expanded requirements were published. So it’s safe to say that providers are jumping on the bandwagon.

Most, however, are worried that the wheels are going to fall off because vendors won’t have enough qualified employees and/or up-to-date resources to meet demand and requirements. One CIO we interviewed believes vendors “will be forced to spend more programming hours around the interoperability and security of their software versus the primary function, which is taking care of patients and making it easier for clinicians to utilize.”

And there’s the rub. Sure, the healthcare IT community will probably benefit from the political machinations going on in Washington, but will the patients? Will vendors rush to provide hospitals with technologies that could have used a few more months of development and trial? Will hospital staff have time to adequately train their IT people to use these new technologies? Will patients pay the price for a rush job?

It’s unfortunate that time will tell, because time is one thing patients don’t have.

Cynthia Porter is president of Porter Research.

Health Reform, Schmealth Reform – Freakin’ Pay Me
By Gregg Alexander

Down here in the primary care trenches, where the pudding meets the pavement (or some such mixed analogy), no matter how much we may want it to, health reform doesn’t seem like it will ever really get to addressing our needs.

What do I mean by that? Simple enough: it is getting virtually impossible to justify staying in traditional primary care any more and, health reform or no, HITECH or no, Congress just walked away and forgot about me and mine.

Despite our efforts to help bring the best we can to those we serve, what do we get? People, be they private insurers or Medicaid, self-pay or no-pay, hospitals, and even IT folks, all telling us what we can and can’t do. We’re told when we are and aren’t allowed to make medical recommendations based upon our knowledge and experience and then we’re told just how much we’re allowed to charge for our expertise. (Disregard whether or not we’ll even get paid anything at all for our time and trouble.)

We fight to get what we believe is appropriate care for our patients, regardless of their insurance or lack thereof. We struggle to make ends meet so that we can offer the advantages of a quality medical home and, perhaps, digital healthcare information management to our patients. We work far too many hours, away from our family and friends, just so we can feel good enough to sleep at night knowing we have done our best to help those who come to us for care.

And then…and then…Congress goes on break before postponing a 21.3% cut in Medicare payments. (Thank you, Senator Tom Coburn, R-OK.) Whether or not they repeal it when they return, CMS will likely withhold payments for at least 10 days before beginning to process those 21.3% reduced payments. For those affected, continuing this Sustainable Growth Rate (SGR) formula is anything but sustainable and quite the opposite of growth.

Ladies and gentlemen, if you’re not already aware, we have a shortage of primary care providers in America. Pushing us toward expensive technology adoption which may or may not truly be ready to really meet OUR needs while reducing the bottom-of-the-barrel payments with which we already struggle, is not going to solve any little piece of our giant healthcare crisis. It will make it much worse as more and more of us leave for less stressful and less beyond-our-control professional lives. All the while, we’ll leave little encouragement for the med school up-and-comers who will doubtful choose to join the ranks of careworn primary care.

Let us worry about dealing with the pressures of making medical decisions and allow us a reasonable income which doesn’t add to the strain. Elsewise…well…how long would you stick around after a 21% pay cut?

From the (weary) trenches…

“Pay me for my work, but I don’t do it for the money.” – Vanna Bonta

Dr. Gregg Alexander, a grunt in the trenches pediatrician, directs the “Pediatric Office of the Future” exhibit for the American Academy of Pediatrics and is a member of the Professional Advisory Council for ModernMedicine.com. More of his blather…er, writings…can be found at his blog, practice web site or directly from doc@madisonpediatric.com.

This Just In: HIRE Bill Signed! Could Hiring Tax Breaks Benefit Your Organization?
By Tiffany Crenshaw

On March 18, 2010, President Obama signed into law the Hiring Incentives to Restore Employment Act (HIRE). HIRE is a $17.5 billion jobs bill that the President says will bolster hiring and incent business owners, creating approximately 250,000 new jobs.

The bill was dramatically scaled back as it passed through the House and Senate, from $150 billion to less than $20 billion. Still, lawmakers say it is the first step in a series of bills designed to encourage job growth.

The Act offers two tax breaks to companies who hire recently unemployed workers, one in the form of a payroll tax exemption and the other in the form of a tax credit. Beginning March 19 and through the remainder of 2010, employers will not have to pay the 6.2% Social Security payroll tax on qualifying new hires. In addition, companies are entitled to a credit equal to 6.2% of an eligible employee’s total salary (up to $1,000) if that new hire is retained for at least 52 weeks consecutively.

To qualify for the tax breaks, new employees must be hired between February 3, 2010, and January 1, 2011. Each new hire must verify in writing that he or she was unemployed for a minimum of 60 consecutive days just prior to being hired. If the worker is replacing an employee in the same job role, he or she is not eligible, unless the previous employee was terminated for cause or voluntarily quit.

There is no doubt that these incentives may not help all companies, but HIRE is a start that could benefit your organization as well as the nation’s unemployment rate. Companies still experiencing depressed revenues due to economic slowdown may not benefit from the tax incentives, but others may find the tax savings to be a valuable advantage towards savings and growth.

Tiffany Crenshaw is CEO of Intellect Resources.

Readers Write 3/24/2010

March 24, 2010 Readers Write 9 Comments

Digital Information is Great, but Only if it’s Accurate
By Deborah Kohn

I am a patient at two local healthcare provider organizations that use the Epic suite of clinical information system modules for their base EHR. Both organizations must not yet have installed Epic’s CareEverywhere because currently, the two Epic systems do not talk to one another (or even look / act like one another). But with time, the installation of CareEverywhere should occur at both.

However, the reason I write this article is that either there is a flaw in Epic’s MyChart, the organizations do not know how to correctly configure MyChart, or there remains an important Epic user training issue. When I visit my providers at both organizations, I receive a hardcopy summary of my visit, which I must assume gets generated by MyChart because also I can view the data online via MyChart. Among many items listed on the summary are Current/ Future/Recurring Orders.

1) Orders listed on the summary and in the system cannot be corrected easily by an organization user, even the provider. I don’t know whether this is a user training issue (e.g., how to easily DC or cancel electronic orders that have been performed but, for some reason, not automatically canceled as Future Orders), a system flaw, or a poor implementation of the function. But for one set of lab orders, I was repeatedly asked for lab work to be performed when the lab work was performed months ago and I had the documentation to support this. Unfortunately, it took several handwritten notes and phone calls from me to the provider to finally update and delete the already performed lab orders from the system.

2) If orders listed on the patient’s hardcopy visit summary are incorrect (e.g., numbers of milligrams, duplicate orders, q 4 months not q 2 months, etc.), again these orders cannot be easily corrected by an organization user. That’s because, according to the organization’s users, these orders come from a different “database” than the “real” orders, which are correct in the system, but don’t print to the hardcopy correctly!

3) Either the Epic clinical system does not include or the provider organizations have yet to install or know how to install the following clinical decision support function: Recently, when my provider at one organization ordered a routine TB test, there was nothing in the system to alert the provider that the same, routine TB test was performed at this organization in July 2009. Consequently, this test was repeated in February 2010 at a cost of $398. When I complained about this, the provider organization commented that it is the provider’s responsibility to look back at all the orders in the system to see if a TB test had been performed within the last several years. I don’t blame the provider for not wanting to scroll through several years of past orders to determine this. And I was sorry I didn’t have my “paper” PHR, which I have kept for at least 30 years, with me at the time to double check this.

Now that electronic PHRs and visit summaries are appearing and patients are beginning to “use” (indirectly) organizational EHRs, not only will the organization’s internal users be complaining about system flaws, poor configurations, or outstanding training issues — but external users, the patients and recipients of health information exchanges, will be added to the lists. Consequently, it’s time our industry professionals address the management of the information, not just the technical and operational mechanisms for the sending and receiving of the information. Because it’s great to receive digital PHRs and visit summaries from provider organizations, but only when the information is accurate! Just ask ePatient Dave!

Deborah Kohn is a HIM professional and power user of EHR systems who not only makes sure her analog and digital health record information is correct, but remains dumbfounded that she need not do same with her bank record information.

We Are In the Business of Letting Clinicians Treat Patients
By Jef Williams

While riding the shuttle to my hotel at HIMSS in Atlanta, I overheard two strangers behind me comparing stories of the conference to one another. Their short exchange encapsulated for me both the HIMSS event and the climate in which we are now living. The conversation went something like this:

Woman: “I attended a session today conducted by an IT expert. You won’t believe what I heard”

Man: “Really?”

Woman: “Oh yes. The presenter was talking about successful EMR and IT implementations and actually said, ‘The physicians are the ones who have received the education. They are the ones who treat patients. So they must be the focus of our implementation.’”

Man: “You’re kidding.”

Woman: “No! I was so offended I nearly walked out.”

Man: “That’s ridiculous.”

Whether one agrees with the federal stimulus package and the push toward EHRs, the fact remains that it has created a significant impact on the business of healthcare IT. Clinicians, administration, and IT each play an important role in running the healthcare organization. Administration and IT serve, however, in support roles to the mission of providing an environment that allows clinicians to do what they do best: treat patients.

Over the past decade, the role of IT has grown significantly as healthcare has played catch-up to the most other industries in moving away from paper and manual systems to electronic and automated systems. This shift has had its share of challenges and most organizations can list a number of tragic stories of failed or messy implementations. Difficult workflow, poor user adoption, and meaningless data are all symptomatic of the problem of letting IT professionals make critical decisions sans clinical input regarding system procurement, design, and implementation.

It appears we have not learned our lesson. Introducing federal subsidized funding and reimbursement into the business model of clinical information systems the federal government has shifted focus to management and IT, leaving clinicians in the trailing position. The idea that caregivers come last could not be more backward to the true value proposition of healthcare. This industry is, and will remain, primarily about providing healthcare. No matter how advanced EHRs, widgets, and handheld devices become, patients will continue to measure satisfaction by whether a doctor knows what she’s doing, has the right tools to treat, and that they ultimately are healthy.

So to that presenter at HIMSS, I am not offended. It seems in this climate we have forgotten that we are in the business of letting clinicians treat patients. No EHR, HIS, PACS, eMAR, or any other system can provide better patient care without a doctor reaching out a stethoscope and asking her patient to breathe deeply. We in administration and IT get to play a valuable role in providing the tools and support to help our physicians provide better patient care. But we are just that — support.

Let’s not let the promise of a few dollars and the lure of a few vendor-hosted parties blind us to that fact.

Jef Williams is vice president of Ascendian Healthcare Consulting of Sacramento, CA.

Readers Write 2/24/10

February 24, 2010 Readers Write 7 Comments

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

February 15, 2010 Readers Write 13 Comments

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

February 8, 2010 Readers Write 14 Comments

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

February 1, 2010 Readers Write 7 Comments

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

January 25, 2010 Readers Write 3 Comments

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

January 18, 2010 Readers Write 14 Comments

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.

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

January 6, 2010 Readers Write 9 Comments

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

January 4, 2010 Readers Write 10 Comments

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.

Pages ... 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50

Recent Posts

Home » Readers Write » Recent Articles:

Readers Write 7/28/10

Readers Write 7/15/10

Readers Write 6/14/10

Readers Write 5/17/10

Readers Write 5/10/10

Readers Write 5/3/10

Readers Write 4/22/10

Readers Write 04/05/10

Readers Write 3/24/2010

Readers Write 2/24/10

Readers Write 2/15/10

Readers Write 2/8/10

Readers Write 2/1/10

Readers Write 1/25/10

Readers Write 1/18/10

Readers Write 1/7/10

Readers Write 1/05/10

Text Ads

RECENT COMMENTS

HIStalk Sponsor Announcements

Job postings

Founding Sponsors

Platinum Sponsors

Gold Sponsors

Industry Events

Webinars

Sponsor Quick Links