In a pilot, a system which permits patients to view all the notes in their electronic health records was such a hit with hospital patients and physicians that Beth Israel Deaconess Medical Center and Geisinger Health System are dramatically expanding their OpenNotes programs.
This article appears in the May issue of HealthLeaders magazine.
Possibly the most famous consumer of electronic health records is Dave deBronkart, better known as e-Patient Dave.
Several years ago, deBronkart participated in a trial of a new program that permitted patients to view all the notes in their EHR.
"I experienced a direct benefit," deBronkart recalls. "Weeks after a visit, I thought, 'Wasn't I supposed to have something followed up?' Heaven knows where my printed visit notes were … it was late in the evening, so ordinarily I'd have waited till morning and maybe remembered to call in and have someone look it up—very inefficient and vulnerable to 'I forgot.'
"Instead, I went online right then and there, just as you might with anything else, from airline reservations to credit card info. There it was: actinic keratosis—a precancerous lesion. I had it removed, quickly, easily, inexpensively." deBronkart says the diagnosis was "not academic" for him. "Thirty years earlier I had a skin cancer removed from my nose. And about a year later I was found to have a new one on my jaw.
"As a guy who worked in technology all his life," deBronkart says, "it's clear to me that what's happening here is that value in healthcare depends on information plus awareness. In that moment I was aware of the information, which enabled action."
Now deBronkart's OpenNotes experience is being deployed at scale, and healthcare will never be the same.
The OpenNotes movement was tested for 12 months at three institutions: Beth Israel Deaconess Medical Center (649 licensed beds), Geisinger Health System (1,363 licensed beds), and the 413-bed Harborview Medical Center, a safety-net hospital that is part of the UW Medicine system in Seattle. Results from the study were published in the October 2012 Annals of Internal Medicine.
At the end of the tests, providers and patients liked OpenNotes so much that for those patients, access to those notes was restored after the trial. This year, Beth Israel and Geisinger are both dramatically expanding their OpenNotes programs.
A total of 105 primary care physicians from the three institutions volunteered to participate in the 2010 trial. About 20,000 patients overall were automatically given access to the clinical notes stored in their electronic medical records, says Jan Walker, RN, MBA, coprincipal investigator with Tom Delbanco, MD, of OpenNotes at BIDMC and Harvard Medical School.
When physicians would compose notes electronically, each institution's EHRs would automatically trigger an email message to the patient, letting him or her know the note was ready.
"Two weeks before the next visit, we sent them another message saying 'You have a visit coming up, and we suggest you might want to look at your last note, just to refresh your memory,' " Walker says.
Doctors who signed up were initially skeptical about the impact of OpenNotes on their workflow and the effect on their patients. "They were pretty worried that patients reading their notes would trigger an avalanche of questions—emails, telephone calls—that they just didn't have the time to deal with," Walker says. "And then they were also worried that patients would be worried or confused or upset by reading their notes."
After the 12-month experiment, the results were positive: more than 80% of patients who had visited and thus generated a clinical note, had viewed at least one of the notes written during that time. "On the doctor side, they found that those worries about questions and patients being worried basically didn't materialize," Walker says. More than 70% of patients reported that they understood their medical conditions better. "They said they took better care of themselves, they better remembered their plan of care, they felt more in control, and about two-thirds of the patients taking medications said they were taking their medications better."
At all three institutions, researchers asked patients if they wanted to continue to have access to their clinical notes, and 99% in all three places said they did, Walker says. "I've never done a survey before where 99% of people said anything."
In the survey done at the end of the study, 20% of the participating physicians indicated they would not want to continue using the OpenNotes method, but when their commitment ended, not one followed through on those wishes. After reviewing the results of the study, the leadership at BIDMC, including all the clinical chiefs, voted unanimously to expand the OpenNotes program, Walker says. By the end of this summer, it will be rolled out to the 50,000 patients who are registered on BIDMC's online, she says.
Geisinger's big OpenNotes expansion, scheduled for April 2013, netted 585 doctors who volunteered to go live, up from the 25 doctors who participated in the trial. "We have some folks who've also embraced it very wholeheartedly, including some of our surgeons, which I'm thrilled about," says Jonathan Darer, MD, chief innovation officer at Geisinger, a system which serves more than 2.6 million residents throughout 44 counties in central and northeastern Pennsylvania.
Leading up to this spring's expansion, Darer gave 30–40 internal presentations to departments and small groups, listening to concerns. "There are a couple of themes that people express, and I can head those off with a presentation and try to help them understand how we're going to manage some of the more sticky points," Darer says. "For example, everybody's got somebody in their clinic who's, you know, complicated, emotionally—family issues, whatever it is. I say, 'Don't worry. We give the physicians the ability to exclude patients.' "
Indeed, Geisinger's study didn't find the unanimous good patient vibes found at BIDMC. Two to eight percent of patients "felt some kind of negative impact," Darer says. "Some felt offended, some felt more worried. Giving the physicians the ability to exclude patients, just like they do with any medication or any medical treatment, based upon their good judgment, is appropriate."
Nevertheless, at Geisinger, 87% of the patients who participated in the study read every single note generated by caregivers, Darer says. "Eight-seven percent of patients doing anything is just remarkable, and all we did was send them a little note," he says. Even more remarkable, 33% of the patients had a high school education or less. "Some of the language or terminology in a physician's progress note can be pretty challenging for somebody to read, yet there's incredible engagement with the material, people reading these notes, or at least opening them," he says. The data also showed patients repeatedly reading their clinical notes, and 20% of them reported sharing their notes with someone else.
"Some of the explanation is that folks are used to figuring out how to get information about health, but not from their physician, so if they can't understand something, instead of asking their doc, they ask their cousin the radiology tech, or their brother-in-law who's a nurse, or whatever," Darer says. "People are more savvy than we give them credit for."
Darer says patients pointed out occasional errors left in the notes by physicians. "Doctors are not perfect," he says. "We're human. The patients would sometimes comment, 'By the way doctor, it wasn't my left knee, it was my right knee.' And I never had a single physician feel like that was a bad call. They always felt like it added value. The chart was safer."
For several kinds of patients, OpenNotes will be slow in coming. Darer describes four categories of exceptions.
"Psychiatry is certainly one of them," he says. "There are three others that come to mind very quickly. One is there are concerns about child abuse. We're going live in the pediatric arena, and that's just very sensitive, and nobody's comfortable at this point lighting those notes up. The other is the interesting, fascinating area of care of adolescents, where at a certain point, parents are asked to leave the room, because this growing young adult can then ask questions of the physician without having their parent there, and we don't want the notion that the parent might be able to see the note to inhibit the kid from asking whatever it is they want, so we're going to exclude patients between the ages of 12 and 17, so that there's just no question that the parents would be able to see anything at that point."
Finally, there is a concern about doctors administering therapy for pain. "It's a less simple relationship with some of their patients due to the issues around potential drug-seeking behavior," Darer says.
Can OpenNotes make patients healthier?
"That's the million dollar question, isn't it?" Walker says. "We didn't try to do that in this study. And we will probably be looking at that going forward. …. But you know, when people say they understand things better, and they remember what to do, and they're taking their medications better. I just can't believe that people aren't better off with this."
Harborview Medical Center, the safety-net hospital, faces logistical and budgetary challenges before it can expand its use of OpenNotes, says Joann Elmore, MD, MPH, professor of medicine and adjunct professor of epidemiology at the University of Washington School of Medicine, whose dean and medical staff run Harborview for King County in Washington State.
The medical center's patient population differs dramatically from the other OpenNotes test sites, and includes substantial numbers of patients who are part of separate groups, including homeless, incarcerated, nonEnglish-speaking, immigrant, and those with psychiatric problems and major trauma, Elmore says. Some had never used a personal computer before. Even if patients don't own computers or are homeless, they are accessing computers at community libraries and at the hospital in its Patient Education Center.
In addition, since the 2010 trial concluded, Harborview replaced some of its older EHR systems with newer ones, and budget concerns have prevented integrating the OpenNotes tab into those newer records but Harborview is actively working on it, Elmore says. "I should say that Eileen Whalen, our executive director, is so impressed with this, as is the dean, and they want to see us move forward," she notes.
Reprint HLR0513-6
This article appears in the May issue of HealthLeaders magazine.
When healthcare technology is really on point, it provides a quick return on investment, improves quality, and usually disrupts business as usual. This week, I have the perfect candidate.
The Agency for Healthcare Research and Quality estimates 2.5 million people in the US develop pressure ulcers per year, 60,000 of whom die from complications. Despite advances in bed technology and many aspects of wound care, the number of hospitalizations for pressure ulcers reported to the Centers for Medicare & Medicaid Services increased 80 percent between 1993 to 2006, despite an increase of only 15 percent more patients.
One of the causes of HAPU, or hospital-acquired pressure ulcers is too much time spent in one position. A study in the February 2013 issue of the journal Wounds, "Pressure Map Technology for Pressure Ulcer Patients: Can We Handle the Truth?" found that a new pressure-sensing technology, deployed on beds, improved the timeliness of patient turning improved greatly.
The study's authors concluded that the new technology enabled between 56 and 63 percent less potential tissue damage that would otherwise have occurred because patients weren't turned enough to relieve pressure points on their torsos and heels.
Outside of healthcare, sensor technology is catching on in a variety of applications, ranging from automotive tech to computer gaming. Now, sensors are tackling HAPU.
Here's how the system works. A thin mat, part of the MAP system developed by Wellsense, Inc. of Nashville, gets placed on a mattress with a color monitor attached. The mat contains thousands of sensors and is secured to the top of the mattress with straps.
These sensors measure pressures through a sensing area about the size of a single bed. These sensors display specific areas of pressure, and as clinicians reposition patients, the system provides live feedback to them so they can see the changing pressure in real time. The monitor acts as an educational tool for staff, patients, and family by showing where the pressure points are located.
Another key feature: a bed alarm that clinicians can set to sound at a desired interval to alert nurses or other clinicians when it is time to turn a patient. For this study, the alarms were set for two hours.
Matthew Q. Pompeo, MD is medical director of the long-term acute care facility where the Wounds study was conducted. Pompeo has been handling wound patients for 17 years, and says he conducted the trial in three stages.
In stage one, he put the mats on the facility's 55 beds, but "didn't really say much" to staff about what the mats were for. This established a baseline turning frequency. In the second phase, staff could see the pressure map on the video screen so they could reposition patients, but still did not know that the turnings themselves were being recorded. Not surprisingly, turning frequency did not improve much.
In the final phase, the center's staff were made aware that the turnings were being recorded around the clock, and at that point, turning of patients improved significantly.
Oddly enough, there isn't much science behind the turning standard of care being two hours, Pompeo says. "One of the original articles that made that popular was done simply because that's how long it took them to finish their rounds and start over again," he notes.
With the MAP system, clinicians can customize the frequency of turning to match patient needs, which can vary. Some patients can go as long as 3 or 4 hours without being turned, Pompeo says.
The key is that the technology starts a process of measurement, so caregivers can begin to answer the questions of which kinds of patients need to be turned more frequently than others, he says.
That is a key point to me. Just because a technology gets installed, we shouldn't make unsupportable assumptions about the frequency of a given practice or procedure. Let the requirements of care always drive the practice of care, and don't assume that just because an alarm can be set to go off at a prescribed time, that it must be set to that interval for every patient.
Every technology also has its limitations. Although pressure exerted over a duration of time is the main contributor to these ulcers, Pompeo says another minor contributor is shear – forces going not directly into the tissue, but perpendicular to it – a kind of friction. Over time, sensors will probably evolve to measure all of the forces in play. But the 80/20 rule applies here, as many other places, and the MAP system is moving the conversation in the right direction.
Now for the disruption I mentioned. As you probably realize, all hospital beds are not created equal. In fact, over the past ten years, according to Pompeo, "there's been a race to the bottom as far as pricing and in some degrees, quality. Beds are probably about a third of the price they are now per rent per night compared to ten years ago."
Pompeo hastens to add that a bed a third the price is not necessarily a bed a third the quality. But beds "have taken a hard hit," and he says data from the MAP system will shed light on which beds are better, and which are not, in terms of their tendency to promote pressure ulcers.
As for the price of this technology, Pompeo says it is roughly equivalent to the cost of renting the bed itself, which is somewhere in the $15-20 per day range. Giving the enormous cost of treating pressure ulcers, that seems affordable. And the cost of sensors is riding its own downward cost curve down, as most any other technology.
During the study, patients also loved having the MAP system at the bedside. "Their families would become very engaged, start paying attention to it and sort of understand it," Pompeo says.
As for caregivers, the reaction has been more subdued, but the good ones realize that the technology can show management that they are doing their job properly.
Response to the Wounds study is still rolling in, but Pompeo did talk at a National Pressure Ulcer Advisory Panel event with officials from CMS. "They were quite interested, because they want to do this evidence-based medicine and really try to be proactive with things, so we'll see," Pompeo says.
I came away from my conversation with Pompeo inspired to look for more applications of low-cost, ubiquitous sensors throughout healthcare. The Internet of Things promises a revolution in the inside and out of hospitals, and the healthcare benefits now seem to be within our grasp.
Physicians' use of electronic health records may lead to denial of reimbursement for some services, the American Medical Association chair warned last week.
During a CMS listening session, AMA chair Steven Stack, MD, who is also a Lexington, KY emergency physician, said that some Medicare carriers have already issued rules that if patient charts look too similar, they will deny payment for them.
Stack says this is happening even when physicians are using EHR software appropriately and under threat of financial penalty if they do not use EHR software.
In essence, physicians "are being instructed de facto to reengineer non-value-added variation into their clinical notes," Stack says. "This is an appalling Catch-22 for physicians."
Between 2010 and 2012, the percentage of doctors who would not recommend their EHR to a colleague increased from 24 percent to 39 percent. Approximately one third of the 4,279 physicians surveyed said they were very dissatisfied with their EHR, and that it is becoming more difficult to return to pre-EHR levels of productivity.
"Simply stated, many EHRs are not friendly to the user, and rather than improving physician efficiency, they are a widespread source of frustration," Stack says.
Stack praised the general effort toward electronic health records. "Widespread adoption of EHRs, in combination with a progressive shift toward team-based care—both things which we would assert are good—are rapidly and dramatically changing clinician documentation," Stack says.
Documenting a full clinical encounter in an EHR, however, "can be pure torment," Stack told CMS officials. "The full chart doesn't fit on a computer screen," he says. "Each element is selected by a series of clicks, double clicks, or even triple clicks of the mouse." Furthermore, "Hunting, clicking and scrolling just to complete a simple physical exam is a tedious, time-wasting experience," he added.
In response, physicians have turned to three time-saving methods, each of which has the potential for abuse leading to the denial of payments that alarms Stack and the AMA.
The three methods – cut-and-paste, templates, and macros – can be logical and beneficial for static information, such as the date of an appendix removal, Stack says.
"Cut and paste becomes bad, and is appropriately criticized as cloning, when physicians reproduce information created by themselves or others, either without attribution or without attention to its accuracy," Stack says.
"It is not appropriate for a clinician to copy another professional's history verbatim and present it as if he had obtained it from the patient himself," Stack says. "It is often appropriate, however, for a clinician to document that she has reviewed the note of another professional, and to summarize the key elements in her own note, with attribution to its source."
Regardless of the frustrations associated with the EHRs, physicians, and other clinicians still have the obligation to review their own documentation to ensure that the information is accurate, Stack says. "EHRs can make this process infuriatingly difficult at times," he says. "Even so, though it may not be fraud, glaring inaccuracies created by carrying forward prior notes with obvious errors are simply not acceptable."
Many payers and compliance officials have long criticized inconsistencies and variation in physician documentation, but EHRs have shifted the criticism to one of overwhelming homogeny, Stack says.
"Even if the clinician accurately selects individual data points on a template, every single chart containing that documentation template will look essentially the same and make use of the exact same words," Stack says. "In this case, it looks as though every clinician has plagiarized the words of every other clinician. In fact, many of our EHRs enable users to access templates and macros created by any user in the system.
If one physician has a particularly pithy, erudite, or precise way to describe a certain finding or condition, and saves it as a favorite, she may later find that her own words begin to appear in the notes created by other clinicians, who liked her descriptions so much, they adopted it themselves, Stack says.
The AMA urges the Office of National Coordinator to address EHR usability concerns raised by physicians, and to take "prompt action to add usability criteria to the EHR certification process," Stack says.
He suggested ONC reconsider Stage 2 of Meaningful Use to allow more flexibility to providers to meet its requirements.
On Monday, the College of Healthcare Information Management Executives (CHIME) called for a one-year extension of Meaningful Use Stage 2. In a statement, CHIME said that the one-year extension would maximize the opportunity of program success.
The organization of healthcare CIOs said the additional 12-months for meeting Stage 2 would give
Providers the opportunity to optimize their EHR technology and achieve the benefits of Stage 1 and Stage 2;
Vendors the time needed to prepare, develop and deliver needed technology to correspond with Stage 3;
Policymakers time to assess and evaluate programmatic trends needed to craft thoughtful Stage 3 rules
CHIME defended much of the federal incentive program's progress to date, arguing that fundamental shifts in health IT adoption and EHR product capabilities have been made possible through the policy of Meaningful Use.
CHIME's statement follows concerns levied by six Senators that the current direction of the HITECH program is flawed. A white paper released April 16, "REBOOT: Re-examining the Strategies Needed to Successfully Adopt Health IT," outlines several concerns including increased health care costs, lack of momentum toward interoperability, patient privacy, and long-term program sustainability.
The REBOOT report "highlights a number of fair and responsible criticisms of the program and it echoes many of the concerns CHIME has voiced over the last three years," CHIME's letter said. "But given the nation's increased adoption of EHRs, the increased investments in interoperable solutions and the early-stage transformations encountered every day by our members, we remain convinced that the trajectory set by Meaningful Use is the correct one.
"CHIME believes the industry's guiding principle should be to maximize the opportunity of program success and monitor the timelines needed to do that. For this reason, we formally and strongly recommend a one-year extension to Stage 2 before progressing to Stage 3 of Meaningful Use," the organization concluded.
In its letter, CHIME also called upon Congress to request an update from ONC on what technologies, architectures, and strategies exist to mitigate patient matching errors; seek feedback from the public via congressional hearing or other formal commenting mechanism; and determine how current work at the HHS Standards and Interoperability Framework could be leveraged to address the foundational challenge of patient data-matching.
HealthLeaders: How does your book treat the topic of analytics? Do you get into it at all?
HealthLeaders: What's the message of your book?
Fasano: I get into it a little bit, and I can tell you, as we're looking at the world of this space of healthcare and data, big data particularly, and the use of medical analytics—population care tools, chronic care management tools—[that] we've used them extensively at Kaiser Permanente.
And the forecast I'd make, and I believe I make in my book, is that the healthcare industry is just in its infancy in both getting and using data, and then analyzing that data sufficiently, so that we can get all the learnings from it. I believe that the largest medical breakthroughs are truly ahead of us, and not behind us.
HealthLeaders: I even hear the term "near-real-time analytics," defined as anything you can get before the patient is discharged.
Fasano: Yes. There's this concept of real-time healthcare, which is what the industry is moving toward, and predictive health, predictive analytics. [It's] basically looking at patients' current conditions, if they're in a hospital, and predicting they're going to get sepsis, and then treating them before they get sepsis.
At Kaiser Permanente, we've done that. Some of our hospitals have had no cases of sepsis for over a year, and that's great work to do, because obviously sepsis cases have really bad outcomes for patients.
That said, [there are] many conditions [to which you can apply] information technology, coupled with phenomenal caregivers who are focused on those conditions, to improve patient health, everything from cardiac patients to diabetic patients, to folks who are sitting in hospitals who could develop something like sepsis.
HealthLeaders: How do you feel about Meaningful Use Stage 2 at this point? Are you feeling good about it? Kind of tense?
Fasano: I think, like any other leader of an IT organization in healthcare, Meaningful Use as a topic is a substantial amount of work, and is not without challenges. Our organization is facing the same challenges as every other, in terms of getting to the level of performance Meaningful Use Stage 2 requires.
That said, within Kaiser Permanente, I'm quite confident in the many teams we have working on this particular effort, the way they're focused on the effort, and frankly, the progress they've made. That gives me comfort that we'll make the deadline and we'll certainly, reasonably well, if not comfortably, clear the hurdles that Meaningful Use Stage 2 has put in front of us.
HealthLeaders: How about ICD-10?
Fasano: We're equally focused on ICD-10, and I can tell you from the health plan standpoint, as we're thinking about our ICD-10 work—even in the world of just claims systems, that have to be augmented for ICD-10—we're in the throes of creating our next-generation claims systems at Kaiser Permanente, so we will go and do what's called a wrapper around our current legacy claims systems to allow them to meet the ICD-10 deadlines of 2014.
Our expectation is that all of our claims systems will do that. During the course of 2013 to 2016, we'll be replacing our current claims systems with new claims systems, a common platform across the entire institution, all of which will be ICD-10 functional, compatible, and organized. So from our standpoint, we'll meet it today, and we'll have our next generation of claims systems, which will meet the requirements as well.
HealthLeaders: And the technology is there? Epic is on board?
Fasano: They are. They absolutely are. I'll say this: I'm highly confident of Epic's ability to meet ICD-10.
HealthLeaders: I was just speaking with a small practice, and they were talking about ACOs and shared savings, and how one of their challenges was just getting claims data from that universe of other providers who work with their population. It took them three to six months to get claims data out of some payers. You have to respond to some of those requests as people go into ACOs, because some of them might be seen at a Kaiser facility. How is that going?
Fasano: In some communities, we're an end-to-end health system, so we own everything, including the hospitals. In other communities across the country, we're not, and we do use community physicians, community specialists, community hospitals.
In those situations, a lot of our contracts include interacting and coexisting with medical records between the hospital and us, and we clearly integrate our claims process, so we have relationships already in place that allow us to bring a lot of the data together between claims and the medical record, and do that across all of our operations across the country.
HealthLeaders: What is your perspective on interoperability efforts such as the CommonWell Alliance, and what Farzad Mostashari is trying to do with the Direct Project and Nationwide Health Information Exchange?
Fasano: We're an enormous supporter of NwHIN. I really think the ONC and HHS have done a great service in creating capabilities. They're focus on Direct is really important for the industry, and it's a first step.
In addition to that, and frankly coexisting with that, Kaiser Permanente, along with other very leading care providers, founded the Care Connectivity Consortium [CCC] two years ago, and we all focused on interoperability of medical records to treat patients, and set the technology up to seamlessly allow us transfer of medical records on behalf of patients being seen in five different systems, and the systems are Mayo, Geisinger, GroupHealth, Intermountain, and Kaiser Permanente.
HealthLeaders: How is that effort going?
Fasano: It's actually going really, really well. In February we had a press release with Healtheway. We've organized a coalition between us and CCC and Healtheway, which now brings the CCC capabilities and Healtheway's capabilities together. [This allows] us collectively to now participate with their efforts to support an additional 40 providing organizations, and I understand Healtheway has a pipeline of almost 100 other providing organizations.
So I would expect this activity of connecting electronic medical records and health information exchange to start accelerating and accelerating as a consequence of the technologies that have been created at CCC.
The desire of all of us [is] to do what we think is absolutely critical, and I'll just sum it up in one statement: Every citizen of this country should have the right to have their medical record present when being treated by a physician, and that shouldn't be a privilege. Currently, it is a privilege. So by connecting medical records in the fashion I think a lot of us are focused, [we] will actually fulfill that vision of medical records being available.
HealthLeaders: I take it you were supportive of the governance role the government is playing.
Fasano: I think the government has a real responsibility to create guardrails. I think the healthcare industry has the responsibility to really connect. Connected health is better than discrete health. Connected health allows every physician to practice to the best of their ability, because they have all the information about all the patients all the time.
Lacking that, physicians [are doing] doing the best they can. It's a best effort, but it's not to the best of their ability, because they just don't have all the information. It's only what you can remember when you sit in front of your physician, and you manage to tell them about your health history, if you and they have a new relationship at that moment.
HealthLeaders: What are the other takeaways from your book and calls to action?
Fasano: This whole concept of mobile health has emerged, but the concept of digital health, which is in my opinion a broader topic—that is really bringing together the clinical devices, the mobile devices, at a price point that just about every consumer over time will be able to afford.
In my opinion [that] will start to enable this monitored life, if that's something we choose, where we can fully embrace our responsibility[for] our own health, but also have the benefit of having physicians, [and] clinical staff following some of our conditions, so that they can help keep us of track as well.
HealthLeaders: So the call to action is to be more involved in mobile health? I know a number of providers are becoming entrepreneurial. Kaiser has some of its fingers in that too.
Fasano: We do.
HealthLeaders: If there's innovation going on, you're going to help foster that?
Fasano: We are, and I'd say the call to action is really for the healthcare system and the information technology community to really get going on this work.
I really believe that this industry is at a tipping point, and over the next five years, can truly transform, to where we [have] used information technology to make healthcare as convenient as your banking relationship, as convenient and accessible as any other relationship you have as a consumer.
And now your expectations have been heightened by all the apps that are available to you. Healthcare should be just like that. It should be a simple, convenient experience that satisfies you. A phrase I like to use in our organization is, 'delight our members, delight our customers, delight our patients.'
Healthcare should be delightful. It would be nice if it [were] at every touchpoint. I think the technology and the healthcare industry now [have] a responsibility to come together and really create a delightful experience that not only is delightful, but also benefits everyone's health.
HealthLeaders: To what extent is shortage of talent resources an issue? There are only so many trained people out there to build some of this stuff. Doctors only have so much time to devote to sitting down with the technologists and sharing what they have, because they're busy treating patients. To what extent is that an impediment?
Fasano: The talent challenge in health IT is a significant issue for the United States today. As an industry, the demand for really high-quality information technology skilled professionals is going to be a key turning point for the industry's ability to go through this kind of a transformation.
That said, the great thing about being in Kaiser Permanente is [that] we have 17,000 physicians who are a part of our system, and their passion is for better health, and their passion is for innovation.
So they're oriented exactly right to really drive the future that I'm describing in this book. I'm thankful to have that as a great resource to partner with in the organization. But I would say that my only concern is that we as an industry need to be thoughtful about leveraging the technology capabilities that are being built, because there is a finite resource in terms of numbers of people who will be available to us.
HealthLeaders: Just think what you could do if you had twice as many.
This article appears in the April 2013 issue of HealthLeaders magazine.
Healthcare being a round-the-clock, up-to-your-elbows business, CIOs have recognized that the IT help desk must change—and at a few institutions, that change has already occurred.
"Typical service desk analysts are not skilled in clinical applications, which are very unique to this industry, probably more so than any other industry," says Chad Eckes, CIO of Schaumburg, Ill.–based Cancer Treatment Centers of America. "The minute a [clinical] topic comes up on an electronic health record, for example, the call is shut down, and the ticket then is passed on to your clinical applications team to provide that support, and amongst all that, you end up with this delay in providing an answer to that user, who probably has a patient in front of them."
Subsets of help desk personnel must know and understand the EHR being used in that facility, Eckes says. Those specially trained personnel "need to be able to look through the lens of either the nurse or the physician and say, 'You're trying to do X in the system, and here's how you would go about doing that.' "
Rather than generate these personnel in-house, a number of providers have opted to outsource clinical IT help desk services. One such company formed in 1998 as a joint venture among the Detroit Medical Center, Oakwood Healthcare, and Compuware Corp. The company, CareTech Solutions, charges for help desk calls on a per-call basis and recruits help desk personnel with clinical experience.
"A clinician like a physician who is in the hospital only one day a week doesn't remember everything he should be doing as he logs on to the system, and so there will be a time where he doesn't have a colleague around him, or he has an issue—'I can't figure out why my patient list is not as complete as I thought it was going to be,' " says Joe Francis, interim CIO of Detroit Medical Center."He needs to have someplace that he can get an answer quickly."
In the support model DMC pioneered, physicians receive a special phone number to call for clinical IT help desk issues, Eckes says. The help desk staffers "are held to a different service level agreement in terms of time to answer the phone, the ability to respond to their issues, and when somebody follows the physician path, they immediately get somebody who is going to be a clinical person by nature, because you know the person is probably calling about the EHR."
Through the normal channel, the phone will be answered by a live person within 30 seconds, Eckes says. Through the clinical channel, the response is cut to no more than 21 seconds.
"Nine seconds doesn't sound like a lot, but when you're sitting on hold, and if you watch a stopwatch, nine seconds feels like ages," Eckes says.
A typical IT help desk query might be a case where someone is having difficulty logging in to his or her personal computer. A typical clinical IT help desk query would be where the physician needs help building a prioritized list of patients within the EHR. Another typical request would be a physician trying to display clinical summaries—snapshots of a dozen different measures on a specific patient—to look and feel a certain way.
As with typical IT help desk setups, clinicians can share viewing and control of their PC screen with personnel on the other end of the phone to get faster help.
"I was personally with one of our physicians the other day, and the physician says, 'Every single time I'm in this clinical documentation note, all of these cells are grayed out, and I can't do the documentation. Is there a bug in the system?' " Eckes recalls. "And immediately the help desk would use PC Anywhere into the physician's machine and see that the reason that the cells are grayed out is that they needed to click on one of the radio buttons at the top of the screen that says 'Enter Allergies.' And that would open up all of the boxes."
Such a session also serves to reinforce the clinician's previous training on the EHR. "These systems are so complex and there are so many different options that if a physician is only using one of those options every month or two, they'll forget about how to do it, so that clinical help desk will be a real-time training option for them," Eckes says.
Eckes says the setup fees for CareTech's clinical IT help desk were recovered within three months, and that the system has been saving money for Cancer Centers of America ever since. "They were taking on more calls and solving more issues in terms of first-call resolution, versus my internal team having to step in and address those same calls."
At Englewood (N.J.) Hospital and Medical Center, the clinical IT service desk arrived as part of a service desk improvement initiative that saw the establishment of the hospital's first service-level agreements (SLAs), says Ron Fuschillo, CIO of Englewood Hospital, an affiliate of the Mount Sinai School of Medicine that is licensed for 550 beds and operates 328 beds.
Prior to the improvements, "about 60% of our calls would end up either in voice mail or some type of a queue, or people would just hang up, and that was due to the staffing ratio," Fuschillo says.
Service desks typically are organized in three tiers, Fuschillo says. Tier 1 is where calls get resolved by the service desk itself. Tier 2 represents calls that need to be resolved by more experienced analysts in a subsequent call. Tier 3 is for problems that require involvement by the EHR vendor.
Resolving calls in higher tiers is more costly, Fuschillo says. The challenge of bringing a clinical service desk online is to demonstrate to leadership that calls are being resolved at a lower tier.
To help implement the service desk, Englewood Hospital retained an outside consulting company, which created organizationwide SLAs on 300 different items and helped the hospital select the actual provider of service desk services, weighing the capability of in-house staff to deliver these services, as well as issuing an RFP for an IT service desk that garnered 12 responses from service desk service providers.
From those dozen responses, Englewood Hospital narrowed the competition to four or five vendors. "We brought them in for four hours each to present what they had to offer, went through a very managed process with questionnaires from all the senior-level managers as well as directors who sat through those presentations to help us select the right service desk company, and we narrowed it down to CareTech, and that started the contract negotiations," Fuschillo says.
Another key to deploying a clinical IT service desk is understanding the personalities of physicians, he says.
"I say that with a smile," Fuschillo says. "You need training to recognize that and appreciate that. They may have just had a patient pass away under their care, and now they're moving to another patient, and if the systems aren't working, you can appreciate that the emotions of that individual are a little different than the rest of us. What they experience when they go through the course of the day is incredible."
Clinical IT service desk personnel are "trained to respond to those calls, and be able to calm somebody down, or at least expect that level of disruption," he says. "Some of the IT service desk vendors we looked at did not have that healthcare niche, and you can tell during the questioning—they failed to provide the adequate responses that we were hoping for."
Physician satisfaction with the in-house service desk system had been in the 20%–30% range; that jumped to about 95% with the outsourced CareTech service, Fuschillo says.
Hospitals are realizing that they need to continue to centralize IT service desk features and not disperse them through different service lines, Fuschillo says. Decentralized IT service desks are "costly, inefficient, ineffective, and no one owns it," he says. "The more centralized the similar skill sets, the more accountability. Who's responsible for passwords? Who's responsible for change control? Who's responsible for the production environment, the data that's housed in there, and on and on? You're going to see a more centralized model, taking direction from key business owners who are leaders across the organization" such as CMIOs and CNOs, he says.
Fuschillo finds the return on investment of implementing an improved IT service desk to be difficult to summarize for a CFO, but he says when properly implemented, "patient care is not disrupted. Clinicians remain on the floor, treating the patient with minimal workflow interruptions."
Detroit Medical Center's extensive automation at its seven hospitals, all certified for meaningful use Stage 1, means its systems must perform well. Just making sure the software itself is up and running isn't sufficient, Francis says.
"We spent a lot of time with our help desk and with the help desk personnel in putting together the documentation, the questioning that they should be doing, and identifying the things that they can resolve at that first call," Francis says. "It's really important that as soon as that call comes in, again, the quicker you can do it, the faster that that clinician moves on to continuing his care for the patient and goes on to his next adventure.
"So what we've done is that at this first line of support, they can do the simple things: How can I find an order? How do I fix my patient list? I seem to be hung up here; what did I do wrong? Help desk automation helps out a lot with this, because you can build a tree structure of questions and answers, and how to get to the point real quick and resolve issues, so that helped out."
The clinical IT help desk can also help management spot trends early. "We have close to 20,000 personnel who can get at our clinical systems," Francis says. "Being able to recognize when you're starting to have a trend of calls in a certain area is also very critical, and the mechanisms that they put into place, where they start getting two or three calls that are in the same area, where there's either a slowdown or some sort of process issue, even before it becomes a fire drill, they immediately alert not only the second-level support, but they also will alert the vendors that might be involved with that, so that's another thing that reduces the cycle time to resolving these issues. We've caught some things early on that prevented a much wider spread of issues."
Fuschillo cautions that "if you're already having issues with your service desk, it's going to be very hard to rectify those at the same time as an EHR implementation."
Eckes notes that the next step on clinical help desks may be to deploy "free-floating" personnel to be on the hospital floors helping out, not just at the other end of a phone line or a browser. "I think we are bleeding edge in terms of clinical service desk—to my knowledge in the top 5%—and I also believe it's only getting better, and we're continually trying to trump ourselves," Eckes says.
Reprint HLR0413-6
This article appears in the April 2013 issue of HealthLeaders magazine.
Healthcare is transforming, says Philip Fasano, CIO and executive vice president of Kaiser Permanente, the nation's largest not-for-profit health plan and healthcare provider, with annual operating revenue in excess of $42 billion. He oversees 6,000 employees, who work to support the organization's 14,600 physicians. KP serves more than 8.8 million members.
Fasano: It's really focused on being a bit of a call-to-action for the healthcare industry, and for the information technology industry to create the capabilities that will allow the industry to connect medical records, infrastructure, and ultimately create the capabilities that members find useful in managing their health, from a number of aspects: convenience, affordability, and availability of the system.
All of that is pretty much talked about in the book, from the EMR up, and from the EMR out to, from inside the system to patients and members and their interactions [as] consumers.
HealthLeaders: Technology's obviously very important, but I also hear that a lot of it is about organizational, leadership, managerial, and financial hurdles to overcome.
Fasano: In my opinion, there will be a rise of consumerism in healthcare in the United States, unlike what we've seen historically. We've seen so many other industries. I've been in the financial services industry and the healthcare industry deeply.
HealthLeaders: Who did you work for in financial services?
Fasano: Everyone from Deutschebank, Banker's Trust, JP Morgan Chase, Capital One, and then basically came into healthcare.
HealthLeaders: So you made the rounds.
Fasano: I did, and at pretty senior levels. So I had the ability to both participate in the change that the financial industry went through, and also lead some of it. That was fun to do, but we're going through a lot of similar changes in healthcare at this point. But I will also say that they're fundamentally, foundationally more important, because they're really about our health. But consumerism is going to change the way healthcare has to really deliver its capabilities.
HealthLeaders: Does [consumerism] redefine what a healthcare system is, or should be?
Fasano: I think it redefines what healthcare could be and can be in this country. Clinical devices are getting so inexpensive, and they're so connectable now, that you can just see how that all converges, where the consumer really can take control in ways they just couldn't before.
From the standpoint of really having high-quality healthcare, and being the best in the world, something we should certainly aspire to, given how much we spend on healthcare in the United States, I think the tools are now present to enable that. It's really up to the industry, and the technology providers themselves, to really help us engage in that next wave of work that's really in front of us.
I would assert that the tools, done right, will enable the industry to take cost out of our cost structures. Even the simplistic issue of connecting medical record systems, so we don't have to take duplicate lab tests as we go from doctor to doctor, will make a material and meaningful difference in the cost structure. That can be redeployed in a lot of ways across the health system to really allow us to go through this transformation.
HealthLeaders: Where do you stand on the whole PHR issue? This is the idea that we have all this heavy lifting going on about health information exchanges, but maybe the better thing to do is to do what Google tried to do and failed, which was give everyone a personal health record and have that travel with the patient. Do you see that playing a big role still, or did that all peter out when the Google thing failed?
Fasano: I'll give you two points of view. One is, I think the Google thing failed for a reason. I don't think the technology industry or the healthcare industry was ready to really support that in the way that it needed to be supported.
The second point of view on this is, I think electronic medical records, given the content, is consistent with and from doctors, and really aligns with the treatment of patients, is the best resource for the start of PHR.
And then having the tools to integrate how much I walk, what I eat, and all of the other aspects of health that are important to me from a personal perspective, those are beginning to emerge and have emerged just recently, that really will enable a true PHR capability for patients, that will empower patients to both interact with their health in different ways, and leverage the content of electronic medical records.
But then the bridge has to be built between electronic medical records and personal health information, so that patients can be empowered in that way, and I think mobile capabilities, the connectivity that's being demonstrated across the board, starts to become the bridge to that future.
I think Google might have been a little early in the capabilities they were bringing forward, and they were quite rudimentary in terms of how they were planning to connect them. They were really trying to get the industry to do it. The consumer will naturally go there, but I think it has to be based on electronic medical records, and the merging of that information with the consumer's view of their health as well.
HealthLeaders: And cloud technology is maturing too.
Fasano: It sure is.
HealthLeaders: So we're getting to the point where we can put HIPAA stuff up in the cloud and not be worried about it.
Fasano: Well, as the CIO of Kaiser Permanente, I wouldn't say that. My point of view on putting private health information up in the cloud is that I don't think the cloud is necessarily really ready for that yet, and I say that as having a responsibility to our patients for managing their privacy with respect to their health information.
If they choose to do that, they make a personal decision about whether or not they accept the cloud. That's different from Kaiser Permanente choosing to do that, which we're not ready to do, because I can't get a vendor of cloud capabilities to give me a guarantee on security, and I think the real challenge today, and we all talk about this, is [that] cybersecurity, just overall, that topic is out and about.
Cloud technology has great promise and potential. I think we still have some work to do to really make it ironclad, in terms of the kind of security we all would expect. This isn't financial information. You lose a credit card number, you get a new credit card number, and you can manage the damage of that. If you lose personal health information, that has a longstanding effect.
So I believe we have to actually hold the technology community to a higher standard when it comes to personal health information, and inside Kaiser Permanente, I feel I have the ability, with my team, to truly manage the security of that. I won't say it's perfect, but I'd say we're very, very diligent.
HealthLeaders: Even Kaiser's had a breach or two.
Fasano: We have historically, but we've actually been really proactive in buttoning up our capabilities, so that no one in Kaiser Permanente, for example, can leave the institution with your medical information unless it's completely encrypted, and for the purpose of treatment.
They're not taking it and just running around willy-nilly with medical information on our patients. In fact, they have to be the person who's supposed to be accessing your information, and two, if they try to put it in a form that's transportable, we don't allow them to take it anywhere unless we've encrypted that information fully.
HealthLeaders: There is kind of a continuum though, between what you do in your data centers and then the private cloud things I hear about, like the Perot Systems that Dell bought, that is being used to run the data centers of 200 hospitals in a private cloud.
Fasano: Yes.
HealthLeaders: And then over on the far side is the public cloud, and putting your medical records on Amazon Web Services. I saw someone demo something last week that helped people do that by encrypting some of that before it gets put on the public cloud.
Fasano: It's moving in the right direction. I'd like to see it mature a bit more, and I'd love when the IT industry can come to me and give me the guarantees I'm looking for on protection and privacy and security. To the extent they're willing to do that, then that becomes an available option for us. We do use private clouds at Kaiser Permanente. They're broadly used across our institution. We love the technology, but we want to make sure that the security standard is to our expectations.
HealthLeaders: I do wonder, though, whether we're headed for some rough bumps in healthcare privacy and security, just because so many other industries—and you would know better than anybody coming from financial services—really thought that through very carefully before they deployed. In this rush to deploy with meaningful use, I'm not so sure that those steps are being taken in healthcare the way they were in financial services.
Fasano: You're probably not too far from the truth in some cases. Most organizations take very seriously the responsibility they have to protect people's privacy. That said, I can tell you that the steps necessary from the ground up to build secure data centers, to manage those centers in a particular way, so that they're always on in support of life-critical systems, and then to make sure they're truly secure, and that you're managing end-to-end the relationship between data at rest and data being used by anyone who has the right to use it, [are a] very complicated set of issues.
And they do require a high level of professionalism from an IT staff or a technology partner, that understands not only implications today, but can kind of forecast and is looking out into the future about the threats that we might experience, and is engineering their capabilities to really solve for those future threats.
Healthcare innovators looking to fuel their big data analytics dreams have a new source of inspiration – and money.
The Care Transformation Prize Series will provide at least three quarterly prizes of $100,000 to the teams that develop the best solutions to challenges to be selected by the public and vetted by a panel of judges.
If it sounds a little like the Heritage Health Prize, the winner of which will be announced this June, that's probably because like that other competition, the leader of the Care Transformation Prize Series is Richard Merkin, MD, president and CEO of Heritage Provider Network.
The new national contest is co-sponsored by the Bipartisan Policy Center, which announced the initiative this week with introductory remarks by BPC health project co-chair and former U.S. Senate Majority Leader Bill Frist. The Advisory Board Company is also a co-sponsor.
In a phone interview, Merkin said the new competition leverages the community of big-thinking scientists who were attracted to the original Heritage Health Prize.
"There are so many other issues in healthcare, so we decided to bring it to Washington to open up the questions that people want to know the answers to," Merkin says. "We are asking the country to ask questions that they may be interested in, such as what is the difference between prenatal care and low birth weight babies in Virginia versus Arkansas. Why is it that Connecticut might have a much lower knee replacement than Boston, or why do they do more hip replacements at Yale than they do at Harvard?"
"We're asking what questions America wants answered," he said.
Once the questions are in hand, a panel of judges will choose the ones to be answered by big data scientists and other entrants, Merkin says, and the answers will be addressed by the growing community of scientists brought together initially by interest in the Heritage Health Prize.
The data needed to answer these questions has already been collected and is just waiting for the right questions to be asked, Merkin says.
Merkin also addressed recent indications that, as laid out in the original competition rules, the Heritage Health Prize grand prize of $3 million may not be awarded in full this June. There is no guarantee that the competition for the grand prize will be extended beyond June.
Merkin likened the Heritage Prize, a data-mining, predictive-modeling competition to reduce avoidable hospital visits, to the Orteig Prize, a $25,000 award offered in 1919 to the first aviator to fly nonstop from New York to Paris, or vice-versa.
"Originally, no one flew transatlantically," Merkin says. "At the time they thought it was too hard, too dangerous, and actually people died trying." The contest was then extended, he notes.
The eventual 1927 winner, U.S. Air Mail pilot Charles Lindbergh, had minimal financial backing and experience, but gambled on a different approach to the challenge than other challengers, Merkin notes.
"He was successful, and started an entire new industry flying transatlantically," Merkin says.
Is your laboratory thinking about Meaningful Use yet? In all the hubbub over ONC's mammoth incentive program (and the penalties that follow in a few short years if you don't get on board), technology changes affecting every medical lab will provide their own benefits to healthcare's bottom line.
It's been a long time coming.
As far back as the 1960s, it was already understood that a standardized vocabulary for the multitude of lab tests performed in this country was lacking. Those lab tests now amount to about 30-billion-per-year.
While the industry argues about which version of ICD to agree upon in the diagnostic code area, and just how we would get physicians to agree upon these diagnosis codes, information about lab tests were always more amenable to being digitized. A serum sodium test is a serum sodium test, and once a lab test standard exists, there's no reason not to bake it right into the diagnostic equipment itself.
Take 66% OFF the Clinical Integration/ACOs Collection Includes top-selling HealthLeaders webcasts, Rounds, and books: Building ACO Foundations with Kaiser Permanente, The Healthcare Executive’s Guide to ACO Strategy, and more.
And yet, as of today, there is no government requirement for labs or healthcare providers to present each other with lab tests coded in a standard way. Regrettably, labs have built their own mini Tower of Babel using proprietary or home-grown codes.
This means that sending results from one system to another, part of that continuity of care we're always talking about, can involve lots of expensive, time-consuming recoding of lab test codes from one system to another.
Meaningful Use stage 1 didn't do very much to move toward standardization. According to Regenstrief Institute Investigator Daniel Vreeman, if a laboratory sent an electronic health record system digital lab test results encoded with LOINC, that EHR had to retain those LOINC codes.
Backing up for a moment, LOINC stands for Logical Observation Identifiers Names and Codes. It is a universal code system for identifying laboratory and clinical observations. In Meaningful Use stage 2, LOINC has become a full-fledged menu item. It's still not a core requirement for an EHR, though if the past is any indication, it will be required in the core when we get to Meaningful Use stage 3 in 2017.
But as with many technologies, moving to a standard early can position your organization for productivity gains that could give you an edge over a competitor that lags behind on LOINC.
To understand why, I recently spoke with Robert Coli, MD, a retired gastroenterologist who seems to know everything and everybody connected to laboratory information systems. He is a committed member of the Standards and Interoperability Framework, a public/private group that spearheads the standards embraced in Meaningful Use.
"If you're reporting the test as fragmented data, using infinitely variable reporting formats that change every time a new test is added, the ability to follow the trends over time becomes impossible for the human brain," Coli says.
Fair enough, but now realize that this has bothered Coli since he was interning from 1963 to 1965, and you get an idea of how long forward thinkers in laboratory information sciences have been waiting for a solution.
Since 1979, Coli and others have been trying to standardize the format of lab results "as clinically integrated, actionable information, not incomplete, fragmented, almost raw data," Coli says.
When I spoke with Coli, he revealed that LOINC-compliant interfaces are now in pilot testing at nine major sites. S&I Framework participants, including lab giants Quest and LabCorp, have created implementation guides and reference implementations, and these have been balloted with HL7, the nonprofit organization whose standardizing messaging undergirds most of the communications between disparate health IT systems today.
Through these pilots and EHRs that support LOINC, lab results can flow into EHRs in doctors' offices and hospitals and be understood with no recoding necessary.
Why you should care deeply about all this is the opportunity it presents to commoditize the currently (in Coli's words) "exceptionally lucrative business" of writing custom interfaces for every laboratory information system to EHR. We're talking thousands of dollars for each new custom interface developed today. And the EHR vendor is not required to sell the interface any more cheaply to the second, third or later customers of that same interface.
In that sense, Meaningful Use stage 2 is exceptionally good news for healthcare executives: For the first time, EHR vendors will be required by regulation to disclose the costs of these custom interfaces before you, the customer are required to purchase them.
But commoditization of these interfaces goes further still. According to Coli, the cost of such interfaces will be "remarkably reduced" by standardization on LOINC.
There's also a precedent for widespread adoption of LOINC, and that is the Direct Project, an agreed-upon protocol for securely transmitting records from one disparate EHR to another. Created by the same S&I Framework team, it is an absolute requirement for every EHR that plans to be Meaningful Use stage 2 compliant, and in the U.S., that would be every EHR that wants to remain in business.
Direct's rapid adoption curve will begin to prove that EHR technology providers can compete more completely on the virtues of their products' features, and not on customer lock-in to a particular set of data formats. Direct's creators hope to see a similar commoditization of EHR technology, all the more remarkable because a number of Direct's creators were the vendors themselves.
Putting Direct and LOINC in perspective goes a long way to explain the immense pressure on the industry to solve other pressing technology interoperability challenges, such as patient identification matching, the main impetus of the CommonWell Health Alliance announced at HIMSS.
CommonWell has the industry atwitter, dominating a portion of the most recent HIT Policy Committee meeting with both skepticism and perhaps wishful thinking as we all wait for the actionable details.
But while we wait to see what fruit CommonWell produces, the payoffs of Direct and LOINC are within our grasp. I asked Vreeman what some of the benefits of LOINC vocabulary being everywhere would provide.
"From a provider standpoint, this movement towards electronic health records and health information exchanges is all about having the data follow the patient," Vreeman says. "Their results, their medical record information, follow the patient wherever they go throughout the healthcare ecosystem. And so, having LOINC codes allows for that to happen between independent systems, but also for say a primary care provider to sort of take in data that might have been originated from several other different sites."
When we can spare a moment to look up from the immediate benefits, standards such as LOINC have an even brighter future. "There are many secondary uses as well," Vreeman says. Among them:
Pooling data for electronic quality initiatives
Writing decision support rules
CMS reporting
Reporting to public health agencies trying to track STDs or other diseases on the public health radar
One other bit of good news Vreeman shared with me: Some independent labs are already able to include LOINC codes with the results they return to providers.
To me, that's a remarkable testimony to the power of standards whose time has come. As far as I'm aware, independent labs are not eligible for Meaningful Use incentive money. They are vilified as money mills who are happy to crank out the next duplicate test result.
To me, it's the power of the market—that's the power of you, the reader—finally, relentlessly convincing the sellers to listen to the buyers, to deliver the actionable data they demand. As we move further toward patient-centered care, and further toward value-driven care, that's where technology should be headed, and apparently, already is.
Healthcare leaders' brows were mostly furrowed by the Obama Administration's proposed budget for the fiscal year 2014, released Wednesday.
"Today's proposal contains troubling reductions to assistance to hospitals that help defray some of the costs of caring for low-income seniors known as bad debt," said Rich Umdenstock, president and CEO of the American Hospital Association in prepared remarks.
"In addition, the budget would jeopardize the ability of hospitals to train the next generation of physicians by cutting funding for graduate medical education, and hinder care for people in rural communities by reducing funding for critical access hospitals."
Proposed cuts to post-acute providers, particularly to inpatient rehabilitation hospitals, would limit specialized care, while an expanded Independent Payment Advisory Board would remove elected officials from the Medicare decision-making process, Umdenstock said.
By limiting charitable deductions, the administration may discourage private giving to hospitals, Umdenstock added, urging that charitable giving be excluded from any limitations on deductions and the existing federal tax charitable deduction be maintained.
"Unfortunately, the Obama Administration's budget proposal for fiscal year 2014 contains yet another new round of hospital funding cuts, piling on to the most recent hospital payment reductions used to finance half of the nearly $30 billion Medicare 'doc fix' contained in the New Year's Eve fiscal cliff agreement," said Chip Kahn, president of the Federation of American Hospitals in a statement released by the organization.
Kahn says the Administration's new cuts would be added to more than $320 billion in hospital cuts under the Affordable Care Act, and would aggravate the effects of hospital Medicare payments which have remained below the cost of care for 11 straight years.
The Obama Administration and Congress should seek "a more transformational approach to reduce costs," said Blair Childs, senior vice president of public affairs for the Premier healthcare alliance in remarks released to the media.
"We urge a focus on accelerating and expanding delivery system reforms that simultaneously achieve sustainable savings and improve healthcare quality," Childs said. "Providers need tools to bend the cost curve and improve quality. We should look to bipartisan reforms such as accountable care organizations and bundled payments that have proven to incent quality and successful outcomes and improve coordination, thereby generating better value for beneficiaries and the government."
The American Medical Association applauded the new budget's recognition of the need to eliminate the SGR Medicare physician payment formula.
"The president's proposals align with many of the principles developed by the AMA and 110 other physician organizations on transitioning Medicare to include an array of accountable payment models," said AMA president Jeremy Lazarus, MD, in a press statement. "It is critical for physicians to have a period of stability and the flexibility to choose options that will help them lower costs and improve the quality of care for their patients."
While eliminating the SGR would be a step forward, the budget takes a step backwards by aiming to achieve more savings through the Medicare Independent Payment Advisory Board (IPAB), which would set another arbitrary spending target and rely solely on payment cuts to reach it, Lazarus says. The AMA strongly supports bipartisan proposals to eliminate this panel, he added.
"We are also concerned with other proposals in the president's budget, including cuts to graduate medical education (GME) programs known as residencies," Lazarus said. "In 2013, 528 U.S. medical school seniors failed to match to a residency program. As the nation deals with a physician shortage, it is important that all medical students can complete their training and care for patients."
Both the AHA and the National Association of Public Hospitals and Health Systems (NAPH) applauded the Administration's willingness to delay cuts to disproportionate share hospital (DSH) payments until 2015, given the uncertain future of Medicaid expansion. "But we're concerned the delay comes at the expense of higher DSH cuts the following two years and a $3.6 billion baseline adjustment in 2023," said Bruce Siegel, MD, MPH, president and CEO of NAPH in prepared remarks.
Siegel says the DSH reductions "remain a looming threat to hospitals that care for our most vulnerable patients. Congress and the administration must repeal or reduce these damaging cuts and work toward a policy that achieves savings and recognizes the actual level of uncompensated care nationally. Further, savings from long-term baseline adjustments to DSH should be reinvested in the nation's safety net."
NAPH also urged lawmakers and the White House to carefully weigh Medicare cost savings proposals against their potential to financially burden beneficiaries and their providers. "In particular, we oppose the cuts to Medicare coverage of bad debt and to medical education payments—both would weaken the ability of hospitals to provide comprehensive services to communities and to train the next generation of physicians, nurses and allied health professionals," Siegel said.
The Association of American Medical Colleges (AAMC) applauded the proposed budget's modest funding increase for the National Institutes of Health, but its president expressed concern about cuts to Medicare.
"The proposed drastic reductions in Medicare indirect medical education (IME) payments will make it increasingly difficult for teaching hospitals and their physicians to provide care for the sickest in their communities, especially seniors and the underserved," said AAMC president and CEO Darrell G. Kirch, MD, in a statement released by the group. "These cuts also may force teaching hospitals to curtail vital services such as 24/7 trauma and burn units that are not available anywhere else in the community, and will worsen an already critical shortage of doctors in the United States."
In addition to training new physicians, teaching hospitals train nurses and first responders. Cutting essential federal support for teaching hospitals could mean up to 10,000 fewer physicians trained every year when the nation already faces a shortage of nearly 92,000 doctors in the next 10 years, Kirch said.
Cuts to health professions training programs, including doctor training programs at the nation's children's hospitals (CHGME), will endanger the supply of pediatricians and pediatric specialists that all children need, he added.
In a statement, the Children's Hospital Association stated it was pleased that Obama's budget protects funding for Medicaid by avoiding short term cuts to the program, but it echoed the NAPH's concerns about proposed cuts to DSH payments, and AAMC's concerns about cuts to CHGME.
"The reality is that one in four hospitals operate in the red, so additional cuts will hamper their ability to provide access to the latest treatments and technologies, and could result in fewer caregivers and longer waits for care," the AHA's Umdenstock also said.
Concerns over potential Medicare cuts were also echoed by the Healthcare Supply Chain Association (HSCA) and the Center for Medicare Advocacy.
Last June, I bemoaned the fact that in the midst of everything that healthcare is facing on the technology front, it was the worst possible time to upgrade to a new version of Windows.
The fall came, and Windows 8 started showing up on new PCs and tablet computers. The reviews were mixed. "I found the transition to Windows 8 rather jarring," wrote WindowsSecrets editor-in-chief Tracey Capen. The months since have continued to see unkind reviews in the technology press. One that ran this week called the operating system "clunky and cumbersome."
But as the months have ticked by, it's clear that Microsoft is determined to stay the course with Windows 8, and healthcare providers are starting to make the best of it.
They don't really have a choice.
Like the rest of corporate America, healthcare has a massive investment in Windows. The quarterly Piper Jaffray CIO survey released in February found Microsoft "the most critical 'mega-vendor' for the future," according to Redmondmag.com.
Moreover, I've recognized since Windows 8 shipped that this latest Microsoft operating system contains some elements that could serve healthcare well, despite all the negatives. Among these are
The superiority of today's touch-and-gesture interfaces to yesterday's point-and-click interfaces
The inevitable move toward tablet-friendly computing
Widespread physician unwillingness to jettison keyboards entirely
The inertia of an installed base of millions of Windows PCs that aren't going away any time soon
One clue to understanding this is to note that while the iPad has become the darling of healthcare, many of these iPads are actually running Windows software throughout the day, through virtualization software from companies such as Citrix. That pattern was prominent in my recent cover story about tablet computers.
The Citrix experience, however, as compelling as it can be, is not the immersive tablet experience. Software written natively for the tablet is more responsive, and utilizes the multi-touch tablet interface and gestures in ways that older Windows software cannot.
Electronic health record software has to get more intuitive, and the answer is not simply to count the clicks on older software and try to reduce that click count while clinging to keyboards and mice.
The Apple approach was to go 100 percent to touch, but being Apple, there were design decisions that worked against the interest of information technology executives. Of greatest concern to healthcare, Apple has yet to provide that management with a granular enough way to manage deployment and upgrades to applications through its App Store.
This gives Microsoft and others lots of room and time to copy some of the better ideas from the iPad, just as years ago it copied the user interface of the Macintosh. Despite a flurry of litigation and threats, Apple hasn't been able to keep competitors from implementing most of the slicker concepts of the iOS user interface.
The final advantage Apple had maintained was that it had captured the imagination of developers. But a recent survey of 450 software developers revealed that more than two-thirds identified Microsoft as the platform most relevant to their development plans.
Case Study Pediatric Associates is a private, pediatrician-owned practice in Bellevue, Washington, with 80 pediatricians across 7 offices seeing about 250,000 patient visits per year. The practice is piloting Windows 8 tablets running Greenway Medical Technologies' EHR for Windows 8.
"It's caused a fair amount of excitement within our organization," says Brock Morris, CIO of Pediatric Associates.
Windows 8's ability to support different input styles—touch, stylus, and keyboard—is the winning combination, Morris says.
"[Users] can pull up the mobile application and the full client side-by-side, [getting] quick reference to patient information that they need through the mobile application, and then for more intensive documentation that they need to do in the full client version, side-by-side, quick and easy," Morris says.
It's worth noting that every new wave of technology starts with similar optimism. Too often, that wave washes ashore as another example of the productivity paradox, where technology advances continually surpass productivity advances.
In part, this could be because each new computing paradigm jettisons a set of skills that were useful during the previous wave of tech. For instance, tablets without keyboards can be cumbersome ways to input clinical narratives. Speech input is an option, but still not in widespread use.
Still, technology marches on, and in Windows 8 I see incremental progress. As Morris admits, some physicians will prefer narrative input and opt for their keyboard as before. Others will take to the touch-and-gesture interaction of newer tablet software, and make admirable progress on that front.
"All of it adds to the ability to honor the autonomy of the clinician, how do you best work taking care of patients," says Josephine Young MD, chief operating officer of Pediatric Associates.
Now I'll be honest, Pediatric Associates was brought to my attention by Microsoft. Its business is in Microsoft's backyard, the greater Seattle region. But consider the first-mover advantage for the firm if Windows 8 endures. It has the ear of one of the first EHRs for Windows that looks past mouse-clicks and towards touch and gesture.
As Greenway's software matures, the workflow preferences of Pediatric Associates will make a bigger imprint than those of customers who come later. The more mature a piece of EHR software gets, the less influence later customers have on its design and development. (See: Epic.)
Windows 8 is it
So, if you are a Windows-powered provider through-and-through, it's probably time to give Windows 8 a look. Remember that on April 8, 2014, just 12 months from now, Microsoft will officiallystop supporting and patching Windows XP. While Windows 7 isn't going away anytime soon, there are still thousands or millions of XP machines running in hospitals or doctors' offices, and it won't make sense to upgrade them to Windows 7 this year. Windows 8 is it.
Because of Windows Vista and Windows 7, a long freight train of older Windows versions will continue to trail the current version, much of it determined by when older PCs wear out, or any number of other factors not directly related to the mission of the healthcare provider.
Pediatric Associates is in the process of building out its Windows 8 use cases. And because there are already 1,500 different systems running Windows 8—everything from traditional desktop PCs to futuristic all-in-one monitors and even "phablets" (combination phone plus tablet – and a horrible mutant word)—if anything, the design of future technology systems for healthcare is likely to be a creative art.
But I take heart that we are at least moving away from the consistently ugly user interfaces that EHR software exhibited as recently as a year ago. Designing for touch and gesture is making all EHR software designers clean up their act, and it's about time.
The bring-your-own-device (BYOD) phenomenon also seems to be settling down, as organizations such as Pediatric Associates deliberately plan for acquiring tablet-style technology, and doctors can get back to doing what they do best, rather than relying on their own devices and the nearest app store. There will be physicians who will cling to their iPads as part of that autonomy Young mentioned.
Where will Windows be when the Windows XP clock runs out next April? By then, Pediatric Associates expects to have a larger base of its pediatricians running Windows 8.
It will be interesting to see if they settle on one or two particular form factors, and are carrying just a single machine on rounds, or if a mix of desktops, laptops and tablets continues to make Windows a sometimes jarring experience, and from a workflow perspective, an overly complicated one.
