When a CIO I spoke with recently stated that Twitter scared him, I doubled my efforts to seek out a good story about use of social media by a healthcare provider. Within a couple of weeks, I found four.
Farris Timimi, MD, a cardiologist and the medical director for the Mayo Clinic Center for Social Media, uses social media strategically. Speaking at the annual meeting of the Association of American Medical Colleges in San Francisco, Timimi made those strategies come alive.
The first story involved Philip R. Fischer, MD, a Mayo physician and expert on Postural Orthostatic Tachycardia Syndrome (POTS). Fischer's administrative partner, Lee Aase, made a 22-minute video of Fischer speaking about POTS.
A news station used 8 seconds of the footage. "If you don't have POTS," Timimi says, eight seconds is all you really need to hear. But if you have this disease, or have someone you love and care about who has it, you're missing out on some deeper conversation that has value."
To reclaim what the TV station hadn't used, Mayo's social media team turned the entire 22 minutes into a podcast. Five years later, that podcast, posted on Mayo's Web site, has been hit 60,000 times. It required no additional effort on Fischer's part, merely 90 minutes of editing work by staff.
To optimize search engine discovery of Fischer's expertise, Mayo created a blog post with a 4-1/2 minute video of Fischer telling the viewer what he tells his patients every day: "Your child has POTS, here's what I can offer you, here's what you can expect." That video has been viewed 44,000 times and helped numerous patients who never visited Mayo Clinic.
Timimi's second story about social media concerned Dick Berger, MD, who helped identify UT ligament split tears, where the ligament tears along the long axis like a stalk of celery. Many who suffer from it are not diagnosed properly at first, but once diagnosed, can be effectively treated.
Berger's most famous patient is Jayson Werth, a major-league baseball player who suffered a broken wrist in 2006. His UT ligament split tear went undetected and although he played again, Werth was thinking of quitting baseball because of the pain.
A friend suggested seeing Berger for a second opinion. After being diagnosed correctly and having the ligament repaired, Werth signed an $850,000 contract with the Philadelphia Phillies.
The Mayo marketing department tried to share the story with local media, but in Timimi's words, "We threw it and no one swung at it." Then, using a consumer-grade video camera, Mayo made a recording of Werth telling his story in his own words and posted it to the Mayo Clinic blog.
A few years later, Werth hit two home runs for the Phillies in the World Series. "We had the video, we had the blog post, and we had the transcript," Timimi says. The Rochester, Minnesota newspaper did a splash story on Werth's recovery, and the local TV station used Mayo's relatively poor-quality video for an on-air broadcast.
"It's not how it's captured," Timimi says. "It's the message that's the issue."
USA Today picked up the story and featured it in its health section, but the next twist was a social media one. "We had USA Today embed a Twitter widget, so for one hour, you could talk to Dick Berger on Twitter about wrist pain, UT split tears, and how they're diagnosed and treated."
Erin Turner, a resident of Washington D.C., had been living with wrist pain for about five years. Her mother spotted the USA Today Twitter chat with Berger and told her daughter to get online and follow it.
"She felt during that conversation on Twitter that she understood enough about Dick Berger, about the disease, about its management, to come and make an appointment to be seen at the Mayo Clinic," Timimi says. A successful treatment followed.
Timimi's third social media story picks up on the e-patient phenomenon. Spontaneous coronary artery dissection (SCAD) is a rare syndrome where people develop a spontaneous tear in the coronary lumen. "The tear propagates, a blood clot forms behind the torn flap, and occludes the artery," he says. "It could lead to debility, heart failure, or death."
Until recently, few studies had been performed on SCAD. Katherine Leon received the diagnosis, and joined an Inspire.com community of over 7,000 female heart patients hosted by "WomenHeart: The National Coalition for Women With Heart Disease." Soon, Leon and another SCAD sufferer, Laura Haywood-Cory, decided it was time to make someone in healthcare study the syndrome. They discovered a women's heart conference in Rochester and went there in person.
To make a long story short, Mayo set up a SCAD clinic and an IRB-approved pilot study involving 12 women. Before Mayo researcher Sharonne Hayes could post a recruitment notice, Leon and Haywood-Cory had already identified 18 candidates.
Within six months, Hayes had full medical records including angiograms and echocardiograms from subjects from around the world. Hayes is now on track to develop the first DNA biobank of 200 SCAD patients worldwide, plus 400 of their relatives.
"None of them came to Rochester for primary care," Timimi says. "Now this occurred because they made it happen, not because we made it happen. We were available, and interested in the opportunity, but they drove this research. We didn't." The program has since been featured in the Wall Street Journal.
The final story notes that social media can continue to pay dividends years later. Timimi shared the story of Haley, a 13-year-old who suffered symptoms of nausea, vomiting, and diarrhea. Haley saw more than 50 physicians, "none of whom were able to yield a diagnosis that made sense to her or her mother," Timimi says.
In desperation, Haley's mother, Christine Lairmore, turned to the Internet, and found a blog post describing a child who looked just like Haley, who at that point was down to 76 pounds. In that blog post was posted Phil Fischer's 4-1/2-minute video about POTS, four years after it was shot. Lairmore found Fischer's information and scheduled an appointment for treatment.
Social media turned out to be a resource that's scalable, requires little labor, and still has value to patients four years after being produced, Timimi says. Mayo filmed Lairmore telling her story, again using a simple Cisco flip camera, and the footage this time ended up being used by ABC News Online.
"I think we have a moral obligation to do this," Timimi says. In an age of too much information, less time for direct patient care and patients spending more time than ever online, providers can use social media to shape the conversation.
So grab a video camera, find some engaged e-patients at your facility, and jump into the Twitterverse and the blogosphere. Even if you're not Mayo Clinic, you never know where it might lead.
I've been a part of some great healthcare technology discussions while at HealthLeaders Media, but perhaps none covered more ground and got to the heart of more issues in less time than a meeting last week between some of Silicon Valley's top healthcare entrepreneurs and four top executives—three of them CEOs—representing healthcare providers with a Valley presence.
Hosted by the University of California, San Francisco, this 100-minute meeting of minds got right to the promise and the pitfalls of technology in healthcare, and highlighted just what an inflection point we've reached as 2012 draws to a close.
For one thing, I was struck by how many hospitals are taking selected tech startups under their wing, offering business advice and intimate glimpses for a lucky few developers into their particular workflow challenges.
For another, I was struck by the intricate knowledge these top executives had about technology. Gone are the days when the CEO left all that to the CIO or the CFO. These industry captains know their way around Meaningful Use and cloud computing.
It also struck me that the current explosion of investment in healthcare tech startups is going to run into a buzzsaw at some point, because the savviest CEOs know that stitching together best-of-breed tech solutions must give way to integrated, interoperable systems. The continued success of "big box" EMR suites this year points the way. But as one CEO said, "Epic is successful not because it's so good, but because the others are so bad."
With that, here's my top 10 list of takeaways from HealthTech Conference 2012:
The tsunami of change. "The mandate is, we bring these large, diverse, disparate organizations together very quickly, urgently, to try to have single-minded purpose in trying to improve community health," says Tomi Ryba, president and CEO of El Camino Hospital in Mountain View, CA. "And to do that urgently, we are bringing totally different cultures together, and government structures together, and then to be able to quickly achieve the triple aim by making sure that we keep our eye on quality, service, and affordability all at the same time. It's like a tsunami of change."
AICUs are coming. Meet the ambulatory intensive care unit, or AICU. "This is a complex-care medical home," says Amir Dan Rubin, president and CEO of Stanford Hospital and Clinics at Stanford University. "I call it concierge care for sick people." Rubin says Stanford intends to "spend more time and effort with people who we think we could prevent downstream complications from happening. So there we have leveraged our electronic data warehouse and we're tracking data over time across the continuum. That might be diabetes, cholesterol, blood pressure, [and] emergency visits." But AICUs introduce interesting, unanswered questions. "Does this population want a Fitbit? Do they want to be monitored? Some maybe, some maybe not. If it's your grandma, what should you attach to her? Maybe it's a phone call. Maybe it's an office visit. Maybe it's a health coach. I think there's a lot to be learned there. At some level, that field is in its infancy."
Nurse practitioner clinicians, bring your doctorate. The U.S. will be short 45,000 primary care physicians by 2020, Ryba says, and the shortage is felt more or less keenly depending on where you live. Ryba says 250 nurse practitioner-led clinics have popped up around the U.S., but in 2015, nurse practitioners will be required to have a doctorate. But since the alternative may be no primary care at all, expect to see more of it.
Technology to monitor medication compliance. Home monitoring of blood pressure and weight is catching on, but Ryba hasn't yet seen effective technology that can monitor medication compliance. "In the hospitals, every single patient goes home with the med in their hands, and we're doing that now, and we're making sure those meds follow them to skilled nursing facilities," she says. "But in the home, I think that we don't have the technology that really does influence behavior" to make sure those medications are taken.
Medical school takes too long. "What if it took half the time?" Rubin asks. "When you cut a year or two down, do you have more people?" He points to the writing of Stanford economist Victor Fuchs on this issue.
Specialists are headed for call centers. "Technology gives us the opportunity to do things that couldn't be thought about," Rubin says. "Maybe you could just do rounds on your iPad or iPhone or whatever the device is." If the physician needs to consult with a specialist, the days of waiting four hours for a call back may be numbered. "Maybe a specialist is sitting in a call center" and the physician brings up the specialist on a screen in the patient's hospital room. "There's a tremendous opportunity to transform how we train, how we work as teams, to leverage the technology, and to change the way we deliver healthcare," he says.
Tell the total patient story with technology. "We have fundamental EMRs in place, and we have them in hospitals and in ambulatory care settings, but what we don't have is the coming together in a meaningful way that actually tells you the story of the total patient at different episodes," Ryba says. "If there was a way with payers, with providers, with businesses, to really come together on some type of common platform that actually tracks life, life episodes, [and] life changes" and stresses prevention efforts, that would make a big difference, she says.
Expect government requirements to change as the science changes. "It's dangerous when the government says, Here are the processes that you should be ranked on, and then you find five years later, ‘Oh never mind, those were irrelevant,'" Rubin says. "Documentation of smoking cessation advice is just a joke. That you have a checkbox at admissions, and really what you should have been looking at are these three or four prime comorbidities." There's "tons of room for innovation" in technology that can track multiple chronic comorbidities or different disease categories, he says.
The care team social network. Instead of physically collocating team members from different disciplines, another panelist suggested a technological equivalent. "We're using Salesforce Chatter to allow providers in a confidential way to share their thoughts across the continuum," says Mark R. Laret, CEO of UCSF Medical Center in San Francisco. "It's been very helpful."
Free technology is never really free. "Companies underestimate the cost that we bear to do something for free," Rubin says. "When you think you're giving us something for free, we're probably spending $300,000 to get that thing for free, in internal costs, just given our cost structure." Rubin says it's a matter of priorities. "I just had all the dermatologists in my office yesterday, because they don't like the order entry in the Epic workflow. If you can fix that, it would be a good one. I could work on that project for them, or I could get my IT people to spend the time doing [some] gainsharing analysis" with a technology vendor offering a solution to some other problem. "Which one am I going to choose?" Rubin asks.
According to the American Hospital Association, the OIG letter went to all hospitals that received an incentive payment between Jan. 1, 2011 and March 31, 2012, directed specifically to the CEO's or administrator's office. The letter requests that responses be submitted by this Friday—one week from issuance.
The AHA says OIG will use the information from the survey as part of a report expected out next year. OIG staff informed the AHA that hospitals may take additional time to respond to the survey if needed. In addition, OIG will allow a health system to file a single response for all facilities, where the survey responses would be the same for each entity in the system.
(Health systems that choose to submit a single response for all their facilities should contact Kim Yates at kim.yates@oig.hhs.gov prior to completing the survey, to ensure that OIG properly accounts for their system-level response. AHA urges hospitals that respond to the OIG survey to e-mail a copy of their responses to the association at oigsurvey@aha.org.)
The day before this story unfolded before me at CHIME, I thought I would get into the spirit of the season and started asking some CIOs which part of technology or their job was scary. Little did I know the scare they were receiving in the mail while we were all in Palm Springs.
At any rate, my mini-scare survey elicited a variety of fears and concerns.
Leslie Clonch's response spoke to the fears of all HealthLeaders readers.
"I think the scope of what has to be done, and more importantly, the time frame we have to do it in, the pace at which folks have to be able to digest it and embrace it and use it, adopt it, to drive the benefits that we're all trying to get to—I think that's what's worrisome," says Clonch, vice president and CIO of University Health Care System in Augusta, Ga. "It isn't the complexity of the tasks as much as it's the combination of everything kind of happening at the same time, and being able to juggle all these things in a way that is organized and structured, that's measurable, where we can continue to keep people engaged and informed."
Clonch also had choice words for the concerns raised by cloud computing.
"If everything goes to the cloud, how does that change our liability as healthcare delivery systems with respect to patient security and privacy?" she says. "It holds tremendous promise. We need to figure out a way to take advantage of it in a way that's meaningful. We obviously see benefits in it in terms of our ability to restructure cost, to restructure how we leverage our capital, all those kinds of things, but how do we take advantage of it knowing that we still are fully liable for the information we share outside our borders, and will the regulations and the rules ever catch up with that?"
Jim Albin, vice president and CIO at St. Luke's Episcopal Health System in Houston, says radiation technology in oncology systems is the scariest technology. "Even some of the mundane hardware configurations can cause issues, and you don't realize it," he says.
The only things that ever worry Bill Spooner, FCHIME, CHCIO, in his job is the possibility of a big outage or a security breach. "Those are the things that just scare the hell right out of me," says Spooner, senior vice president and CIO of Sharp Healthcare in San Diego. Knock on wood—he's faced neither during his career.
Spooner says the scariness of healthcare technology pales next to his experience in another industry: the military. "I was in a classified Navy program 40 years ago," he says. "That's probably the scariest."
For Todd Richardson, CHCIO, vice president and CIO of Aspirus, a three-hospital health system in Wausau, Wisc., Twitter is spooky.
"I think I tweeted twice and I was afraid, because I'm not sure what I just did," Richardson says, tongue in cheek. "I'm still trying to understand the reason [for Twitter.] I'm sure there's something out there I don't know about, but I don't know what I don't know."
Sounds like the common journalists' fear of not knowing what you don't know. But in the words of journalist Hunter S. Thompson (author of Fear and Loathing in Las Vegas), when the going gets weird, the weird turn pro. So like the professional I am, I pressed on with my survey.
One other CIO responded that it wasn't technology that scared him, but people.
"They're the most unreliable technology," quips Rod Dykehouse, CIO of Penn State Hershey Medical Center. "For the most part, you can make [machines] work the way they're supposed to. It's how we as people and individuals manage them or not."
I sympathize with Rod. One of my upcoming technology articles is all about how to overcome people's resistance to technology. It's not easy, especially if the technology they're resisting is the wrong technology in the first place. It's up to all of us, me included, to find and tell the stories that lead past the fear and the loathing.
Attention, hospitals that have attained meaningful use status: The U.S. government may be asking you some tough questions as part of its oversight mandate, and you will have to answer quickly.
Providers have until Friday, October 26, to respond to an 18-page, 54-question survey probing their electronic health record system data entry habits, security practices, and more.
The letter originated in the Office of Inspector General (OIG) of the Department of Health and Human Services, whose work plan published earlier this year includes "identifying fraud and abuse vulnerabilities in electronic health record (EHR) systems."
Recent reports in the New York Times concluded that some providers have used EHRs to inflate Medicare charges. Those reports prompted letters calling for investigation of the Meaningful Use program by Republicans in both the House and the Senate.
A growing criticism of EHRs is the ability for providers to cut and paste notes from one patient's records to the next in an effort to save time. One question in the OIG survey asks is "Does the hospital have a policy regarding the use of the copy/paste feature in EHR technology?"
Although the OIG work plan has been posted on its Web site for some time, providers noted the "interesting" timing of the survey letters, coming less than a month before the presidential election.
"I'm a little riled up right now," says Pamela McNutt, vice chair of the policy steering committee of the College of Healthcare Information Executives (CHIME), who shared her concerns in a session on Meaningful Use at CHIME's Fall CIO Forum last week in Palm Springs, Calif.
The survey is "all over the place, from HIPAA privacy and security questions to coding practices, copy and paste functions and detailed questions on audit log functionality," McNutt says.
Asked about the timing of the survey, an OIG spokesman referred to the agency's work plan.
CEOs of at least ten hospitals received the survey last week, says McNutt, CIO at Methodist Health System in Dallas.
Among the other specific questions asked in the survey:
How diagnoses and procedures are coded (manually, automatically with coding software, or other)
Whether the hospital has plans to adopt computer-assisted coding
User authorization methods (unique user ID, password, tokens, biometrics, public key)
Access management (session time-out, minimum password configuration rules, regular changing of passwords, user agreements or contracts to prevent sharing of passwords, or other)
Whether outside entities such as payers can access the EHR, and if so, how such access is tracked
Barriers to allowing outside entities access (lack of software or hardware support, insufficient staffing, funding restrictions, performance concerns, privacy concerns, etc.)
Numerous questions about audit log practices and availability
How physician progress notes are entered into the EHR (free text, via structured templates)
Whether narrative nursing notes are directly entered into the EHR or handwritten and scanned into the EHR, and if so, why
Whether the Print-Screen function is disabled for the HER
Whether patients have access to the EHR, and if so, how
Procedures for identifying patients upon hospital check-in
This article appears in the October 2012 issue of HealthLeaders magazine.
Cloud computing is taking hold in healthcare as a form of data sharing and for archival storage, an infrastructure cost-cutter and a time-to-market accelerator, and even as a method of recovering from disaster. But as author William Gibson famously said, if the future is already here, it isn't evenly distributed yet, and cloud computing is a textbook example. Concerns about security, privacy, regulatory compliance, and service-level agreements are just a few of those cited in and around healthcare as go-slow signals for adoption of the cloud.
Just don't show those signals to a growing contingent of CIOs and other healthcare technologists who are making real use of cloud computing today to help solve pressing needs.
"We have several examples of what we're doing in the cloud,” says Joe Bengfort, executive director and CIO of University of California San Francisco Medical Center, which posted net patient service revenue of more than $1.8 billion in 2011. "Some are quite closely related to the medical record system and patient care. Some of them are more back in the weeds of the infrastructure and the back-end technology.”
At the same time as UCSF is making these preliminary steps into the cloud, it's also just bet big on a traditional client/server-based electronic medical record from Epic, which went live in June 2012. "We use an approach we call development on the edges of the medical record,” Bengfort says. "Our strategy is to develop capabilities outside of the medical record, and then feed that information back into that system, or to link from the medical record environment into some outside system.”
One of those outside cloud systems, Salesforce.com, has deep ties to UCSF. In 2010, its founder, Marc Benioff, pledged $100 million of his fortune to the UCSF Children's Hospital now under construction. Salesforce.com's development engine is powering a breast cancer research project spanning UCSF and the rest of the University of California system, Bengfort says.
"We're using the Salesforce platform to develop applications really around surveys—surveys associated with screening or survivorship, things of that nature—that our patients utilize,” Bengfort says.
"They can either utilize it by going into what looks a lot like a website, but it's really the Salesforce cloud,” he says. "Or they can access it through an iPad application that we've developed that they use on an iPad while they're at the doctor's office.”
UCSF has different programs written in the Salesforce.com environment that do basic things like organize the data from the survey. These programs also do computations on the risk scores for developing breast cancer based on the input that they've gotten from the patient. These results can be linked to or moved into the medical record, so that if this patient presents at the hospital or at a clinic, that information is accessible by his or her care team, he says.
"We still have all the issues of patient information, PHI that has to be protected, that can't be shared unless it's agreed to by the patient, so you still have all those restrictions,” Bengfort says. "We've done a lot of work with Salesforce in certifying their environments for our PHI, so we think we're in good shape around all those issues.”
UCSF's boldest cloud move has been to develop a way to back up its new Epic medical records to the cloud. "All the infrastructure is in place,” Bengfort says. "We're replicating our data right now. We're through two rounds of disaster testing, and we're at a point now where we want to test the ability to not just fail over to switch to a redundant system but to fail back to restore the system to its original state.”
The capability is so new that the providing cloud vendor, Dell Healthcare, has only implemented it with UCSF, Bengfort says. This implementation was key to UCSF as it prepared to achieve compliance with Meaningful Use 2011; the 600-bed main hospital was on track to attest last month.
Those medical records predating the Epic system also found a home in the cloud. Legacy Data Access takes records from old medical systems and converts them to a format that can be stored and retrieved in the cloud. "They will custom-develop a webpage so you can see it in the format you want to see it back, and then you just pay a subscription service for the access to that data,” Bengfort says.
Some healthcare organizations laid solid groundwork for the move to the cloud by investing substantially in application virtualization some years back. "We've always been a proponent of looking at how we use computing resources on the fly without having to add a lot more hardware infrastructure and software licensing to go along with that,” says Dee Cantrell, CIO of
Emory Healthcare.
With more than 1,830 licensed beds, more than 20 health centers, and 9,000 employees, Atlanta-based Emory has partnered with GNAX for the past five years to provide niche clinical systems.
"I've actually taken work off of my technical team, who was previously having to work on setting up servers and getting the hardware connected appropriately with the network and making sure all the security safeguards were in place, as well as loading the applications, and of course with that comes a lot of licensing expenses,” Cantrell says. "Now, instead of doing that, we actually have our technical resources really focused more on going out and working with our customers, looking at strategy for new solutions, and working on implementing new things.
"So they don't really do the setting up of the hardware, the application, or supporting that anymore. We actually get that service through the cloud offering that GNAX provides.”
One such niche system being served up in the cloud is Emory's cardiology images, Cantrell says. "We actually acquired two new hospitals that have their own systems that we're in the process of consolidating and moving to the Emory Healthcare systems,” she says. "We need to be able to store these images in a secured location and not have to do a lot of up-front investment for hardware. The cloud offering allows us to do a subscription-based approach, so we're using operating dollars instead of the capital dollars that are so hard to come by these days.”
Some software controlling Baxter infusion pumps is now being provided via software as a service. Cantrell says migrating these types of applications over to the cloud has realized Emory a 30% savings by avoiding unneeded hardware, hardware maintenance, and related infrastructure components.
Sheer speed of deployment is driving many hospitals to implement their ambulatory medical records via software as a service. Three years ago, 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—selected eClinicalWorks as its ambulatory EMR.
"We really didn't want to expand our internal staff organization to the degree necessary to really support the implementation and the rollout at the same time,” says Mark Moroses, senior vice president for information technology and CIO at Continuum. "We could move quicker by not having to support the application infrastructure as well as the complexity of going from practice to practice and dealing with the application integration issues, the data migration issues, the workflow issues, and the adoption issues.”
By the end of 2012, Continuum will have more than 500 physicians utilizing eClinicalWorks, Moroses says. "So that's been pretty successful for us.”
Moroses makes the point that the software-as-a-service industry has attracted vendors who now have their own clinical resources on staff, supporting the rollout of cloud services in healthcare in a far more knowledgeable way than just a few years ago.
"These are companies that are specifically focused on healthcare, so they understand the HIPAA regulations,” Moroses says. "They understand all of the privacy concerns. So when we express those, they have a better answer, and they also are able to provide and are more willing to provide different things that we would insist upon, like a biannual audit of their data center that they have to provide us with their own internal audit documentation.” Moroses says the software can review the audit trails on a consistent basis.
"In another industry, that maybe seems onerous or they may not be able to provide those as regularly, but because these guys are savvy in healthcare, our lawyers and the data people, anything that we ask, they weren't surprised at the request, and they had an approach to answer it,” Moroses says.
One place where the cloud and healthcare seem to have a natural fit is the build-out of health information exchanges. Cantrell says cloud computing makes image sharing in such an exchange much easier.
Likewise, Moroses says Continuum went live in January with a cloud-based HIE from Caradigm, the joint venture between GE and Microsoft.
"We didn't want to have to deal with the massive amounts of data and the complexities of integrating with every practice we brought on board,” says Moroses. "We wanted to focus on the use of the HIE and the use of the data, so it was really a strategic decision to say, ‘Okay, the things that are really most important to us are not the infrastructure nuts and bolts kind of stuff. That, we can just go to the cloud for. We can just rely on somebody else and pay a flat fee.' ”
Archiving in the cloud is also on Continuum's radar. "We're having conversations with people around the idea of putting images and long-term archive in the cloud, and that has some appeal to us, too, because as part of a medical record, it's a pretty dense element of data,” Moroses says. "Images are pretty large size, and for people to be able to access them anywhere and not have it really pulled across your network is appealing.”
Static storage media, such as DVDs or optical disks, have a lifespan. Pediatricians may have to keep images for 21 years, and even tape won't last that long, Moroses says. "Probably the safest thing is some kind of form of spinning disk that I can either mirror or have multiple copies. [of].”
Still, all three health systems are typical in that they continue to run their own data centers for storing their primary inpatient EMRs. A big reason: These systems were purchased so recently in the rush to attest for meaningful use, the institutions are still amortizing the cost of building and equipping these data centers with software licenses. "It is going to be a matter of finances as we look to do more migration,” Cantrell says. "One of the first things that we look at now, any time a new solution is approved for implementation, is [to] offer it through the cloud service offering through GNAX.”
Bengfort sees rapid growth for cloud computing in healthcare. "From a medical center standpoint, I tend to be a little bit more conservative about it,” he says. "It may not sound that way, because we're using a lot of cloud today, but we're using things that either we've been personally involved in developing the criteria for, much like the Dell example, or they are quite mature, proven rock solid.
"When you are providing care to patients, the closer it is to the patient, the more rock solid it has to be,” says Bengfort. "I love innovation. I hope you can tell I'm certainly pushing the edges where I can, but when it comes to patient care, it's got to be a well-proven and very secure environment. From a medical center standpoint, I might be a little more cautious than we're going to be on the university or the research side, where we can be a little bit more assertive about what we push into the cloud. So that's kind of just the high level of it, but I certainly think leveraging capabilities like this are going to be more and more prevalent as we move forward.”
Another concern is to address service expectations with the vendor.
"The contractual arrangements that you have in your agreement are really key,” Cantrell says. "I don't think you can shortchange that process, because you do want to define pretty clearly what your service-level expectations are, not only from a performance perspective, but also from a turnaround time perspective, if you happen to have an issue.”
The cloud also represents a starting point for many future innovative healthcare technologies. "In
the home healthcare space, where you're sending patients home with monitors and telemetry data is being sent back out, I would see using a cloud-based service to gather that data, process that data, maybe analyze it, have certain thresholds, certain trends that they're analyzing for,” Bengfort says. "I would see that as a great innovative service for the cloud that doesn't exist today, specifically for the healthcare space.
"We could probably come up with lots of examples as we start to push accountable care organizations and we're trying to manage proactively the health of a community before they ever even present at the hospital or at the clinic,” Bengfort says. "There's got to be creative cloud-based solutions to help provide services to those accountable care groups.”
Reprint HLR1012-6
This article appears in the October 2012 issue of HealthLeaders magazine.
As the election nears, I'm not surprised to see the shortcomings of today's electronic medical records being used as yet another political football. But could it be true that the federal government isn't regulating EMRs enough? According to an October 4 letterfrom four House Republicans to Health and Human Services Secretary Kathleen Sebelius, the just-published Meaningful Use Stage 2 regulations are "in some respects, weaker" than Stage 1 regulations. They called for immediate suspension of distribution of EHR incentive payments.
(Note of clarification: The regulations just published include a set of updated Stage 1 regulations that will also take effect in 2014, as the Stage 2 regulations will.)
As an example, the letter says that e-prescribing and medication reconciliation compliance thresholds fell from 75% and 80%, respectively, in the proposed rule to 50% in the final rule.
But the main body of the letter then charges that the Stage 2 rules "fail to achieve comprehensive interoperability in a timely manner, leaving our healthcare system trapped in information silos, much like it was before the incentive payments."
In response, HIMSS counters that "significant progress" has been made in EHR adoption because of the incentives, and rejects the call for suspension of payments.
Now to be sure, there is some disturbing evidence that EHR adoption is actually causing increasing costs to Medicare. A recent New York Times investigation just validates concerns that this system could be gamed by unscrupulous providers, just as earlier government programs were able to be gamed.
But Farzad Mostashari, MD, national coordinator for health information technology at HHS, has demonstrated the diminishing returns of heavy-handed government meddling on solving our healthcare IT problems. Mostashari is fond of describing government regulation of healthcare as a "blunt instrument."
During an ONC town hall meeting at last week's Health 2.0 conference in San Francisco, the president of a software company complained that EHRs that certify their parts only as a complete suite of products, rather than module by module, were freezing out best-of-breed solutions from the marketplace. Mostashari acknowledged that particularly in ambulatory settings, this kind of market abuse is occurring.
That speaker was followed by another who noted that EHR companies are charging transcription companies between $5,000 and $10,000 to get their transcribed information into those EHRs.
"The intent is that information follows the patient, and that there are not market abuses in terms of companies taking their business position in one area and using it to create unfair policies," Mostashari responded.
In defense of the current regulations, Mostashari noted that vendors are at least required to reveal these charges. He also said that HHS' Regional Extension Centers are able to argue "on behalf of a thousand small practices instead of having the small practices go up against the vendor one by one."
But ultimately, Mostashari had little comfort to give small practices looking for best-of-breed, and to the small companies providing that best-of-breed software or service.
"Am I aware that some vendors already built the interface five times, [and] they charged $10,000 to the lab or to somebody else for the next interface?" Mostashari said. "Yes. I'm aware of that. Is there an easy regulatory action that we could take without getting into every contract that everybody signed with everybody else? I don't see it."
Mostashari offered to sit with the questioner afterwards and go through what it actually would take to regulate every contract between every EHR vendor and every other party in the environment, and how difficult it would be to do that and avoid unintended consequences.
So if you're wondering whether the problem with healthcare IT is too little regulation, I suggest you heed Dr. Mostashari, who seems to have a keen grasp on how much regulation is too much.
Far better for Congress to turn its eye to some of the big vendors themselves, who apparently abuse this system and regulatory environment to line their pockets. They know who they are.
As the November election approaches, money isn't flowing only into the political campaigns. Last week, healthcare seemed to be swimming in money in motion, all of it having to do with investing in technology initiatives.
The Health 2.0 conference, which began yesterday, has doubled in size in the past two years, after growth had slowed for a few years. The halls of the San Francisco Hilton are thronged by a fast-talking crowd. Deals are being made in corridors and every third person you meet seems to be a doctor with a dream and some startup capital talking to an investor looking to get in the game.
The bad news for many healthcare systems is that a lot of this money doesn't presume the continuation of the current hospital-oriented care system as we know it. Calculating the new Medicare penalties for 30-day readmissions are even the subject of a startup's website (whose URL I won't give here because the first thing the site asks for is an email address). But some hospitals will be desperate enough to take the bait, just to see how bad the news is.
Meanwhile, it turns out that CMS miscalculated some of those penalties due to a computer "programming error." As if technology isn't already playing enough of a role in determining the fiscal fate of hospitals.
Win or lose, Obamacare has unleashed private business to solve the healthcare problem. Central planning isn't ruling the day: witness the ONC's recent decision to put off governing the nationwide health information network. Everywhere government chooses not to go in healthcare, private money appears ready to rush in.
Just look at this past week's deals. The Qualcomm Foundation awards $3.75 million to Scripps Health to develop wireless biosensor systems to help detect and treat heart attacks, type 1 diabetes, and certain types of cancer.
"Our intention is to add to our existing investment in electronic health records and financial information systems, with additional investments to support data models and technologies, appliances, tools, applications to really unlock the power of our digital information, and to really be able to study and understand and answer questions related to patient care, patient outcomes, quality, quality metrics, care delivery, and especially science," explains Lisa Khorey, vice president of enterprise systems and data management at UPMC.
"Appliances" translates to purpose-built servers that drive analytics speed and efficiency. Those don't come cheap.
Khorey says it's money UPMC would spend anyway, and the system "will drive efficiencies that will pay for it." But the investment is also a mix of outcomes-oriented work and research, because personalized medicine based on analyzing genomic data is still a bit of a science project. "New models of care and good science is the UPMC agenda for personalized medicine," she says.
When UPMC looked around a year ago, no comparable institution had made a similar investment in personalized medicine analytics R&D. "We have friends at Intermountain and Kaiser and other large organizations that have huge analytics shops, but they tend to be focused on one facet of the problem, whereas we're basically saying it's a personalized medicine agenda, and we're going to solve the information management problem for all," Khorey says.
Of course the money can't just sit there for five years with nothing to show for it. "The goal is to do something quickly," Khorey says. She rattled off a punch list of early efforts: patient outcomes related to cardiothoracic patients; a small, intersecting set of breast cancer genomic and phenotypic data; some CMS quality compliance reporting. If any of them click, they can be scaled up quickly, she says.
Keep in mind that UPMC already has a substantial set of data warehouse technologies in place throughout the organization. The new $100 million effort doesn't replace any of those. Down the road, there could come a point at which they get combined into a larger, unified warehouse. But the effort to get something done now in personalized medicine doesn't afford UPMC the luxury of stopping to sort all that out.
"There are data warehouses associated with our electronic health records that lend insight to the clinicians who you know are just trying to understand their own departments and tend to find efficiencies there," Khorey says. "What the higher-level personalized medicine data warehouse really seeks to answer are the points of intersection, where either the business units cross boundaries, or the patient crosses boundaries. And it's not limited just to discrete data, but also has an unstructured data or a ‘big data' element to it that actually is not available in the other data warehouses."
Non-profit status allows UPMC to avoid paying $42 million in property taxes to municipalities, school districts and the county, which helps explain why the system didn't have to fish around under the couch cushions for that kind of scratch.
It's all happening at once in healthcare. As small community hospitals try to scrape together the resources they need to attest to Meaningful Use guidelines, large systems like UPMC double down on mind-numbingly large capital and operating outlays to push patient care and science through technology. Somewhere down the road, the big are bound to swallow the small, don't you think?
In his 2008 book The Big Switch, Nicholas Carr draws lots of comparisons between electricity and information technology. When the United States began generating electricity, it came from a thousand sources and there was no electricity-sharing grid. Worse, different power sources were generating different kinds of power, with varying voltages, amperages, and protocols (think direct current versus alternating current).
Eventually, through the rough-and-tumble of capitalism and some heavy-handed government meddling, the country converged on a single power system for the public electricity grid, and a variety of other industry standards governing electrical use in everything from cars to lithium batteries. That process took a few decades. To this day, as lightning strikes prove, electric devices are at risk from variations in that system. A whole network of uninterruptible power supplies—more ubiquitous than you might realize—now has to supplement the system. The process of standardizing and safeguarding information will probably end up taking longer. The inputs are all over the place. The outputs can be wildly different from each other. That much parallels the story of industrialized electricity.
In healthcare, doctors are the primary generators of information. Movements toward accountable care, value-based purchasing, and patient-centered medical homes are efforts to standardize the generation of that information. Without standardization, the kind of data analysis I described in the September HealthLeaders magazine cover story is difficult, if not impossible. In the forthcoming December issue, I'll delve into this issue further in an article I am currently writing about the role that online order sets play in this standardization.
In the course of researching the analytics cover story, I talked to more healthcare provider organizations about this standardization challenge than I was able to quote. One such organization is Mountain States Health Alliance, a 13-hospital system in east Tennessee and southwest Virginia.
Like many other providers, Mountain States is forming an accountable care organization. As such, the organization has to quickly identify major changes in admissions, patient days, length of stay, case mix index, and payer mix. "We're developing a very robust data governance structure, to where we're talking about access to data, turning data from just information into actual knowledge, so we don't have 50 people in the organization trying to get to the same number in different ways," says Logan Pigg, director of finance at MSHA.
Arriving at a "single version of the truth" from all of these data sources has enabled MSHA to detect surgical volume moving from inpatient to outpatient, Pigg says. "These shifts can really affect your bottom line," he says.
"It takes business analytics, digging into the details to figure out why the revenue isn't there, and why it legitimately isn't there," says Pigg. A traditional inpatient surgical DRG might get $20,000, but the same type of procedure done on an outpatient basis may only bring in $10,000.
As a result, MSHA has started shifting more low-margin surgeries out of its tertiary hospital, 445-bed Johnson City Medical Center, and into its clinics and surgery centers.
"We're going to have to find the lowest-cost settings to care for patients. We're not going to transfer patients to our tertiary hospital just because we have vacancy," Pigg says.
One thing is constant across the different providers I've talked to about analytics. You need a whole toolbox, not just one tool. MSHA uses a bunch: Siemens Soarian (EMR and data warehouse), Avantas Smart Square (scheduling software with demand forecasting), SCC Soft Computer's SoftLab (laboratory management), Surgical Information Systems (OR management) and others, Pigg says.
The combination of these tools can advise MSHA how to adjust its mix of labor, which can account for 50% of overall operating expenses, Pigg says.
Going forward, though, those standalone tools will be continually reevaluated by management in order to bring clinical and financial reporting together into a shared data structure, Pigg says. This will bring a whole new meaning to that goal of CIOs, "a single version of the truth."
"We're starting to see a lot of different organizations, either through GPOs—group purchasing organizations—or integrated networks, where people are really starting to develop standard definitions for a lot of things," Pigg says. "As we go even farther down the road of one unified medical record, we will have a true definition of what a readmission is. I'm hearing more and more conversation about that."
Truly, it takes a lot to build an interoperable data grid. Just ask the electric companies.
This article appears in the September 2012 issue of HealthLeaders magazine.
In 1999, Microsoft chairman Bill Gates popularized the term "digital nervous system," which describes how technology could be used to let enterprises make better decisions faster, mimicking the autonomic nervous system of living organisms.
Today, leading healthcare organizations increasingly rely on their own digital nervous systems—improving the quality of care, sustaining operations, and ensuring profitability. With unprecedented transparency, the metrics of running a healthcare enterprise trigger rapid responses to all sorts of changing conditions.
Take, for instance, the Cleveland Clinic, a multispecialty academic medical center that handles 4.6 million patient visits a year. CFO Steven Glass knows that his organization requires constant awareness of key business indicators in order to stay on top of its game.
"I'm on the dashboards probably 320 days out of 365 days a year, and it's really a key way for me to pulse how the organization is actually performing," Glass says. "That includes volumes, occupancies, patient satisfaction, quality metrics, utilization, cost, all kinds of different classifications."
When Cleveland Clinic deployed its first dashboards eight years ago, they were "relatively basic, showing overall volume information in the organization," he says. "It's evolved drastically, to where now on our dashboards, we have information that's updated as frequently as every 30 minutes."
Why so often? "On a particular day we can be running at 95% occupancy, so we really need to understand that the house is full," Glass says. "It's critically important for executives across the organization. It is a way that, as the CFO, I know are we having a good month or a bad month.
"Long before you see revenue numbers and expense numbers, if you really know your business and you track it pretty closely, you can see where you've got trends in different parts of your organization," he says.
Glass says midway through the month, if he sees light volume in a unit, he will pick up the telephone to make sure expenses are being appropriately managed.
But the real key to today's business intelligence at an institution such as Cleveland Clinic is distributing the information gathered by the digital nervous system not just to top leadership, but to all those in the organization with a need to know.
"People know I'm going to call," Glass says. "They know executives are paying attention to this on a regular basis, so as a result, people aren't waiting for the phone call. It builds an expectation in front of people that this kind of information is being monitored, so people don't want to get that phone call and not have answers as to what's going on in their organization."
Single source of truth
Business intelligence dashboards don't just happen. Behind their creation is a vast amount of tech-powered preparation and careful design, as healthcare executives sift through the many sources of data being generated in their enterprises, looking for the holy grail: a commonly agreed–on set of key metrics aggregating data from widely different information systems throughout a modern hospital.
These rollups are commonly referred to by healthcare CIOs as the "single source of truth," which, when properly designed, also allow a wide variety of enabled professionals to drill down multiple levels from the top figures in dashboards all the way to performance of individual units and physicians, if needed, to understand trends.
Retail and financial enterprises learned early how to employ business intelligence to respond to customer demands quickly. Healthcare is a latecomer to this, driven by the more recent move away from pay-for-performance to value-based healthcare and accountable care.
In this new environment, "you're going to be judged on patient experience, quality outcomes, and how you are managing the cost for that value of service delivered," Glass says. "These dashboards are tools that are already in place that allow us to focus on that."
Analytics don't just let executives compare results over time, but they also let them measure performance compared to national metrics. "You want to be able to see how your docs are doing compared to other docs in the country, as well as your region; that includes length of stay, cost per case, utilization of pharmaceuticals, and mortality," says Rick Schooler, FACHE, FHIMSS, FCHIME, the CIO of Orlando Health, a 1,780-bed network that includes Orlando Regional Medical Center and five other hospitals.
About three years ago, Orlando Health realized it had to begin developing its own single source of truth, Schooler says. "We could not continue to have multiple metrics—often the same metrics coming from different resources and different sources—that reflect different answers for the same question," he says.
The goal was to populate an information repository to let service line workers go after whatever they need, Schooler says. "We've been heads down at this for maybe a year and three or four months, [and] we believe there is a three- to five-year initial deployment to get to where there is what we would consider a critical mass of information from across the organization."
Schooler selected an Oracle-based enterprise data warehouse hardware appliance from Columbus, Ohio–based Health Care Dataworks. "You basically then have to develop the feeds out of your systems to populate that data model and then you use different toolsets on the front end to give people access to the information and to slice and dice and to view and scorecard and dashboard yourself to your heart's content," he says.
Although many healthcare systems are new to data warehouses, Schooler isn't. As far back as 1988, he was implementing data warehouse technology in the telecommunications industry.
"When you think about the concepts of accountable care, and that many of us are going to end up managing a population of patients, multiple populations, and at some point we're all going to be assuming some level of risk to keep them well or risk to effectively manage the care we have to deliver, there's no way to survive without these kind of tools," Schooler says.
Uses of analytics
One of the key uses of analytics in healthcare is to improve the quality of clinical outcomes. At Allina Health, Chief Clinical Officer Penny Wheeler, MD, and her team used analytics to look at the timeliness of breast biopsies. "We could tell that some sites were doing same-day breast biopsies when a concern was raised with a worrisome breast lump, and some of our sites were doing it up to 10 business days later," Wheeler says. "That was able to guide an initiative and have us give oversight over timeliness of breast biopsies."
Analytics also revealed that 14% of the time, Allina Health clinicians were electively inducing labor before 39 weeks. It meant too many babies going to intensive care and too many cesarean sections, Wheeler says. In the past year, by putting analysis of this data in the hands of the clinicians who knew best, 235 women did not have to have C-sections, she adds.
As much preparation as these analytics systems require, they have become more automated than before. "Knowing that times are tough and knowing that more and more measures are being required of us, we couldn't laden the organization with hundreds of FTEs that were in the measurement and analysis area," Wheeler says. "Much of the business case for this was to actually rightsize the measurement and analysis team by creating automated platforms to get the information we needed."
With 11 hospitals and 82 clinics in Minnesota and western Wisconsin, Allina Health generates $3.5 billion in annual revenue. To build its current analytics system, Allina hired Healthcare Quality Catalyst in Salt Lake City, a consulting firm run by two former executives of Intermountain Healthcare.
Then Allina added another analytical layer using QlikView business intelligence software by Radnor, Pa.–based Qlik Technologies, Wheeler says. "It allows people to look at the data and interpret it without needing to wait four weeks for an analyst to do so," she says.
There have been measureable returns on Allina's investment, she says. For instance, Allina netted $1 million to $2 million in a pay-for-performance initiative from payers wishing to reduce unnecessary C-section costs.
"But remember, we've given up revenue to do that, when you're not doing as many cesarean sections," Wheeler says. "If you don't have this infrastructure and capabilities in place, then as we move to outcomes per dollar spent, you're kind of hosed." But with that infrastructure comes greater confidence of success because the leaders know how to focus their efforts.
Allina moved strongly into outcome-based payment this past January, when it kicked off its initial ACO efforts as one of 32 Pioneer ACOs in the United States, even working in conjunction with a rival provider. "We couldn't get to actionable data without the integrated data warehouse," Wheeler says.
Measuring key business indicators in a healthcare system often precedes clinical business intelligence, but not always. At Memorial Sloan-Kettering Cancer Center in New York City, use of a clinical data repository began 25 years ago, while the financial operational data warehouse is less than two years old.
A single hospital with 470 beds and a number of regional facilities, Memorial Sloan-Kettering Cancer Center evolved its clinical data warehouse six years ago to be Web-enabled and HIPAA-compliant, says Patricia Skarulis, vice president of information systems and CIO.
To help take care of patients closer to their homes, patients may have surgery at Memorial Sloan-Kettering but receive radiation at a regional facility in northern New Jersey, Long Island, or Westchester County in New York. "We have a database of over a million and a quarter patients, and we have everything about them for their inpatient and outpatient cancer care," Skarulis says.
Every event that occurs with those patients is time-stamped, allowing clinical analysis to begin quickly. "We can begin to simulate what a bottleneck might be," Skarulis says.
Memorial Sloan-Kettering's newly developed business intelligence warehouse, built on IBM's Cognos and SPSS software, can drive decisions from the detail-oriented work of matching invoices and purchase orders to more mundane analysis.
With budget planning for 2013 under way, unit managers will have the ability to spot changes such as how performance in a given month compares to the same month going back two years. Predictive analytics will still require expertise. "We have several analytics groups within the institution, including advanced analytics and predictive analysis to clinical work," Skarulis says. "They have been so used to doing it for all of their clinical studies that to be able to have this database that will match up square footage and buildings with people and salaries and expenses and all of that and revenues, to have a total comprehensive picture—it will be extraordinarily useful to some of these super-analysts to be able to pull together insights for our business operations."
Clinical implications
Jonathan Perlin, MD, is chief medical officer and president of the clinical and physician services group at HCA, a Nashville-based hospital company that includes about 163 hospitals and 109 freestanding surgery centers in 20 states and England. He notes that data can move the needle on best practices for healthcare.
"During the pandemic flu threat of a couple of years ago, we partnered with the CDC and the Department of HHS to share not just data about prescriptions for flu-related medications, but also to share something that we've been doing for a long time: anything that would indicate an increase in influenzalike illnesses, or laboratory data that would show increases in white blood cell count or other markers of infection," says Perlin, who is a former undersecretary of health for the Department of Veterans Affairs. "The ability to span multiple states, multiple markets, multiple environments, and detect trends and aggregate those data was immediately beneficial to the public health in terms of detection of potential trends in influenza."
More recently, HCA partnered with Richard Platt, MD, a hospital epidemiologist at Boston's Brigham and Women's Hospital, to help the Centers for Disease Control understand the best way to prevent MRSA infections in hospitals.
Pulling in data from 42 HCA hospitals, Platt and Perlin's team brought together information about infections, cultures and sensitivities, antibiotics, and changes in practice. The results, to be released in October, will suggest a definitive way to avoid MRSA infections in hospitals, especially for patients in intensive care, Perlin says.
"We conducted a study over 42 hospitals in three interventions to detect which was the best to reduce MRSA," Perlin said. "The benefit of large-scale information systems spread across a large number of hospitals is to study more than 70,000 patients in more than 240,000 patient days to identify definitively the best way to avoid MRSA in hospitals."
A third HCA study, still unreleased, analyzes different pain medications used in and around anesthesia. "We find that certain medications allow the patient to go home earlier than other medications," Perlin says. This study may yield not only clinician guidance for a better patient experience, but also allow HCA to deliver the best care as efficiently as possible, he adds.
"Good quality is good business," Perlin says. "We believe that good quality in healthcare has to be supported by robust information, supporting the day-to-day decisions with insight that derives from analytics."
The Joint Commission designated 76 of HCA's facilities as being among the 405 top performers in the country last year, Perlin says. "That's a disproportionately good representation in terms of the positive performance, and demonstration to the power to be able to use clinical analytics to drive focus on clinical performance and improve outcomes," he says.
Obstacles to analytics
The difficulties in implementing business intelligence mean that not every healthcare organization is able to jump right in. The scale of data being fed into today's healthcare data warehouses can be astronomical. HCA attested to Stage 1 of meaningful use at virtually all of its 145 hospitals nationwide in 2011. HCA records more than one billion medication administrations annually, Perlin says.
"We want to put tools and information in the hands of clinicians and business leaders. We want to move as much as possible from a library metaphor to an Internet metaphor," Perlin says. By that, he means, "We want to move from something you have to go to a certain individual with a certain set of skills to answer every question to really provision users with the capacity to check out data and perform analytics, obviously in an appropriate, secure, and private fashion."
Complicating the move to these tools are migrations from point solutions that many healthcare systems have adopted under the influence of what Schooler calls "the tyranny of the urgent."
For years, technology providers have supplied analytics packages that explore one large but siloed system of information, such as revenue cycle, supply chain, or performance management of physicians.
"Ask the average organization to show you their enterprise data warehouse platform from which they do enterprise analytics on their data," Schooler says. "Ask someone to show you where that's all integrated in one spot, and you'll find few and they're far between.
"This is a discipline that our industry has to embrace and adopt and has to master going forward," says Schooler, who was named CIO of the Year for 2011 by the Healthcare Information and Management Systems Society and the College of Healthcare Information Management Executives.
Care management platforms, such as patient registries or disease registries, will also need to feed data into these data warehouses, Schooler says.
Another hurdle to implementing analytics is that all healthcare organizations also have to wrestle with both structured and unstructured data, says Jesse Spencer-Smith, director of clinical analytics with the clinical and physicians service group at HCA.
"Administrative data is coded and clear," Spencer-Smith says. "Data elements are highly structured. Some of our clinical data may be less structured and needs to be mapped. That's an ongoing project. Each of these presents its own challenges in terms of analyzing the data."
Schooler has some advice for hospitals trying to harness the power of analytics—particularly smaller community hospitals that lack funds to install expensive IT systems.
"Governance and prioritization are absolute keys," Schooler says. "As a standalone 250-bed community hospital, you may not need to invest in a separate platform. You may be running your entire organization off of one health information system."
Next, look for market partners, he says. For instance, two or three different vendors provide well-established physician performance technologies and can help providers fill gaps in their current data collection.
In a world where speed of insight is where healthcare providers keep their competitive edge, metrics that matter and the tools to create them will continue to provide that edge.
Reprint HLR0912-2
This article appears in the September 2012 issue of HealthLeaders magazine.
Healthcare is in crisis, and I'm here to report that IT is no panacea.
In fact, if you're in a healthcare IT leadership position, doing your job may feel a bit like running the gauntlet. In this ancient, barbaric practice used by both Europeans and Native Americans, prisoners or wrongdoers were forced to run between rows of soldiers or warriors who administered beatings.
Contrast the bright, shiny promises of healthcare IT vendors with the brutal, unforgiving punishment of making wrong choices in IT program selection, training, budgeting, and deployment and you get the picture.
There's a reason they call it execution.
The right technology, deployed wrongly, can burden providers with crushing workloads, plummeting morale, and bad headlines.
It's tough to gain the confidence of payers and patients if laptops packed with hordes of personal information are being lost or stolen. When patient wait times go up and customer satisfaction goes down, the public isn't going to be satisfied by excuses blaming "technical difficulties."
And yet, technology may be the only thing that gets and keeps healthcare costs under control. In all my travels, I keep encountering dedicated healthcare executives who have spent their entire careers growing up with technology, making it do the seemingly impossible.
And then I hear about a hospital where claims data had to be transferred from provider to payer on reel-to-reel magnetic tapes. And I walk away shaking my head.
But we are kidding ourselves if we think that the blazing fast computers of 2012 and the ubiquitous wired and wireless tendrils of the Internet are sufficient to complete the task at hand.
A mantra often repeated is that healthcare lags behind other industries in the use of technology. I would submit that the challenges healthcare faces are far greater than the challenges faced by other industries.
Lives are at stake. Just like healthcare itself, healthcare information needs to be delivered at the right time, to the right place, to the right people, and only to them. Yet we have a federal privacy law, HIPAA, which actually makes that more difficult than it should be. I wonder if it's even conceivable to modify HIPAA to bring it into the 21st century. Probably not while so many laptops keep getting lost and stolen.
I sympathize with CEOs such as Anna Roth of California's Contra Costa Health Services, who last week faced her second public worker protest since her system went live with Epic on July 1.
The first time around, it was the nurses, sounding alarms about patient safety and inadequate training. This time, Ori Tzvieli, MD, Contra Costa Regional Medical Center medical staff president, whose union is negotiating a new contract with the county, drafted a letter which was signed by 14 physician colleagues, including the chairs of the departments of family medicine, internal medicine, pediatrics, surgery, and dentistry. Talk about a gauntlet.
The letter brings fresh insight into the challenges this one system faces, challenges probably being faced by many other systems, only for whatever reason, it's all gone public in Contra Costa:
Since paper charts aren't available, clinicians are spending hours recreating "abstractions", summaries of medical histories, or are having to abstract them in real time during visits, further slowing care.
Unresolved processes not put in place at the time of go-live have to be integrated into the EMR.
Huge amounts of work, such as nearly all discharge orders, have been shifted from medical assistants and nurses to providers.
While Epic recommended a particular reduction in expected patient load on providers during the transition, hospital leadership expects an accelerated return to normal workloads.
Some well-trained clinicians, known as super users, are having to return to normal duties, reducing their ability to help continue training others—a form of training particularly necessary with adoption of EMRs.
The list goes on and on. Brenda Reilly, MD, chair of the department of emergency medicine, told county supervisors that one patient waited 40 hours to get a bed after the Epic go-live.
None of the new news stories included a comment from Roth, who I interviewed last month. I contacted her office again, requesting a new statement. Here is what she sent:
"We reduced workloads for medical staff when we went live with our electronic health records [system] to help support them during this transition. Based on staff feedback, patient rosters remain reduced, and we are committed to working collaboratively with staff to develop a longer term plan that allows us to continue to provide the highest quality care for those we serve. As with any electronic health record implementation, we knew it was only the beginning when we launched our EHR on July 1 and that this process would be ongoing. Our integrated health system presents both unique opportunities and hurdles.
Though the implementation process has been challenging, we have already seen benefits and are making progress. Many of the reported issues have been resolved and we are working aggressively on issues that remain. The EHR is one of many critical steps we are undertaking to ready our system for health reform, and we will continue to work side-by-side with frontline staff to meet these challenges and take these opportunities to transform and improve care."
It's probably only the public nature of such healthcare systems that exposes their woes to so much inspection. Systems with much more private governance may be in similar straits. But it can't be a good time to be a county hospital.
Not to dwell on Contra Costa's misfortunes, but if you think dealing with EMRs is scary, there are more dangers just around the corner.
The things I'm learning about ICD-10 downright scare me. This is a huge change to healthcare and the costs are considerable. In 2011, CMS urged providers to make sure they have a line of credit to cover interruptions or unforeseen changes in reimbursement due to the often unpredictable effects of the coding changeover.
I can understand why the AMA howls about ICD-10, including a comment from AMA president Jeremy Lazurus, MD. But I also know the transition is key to HHS's plans to control costs and reduce fraud and abuse. More precise coding means the difference between a payer knowing that an amputated finger was barely nicked, to one where the injury was massive. Today's old-fashioned coding lumps it all together. That is unsustainable.
And yet, at Monday's HFMA Northern California chapter meeting in Santa Clara, I also learned that the very nature of ICD-10 makes the kind of analytics that healthcare so desperately needs harder to produce. Joseph Nichols, a Seattle-based consultant, just released a white paper about this that is required reading.
I'm not completely down on technology. Last week did see its fair share of technical progress. The iPhone 5 made its bow and Apple sold an astonishing 2 million of them in the first 24 hours. But as healthcare professionals, it is our duty to educate our patients, payers, shareholders, lawmakers and the public at large.
Bright shiny objects by themselves may offer instant gratification to the masses, but it does not necessarily follow that the technology transition now underway in healthcare is all that bright, or shiny. Sometimes it's like mountain climbing. Other times, it's more like that gauntlet.
One piece of advice: Think hard about whether this is really the time to build that bright, shiny new hospital structure you've been thinking about. You're going to need plenty of cash on hand to deal with the IT-related challenges I've just described.
I understand the temptation to build tangible things with healthcare dollars. As I left the HFMA meeting, across the street the new San Francisco 49ers stadium is rising from the earth. Healthcare wants its own tangible monuments. But it may have to postpone some of them for now.
