Readers Write 11/2/09

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

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

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

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

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

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

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

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

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

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

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

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

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

Figure 1

Figure 2

Figure 3

Figure 4

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

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

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

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

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

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

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

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

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

Surgeon and OR Staff Recruitment and Retention

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

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

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

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

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

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

Conclusion

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

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

Kermit Randa is Senior Vice President, Surgical Information Systems.

Readers Write 10/27/09

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Readers Write 10/12/09

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

Health 2.0
By DrLyle

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

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

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

Seeing new/interesting startups in the Internet space.

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

Keas.

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

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

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

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

 

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

Readers Write 10/5/09

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

Web Services are Changing the Industry, Slowly
By Mark Moffitt

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Chart 1

Chart 2

Chart 3

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Readers Write 9/23/09

Thoughts on the Proposed Acquisition of Perot Systems by Dell
By Ralph P. Fargnoli, Jr.

The Dell acquisition of Perot means that Dell wants to be taken seriously in the HIT market, providing PCs, servers, and strategic outsourcing and consulting services to the HIT industry and beyond. As others before them, they are interested in their piece of the $2 trillion market. With Perot, they have a name recognition factor going for them.

With Dell focused on services with the Perot acquisition, they need to keep the Perot management that understands the HIT market. If they are not successful holding onto the people that made the Perot acquisition attractive, some of their HIT verticals will disappear from the market. Perot is the recognized player in HIT services, not Dell.  

This will also drive competition for the benefit of the HIT market, as HP and IBM also have a recognized HIT services group. Overall, it can be a win for Dell and the HIT market as there are more choices for HIT adoption along the technology vertical.

As it relates to the consulting business, we believe it is a positive because over the long term, the acquisition removes a layer of competition due to strategic focus and revenue needs of public companies. We saw this with the acquisitions made by ACS, IBM, CSC, and others. The billion-dollar players cannot meet Wall Street expectations being everything to everyone. That opens the gate for Beacon Partners to grow.

Ralph P. Fargnoli, Jr. is the president and CEO of Beacon Partners, Weymouth, MA.

Order Set Software: Clinician-Focused Design is Key to Adoption
By Stephen Claypool, MD

Few physicians will argue that standardized order sets are valuable tools. Paper versions have been around for decades and typically enjoy high adoption rates because they are easy to use and don’t disrupt the clinical workflow. But they are also time-consuming to create, nearly impossible to keep current and cannot be altered when a patient’s needs fall outside the norm.

For these reasons — and because they are key requirement for HITECH funds — more hospitals are seeking to automate the development and use of order sets. Unfortunately, many are discovering that their physicians are far less receptive to electronic order sets than they were to their paper-based counterparts.

The problem is that too many order set applications are designed by engineers with little or no understanding of actual clinical workflows. They work, but not in a way that actually drives efficiencies for physicians.

To avoid adoption problems, it is important to evaluate the software through the eyes of the clinicians who will be using it. Starting with the basics, any order set application should include:

• A large selection of prebuilt, yet customizable, order sets based on nationally recognized best practices
• Templates for creating new order sets
• Links to trusted medical content
• Robust authoring and editing tools
• Ability to track reviewer comments and version changes
• Easy integration with any EMR/CPOE system
• User-friendly navigation requiring little training to achieve proficiency

Beyond the basics, order set software must offer features and functionality that enhance — rather than complicate — authoring and use at the point of care. For example, applications with a sizeable library of orderable items will eliminate the need for manual re-entry. Software with an underlying structure that is data vs. text-based will streamline mapping and simplify integration into EMRs or CPOE.

The solution should also deliver intuitive clinical decision support during authoring and at the point of care. “Intuitive” is key, as it avoids alert fatigue by taking each order in context and delivering only meaningful alerts or recommendations.

Formatting is also important. Like their paper-based counterparts, electronic order sets should be easy to read and make clinical sense. The trouble is that many applications are too rigidly constructed, which can hamper treatment of conditions (e.g. meningitis) that fall outside routine protocols. Yes, the elements of the order set must be mapped to specific orderable items, but an appropriate level of flexibility must be built in to allow for necessary alterations to the sequence in which individual orders are issued.

On the back end, maintenance is the greatest long term challenge facilities face with evidence-based order sets. Look for an application that automates medical content monitoring and delivers alerts when new evidence or guidelines are available.

Creation happens once and maintenance is forever. Thus, a powerful maintenance component must be considered alongside the format, functionality and the intuitive nature of order set solutions.

Stephen Claypool, MD is a practicing physician and vice president of clinical development and informatics-clinical solutions with Wolters Kluwer Health.

Healthcare Clearinghouses and the 80/20 Rule
By Nick Revak

The Pareto Principle, also know as the 80/20 rule, states that, for many events, roughly 80% of the effects come from 20% of the effort.

Variations of this principle can be applied to a wide range of situations, including healthcare EDI transactions. That is, 80% of a provider’s EDI transactions will be exchanged with 20% of its payers.

Here’s another one. In software development, 80% of results are achieved with the first 20% of effort.

Providers would do well to heed the 80/20 rule when considering their EDI transaction strategy. Providers should consider building their own connections to their top 3-4 payers (Care/Caid/Blue) and leave the rest to a clearinghouse. This will result in the provider saving 80% of the transactions fees while leaving 80% of the effort to the clearinghouse.

Nick Revak was a senior developer with Healthcare Data Exchange (HDX) for many years and is currently an independent consultant/contract programmer on assignment to Stanford University Medical Center.

Healthcare Litigation Reform Versus Pay for Performance
By Greg Park

Defensive Medicine is a significant factor in healthcare costs. In fact, studies by The Harvard School of Public Health found that eight percent of healthcare spending is directly related to physicians ordering tests, procedures, and scheduling visits primarily to reduce malpractice exposure. These numbers are nearly twenty years old, but logic tells us they have compounded since the study was first published.

Three out of four physicians recommend some form of malpractice reform. And why not? Fees for malpractice insurance have skyrocketed to a point where many physicians simply pack their bags for less risky waters. Worse than that, medical students understand these conditions and are opting more for specialization and research rather than direct patient care. 

But is the issue really that physicians are so worried about being sued that they over analyze? Or is the problem of over-analysis a symptom of the volume-based practices that exist today?  Isn’t it much easier to diagnose an unknown medical condition with a sledgehammer of tests when your daily office queue exceeds forty patients? Aren’t we as a nation rewarding this behavior by continuing our payment methods that reward tests, but turn a blind eye to results?

No, malpractice reform is either another distraction or a means to treat the symptom rather than the disease. 

Let’s dig further into this issue and support those who are promoting evidence-based medicine and the financial rewarding of physicians with positive outcomes that follow established medical pathways. Agree that there will be those clinical situations that exist outside the norm, or where the chance of positive outcomes will be slim. These are high-risk situations that need to be examined differently, but whatever we do we do not want to create disincentives for care.

There are deeper issues than malpractice reform, single-payer systems, and public options that are not the focus of our public debate. We need to discuss how physicians can spend quality time with patients while maintaining their practices. We need to discuss how to grow the ever-shrinking demographic of general physicians while giving them the time to review a deluge of medical information published daily. 

Perhaps we even need to discuss why medicine must be a for-profit industry. Economists will tell you that competition and the pursuit of wealth creates strong markets, but do we really want our healthcare professionals wondering how to squeeze profits from the system? I believe that those driven to the industry are motivated beyond personal profit and are focused on providing care. Quality care.

I know many of you are debating these topics in your think tanks, ivory towers, and specialized committees, but this is pure Latin to a majority of Americans. The general debate going on now is distraction which prevents us from considering how the fundamental beliefs of our system must radically change.

Greg Park is national account and product manager at DB Technology.

Readers Write 9/9/09

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

Healthcare Clearinghouses
By Skip Tumalu

You’re asking the right questions about X12 and clearinghouses. The answers, as is sometimes the case with EDI issues, may lie beneath the surface. And bravo for insisting on transparency. But do take the time to investigate, measure and test. Do not let the inability of your business partners to approach transparency trap you into a corner with no exit. Let’s take a quick snapshot of the surface issues and “what lies beneath.”

Eligibility on the surface
Provider transmits data elements per payer requirements. Payer responds with Eligible or Not.

Eligibility underside
The more non-required data elements the provider transmits, the more likely the payer will falsely respond Not Eligible. Why? There was a keystroke or other error in one of the data elements. The data set did not match. Not Eligible. Or, the payer eligibility system is old, cranky, or attempting to comply with governmental program rules and “just says no.” Don’t worry — false negatives on eligibility are usually less than 15%. Remember this when we discuss how much you might invest to get YOUR own revenue cycle to Six Sigma, as measured internally.

Claims on the surface
Provider transmits complete claim and “scrubs” the data elements or pays for “scrubbing.” Payer accepts and pays some claims, but a double-digit percentage are rejected or pended. Providers don’t like to reveal their percentage of claims that are sent in a second time. Want to see real discomfort? Just ask about the percentage that must be sent in a third time. It is not always a single-digit number!

Claims underside
Payers have massive legacy rules tables for claim editing/adjudication. A payer might say they have XX thousand rules they apply to filter and route claims in their processing silo. If you run enough claims and keep track of results, it is not hard to show that the payer is wrong. It is not XX thousand rules, but perhaps 150% of XX thousand rules.

How can this be? Payers edit their adjudication tables. They do it frequently. The process may be less than Six Sigma, folks! Over time, they have a table full of best efforts — not a Six Sigma system. And no, you won’t get any payer to agree that this is remotely possible. This also means that if you measure diligently, your payers won’t be very responsive to this issue. Why? Can you imagine the consequences if they stepped up to solving this one?

I met with a provider who admitted to having most claims submitted more than once and many claims submitted a third time before payment. I said, “Gadzooks – your Days Revenue Outstanding must be really large.” They said, “No, it is less than two days.” I asked how that could be. The response was, “We deposit payer reimbursement checks the same or next day — we have about 1.5 Days Revenue Outstanding.” I said that we need to count from the day the claim dropped and had my head handed to me — I was yet another false expert with no understanding of how the revenue cycle really works. This type of “unintended conspiracy” of weak partner systems and small misunderstandings can indeed cause some major pain!

It is interesting to note that with big ERP installations down, the large systems integrators are selling a lot of engagements for “total Six Sigma healthcare revenue cycle reengineering.” I’ve chatted with some nice folks about the view above regarding eligibility and claims, the surface view, and the underside view. They’ve said, “So what, our re-engineering is underway and we are not Six Sigma yet.” I’ve asked the about the cost and payback for total re-engineering and heard of many projects investing more than $10 million with paybacks greater than one year.

Cheeky bloke that I am, I’ve asked what the “process quality” of eligibility and claims might be, based on local estimates of the “surface” and “underside” issues mentioned above. Folks will readily agree that process quality on eligibility may be 80% on a good day and claims process quality may be 60% on a good day. I then ask what happens when the middle of the 80% and 60% goes to Six Sigma. The response is, “Please don’t mention this to anyone — it was an important investment that we were counseled we had to make urgently.”

If you’re still doubtful, there is a test you can perform to understand “aggregate process performance” — not of your provider systems, but your total environment. Got Self-Pay? Got Unpaid Self-Pay? Sending any Unpaid Self-Pay to Early Collections? Screen your output file heading to Early Collections a day in advance — ONLY if you’re prepared to see 5% or more of the accounts with valid current eligibility that will pay the claim! If you get 7.5%, 10%, or more, be prepared to call it “an anomaly” and do re-testing over an extended timeframe. 

You can do your own math on the implications this has for what payer eligibility responses and payer claims adjudication are doing to YOUR revenue cycle, regardless of your standalone process quality. Besides, don’t you think there might be a compliance issue you’d rather avoid in heading towards collections with folks covered by Medicare, Medicaid, or a commercial payer where you’re in-network? If you don’t have resources to do this screening, then it might be worth paying to get it done. And remember, this is hardly your fault. Even if your “process pipes” are Six Sigma, if you’ve got “gray water” in the eligibility data incoming and “gray water” in the claims back from payers, you are simply using a pristine Six Sigma solution to “pump gray water.” At least don’t promise that the new Six Sigma system will reach process levels that your business partners don’t support and have no capability of reaching. Prepare to measure and report the “grayness” of your business partners’ water.

OUCH!

What are the implications of these possibilities? (I don’t expect them to be real for you until you check it out in your environment with your own payer mix, systems and data results)

1. Ignore processing charges at first. Instead, focus on process performance. If you’ve gotta pay to get process quality end-to-end, pay for performance before you get trapped chasing “false economy.”
2. Expect weak results on eligibility and focus on making it as easy as possible for staff to check eligibility when and where it makes sense. Unless it is absolutely EASY, your results will only be worse than the typical “gray water result.”
3. Expect >> 90% of claims to be accepted and paid as submitted, first time in. Impossible? Ask around. Quality solutions are not free and they are out there. Don’t settle for “we send the claims on as quickly as we can” or “we check each data bucket, for sure.” Use process metrics and announce that your headed for excellence. You’ll be surprised to see the world change around you. And yes, you may need to pay some small fees. Those are small compared to the cost of carrying one or two months of needless Days Revenue Outstanding at a time when banks and revenue bonds are “not behaving normally.” Your Treasurer can provide updates on that issue. Only ask if you have time to listen to a true tale of woe.

The Value of Clearinghouses
By Jim Denny

Scott Bayou’s Sept. 2 commentary on healthcare clearinghouses raised some good questions — and ultimately was dead-on.

In theory, there should be no necessity for transaction or interface fees. The intent of HIPAA was to provide, and ultimately enforce, an interoperability standard. In reality, however, that hasn’t happened. This means that practices and hospitals must force the issue by refusing to do business with vendors that charge these fees. They must instead insist upon free and unlimited access to X12 transactions.

Within this imperfect environment, it’s also wise to recognize the value that clearinghouses bring to the current marketplace — hospitals and medical practices alike — through standardization, efficiency, and leverage.

First of all, if electronic transactions were truly standardized as noted above, today’s typical clearinghouse might indeed be redundant. But the truth of the matter is that different payers transfer files in divergent formats with varying content, supported by a wide range of service levels. Providers are saddled, in other words, with a myriad of technical challenges when it comes to claims and revenue cycle management. Advanced clearinghouses serve as an “EDI translator” that can streamline submissions, provide meaningful visibility into claims status and adjudication, and reduce days in A/R.

Secondly, clearinghouses give providers efficiency (and economies of scale) they otherwise would not have. Let’s say that all providers across the country unerringly run into problems submitting one type of claim with one specific payer. To make adjustments, each provider would have to modify its own system. A clearinghouse, however, could update its edits engine or change processes for all its clients, relieving them of monitoring and “fixing” payer-specific anomalies. This is particularly true for SaaS-based clearinghouses.

Lastly, clearinghouses provide operational leverage. Consider data warehousing and the business or clinical intelligence it can supply to providers. If information is locked in a payer-biased clearinghouse, providers will be unable to extract, aggregate and analyze data in ways that are meaningful — much less beneficial — to them. Payer-sponsored data clearinghouses perhaps provide a more cost-efficient option. But we must remember that their objective is to serve payer interests, not provider interests.

Provider-centric clearinghouses, on the other hand, are able to offer provider-focused information that delivers valuable insight about performance, utilization, and outcomes that allows them to track key measures and gain leverage during contract negotiations.

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

Follow the Yellow Brick Road
By Craig James

Call me the EHR heretic or the guy whose sister the house crushed in the Wizard of Oz. My comments have nothing to do with how hard everyone is working, their professionalism, or their skills. So much for my disclaimer.

You can’t read a blog or Twitter post without tripping over hopeful accolades anticipating some miraculous intervention by one of the standards committees, the RHIOs, the HIEs, or the Meaningful Use  or Certification Committees. Example:

State CIOs Get ‘To-Do’ List, HDM Breaking News, August 25, 2009 — The National Association of State Chief Information Officers has published a report giving guidance to CIOs as their states implement health information technology provisions of the HITECH Act within American Recovery and Reinvestment Act.

The act requires state leadership in two primary areas: oversight for the planning and deployment of health information exchanges and management of the Medicaid incentive payments for meaningful use of electronic health records, the report notes.

“The HITECH Act placed a significant amount of new responsibilities on states in regards to state oversight for HIE and the planning and implementation grants for preparing for HIE,” the report states. “During this initial planning period, state CIOs must secure a seat at the table to establish themselves as key stakeholders and also to recognize strengths and identify weaker points that require resolution within their own offices relating to statewide HIT/HIE planning. They must ask themselves what they, with their unique enterprise view, can do to support and contribute to each of these areas.”

Let us remember the mission — accurately and timely delivery of your records from A to B. You are 1,200 miles from home, unconscious, and are rushed to the ER in a clinic in Smallville. EMRs from your oncologist and cardiologist, your CT-Scan, and your nuclear stress test, along with a list of your meds, are in the hands of the nurse practitioner as she awaits the doctor’s arrival.

Now let the grownups apply logic. Hundreds of vendors, an equal number of standards — by definition, an oxymoronic statement — home-made EHRs, outpatient EHRs, EHRs serving as RHIOs, IPA EHRs, IPA RHIOs, real RHIOs, and HIEs. Certification and Meaningful Use — another oxymoron.

Here’s a simple question. Who among us can make a reasoned argument that the current plan will enable everyone to get from A to B in 3-5 years? Right now, we call it interoperability. It’s the fly in the ointment and its degree of difficulty and costs are grossly underestimated. If you believe you can, I would love to see it articulated. I do not think the RHIO / HIE / Certification / Meaningful Use plan will work, not do I think anyone who isn’t making revenues from the current plan can make a reasoned argument. Couple that design with the fact that the vast majority of IT projects that cost more than $10 million will fail.

So what? In six to eight years we will have an open, national, browser-based EHR. Maybe we should spend time figuring out how that will work.

TPD’s Review of Semantic Web Concepts
By The PACS Designer

The Semantic Web is a term that some might find confusing when they hear about it from others. The Semantic Web consists of websites that can converse with each other to provide a more robust web experience. Sir Tim Berners-Lee, an English engineer, computer scientist, and MIT professor is the director of the World Wide Web Consortium (W3C), which oversees the Web’s continued development. He is the inventor of the World Wide Web, which was launched on December 25,1990.

Berners-Lee in 1999 had a vision of what the Semantic Web should be. “I have a dream for the Web in which computers become capable of analyzing all the data on the Web — the content, links, and transactions between people and computers. A Semantic Web, which should make this possible, has yet to emerge, but when it does, the day-to-day mechanisms of trade, bureaucracy and our daily lives will be handled by machines talking to machines. The ‘intelligent agents’ people have touted for ages will finally materialize.”

In order to improve the World Wide Web (WWW) with more semantic capabilities, we need to review the current framework of the web. The World Wide Web is constructed using a Uniform Resource Locator (URL), the generic term for all types of names and addresses that refer to objects on the World Wide Web. A URL is one kind of Uniform Resource Identifier (URI).

Another Web term is Resource Description Framework (RDF), which is intended to provide a simple way to make statements about Web resources such as Web pages and other online resources.

Now, at the end of our first decade of the 2000s, we are set to embark on a move to a more interactive Web experience.

One way to improve the Web experience is to improve the linking capabilities to the various web resource storage locations.

The Universal Data Element Framework (UDEF) provides the foundation for building an enterprise-wide controlled vocabulary. It is a standard way of indexing enterprise information that can produce big cost savings through the linking of Web resources.

One of the early linked solutions available that employs semantic Web attributes is called “Twine.” Twine is a new way for you to collect online content — videos, photos, articles, Web pages, products — and bring it all together by topic, so you can have it in one place and share it with anyone you want. Twine can be called a “mashup for the Web 3.0 era” as we move toward a Web 3.0 world. All we need now is for Tim O’Reilly to say it is officially here!

So for healthcare collaboration, if we combine linked resources in a secure private cloud, we can create a place where decisions can be made to treat patients using a broader  base of information sources.

Also, healthcare can really benefit from the move to employ more semantic Web concepts in the years ahead and begin to obtain more knowledge in the war against diseases!

http://semanticommunity.wik.is/
http://en.wikipedia.org/wiki/Tim_Berners-Lee
http://www.viswiki.com/en/Universal_Data_Element_Framework
http://www.twine.com/

Readers Write 9/2/09

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

Implementing the Continuity of Care Record in PDF Healthcare Format
By Stasia Kahn, MD

 

As an Internal Medicine physician working in a small digital office, I am frequently called upon to share data with other healthcare providers and patients. In 2005, a colleague introduced me to the Continuity of Care Record (CCR) standard. 

I was impressed with the interoperability of the CCR standard that would allow me to exchange healthcare data electronically with my peers, some of whom are working with an electronic medical record and others whose records remain paper-based.

Since the fall of 2006, I have been exchanging healthcare data primarily for referrals of complex patients. Data exchange based on the CCR is richer than the traditional paper medical record that most primary care physicians fax to their consulting providers.

For example, one of the beauties of the CCR is that complex medical terms are presented in a codified manner, such as ICD-9 codes for problems, NDC codes for medications, and LOINC codes for laboratory tests.  In addition, the CCR generator I use to pull the data from my database allows me to be selective and choose the relevant information that is needed to solve a particular medical problem; thereby improving the efficiency of the receiving providers.

The PDF Healthcare Best Practices Guide and Implementation Guide, which were released in 2007, supplied me with the tools to attach diagnostic images and text documents to the summary document. Most tests and procedures are in either image or text format, and by including these in the information exchange, I am able to help reduce healthcare costs.

In addition, the positive feedback I received from my peers who received PDF Healthcare files in place of traditional medical records gave me the confidence to recently begin exporting PDF Healthcare files to my patients for the purpose of populating an untethered personal health record (PHR). I believe that a patient-directed PHR that has been pre-populated with authoritative data from a primary care physicians’ electronic medical record is the quintessential, longitudinal health record that our national leaders believe to be the Holy Grail that can solve the ills of a broken healthcare delivery system.

In closing, my implementation of the CCR in the PDF Healthcare format has helped me to improve the quality of care I deliver to my patients and at the same time reduce the cost of caring for them. The CCR standard used with the PDF Healthcare Best Practices and Implementation Guides allows for the interoperable, electronic sharing of relevant, codified healthcare information at the point of care for specialty referral and into a robust longitudinal health record of interested patients.

Stasia Kahn, MD is an internist with Fox Prairie Medical group of St. Charles, IL.

Healthcare Clearinghouses
By Scott Bayou

Perhaps I am missing a piece of the puzzle, but I really don’t understand clearing-houses like Emdeon and others.

We have X12 transactions that are supposed to level the paying field, yet most hospitals that I speak with are still sending their payment data through a clearinghouse and receiving the remittances back from the clearinghouse.

On the way back is where the real confusion comes into play for me. I know from companies like HDX that there is a per-transaction fee associated with the creation of the transaction. This per-transaction fee is variable (based on your ability to negotiate?) and varies from 15-40 cents per transaction.

Why? What benefit is being purchased? Each hospital has the right to obtain their 835 remittance, and there are various products on the market that allow for conversion to fixed text formats. Buy once and create postings to your HIS while avoiding per-transaction fees.

What am I missing?

Reporting? Most people I speak with get a limited set of reports from their vendor, and have to pay more if they want to customize reports or add new.

Archival? These transactions are not that big and can be held in most hospital’s Imaging or Document Management applications.

Relationship with vendor? Perhaps, many Siemens customers are given options to purchase HDX – or are they a partner?  Not sure of the real relationship, but someone is making a ton of money out of something that should be transparent.

Management of variances? Perhaps, this is a problem that shouldn’t be, but always seems to exist in the X12 transaction processing world.

Managing the minute differences that are expected by various payers? This might be it! Lack of governance in the payer market begs the need for clearinghouses?

Maybe, but I would love to hear what others think about this.

Readers Write 8/19/09

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

Health 2.0’s Social Networks Get Down to Business!
By Deborah Kohn

Forrester predicts that by 2013, social networking will account for nearly half of the $4.6B market it forecasts for all Web 2.0 products (or, as we in healthcare refer to these products, Health 2.0).[1]

Web 2.0 / Health 2.0 products are the suite of online technologies and applications (e.g., blogs, wikis, Really Simple Syndication [RSS], content communities, mashups, podcasts – in addition to social networks) that are used to share information via text, images, audio, video in a participative, communicative environment. They are based on users’ opinions, expertise, insights, interests, or work activities.

Social networks (e.g., Facebook, LinkedIn, Twitter) can be differentiated from the other Web 2.0 / Health 2.0 products because they give users the ability to create individual profiles that foster interaction among many people (“many-to-many” as opposed to “one-to-many”). First made available on the consumer-oriented MySpace site, in general, Web 2.0’s social networks finally are finding a solid niche in the business world, and, in particular, in healthcare. The reasons are that social networks can assist information workers in collaborating and accomplishing work more quickly, productively, and cost-effectively than current collaboration tools.

Information workers spend an inordinate amount of each day collaborating in e-mail. Where e-mail was once considered a “messaging system” — the electronic equivalent of the Post-it note, replacing paper office memos and telephone messages — eMail evolved into a “communication system”, essential for a healthcare organization’s business processes. While soliciting and sharing information via e-mail is effective, relying on an e-mail system for collaboration and compliance is risky. Version tracking becomes nearly impossible, and visibility is limited to those on the “To:” and “cc:” lines. If a worker is hoping to find and re-purpose an e-mail or its content at a future date, it’s not practical. Same for using file shares.

However, Twitter, for example, gives information workers the unprecedented ability to tap into customer-driven feedback loops and turn them into message amplifiers, focus groups, and even goodwill ambassadors! In addition, all workers inside the organization, not just selected groups, can create, edit, and distribute ever-increasing volumes of ad hoc and informal information. Even with limiting posts to 140 characters, many-to-many can still efficiently link to educational podcasts, budget decisions, and quality and safety videos as well as search for the information.

If healthcare organizations have a receptive culture, a clear business strategy, and a clear technology strategy that allow for social networks to be appropriately integrated into established healthcare business processes, I predict that, like e-mail, social networks will become integral to a healthcare organization’s activities and will achieve a level of legitimacy and value that will rate them a secure spot. In other words, instead of sending one-to-many e-mails for certain collaborative activities, the ability to post announcements many-to-many using social networks will become the next generation of e-mail and file shares.

[1] Owyang, JK; The Future of the Social Web, April 27, 2009

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

Survival of the Fittest
By Mark Steele, MD and Jack Callahan

Any highly adaptive species will thrive on its evolutionary journey; any species that is not responsive to its environment will inevitably come to extinction. The EMR and its more adaptive descendent, the hybrid EMR, offer a clear example of this process of natural selection in the digital world.

As the name implies, the hybrid EMR represents a synthesis — in this case, between the traditional EMR and how doctors actually practice medicine in reality. The hybrid EMR is a highly flexible adaptation that has split off from its original species and continued to evolve, while its ancestor, the traditional EMR, still struggles to survive. The incontrovertible success of the hybrid EMR in the marketplace is a perfect illustration of the survival of the fittest.

When the EMR first emerged from the primordial swamp of legacy code, it was poorly adapted to the healthcare IT environment. Its genetic inheritance of hard-to-use, rigid data entry syntax and non-intuitive navigation kept it from thriving, particularly with demanding, high-performance practices. But because it had a few attractive features, along with some colorful-looking plumage and no natural competitors, it did gain a toehold in the market. Still, no matter how many tried to domesticate the primordial EMR, few succeeded.

Later generations of the EMR species made clear the need to regulate its unstable genetics. CCHIT engineering was engaged, with government funding, to control the breed. Yet despite Herculean efforts and even crossbreeding with the PM species to deliver a combined, integrated entity with a single DNA set, maladaptation continued. High-performance practitioners and specialists, who demand a stable, productive, usable species of EMR, were not consulted, and they were not convinced. They did without, waiting for the species to evolve still further.

Finally, it did. The hybrid EMR emerged, with new genetics and usability, and met with huge acceptance and adoption.

This meant that the traditional EMR species had reason to fear for its survival. Its only hope of getting off the endangered species list was a cataclysmic event that might give it a chance to catch up to its competitor. Eventually, the dire state of healthcare led to unprecedented funds being allocated to encourage medical practices to adopt traditional EMRs. This was supposed to benefit the practices, but since EMR genetics remained the same, maladaptation continued, endangering the very practices that adopted them.

The beginning of the end of the traditional EMR species is at hand and the government health IT stimulus program will hasten the demise of the woolly EMR mammoths. As physicians realize that complying with government EMR "meaningful use" protocols requires significant productivity losses, the traditional EMR will be relegated to a minor role for low volume and non-fee-for-service practitioners … or even to extinction.

Natural selection favors species that can evolve and adapt to the demands of a changing environment. Such is the hybrid EMR. Its strength is a fundamentally simple, strong, and very nimble DNA architecture that can accommodate the changing requirements of its users. Unlike traditional EMR systems, which force the user to conform to their structure and syntax, the hybrid EMR thrives because it conforms to the unique needs and productivity requirements of the healthcare provider, even the high-performance healthcare provider. The hybrid EMR is the highest state of EMR evolution; its survival is assured.

The Green Provision to the America’s Affordable Health Choices Act of 2009?
By The Alchemist

In the year 2010, the global economy is on the brink of absolute collapse with overcrowding in the cities, rampant unemployment, and a mandated rationing of healthcare resources because of the increased demand and the sudden swollen health insurance membership. Hospital palaces from around the world are converted to efficient and effective government-run bureaucratic clinics for the delivery of appropriate metered care according to the QARY paradigm.

The United States of North America has implemented a novel solution to scarce healthcare resources by augmentation of the Patient Self Determination Act 1991 (PSDA) within the America’s Affordable Health Choices Act of 2009. The purpose of PSDA is to relieve the burden on the healthcare delivery system by introducing a process that might produce the desired “green” effect by reducing the supply impact to our environment of care.

PSDA is re-crafted and claimed successful within the green movement for scarce resources and has become known as the Solyent Green Movement where tired citizens can “go home” to their favorite government clinic for care. Solyent Green is for people!

Readers Write 8/11/09

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

Well, it appears that the only readers writing this week are Gregg Alexander (from HIStalk Practice) and me. Technically, we’re readers too, but it would be nice to have some company up here on the good old Internets. Who’d like to contribute? Anyone? Anyone at all?

BrevIT Revisited
By Mr. HIStalk

Ah, the late, lamented BrevIT newsletter I used to write every Saturday, giddy and dog tired after many hours of writing HIStalk throughout most of the same day. BrevIT was sometimes insightful, often educational, and usually funny (the headlines, anyway). I’m really proud of having done it from mid-2007 to mid-2008, but it took a lot of time and, like most e-mail newsletters, most recipients weren’t reading it even though it had a loyal core following.

I miss it, and if I ever figure out how to do this full time, I’ll bring it back in some form. Or, maybe I’ll roll it into HIStalk in some fashion (I’m open to ideas).

Here’s the index of issues in case you want to read some old ones (odds being that you probably never read it when I was e-mailing them out). Below are some of the headlines I liked as I read back over the old issues. You can probably guess the stories.

• Cerner Announces Millennium for Xbox
• Cerner Slashes Payroll, Stock Price By Dis-Association
• Study: Government’s HIT Initiatives About as Ineffective as Government In General
• RHIO Failure News Slow to Reach Maine, Apparently, as HIE Launches
• Wal-Mart Starts PHR Rollout Quickly After Omnimedix Rollback Special
• Dumped in Dubuque: McKesson Horizons 79
• Hydroelectric Power: VA Facilities Close Due to Data Center Flooding
• Non-World Wide Web: Internet Outage Cuts Off Asia, Middle East
• QuadraMed Curries Little Employee Favor by Offshoring
• Revolution Health Brags That It Has More Freeloader Readers Than WebMD
• Microsoft Bobs in Rough Healthcare Applications Seas
• Allscripts, Eclipsys, WebMD Shares Trampled in Investor Stampede
• Wal-Mart Has a Blue Vested Interest in eClinicalWorks
• HIMSS Fills Orlando with Non-Mouse Ear Wearing Tourists
• Cerner’s Legacy: Taking Yet Another Epic Beating
• Is That Your iPhone In Your Pocket Or Are You Just Glad To See Me, Doctor?
• Looking Up Britney’s Dress Was Free, But 13 Play Dearly for Ogling Her EMR
• Ohio Dots the I in its Standards for Practice-Friendly EMR Contracts
• Cerner Looks to Inhaler to Cure Its Heavy Breathing for Earnings Growth
• Allscripts and Misys Consummate Desperate Lust; Shareholders Hose Them Down
• Data-Selling EMR Vendor Insists on Privacy – For Itself, Not Patients
• McKesson Goes to the Head of the Class (Action)
• Philips Needs Milk of Magnesia After Eating Tomcat
• Survey: Old People Don’t Want to Pay for Health I.T. or Any Damned Thing Else
• Admitted John’s Sidekick Makes it Rain for RHIOs
• UCLA Belatedly Admits Fawcett Leak
• Tricky Dictaphone: Nuance Announces Plan to Acquire eScription
• GE: Imagine Our Stock Didn’t Really Just Tank
• TriZetto Processes Its Biggest Transaction: Selling Itself to Private Equity
• Article: PHRs Are Great, Except for the Untrustworthy Companies Offering Them
• Tick, Stock: Cerner Beats Estimates
• UCSF: So Many Ways to Compromise Patient Privacy, So Little Time
• Allscripts Proves Analysts Wrong with Unimpressive Profits
• HTP Improves its Own Revenue Cycle with McKesson’s Money
• Dollar Menu Choice – One McDonald’s Burger or Three MRGE Shares
• Can You Cure Me Now? Researchers Turn Cell Phones Into Imaging Systems
• Vivalog Vegas: McKesson Rolls Dice on Radiology Case-Sharing Site
• Emageon the Possibilities of a Hostile Board Takeover
• Rardin’ to Go: Merge Healthcare Dumps Suits, Troops, Loot
• California: Doctor Shopping is the One Type of Drug Abuse We Won’t Tolerate
• Leapfrog’s Leaps Not as Giant With One Foot in Mouth
• Eclipsys Announces Good Numbers, Not Just Improved Excuses
• Where’s the Strangest Place athenahealth Made Whoopie? That Would Be H.E. Butt, Bob
• German Re-Engineering: Siemens Corporate Layoffs Whack Hundreds in PA
• MyWay or the Highway? iMedica Gives Misys the Answer: B
• Perot Makes Giant Acquisition Sucking Sound

Cash for Clunkers?
By Gregg Alexander

“Cash for Clunkers”? Hot diggity dog! What a great new idea to adapt into the whole new ARRA/HITECH EHR adoption drive!

I mean, think about it…we’re trying to drive users to EHR adoption, right? We’re hoping to encourage “meaningful use” which could sort of be interpreted as improved mileage, yes? We want every new EHR driver using a system which will participate and share safely on the health information sharing multilane highway, no? And, ultimately, we’d like to see all those non-CCHIT-certified, non-government-approved EHR clunkers off the road, eh?

So, if you read or watch any news lately, you know the auto-selling industry has had a landslide success with the government’s “big bucks for your trash trade-in program” formally known as the Car Allowance Rebate System or CARS. (Cute, huh?) Intended to run until November, the billion dollar budget appears to have been blown in only one week. Talk about end user adoption!!!

Such blazing success should not go unimitated. You want an EHR in every provider pot? Let’s take a lesson and forget the whole 44K reimbursement nonsense. Here’s the new deal:

• First, we pick a catchy name like “Every Human Receives Something” or EHRs
• Next, we choose a cute-ish informal moniker, say, “Moolah for Medicine”
• Third, we decide upon a set of high mileage models worthy of reimbursement … of course, CCHIT-certified systems will likely be the de facto choice.
• Finally, we offer cold, hard, trade-in cabbage to all clunkers out there — those notoriously antiquated non-CCHIT systems and, obviously, anyone still driving the prehistoric pen-and-paper monstrosities.

If $4,500 for a running, drivable, used car inspires sufficient adoption of new, high-mileage models to burn through a billion bucks in one week, I’ll betcha an upfront $44K to turn in old, gas-guzzling EHR junkers or paper-based jalopies for sleek, new, energy efficient health record roadsters will tear through 19 billion greenbacks in two, three days, tops.

Dr. Gregg Alexander is a grunt-in-the-trenches pediatrician and geek. His personal manifesto home page…er..blog…yeh, that’s it, his blog – and he – can be reached through http://madisonpediatric.com or doc@madisonpediatric.com.

Readers Write 8/4/09

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

HIE: To Be It or To Do It
By Kipp Lassetter, MD

Since the start of the ARRA-generated deliberation over the definition of meaningful use, health information exchange (HIE) has become one of the healthcare industry’s hottest buzz terms. Yet ask what this crucial term means and you may have trouble pinning down a consistent response.

HIE has typically been viewed as a synonym for a regional health information organization (RHIO). However, as the industry has evolved, the real-world use of the term has expanded, making HIE a notoriously gray area. Distinguishing between an HIE as an entity and HIE as an action is key to resolving this confusion.

An HIE-as-RHIO — like CalRHIO or the Delaware Health Information Network (DHIN) — is a regional entity run by a third-party, neutral organization with a fixed governance structure. But in its broader sense, HIE is an action and an objective that applies more broadly within the care community to any hospital, health system, and physician practice pursuing health information exchange.

In the realm of this broader definition of HIE-as-an-action, hospitals, health systems and RHIOs share the common goal of exchanging healthcare information with their affiliated physicians, laboratories, member hospitals, payers, other ancillary service providers, and with patients directly.

In fact, hospitals, health systems and RHIOs can use the same technology to ensure the acquisition of data from disparate systems across dispersed care locations and publish that information to data consumers. With a sufficiently robust HIE technology, these data consumers — including providers, payers, hospitals, and patients — can, in turn, publish information to the network, producing a bi-directional exchange of actionable health information.

It is important to pay attention to this distinction between the concepts of HIE as an entity and HIE as an action, i.e. organizations like RHIOs and the act of exchange itself. If HIE is a requirement for demonstrating meaningful use, does the government declaration refer to HIE as an entity (an HIE organization) or does it refer to the action (the exchange of health information)? Though this may appear to be a purely semantic argument, the distinction becomes relevant when selecting a health information exchange solution.

If a vendor promotes its product as an HIE solution, does that mean the solution provides health information exchange only within the four walls of the hospital? Or is it also capable of connecting to broader state, regional, and/or national health information exchange platforms? The latter aligns best with the government’s current explanation of meaningful use.

Per the federal HIT Policy Committee’s revised recommendations for meaningful use, the capability to exchange health information is required where possible in 2011. Also, significantly, participation in a national HIE is required by 2015. This clarification suggests that hospitals and health systems should ensure that their HIE solution delivers two levels of capabilities — providing data exchange within the organization and then seamlessly connecting to broader HIE platforms.

Kipp Lassetter, MD is the CEO of Medicity.

Office of Civil Rights and HIPAA
By Deborah Peel, MD

 

This could be scary. These are the people who responded to the over 40,000 complaints of privacy violation citizens sent to them by having DOJ investigate and penalize a handful of individuals for identity theft.

On the other hand, most privacy complaints were for disclosures of PHI that do not violate HIPAA because there is nothing much left in it to violate. HIPAA was gutted in 2002 and virtually every player in the healthcare system (all CEs and BAs) was granted the right to use and disclose every American’s PHI without consent for TPO. People are outraged to learn that when others decide to use, disclose, or sell their PHI, it is no longer a privacy violation because the Bush Administration removed the key consumer protection in the HIPAA Privacy Rule.

Once HIPAA was gutted and over 4 million CEs/BAs can decide when to use and disclose our data, there was not much left to protect consumers. Ensuring the security of health databases and software is very critical, but alone, without consumer control over PHI, is not enough to make systems trustworthy.

HIPAA is an exposure rule now; HITECH did not restore the patent’s right of consent at the federal level. But, the right to health privacy still exists in Constitutional and common law, so complaints about privacy violations sent to OCR have to be dealt with via the state and federal court system instead, which is almost impossible for an individual to pursue. HITECH did authorize state AGs to enforce HIPAA, but again, the key enforcement that patients want is the right to control use and disclosures of PHI, which do not violate HIPAA, but do violate medical ethics and Constitutional and common law.

Looks like OCR will now enforce security requirements and will eventually make the rules to ban sales of PHI (they will go through a rulemaking process and propose amendments to HIPAA, so HIPAA will comply with the ban on sales required by HITECH).

Again, OCR has not met the public’s expectation of being the watchdog for their interests.

Deborah Peel, MD is a practicing physician and a board member of Patient Privacy Rights.

The PACS Designer’s Review of Meaningful Use Concepts
By The PACS Designer

With the American Recovery and Reinvestment Act of 2009 (ARRA) allocating funding for Healthcare IT solutions to promote meaningful use of software solutions, TPD thought it would be  good to review how it can be accomplished meaningfully.

We’re all aware of the controversy surrounding CCHIT-certified EMRs  and what they can bring to the adoption of usable software for physicians without significantly impeding their daily work routines. While obtaining the CCHIT certification draws attention for the vendor to their product offerings, it doesn’t guarantee that using their EMR will bring new efficiencies to your practice. The reason is there’s much more to the implementation than the a standalone certified EMR solution.

First, when installing an EMR solution, you need a central database location to store patient data for further clinical use in daily activities. Typically the EMR vendor supplies a data storage location for its software only. This causes another silo to be created with limited functionality ,thus hampering its expansion for other data collection activities (i.e. lab results and other data parameters). If the EMR solution comes with a data port to receive and send data, then some progress is possible for further integration efforts for the practice.

When it comes to measuring meaningful usage, it should be viewed with a broad spectrum of daily activities beyond the clerical function that is present in most EMRs.

One early benefit of an EMR that physicians can utilize is the e-prescribing function. If the EMR software has an export function, you will be able to forward your prescriptions to the appropriate pharmacy, thus eliminating the need for giving the patient a paper copy and/or faxing it for the patient. Also by using electronic forwarding for prescriptions, you are beginning the meaningful use process which should prove that payment for performance is actually happening within the practice.

An example of an e-Prescribing application is "The National ePrescribing Patient Safety Initiative (NEPSI)", which is a joint project of dedicated organizations that each play a unique role in resolving the current crisis in preventable medication errors. Their website, Nationalerx.com, offers physicians a free solution that will help them create an electronic prescription that can be forwarded to a pharmacy. Also, by using such an application, CMS will pay each physician $3K to $5K for proving that meaningful use is taking place within an EMR system.

Some other questions that need answering are:

• Does the EMR solution permit import of lab results through a data port? If not, it should not be viewed as enhancing further meaningful usage.
• Does the EMR solution have export capabilities to send data to a remote storage location for redundancy and secure archiving purposes? If not, what other method will you use to protect valuable patient data parameters that could populate a PHR for the patient, or a Continuity of Care Record (CCR) for another provider?

In summation, the most practical solution should interface with a master database to permit easy creation of electronic prescription capabilities, a data import/export feature, and adequate security protection to insure safe meaningful use concepts.

Finally, while it doesn’t affect the primary care marketplace to any great degree, it is important to note that the trend for the future will be migrating data from numerous silos into a federated architecture to enhance the chances for data sharing, and also help in the review of trends to improve the overall quality of health treatment processes.

Readers Write 7/8/09

iPhone for Clinical Data – A Different Approach
By Mark Moffitt, MBA, BSEE

Many hospitals are using the iPhone as a tool for physicians to view clinical data. There are two ways to integrate the iPhone with an EMR:

• Buy a package from a vendor to display clinical data on the iPhone.
• Build a Web-based or native iPhone application.

The first option is the most common approach. Benefit: no development costs. Disadvantage: limited ability to customize the application to an organization’s specific needs.

We elected to build a Web app for the iPhone because we wanted to customize the solution to our needs and did not have funds to purchase an application from a vendor. Some of the features in our iPhone web app include:

• Sign on with four-digit PIN using large numeric virtual keypad (see image) versus entering username and password on the iPhone virtual keyboard.
• Lab data displayed as three most recent values in a simple table (see image). Lab tests grouped using common categories.
• Select and play a radiology dictation when viewing a patient’s record.
• Rounding list defined and built to physician specification. Physicians can add and delete physicians in their group using the iPhone.
• Length-of-stay information from our Case Management and Bed Tracking application, also written in-house.

It’s the subtle features that make the difference in user acceptance of software. This is especially true in healthcare for reasons too numerous to list here.

For example, physicians don’t like entering their username and password on the iPhone’s virtual keyboard, an approach many vendors use. Using the virtual keyboard takes a certain touch that is difficult for some physicians to master. We built a security feature that ties a specific iPhone to a specific physician to a specific PIN they choose. The PIN is only valid on the physician’s iPhone and is entered using a large, virtual numeric keypad that mimics an ATM. Users need only enter their four-digit PIN to log in.

The ability to ask physicians, “How would you like it to work?” versus “This is how it works” makes the difference between good software and software that physicians accept. This can best be accomplished by building the front end custom to your needs. While building software is harder and more difficult (for IT personnel) than buying vendor software, the ability to build initiative, easy-to-use software makes training, implementation, and support much easier. And the extra effort makes it much easier for the user to incorporate into their work.

It really is that simple. And why “generic” software requires much more training and process redesign than custom software. Another advantage of build versus buy is we can continue to deliver applications without being dependent on available capital dollars.

Future plans include using the iPhone with the Web app to record dictations and use of the iPhone for eMAR.

Mark Moffitt is director of information systems at Good Shepherd Medical Center of Longview, TX, proof that you don’t have to live in a big city to innovate in healthcare IT.

Meaningful Use Criteria Comments
By Arlen Dominek

I thank the members of the Health Information Technology Policy Committee and, in particular, the members of the Meaningful Use Work Group for their time and effort. I would like to provide my own comments upon the draft presentation of Meaningful Use.

I think that it will be very difficult for all ambulatory and acute care provider organizations to implement an EHR by 2011 simply because of ramp-up time and change management considerations. It takes time for an organization not only to put together an implementation team, but to ensure that the appropriate governance structure is in place. The organization must also formulate a clear focus of where it wants to go, a plan for how it’s going to get there, and how it can assess its progress in getting there.

The organization must identity the members of the implementation team. Often, the organization must recruit additional personnel or retain consultants. In addition, there is training to take into consideration. Equipment must be ordered.  Appropriate telecommunications must be in place.  Interfaces must be implemented. In addition, simultaneous implementations of ambulatory and acute applications by a delivery system can be onerous, yet a certain amount of collaboration is necessary to promote maximum utility.

Vendors will have constraints as well. Many vendors are running very lean implementation organizations today; this minimizes the number of implementations that any one vendor can support at a time. It’s no different than any other manufacturing environment;  there are capacity limitations. Moreover, any rapid implementation cycle provided by a vendor should be carefully evaluated to ensure that the needs of various provider and patient populations are being adequately met.

It’s one thing to provide content satisfying a general med/surg model, quite another to meet the needs of a pediatric BMT program. Rapid provider adoption of workflows and clinical documentation applications will be effected if provider needs are considered during the initial build of content and workflows. Workflows should be designed to meet the particular needs of the provider, e.g., a diabetes clinic or a nephrology clinic. Such consideration can minimize costly re-engineering at a later point and contribute to the success of an implementation.

Hence, Meaningful Use criteria should:

• Be sensitive to the ability of an organization to initiate its EHR implementation and in meeting Meaningful Use criteria, that is, no organization should be penalized because of implementation delays that are out of its control or the population it serves has minimal broadband connectivity;
• Be cognizant of ramp-up time;
• Reflect the maturity of any particular implementation, for instance, if evidence-based order sets comes two years after CPOE implementation, then the criterion should reflect the stage of a particular implementation and not simply a calendar year.

CDS at the point-of-care is somewhat ambiguous and restrictive. Are we referring only to those kinds of CDS that present during CPOE or are we also considering alerts which reflect changes in patient conditions and availability of new data to alert a provider and inform a decision? 

Meaningful Use calls for the capture of clinical data that can be queried and trended. I can appreciate the issue of data capture with which the Work Group has contended;  however, I feel that the objectives have minimized the value of these data and other data for data warehousing and analysis as well as for interoperability through such mechanisms as ELINCS. Hence, such data should utilize standard classification systems such as LOINC, SNOMED, and ICD-10CM to support data warehousing and analysis. Such requirements should be clearly called out so that provider organizations and vendors will incorporate this into their project plans.Such classifications are essential and often mandatory for reporting to quality, epidemiological and public health agencies and to various registries.  Meaningful Use should clearly call this out.

Moreover, there is far more information within a patient chart that could be subject to further structure and encoding. The use of standard classification systems or languages should be implemented so there is a consensual, meaningful and useful framework which governments, providers and consumers can use as a common language.Internationally endorsed classifications facilitate the storage, retrieval, analysis, and interpretation of data. They also permit the comparison of data within populations over time and between populations at the same point in time as well as the compilation of nationally consistent data. (http://www.who.int/classifications/en/) It appears to me that CCHIT and vendor organizations have avoided the issue of incorporating standard classifications or the usage of common classification languages.

Our goal should be to maximize the value we obtain by automating CPOE, clinical documentation, and result reporting.

Order sets are often viewed as provider productivity tools and are conducive to provider adoption of CPOE. Considerable effort is entailed in adopting and implementing evidenced-based order sets. The effort to implement an organization’s existing order sets only to be followed within two years by the adoption of evidenced based order sets is considerable.Perhaps such adoption should be moved up in the timetable.Reimbursements and grants should reflect the licensing cost of evidenced-based order sets. Available evidenced-based order sets tend to focus on medications;  however, standard classifications would encourage incorporation of evidenced-based data for other procedures such as radiology and laboratory.

Multi-media support capabilities are existent in many commercially available EHRs. Perhaps this objective could be moved to an earlier year.

The Meaningful Use Matrix calls for the use of bar coding in medication administration, yet it does not call for the bar coding in the administration of blood products or for positive identification of patients on whom procedures are to be performed, e.g., specimen collection. While CCHIT addresses medication administration in its category Decision Support for Medication, Immunization, and Blood Products Administration requirements, there is no mention of similar functionality for blood product administration, etc. It’s important that Meaningful Use expand beyond current CCHIT requirements and vendor offerings.

It’s admittedly difficult to elaborate workflow efficiencies, but there are some examples

• CDS for administration of immunizations and blood products and positive patient identification as mentioned previously.
• Use of commercial databases to quickly inform the provider whether a medication or procedure is covered by a patient’s payor, thereby reducing time spent in remediation or in losing revenue.  (And payments should reflect the expenses of these databases.)
• Reduction of labor costs in collecting specimens and increasing patient satisfaction by reducing needle sticks when a central line is available.
• Centralized coordination of appointments.
• Automated patient referrals.
• Improved patient satisfaction when the provider has the patient’s information at the right time and place.
• Improved transfer of information between providers.

I apologize if any of my comments have been redundant or because of my failure to notice their having been addressed elsewhere.

Arlen Dominek is practice director at Peer Consulting of Mercer Island, WA.


Subrogation
By William O’Toole, O’Toole Law Group

Regarding the SubroShare(R) press release, Mr. HIStalk was understandably a little off in his assessment; this is not about a policyholder suing the healthcare provider. It is all about personal injury claims.

Subrogation is a legal remedy that enables an insurance company to recover amounts it paid for the care of its customer (the injured patient) in situations where the patient also receives payment covering the same services from a third party (the one that caused the injury to the patient and was sued by the patient).

The key here is the third party. There must be some other party that caused the injury to the patient and from which there is the possibility of payment resulting from a lawsuit (damages) or settlement of that lawsuit.

I will go out on a limb and state that I cannot imagine any health insurance policy not having a subrogation clause. Whether or not attorneys have an obligation to inform the insurance carrier of secondary (duplicate) payments is irrelevant, because where there is a subrogation clause, there is also the obligation for the insured patient to inform the insurance company that the patient’s injuries were caused by a third party, thereby raising the flag for the insurance company.

That said, unfortunately there are those patients that do not, and processes are not always what they should be and some claims "fall through the cracks" and are not identified properly up front. Consequently insurance companies are left to hunt down reimbursement in these situations.

What I believe SubroShare(R) offers is a method to assist insurance companies in identifying situations where they may recover, through subrogation, some payments made on a patient’s behalf.  The trigger seems to be the request for the patient’s records by an attorney, which might mean third party involvement in the patient’s injury, and consequently might mean the possibility of payment to the patient directly for services already paid by the patient’s insurance company.

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

Provider Profitability
By Dichotomous Dweller

I watched with sardonic amusement as a whopping 19% of readers voted that healthcare providers are sandbagging on IT to keep the public from seeing how profitable healthcare delivery is. Really? 19% of people who read this site think that patient care plays second fiddle to profitability when it comes to EHRs?

Given the way the question was phrased, I’m supprised the number was so high, but then I think the poll question missed the point, so maybe others saw through it as well. Some better questions might have been:

• Do you believe that profitability (here defined as free market economics) enhances or threatens the quality of healthcare received by the general public?
• Do you believe that healthcare providers are have a vested interest in keeping the public from seeing how profitable healthcare delivery is?

There are lots of trick questions like these, but the answer is always both ‘yes’ and ‘no’.

The simple truth is that a dying person will usually give their last dime for a shot at one more day. Healthcare in these circumstance is every man for himself. If you are sick or dying, you’re not going to mind that the person in the bed next to you is subsidizing your stay at a rate of $100 per tablet for over the counter drugs or 33% year in income taxes. Profitability can be created by reducing costs as easily as by increasing sales, but in these circumstances, money doesn’t mean much.

Do you really think that there aren’t people profiting in healthcare from deals that they’d rather the public not know about?  (Thank god we have people like Mr H to keep us up to date on the salaries of major ‘non-profit’ executives). But why stop there? What about those doctors with lucrative research deals with pharmaceutical companies, or pharmaceutical companies who perk doctors who use their products? 

Now I have no idea if such profiteers are going to be exposed by EHRs.  Indeed, it seems EHRs can be their own unique breed of profiteering. But let’s be honest, we all know people who profit from healthcare, and no matter what happens next, single payer, socialized medicine, co-ops, EHRs, RHIOs, status quo, bankruptcy of Medicare, etc., there will always be people profiting from healthcare.

The real question is: is it fair? And it is this question, no matter how simply stated, that we can’t possibly come to agreement on. So we’ll let the market decide for us. I bid 10% of my salary. And rising.

Readers Write 7/1/09

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

Hats Off to AMDIS
By Ann Farrell

Congratulations to AMDIS for saying what many of us believe and promote, but had feared was falling on deaf ears or been drowned out by politics and ego. It’s not surprising that the “Boston Docs” known MD-centric view of the world (healthcare and IT) produced a largely MD-centric, “CPOE first” meaningful use strategy. Hopefully this attitude was rejected when Version One of MU was sent back to the drawing board the day after the first draft was issued.

Chasing ARRA money already put some hospitals on a dangerous path to drop everything in hurry up mode to “install” CPOE without examining physician workflow, decision making, cultural and change management needs, and foundational applications. Some EMR companies and their advocates encouraged this — some unwittingly, others with an eye on increased or accelerated quarterly revenue recognition, the metric vendors are held to (incented by), particularly public companies.

For CPOE to be more than an automated requisition generator, MDs need to get tangible value, including the ability to make better informed decisions based on more timely data (not meaning the computer is making decisions for them). Since ancillary systems were ground zero for hospital clinical automation, lab and X-ray results are almost always online before or with CPOE. 

What may not be present is assessment data entered by nurses, ideally at the point of care in near real time, e.g. allergies, height/weight, vital signs, I & O, nurse-collected lab values, and an accurate medication record. That is critical data for clinical decision support (CDS) for MDs in ordering. Not having these data available wastes MD time and steps and results in suboptimal or even unsafe ordering decisions. If data is not easily retrievable (preferably “pushed” to MDs in the ordering process at the right time), physicians are forced to look for paper charts, call for information, chase nurses down, or make ordering decisions without important or current information.  

In addition to providing a clear path to CPOE, automating the eMAR/BCMA has greater  potential impact on med error reduction than CPOE. Not killing or harming patients would seem a primary goal to improve quality of care.  MDs and RNs make approximately same number of errors, but pharmacists or RNS catch 50% of MD errors downstream whereas 98% of RN errors reach the patient. And, nurses work for hospitals and are more easily corralled (in theory), thus making clinical and business sense to start with foundation pieces first.

Hopefully Drs. Glaser and Halamka (and Blumenthal) are listening. Some have recommending staging implementations as if it’s a pecking order — doctors first! To be effective, CPOE needs to be part of a bigger strategy –patient-centric, outcomes (not IT) focused, with staged functionality and a 21st century interdisciplinary care team approach that respects all caregivers’ roles and contributions.

For the good of all, we want CPOE to be embraced by MDs, but also for MDs and US healthcare reform to be more inclusive and patient-centric. I speak as clinical consultant, former EMR vendor exec, and RN who worked with first commercial EMR in a hospital with near 100% CPOE in early 1970s. CPOE is hardly a new phenomenon, yet some MDs and vendors act as if it started with them. We’ve known for decades how CPOE can be implemented successfully. Now’s the time to really get this right.

Ann Farrell is a principal at Farrell Associates of San Francisco, CA.

An Alternative Desktop Standard
By Mark Moffitt, MBA, BSEE

We have deployed a unique desktop configuration at our healthcare provider organization. The configuration is a Mac-mini running Windows 7 release candidate (RC) with a 17” wide-screen monitor.

The advantages of this configuration over a conventional PC are:

1. Smaller footprint
2. Less expensive
3. Higher quality hardware
4. Better cloning capabilities, i.e. ability to clone the windows partition using the OS X operating system
5. Run Leopard and/or Windows 7

We skipped Vista as a desktop standard. We found W7 RC to be very stable. So, rather than install XP on newly deployed machines, we opted to deploy W7 RC. Once W7 is released, we will install it over W7 RC.

The cost of the Mac-Mini, display, and keyboard and mouse was less than the conventional PC configuration we were considering. Your mileage may vary.

Power users in IS run both Leopard and W7 RC. They are both really good operating systems. Leopard is much better working with multimedia, while W7’s sweet spot is “corporate computing.” I run both on my MacBook Pro.

Mark Moffitt is director of information systems at Good Shepherd Medical Center of Longview, TX.

Physicians Using PCs
By Ben

I think you need additional inspiration!

Seriously, I think you’re confusing the work flow of an office based physician with the work flow of an inpatient physician (i.e., hospitalist or critical care specialists as examples). We (hospital-based physicians) spend much more time sitting down, sifting through and analyzing data (whether in electronic or paper formats) than we do with hands-on patient care. That’s NOT because the data analysis pulls us away from the bedside, but rather it is the bulk of the work: analysis, married with the patient visit and examination, tempered by experience and judgment, aided by decision support as available, leads to action. 

Why do computers in patient rooms fail to attract physicians? We want to work at a desk, adjacent to our colleagues, where we can sit and work without being distracted by what’s going on in the patient’s room. Doesn’t matter whether we’re working from a computer record or a paper record. 

And BTW: the “pecking away at a keyboard” has made me a vastly more efficient and informed physician than when I worked off of paper. Lawyers have the option of turning the work over to “associates”. In the absence of medical students, the patient gets the full attention of the “partner”! Score one for physicians.

Readers Write 6/24/09

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

What Interesting, Light, and Cheap Technologies Are We Using?
By EncoreDiva

We don’t have a single server of our own.  We use hosted solutions for e-mail and SharePoint. 

We have a Web-based accounting system, timekeeping system, and expense reporting application.

We’re experimenting with Yammer to encourage collaboration within a virtual organization (and to cut down on e-mail), we have a page on Facebook, we utilize the status feature on LinkedIn to update our network on what’s new with the company and we utilize Skype for IM and quick calls. 

We use www.freeconference.com for internal conference calls and www.dimdim.com for internal webcasts. We utilize Administaff for our payroll and benefits and they administer (securely) all employee information. Our recruiting system is Web-based and open source (www.catsone.com) and it’s easily accessible from an iPhone. From a desktop perspective, we’re playing with OneNote and so far I’m LOVING it!

Meaningful Use: A Brief History
By Dr. J

13,000 BC: Prehistoric humans decorate their caves with images of herbal remedies used for their medicinal purposes. Unfortunately, these primitive clinical information systems are not CCHIT certified and reimbursement for shamanism drops dramatically. Neanderthals go extinct.

2600 BC: The Egyptian Imhotep describes the diagnosis and treatment of 200 diseases. ICD-10 soon expands this list by nearly three orders of magnitude.

460 BC: Hippocrates, the “father of modern medicine,” writes the first draft of his famous oath. After an extensive public comment period, Hippocrates tones down his commandment to “first, do no harm by taking an extensive medical history, including prior medications, allergies, and surgeries and accounting for the patient’s renal and hepatic function” out of concern that this tough requirement may hamper widespread adoption.

150 AD: Galen of Pergamum, pioneering Roman surgeon, insists on using only papyrus. He refuses to implement parchment in his practice because he finds it so disruptive to his workflow.

1231: Theodoric, Barber of York, proposes standardized terminology for various forms of bloodletting, primarily so he can “upcode” to get increased reimbursement for using leeches.

1427: As the Black Plague sweeps through Europe, self-flagellation is lauded as a pioneering effort for health information exchange. Whole communities get into the act by burning sufferers alive, using the fiery glow as a novel public health reporting tool.

1601: James Lancaster proves that consumption of citrus fruits prevents scurvy in British sailors in the world’s first controlled clinical trial. Unfortunately, in a world without quality metrics for scurvy prevention, Lancaster fails to achieve his pay-for-performance bonus for the year.

1795: After a mere 194 years (and 1 million scurvy deaths), the British navy mandates lemon and lime juice as standard sailor’s rations. Next up, EHR adoption.

1816: Rene Laennec invents the stethoscope, which is subsequently rated “Best in KLAS” over the objections of the Open Source community.

1845: Surgical anesthesia is pioneered at Massachusetts General Hospital. The Federal government sets up “Regional Anesthesia Extension Centers” to assist in anesthesia implementations nationwide.

1854: Florence Nightingale begins a medication bar-coding initiative during the Crimean War, but then realizes it would be preferable to save lives by cleaning the army hospital’s sewage system.

1884: Robert Koch establishes his famous postulates to identify microorganisms responsible for various diseases. Privacy advocates successfully sue Koch, forcing him to go back and de-identify the pathogens.

1889: Sir William Osler creates the medical residency but completely fails to anticipate the headaches his other creation, the co-signature, will cause in 120 years.

1895: X-rays are discovered by Wilhelm Röngten, without the assistance of a PACS. Nevertheless, for years Röngten would claim that his images conform to DICOM standards.

1928: Alexander Fleming extracts penicillin from mold growing on a tablet PC he had forgotten to plug in for several days. He tries to e-prescribe the antibiotic for a patient, but the antibiotic is not in his “favorites” list, so he handwrites the prescription and gets the dosage wrong.

1967: Christiaan Barnard performs the first human heart transplant. No one ever hears about it because Twitter has not yet been invented.

2003: The human genome is completely sequenced. Instead of the expected ACTGs, the genome is apparently filled with strange acronyms like LOINC, CCD, CCR, and HL7.

2008: CCHIT is involuntarily dissolved for the first time.

2009: David Blumenthal, the National Coordinator for Healthcare Information Technology, delivers the government’s definition of “meaningful use” to an immense crowd of jubilant healthcare providers from the steps of the Lincoln Memorial, after an opening concert by U2. Healthcare in the US is saved! The rest of the industrialized world yawns while besting us on nearly every relevant quality measure for the tenth straight year.

The PACS Designer’s Review of Cloud Acronyms
By The PACS Designer

Illustration: Youseff, UCSB

The number of acronyms applied to cloud computing is growing, and even TPD is confused about what they really mean when it comes to providing users solutions for expanding the computing universe of an institution.

Even IBM has gotten into the marketing hype by calling their cloud offering Computing as a Service with their introduction of their Blue Cloud.

So let us look at what the Wikipedia has to say about the types of service renderings related to cloud computing solutions.

The most common term heard is Software as a Service (SaaS).  The Wikipedia definition is:

"Software as a Service (SaaS, typically pronounced ‘sass’) is a model of software deployment whereby a provider licenses an application to customers for use as a service on demand. SaaS software vendors may host the application on their own web servers or download the application to the consumer device, disabling it after use or after the on-demand contract expires. The on-demand function may be handled internally to share licenses within a firm or by a third-party application service provider (ASP) sharing licenses between firms."

Another cloud computing term is Platform as a Service (PaaS) which is defined as:

"Platform as a service (PaaS) is the delivery of a computing platform and solution stack as a service. It facilitates deployment of applications without the cost and complexity of buying and managing the underlying hardware and software layers(1), providing all of the facilities required to support the complete life cycle of building and delivering web applications and services entirely available from the Internet(2)—with no software downloads or installation for developers, IT managers or end-users. It’s also known as (cloudware).  PaaS offerings include workflow facilities for application design, application development, testing, deployment and hosting as well as application services such as team collaboration, web service integration and marshalling, database integration, security, scalability, storage, persistence, state management, application versioning, application instrumentation and developer community facilitation. These services are provisioned as an integrated solution over the web."

The next cloud computing term is fairly new, and is Infrastructure as a Service (IaaS) and is defined as:

"Infrastructure as a Service (IaaS) is the delivery of computer infrastructure (typically a platform virtualization environment) as a service. These virtual infrastructure stacks(3) are an example of the everything as a service trend and shares many of the common characteristics. Rather than purchasing servers, software, data center space or network equipment, clients instead buy those resources as a fully outsourced service. The service is typically billed on a utility computing basis and amount of resources consumed (and therefore the cost) will typically reflect the level of activity. It is an evolution of web hosting and virtual private server offerings."

Lastly, IBM’s term of Computing as a Service will most likely be used as a marketing tactic only as their already is a CaaS which stands for Communications as a Service!

Hopefully posting all of these terms in this entry will help users understand solution offerings by vendors, and be a guide to everyone contemplating using cloud computing structures as solutions.

(1) Google angles for business users with ‘platform as a service’
(2) Comparing Amazon’s and Google’s Platform-as-a-Service (PaaS) Offerings | Enterprise Web 2.0 | ZDNet.com
(3) IT as a Service is a model ripe for adoption
https://spaces.internet2.edu/download/attachments/8817/ComputingAsAService08.pdf?version=1
http://en.wikipedia.org/wiki/Software_as_a_service
http://en.wikipedia.org/wiki/Platform_as_a_service
http://en.wikipedia.org/wiki/Infrastructure_as_a_Service

Readers Write 6/8/09

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

The problem with publicly traded companies is they serve the spreadsheet, not the customer.

In the last year, I have heard:

• the VP of implementation of an HIS vendor said that she does not have the personnel to devote to our implementation because she needs to hit a certain metric and this would blow her numbers.
• a sales VP at a major ambulatory EMR vendor tell me that because of their end of year, they needed me to commit to buying six more licenses (to true up a five-year-old old problem THEY created) within 24 hours or they would “turn us off”.
• the SVP at a major ERP vendor, admitting that the sales team “made a mistake,” said they can’t fix it because they have to hit a certain profit margin (FYI, your company hitting a certain double-digit growth or profit margin is not a large concern of my non-profit health system struggling to break even — know your audience, people).

Whatever happened to partnerships? It is clear that the ‘partnership’ with the shareholder is far greater than the ‘partnership’ with the client.

I have been fortunate enough to work for privately held software vendors and unfortunate enough to work for publicly traded software vendors. I have worked at a privately held software vendor that was purchased by a publicly traded company. I have seen the difference from both sides. I know that the customer is not at the center of decisions in a publicly traded company; spreadsheets are at the center of decisions.

As a client of both publicly traded and privately held vendors, I am experiencing both sides of the equation. Without question, the privately held vendors make better ‘partners’.

I would not imagine the 14K that caused such a barrier to customer service at a major healthcare ERP vendor is worth the damage it has done to this two million dollar ‘partner’. The 20K that created a competitive environment was not worth putting the client at risk. The confidence lost at the executive level was not worth the implementation team hitting a certain metric for the quarter.

We all have to hit certain metrics. We all have our own challenges. Publicly traded software vendors often keep the short term revenue recognition or expense metric in focus when the big picture should be on customer satisfaction and retention. This quarter’s financial statement will not keep you going in the long run. Your ability to attract and retain happy customers that buy from you again will keep you going.

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

Is Data In Your CDR Accurate? Are You Sure?
By Unfrozen Caveman CIO

I’ve always wondered about the accuracy of the process of duplicating data in ancillary systems, such as a laboratory information system (LIS) or radiology information system (RIS) to a clinical data repository (CDR). The most common process consists of parsing HL-7 messages and storing the data in a CDR. Sounds simple and straightforward. What could go wrong?

It turns out it’s not so simple and things do go wrong:

1. HL-7 is not simple or straightforward to work with. Parsing data can cause random discrepancies.
2. Changes, such as revising clinical data, e.g. change a lab value, revising a finalized report, etc., can cause discrepancies.
3. Software updates in the ancillary system can cause discrepancies between data in the ancillary system and CDR.

My organization is moving away from the CDR-centric framework to a web services framework (aka service-oriented architecture). In this framework, clinical data is not reproduced in a CDR unless absolutely necessary and data is retrieved from ancillary systems using web services when needed. However, for reasons related to response time, we needed to duplicated lab data in a lab data repository outside the LIS.

During this process we discovered that a vendor-supplied CDR and a second, smaller CDR, purchased as a package from a vendor to provide mobile access to clinical data, store lab data that does not match data in the LIS.  These systems are no longer used for clinical operations for reasons unrelated to the discrepancies noted.

As part of our effort to build a lab data store, we also built a program that validates lab data by comparing data in the ancillary system with data in the CDR for a specific date. We are experimenting with the best strategy for running this program. For example, run the program every morning for dates equal to yesterday, last week, and last month.

How significant were the discrepancies? That question misses the point. The question should be what do you do about it? Ignore it and pretend it doesn’t exist? Or have in place a data validation process that identifies, reports, and fixes discrepancies. Did your CDR come with one? If not, what are you going to do about it?

Forget eHealth Ontario
By Justen Deal

Forget eHealth Ontario! Take a look at the federally-sponsored not-for-profit entity, Canada Health Infoway, which actually appears to be accomplishing even less. Plus, because it is not actually part of the federal government, it gets to be much less transparent to boot! 

So far, since 2001, it has received $2.1 billion in funding, including $500 million for 2009 it just got in January.

Their longstanding goal has been to ensure 50% of Canadians are covered by electronic health records by 2010. According to a recent survey by the Commonwealth Fund, only 23% of primary care physicians in Canada are using electronic health records (compared to 28% for the United States). Sounds like they’ve got a long way to go in the next seven months, eh?

That might be why they’re now focusing on a new (and improved!) goal of covering 100% of Canadians by 2016. They estimate more funding will be required…  😉

Justen Deal is venture director at QuarrierWade of Charleston, WV.

NAHAM Report
By John Holton

This is a belated update on the NAHAM (National Association of Healthcare Access Managers) convention a week ago. The most exciting aspect of the convention was the formation of the Healthcare Access Management Coalition which is comprised of NAHAM, hospitals, other healthcare providers and industry vendors.

Everyone acknowledges administrative waste in our healthcare system and yet access to care and the arcane reimbursement environment created by the insurance companies is missing from the current debate. The new coalition is focusing on educating policymakers on the importance of efficient and quality management processes from a patient’s point of entry through the continuum of care. Hopefully through this education, new policies streamlining the administrative end of healthcare will result in more dollars being spent on the actual delivery of patient care.

The goals of the coalition are:

• Improve access to care and reduce healthcare costs through dynamic healthcare management
• Ensure healthcare reform includes entry point and patient management processes
• Educate policymakers about technologies that improve service delivery models
• Support technology solutions that make healthcare more affordable and efficient

Anyone interested in these topics can get more information by contacting John Richardson, NAHAM Director of Government Relations at (202) 367-1175 or jrichardson@smithbucklin.com.

John Holton is president and CEO of SCI Solutions of Los Gatos, CA.

Readers Write 6/1/09

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The Psychology of Health Information Technology: What’s Missing?
By Mark Hochhauser

I’m a psychologist whose spouse works in a hospital pharmacy implementing an EMR system. My interest is the missing psychological aspect of the current drive towards electronic medicine.

Behavior change theories

Assumptions about the ability of various electronic health systems to change physician and patient behaviors are not based on an understanding of behavior change principles. Information may help change someone’s knowledge, but changing their attitudes and behaviors is much more difficult.

For example, about 20% of US adults still smoke, down from about 50% in 1964 when the first Surgeon General’s report on smoking was published. That represents about a 60% reduction, but it has taken 45 years to get there. Why does anyone assume that information alone will lead to behavior change when that conclusion not supported by the evidence?

One goal is to give physicians and patients information that will lead to behavior changes by both groups (and healthier patient outcomes), but nowhere have I seen any references to the behavior change literature. For example, relevant behavior change theories such as the 1) Health Belief Model, 2) Stages of Change Model, 3) Consumer Information Processing Model, 4) Theory of Planned Behavior and 5) Implementation Intentions Model are absent from the HIT literature. How can behaviors change when HIT programs are not based on any understanding of behavior change theories? What you’re left with are trial-and-error programs.

Limited patient health literacy

Presumably patients will become more active participants if they get more information via electronic patient records. Missing from that assumption are any insights from health literacy research. The 2006 “Health Literacy of America’s Adults” [http://nces.ed.gov] estimated that 14% of adults had “below basic” health literacy, 22% had “basic” health literacy, 53% had “intermediate” health literacy, and 12% had “proficient” health literacy. What level of health literacy is needed to understand health information and complicated health information tasks such as keeping and updating electronic personal health records? Not everyone is as smart as you.

Lack of an evaluation plan

Years ago, when I reviewed prevention proposals for federal agencies, they recommended that 15% of the budget be spent on program evaluation. Although I’ve read extravagant claims for the future benefits of EHRs, I have yet to see a decent program evaluation plan described in the literature. Unless an appropriate plan has been developed with experimental (EHR, CPOE, etc.) and control groups (no EHR, CPOE, etc.) along with relevant definitions and measurements of physician and patient behavior changes before, during, and after implementation, there will be no way to scientifically determine whether these programs work or do not work. Hype is not an evaluation plan.

Conclusion

Getting physicians and patients to change their behaviors is harder than anyone seems to recognize. The absence of key psychological perspectives in the development and implementation of HIT programs means that they will probably not be very effective. Psychologically, current HIT programs represent the triumph of hope over evidence.

Mark Hochhauser, PhD is a readability consultant in Golden Valley, MN.

Since consumers rely on quality and cost information in many other segments of their lives, I believe it is the consumer who will soon begin to drive improvements in quality and price transparency in healthcare. Further, the American Recovery and Reinvestment Act of 2009 will result in the industry’s increased adoption of technologies that are critical to creating the environment of transparency that consumers will demand.

As consumers become more and more involved in their care, they are coming to realize that better information about cost and quality will allow them to make better, more informed choices. Just as they can book hotel rooms anywhere around the world—and find data on cost and quality that is readily available—they will begin to expect the same in healthcare. Providers operating in a competitive environment will be forced to improve the quality and cost of care if they are to compete effectively. In addition, transparency will encourage these consumers to reward high quality/low cost care. Over time, consumers will not tolerate a healthcare system without quality and cost transparency.

Hotels and healthcare

Already, today’s consumers feel that the current state of information is inadequate. They rarely have cost and quality details about healthcare services, and even physicians rarely have comparative information on the quality of their own care or of the care of physicians to whom they refer patients[1].

Quite unlike decisions about a hotel stay, the unique characteristics of healthcare decision-making includes a high degree of risk and value–both perceived and real. Healthcare decisions therefore necessitate that consumers maintain a high level of involvement in the decision-making process. Unfortunately today, most consumers overall could spend considerable time and effort to uncover a minimal level of information to make their final purchase decision. Further, even though they have researched the service, sometimes the end-user experience differs greatly from what they expected, since the healthcare delivery processes includes many touch points. This variance in the consistency of services and involvement of diverse processes in the system raises additional issues of cost and quality transparency.

Opportunities and solutions

Cost and quality transparency would help patients to make informed choices about their care, encourage private insurers and public programs to reward quality and efficiency, and compel providers to improve services by benchmarking their performance against others[2]. To develop and implement a national strategy for health care quality measurement and reporting, for example, the National Quality Forum (NQF), a private not-for-profit membership organization, was incorporated in 1999. NQF is also involved in standardizing health care performance measurement and reporting. Some of the selected projects include cancer care quality measures, mammography standards for consumers, cardiac surgery performance measures and nursing care performance measures. Some effective state-driven transparency efforts[3] in the US include various programs such as the Pennsylvania Health Care Cost Containment Council, California health care reform, Florida Compare Care and the Massachusetts Health Care Quality and Cost Council.

The demand for details and quality in the form of report cards and rating systems for hospitals has also provided business opportunities for private companies. Some of these report card providers are:

• “Consumers’ CHECKBOOK,” which provides “desirability” ratings for hospitals based on surveys of physicians, risk-adjusted mortality figures, and adverse outcome rates for several surgical procedures
• “Leapfrog Group,” which surveys hospitals on about 30 safety practices and then combines them to provide an overall safety score
• “HealthGrades,” which rates hospitals by individual procedures and conditions[4].

These report card providers may differ in the methodology of their rating systems, so it’s become important for consumers to have a broad perspective in order simply to evaluate these ratings.

Key conclusions

Going forward, the cost and quality transparency and standardization of services will act as key purchase drivers and contribute to the success of a healthcare system.

Therefore, if stakeholders in the health sector wish to look forward to assured profits from this industry, they have to execute activities such as in-depth planning, deployment, execution, and monitoring of various parameters which can equip them to deal with customer sensitiveness for quality and cost transparency. What might the role of technology play in this arena?

[1] Collins SR and Davis K. Ibid

[2] Collins SR and Davis K. Transparency in Health Care: The Time Has Come, The Commonwealth Fund.2006 Available at:
http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=361215. Accessed February 6, 2009

[3] Health care price transparency: A strategic perspective for state government Leaders, Ibid

[4] Hospital report cards: Making the grade. The Harvard Medical School Family health guide Available at: https://www.health.harvard.edu/fhg/reportcards.shtml . Accessed February 6, 2009.

Colin Konschak is a managing partner at Divurgent.

EMRs are more than Electronic Filing Cabinets with Advanced Health IT – Improving Care and Lowering Costs
By Rich Noffsinger

The act of digitizing patient information won’t lower costs or improve care on its own. Improvements cannot be accomplished without aligning patient, provider and payer interests. Health IT contributes to this alignment by integrating critical patient, clinical and insurance data – enabling stakeholders to leverage multiple sources of information at once to personalize care, improve quality and lower costs.

Similar to how the Internet reformed the investing and travel industries by opening up access to information that was once siloed or guarded, health IT will enable a level of information sharing that simply does not exist today – between doctors and patients, laboratory and other health care providers, health care facilities, insurance companies and providers, etc. It will also allow us to apply computing power throughout the health care supply chain.

Once we unleash these kinds of processing capabilities such as modern analytics, we will see rapid advances in closing gaps in care, revealing wasteful spending, the application of evidence-based treatments, and even broadening medical research. However capitalizing on this data and computing power requires a Herculean level of interoperability and participation.

The value is not simply in digitizing health information; rather, the ROI comes from what you can actually do with the data electronically – through advanced tools and IT strategies like clinical decision support, predictive modeling, comprehensive risk stratification and evidence-based medicine.

By ignoring sophisticated health IT tools and technologies, patients, payers and providers miss opportunities to leverage the volumes of medical guidelines, insurance rules, treatment comparisons and best practices – that can improve health care and lower costs.

Rich Noffsinger is CEO of Anvita Health.

Readers Write 5/27/2009

Submit your article of up to 500 words in length, subject to editing for clarity and brevity. I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

CIOs: Sell Your Board and Executives on the Big Picture
By Ivo Nelson

If you think your IT staff and budget will decline in the next five years, think again. By 2010-2013, hospitals will be in full-scale EMR implementation mode. At the same time, they will be reengineering their revenue cycle processes and systems to accommodate some level of healthcare reform, while preparing for conversion to ICD-10.  

All of this activity will be on the same scale as converting to DRGs (1983) AND converting to Y2K (1999) AND implementing HIPAA (2003) times two (or more). And keep in mind, because these changes are mandated by the government, ALL hospitals and physicians will have to comply at the same time.

If you think your vendor contracts will cover all this, think again. If you think you’re at the top of their priority list, think again. If you think you’re going to get a break when you wind down your EMR implementation, think again.

Why?

I’ve met with over 60 CIOs in the last couple of months,  looking for insights into their strategies, concerns, and challenges.

The ARRA HIT stimulus bill is on everyone’s mind. Most CIOs have done more PowerPoints in the last couple of months than in the last five years due to inquiries from their CEOs and boards who smell money. The focus is the stimulus money and how their hospital is positioned to receive the maximum amount from the government. They allude to an END, when the EMR is implemented and demonstrates “meaningful use”, some minimal level of interoperability all within the boundaries of HIPAA security and privacy regulatory changes.

The ARRA HIT stimulus is just the start. Healthcare reform will change reimbursement to true pay-for-performance, requiring billing systems to be based on outcomes and quality. Additionally, if bundled payment is adopted, it will require unparalleled coordination to bring the hospital, physician charges, and other services into a single rate. Any emphasis on coordination of care requires a level of interoperability that doesn’t exist today. 

On top of all that, the impending ICD-10 coding conversions requires the number of diagnostic codes to swell from 13,500 to 120,000. For inpatient procedures, the number jumps from 4,000 codes to 200,000 codes. The IT implications are huge. The impact on the hospital operations process and analytics will be even greater.

Quality is the new battleground. Once we are required to produce consistent quality reporting as a requirement for incentive payments (and eventually to avoid penalties), the game changes. Quality comparisons among competitors will be posted on the sides of buses, billboards, magazine ads, and on the TV. Quality care will be the first thing patients look for when it comes to the well-being of themselves, their family, and their community.
The usual Press-Ganey patient satisfaction measure will become almost irrelevant. Patients will endure long lines, rude staff, and will sit on the floor if they believe they will receive higher quality of care.

For the CIO, there will be immense pressure to be agile in producing reports to manage and report quality. Many are already coming to the sad reality that, after spending tens of millions of dollars on their EMR, all they have is a transaction system that doesn’t produce information. An entirely new genre of HIT now emerges around healthcare analytics. Remember, reimbursement will likely be tied to this information. Losing revenue because IT can’t produce reports, systems aren’t integrated, or vendors aren’t responsive isn’t going to be a conversation any CIO wants to have with his/her CEO or board.

Interoperability/Community Connectivity? Obama’s view of community connectivity is the sharing of patient information between heathcare organizations regardless of their competitive stance and strategy with each other. Our president greatly underestimates the power of local political will. Connectivity is contemplated, in the short term, only when organizations use it to capture a greater share of referring physicians – damn the community good. Elaborate arguments  will justify the self-serving, digital capture of community (e.g. referring) physicians. There is a good chance ‘connectivity’, in the Obama sense, will eventually be defined in the courts.

Most CIOs are aware of the issues around interoperability. Most are participating on some committee on the state or local level as per their boss’s direction. Most roll their eyes at the naïve, non-healthcare participants who see the healthcare exchanges and interoperability as the holy grail.

Most realize they are being required to respond to some government mandate that doesn’t completely comprehend the data complexities that exist within the walls of most organizations. One organization has  92 different definitions for glucose and another has 16 different ways to define death. And they’re going to talk to each other? It’s a good thing there are some smart people on the ARRA HIT Standards Committee.

Of course, all of this is going on while we’re in a recession and CFOs are ratcheting back on capital and asking CIOs when their staff will downsize post-EMR implementation. It is not just that the CFOs are asking for reductions, it’s that the credit markets have tanked and the money simply isn’t there. It’s one thing for a CFO to say we need to reduce expenses; it’s another thing for a hospital to find out they have no credit because the bond market has tanked.

If I were a CIO, I’d be adding a few slides to my PowerPoint presentation to include ALL of the potential changes coming down the pipe, not just the stimulus incentives. I wouldn’t do a full-scale strategic plan, but I would dig deeper into a staffing analysis and make sure I didn’t prematurely reduce or redeploy staff. I’d create some what-if scenarios on the high and low end of change. I’d also take more advantage of the current access to my board and executives to educate and "sell" them on the bigger picture. Yep, and all this needs to be done while you’re trying to get the printer to format labels for the lab accurately.

The budget cycles are starting now for 2010. Make sure you get all of your cards on the table. I know it’s not all defined yet, legislation isn’t passed, and some changes may be a moving target. Like it or not, this is a government that makes decisions. The stakes are high. Now is not a time to be timid.

In the words of the great Wayne Gretzky, “A good hockey player plays where the puck is. A great hockey player plays where the puck is going to be.” Let’s keep the puck on the ice. Go Red Wings!

Ivo Nelson is chairman of Encore Health Resources, a healthcare IT consulting organization.

From DVR-Challenged to an EHR?
By Gregg Alexander

Bringing real change to healthcare information integration will never happen until the focus is off of the “technology” and onto the training, education, implementation, and ongoing usage support of such complicated tools. Period.

Of course you can force the horse, but he he’ll die of dehydration if he can’t figure out how to drink. Geeks docs get it, but most clinicians are not geeks and couldn’t care less about technology if it doesn’t:

1. Make their lives easier;

2. Strengthen their profit margins;

3. Help them be better doctors, AND;

4. Come with ongoing, easy-to-access, stupid-simple support.

Number 4 is probably the most important, yet most often shortchanged component of these quadrangular conditions. Both the technology and the issues it is trying to support (healthcare issues) are far too complex for the general masses of providers to wrap their brains around all together. Just being a clinician is hard enough. Giant new learning curves for techno-tools which – let’s face it – don’t really hold much fascination for most normal folks are off-putting, even repulsive.

Here’s what I hear: “With pen and paper, I can be a decent doctor (#3), get by financially (#2), and I already, almost innately, know how to use them (#1). Sure, paper has a ton of associated problems, but until there are sufficient helpmates (#4) to hump me over that technological learning curve mountain, I’ll do what I know and spend my extra time trying to get the hang of my DVR. By the way, speaking of computers, what’s this Twitter thing? Is it … (hushed) … sexual?”

Dr. Gregg Alexander is a grunt-in-the-trenches pediatrician and geek. His personal manifesto home page…er..blog…yeh, that’s it, his blog – and he – can be reached through http://madisonpediatric.com or doc@madisonpediatric.com. He writes regularly for HIStalk Practice, but we decided to put him on HIStalk this time just for fun.

Blade Server Review – Main Features and Values
By The PACS Designer

There has been a lot of press lately about blade server architectures, so TPD thought it would be a good idea to highlight some of the main features of this type of architecture.

A blade is a plug-in device that is installed in a chassis. Its Wikipedia description reads, "The name blade server appeared when a card included the processor, memory, I/O and non-volatile program storage (flash memory or small hard disk(s)). This allowed manufacturers to package a complete server, with its operating system and applications, on a single card / board / blade. These blades could then operate independently within a common chassis, doing the work of multiple separate server boxes more efficiently. In addition to the most obvious benefit of this packaging (less space-consumption), additional efficiency benefits have become clear in power, cooling, management, and networking due to the pooling or sharing of common infrastructure to supports the entire chassis, rather than providing each of these on a per server box basis."

Blade servers and storage systems generally consume 50% less energy than traditional servers. They also occupy much less floor space, so valuable real estate can be put to better use. They also require fewer cables, have smaller power needs, and fit into 19" slots in a chassis.

Blade servers won’t replace mainframes any time soon, but they will be deployed for Web solutions and  cloud computing. An effort to move mainframe software to external users through conversion to SOA and REST solutions would typically be good for installation on blade server/storage systems, provided adequate security methods have been installed.

IBM’s partnership with Sentry Data Systems, which serves pharmacies and hospitals in over 20 states, is an example of a cloud solution that was deployed to reduce power consumption and  meet the growing needs for servers in a smaller operating space with less cabling.

Since the genie is out of the bottle, so to speak, for Web 2.0 and cloud computing, we will be seeing more need for blade systems solutions in the years ahead.

Readers Write 4/30/09

Submit your article of up to 500 words in length, subject to editing for clarity and brevity. I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Note to the US Healthcare System: Treat Me Like a Dog
By Peter Longo

I think everyone knows the US healthcare delivery system seems to have more challenges than solutions. From my vantage point, working in healthcare technology,I sometimes wonder if we can ever put all the crazy puzzle pieces together. I never thought that one day, soon after a long overdue physical and a trip to my dog’s vet, I would deem it in so need of repair that I begged to be treated like a dog.

Recently my beloved dog Hamlin’s digestive system grew tired of his “Cowboy Chow” dog food. Without a moment’s notice, my wife quickly went out and purchased him three other kinds to choose from. (I wonder if tonight I complain about dinner, will my wife run out to three different restaurants and find me something I prefer?)

Even the newly purveyed dog food did not settle Hamlin’s stomach. My wife, busy escorting three kids about town, informed me I had to take him to the vet. Since I work for a healthcare technology firm, I assumed going to a doggy doctor would be fun and enlightening; a respite from seeing human hospitals and doctor offices.

Hamlin and I eagerly pranced into the office with me ready for the inevitable “doctor wait”. Interestingly enough, I was greeted at the counter by a smiling receptionist calling out Hamlin’s name. But of course, they were expecting him because he had an appointment! Wow, novel concept here I thought.

Next I had my wallet out, ready to be accosted for money before I could even get a quick question in. Before I could eject my credit card, the side door opened and a smiling “nurse” asked Hamlin to come this way. (I assumed they were smiling because they were going to make a fortune out of me). Guarding my wallet, I followed our escort down the hall. I was still dazed from the fact they were expecting us and recognized Hamlin.

As we entered our exam room, I was perplexed to see a shiny new notebook computer on display. Before I could gasp in shock, the vet walked up behind me, introduced himself to Hamlin (the patient) first, then to me. Casually, he turned toward his shiny new laptop and within two key strokes had Hamlin’s medical record on the screen. My dog’s entire record. Looking like the complete geek that I am, I jumped at the vet asking to see everything on the system.

Eyeing me as though I might be in need of medical help myself, he leaned back to show me Hamlin’s electronic medical record. His life history, his owners, where he was born, any past medications he had, everything. Even his lab results were in there. The polite but guarded vet then showed me three other exam rooms, all equipped with shiny new laptops, all with Hamlin’s record available on them.

After a quick and thorough exam, the vet punched a few more keystrokes. He electronically ordered various lab tests — right then and there! I asked him about the firm that performs the tests and he told me the lab he uses provides great service and is top notch. He said the lab results will be sent back electronically and into Hamlin’s file directly! (In a moment of serendipity, I later discovered it was my company’s software providing the lab with the tools to accomplish this small miracle).

As I left the room and approached the front counter, a nurse had a prescription waiting for me along with three cans of super special dog food. Now I was really confused — is it not the patient’s job to walk the prescription and files to the front counter? Did my paper shuffling job just get outsourced to a computer? Adding to staff’s perception of my total geekiness, I asked how she did that. With a slight chuckle, she showed me the computer screen where the doctor requested it from the exam room. It just angered me to see such efficiency. I know my kids feel Hamlin deserves only the best, but better healthcare service than me? Adding injury to insult, I paid only $55 for the visit.

Hamlin’s enlightening experience really made me think of my own recent medical episode. A few weeks earlier, I went to my annual check-up. I scheduled the appointment and diligently showed up on time. As I checked in to see my doctor, one hand shoved a clipboard in my face, while a second hand went for my wallet. No verbal communication yet. Even though Hamlin theoretically can’t speak, he was treated to verbal communication and a custom greeting. I then proceeded to brush up on pop culture in a six-month-old People Magazine (I did not know Britney had a second baby and broke up with K-Fed?) while waiting 27 minutes for my appointment. If only someone told me how long my wait would be — but hey, that would take the fun out of guessing when I would be home.

I finally entered my exam room to be greeted by a nurse,a sheet of blank paper and a $.25 pen. She took my vitals. Later, my doctor sashayed in with that same high tech paper but a more expensive pen (with a drug company’s name on it) to drill me further. As all checked out fine, he indicated he needed some lab work to complete the exam. Amongst some forms floating on a table (uncomfortably near my half-clothed rear end) he found an order sheet. He checked a few things here and a couple things there then gave me the nod to transport the paper across the hall; then my lab orders and I waited some 18 minutes more.

A couple of weeks after my exam, I received my lab results “in the mail.” Next to each test result, the doc was kind enough to scribble an “OK.” Then a nice hand-written note claiming, “All looks OK, see you next year.” I put that report in a sophisticated manila folder and filed it. Why did I have to have this manual, impersonal, medical experience right before my vet visit?

Dazed and confused after leaving the vet, I wandered back to our house. Upon opening the door, my three kids showered Hamlin with love. They rubbed his back, gave him endless kisses and asked him easy softball questions. “Have you been a good boy?” My wife brought over doggie treats and “king” Hamlin relaxed on his back as the kids indulged him full of treats. My life quickly went to the store to find him “the best food money can buy.”

I was left standing at the door waiting to even be recognized. I sure did not get any kisses, let alone a back rub. I put myself on the couch and wondered if anyone was going to fetch me a treat. I would have been happy if one of my three kids just pushed the remote closer. As I stared at a blank TV screen, it dawned on me … I really need to be treated more like a dog.