I've previously remarked that software can't do it all—resolve all antiquated workflows or figure out stumbling blocks in people and politics. Unfortunately, that's just what EMR software is about to be asked to do.

Software is a funny thing. Done well, it anticipates the needs of human beings, or other software, and responds in flexible, flowing harmony.

Done poorly, software epitomizes everything wrong with modern society: impersonal, inflexible, regimented, mundane, boring, even maddening.

Where does your electronic medical record software wind up on that spectrum? Chances are, it doesn't look so good in comparison to your searching experience on Google or your shopping experience on Amazon.

"We need the EMR that's going to intuitively know the way our physicians practice and know the difference—and not every time a physician wants a change, we get a call, and we say we'll take that to the team, and the team will analyze it, and then the team will take it to the programming team, and in about a month, we should have your change put in our system," says Pamela G. McNutt, senior vice president and CIO of Methodist Health System in Dallas, Tex.

"'EMR 2.0,' as I call it has to be intuitive. It has to adapt to the physician workflow without an army of 200 people in IT behind it trying to change the code," McNutt says. "That is not a sustainable model for us to have that many people behind the scenes creating all these boxes and screens. It has to be intuitive but we're all busy dotting I's and crossing T's.

"Even the 'Cadillac' systems for physicians and hospitals are nowhere near EMR 2.0 that I envision for the future," she adds.

McNutt hopes for some "dark-horse" software from an as-yet unseen vendor, maybe from Europe or sitting in some incubator deep inside MIT, to leapfrog the capabilities of current systems. "I could make a fortune if I could figure out who this is that's going to do that," McNutt says with a laugh.

Unfortunately, software innovators—the Amazons and Googles—only come along once in a great while. Healthcare CIOs appear to be stuck living with our current generation of imperfect software.

Another option kicked around, even more unrealistically, is to hope that clinicians adopt some kind of standardized workflow. That would help software immensely, because today's software has been constructed with layer upon layer of options to accommodate different workflows. This complexity in turn adds to the complexity of the software, of training for the software, and of trying to keep the training for the software inside one human head once training is completed.

But I don't see any standardized workflows on the horizon. Nurses in two departments of the same hospital often don't have the same workflow for administering medication. How can an entire healthcare industry be expected to standardize workflows?

The free market has its own way of imposing standardized workflows on healthcare. It's called mergers and acquisitions. But each merger or acquisition brings even more risk to the endeavor, as executives strive to merge two workforces. More massive consolidation also means a lessening of responsiveness to local market conditions.

The media, myself included, subtly encourage the big getting bigger, guilty of paying more attention to the largest healthcare systems, where ample money and resources permit early and well-planned adoption of the latest and greatest technology. But those systems "live in rarified air differently than we do," says Charles E. Christian, CIO of Good Samaritan Hospital, a 237-bed hospital in Vincennes, Ind., serving a 10-county area of 250,000.

Christian is working on Stage 1 of Meaningful Use. "I won't attest [for Meaningful Use] until September of this year," Christian says. But rather than feel a sense of accomplishment at that point, this rural hospital instead faces the starting gun of reaching attestation for Meaningful Use Stage 2. And it is daunting. Final rules are now expected at the very end of summer or even a little later.

"It means that I've got only about 12 or 14 months to learn what the certification requirements are, get my vendor to install software, and have it ready to go by October 1, 2013," Christian says. "I hyperventilate just to believe that, because I realize what that requires. But don't think that's just a tiny issue for community and rural hospitals. I think all of us in healthcare, even the larger systems" feel the pressure.

No one will feel that pressure more than physicians being asked to do even more than they do today. Even when they learn how to navigate all those new check boxes and unintuitive workflows, they may still be using software that hasn't been adequately tested.

"Just because we get rules out today doesn't mean the vendors are able to generate code tomorrow and get stuff out to implement," Christian says.

For now, expect the entire healthcare profession to lean even harder on the current software industry, with all its faults and shortcomings, to perform miracles. Given the massive amounts of money flowing from government to provider to vendor, it shouldn't be too much to ask.

This article appears in the June 2012 issue of HealthLeaders magazine.

Healthcare leaders are facing the challenge—and opportunity—presented by physicians and clinicians bringing ever more of their own technology with them to work.

Two years after the iPad's debut, the devices are making inroads in all aspects of society, and healthcare is no exception.

Those who are benefiting now had a virtual desktop strategy already in place. Tablets and other larger-screen devices are often able to fit into the IT picture with relatively little work.

It will take longer for vendors and healthcare IT leaders to truly leverage the native power and ease of use of these devices, and for now there may be a bit of cat-and-mouse game. Rogue innovator-clinicians are being tempted by an ever-increasing number of cloud and device apps available over the Web outside traditional IT approval, while network managers rely on increasingly clever network application monitoring tools to identify protected health information being inappropriately captured, analyzed, and transmitted by these new apps.

As the desktop morphs into a touch-powered platform, vendors are working to bring tablet implementations of their existing desktop apps to market fast enough to avoid being disrupted by newer apps built from the ground up for a touch-based experience.

But even among tech-savvy healthcare leaders, there are differences on the approach organizations should take regarding the "bring your own device," or BYOD, trend.

In the heart of Silicon Valley, leaders at Mountain View, Calif.–based El Camino Hospital—which has a second campus in Los Gatos and is known for HIT innovations—believe now is not the time to embrace this trend. "We are not engaging in BYOD, as I am convinced it is too early for this organization," says Greg Walton, chief information officer of the 542-licensed-bed hospital.

Where BYOD is happening, two things are in place: virtualized desktops and a guest wireless data network for users, rather than the main hospital data network.

One such robust guest network at the 711-bed Maimonides Medical Center in Brooklyn, N.Y., has seen a recent surge of use, with more than 275 logged-in users on the guest network during a recent late afternoon. "We believe a substantial fraction of those are employees," says Steven Davidson, MD, senior vice president and chief medical informatics officer at Maimonides.

"Anyone coming into the institution, with a simple verification process, can log into the guest network," Davidson says. "If you're not known to the institution but have a cell phone, you can usually get a 24-hour password and authentication. If you are known to the institution and have a network login, you can be diverted to an employee portal, which is still a log-on through the guest network and all of its security, but allows a 30-day expiration on your password."

The guest network allows Maimonides physicians to log in to the physician portal, and all users are able to access the public Internet.

A dedicated, high-resolution PACS workstation offers no compromises when viewing images, but a mobile device has its limitations. Performance is only one of them. The virtual desktop software that presents desktop data on portable devices such as iPads carries its own set of tradeoffs.

"The Citrix [virtual desktop] on the iPad is not the world's most friendly user experience," says Davidson. "Because the iPad is a touch-driven tool, you're constantly toggling back and forth between driving the window—the Citrix client—and driving the application inside the window. Sometime in recent months, Citrix has made toggling back and forth easier."

Maimonidies' inpatient EMR, Sunrise Clinical Manager from Allscripts, when delivered on a 1024-by-768 resolution screen such as the iPad 2—or even the new iPad with its Retina display (2048-by-1536)—still is not intended for touchscreen use, Davidson says.

"If you're doing it as I do sometimes from my MacBook Air, it's fine, because I've got my touchpad or mouse," Davidson says. "It's a lot easier to point with that on a screen that was designed for mouse-type pointing and clicking."

At the recent HIMSS conference, Allscripts released an improved client for the iPad, and Davidson says it "seems like it would be worth evaluating and getting some feedback from clinicians as to what they think might be its value."

With a mix of employed and nonemployed physicians, it's possible that Maimonidies might be able to reduce its burden to purchase, implement, and maintain client devices, Davidson says. A study dating back to the 2006 HIMSS conference found that hospitals need one device per active person using devices. But referring to the Allscripts client he saw, Davidson notes that it only solves the tablet problem for one application. "It doesn't solve access to all the other applications in the hospital that people have to use."

At Vanderbilt University Medical Center, a 916-licensed-bed facility in Nashville, BYOD is "a journey," says William W. Stead, MD, associate vice chancellor for health affairs and chief strategy and information officer.

"Our bias is that we have to incorporate whatever consumer technologies people have, rather than trying to stop that," Stead says. The medical center's increasingly virtualized clinical desktop is the enabler, he adds.

Another advantage of BYOD is it lets clinicians move all their personal messaging off the Vanderbilt email system and into a more appropriate system such as Gmail, Stead says. "I can still see messages as they come into both [mailboxes], interleaved as they arrive.

"Prior to that, either everybody put everything into Vanderbilt [messaging] whether it needs to be there or not, or they forward everything Vanderbilt out, so nothing's secure. So once you begin to use some side by side and use the technology to knit them together so they look like one to the user, you create a win for the user, and you actually increase your ability to secure the part that needs to be maintained securely."

Stead knows that physicians can be tempted to use the inherent photo-taking and messaging capabilities of their devices to easily ask for a specialist's opinion directly through texting or photo multimedia messaging services.

"We do have policies that basically say you're not supposed to move protected health information or research health information outside of our secure messaging environment," Stead says. That environment "provides easy tools to communicate both within the Vanderbilt team and to push stuff to the referring providers."

Failing that, Stead's IT infrastructure monitors "for things that appear to have PHI leaving the network, and we spot-audit those, and we use those to identify all sorts of problems," he says. Still, "there are pieces of it we can identify and pieces of it we can't." An example of the latter: communications going from one Verizon network device to another, which never touch the Vanderbilt network.

As for whether BYOD will lower Vanderbilt's capital IT equipment costs, "I think we're going to move to some sort of a communication allowance that will allow people to have whatever they want to have and have us pay some reasonable amount," Stead says. "That's not yet in place. Of the many things we talk about, that seems to be the most likely."

BYOD users also appreciate being able to choose their own tech support provider, says Mark Farrow, vice president and chief information officer at Hamilton Health Sciences, a six-hospital organization based  in Hamilton, Ontario. "They're happier to work with those people than they were to necessarily have us messing with their devices," Farrow says.

Outside the hospital walls, physicians' devices, with data protected by virtualization technology, can boost happiness in other ways. Farrow recalls when a physician had just stopped on his way home to pick up a hot meal for his family. "His phone rings, and it was a nursing station calling him saying there was an issue with one of his patients, and they needed to know what to do," he says.

The physician was able to pull up the patient's EMR on his iPad, then call back the nursing unit and give them the instructions they needed.

"A few years back, it would have meant a trip back to the hospital, going through the charts, making the change, and then going home," Farrow says. "It could have cost him an hour or so and a cold dinner."

Even El Camino's Walton sees the writing on the wall. "I agree BYOD is inevitable, but this will be a space where, again, healthcare will lag," he says. "Just because we lag, doesn't mean we don't understand why other sectors are rushing toward it. For healthcare, the lag might come in some cases from unions. In others it will be fear of the employer peeking at private data. In other cases it will be that many more IT priorities are higher. In some it will be hard to find the ROI."

Walton says El Camino Hospital "is ready now from a technology standpoint but … given some of the reasons I just cited we won't be setting any speed records going on that journey."

This article appears in the June 2012 issue of HealthLeaders magazine.

Reprint HLR0612-7

This week, some voices of healthcare CIOs and CMIOs, speaking out about last week’s U.S. Supreme Court decision on the Patient Protection and Affordable Care Act:

Marc Probst, Chief Information Officer, Intermountain Healthcare, Salt Lake City, Utah

Bottom line is politically I don't like the ACA and the lack of financial responsibility which our country’s leaders have. In the end, the problem of "going broke" just continues to escalate. 

Craig Joseph, Chief Medical Information Officer, Agnesian HealthCare, Fond Du Lac, Wisc.
Clearly, HITECH (and the Meaningful Use money that accompanies it) was not endangered by the SCOTUS decision. If the ACA were overturned, there was reasonable concern about CMS' Shared Savings program, value-based purchasing, and various quality improvement methodologies. That said, I think many CMIOs are confident that the train has left the station with regard to healthcare information technology. The future practice of medicine will require physicians (and the hospitals in which they practice) to prove they are providing quality, evidence-based care. This is impossible to do without HIT. So even without ACOs and the CMS programs, HIT will remain an inherently necessary ingredient for population management, evidence-based medicine, and quality healthcare.

Michael Zaroukian, MD, Vice President and Chief Medical Information Officer, Sparrow Health System, Lansing, Mich.
Having said that, I think the most important thing is the fact that the vast majority of the Affordable Care Act was considered constitutional and remains intact, which allows us to continue on the path that most of us in healthcare and in healthcare IT have been using as our guide to try to help with the process of redesigning systems to support the expected increased number of care recipients we'd be able to provide care for, the nature of the practices and the workflows necessary to support that care, and to be able to predict a little bit better the resources necessary to be able to support care for those patients in our organizations.

So I think the biggest part of this is to create some sense of certainty about the kinds of patients we'd be seeing, the kinds of care we could be expected to deliver, and the ability to expand our services to populations that need care (and who have perhaps for example been underserved with regard to preventive services), to care for chronic conditions, and to be able to know that there are resources beyond what have been considered before, such as lifetime limits on coverage for some of those chronic conditions, or the ability to provide care for preexisting conditions.

Michael Zaroukian, MD, Vice President and Chief Medical Information Officer, Sparrow Health System, Lansing, Mich.

On the impact of the decision on Sparrow Health's priorities: I'm not sure it changes our priorities much. We saw the HITECH Act as giving a pretty clear roadmap for us to follow in the health IT world. I think the biggest issue is knowing that there will be more patients in the system, and an even greater reason to have health information exchanges, since those patients will receive care in various settings, and basically in some ways just some excitement about the ability to make sure more patients get the care they need and don't have to make the difficult decision about waiting to get care until their care needs are more extreme than they would otherwise be.

On the ruling that states could opt out of Medicaid without a penalty: I'm empathic with the judgment that says on the one hand it's expected that states will indeed participate in one form or another of this. It is an underserved population. I think the court's view of it being a bit too aggressive or assertive to say that if you fail to fully participate in this, then you lose all of your funding, I actually resonate with that. I think many of us would. I think it's a little bit hard to say exactly what does it take for a state Medicaid program to feel whole in this process. So I think it probably is the better approach to say, given the alternative of either saying you have a choice or you lose all of your funding, it's better to allow states to have the choice. I think most states want to do the right thing with regard to covering their patients, and that they'll find their way to that process a little bit better if they aren't held against sort of an all-or-nothing participation approach.

On the possibility that the public may opt to pay extra taxes rather than purchase healthcare: I think it's a little hard to predict indeed early on, because some people will make their early decisions philosophically, but since none of this really takes place until 2014 in that regard, I think most people will make decisions based on common sense, their economic interests, their perspective with regard to the likelihood that they'll need care, and with some experience that we accumulate in the time between now and then that shows indeed what are the likelihoods. I think most people want to have the safety net that insurance provides. I think when they consider the cost of a penalty, if you will, for not doing so, versus the cost of it, they'll make the decision most of us end up making. In Michigan, there's a requirement to have auto insurance. So it's not that foreign from that perspective. That of course is a state as opposed to a federal type of mandate, but I think in the end most people will make an economic decision and talk about it within their families and decide how best to spend their money.

On occasion, medicine resembles the game of golf, and not just because some doctors like to hit the course on Wednesdays. For instance, the secret of a successful patient-centered medical home may boil down to this: a lot of hard work and a few technology tricks.

That's essentially the case at The Johns Hopkins Community Physicians, a division of Johns Hopkins Medicine. JHCP has 35 practices in 11 of Maryland's 23 counties and throughout Baltimore City. The entity consists of more than 400 providers with more than 800,000 encounters annually.

"That was our proof of concept," says Steven J. Kravet, MD, MBA, FACP, president of JHCP. The three goals of the initiative are closely aligned with the objectives of healthcare reform:

1. Improve health in measurable ways.
2. Improve care through improved patient experience.
3. Reduce cost by reducing unneeded and over-utilized acute care.

Improved management of patients with chronic disease states has been an early success of the JHCP efforts. "New patients with a diagnosis of diabetes had a baseline hemoglobin A1C of 8.65," Kravet says. "After they had attended an educational class, their hemoglobin A1C came down to 6.56, and their most recent measure of 6.80 suggests that the improvement was sustained several months later.

Patients who the practices failed to recruit into the classes had essentially no change in hemoglobin A1C. "It's suggesting the power of patient engagement and improvement with group visits and education."

Achieving cost reductions
Reducing the healthcare cost medical loss ratio was another achievement of the pilot at Water's Edge. This figure declined from 86 percent in fiscal year 2010 to 83 percent in fiscal year 2011, and is estimated to drop to 78 percent in fiscal year 2012.

Now that clinical outcomes and cost reduction have been demonstrated, JHCP is turning its attention to issues of staff teamwork, job satisfaction, working conditions and perceptions of senior management. "Those measurements have all gotten worse over the past few years," Kravet says. "We've made the place busier. We haven't paid as much attention to the experience, which has now become our focus."

A key way forward is to customize the technology to meet the needs of managing populations. For example, JHCP has created and is refining preventative care templates for its electronic medical records system. "It forces providers and ancillary staff to ask certain questions and document certain things, so we identify if a patient hasn't had certain types of care or is falling below the standard. All that takes time to develop," Kravet says.

During my recent HealthLeaders webcast on the patient-centered medical home, Kravet revealed a few other tech-related secrets of Hopkins' success. "We used a tool called Conversation Maps that we actually learned from Merck," Kravet says.

A better patient experience
"So one of the key principles of the medical home is changing the approach to care, which is historically very transactional," he says. "In the old model, which is really the current model, people come to see the doctor. They have stuff done to them. Maybe some medications are changed, then they're sent away and they come back in 3 or 4 months or 6 months and they get readjusted.

"But there's a lot of white space between the visits, and that becomes very important in the patient-centered medical home. We began to focus on this big white space, which is really a golden opportunity. We employed care coordination processes, including this perihospital consultation and communication."

Robust tech-powered tracking mechanisms keep tabs on everything from referrals to scheduled tests, and in collaboration with Hopkins' payer arm, Kravet's team assesses risks for each patient. "The highest-risk folks got an RN case manager, and the medium-risk folks got health coaches."

Over the past three years, Kravet says, those clinics where patient-centered medical home practices have been implemented have seen a decrease in emergency room visits, admissions, and readmissions have significantly decreased, and because of this, costs to the related Hopkins payers have declined significantly.

Using Microsoft's Sharepoint, JHCP shares a dashboard that lets all providers, on a secured link, see metrics on quality, workflow, and productivity, and see how they compare to their colleagues. "Once we began sharing this information transparently, we obviously began to see a transformation in our outcomes," Kravet says. "I think that's just because of the inherent competitive spirits of providers, who are all trying to do the right thing."

Overlaid on top of JHCP's electronic medical record are registries, views of data by provider or group that can manage populations. "Again, it's a big part of how we are able to help drive success, because our chiefs and our regional directors can work with practices that are lagging, and help them brainstorm on how to improve their processes," Kravet says.

A large banner hangs in Water's Edge, inhabiting nearly an entire wall. "What good choices can you make today that will affect your health tomorrow?" it asks patients.

Clearly, what Kravet's team has already accomplished has begun generating the shared savings that can fund even more effective patient engagement. His efforts represent the kind of virtuous cycle that healthcare needs to get out of its fee-for-service sand trap.