The federal Office of the National Coordinator (ONC) for Health Information Technology, stung by a negative report on health informati on exchanges (HIEs) last month, responded last week, handing out nearly a half million dollars to spur private efforts in the area.
"We will work closely with each of these entities and their partners to develop policies, interoperability requirements, and business practices that align with national priorities, overcome interoperability challenges, and reduce implementation costs," says Claudia Williams, director of ONC's State Health Information Exchange Program.
Williams says the grants provide ONC the opportunity to urge its many partners, including providers, vendors, and HIE initiatives across the nation, to participate in fledgling HIE governance initiatives, now that the ONC has decided not to take the levers of such governance for itself—at least for now.
ONC's support for DirectTrust will fund continued development and implementation of its accreditation program for health information service providers (designated as HISPs), developed in partnership with the Electronic Healthcare Network Accreditation Commission (EHNAC), a nonprofit standards development organization and accrediting body.
"The purpose of DirectTrust is to help support Directed Exchange," says David Kibbe, MD, president and CEO of DirectTrust. "Directed Exchange in turn is a means of inter-vendor, standards-based exchange of health information that is designed to overcome the barriers of organization and IT platforms that have really significantly impeded interoperability and exchanges of health information for as long as most of us have been working in this field."
Directed Exchange, when built into electronic medical record software as early as this fall, is a requirement of stage 2 of the federal government's Meaningful Use protocols for healthcare providers.
"Directed Exchange is designed to be as easy as email," Kibbe says. "That's because Directed Exchange really is email. It uses protocols and specifications from email very similar to what we all use with Gmail or with Yahoo mail to send messages and to attach attachments, and move data to where we want to between known parties.
"But there's a big difference, and that is that in healthcare, when health information is being exchanged, we need it to be private, we need it to be secure, and we need to have trust in the identity of the persons or organizations with whom the information is exchanged, whether it's going between one doctor to another, or a doctor to a nurse, or from a nurse to a patient,"Kibbe adds.
The new ONC grant is a key enabler to EHNAC's accreditation program to certify "trusted agents," who act on behalf of Direct Exchange users to assure that a layer of security is in place, and that the parties providing those services are held accountable over time, Kibbe says. So far, a dozen HISPs and certificate authorities are undergoing accreditation, he adds.
"Health Internet service provider A serves a group of providers, and health Internet service provider B, who services another group, need to be able to exchange information and to trust one another with respect to privacy, security, trust, and identity," Kibbe says. "Contracting between HISP A and HISP B with legal contracts is not a very efficient way to do that at all. As a matter of fact, it probably wouldn't work at scale. Accreditation is a means of allowing those parties to voluntarily take a test and then achieve recognition and a seal of approval with respect to having passed that test, and having kept their security and trust and identity procedures up to date."
Continuing federal efforts to promote health information exchange came under fire in the March 13 issue of The Journal of the American Medical Association in "Putting Health IT on the Path to Success," an article co-authored by William A. Yasnoff, MD, president of the Health Record Banking Alliance. From 2002 to 2006, Yasnoff was HHS senior advisor on what was then known as the National Health Information Infrastructure.
In an email to HealthLeaders commenting on last week's ONC HIE grant announcements, Yasnoff said ONC's latest efforts are misguided.
"Governance of HIEs will continue to be problematic as long as patients do not control their own data," Yasnoff says. "Only patients through their consent can overcome the complex tangle of state and federal legal requirements about the use and transport of medical data."
Continuing efforts to accomplish this through "governance" without patient consent will never work, Yasnoff says. "We must give up our paradigm of trying to automate the current (and ineffective) process of contacting other providers to get missing records. This approach does not, and cannot, get us to a system that ensures the availability of comprehensive electronic patient information when and where needed—as ONC itself admitted in their 3/6/13 RFI."
ONC's March 6 request for information seeks public input about a variety of policies that will strengthen the business case for electronic exchange across providers to ensure that patients' health information will follow them seamlessly and securely wherever they access care. Public comments on the RFI are due April 21.
It was a long holiday weekend several years ago, and I received a message on Facebook from someone I trusted, a longtime acquaintance from a well-known high-tech company. He had posted something to my Facebook wall. I thought it was benign. But his Facebook account had been compromised, and now I had been phished.
I knew about phishing; essentially it's an email fraud scam or online con game. I thought I would be safe if I only opened messages from people I knew, on networks I believed to be safe. I spent the next day, however, profusely apologizing to my Facebook friends, who now had postings to their own Facebook walls, from me, inviting them to click and be sucked into the digital chaos. We all had a good non-laugh changing our passwords and apologizing on down the line.
I was lucky that the only harm I suffered was a little embarrassment. And I now I know I'm in pretty good company. Last week, we learned that Supreme Court Chief Justice John Roberts has been the victim of credit-card fraud. The court did not provide any other details, according to the Associated Press. But if you ask me, the odds are that Justice Roberts had been phished.
As we recover from our annual holiday of pranks, let's take a moment to assess our preparedness for the digital pranks continuing to head our way that are no laughing matter. Healthcare is on particular notice as of last week, when revised Health Insurance Portability and Accountability Act (HIPAA) regulations took effect, and enforcement in September suddenly seems a lot closer.
Much is written about the data breaches that occur when someone's laptop is lost or stolen. The HIPAA wake-up-call no doubt will cause many of those laptops to finally be encrypted and outfitted with data-loss prevention technology.
Unlike some other occurrences of malware, phishing isn't going away. Instead, we can expect to be continually challenged by bad actors trying to hoodwink the healthcare system out of protected health information (PHI).
How can it happen? Let me count the ways: It might be a classic scam, like five years ago this month, when thousands of CEOs fell victim to a fake subpoena. Or the annual phony emails claiming to be from the IRS that pop up every year around this time. Fake package delivery emails with links to who-knows-where remain a popular vehicle. So do emails about current events.
Or it might be one of the newer scams making the rounds these days, like this one described by a security expert I spoke with recently: It comes in the form of a one-line email message from someone you trust. "There's not enough information for me to make a decision, so I'll click on it," the expert says. The attacker may have pulled your name from your social network, or may have even found and spoofed your email address. But don't click on that email link.
Too many of the bad links in emails lead will immediately load rootkits into PCs, and at that point, unless your anti-malware protection is on top of its game, a data breach has occurred. With the new HIPAA regulations, you can't assume a breach hasn't occurred just because nothing else appears to be amiss. You'll soon be up on the public HIPAA breach Web site and headed for some stiff fines.
So, no fooling—it's time to make sure that your organization, and those of your business associates—are practicing "safe email."
Increasingly, we will see insidiously intelligent attacks on healthcare. Bad guys can guess at org charts for most healthcare organizations by searching for companies and job titles on LinkedIn. Other baddies masquerade as a company's IT support department, offering bogus expanded mailboxes or benefits enrollments—anything to get you to click.
Time and again, the technology industry has assured us that communications would be secure one day. Up to this point, the best the industry's been able to do is to direct us to secure Web portals. Meanwhile, the everyday email we use remains unsigned, unauthenticated, unencrypted, and open to the same sorts of phishing attacks effective during the better part of the past 20 years.
So, what can be done? In the past year, the Domain-based Message Authentication, Reporting and Conformance specification has become a force for positive change in the phishing war. DMARC lets senders and recipients exchange email authentication between themselves.
If your healthcare organization sends any email, or contracts with an organization that sends email in your name, and you haven't implemented the DMARC standards yet, there's a free set of training videos available. It's one of the best ways to immediately step up your response to the new HIPAA regulations.
Now let me scare you a little bit. Facebook is in the process of gradually rolling out a new form of search known as Graph Search. While there may be good reasons for Facebook to expand the search capabilities of that system, according to industry experts, Graph Search will be "a phisher's best friend."
That's because Graph Search will allow phishers to even more intensively data-mine people and organizations. Sadly, it seems that every time social networking takes another leap forward, we have to put our guard up a little higher.
As my security industry expert puts it, "if you're in IT and have privileges to systems that store medical records, you are likely a target. They might also research if you participate in industry organizations. They will find your name based on things that you have published, papers you've published or talks you've given."
On its Web site, the HIMSS Privacy and Security Committee goal is stated: "By 2014, all entities who use, send, or store health information meet requirements for confidentiality, integrity, availability and accountability based on sound risk management practices, using recognized standards and protocols."
Let's hope HIMSS and the efforts of other professional organizations are sufficient to keep the spotlight on security as the amount of PHI on servers and in transit from organization to organization escalates. Otherwise, we might face a scenario imagined in the January 2013 issue of the journal Telemedicine and e-Health.
You can't write a check to make the problem go away. PHI is now more valuable on the black market than ordinary consumer data. The onus is on all of us to do our part to keep the data safe and to prevent Internet-triggered medical errors.
A lot of very bright people are convinced that the current healthcare IT revolution will happen last at hospitals and in doctors' offices.
Some of them are in significant positions of influence. One such influencer is Chris Wasden, a managing director and innovation practice leader at PwC. I caught up with Wasden at the recent HIMSS conference, and what follows are some excerpts of our conversation.
HLM: Do we have enough technology but not the logistics to deploy it in healthcare?
Wasden: I don't believe that we are ambitious enough with regards to what we want to accomplish, and so we are applying too much technology to do nothing more than create digital versions of the current world, and we're not trying to create a new world.
HLM: I'll give you a perfect example. On the front page of HealthLeaders this morning is a story that says 87 percent of physicians say they get too many alerts.
Wasden: This is the analogy that I give often times. How successful would the pharmaceutical industry be if the business model in pharma was you have all these smart scientists inventing new technologies, getting patents, and then what the pharmaceutical industry does is they license the patent to individual physicians and sell them a chemistry set and say make as much as you want.
But that's what we do in technology. We have all these guys invent technology, then they give it all to the doctors and say, I'm sure you'll figure out something to do with this. Good luck.
Doctors want technology to be as simple as writing a script for a drug. We'll even provide a monitoring service for it, and you doctors, as far as you're concerned, you're done. That's what technology has to do for doctors. I'm going to find out only when someone else has got a bazillion alerts, and everything they've tried still isn't working, and you actually need to see me again.
But I'm not going to get all the alerts. I'm not going to monitor you. Someone else is going to do all that. I'm just going to see you when everything else has failed.
HLM: I guess the question you're posing is, who is that someone else?
Wasden: Basically you've got these new systems integrators that are emerging on the scene that are saying, we're going to take all the complexity of all this technology and we're going to simplify it for you. Doctors are going to be the last in the healthcare ecosystem to adopt most of these new technologies. Consumers are going to drive it. Employers are going to drive it.
We're very bullish on the employers driving, because within five years, I think almost no employer is going to have a defined benefit for healthcare. They're going to have a defined contribution.
Here's your money. If you want to go to an exchange and get your health insurance, fine. If you want to get it through us, fine, but the amount that we're giving you is capped. You want more than that, you pay for it yourself.
If you look at behavioral psychology, you find that people actually have five times the receptors for pain that they do for pleasure. So you've got to have these carrots and sticks. You've got to have metrics. They need to be objective. They can't be self-reported.
The other problem is that unless you have the inpatient, the outpatient, the lab, the claims data, patient-generated data, you don't have a perspective on what the patient needs or what's going on.
Everyone has one piece of that information, but they don't have the entire picture. From a consumer perspective, there's no EHR system that I've found anywhere that enables you to collect patient-generated data and integrate it into the record.
HLM: There's talk about it in the Health IT Standards Committee.
Wasden: I'm writing a chapter for a book right now on all the barriers among providers to patient-generated data, and the reality is, providers don't want patient-generated data. You have this alert issue. "All it's going to do is give us all these alerts we don't want."
They've got issues around privacy and security. They've got issues about liability. This is an interesting one. Right now, if I have no information on you, no digital information, and I make a diagnosis, and I'm wrong, what's the downside? Some other doctor's going to say that I was wrong, but that's his opinion, and he wasn't there at the moment.
What's the patient know? The patient doesn't know anything. So it's my word against somebody else's word. If I have a lot of digital information, now there's a fact base. What sort of risk am I now exposing myself to when there's actually data and facts as opposed to my opinion? So my liability goes up a lot, by adding digital information, so they're concerned about that.
HLM: So is that where government comes in and says you will do it? Does that make any sense? A lot of people say that's the worst solution.
Wasden: So I was with the chief medical officer for CMS, and I was talking about all these issues, and he asks me, how do we get more rapid adoption of mobile health solutions? If you look at a mobile health technology, versus a traditional clinical technology, a mobile health technology generally costs one tenth, so you can eliminate 90 percent of the cost of the device by moving it to mobile versus the traditional model.
HLM: There's a lot of things you can do with these devices.
Wasden: My recommendation: Stop paying more for the old way versus the new way, and pay a lot less for the new way than for the old way. So if you want doctors to adopt a mobile health solution which has the potential to be a third to a half less costly, then pay a third to a half as much for that solution, and pay even less for the old way, and you'll get immediate adoption.
Doctors don't want that! Hospitals don't want that! I worked with the CEO of one of the largest academic medical centers in the country, and they did an exercise where they looked at all of the unnecessary testing that they did, to see if they could eliminate it.
What they found is if they eliminated unnecessary testing, they would go bankrupt. Our entire healthcare system is based upon unnecessary testing. It is! We have new technologies that can easily eliminate a third to a half the cost of healthcare, that we provide no incentive or support to adopt, and so in the absence of all that, what's going on? Consumers are adopting it. Payers are adopting it. Employers are adopting it.
Physicians and hospitals will be the slowest to adopt.
This article appears in the March 2013 issue of HealthLeaders magazine.
Resistance to new technology may be futile, but it remains an issue for healthcare.
"Physicians do have to spend more time at computers now, which diminishes the amount of time we can spend at the bedside and interacting with patients and actually doing those things like surgical procedures and interventions that only we have the skill and the knowledge and the training to do," says Steven J. Stack, MD, chairman of the board of the American Medical Association.
Stack, who also heads the AMA's health information technology advisory group, says physicians flock to new technology when it helps them provide better diagnosis or treatment in a more timely fashion. "Just look at robotic surgery," Stack says.
But Stack faults the rush to deploy electronic health records for much of the continuing resistance to tech. "There are poor user interfaces with clumsy drop-down menus [and] a one-size-fits-all approach to the documentation process," he says. "As you would imagine, the documentation for an ophthalmologist focusing their entire professional life on a few centimeters of the human body contained in the eye is very different from a general internist taking care of the entire wellness of an entire human being."
As recently as 2007, the majority of all outpatient care in the United States was provided by physician group practices of fewer than three or four doctors, Stack notes. "There's no IT staff or CIO in the office," he says. "The CIO is either the physician themself or the practice manager. That's a real problem. And the cost to upgrade and maintain and troubleshoot is enormous."
While the industry scrambles to equip each provider with its own interoperable electronic healthcare system, what can be done to counter such fears and resistance? A wide range of providers says the answer lies in changing the culture of organizations, and even sometimes resorting to flashy incentives such as giving physicians iPads.
Still, continuing resistance should be a wake-up call to technology vendors to make rapid improvements in the quality and usability of their products, say some physician critics.
"The health IT industry needs to be transformed into a quality- and evidence-driven industry, not a purely profit-driven, unregulated free-for-all, where, in my view, hospitals are used as beta testing," says Scot Silverstein, MD, adjunct professor of healthcare informatics at Drexel University in Philadelphia.
That concern is echoed at the highest levels of healthcare. "Many of these [EMR] technologies are not yet very well designed," says Dawn Milliner MD, chief medical information officer at the Mayo Clinic, the 4,000-physician, 70-hospital system. "They're not very intuitive. Physicians work very hard. They do rapid, constant work, day in, day out, night in, night out, that requires a lot of concentration, a lot of effort, interacting with the patient and the record, if not simultaneously almost simultaneously, and when things are clumsy or cumbersome or take longer than old conventional methods, it's understandable that physicians get frustrated," Milliner says.
Silverstein also notes how doctors deal with less-than-ideal technology. "Physicians, being pragmatists, they get this IT thrown in front of them that's designed as if it's for maintenance of widgets in a warehouse, and they say, ‘This stuff's awful, slows me down, I can't find what I need, it's a lot harder to use than paper,' and so they may have been very skeptical." He cites a 2012 report from the Institute of Medicine saying that the magnitude of risk from health IT remains unknown.
Yet for every note of criticism, there seems to be a success story. Mercy Health—a 31-hospital system based in Chesterfield, Mo., that serves communities in Missouri, Kansas, Oklahoma, and Arkansas—completed its transition to electronic health records in a five-year period by emphasizing the standardization of care that technology brings to the organization, says William Walker, MD, chief quality and safety officer.
"Variation is harmful to patients at a net population level," Walker says. "We have to agree to do it one way, because while we're doing the thought work, the care is often rendered through the hands of other folks—nurses, physical therapists, whoever that is. We've got a graduate nurse in the middle of the night who's inexperienced and doesn't have a lot of supervision, and she's having to reinterpret two completely different sets of orders. Wouldn't it be better if we had an expected approach?"
Yet the responsibility for making EHRs effective continues to rest on the care team as well as the technology, Walker says. "We have not put enough structure around the information that doctors enter and whether or not that can be discretely tapped, and I'm as guilty of that as anybody."
Mercy's solution: an aggressive deployment of what it calls care paths, which build upon the notion of order sets to capture all the care, intervention, and evaluation required for a patient's entire length of stay, Walker says. Without incorporating these care paths into EHRs, hospitals haven't done much more than install very expensive electronic typewriters, he says.
Early proof that care paths are working: their use allows Mercy to intervene earlier in sepsis episodes. "We have cut mortality by 50%, average cost per case by over $3,000, length in the intensive care unit from 81/2 days to about 3 or 4 days, and the patients are healthier and happier and going home sooner," Walker says.
A key to overcoming physician resistance is being realistic about the hit productivity takes during the transition from paper records. At Mercy, that usually takes three to six months, says Jim Best, vice president of clinical business solutions.
Without pre-live training, physicians could take up to a year before they attain the same productivity levels they had prior to the EHR transition, he says.
"Then they usually have to go back and retrain and relearn, because they were more worried about just keeping the patient flow going than they were learning a new tool," Best says.
Leadership has to do its part, selling the transition to EHRs as hard as any sales job, says Kshitij Saxena, MD, medical director of medical informatics at Adventist Health System, a 31-hospital organization based in Altamonte Springs, Fla., which spans 12 states in the South and Midwest.
"You have to go and tell it to them in front of hundreds of doctors who are ready to kill you," Saxena says. "You go and give them the benefits. You go and tell them the negative side of it as well. You tell them up front, the first three weeks there will be yelling and screaming. Please be prepared. And then you tell them the ways where the pain can be minimized."
Buy-in from the rest of the C-suite is essential, Saxena says. "You make the training mandatory. You would never sit on a plane that was being flown by an untrained pilot, right? Same goes for the doctors. The ones who do not know how to deliver safe patient care, do not know how to use systems so that there can be no safety issues, they shouldn't be allowed to practice," he says, suggesting an analogy to board certification.
It's also essential to have physicians engaged during the design phase. But how do you get these busy professionals to take time out of their practices to do so? Saxena's answer: You pay them for the time it takes to get them, and the EHR, up to speed.
"I would prefer to bring in those physicians, get their input at the time of design, and make them the physician champions at the time of go-live instead of bringing 100 people from the vendor at the time of go-live," Saxena says.
After a 30-month rollout, the Adventist system generated a million electronic physician notes in the past 12 months. "It's not that we didn't have hurdles or obstacles," Saxena says, "but if you create the culture, if you design the steps right, it usually works out."
All Adventist physicians were compensated for completing EHR training, some received cash and some received payment in the form of an iPad, Saxena says. This paid a dividend when those physicians tapped into new hospital infrastructure that let them round with their iPads, reinforcing the physicians' ownership of the EHR system.
Calculating a return on investment for all this technology remains elusive, but Mercy estimates that half the system's recent growth is attributable to having technology and infrastructure in place. "We've added about 500 to 600 additional integrated physicians into our networks in our four states," Best says.
"Since meaningful use has been in play, physicians have been attracted to us, wanting to be a part of a health system that knows how to manage meaningful use," he says.
Most dramatically, Mercy's hospital in Joplin, Mo., was destroyed just three weeks after its EHR went live. Because it was all electronically stored, "we were able to retrieve the records within two hours," Best says.
Joplin patients showed up at the hospital in Carthage, Mo., about 20 miles from Joplin, a small critical access hospital that was doing its best just to help Mercy. "We walked in the door that very same evening with packets of complete, 100% intact patient records," Best says. "They were so impressed we began an immediate relationship with that hospital, and they eventually became part of Mercy less than a year later."
Such success stories will continue. Meanwhile, the industry is redoubling its efforts to improve. For instance, in December 2012, HHS' Office of the National Coordinator issued its first Health IT Patient Safety Action and Surveillance Plan for public comment.
"We've still got some bugs and kinks to work out, but I think you would find that if you took a survey of docs, overwhelmingly, all of us would heartily embrace better technology that enabled us to have all the data we needed when we needed it and not waste time and money repeating things we would like not to repeat," says Stack.
Reprint HLR0313-6
This article appears in the March 2013 issue of HealthLeaders magazine.
In the scramble that is today's healthcare industry, expect to see the unusual. At the HIMSS conference in New Orleans this month, Exhibit A was tech goodies on display at Intermountain Healthcare's booth and its announcement of a strategic alliance with Deloitte.
At the HIMSS booth, Intermountain chief technology officer Fred Holston was demonstrating new technologies developed internally, and looking for technology partners to help mass produce them.
The first invention was fiendishly simple: A wristwatch that can sense when the wearer has washed his or her hands. If they're washed, a light on the face of the watch glows green. If they aren't washed, or if the caregiver has left the room, the watch face displays a red light.
"Imagine the impact we can have on the whole infection control conversation," Holston told me. Now, instead of a scoreboard somewhere showing that hands are washed, there's a beacon to remind the clinicians and their patients that a hand-washing regimen is being followed, or not.
It was just an idea that came "off the floor" of an Intermountain facility, Holston says. "It would not have made in the top list of Intermountain's priorities, because it's not what we tend to do. [But] I'm pretty sure we'll be the first customer, and roll it out to all the caregivers to improve our handwashing compliance."
Intermountain's initiative is so totally contrary to traditional big-company thinking, where a department cranks out RFPs or fruitlessly searches for products already on the market. Today it's different. Holston has 22,000 square feet spread across two buildings to crank out concepts and partner with tech companies such as Xi3.
"It's companies that have real businesses who want to make stronger impacts in healthcare," Holston says. "They need a little effort in making sure their products work well in healthcare, or are in a position to tweak to do what we need to do, and in some cases, yeah, build the whole thing."
Another Intermountain product concept, a little further off in the pipeline, Holston calls the Life Detector. "So instead of all the monitoring that occurs, and there are plenty of monitors out there for collecting vitals, we flipped the idea and said so there's a number of situations where we want to detect—death," he says.
It's a patch containing a single-line EKG, not for recording, but simply to note if the signal ceases. At that point, a window of opportunity exists for reviving the patient, whether it be a SIDS-prone baby, or a patient on suicide watch.
"I can't guarantee you can do anything about it, but I can give you a window to do something, to try," Holston says. It could activate a mobile phone app that calls 911 or starts telling someone things to try.
And, in those cases where the victim is too far gone, it can also alert authorities before a loved one or neighbor has to encounter a body hours or days later. Holston's own brother found their mother in that state, "and that's an image that will always be in his mind," he says.
The point of many tech innovations, Holston says, is to "chew away at the problem of how healthcare works and how we can improve, and how we can save, or how we can bring dignity to life or whatever the case may be."
The big data announcement
Intermountain's alliance with Deloitte, announced at HIMSS, takes a big-data twist on innovation. Deloitte will bring 30 years of data analytics extracted from Intermountain's electronic health records to life science, pharmaceutical and maybe even other healthcare provider customers.
"This is our patients' data, not ours," says Intermountain CIO Marc Probst. "But we did think we were learning a boatload of stuff based on this data."
Deloitte's recent acquisition of big-data analytics firm Recombinant gave Deloitte the skill set to become Intermountain's go-to partner, Probst says.
Although financial benefits of the deal will hardly be a blip on Intermountain's balance sheet at first, Intermountain is taking a longer view. "Right now we have around 150 formalized completely researched and implemented protocols," Probst says. "If what we can do with this process with Deloitte is triple that, imagine how much better our care will be, and what it could do to lower costs."
Initial targets of the alliance will be to unlock research insights, including best practices in treating diabetes and asthma, Probst says. "As we continue the relationship, as other people get involved, that should broaden the data, and therefore the quality and the types of research that can be done," he says.
Probst hopes to see the first fruits of the alliance by July, although with a laugh he adds, "Just what I needed was another published goal to hit."
Probst reminds me that wherever these centers of innovation exist—at Intermountain, at Partners, at Mayo, or wherever—part of the investment is to recognize that healthcare providers are generating inventions and that means intellectual property to protect. "We've got 30,000 people coming up with great ideas, so some of them you definitely want to protect," he says.
Healthcare reform continues to make strange bedfellows. On the technology side, stranger days are yet to come.
Another HIMSS conference is history. The technology cart, however, may be getting ahead of the horse. Everywhere I turned, vendors touted their technology solutions to transform existing healthcare providers into ACOs. Many of these solutions tackle the worthy challenge of correlating claims data coming from payers with clinical data coming from providers, in an effort to create longitudinal records of care for any patient who walks through the provider's doors. In this way, providers will catch comorbidities they are missing today, eliminate duplicative tests, reduce readmissions, and increase patient satisfaction, all in one fell swoop.
At least, that's the theory. But wait—if the brave new technology future is at hand, why are the Pioneer ACOs petitioning CMS to ease up on demanding early results?
I think I now understand why the pioneers are freaking out.
The ACO concept only works if health information exchange between providers is mature enough to handle what the ACOs require. And I'm here to report that health information exchange still has a long way to go.
That's why, in the midst of a HIMSS packed with innovations that I will describe in future columns, the National Coordinator for Health Information Technology, Farzad Mostashari, sees the maturation of HIE as the biggest challenge of 2013. (Mostashari views the HIE acronym as a verb and a desired state of being, rather than as only a description of HIE/HIO organizations.)
"There are technical challenges," Mostashari told a packed HIE town hall on the final day of HIMSS. "There are governance and trust challenges to information being exchanged. And there are business practices and a business case for information exchange, all of which need to be addressed in order for information to move. We intend to act on all of them this year to create a context where we get to the goal and the 'why' of all this, which is that information follows the patient wherever they need it to go, across organizational boundaries, across vendor boundaries, across geographic boundaries."
Security and identity
During Q&A, a doctor from a large practice in New York City strode to the microphone to warn about the litigious atmosphere that HIE may enable. Attorneys able to openly access electronic medical records will have a field day with that longitudinal patient data, he warned, accelerating the pace of malpractice suits in the U.S.
Mostashari ranged from smiling to brow-furrowing in answering this issue. "The patient owns the data!" he exhorted at one point, stepping away from the microphone to plead his case. More soberly, he characterized the legal worries as "problems we didn't imagine happening before."
Meanwhile, away from the microphones, ONC's health IT policy committee labored in January to assure that patient consent travels with that data from provider to provider. Toward that end, ONC has tested new eConsent processes, starting in western New York state, with results to be published later this year.
Fruits of this effort can't arrive soon enough. Without clear consent, some patients will freak out when they see their healthcare data following them around. What providers see as their ticket to ACO nirvana may appear to some patients as a kind of Big Brother, if they haven't been fully educated about all the consent forms they normally sign without reading.
Then there's what I consider the elephant in the room: what the technologists, including Mostashari, describe as a lack of digital key distribution that continues to prevent easy verification of patient identity as patients travel from provider to provider.
The federal government is prohibited by law from being the provider of digital keys that would establish a national patient identification system in the U.S.
This puts us at odds with practically every other industrialized nation on the planet, and hampers our efforts to implement not only ACOs but all manner of population health and public health innovations, not to mention to greatly reduce fraud and waste.
The distant goal of interoperability
Private industry is starting to step up, but slowly. Mostashari pointed out that one such effort is the CommonWell Health Alliance, announced at HIMSS last week.
What he didn't say, but I will, is that the CommonWell announcement was mostly marketing spin and very little substance at this point.
In the words of two of its vendor founders, CommonWell "plans to build, certify, and deploy a national infrastructure which will create an ecosystem for universal connectivity providing patient record linking, along with standardized consent and authorization services, so that providers can gain access to needed patient data, regardless of their electronic health record [EHR] supplier or the setting of care."
Cynics pointed out that CommonWell looked a lot like the health IT industry minus one glaring exception: Epic. The market share leader in EHR software in the larger-than-200-bed market wasapparently not invited to join CommonWell. I've seen these kinds of theatrics in IT before, and question how sincerely Epic's competitors were pursuing a détente with the 800-pound IT gorilla.
But around the show floor, some hospital and health system executives confided that Epic will quietly implement some interoperability with other EHR systems, particularly for large customers, although that's apparently not something Epic wants to be highly publicized, and probably is aimed at continuing to assimilate that data into Epic somewhere down the line.
So it may be that Mostashari's exhortations and CommonWell's developmental goal won't be enough. Providers are the ones who can and must demand that health data exchange become ubiquitous. Those providers who fear the legal ramifications have to try to work within our existing litigious system to provide a level of comfort with letting go of data that is, after all, the patient's data.
And with the ongoing sequestration of funds from government programs hampering the ONC itself, vendors who until now have been prospering from government HIT incentives must turn to the hard work of getting that tech cart behind the horse, and keeping it there, by cooperating in ways they never imagined.
This article first appeared in the January/February 2013 issue of HealthLeaders magazine.
Like a surging tide, the next wave of technology has landed in hospitals, changing the nature of healthcare delivery. Tablet computers are overturning concepts of how clinicians will use technology, raising work-life balance issues, and having a beneficial impact on hospital IT budgets.
Tablet computers have gone from relative obscurity to something approximating the appearance of stethoscopes: Nearly every doctor has one. What's different with this generation of technology is that demand is coming from clinicians rather than being rolled out by IT departments.
"Certainly the iOS devices from Apple are very popular among physicians," says Ferdinand Velasco, MD, chief health information officer at Texas Health Resources, an Arlington-based system that includes 25 hospitals, more than 21,100 employees, 5,500 physicians with staff privileges, and 3,800 licensed hospital beds.
A recent internal survey of more than 2,000 Texas Health–affiliated physicians found that 80% of them have smartphones and 50% have tablets, Velasco says.
The spread of these devices parallels a recent surge in bring-your-own-device—or BYOD—behavior at hospitals. But the so-called consumerization of IT is hardly unique to healthcare, Velasco notes.
Apple's iPad has been the catalyst for tablets in healthcare, says Frederick Holston, chief technology officer at Intermountain Healthcare, a Salt Lake City–based network that includes 22 hospitals, a medical group with more than 185 physician clinics, an affiliated health insurance company, and more than 33,000 employees.
"We have PCs at every bedside, so tablets haven't been a big thing for us," Holston says. "But for us, the word tablet changed with the iPad, and it changed because we had a long-battery-life device that was very light and had a very intuitive user interface that was very responsive and provided what was really missing in tablets."
Unlike many previous iterations of the personal computer, clinicians want to use them, says Jonathan Perlin, MD, CMO and president of the clinical and physician services group at HCA, the Nashville-based for-profit company that includes about 163 hospitals and 110 freestanding surgery centers in 20 states and England and employs approximately 199,000 people.
"We love tablets because our providers, physicians, nurses, and pharmacists have an emotional attachment," Perlin says. "They want to use these devices. That makes uptake really easy, and it improves the security because they tend to store their own personal information, have their own apps, so they guard devices judiciously."
More than 5,000 HCA physicians use tablet technology daily, and Perlin describes the technology as providing a new level of work-life balance for these physicians. He describes a typical day in the life of one of those physicians, starting with the ability to log in to a virtual desktop from home, checking Meditech electronic health records and vital signs from her tablet computer.
"In an electronic age, we couldn't possibly have enough workstations in the hospital, and even if we did, the workstations are in one place. Tablets allow the information to be securely available anywhere a decision-maker needs it."
"In an electronic age, we couldn't possibly have enough workstations in the hospital, and even if we did, the workstations are in one place," Perlin says. "Tablets allow the information to be securely available anywhere a decision-maker needs it."
The rise of tablets is being matched by the decline of interest in laptops in hospitals. "A lot more clinical services now are mobile and also outside of the hospital walls," says Mark Moroses, senior vice president for information technology and CIO at Continuum Health Partners, a New York City–based system with seven major facilities, 2,180 certified beds, and an annual operating budget of $2.8 billion. "Laptops are kind of clunky when you do that; iPads have a nicer fit in terms of form factor," he says.
"The mobile technologies we now finally have are actually very compatible with the workflow of clinicians," Velasco says. "Clinicians are fundamentally a mobile workforce. They don't work in a desktop or a work office type of environment like in other businesses. They're constantly moving about. They move between their physician office setting and the hospital, and when they're in the hospital, they go from room to room and floor to floor. Even in their own office they're not sitting behind a desk. They're going from one patient room to another, one exam room to another, and to some extent that also applies to the other healthcare workers as well.
"Rather than the old paradigm where we were encouraging clinicians to use these fixed devices, or at least somewhat semi-fixed devices with the laptops on carts or WOWs [workstations on wheels] or COWs [computers on wheels], now they actually carry these devices around, and so the adoption actually is much easier."
"It is becoming a smaller and smaller footprint with greater and greater capacity to be able to help us organize, aggregate, and utilize the kinds of data that are the outputs to make good clinical and business decisions."
Cost to health systems
Fewer clinicians are clamoring for the latest and greatest laptops, so these new consumer devices will result in less expensive hardware at the bedside and in the patient care area, Velasco says.
"This small footprint of the device replaces the biomedical equipment interfaces that we see in laboratories, our clinical research benches, and in the critical care units where we have so many monitoring devices," says Mary Alice Annecharico, senior vice president and CIO of Henry Ford Health System, a Detroit-based seven-hospital system with more than 1,900 beds, 2011 revenue of $4.22 billion, net income of $21.5 million, and more than 24,000 employees. "It is becoming a smaller and smaller footprint with greater and greater capacity to be able to help us organize, aggregate, and utilize the kinds of data that are the outputs to make good clinical and business decisions."
"There's tremendous convergence between what our clinicians want and what we'd like to have happen," Perlin says. "From the clinician's perspective, their life is incredibly complex. Healthcare is more complex, the administration of medicine is more complex, and people are working very, very hard. When they say, ‘If I could use my device, it would improve my efficiency and my effectiveness,' that's a pretty compelling statement."
Leadership's goal is safe, effective, efficient, compassionate, informed patient care. "So this is a wonderful meeting of the interests: their desire for efficiency and effectiveness, our desire for efficiency and effectiveness," Perlin says. The tablet trend may be about to kick in to a higher gear, as clinicians clamor for the latest iPad, the lab coat pocket-friendly iPad Mini, which shipped in November.
"It's almost a perfect size for a physician who's doing rounding or somebody who wants to travel with less in their hands, if you will, and just put things in their pockets," says Michael Saad, vice president and chief technology officer at Henry Ford.
Enhanced clinical care
Aside from convenience, smartphones and tablets are also playing an increasingly important clinical role—involving both physicians and patients. At Texas Health Resources, as part of a secure messaging initiative, the system is purchasing iPhones for its employed hospitalists, Velasco says. But messaging is just the start. For physicians with heart patients, Texas Health supports AirStrip, a suite of applications delivering critical patient information, including virtual real-time waveform data, directly from the patient's location to a doctor's mobile device.
"There's tremendous convergence between what our clinicians want and what we'd like to have happen...When they say, ‘If I could use my device, it would improve my efficiency and my effectiveness,' that's a pretty compelling statement."
"These are actual digital representations of the EKGs, the waveforms, so they can zoom in and do fine evaluations of the waveform on the EKG that would not otherwise be possible on a static, just purely analog representation of EKGs," Velasco says.
Because AirStrip's applications are FDA-approved, Texas Health is assured of the integrity of the data being transmitted wirelessly to phones and iPads, Velasco says. Texas Health obstetricians are using the AirStrip OB application to remotely monitor fetal heart rates with these same devices, he says.
R. Malcolm Stewart, MD, of Neurology Specialists of Dallas, is a leading researcher of motor disorders and interim director at the neuroscience center at Texas Health Presbyterian Hospital Dallas. Stewart developed a number of tests to assess patients for early signs of Parkinson's disease and similar motor disorders. In the future, Texas Health will be porting these applications to the iPad so patients will be able to take these tests on their own tablets without having to travel to Texas Health's laboratories, Velasco says. Clinicians can track these patients' progress and, if necessary, make adjustments to their treatment regimens.
Due to their newness, tablets aren't yet running full implementations of the most popular EHRs. "As the EHR vendors improve their support for tablets with better user interface, additional functionality, and less typing, we will see more use in the hospital and the office," says Mark Laret, CEO of the UCSF Medical Center that has a total of 660 beds, 180 of which are for the UCSF Benioff Children's Hospital. "Once they can support ordering [CPOE] and note writing, they will start to replace some of the workstations.
"We will deploy tablets in creative ways going forward: patient self-registration, MyChart sign-ups, providing educational content in waiting rooms and patient rooms, patient questionnaires, etc.," Laret says. "Still, they are a piece of technology and tactical infrastructure. Our strategy is to use whatever device is most appropriate to provide the most complete, accessible information to our patients and caregivers at the ideal time. I expect that providers will have their own devices, and that we will provide the infrastructure to support them. We may consider a device for trainees when they start here."
"As the EHR vendors improve their support for tablets with better user interface, additional functionality, and less typing, we will see more use in the hospital and the office."
Clinical and business opportunities
As healthcare organizations strive to innovate their way into new business and clinical opportunities, the tablet platform is rolling out the steadiest supply of innovative applications in computing today. In Perlin's day-in-the-life scenario of an HCA clinician, he describes several applications for the iPad in widespread use at HCA:
Before heading to the office, the clinician can log in to eClinicalWorks to check her outpatient schedule for the day.
To find out the latest information about her patients' status, the PatientKeeper application allows her to plan her rounds most effectively and alerts her if a fellow physician is on vacation, which adds to the list of patients who she must see on her rounds.
Fujifilm Synapse Mobility allows the clinician to review x-rays and echocardiograms of patients on the tablet.
While counseling a family member of a cardiac patient, the physician demonstrates an animation of a beating heart suffering from blockage in the left anterior descending coronary artery, using a tablet application called HeartPro.
A tablet application provides the Chads2 stroke risk calculator to let the physician calculate stroke risk for atrial fibrillation while the patient and caregivers look on.
To calculate the safety of anticoagulant medications, the physician turns to the UpToDate mobile app, which includes a reference library.
Mobile apps from Lexi-Comp, Epocrates, and others permit the physician to consider dosing and side effect questions about different medications.
Perlin notes that HCA also developed an in-house tablet app that gathers the work of hospitalists and makes the necessary referral to a specialist such as a cardiologist.
Because of new technology that connects monitoring devices to the EHR, caregivers can follow patients' vital signs on their mobile devices in real time rather than relying on data entered by hand at the end of shifts. The program, HCA Vitals Now, reduced the average time it took for vital signs to enter the patient's EHR from up to 41 minutes using pen and paper to 23 seconds per patient. The vendor partner is now making the app available to non-HCA providers.
Mobile devices also follow caregivers where computers haven't traditionally been. Intermountain developed an application for emergency responders, the first version of which is being tested by the Life Flight Network of Aurora, Ore.
Responders of Life Flight Network, which operates EMS helicopters in Intermountain's mountainous service area, typically had to document patient information once the helicopters touched down at hospitals. Using the Life Flight app, they can now document while en route to the facility, Holston says.
As a result, patients begin receiving treatment faster, responders write down information while it's still fresh in their heads, and legibility isn't an issue, Holston says. It also speeds Intermountain's billing process, he adds.
In the future, Intermountain could make its app available for sale for other healthcare providers, since it could apply equally effectively to any emergency responder, Holston says. For now, pilot testing continues as Intermountain fine-tunes the application's user interface. Clearly, it is a strategic initiative for Intermountain, but Holston declined to say how much money the organization has invested in its development.
Considering the tradeoffs
As with any new technology, there are some tradeoffs that accompany the tablet and mobile device upheaval. For the vast majority of clinicians, saying hello to tablets means saying good-bye to keyboards, which opens up a host of issues, not the least of which is the tendency of longtime clinicians to narrate their way through their notes, rather than enter them in a more structured format.
"It's really hard for people to get used to the typing on an iPad, the feel of it, so that there's still stronger preference for a keyboard when you're doing order entry or doing any kind of heavy input that would require a lot of typing," Moroses says. "We're hoping in 2013 to focus a couple of different pilots around EMR use when the EMRs are customized for that device, to have less typing and more point and click."
The keyboard gets its share of vilification as a source of germs in hospitals. "A smooth screen is inherently easier to remove bacteria from than the difficult topography—the nooks and crannies—of a keyboard," Perlin says. "So they're cleaner, with the proviso that one appropriately cleans the device."
Holston notes that when clinicians are touching a keyboard, they're usually "in a pretty clean state. Of course, we try to use a lot of barcoding to put in a lot of information along the way so they're not spending a lot of time typing on it; and then for most physicians in our world, I don't see them doing their notes in the room. They tend to go out to kind of a nursing station or a pod to finish those things up."
Elsewhere, such traditional charting habits haven't stopped clinicians from dumping their keyboards as fast as possible as the tablet revolution gathers steam.
"The patient-physician interaction is much less disrupted by the tablet," Velasco says. "It's much more like the clipboards that some physicians used to have to take notes or to refer to information when they saw patients, either in an exam room or at the bedside, and so it does really lend itself to a much more appealing interaction, and the iPad Mini may prove to be a more attractive form factor because of its smaller size."
Some patients actually like having a doctor typing away during a consult, thinking that when the clinician types something in, the information has been entered properly, Holston says.
Organizations such as Intermountain still haven't completely bought in to the BYOD trend. Only the iPad and iPhone are approved as BYOD, and they must remain off the internal Intermountain network and use the guest network instead, Holston says. Intermountain also gets each employee's agreement to allow remote wiping of the device, including all personal information, should it be stolen or lost, he adds.
While the keyboard debate continues, the growth of tablet-friendly EMR systems, plus alternate forms of input such as speech, will further whittle away the virtues of keyboards, clinicians say.
"The challenge will be for app developers to optimize the entry of information that minimizes the keyboard paradigm, maximize the use of template-driven documentation, and therefore keep free text to a minimum, and perhaps support the need for free-text narrative using dictation and voice recognition," Velasco says.
"The more we move to coded data," Holston says, "where you're selecting very distinct values of things that have well-understood codes that all come together to tell a story the computer can act on, I think, is a powerful platform for touch." But if the industry continues to have a box for extensive open text "and you type whatever you want, even if you try to format it the same every way or we put some form in there that you fill in the blanks but it still ultimately kind of poops itself out as a big text blob, I think it's tough on touch."
Tracking, throughput, and savings
Tablets and phones are being joined by a variety of other connected electronic devices. Some are being used to improve the efficiency, quality, and accuracy of lab work. In an older setup, nurses would have to print barcodes at workstations and walk them back to patients' bedsides to be applied to blood specimen tubes. This printing often would occur in batches, requiring extra care by nurses to not misapply labels to tubes. With small bedside devices now under consideration, these barcodes can be printed right at the bedside, says Annecharico.
By placing RFID chips in digital devices and wristbands, as well as on patients and other equipment, hospitals are coming alive with ambient up-to-date digital information. Such real-time location systems are "a parallel swim lane" to the adoption of tablets, Moroses says.
For instance, one HCA hospital, 94-bed Summerville (S.C.) Medical Center, installed an RTLS system that ensures that clinicians wash their hands by sensing when they enter and exit patient rooms and whether they use hand sanitizers in the rooms. "We've seen about a 25% improvement since we started measuring and analyzing the data in May 2012," says Louis Caputo, CEO of Summerville Medical Center. Have infection rates dropped? Summerville had few to begin with, but the goal is zero and RTLS helps, Caputo says.
Another HCA hospital uses RTLS to maximize patient flow. Last year, Aventura (Fla.) Hospital and Medical Center, a 407-bed acute care facility, faced lag times of three to four hours from the time admission orders were issued to patients in the emergency room to the time those patients got up to nursing units. Not only were the delays complicating care for those patients, but they also created overcrowding in the emergency department, says Chief Nursing Officer Karen Bibbo.
Using RTLS technology from GE, Aventura was able to identify rooms for cleaning as soon as they were vacated without requiring phone calls from nurses to housekeeping. Before implementation, more than 40% of admits waited in excess of an hour for a bed; after implementation, that number declined to as low as 7%, Bibbo says. "Patient satisfaction is much improved," she adds.
The latest tech surge can also mean big savings in further eliminating paper and printing costs. "We have managed to reduce the footprint of printed material that is used for meetings and just general distributions by introducing the iPad for meetings," Annecharico says. "Those who meet on a regular and consistent basis are replacing their laptops with iPads for purposes of having materials distributed to them, and they bring it right up in the meetings, therefore not requiring two things: one, the use of paper, and two, the use of color ink, both of which are simply wasteful in my perspective." Within a four-month time period, one midsize Henry Ford facility reduced its operating expenses by $90,000 by reducing the paper previously required, she says.
"We're at an amazingly exciting point where we're beginning to expect device-enabled support for better care today, and we're beginning to really imagine scenarios that elevate not only care but health tomorrow," concludes Perlin.
Listening to the opening keynote at Monday's HIMSS conference, I was struck by a question posed to the speaker, Warner Thomas,President and Chief Executive Officer of Ochsner Health System: What was Ochsner doing to engage patients?
Now in fairness, what Ochsner has achieved in the six-plus years since Hurricane Katrina is nothing less than breathtaking. For example, the health system has invested in an electronic health record-driven initiative to serve the resurgent city of New Orleans.
But in the best "what-have-you-done-for-us-lately" spirit of HIMSS, the question posed was one Thomas tried to address, but it's clearly among Ochsner's next set of challenges. Thomas emphasized Ochsner's efforts to engage via increasing patient surveys. All good. But to see where the cutting edge of patient engagement is really underway, you need to hop a plane and head over to Alabama.
At Cullman Regional Medical Center, a Tier 1 heart and stroke center, they're engaging with patients using a just-enough-technology approach that points the way to further cost-effective innovation on the patient engagement front.
Post-Discharge Instructions On Demand Specifically, Cullman has been able to reduce 30-day hospital readmissions by 15 percent by giving nurses iPod Touches with an app that lets them record the post-discharge instructions they are giving to patients, then allowing those patients to retrieve those recordings by phone, Web, or mobile device.
The app works on any iOS device—iPod Touches are just the least expensive ones. "The nurse tells the patient, I'm going to record the instructions that I'm providing for you, so that when you get home, if you have a question, or you forgot something that I covered with you, you or your family can call in and listen to what I'm telling you," says Cheryl Bailey, Cullman CNO and vice president of patient care services.
"Or you can log on to a computer, or your smartphone, and you can not only listen to this actual conversation, but you can also see other information related to your diagnosis."
This simple tech augmentation to discharge helps overcome the impact that a distracted patient can create by not paying close attention to complex discharge instructions, or by not being able to understand the instructions upon just one listen to the instructions, Bailey says.
"When the nurse typically goes into the room to provide the discharge teaching, the patient knows they are on their way out the door, and the nurse is the only thing standing between them and that door," Bailey says.
"When you're focused on that, you're not listening to what the nurse says. So if you're not listening, that sets you up for not following the discharge plan, because you don't remember it, and then you could be readmitted."
In addition, Cullman staff recognize that there is often no one else in the room during the discharge instruction phase. Family caregivers benefit from being able to listen to these instructions, too.
Improved Accountability, Lower Readmissions Bailey says the tech also improves accountability of both clinicians and patients. Directors and chief nurses can randomly listen to these recordings. "The nurses know that, so they do a better job up front teaching," she says. "[And] when the nurse says, 'Miss Bailey I'm going to record what I'm telling you,' the patient thinks, 'wow, this must be important if they're going to record it, so I better listen.' And so they're doing a better job listening. So both parties are doing a better job."
The 15 percent readmission reduction was based on a six-month trial on a 31-bed "step-down" nursing unit at Cullman where many stroke, pneumonia, and congestive heart failure patients recuperate after the ICU.
"My goal was, if we can make a difference on Four East with those patients, then I can replicate that on any of my other nursing units," Bailey says. In addition, Cullman saw a 62 percent improvement on HCAHPS patient satisfaction scores during the trial.
"We started thinking, okay, where else can we implement this in the hospital that's going to be beneficial? We next rolled it out into maternity," not to reduce readmissions, but to improve education. "This generation is all about technology, so they all have a smartphone, so we created information that the parents can watch videos, can read information on how to bathe the baby, anything they need to know. They can just log on," Bailey says.
Customizing Content for LT Care and Billing The selection and details of a move into long-term post-acute care are also being targeted to benefit from this technology. "You might have a case manager that goes into the patient's room on Monday, and they talk with the family to ask them which nursing home they would like their father to go to, they choose their nursing home, then the case manager will record that conversation on everything that they need to do," Bailey says.
Last week, Cullman even began using this technology to record conversations with patients about their billing and payment options and make them similarly available after discharge.
And nursing homes are also excited about being able to access these discharge instructions, and will be providing their own content to be customized and packages as part of the post-discharge information available to patients and family.
When you think about it, much of this innovation is about providing ever-more customized content to patients. To me, that's the true power of patient engagement at work. Cullman may be the vanguard of a huge positive development in healthcare IT, one that goes far beyond many of the basic innovations that an electronic health record represents.
And eventually, the EHR will benefit as well. Bailey says the basic technology will be integrated into EHRs so that this custom content becomes part of the medical record. When that happens, watch for a healthcare IT system to be much more than the sum of its parts today.
They call New Orleans the Big Easy, and next week's Healthcare Information and Management Systems Society conference, March 3-7 at the Ernest N. Morial Convention Center, will be a chance to enjoy that unique city's style and grace.
But while some will hear a funeral dirge for the way healthcare used to be, others will detect the romping, stomping, second-line beat of technology-fueled change.
It will be big: Former President Bill Clinton will be a keynote speaker, as will political heavyweights Karl Rove and James Carville. As of this writing, I've already been contacted by 152 technology vendors and service providers asking to meet with me at the show.
But it won't be easy: I will be lucky enough to have time to meet with only few of them, though none is a former occupant of the White House.
Nevertheless, I'm excited about the lineup. More than ever, the HIMSS conference will be showcasing healthcare that fits in your pocket or tucks neatly onto your tablet. One workshop, led by Copper Mobile CEO Arvind Sarin, provides a direct hands-on experience of what it's like to develop a mobile app.
Also for the first time, there will be a special portion of the show floor dedicated to Meaningful Use demos and presentations. Off the floor, the patient engagement requirement of Meaningful Use Stage 2 will be the focus of a Patient Experience through HIT Forum.
Some of the most interesting ideas promise to come from the strong lineup of breakout sessions:
Other breakout sessions are equally deserving of your time. Try to arrive by Saturday if you can, to catch some of the pre-conference sessions on Sunday.
Big News or Big Snooze? As for breaking news, the big buzz is all about a possible interoperability announcement to be made by EHR system competitors Cerner and McKesson. They'll be holding a joint press conference at HIMSS, so we'll have to wait and see.
After last year's HIMSS—where I struggled to find acknowledgement at any major EHR vendor's booth that other EHRs existed—this could either be the start of something big, or it could be little more than a marketing ploy.
Who Supports Direct Project? I doubt such developments will cause any provider to switch from one EHR to another. I will spend far more time at HIMSS asking IT vendors and service providers about their specific support for the Direct Project, which "specifies a simple, secure, scalable, standards-based way for participants to send authenticated, encrypted health information directly to known, trusted recipients over the Internet."
I get mixed signals from the industry. Are they supporting Direct, or not? And how and when will patients be able to access data via Direct? I hear they must have a special email address and must go through patient Web portals as they do now. What patients want to hear is that they can also use popular email programs such as Gmail or Outlook to get at their Direct-authenticated messages. I will look around HIMSS and report back on what I find.
Half the fun of HIMSS is asking the tough questions of vendors and providers alike. For instance, a big wrinkle in the transition to EHRs is that patients' psychiatric histories are now being incorporated into EHRs that all care providers in a system can access.
This makes sense from the system's point of view, but runs counter to what many psychiatrists have been telling their patients for many years: that their notes are not shared with other providers in the same system or other systems such as health information exchanges.
An audio from the 2012 Health Privacy Summit, features some disturbing experiences by patients who felt their trust was violated by this larger sharing of their psychiatric histories. Some are even reluctant to share information with their physicians due to this sharing.
At a time when the industry is struggling to accommodate HIPAA and deal with a variety of privacy breaches, it must also deal with the unexpected ways digital information flows within its own systems.
As I said, the show will be BIG—the conference brochure (PDF) alone is 51 pages—and I can't get to every session I'd like to attend, but I've selected a few specialized topics I will be delving into at HIMSS.
Did you know that FICO, the credit score people, now markets a Medication Adherence Score with data purchased from large pharmacies? How will this data affect the cost and availability of care, and what issues does it raise, such as poor patients having to choose between paying for medicines and paying for food?
In many states, patients can “self-refer” and order their own lab tests. How will this play out under accountable care organization models?
Is ERP technology a blessing or a curse for providers? Or is it a bit of both?
For the answers to these and other questions, follow me to HIMSS next week. Don't be surprised if I've heard from upwards of 300 vendors by then... and maybe some Washington big shots.
This article first appeared in the January/February 2013 issue of HealthLeaders magazine.
Talk about enterprise imaging, and you're likely to witness some pained expressions from healthcare CIOs.
In recent years, the healthcare information technology industry has been particularly innovative when it comes to creating images. Picture archiving and communications systems are in every radiology department, and mini-PACS have proliferated in many other specialty departments, everywhere from cardiology to pathology to dermatology. Meanwhile, tablet computers equipped with 5-megapixel cameras are in the hands of a large number of shutter-happy clinicians.
The vendor industry's response—enterprise imaging—largely amounts to a series of promises waiting for implementation at all but a few pioneering organizations. According to a July 2012 survey by KLAS, most healthcare providers are just in the early stages of forming an enterprise imaging strategy.
"This is both an exciting time and a little bit of a confusing time for enterprises. Vendors have recognized that there is a need for and an emerging marketplace for 'vendor-neutral' archives that will handle not just radiology DICOM images, but all kinds of documents and images from multiple disciplines, everything from photos and light photography to pathology slides and ophthalmology images," says David S. Mendelson, senior associate in clinical informatics, director of radiology information systems at Mount Sinai Medical Center, a 1,171-bed tertiary care teaching facility in New York City. He also serves as cochair of the board for Integrating the Healthcare Enterprise International.
"Enterprises, through their CIOs predominantly, have said that there is an economy of scale by trying to have one central archive ultimately that would handle all these things. Intelligent applications sitting behind that archive would enable the ability to distribute all those various types of images in an intelligent manner to the right people," Mendelson says.
"You need some authentication rules behind it. Not everybody is entitled to see everything, but if you have everything aggregated in one place, it may become less expensive to manage. It may become less expensive to build a business continuity or disaster recovery system behind it. Then what you need is a set of business rules for who can look at what and when."
Traditionally, PACS applications and PACS archives were closely integrated. In an enterprise imaging model, the archives—the storage and the information associated with the stored images—are often separate from the applications. At least, that's the ideal. Between reality and the goal lie a host of issues. Existing PACS archives have to be upgraded to vendor-neutral archives, able to store and serve up images in all their many file formats. A fast, powerful network architecture must be able to scale and yet provide assured levels of service, both in terms of availability and latency. Rule sets established at the archive must be enforced across an ever-growing toolbox of imaging applications.
"For those of us, particularly radiologists, who have existing archives, the cost of data migration into a vendor-neutral archive is a real factor that has to be taken into account," Mendelson says. "Not just the cost, but the process and the time it takes."
At Mount Sinai, the strategy to achieve all these aims is, of necessity, an incremental one. "Right now in many places, electronic medical records are eating up all the dollars for IT projects, which means vendor-neutral archive only gets a middling priority, and that may be very appropriate if you're functional right now," Mendelson says.
"Some places are in the process of replacing PACS systems," Mendelson says. "That might be the moment to begin to entertain moving toward a vendor-neutral archive instead of going to a traditional PACS model."
Mount Sinai is evaluating migrating to a vendor-neutral archive, which would also lay the groundwork to allow the organization to provide images to health information exchanges without increasing the vulnerability of its primary imaging applications, he says.
The vendor-neutral archive may serve double-duty as an upgraded business continuity and disaster recovery system, replacing a cumbersome magneto-optical disk backup system, he says. Planning, and lots of it, is the place to start with enterprise imaging.
"Unless you have a comprehensive enterprise strategic plan for enterprise images, you will waste a lot of money," says Paul Chang, MD, FSIIM, professor and vice chairman of radiology informatics and medical director of enterprise imaging at the University of Chicago School of Medicine. "You're going to consume a lot of cycles, because it is unsustainable having this menagerie of various mini-PACS without a comprehensive management plan. And unless you have optimized work flow, you won't leverage and achieve the efficiencies."
Chang says the often-heard goal of integrating DICOM and non-DICOM images into a single image archive is a solved problem at scores of medical centers. The real need, he says, is for mature work flow technology that allows those capturing the image to enter necessary metadata about the image at the time of acquisition.
One such application, built at the University of Texas MD Anderson Cancer Center, which conducted more than 10 million diagnostic imaging procedures in fiscal year 2011 at its 594-bed hospital, was demonstrated at the 2012 HealthData Initiative Forum's Health Datapalooza event in Washington, D.C. The application, ViSion, was described at the event by David J. Vining, MD, medical director of MD Anderson's Image Processing and Visualization Laboratory. "What we've tried to do, though, is capture the natural work flow of a radiologist, and that is simply sticking our finger on the film and saying, 'Where is it and what is it? Like, lung cancer? Colon polyps? Gall bladder? Gallstones?' And that's the essence of what we have done with this app."
Application development is not the typical hospital's strong suit. Chang cites two government agencies—the Air Force and the Veterans Administration—that have built metadata-at-image-capture applications. The rest of healthcare is still waiting for imaging system vendors to offer mature solutions of their own. It doesn't help, Chang says, that some vendors are still trying to get providers to buy bundled archive systems, even as those providers have invested heavily in their own storage solutions.
"One of the problems with non-DICOM images is it was too easy for us to just throw them into a PACS without really associating with metadata or orchestrated work flow to be useful," Chang says. "You've got all these pictures, but they're not as discoverable, they're not as useful to us as radiology images, because of the lack of association with metadata.
"You might, if you ever get around to it, tag [or] associate with some metadata post-hoc. That's very dangerous. We would never do that in radiology."
At the University of Chicago, Chang is building an iPad app that integrates work flow into the act of taking a picture. A nurse opening the app will be able to obtain a patient list, select the patient being photographed, and use drop-down menus to indicate the target, such as a skin lesion. Then the application will give the nurse pointers for how to take the picture.
But a total solution takes a lot more than building one iPad app. The University of Chicago first built a sophisticated service-oriented architecture infrastructure, and could rely upon Chang's earlier experience at the University of Pittsburgh, where he helped build the Air Force's system that was under contract at the time.
All of which indicates that solving the enterprise imaging puzzle requires expertise, years of time, and money. It's more appropriate to think of enterprise imaging's potential to create value than it is to think of it simply as a potential return on investment, says Eric Yablonka, vice president and chief information officer at University of Chicago Medicine.
"It's hard to quantify the ROI, but we can tell you that it's created value," Yablonka says. "It's significantly improved our turnaround times and our service to patients, and it's improved our teaching program. It's allowed us to more quickly and with better accuracy report the quality of our imaging service, so it's not just return on investment. I would say the same thing to anybody else who wants a strict ROI interpretation of any IT investment. It's about creating value."
Enterprise imaging "is an opportunity both to leverage cost and infrastructure, but also to deliver integration and work flow to the EMR, and I think that's critically important," Yablonka says. "It is really critically important to have high-quality, very productive imaging groups, and whatever we can do to improve their work flow using technology, we should."
As information flows increasingly from provider to provider via health information exchanges or accountable care organizations, enterprise image management will be crucial, adds Yablonka. "You don't necessarily want patients to be imaged over and over as they move through different phases of care, but you then have to have an image sharing platform, almost like an image HIE kind of capability, and traditionally images have not been core to HIE plays. So I think that's a huge opportunity going forward on the imaging side to both save money in the industry and reduce exposure to patients of excess image radiation and to improve the quality of care. That's going to be very big."
So far, the Centers for Medicare & Medicaid Services has not made access to images through an EMR a requirement for providers. But meaningful use Stage 2, the rules for which were finalized in October 2012 and which take effect in October 2014, includes for the first time as a menu option the requirement that EMRs be able to access more than 10% of all test results of which is one or more images ordered by an authorized provider of the eligible hospital for patients admitted to inpatient or emergency department. And CMS has a track record of incorporating menu items in one stage of meaningful use into the core requirements of the next stage.
"Meaningful use says it doesn't matter if this patient had a chest x-ray from another hospital or another PACS," Chang says. "You need to be able to display it on this other EMR. That's a nontrivial issue. This is a huge issue. So the real challenge of enterprise images is not the enterprise as we know it today. The real challenge of enterprise imaging will be when the definition of the enterprise goes beyond our firewall."
At 550 beds, Chang says Chicago is not a big system. "We don't have that problem. But trust me, a lot of folks call me all the time asking for my advice on how to address that nut, because it is a really difficult problem when you get beyond a simple definition of the enterprise."
Realizing that vendors alone will be challenged to solve this problem, the National Institutes of Health recently renewed funding for RSNA Image Share, a project headed by the Radiological Society of North America. Mount Sinai's Mendelson is the principal investigator.
Initially aimed at sharing of radiology images, RSNA Image Share builds on the IHE XDS-I profile, a solution for publishing, finding, and retrieving imaging documents across a group of affiliated enterprises. The preliminary focus is for patients to control the routing and exchange of their imaging exams through image-enabled personal health records. In its first pilot stage, the project already empowers more than 2,000 enrolled patients to direct how such images will be shared. "That cuts out an entire layer of security and confidentiality concerns, because in a health information exchange, the patient has to be consented and give permission," Mendelson says. "There's a whole layer of bureaucracy around that, and there's good and bad in that, but this other methodology would let patients build their own imaging records in a personal health record that's been image-enabled. The patient then directly controls image distribution."
Looking even further ahead, there may come a day when providers and patients can browse relevant images on a tablet in a manner vastly easier than today's medical record. MD Anderson's ViSion project sports a user interface inspired by the Operation silly skill game, where images are laid on the outline of the human body, and physicians and patients can flip back and forth through images to see a timeline of disease and treatment.
"We are now actually integrating treatment icons, so that we can show when certain treatments like surgery or radiation therapy have been effective and might have affected the course of disease in terms of the images," said MD Anderson's Vining at the Datapalooza event.
Best of all, the images are brought into ViSion by that lowliest of PC-based imaging technology: the screen capture, "whether it's a PACS system or a 3-D imaging workstation, and we extract the image off of this screen capture and upload it to a cloud server," Vining said. "As I talk about this image with my microphone, I capture this image and my voice, I upload it, and from that voice we extract metadata to tag that image, but because we use screen captures, we integrate with no one vendor but we interface with all of them."