Have you ever been walking around barefoot on a great summer night just looking up at the sky with all the stars thinking wow this is really beautiful and then wham you stub your toe on a rock and now you see stars much closer? This is a good analogy to where we as an industry might end up with a severely stubbed big toe. Why, because with Meaningful Use burning like a supernova and 5010/ICD-10 showing the potential to be a black hole sucking in every resource within the program’s reach (and not letting go) – we have the potential to get caught looking in the star field of standards and standards development organizations (SDOs) and smack our collective big toe on a big ‘ol rock.

HL7 V2.x, HL7 V3.0, XML, SNOMED, PIX/PDQ, EMR, HIT, ONC, CCHIT, IHE, eHI , LOINC, ICD, CPT, DRG - we are caught in an alphabet soup of standards and vocabularies that seemingly should have or will quickly need to be in place. The challenge for us is that in groups like HITSP and AHIC (yes we have expanded far beyond the TLAs), that are recommending industry level standards, the leadership is usually from extremely well funded medical centers, academia and academic medical centers. Now don’t misinterpret this, these folks do spectacular work and have been wildly successful in moving the need for healthcare standards forward – their efforts simply stated are herculean. The challenge is for the majority of care delivery that genuinely do not have the budgets or funding sources, the deluge of required standards needing to be implemented so quickly will result in stretched or broken funding strategies, mistakes and missteps and unfortunately too many people and careers ran over by the standards bus.

The majority of care delivery does not have an exclusive on challenges with the standards - even within the SDOs there is jostling, negotiating, tension and healthy doses of politics. These groups also tend to issue many redefinitions, tweaks and modifications as things move forward. This is where these organizations can stumble while looking at the stars – they are volunteer organizations and regression testing and/or impact analysis of the modifications/tweaks get a bit shortchanged.

So with all this said, what are the key organizations (to name just a few):

• HL7 (Health Level Seven) provides a framework (and related standards) for the exchange, integration, sharing and retrieval of electronic health information.
• NCPDP (National Council for Prescription Drug Programs) uses the NDC (National Drug Code) number to identify drug products and medical supply items for the purpose of transmission and reimbursement of claims.
• ASTM (American Society for Testing and Materials) is the grandfather of all standards. ASTM issues standard in six categories
  • Defining Standards
  • Testing Methods
  • Practice Standards
  • Guideline Standards
  • Classification Standards
  • Terminology Standards
• HITSP (Health Information Technology Standards Panel) is a partnership between the public and private sectors tasked with harmonizing and standards that will meet clinical and business needs for sharing information among organizations and systems
• DICOM (Digital Imaging and Communications in Medicine) standard has several levels of support, or different dimensions. The most fundamental and primary level of support is the support for image exchange for both senders and receivers. Other dimensions deal with image management, patient scheduling information, image quality, media storage, security, etc.
• IHE (Integrating the Healthcare Enterprise) re-uses existing standards such as DICOM and HL7 as the building blocks for assembling larger integrated solutions

So while these SDOs are swirling around looking to form some new constellations, we have to be careful to not stub our toe while watching the formations grow. How can we do this – some basic blocking and tackling and maybe we put on a pair of shoes? Based on experience, here are a few key things to consider:

• Things constantly change; final standards are never quite final, emerging standards that must be harmonized. The result – there are only temporary interfaces. Budget for this
• Assess your current environment:
  • Current systems documentation in place and up to date?
  • Will your equipment handle the inevitable increase in volume?
  • Has your environment been optimized?
  • Have you had an outside objective assessment of your current environment?
  • Are you on the most current level of software, system and operating?
  • Built enterprise standards for development and system assessments?
  • Create repeatable testing processes and plans for future integration activities?

When things begin to coalesce, the new constellations will be great to look at; the sky could be filled with some great new stars. Until then, we could be walking around with a huge bandage on our big toe. Don’t get caught looking and waiting – there are so many things going, get that pair of shoes on your feet, then look up a little and enjoy the view, watch the ground a little so you don’t trip and enjoy the shoes.

Santa Rosa Consulting is highly experienced in finding the right pair of shoes for you. Allow our experienced associates to help you watch the stars, watch the ground and protect your feet.

Request an experienced Santa Rosa associate to contact by logging on to our web site at www.santarosaconsulting.com.

Healthcare organizations have changed -- and the progress is amazing!

The organization, skills and the ability to execute are vastly improved and the trend is accelerating.  The people populating the executive suite and those in operational roles are more adept than at any time in my 30 years of serving the healthcare industry.  To be sure, the challenges the healthcare industry faces have become more profound, more complex, more numerous and amazingly – originate from more sources - than at any time in history.   The challenges and issues may originate in economics, politics, demographics, regulation or public perception.

The progress in development of culture, process, collaboration, and efficiencies is accomplished even without good information systems.  We recently conducted a broad study regarding patient safety and quality.  Patient Safety and Quality practices have life-and-death consequences for patients and also provide the opportunity to enhance or destroy operating margins.  The cultural and process changes can be implemented to great effect, but the lack of adequate information systems hinder embedding the improvements in the care setting.  In most instances, data required of regulatory and watchdog agencies are sourced from re-purposed billing or coding data, or through paper compilation of static studies.   This is akin to flying an airplane by looking at last week’s weather reports.  You may get there on the skill and perception of the flight crew, but your chances of a safe journey would be much better with real time information.

Some of the technology and information is in place.  More of it has been developed and is waiting to be implemented or optimized.  Now is time to knit the data systems to supply the best information where it is needed, when it is needed, and in the current and correct form.

You have just left a meeting with your key vendor(s) and received assurance that they will get you to Meaningful Use. With your estimated $6M in ARRA incentives now well in hand, you should be feeling pretty good or should you? The question is who is really responsible for attaining Meaningful Use? The answer is, the responsibility is squarely on your shoulders.

The challenge with Meaningful Use attainment and sustainment is that the rollout out of software system upgrades and construction of the technical infrastructure is the relatively easy component of the overall project. You should ensure that your vendor is holding this hot potato by providing CCHIT ARRA certified products. You should also expect your vendor(s) to provide training and rollout assistance. Additionally, your vendor should provided plenty of implementation accelerators like large quantities of sample orders sets and care plan templates. So with these expectations, when your vendor says they can get you to Meaningful Use, there is really no mistruth spoken – they should be able to do that.

So now your vendor is on the hook to provide CCHIT ARRA certified products, where does your organization go from here? That is the challenge and the idiom, you can lead a horse to water, but you can’t make it drink, now applies.

Your vendor can not prevent you from the following all too familiar scenario – you successfully complete the most elegant architecture and the smoothest upgrade(s) ever done at your organization. The system is rolled out with much aplomb and the result – the adoption rate is abysmal. Despite the elegance of the technology and providing a technical platform to attain Meaningful Use the system is a failure due to lack of adoption. The painful reality is that the responsibility for system adoption weighs squarely on your shoulders – it is your hot potato, not the vendor’s. Too many sites spend tremendous energy on building the perfect software upgrade/installation/deployment project plan from a technical perspective. As the plan is reviewed the workflow impacts, applicability and risk mitigation is “short sheeted”. Your organization must understand the impact of “going electronic”. Some examples are:

• CPOM, in many cases, can initially cause ordering times to go from 2 minutes to 9+ minutes
• Vendor supplied generalized documentation templates usually do not work in specialty units like the NICU or Burn Unit and have to be modified
• IT systems, under Meaningful Use, become absolutely mission critical and require detailed planning for disaster recovery/business continuity, 24x7x365 help desk support, etc.
• Risk mitigation strategies and plans must be in place in for both technical and business challenges

These are the gnarly, tough challenges and can be as difficult as untying the Gordian Knot. While your vendor can help – your organization ultimately owns these challenges/issues and the solutions/resolutions.

Hopefully this brief review helps clarify the problem, but what about the solution. Remember that there is really no way to ensure success, but there are ways to ensure failure (these are the ones to avoid). There are a few key components that can be implemented that will significantly enhance the probability of success. They are:

• Establish a governance structure that is inclusive of representatives spanning the organization (clinical, IT, finance, and executive leadership)
• Ownership of the project must NOT reside in the IT department
• Ensure there is a dedicated overall program manager that is not “vendor supplied”
• Define the IT department as a service organization supporting the business and not vice versa
• Clearly understand the workflow impacts of Meaningful Use requirements
• Strategize and document how to move from the Year 1 90-day trial period with attestation to Year 2 where 100% of the requirements must be met 100% of the time with electronic proof
• Develop adoption and risk mitigation strategies including an “alternate plan B”
• Budget appropriately for supporting the 24x7x365, mission critical environment remembering once you are paperless your fallback strategies are limited

Remember this list cannot ensure success, but will provide a series of best practices that can help avoid failure.

So back to the original questions that started this:

• Is the funding in hand?
  • Most likely for Year 1, but going forward no real guarantees.
• How should you feel?
  • With appropriate planning confident, but a tad nervous.
• Who is the last to hold the hot potato?
  • Definitely the organization and not the vendor.

As you move forward with ARRA remember the hot potato will ultimately end up in your lap, plan for that and it will not be too painful.

For more information on how Santa Rosa’s “tell you what you need to hear”, experience-based approach, can help you manage the hot potato, please contact us at http://www.santarosaconsulting.com.

Back in the early 90’s during the height of cut backs to the defense industry, I remember reading an article in one of the major magazines about how the economic struggles of the defense industry was a boon for the automobile industry. According to the article, there was a major shift of “technological talent” from defense into the automotive industry.

As I’ve been reading lately of some changes to the healthcare landscape, I began wondering if Healthcare isn’t becoming the newest battlefield for technological talent? So I thought I would piece together highlights from some items I recently came across and offer them up as a blog discussion for our team’s opinions and insights.

First: Visicu Patents Nullified (full article)

The lawsuit between Cerner & Philips over Visicu patents came to a conclusion last month and the verdict was in Cerner’s favor, which was somewhat surprising. Visicu, fairly secure in their legal standing, started the wrangling by threatening Cerner and its clients with lawsuits claiming that Visicu held the patent on the type of sophisticated rule engines used for remote monitoring, diagnosis and treatment of critical care patients. Evidently the jury was unconvinced, and Cerner wins big by having Visicu’s patents nullified, and Philips (who purchased Visicu back in late 2007) is prevented from interfering in Cerner’s business. The ruling may well eviscerate Philips play in the telemedicine space, at least for awhile.

I managed a large Visicu eICU implementation for Sutter Health (24 hospitals, 425 beds, 2 remote monitoring locations) that was completed in late 2006. Visicu used “established technology” components (readily available cameras, speakers, microphones, and networking connectivity), but the proprietary algorithms used by the rules engine in the accompanying software were considered to be a “fortress of solitude”. I guess they have been breached.

Second: Cerner incorporates Microsoft Technologies (full article)

Cerner MyStation (Microsoft Patient Experience Platform)

Cerner is looking to improve the patient experience by creating an interactive information interface that provides hospital patients with a comprehensive, in-room source for communications, education, and entertainment. It looks to deliver an improved patient hospital experience by transforming the standard hospital room into an interactive healing environment.

The Cerner MyStation would be a patient-centric information interface solution that addresses both patient and clinical needs while improving patient experience, satisfaction, and communication.

The Cerner MyStation is a combination of off-the-shelf hardware components from Microsoft and custom-developed software applications including Windows Vista, Windows Server 2003, SQL Server 2005 and Xbox 360. The main components of the Cerner MyStation include:

• My Health, which enables patients to actively manage their healthcare medical record
• My Care Team, which provides patients a pictorial introduction to the individuals responsible for their care and explains their roles
• My Schedule, which presents patients with a personalized itinerary of events as well as a patient-specific task list
• My Menu, which provides patient access to hospital food services systems so they can communicate specific requests or selections
• My Opinion, which enables patients to give instant feedback on assorted topics
• My Hospital, a customizable welcome video and introduction to options within the My Health system
• My Education, which provides patients with access to health education materials prescribed by their care team
• Xbox 360, which provides patients access to a full complement of gaming and entertainment experiences

Third: Microsoft Xbox 360 Platform in Health Sector (full article)

Cerner’s solution is one way Microsoft’s gaming console is being incorporated into Healthcare. Microsoft’s research department is busy conducting research to find a variety of ways to use its Xbox 360, surface computers, and mobile phone applications to offer products to improve healthcare.

Some highlights mentioned at the healthcare technology forum included:

• Enabling users to sync with Microsoft healthcare service to keep track of their medical records
• Using the Xbox gaming console to feed information from an EMR onto in-room display screens for patients (see Cerner solution above)
• Allowing users to log health metrics and monitor daily healthcare activities from Windows Mobile applications

Last: Government to release nearly $1 billion for health IT (full article)

The White House recently announced release of nearly $1 billion in stimulus money. Of the $1 billion, $750 million is grant money awarded to help states adopt frameworks to allow health information to be securely exchanged, plus $ $375 million in grants is awarded to assist healthcare workers in developing and using healthcare IT. And, more than $225 million in Labor Department grant awards will be made available to train 15,000 people for healthcare, IT and other careers.

We’re talking serious money flowing from the American Recovery and Reinvestment Act of 2009, which allocated an estimated $34 billion in federal subsidies to hospitals and office-based physicians and provided another $2 billion to help promote health information exchange and IT workforce development.

Given the recent items to the healthcare landscape I would like to hear your insights and opinions:

• Is healthcare the new landing spot for technological talent?
• Which other new major corporations might get into the healthcare technology battlefield?
• Will the legal wrangling over patents slow or taint the developing healthcare technology?
• Will the government’s interest in healthcare technology provide the spark for a full fledged technology wildfire?

Thanks,

Last week we discussed that when implementing an EHR – or any other new application(s) - the workflow design and decisions are often the most challenging component of the project   What follows is an interview that was published in Inside Healthcare Computing Vol. 20, #7 February 8, 2010.  In it, I discussed seven ideas for helping to handle the resistance to change and therefore one of the ways to best address the need for workflow design during the implementation of an EHR with CPOE system implementation. 

Seven Tips for Managing Change in Your Healthcare Organization

During her career as a nurse and then as a hospital CIO, Karen Hollingsworth, RN, MS, CPHIMS dealt with her share of technology implementations and the challenges of integrating those new technologies into patient care.

Now as an Associate Partner with Michigan-based Santa Rosa Consulting, she spends most of her time sharing her expertise with others. She recently gave us her thoughts about managing the changes that go hand-in-hand with new technology.

1. It’s all in a name. Sometimes hospital personnel just need a little change in nomenclature to feel comfortable with a technology change. For example, Hollingsworth says that she sometimes refers to CPOE as CPOM or “Computer Physician Order Management.” “It’s a mind game, particularly with the medical staff. We say, look, you’re not really entering orders, you’re managing orders – and that’s something they’re used to doing.”  Hollingsworth says that in her experience, when the focus shifts from “entry” to “management,” the comfort level of everyone involved in the project increases.

2. Everyone matters. Anytime a hospital implements new technology, regardless of the department, patient care is impacted. “We all know we have to pay special attention to the medical staff, but they really are a small percentage of the people in the hospital who are providing care to the patients,” says Hollingsworth. “It’s also really important to include other caregivers – nurses, dieticians, pharmacists, therapists, social workers, etc. — all of whom will be impacted by a technology implementation like CPOE, for example.” She says it’s critical to identify and engage stakeholders from the very beginning, acknowledging the special role everyone who is responsible for patient care has. “It’s much easier to spend some time upfront thinking carefully about who needs to have a place at the table rather than moving into the process and then realizing you have to backtrack because you left someone out.” However, she notes, it’s important that hospitals recognize the unseen costs of all that outreach. Hollingsworth says that the time that the unit staff spends evaluating their workflow and helping the project team make decisions is time lost in providing patient care and that leaders will have to plan for appropriate coverage levels.

3. Spend lots of time educating and communicating.
Just as everyone matters, everyone’s concerns are valid and need to be listened to and addressed. “If you’re going to have implementation success, you have to set up a structure in the project that creates communication tentacles into all areas of the operations,” Hollingsworth advises. She stresses that it is important to use a communication structure that respects a unit’s typical means of communications. “Don’t post information on the hospital’s intranet and then make people go hunting for it if that’s not where they’re used to going to find things out. Make sure the information is in people’s faces and easily available.” Hollingsworth recommends that when planning a project’s governance structure, it’s important to think about communication as a separate function. “We create project managers for order sets and other functions. Why not one for communication? Someone should be tasked with making sure that effective communication takes place upward and downward, internally and externally.”

4. Understand clinicians’ workflow and develop technology around it. Hollingsworth believes that as much as possible, it’s important to identify problem areas and develop appropriate responses early on. For example, she recently worked with a hospital that had implemented a single sign-on solution to help its clinicians deal with the various clinical systems. Hollingsworth says that the hospital’s IT department thought this was a great solution, and in theory, it made a lot of sense. However, it ended up taking ED physicians an extra five minutes every time they needed to sign on to use the system, which wasn’t practical from their end. “It’s really important for IT to understand the clinician’s workflow and make decisions in the context of that workflow so that it’s not negatively impacted.” That, she believes, will go a long way in making change more palatable for those who must actually use the system.

5. It’s not all about IT. In Hollingsworth’s experience, projects, and the ensuing change that goes along with them, have a better chance of success when they’re seen as institution-wide, not just IT-driven. That’s why she suggests that CIOs step aside from the steering committee chairperson role and let the COO or another C-level executive sit at the helm. “It’s key to the project’s success if the leadership committee can demonstrate that the COO, the CNO, the CMO, the CIO, and everyone else in a leadership position are in lockstep together.”

6. Identify peer champions to deal with resistance and communicate concerns. One of the benefits of identifying and targeting stakeholder groups is that it in turn helps identify leaders within those groups who can help communicate the benefits of the project to peers and who can bring the concerns of their respective group back to the steering committee. “It’s important to find those leaders who you can count on to connect with their constituencies,” Hollingsworth notes.

7. Reassess and revisit. Managing change is something that has to happen continuously through a project, Hollingsworth says. “If it’s been more than a year since you’ve looked at an area and then gone on and developed your implementation plan, it’s time to go back and revisit that area.” For example, a hospital she worked with is preparing to go live with a new system and prior to go-live, is revisiting workflow issues at patient transfer points. “Things can change really quickly in large hospitals and one thing I tell hospitals to think about doing is going through a dry-run before going live, just to ensure that things will go smoothly and as planned. It’s better to troubleshoot before go-live rather than after.”

There is universal agreement that in the implementation of an EHR – or any other new application(s) - the workflow design and decisions are often the most challenging component of the project.   There are other factors involved in the implementation such as project planning/management, application build, interface builds, hardware deployment and communication but these seem to pale in comparison to workflow.  The industry talks about workflow in each project but workflow is rarely understood by those who will be most impacted – the end users of “the” system.
When you use the term workflow – what do you mean? 

Workflow consists of a sequence of connected steps.   The steps are not necessarily done by the same individual or even the same department in a hospital or in a physician practice office setting.  An example is seen in the Emergency Departments of every hospital.   For a patient to be efficiently transferred from Emergency Department Care to in hospital care a series of steps are required:

1.    ED provider makes decision that admission is required
2.    Decision is documented via a written order on patient ED chart
3.    ED clerk searches for the chart
4.    Chart found ED clerk calls to the Admitting Department to request a bed
5.    Admitting Department reviews available beds
6.    Admitting Department calls Unit where patient will be placed
7.    Admitting Department calls ED to notify of the bed placement
8.    ED clerk calls to ascertain when the patient can be transferred
9.    ED nurse documents on transfer note all the patient data necessary for transfer
10.  Etc, etc, etc …

Each of these steps is connected by the steps before and after – no one step stands alone to attain the desired result – a newly admitted patient in the correct inpatient bed. 

Well – you get the idea – if the steps happen out of sequence or a step is omitted then smooth execution of the patient transfer is going to fail.  How important is the workflow?  Now, imagine a project to implement CPOM (Computerized Provider Order Management) where Step #2 is going to be altered by the ED physician entering a computerized order for hospital admission. Whoops!  A step not identified earlier – the facility requires the ED physician to have discussed acceptance of this patient with a physician with attending privileges.  The design of the admission order has failed to include this step not identified in the current state workflow step sequence.  If a step is omitted – it should be done by design only – not from the failure to identify the required step.  Step #3 above will truly be omitted by the CPOM admission order.  If we proceed to implementation of the system and the ED provider has not agreed to this new workflow step and we have failed to correctly identify and plan for the subsequent workflow steps -our implementation will fail as well. 

Why does new workflow most frequently fail?  How many projects have you personally seen where the application is stated to be “working as designed” and the workflow is identified as the underlying issue?  The underlying reason is generally failure to understand the end user needs and resistance to change.  How can this resistance to change be overcome?   Next week’s blog will provide some ideas for meeting this resistance in a proactive way through project structure and management techniques that have been tested and proven.  Stay tuned....

Stating the obvious – healthcare reform has been pushed to the forefront. Everywhere you look there are articles supporting healthcare reform, articles advocating the status quo, articles discussing the cost of healthcare reform – articles, articles and more articles. While I am not sure what is right or wrong in terms of the various positions advocated in the myriad of articles, what I am positive about is that we are focusing on the wrong numbers. In articles on either side of the fence (and even those on the fence) numbers range from costs of $900B to well over $1T – suffice it to say in terms of dollars healthcare whether there is reform or not costs a staggering amount. In fact the numbers are so large, I have an extremely hard time wrapping my head around them. As a useless piece of trivia to store away – it is estimate a stack of dollar bills equaling $1T would be 67,000 miles in height (about 25% of the distance to the moon).

In order to better grapple with these numbers and perhaps yield more economic sense percentages are better. Percentages are used everywhere in determining affordability and viability. When one applies for a home loan, certainly the cost of the home is important, but the real driver is the debt ratio. So if you make $50K annually will you get a loan on $1M home – most likely not since a principal and interest payment is in the $4.5K per month range. The driver is not the cost/value of the house rather it is the monthly payment as a percentage of your income (which in this example is about 108% of the monthly income). The concept of using percentage allows a relative judgment of affordability. The same $1M house, if a person makes $500K, is a financial no brainer on the loan since the monthly payment as a percent of income is so much lower (about 10.8%).

So instead of getting wrapped in trying to comprehend a 67,000-mile tall stack of money, look at percentages of growth compared to a benchmark number. In the case of a country, the benchmark number that conceptually mimics the concept of annual income is the Gross Domestic Product (GDP). For the USA the most recent numbers put our GDP around $14.4T with an average growth rate, over the past ten years, of about 2.89%. So there is our baseline, perhaps as a nation if we were applying for a house loan these would be our stats. The other component is historical debt trends. Indeed the national debt has spiked especially over the past 3 years. This can be attributed to wars, recessions, bailouts and so on – in other words unforeseen anomalies, albeit huge anomalies. In any case our debt to GDP percentage has ebbed and flowed over the years, but has averaged over the past 72 years a 0.32% increase (to be fair, since 2000 that increase has averaged 2.86% growth). So what does this boil it down to, and how would it affect the nation’s ability to buy a house? Since roughly 2000, the GDP has increased 2.89%, the national debt as a percentage of debt increased about 2.86% - not bad, we could probably buy a house. Now lets jump to healthcare and hold onto your hats:

• Medicare spending has an average annual growth of 9% (each year since 1970)
• Private insurance spending has an average annual growth of 10.1% (each year since 1970)
• Health care has steadily been climbing as a percentage of the GDP – in 1980 we spent $253B (4.77% of GDP) on healthcare, $714B in 1990 (10.1% of GDP), $2.5T in 2009 (17.6% of GDP)
• It is projected that healthcare cost will continue to increase at a rate of 6.7% through 2017 taking an estimated 20% of the GDP.

As a nation, would we qualify to buy a house with these percentages – indeed not! On the flip side of this, maybe we have received tremendous care and improved health from these ever-increasing expenditures (from http://www.cdc.gov/nchs/fastats/healthy.htm & http://www.nationmaster.com/cat/hea-health&all=1) - lets look?

• Life expectancy at birth for females: 80.2 years (30^th in the world)
• Life expectancy at birth for males: 75.1 years (27^th in the world)
• Percent of persons all ages in fair or poor health: 9.9%
• Percent of adults 18 years and over who engaged in regular leisure-time physical activity: 32% (2008)
• Percent of adults 20 years and over who are obese: 34% (2005-2006) (#1 in the world, by comparison Japan’s obesity rate is 3.2%)
• Percent of adults 20 years and over with hypertension: 32% (2005-2006)
• Percent of persons 65 years and over who had received an influenza shot during the past 12 months: 67% (2008)
• Percent of persons 65 years and over who had ever received a pneumococcal vaccination: 60% (2008)
• Percent of children 19-35 months age who had received combined series (4:3:1:3) vaccination: 77% (2006)
• Percent of persons under 65 years without health insurance coverage: 17% (2008)
• Deaths per 100,000 population: 810.4
• Infant mortality rate: 6.69 deaths per 1000 live births (185^th in the world)
• Number of deaths for leading causes of death
  • Heart disease: 631,636
  • Cancer: 559,888
  • Stroke: 137,119

Are we getting a good deal for are vast expenditures – your call. Personally I would like a bit better return on investment.

So back to the topic at hand – it is the percentages when we want to get a real grasp on things. Talking in terms of billions and trillions of dollars we get lost in a sea of zeroes, but when we break it down to percentages it is much more understandable. Simply stated healthcare is growing at economically historically unsustainable rate as a percentage of our national income (measured as the GDP). Healthcare spending is outstripping GDP growth by roughly 2.5 – 3.5x. The national debt, over a similar period of time, a much more controlled growth (although distressingly large).

So when we factor in healthcare, would we as a nation be able to buy a house for ourselves, most likely not. Are we as a nation getting spun up in numbers that are so large they are best stated in scientific notation – most likely yes. Let’s get back to meaningful numbers as percentages against the GDP – this we can handle. When we do this the conclusion is that healthcare spending is simply out of control and needs adjusted. In the words of Jonathan Blum, Director of CMS, "Health care spending as a percentage of GDP (gross domestic product) is rising at an unsustainable rate. It is clear that we need health insurance reform now."

Please call us at Santa Rosa Consulting for more innovative views on the healthcare industry. We have the experts to give you the insight. Visit us a http://www.santarosaconsulting.com.

“A wise man said that you can have everything in this world if you sacrifice everything for it”. But what he meant was…“Nothing comes without a price.” I am sure that hospitals currently successfully engaged in Social Network have figured this out. For those that are considering it, you need to really take a look at the costs, commitment and potential public exposure before just “Setting Up” a free account. So, what really is the cost of Social Networking? Let’s take a look…

Tangible Costs

I have Tweeted daily on behalf of Santa Rosa Consulting, starting with one a day, now up to five times daily on a good day since October, 2009 and have 121 followers on Twitter. The average Twitter account has 124 followers. I am the CTO of the company and enjoying the social networking aspects of my job, but how do I find the time to Tweet all day?

I was amazed when I searched “Social Networking Jobs” as to the numerous employment positions available for Vice Presidents, Managers and staff to establish and manage social networking strategies on behalf of many companies. When reading the fine print, you will see these are “New” positions being developed in the organizations. Most salary ranges were stated as negotiable, some noted in upwards of $110,000 for a manger level. Large companies today are not just hiring “a “ employee to manage social networking, they are building teams led by Vice Presidents to manage it. It has become a new marketing arm that requires skills in Social Networking and Web Technologies. So why is that? Well, recent statistics show that social networking may be bigger than you think.

• By 2010 Gen Y will outnumber Baby Boomers….96% of them have joined a social network
• 1 out of 8 couples married in the U.S. last year met via social media
• Years to Reach 50 millions Users: Radio (38 Years), TV (13 Years), Internet (4 Years), iPod (3 Years)…Facebook added 100 million users in less than 9 months…iPhone applications hit 1 billion in 9 months.
• If Facebook were a country it would be the world’s 4th largest between the United States and Indonesia (note that Facebook is now creeping up – recently announced 300 million users)
• Because of the speed in which social media enables communication, word of mouth now becomes “World “ of mouth

Source: http://ow.ly/11Yaz

In my blog post in December, I shared stats on how Hospitals were using Social Networking. Since Nov. 2009 and January 2010, a significant increase, 67 more hospitals engaged in Social Networking in 2 months.

Last Update November 27, 2009 http://ebennett.org/hsnl/

• 473 Hospitals total
• 218 YouTube Channels
• 254 Facebook pages
• 356 Twitter Accounts
• 57 Blogs

U.S. Hospitals that use Social Networking tools. Last Update January 10, 2010

• 540 Hospitals total
• 247 YouTube Channels
• 316 Facebook pages
• 419 Twitter Accounts
• 67 Blogs

Source: http://ebennett.org/hsnl/

Intangible Costs

Unfortunately the potential for intangible costs exist, ones that can hurt your organization’s image. With traditional marketing we control our message and image, now consumers can say what ever they think about an organization openly, no gatekeeper in place. Here are a few examples, I agree extreme situations, however, buyer beware, nothing comes without a price.

• What do Dan Leone and Jon-Barrett Ingels have in common? Their Way Out of Jobs. http://ow.ly/11WC9. So they were fired, what about the reputations of the companies they worked for, National Football League's Philadelphia Eagles and Barney Greengrass in Beverly Hills?
• The devastation to Domino’s Pizza after employees shared a disgusting video, even after Domino’s posted a YouTube video to protect their brand, there are still other videos posted by consumers that are not favorable . Nothing I would want to share, if interested, go to YouTube.com, search “Domino’s Pizza”.
• An article you can reference: “Social Networking Lawsuits Are Big Risk to Business” by the Connecticut Litigation Blog http://ow.ly/11YO1

So, my conclusion, Social Networking has become the next generation of Marketing, with a twist. A strong Social Networking Team, Strategy and Policy are required and “Buyer Beware”!

On December 30, 2009 the Centers for Medicare & Medicaid Services (CMS) released the proposed rule that would implement provisions of the American Recovery and Reinvestment Act of 2009 (ARRA) that will provide the EHR incentive payments and wow what a rule – 554 pages worth!! The good news is, if you have an interest in this subject, the document was quite readable and very informative.

Since the feeding frenzy started surrounding ARRA/HITECH stimulus money, many questions and interpretations have appeared on blogs and articles authored by the normal healthcare pundits and experts - some accurate, some not so much. The CMS proposed rule provides significant clarity to those questions and interpretations. The proposed rule provides clarity around a range of topics from definitions of Eligible Providers (EPs), to proposals that Medicare and Medicaid use the same EHR incentive calculations, to defining exactly what it means when asked to report on the patients with their hemoglobin A1c (HbA1c) under control. The data is fantastic information and is vital to helping vendors, institutions, consultancies and government agencies understand the parameters to becoming and declaring Meaningful Use (MU).

In fact, the rule makes declaring Meaningful Use for Year One relatively straightforward. The parameter to be a Year One Meaningful User is “any continuous 90-day period within the first payment year”. In fact, an EP can declare meaningful use for the Medicaid Incentive in calendar year 2010 simply by “adopting, implementing or upgrading certified EHR technology” and complying with the 26 MU criteria. Add to this that Year One is certified via attestation from the site. Initial reaction – hey not so bad, most places can do this!!!

Then comes Year Two. In the words of Bette Davis - “Fasten your seatbelts, it's going to be a bumpy night!” Year Two requires 100% compliance with 100% of the requirements 100% of the time with electronic submission of proof (as long as CMS has the technical infrastructure in place to support electronic submission). A few examples of this quantum leap in requirements:

• Year One - EPs need to use CPOE for 80% of all orders, Hospitals 10% of all orders, while in Year 2 – 100% of orders are required for both!
• Year One - At least 80% of all unique patients seen by the EP or admitted to the eligible hospital have at least one entry of an up-to-date problem list of current and active diagnoses based on ICD-9 CM or SNOMED CTâ or indication of none recorded. Year 2 – 100%!

These types of leaps in requirements are throughout the document. Is this fair, some will say yes, some will say no – I say beware.

Let’s further investigate CPOE. Deploying and using CPOE for things like dietary orders and simple lab tests are reasonably straightforward and quite doable. Difficulties arise in specialty areas such as a NICU where orders can be weight-based, age–based and so on. These specialty areas place significant stress on CPOE systems and the teams deploying them. So what’s my point, if a hospital declares meaningful use 90 days prior to the end of the first payment year and uses dietary and other important, but reasonably straightforward orders, to attain the 10% Meaningful Use bogie – Year One will be a somewhat easy to achieve success. If that same hospital waits to really tackle the hard stuff, e.g., NICU, for Year Two - the odds of 100% compliance, 100% of the time may be about as good as being struck by lightening during the year (which by the way are 1:500,000). What is even more striking is, this example only addresses the mechanics of building the order sets in a systems and getting that right, challenges such as workflow impact, increases in ordering time and overall adoption strategies will present an entirely new set of issues, all of which will impact Meaningful Use.

Similarly for problem lists, there are two components here – one is the standardized vocabularies (ICD 9 CM and SNOMED CTâ), if a site has not instituted them the challenge is very significant and will require retraining of the business office staff as well as admission clerks. The other challenge is the words “all unique patients”. Unique is the key here – unique means that if I show up for multiple visits or multiple admissions I am counted once. In contrast if the rule simply said all patients – this would basically equate to the number of admissions or visits. Unique imposes a set of really unique issues – what if I have multiple medical record numbers, what if the site does not have some sort of Master Patient Index (MPI) to name just one – this could wreak havoc on the “all unique patients” requirement and the result could be failure to sustain Meaningful Use.

In addition to the Meaningful Use requirements, we cannot ignore the ICD-10 migration that must be complete by October 1, 2013. This conversion, by any metric, is a huge task in conversion and retraining. When the required ICD-10 migration is combined with MU requirements the amount of change introduced into most care delivery systems will overflow their proverbial cup if they are not prepared. It will stress the clinical staff, the IT staff, Executive Leadership – no one will be immune. So there are really two approaches to this – become an ostrich with your head in the sand or develop a plan to manage to. The latter is much more preferable.

So wrapping this one up, I live in Texas and at each railroad crossing there is a sign that says – stop, look, listen. Since many railroad crossings in this state are unprotected this is sage advice. I would suggest that each of us heed this warning and stop, look, listen and plan for not only how to attain and declare meaningful use, but more importantly how to ensure meaningful use is sustained over the long haul.

For information on how Santa Rosa Consulting can provide the expertise and innovative approaches to help your institution attain, maintain and realize the clinical and financial benefits of meaningful use please contact us at http://www.santarosaconsulting.com and click on contactus@santarosaconsulting.com.

Common Myths About EMR
From the Perspective of a System Implementer

Much is being written regarding how ARRA incentives are the driving force behind EMR adoption. Despite this lucrative incentive, many physicians are still reluctant to adopt this technology. Some have heard horror stories from other physicians who have adopted, others just aren’t ready to embrace the technology, and even more just don’t have all the information necessary to make an informed decision.  With that in mind and based on my experience assisting clinicians and their staff in implementing this technology, I would like to tackle five common myths about EMR that should address some of those same physicians concerns.

Myth #1:  EMRs aren’t going to last
A good number of providers would like to dismiss EMR as just the latest fad to hit the medical world. They have seen numerous advancements in the medical field in both physical medicine and the technology behind it. They have seen how something as simple as penicillin completely changed the medical profession and how something as complex as early Practice Management software be hit and miss. There are providers that have worked in hospitals that have instituted an EMR program that had failed and was ultimately abandoned in full or scrapped for another program. This has left a bad taste in the mouths of those providers.  With the federal focus on money ($2B is not trivial, even by government standards), time (Congress is still engrossed in health care reform), and media attention (articles, news coverage, etc) on automating medical record keeping, EMR is here to stay. Every provider will have to make a decision on which program to go with in the near future.  There are a number of advantages to adopting EMRs, not the least of which is that having all of your patients’ information in one easy to access program allows providers to make better decisions when administering care. EMR can also be helpful when doing coding, which has reimbursement implications beyond ARRA incentive payments. Medicare currently pays bonuses to providers who do well with their Hierarchical Condition Categories coding, something that is much easier to track in an EMR system.  Other insurance companies will soon follow suit with pay-for-performance measures tied to healthcare reimbursement. Many hospitals have already begun to roll out plans in anticipation of this. It would be a great benefit for independent physicians and other providers to do the same and reap the rewards early.

Myth #2: The provider/patient relationship is negatively affected by EMR
There are a number of providers who are hesitant to adopt the technology because they feel they won’t give patients the attention that they deserve. Instead they think that they will be typing away and focused on the EMR screen rather than conversing with the patient and providing a thorough examination. The truth is that you can provide better care with EMR. With the click of a mouse you can pull up information about diabetes for example and show the patient on the screen and discuss a plan of action, even printing out instructions for them. You can generate diet plans based on age, weight, and health. That’s just to name a few. I have some personal anecdotes from my work implementing EMRs. One is a doctor who was reluctant to use his EMR system in the exam room. He decided to give it a try and asked me to be in the exam room with him with his first patient in case he felt lost. The patient at first wasn’t pleased that the doctor would be busy “typing away” instead of focusing on his concerns. However, with little assistance, he was able to successfully input the patient’s history, medications, and give a thorough exam. When the doctor showed the patient how everything was in his virtual ‘chart’ and how he would now be able to manage his care more efficiently, the patient was thrilled and the doctor was relieved.  There are many ways that providers can make the quality of care better for patients with an EMR while still giving them the care that they expect.

Myth #3: All EMR programs are the same
It is a common misperception that because EMR is discussed as a “program” that all EMRs are the same.  The truth is that each software program offers different options. For instance, just because one program allows you to create your own MS Word templates and drop them into a SOAP note, doesn’t mean that the next program will have the same setup. In fact most programs are not compatible with one another. So if you find yourself unhappy with your EMR program, chances are you will not be able to convert existing patient data to another one – at least not easily. Picking the right program the first time is important because of that. I have worked with many providers who have switched EMR programs and have been dismayed to find that they could not do a file conversion and essentially would have to start over with the new one. They felt that making a poor choice the first time around cost them considerable time and money. They had gone into it blindly thinking that if they wanted to switch programs that it would be easy and seamless because they are all the same. Unfortunately, they are not.

Myth #4: EMR software is the bulk of the total cost
Adoption of an EMR can be quite a pricey endeavor. EMR software adoption for larger facilities can cost millions of dollars.  When budgeting for the transition, many make the mistake of thinking the software will be the majority of the cost incurred.  This couldn’t be further from the truth. Many EMR implementations will require additional hardware, additional staff, training for users, and many times the use of “super users” to assist during go-lives. Equipment within an office will have to meet certain system requirements in order to operate EMR software. The data entered into the program will have to be stored on some type of server or infrastructure. Additional staff may need to be hired to ease with the change in everyday workflow. Most will need to hire or acquire system experts at some stage of the implementation to be onsite to answer any and every question that should arise. When all this is factored in, the software ends up being the least expensive portion of the transition.

Myth #5: The technology is the hard part
As a veteran of numerous EMR implementations, I have experienced many highs, lows, and in-betweens and here is the sum benefit of my “wisdom”. Going into a go live, the common belief among physicians and staff is that learning the software will be the most difficult part of EMR adoption. However, they quickly come to understand that the greatest challenge lies in the processes and workflows that must be changed to make adoption of the software successful. Prior to EMR adoption ambulatory practices have their daily routine that they have done for years on paper. They often overlook that things as simple as vitals and patient history will now have to be entered into a new system and not just written down. This change can prove difficult for the staff regardless of how much training they have gone through or walkthroughs they have been given. It is always different when you flip the switch and bring something live. The first time you have real life patients in front of you and have to enter information into a system in their presence can prove difficult. Others will find it difficult to incorporate a computer into their clinical routines.  It is important to try and match the workflow with the program to ease the transition.

These are just a few of the common myths that I have personally come across in my experience implementing EMR systems. This doesn’t address all the concerns that are out there. But as any implementer can attest, the adoption of EMR is an ongoing process and an ever evolving one.

Photo credits:  yorkstudentrn.wordpress.com/

According to Wikipedia, there are many origins to this adage ranging from Chinese proverbs to Napoleon to a pitch for advertising on streetcars from the 1920’s.  In any case the adage seems to ring true especially since the majority of individuals, according to the National Institutes of Health, are either visual or kinesthetic (tactile) learners.  So given that most of us like to see and touch things in order to learn, why is it the 10’s if not 100’s of millions that are spent on health information technology (HIT) are usually based on evaluation from the verbiage in an RFP?  Is it tradition, ease, lack of technology to support alternatives, aversion to change, or something else?   I would postulate it is a combination of the first four with a focus on aversion to change – vendors have 1,000's of canned responses in databases, consultants have an equivalent in questions to put in to RFPs – a nice cycle and relatively easy, why change?  Realistically, if we are all honest, when we get those multi-hundred page responses do we read each and every page to get a holistic view or is the RFP “chunked up” and reviewed by a committee?  I would say the latter rather than a former and that brings to light another adage – “a camel was a horse designed by a committee”.

So what’s my point – how do we get the picture instead of the 1,000 words?  It is accomplished by leveraging the fantastic technologies that are available to each and every one of us.  The needed picture can be provided in the virtual worlds of Second Life and Project Wonderland.  These virtual worlds can be used to visualize and “touch” the impact of the systems being deployed.  Imagine being able to understand that upon deployment of the multimillion-dollar CPOE system the clinicians ordering time will climb above 10 minutes, but that over a period of 3-4 months that time will drop to 5 minutes and more importantly if the encounter is looked at as a whole, the encounter time drops from 17 minutes to 14 minutes (inclusive of ordering).  Imagine being able to understand the impact of real time Master Patient Index (MPI) interaction for the admissions/registration personnel and so many more.  No vendor RFP will enable you to visualize these things, but this can be accomplished in the virtual worlds of Second Life and Project Wonderland.  That is the purpose of this blog.

Virtual Worlds

First and foremost, what is a virtual world?  Well, a virtual world is an interactive simulated environment accessed by multiple users through an online interface.  Virtual worlds are also known as "digital worlds," "simulated worlds" and "MMOG's." (Massively Multiplayer Online Role Playing Game)

All Virtual Worlds have six features in common:

• Shared Space - the world allows many users to participate at once.
• Graphical User Interface - the world depicts space visually, ranging in style from 2D cartoon" imagery to more immersive 3D environments.
• Immediacy - interaction takes place in real time.
• Interactivity - the world allows users to alter, develop, build, or submit customized content.
• Persistence - the world's existence continues regardless of whether individual users are logged in.
• Socialization/Community - the world allows and encourages the formation of in-world social groups like teams, guilds, clubs, cliques, housemates, neighborhoods, etc.

Virtual worlds are best known as a gamers world simply because that is the most ubiquitous use, but that is not where it stops.  The virtual words can be used for educational purposes, training (the military uses virtual worlds for exactly this purpose), sales, what if scenarios and many more.  Specific to healthcare, these virtual worlds offer the perfect environment for:

• Education/Training (both vendor and site specific)
• Collaboration
• Vendor demonstrations
• Proofs of Concept for innovative approaches to improve patient satisfaction (enable time motion studies)
• Workflow visualization
• Risk Mitigation with new system deployments/upgrades
• RFP responses and distribution

The Virtual World Leaders
The following is a little background on the virtual world leaders - Second Life and Project Wonderland.

Second Life ( http://secondlife.com/ )
Second Life (SL) is the leader in the virtual worlds with 2M+ users.  SL enables its user, called Residents, to interact via avatars.  An avatar is a character that can be constructed with SL’s self-contained toolkit, then personalized to reflect the user(s) personality and deployed in the SL Virtual World.  With the avatars SL residents can:

• Explore
• Meet other residents via avatars
• Socialize/Interact
• Participate in individual and group activities
• Create and trade virtual property and services
• Travel throughout the virtual world or grid

Project Wonderland ( https://lg3d-wonderland.dev.java.net/ )
Project Wonderland is an open source 3D toolkit for creating collaborative virtual worlds and sponsored by Sun Microsystems.  From a technical perspective Wonderland is built on top of Project Darkstar (A Massively Multiplayer Online Role Playing Game engine (MMOG)) and Java3D.  With the Project Wonderland virtual worlds, users can:

• Communicate with high-fidelity, immersive audio
• Share live applications such as web browsers, OpenOffice documents, and games.

Project Wonderland is the relative newcomer to virtual world.  Wonderland’s goal is to provide a secure world in which organizations could conduct business and/or allow employees to collaborate online.

Workflow Optimization
One of the key areas of focus for a virtual world is workflow visualization and optimization. Most sites, inpatient or ambulatory, when trying to define, document, modify or deploy a workflow will follow these steps:

1. Establish a committee or working group with appropriate personnel
2. Have several meetings to discuss the current and future states
3. Develop a flowchart defining the workflow
4. Publish the flowchart
5. Have IT or the vendor build the flowchart in the appropriate products
6. Deploy the workflow to visually understand the impact
7. Evaluate the impact
8. If the impact is more pronounced than expected (more often than not the outcome) go back to step 1 and repeat the process until fixed or shelved.

What would it be like if at step #3 the flowchart was built in a virtual world and visually evaluated for impact and/or comparison with the current state.  Then if the impact was too pronounced, changes could be made and retested in the virtual world until the flow meets the needs.  Then and only then will the workflow be published and steps 4 – 8 executed.  The value of the process could be profound and include:

• Risk mitigation – the site would have a much deeper understanding of what they were getting into to as well as the virtual world provides a relatively inexpensive test bed
• Clinical Community Satisfaction – the virtual world build out would greatly diminish the number of workflow misfires and thus the clinical community’s skepticism/cynicism would decrease
• Financial – The cost of the cycle of build, deploy, evaluate is expensive when using the system (not to mention it is much akin to being on a high wire without a net when using the production system)

To help you imagine the opportunities, check out this demo made by the University of Arkansas.

So is a picture worth a 1,000 words – a resounding yes!!  The use of virtual worlds is gaining popularity, in fact some vendors have shown their products on Second Life.  The time is right to expand and use the environments to change the way workflows are built and deployed as well as alter RFP processes and so many others.   The technology is there, the time is right and to quote Benjamin Franklin – “you may delay, but time will not.” 

For these and other highly innovative approaches, contact us a Santa Rosa Consulting and let us help you understand how innovation can help save money, time and effort.

Dale Will
Associate Partner
Santa Rosa Consulting, LLC

Social Networking, “Hmmm”, before joining Santa Rosa Consulting I used social networking sites  to connect with friends on facebook, view videos sent to me on YouTube and connect with current and past colleagues on Linkedin.  All with a bit of hesitation in terms of “How much information to share”.  As the Chief Technology Officer at Santa Rosa Consulting, like any CIO, CTO, COO, CFO, there is always hesitation in what is or is not shared on the internet, given our sensitivity to securing our client, employee and company information.

When I joined Santa Rosa Consulting in May, 2008, my goal was to fullfil our founder’s wish of building out a technology platform that would be very unique; One that would make us the easiest company to do business with and the easistst company to work for.  At some point down this very agreesive path I was tapped on the shoulder and asked “What are we doing to market our services and create awareness?  Why are we not blogging, tweeting, posting videos on YouTube?”   My first thought was “Wow,  how can we go down this path and ensure the security of our client, employee and company information?  Who can create content for Tweets, Blogs, Videos?  How can we overcome some of the negative aspects such as inappropriate blog comments, inappropriate twitter comments, etc”.  So I ventured beyond my own personal use of socal networking and looked at how other industries including the Healthcare Industry are using Social Networking to promote their businesses.  What I found was suprising as well as exciting to me, a marketing shift in “About Us” to “What can we share with you to provide you value”.

So let’s take a look at  some good examples of how Hospitals are using social networking followed by some statistics about how many and what sites they are using.  First some good examples:

• Providence Hospital in Portland uses YouTube to promote breast cancer awareness in a very fun way: http://www.youtube.com/watch?v=OEdVfyt-mLw. 5,272,543 views, that is “Awareness”.
• Sentara Healthcare uses Twitter to share informatin with patients and employees around healthy eating tips, health surveys, employee recognition, success stories.  They have an amazing 1,395 followers on Twitter, this last tweet is an example of how they use Social Networking: New at Sentara Today -- Helping aging parents plan for the future. http://twitter.com/sentarahealth.
• Cleveland Clinic uses Facebook (6,371 Fans), Youtube, Twitter (2,369 Followers) and Linkedin. Sharing information about hearing loss,  wellness tips,  promoting an upcoming “Online Health Chat” about Coronary artery disease (CAD) and video clips of dietician’s discussing healthy Holiday meals.
• The President and CEO of Beth Israel Deaconess Medical Center in Boston started a blog to share thoughts about hospital, medicine and healthcare issues.  To follow this blog… http://runningahospital.blogspot.com/2009/12/blue-glove-medical-record.html
• ProgressWestER uses Twitter to inform patients of wait times in their ER … 5:38 p.m. Less than a 15 minute wait in the ER. To follow on Twitter… http://twitter.com/ProgressWestER.  344 followers.

In the true sense of social networking, these hospitals are creating online communities in ways never possible  before.  A back door approach to marketing that provides value to it’s members through information sharing  using  various approaches made availble by social networking sites.  So how common is the use of social netwroking amongst hospitals?  Here are the stats:

U.S. Hospitals that use Social Networking tools.  Last Update November 27, 2009 http://ebennett.org/hsnl/

• 473 Hospitals total
• 218 YouTube Channels
• 254 Facebook pages
• 356 Twitter Accounts
• 57 Blogs

Top 5 States - Hospitals Using Social Networking http://ebennett.org/hsnl/

So out of the roughly 7500 hospitals nationwide, close to 500 are known to actively engage in social networking.  It will be ineresting to see what this number looks like in another year along with what creative new approaches will evolve.   What do you predict?  How do you see hospitals using online social networking?  What works?  What doesn’t work?

Happy Holidays to all and best wishes for the New Year!

Reta Lock
Chief Technology Officer
Santa Rosa Consulting, LLC

So when the words “health care in the United States” are spoken these days do you think about “how good is my care?” or do you think about health care reform?  Odds are it is about health care reform.  Once there, your mind probably makes a quick jump to terms like socialized medicine, universal access, universal insurance, public options, denial of care, pre-existing conditions, and the uninsured population. It is a new and complex alphabet soup and it is a bit messy.  Care reform and care quality are intermingled and polls show reform is wanted and/necessary and this will impact care quality (in a hopefully positive manner).  In this blog I would like to present a couple of real challenges for the United States to accomplish this change and some factual background.

First a little factual background on the health care system in the United States:

From a business perspective:

• Since 1970, health care spending has grown at an average annual rate of 9.8%, or about 2.5 percentage points faster than the economy as measured by the nominal gross domestic product (GDP).
• Annual spending on health care increased from $75 billion in 1970 to $2.0 trillion in 2005, and is estimated to reach $4 trillion in 2015.
• As a share of the economy, health care has more than doubled over the past 35 years, rising from 7.2% of GDP in 1970 to 16.0% of GDP in 2005, and is projected to be 20% of GDP in 2015. 
• Health care spending per capita increased from $356 in 1970 to $6,697 in 2005, and is projected to rise to $12,320 in 2015[1]

From a national health[2] perspective:

• Life Expectancy is 78.14 years
• Obesity Rate is 30.6%
• Infant Mortality 6.3 deaths per 1,000
• These are some of the worst statistics of the industrialized nations

From an insurance perspective:

• 15.9% of the United States population is uninsured
• 25M US Citizens are underinsured. Underinsured is defined as families paying a deductible that exceeds 5% of their income
  • The underinsured population has increased by 60% from 2003 to 2007.[3]
• At this time estimates show the underinsured or uninsured population totals approximately 62M people or approximately 21% of the total population and 33% of the working age population (18 – 65)
• The United States is the only industrialized nation where medical bankruptcy is a significant challenge
  • A recent study found that 62 percent of all bankruptcies filed in 2007 were linked to medical expenses.  Of those who filed for bankruptcy, nearly 80 percent had health insurance
  • According to another published article, about 1.5 million families lose their homes to foreclosure every year due to unaffordable medical costs.

And finally the Medicare perspective

• Medicare beneficiaries with five or more chronic illnesses account for 23% of the Medicare population, but account for 68% of the expenditures
  • Rising rates of chronic disease are the greatest factor driving health care spending, accounting for 75 percent of every dollar spent on health care – and 83 percent in Medicaid (one or more chronic diseases) and 99 percent in Medicare (one or more chronic diseases)
• This population averages 50 prescriptions annually and have 14 different physicians they see for an average of 37 physician office visits annually.

Whoa, this paints a tremendously bleak picture of health care in the United States.  This seems like a version of Edvard Munch’s “The Scream”.  These facts and figures beg the question: "Is care in the United States good?",  The answer is yes indeed it is, but this comes at a price. So do not confuse cost with quality, we have great quality but at a tremendous cost.  Unfortunately the cost component is not sustainable. In fact the GDP grows on average at a rate of 2% and health care costs rise at a rate of 10% - any economist will confirm this is a perfect recipe for bankruptcy – this is the driver for reform.

So as we look at the facts and figures it is pretty clear that chronic disease is the 800-pound gorilla in terms of cost. The statistics show multi-billion dollar savings could be expected through the efficient management of chronic disease/illness and preventive care programs.  So why is this not taking off like a wild fire?  There are two big reasons - societal issues and educational approach.  The United States’ hallmark “rugged individualism” has served everyone well and has served as a foundation for building one of the greatest cultures this planet has ever known.  The downside is that it does not give much room for being told how to adjust lifestyles to accommodate prevention and efficient treatment.  This causes a great conundrum and conflict – do we bend on a foundational pillar of our country’s culture or do we risk bankruptcy and risk it all going away?  The other component of the societal challenge is that most other industrialized nations have a core belief that access to high quality health care is a a privilege not fundamental right, in the United States this is not necessarily the view. I don’t pretend to have the answer which lays in some type of compromise I am sure. 

From an educational/training perspective, most medical schools in the United States teach allopathic medicine.  Allopathic medicine can be characterized as a scientific approach that is arguably more focused on the treatment of disease versus the prevention of disease.  This does not mean that allopathic approaches are bad or inadequate it is simply a statement of current teaching approaches.

Over time though, it seems there will undoubtedly be more incentives and stricter regulations to get preventive care programs rolling – it is inevitable.  ARRA Meaningful Use is a perfect example.

So what does all this mean?

1. Well one thing for sure, health care screams for some positive change. Perhaps we would serve ourselves well looking at other countries like Germany, Japan and Switzerland not just our neighbors to the North (Canada) and the UK. 
2. ARRA Meaningful use is definitely getting the industry to press the accelerator in the IT usage via financial “carrots and sticks”. 
3. The debate over health care is raging while it is at times quite rancorous.  At least we are talking – more or less. 

All of these things are quite positive and are causing the limelight to be on our care system. These combined with the unheard of dollar amounts being pumped into our system will drive change.  This makes for a tremendously exciting time in health care.

So the conclusion – is our health care system moving at a feverish pace or just suffering from fever? – the answer is yes (on all counts).  It does seem that change is inevitable.  With this change will come the dread, fear and pain associated with most any change. One solid antipyretic for the fever and the challenges of change is knowledge.  So let’s get out there, arm ourselves with facts, not anecdotes, understand the options and help drive the inevitable change to a positive outcome. As I wrap up this blog here is a start – a few basic definitions.

Universal access refers to the ability of all people to have equal opportunity and access to a service or product from which they can benefit, regardless of their social class, ethnicity, background or physical disabilities. It is a vision, and is in some cases a legal term, that spans many fields, including education, disability, telecommunications, and healthcare.

Preexisting condition is any illness, injury, or condition that existed prior to the effective date of an insurance policy.

The public option makes a public health insurance plan available in health insurance exchanges or gateways, alongside private plans, for some uninsured Americans.

Socialized Medicine is a term used to describe a system of publicly administered national health care.

Medicare serves people over age 65, independent of income, younger disabled people and dialysis patients (end stage renal disease). Patients do have to pay part of their costs through deductibles for hospitalizations and other services/costs. Monthly premiums are required for non-hospital coverage. There is a menu of services, policies and supplemental insurance. Medical bills are paid from trust funds. Everyone who pays into the system funds these trusts, currently that is all legally employed individuals via their FICA payment as well as tax on high-income Social Security recipients (retirees making > $44K annually). Medicare is a federal program ran by Centers for Medicare & Medicaid Services and it is basically the same everywhere in the United States. (Paraphrased from the www.hhs.gov website)

Medicaid is an assistance program. Medicaid is funded via a mix of federal, state and local tax funds. Medicaid serves low-income people independent of age. Usually patients pay nothing for covered medical expenses although sometimes a small co-payment is required. Medicaid services vary from state to state. Medicaid is governed by federal guidelines, but is run by state and local governments. (Paraphrased from the www.hhs.gov website)

Private Health Insurance is coverage by a health plan provided through an employer, labor union or is purchased by individuals directly from a private health insurance company.  The following is some additional detail on these 3 types of private insurance:

• Employment-based plans
  • Employment-based health insurance is coverage offered through an individual’s or relative’s place of employment. An employer or a union usually offers employment-based insurance.
• Self employed-based plans
  • Self employed-based health insurance is coverage offered to individuals with self-employed status.
• Direct-purchase plans
  • Direct-purchase health insurance is coverage through a plan purchased by an individual from a private company.

Dale Will
Associate Partner

[1] Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical, NHE summary including share of GDP, CY 1960-2005, file nhegdp05.zip; and Historical, Projected, NHE Historical and projections, 1965-2015, file nhe65-15.zip)

[2] http://www.nationmaster.com

[3] http://health.usnews.com/articles/health/healthday/2008/06/10/...

The past couple years have been tough on everyone.  Unemployment is over 10%, the economy has been weakened, many businesses have failed, and the job market has been bleak.  One bright spot in the economy, however, is the amount of opportunity that exists in the Healthcare industry, specifically in healthcare information technology (HIT). 

This is an exciting time to be in HIT.  Billions of stimulus dollars will be invested in healthcare over the next several years, and through the American Recovery and Reinvestment Act there will be significant investment in HIT.  This investment is expected to improve the quality of care and reduce the cost of doing so, primarily through the use of an Electronic Medical Record (EMR).  As a result, as many as 50,000 new HIT jobs, depending on whose estimates you believe, will be created over the next five years. 

Thousands of new jobs will be available for people to implement EMR solutions, train doctors/nurses on how to use them, integrate the EMR to existing information systems, as well as provide customization of the system to meet the needs of each organization.  The demand for RN’s and other clinical professionals with expert knowledge of hospital operations will be crucial to the successful implementation of EMR solutions.  Because of this demand, there will be plenty of opportunities for non-HIT, most notably physicians, nurses, and traditional IT resources, to transition into this area. 
While EMR solutions may be what you hear about most, there is significant opportunity for other HIT projects.  Security, Digital Imaging, and CPOE (among others) will be hot areas over the next several years as well. 

As we near the end of 2009, it’s exciting to think about the opportunity that lies ahead.  We are in an industry that is rapidly changing, and Santa Rosa Consulting has positioned itself to be a leading provider of these services to our clients.

Matt Welsch
Associate Partner
Santa Rosa Consulting

Answering this question first requires an understanding of the legal definition of a medical device. Section 201(h) of the Federal Food, Drug, and Cosmetic Act, defines a medical device as, "... an instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including any component, part, or accessory, which is ... [either] 1) intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease, in man or other animals ... [or] 2) intended to affect the structure or any function of the body of man or other animals." In short, a medical device is a physical, mechanical or software product that is intended for medical use. Note that the definition includes components, parts and accessories. With a medical device system, the network, server, client devices and related software are all part of the regulated medical device.

For many years after medical device systems first came to market, medical device manufacturers were responsible for the installation, service and ongoing support of their entire systems -- including the network. Medical device manufacturers maintained this control by installing physically separate networks, resulting in "islands of information." Recently, there has been increasing pressure to deploy medical device systems on enterprise networks. There are various reasons for this change. For medical devices that are deployed throughout the enterprise, it is not cost effective to install separate hospital-wide networks for each make and model of medical device that's widely deployed. Such an approach could easily result in multiple networks for patient monitors, telemetry systems, smart infusion pumps, and point of care diagnostic testing devices -- four networks in addition to the enterprise network. Medical device connectivity applications like alarm notification or advanced clinical documentation are also pulling medical device systems out of their private network environments in order to break down those islands of information and get data into other systems.

If you have a medical device, including any component, part or accessory that is running across a portion of your enterprise network, your network has become part of that regulated device. With the adoption of devices like wireless patient monitoring and smart infusion pumps, the only way to really determine if your enterprise network is a medical device (or part of one) is to do a comprehensive survey. Each medical device system should be identified, inspected, reviewed and documented.

So what if your network is part of a medical device system? The potential patient safety impact is such that the FDA hosted a meeting to consider regulating the deployment and use of networked medical devices in 2005. The outgrowth of this study group is IEC 80001, a "voluntary" end user standard for networked medical devices. (Voluntary is in quotes because it is expected that adoption of the standard will be mandated by some organization once the standard is completed in 2010.)

Medical device systems running on hospital enterprise networks do require an organizational response. The main justification is that unforeseen or unmanaged network problems -- problems that may have nothing to do with the medical device system -- could cause a failure that results in a patient injury or death. The challenge is that by moving medical device systems onto shared networks, the industry has created a chimera, a type of system that has characteristics for IT networks and biomedical devices but is different and thus something new in the hospital. In short, neither existing policies and procedures in IT or Biomed are sufficient to properly manage networked medical devices (hence the push to create IEC 80001).

There's been a lot of talk about moving the reporting relationship of Biomed from Facilities (where most Biomed departments traditionally report) to IT. In fact, the lines on the org chart have very little to do with meeting the patient safety challenges of networked medical devices. Besides the survey mentioned above, there are several other industry practices emerging for dealing with this issue.

Operating Framework

The first challenge is providing an operational framework for IT and Biomed to effectively collaborate. Issues include:

• Who "owns the clock" on networked medical device issues, information system support for these issues (IT help desk apps and Biomed asset management apps both have holes);
• The creation of a set of operating policies and procedures for managing this IT/Biomed chimera of networked medical devices, including bring IT discipline to medical device system installations and      configurations, and applying BIomed risk management to the enterprise network and networked medical devices;
• The implementation and application of the above operating policies and procedures to existing medical device systems, including gathering detailed specifications and regulatory details from medical device manufacturers, and audits of current network and system environments; and
• The application of all the above to the purchase and implementation of new medical device systems, including messaging middleware, medical device connectivity solutions and any other application that directly utilizes medical device data (all of which the FDA considers medical devices).

By removing these medical device systems from their private networks, onto the enterprise network, medical device manufacturers have lost control of the operating environment for their systems after their initial installation. The responsibility to maintain that operating environment -- which is increasingly your enterprise network -- falls on the health care provider.

In hindsight, perhaps the best medical device system is the one that IT never has to know about. But the reality of technology adoption is that medical devices are becoming just another information appliance on the enterprise network, albeit a rather specialized one. Continued workflow automation at the point of care means that there's no going back to the good old days of stand alone medical device systems. Future blog posts will delve into other medical device connectivity issues, how they impact the enterprise, and the standards and industry practices that are evolving to meet the challenges outlined above.

Tim Gee
Connectologist & Principal at Medical Connectivity Consulting

Look anywhere in the health care world and acronyms like EHR, EMR, PHR and PHI pop up.  What are they? That is pretty easy!  An EHR is an EMR with interoperability that feeds a PHR with PHI.  There you go – my work is done.  Seriously though, in today’s world acronyms abound.  So let me offer a few baseline definitions, just to level set for this blog:

EMR (electronic medical record) - The electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individual’s health and care

EHR (electronic health record) - The aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one health care organization and is managed and consulted by licensed clinicians and staff involved in the individual’s health and care. An EHR is an EMR with all levels of interoperability

PHR (personal health record) - An electronic, cumulative record of health-related information on an individual, drawn from multiple sources, that is created, gathered, and managed by the individual. The integrity of the data in the PHR and control of access to that data is the responsibility of the individual.

PHI (personal or protected health information) – any recorded information in any format, e.g., oral, written, or electronic, regarding the physical or mental condition of an individual, health care provision, or health care payment. PHI also contains demographic information able to specifically distinguish an individual.

Health Information Exchange (HIE) - The electronic movement of health-related information among organizations according to nationally recognized standards.

Health Information Organization (HIO)  - An organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards.

Regional Health Information Organization (RHIO)  - A health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community.

Electronic Patient Record - In 2002 McGraw-Hill defined an electronic patient record as the personal health library providing access to all resources on a patient’s health history and insurance information

The real heart of this blog is not simply to provide definitions offered.  Rather the goal is to pick an acronym from the list and try to figure out why adoption rates as so low and so slow to climb. 

EHR adoption rates in the United States are very low. A study entitled "Electronic Health Records in Ambulatory Care -- A National Survey of Physicians," was published by the New England Journal of Medicine and is available to readers at no charge.  The researchers said that other recent estimates of EHR adoption rates -- ranging from 9 percent to 29 percent -- may have been too high because those rates were "derived from studies that either had a small number of respondents or incompletely specified definitions of an electronic health record.  Our study indicates that electronic health records are available in the office setting to only a small minority (17 percent) of U.S. physicians at present."  Of the 83 percent of respondents who said they did not have an EHR, 16 percent reported that they had purchased but not yet implemented a system. Another 26 percent said that they had plans to purchase an EHR within two years. In the same report, a survey was given to the physicians with a fully functional EHR (this was a staggeringly small 4% of the approximately 2,700 physicians included in as the population of for the report) and the results showed a very positive review:

·         97% said they used all of the functions some of the time,

·         82% reported positive effects on the quality of their clinical decisions,

·         92% communicated with other health care professionals via the EHR,

·         72% communicated with patients through the EHR,

·         97% reported timely access to medical records, and

·         86% said medication errors were avoided

·         85% of physicians with high-functioning EHRs reported a positive effect on the delivery of long-term and preventive care.

So with these glowing accolades why does adoption remain in the basement? A potential three-legged stool exists with two of the legs being cost and complexity.  The third leg, perhaps the most subtle and important is organizational readiness and specifically the preparedness of the medical staff governance model within a hospital or Integrated Delivery Network (IDN). 

So, how do physicians and hospitals structure their working relationship?  What are the challenges for hospital management in the traditional relationship between hospitals and physicians?  What are the factors that are driving change in that relationship and how is it changing?

Physician/Hospital Employment Model

The relationship between hospitals and physicians is fairly unique in the business world because at any given hospital, many of the physicians with admitting privileges to a specific hospital are not employed directly by the hospitals, in other words they are independent of the hospital. This model presents some interesting challenges since hospitals are dependent on admissions to generate a majority of their revenue, and these non-employed physicians generate the majority of the admissions.  The net is that the hospitals have traditionally had to be very cautious in how this relationship is managed.

Although the majority of the “admitters” are self-employed, there are several categories of physicians that are directly employed by the hospitals.  These categories include hospitalists, intensivists, and administrative types such the CEO, CMO, CMIO and others.  Other roles such emergency room doctors, faculty at teaching hospitals and researchers can be employed, independent or contracted and are usually a mix.  In any case, this is a very tenuous relationship between hospitals and physicians that is usually managed with kid gloves since if the “admitters” go away so does the revenue.  This employment model makes it much more difficult for hospitals to insist on HIT usage and thus there is no solid and consistent way to incentivize usage/adoption.

Governance of the Medical Staff Within the Hospital

The medical staff, i.e., the physicians given privileges to provide care at the site, can be broken into the following categories:

·   Active

·   Affiliated

·   Honorary

·   Consulting

·   Teaching Affiliate

·   Courtesy

·   House Staff

The medical staff is often governed by a separate and relatively independent organizational structure that is established within the hospital and is usually hierarchical.  Additionally, the medical staff officers notwithstanding, the medical staff governance is usually structured by specialty and follows this order/structure:

1.  The  Medical Staff Officers, i.e., President, Vice President, Secretary, and Treasurer
2. An executive committee
3.  A series of committee chairs
4.  A series of department heads

All physicians that have privileges at a hospitals, whether employed, independent or contracted, are members of the medical staff and as such are governed by a series of hospital board approved bylaws that cover things such as:

·         ·         Medical Staff Membership, Qualifications and Privileges  Ethics
·         Disciplinary Procedures
·         Medical Staff Structure and Terms
·         Overall rules and regulations

Challenges With the Traditional Model

As previously discussed, traditionally independent physicians made up the majority of medical staff members and have done an effective job of “self-policing” through models similar to those described above.  Essentially, in the traditional model the hospital takes care of managing the physical plant and provides “workspace” for the physicians to work, i.e., provide care to individual patients.  This model has worked well in the past, but as new pressures for the meaningful use of HIT come to bear and financial incentives and penalties are introduced as Bob Dylan says “The Times They Are A-Changin’”.

The hospital/physician relationship is becoming increasingly complex in the changing world of healthcare.  Physicians traditional role of treatment of patients, is transitioning  more and more as the physician can be a vendor, partner, board member/trustee, contractor and/or an employee of the hospital. In many cases a physician can have multiple roles. Combine this morphing of traditional roles with the intense pressure the hospitals are receiving to adopt HIT, improve quality and patient safety, provide community-based care and build market share while coping with with dropping reimbursements and it becomes apparent that the hospital and physicians are intertwined and cannot go this alone.  The traditional model draws clear and succinct lines between the hospital and the medical staff, the changing and complex business environment smudges and blurs those lines to a degree the traditional medical staff model can no longer support.  The hospital and medical staff must move as one, not as independent entities. 

How is the Medical Staff Model Changing?

From a practical perspective, many hospitals are requiring physicians to sign employment agreements and exclusive contracts.  This helps untangle, to a degree, the relationship web and enables the hospitals to exert more control over quality of care, patient safety, IT deployment and usage as well as provides a manageable level of staff stability.

From a more conceptual level, the traditional medical staff governance model has to be redesigned into an integrated and key component of the hospital, not as an independent organization within the hospital.  These shifts will cause the medical staff to be more accountable for the goals of the hospital as opposed to viewing the hospital as “leased space” – in other words these shifts are intended to get the medical staff more “bought in” to the daily operations of the hospital as well as the hospital’s long-term vision.

From the hospital perspective, changes in the medical staff model will require hospitals to include physicians in:

·         Long term strategy development

·         Approaches to improve quality, safety and general operations

Succinctly stated, the new model requires a partnership where hospitals become more inclusive and physicians become more trusting and willing to operate as a unit.

And the point…

When deploying, upgrading, or acquiring an EHR, organizational readiness/sponsorship has been regularly reported to be more important the actual technology.  If the medical staff is not properly aligned, adoption will not succeed and the EHR project will be a black hole that devours cash, time and careers. Bottom line, as organizations assess their readiness for HIT, they must not forget the medical staff and how they are governed and interact. 

Dale Will

Associate Partner

My last post explained how the system in healthcare IT was flawed and how it was important for buyers of healthcare IT systems to understand the limitations of the system in order to achieve the results they expect from the system.

I posted that vendors are optimized around getting customers to commit to transactions where customers need optimized workflow, maximized adoption and flexible applications and technologies.   If you are following along with this line of thinking, you will then understand that vendors are not well positioned to ensure that their customers are implementing their systems effectively.  It is a shame, because you would expect that vendors should be the most qualified to optimized their product.

Oh contrar, because vendors spend so much of the licensing and maintenance fees on their sales team, they are not well equipped to perform well on the implementation (and maintenance) sides of their companies.  So, what do they do?  Generally, they will send their implementation team to understand your current processes so that they can model the same processes in their system!  Their standard approach is to put the rocket on the dog.  This is the worst possible scenario.  Why would anyone pay $1M, $10M or even $20M to do things the exact same way?  As Albert Einstein said, "Insanity is defined as doing things the same thing over and over again and expecting different results".

So what is a buyer to do?  Here is what we have done to ensure that our clients consistently achieve their intended results from systems implementations:

1. Recognize that the vendor is not the best resource for optimizing your workflow and maximizing adoption and take ownership for both of these (or assign this responsibility to a firm like Santa Rosa)
2. Make sure your intended results are gathered, documented and measured regularly; 
   1. Hold your vendor and your consultant accountable (via payment terms) to business results in addition to meeting milestones
   2. Establish a project outcome dashboard at project initiation and report the results regularly;
   3. Hold leadership (both IT and Clinical or Administrative) accountable for the results
3. Follow Santa Rosa’s unique and proprietary vendor selection approach.  Please contact me for more information on this.
4. Use concepts such as Lean to design optimized workflow taking full advantage of the new system’s capabilities
5. Develop a “marketing-like” approach to adoption that includes great communication, education, and hand’s-on support during and after go-live;  Tier levels of communication, education and support based on expected use of the system
6. Supplement your implementation team with people that have implemented the system MANY times in several different types of environments so that you get a team that does not have a “one-size fits all” approach.
7. Ensure that you incorporate a proof of concept phase in your implementation so that you can see the vendor’s product work in your environment with your data and all your other constraints
8. Compress your implementation timeframe as much as possible;  Multiple year efforts are sometimes necessary but not optimal;  it is very hard for any organization to keep focus on a large scale change initiative for over 12 months.

Please contact me if you are considering a new system as I know I can help you improve your outcome by thinking about your implementation with a focus on optimized workflow and maximized adoption.   We have developed a fantastic ARRA / Meaningful Use Gap Analysis offering that anyone pursuing stimulus dollars must take advantage of to maximize your chances at meeting imposed timelines.

PLEASE do not put a rocket on your dog!

Until next time,
Joe Lavelle  Partner and National Practice Leader, Healthcare Provider Consulting Services
LinkedIn Profile 
Twitter @Resultant

I had a true “aha” moment while sitting in the audience during Tim Gee’s presentation, “Everything is Connected at the Point of Care”, at the New Jersey and Delaware Valley Chapters of HIMSS Fall Conference last week. This was one of the first conferences I attended where I knew many of the attendees personally as I live in the area and have known these IT professionals and clinicians for many years. I watched the reaction of many of them during the presentation and chatted with several after the session. My conclusion? Nurses get it. Clinical engineers (though few and far between at the conference) get it.  Many IT professionals still do not.

What don’t they get? That there is a growing impact or even a true threat to patient health and safety from the rapid yet disconnected implementation of medical and information technology at the point of care. (More information cited by Tim can be found in the attached presentation or here, here, and here). To many of the IT professionals, connectivity is about plumbing. It is not. Medical device connectivity is all about workflow in the service of patient safety and the clinician.

I think it’s safe to say that every hospital represented at the conference is dealing with the following issues.

1. Implementing sophisticated medical devices with embedded computing capabilities, including point of care diagnostic devices, patient monitors, telemetry packs, “smart” IV pumps, ventilators and spot vital signs devices
2. Managing an array of communications modalities at the bedside including nurse call, overhead pages, PDAs, barcode readers, computers on wheels, pagers and wireless phones
3. Nurses who must address an array of bedside tasks, not the least of which is hands-on patient care, but also documentation, alarm management, patient assessments and medication administration

The complexity and disparity of systems (people, process and technology) surrounding the point-of-care  can lead to noise, confusion, and an interrupt-driven environment with consequences such as alarm fatigue, failure to rescue, delays in care, and work flow poorly aligned with how clinicians really do their jobs.

If the vigorous bobbing of heads by the nurses seated in front of me was any indication, we are not managing this well.  What’s missing? I suggest it is the lack of strategic analysis to wrap our arms around this growing interrelated, multi-vendor ‘system-of-systems’.  Yes, each individual medical or information technology decision is assessed, but what about the big picture? Evaluating individual point-of-care applications in a vacuum can result in waste and complexity as previous phases are replaced or modified to support unanticipated impacts from subsequent phases.  We need  to apply the same rigor to evaluating needs, performing risk & budget assessments and taking the necessary steps to measure the impact of adding new component to the ‘system-of-systems’ that we do when replacing applications in our HIS systems.

It’s time for IT professionals to get into the game. They need to understand the interrelatedness of the complex clinical systems they are building piece by piece over time. They must actively contribute to the processes to select, implement & support all components of point of care technology – particularly as they “ride” on the hospital’s IT network.

An excellent reference for IT professionals is the publication, “Medical Technology for the IT Professional,” offered by ECRI Institute, a nonprofit organization dedicated to bringing the discipline of applied scientific research to discovering which medical procedures, devices, and drugs are best to improve patient care. Here’s what ECRI suggests every IT professional should know to assist their hospital to develop an effective ‘system of systems’.

1. Understand the criticality of their work on patient care and recognize that diverse stakeholders must come together to select, implement & support point of care technology
   • Clinical groups (nursing, radiology)
   • Support groups (clinical engineering, biomed & IT)
   • Administrative groups (risk management, contracts/purchasing)
   • Technology vendors & manufacturers
2. Understand the technology at point of care
   • Physiological monitors
   • Infusion technology
   • Asset tracking systems
   • Clinical laboratory
   • OR integration & surgical video systems
   • Anesthesia information systems
   • Telemedicine
   • Imaging systems
3. Know how to
   • Integrate systems & devices in a multi-vendor environment
   • Develop an IT infrastructure to adequately support medical technology and devices
   • Implement reliable wireless systems
   • Comply with standards and regulations
   • Mitigate IT security issues
   • Ensure patient safety and reduce risks
4. Be familiar with IT’s role with regard to compliance
   • Regulations governing medical devices
   • System security and accessibility
   • Hazard and recall management
   • Problem reporting and incident investigation
   • Service and support
   • Standards-related initiatives
   • Environmental concerns

Let’s get going…

Everything Is Connected at the Point of Care by Tim Gee_DV-NJ HIMSS.pdf (3.89 mb)

Why is it I always dread going to the doctors?  Not only the obvious reasons – I am sick or perhaps will be told I have some sort of ailment after going to my annual physical - but just the overall experience of filling out forms with information my doctor should already know like my name and waiting, waiting, waiting. 

This week, I had my best patient experience ever when I brought my daughter to her first orthodontic appointment.  I was amazed at how the use of some simple technologies could make such a difference and had to question why all of my visits couldn’t be the same. 

When I first entered the office I looked around and immediately saw a difference; Dimmed lights with a warm and inviting atmosphere.  As we approached the reception desk, my daughter was asked to scan her fingerprint. At her next visit she would sign in using her fingerprint.  Next I was handed a set of forms to complete. Yes - the dreaded forms.  I was shocked to find that all of the information I already provided over the phone was pre-populated on the forms.  Next - the dreaded wait. What, no wait?  Within minutes we were in the exam room.  In the exam room I sat at a small conference table across from the doctor’s assistant and watched a YouTube video of a new procedure this doctor uses.  They use robots to bend wires; improving accuracy and decreasing the amount of time a patient is required to wear braces.  Next, the doctor arrived. His assistant opened a template on the computer and began typing in the doctor’s evaluation, recommended treatment and next steps.  Within minutes of the doctor leaving the exam room, his assistant printed out and handed me a very professional evaluation including estimated fees and payment plans.  We reviewed together and agreed to next steps of having more x-rays taken.  She opened a calendar on her computer and sees that there is an opening in the schedule, so she IM’s the x-ray technician asking that she come get my daughter for an x-ray.  Quickly a knock on the door and my daughter was off to receive x-rays. 

Next steps would be a comprehensive consultation to review x-rays, discuss treatment in detail and schedule out additional office visits.  Hmmm, how am I going to fit this into my busy schedule?  Not to worry. No need to come to the office for a consultation. We can do this all remotely using a GoToMeeting.  Great! So we scheduled the appointment and I was asked if I would prefer to receive appointment reminders via text or email.  Next I needed to pay for the x-ray. Using a credit card reader connected to the computer, she scanned my card, I signed a pad and watched my signature appear on the computer screen on a pr-populated receipt, she printed and handed to me. 

At the end of the appointment I was provided a little post card and asked to provide feedback on my experience via their website, which turned out to be a blog used to capture feedback.  The post card also outlined the top 10 things I could do on their website, like helpful hints to calm a pokey wire, check office hours, view videos, securely log in to check my appointment schedule, view x-rays and check my balance. All of this was accomplished in the exam room, no need to return to the reception desk.

I have to say, I was quite impressed as was my daughter. She asked why all doctor visits couldn’t be that fun. Most of these technologies are used by us everyday, however, I have never seen them put into play as a part of my patient experience.  Why is that? 

 
Reta Lock
Chief Technology Officer
Santa Rosa Consulting

Every so often, an organization must look to evolve its application infrastructure.  One of the essential elements of this infrastructure is Enterprise Application Integration (EAI) environment.  And in healthcare, the middleware or interface engine is the heart of the EAI strategy.  Introducing or replacing an interface engine in this environment can be a daunting and expensive task.  But when IT chooses and implements the right solution, the benefits to the organization can be amazing.

Middleware in the healthcare provider market has long been dominated by two or three vendors with mature products.  Over the past few years however, acquisitions, consolidations and new technology have led some to question which direction should they take when buying or replacing their middleware platform. 

As with any system selection, a thorough understanding of the things to look for in a vendor and their offerings will allow your organization to choose the most appropriate, cost effective solution that will serve you for years to come.   Aside from feature/function, there are other things to consider.  In this article, I have outlined some of the common considerations when selecting a middleware vendor.

Feature/Function

The basics must be covered to even entertain a vendor solution today.  For healthcare providers the minimum requirements would include:

·          Guaranteed Message Delivery

·          First In/First Out message process (when required)

·          Support for standard communications protocols like SNA, TCP/IP and File Transfer

·          Native support for messaging standard such as HL7, ANSI X12 (HIPAA), and XML

·          Support for database connectivity via ODBC

·          Support for Web Services

Based on existing and emerging industry trends, the following could arguably be considered requirements from today’s technology: 

·          Open architecture such as JAVA, C++, VB

·          Ability to run on multiple hardware and OS platforms

·          Able to run in the prevailing high-availability models

·          Availability of complete libraries of standard messages structures

·          Support for source control and version management

·        Ability to customize communications clients

·       Centrally managed administration and configuration

·        Alert notification mechanism

Scalability

There are many paradigms utilized in the available tools today from traditional Hub and Spoke to Federated, to Peer to Peer.  The size and complexity of the organizations business model often dictates this requirement.  A stand alone hospital running a single vendor solution with limited outside interface requirements simply does not have the same requirements as a multi-facility, best-of-breed Health Care Organization (HCO) serving as a regional reference laboratory.   All paradigms can be made to work, but have obvious implementation considerations that affect complexity and cost.

Skill Availability

Regardless of any vendor claims, no middleware package can be learned with proficiency in a week.    Although most solutions require substantially less programming for typical interfaces than in the past, all solutions are simply technical tool kits that enable the integration process.  Access to quality training, the local recruiting environment, and the availability of vendor or third party resources is important in a product selection.   Things for consideration include:

·          Is the technology used proprietary or open?  Will I be able to find these skills in my geographic area?

·          Does the vendor supply quality training at sufficient frequency for the engineers and management?

·          How robust is the vendor’s professional services organization or can I find third party consultants when needed?

·          Are there other large and aggressive organizations in my geographic area that will hire away my trained and productive staff?

Security

HCO’s continue to identify and remediate IT security risks.  Often forgotten in this process are the middleware tools.  The very tools designed to break the barriers of application limitations and responsible for business content connectivity and delivery.  Not to mention, they are themselves applications, and should be evaluated and secured just as any application in the enterprise.    Vendors should be able to confidently address their solution’s security model and available technology to enable secure communication with internal applications and external trading partners.

Community Support

Never underestimate the benefits of an active and open user community.  These communities or user groups can be of immense benefit to the engineering and support staff throughout the life of the solution.  The activity and openness of the community and the vendor’s support can be instrumental in the solutions success.  You can evaluate the effectiveness of these communities by answering the following questions:

·          What is the activity level of established user groups?  ie. Code and library sharing, success stories, conferences, and open discussions.

·          Does the vendor support the user groups by providing mechanism for collaboration? 

·          Does the vendor monitor and contribute to discussions?

·          Does the vendor filter negative content in user group discussions?

·          Are third parties, such as consultancies, welcome to participate?

Cost

Each vendor has a different model for solution pricing.  Some offer enterprise licensing, some charge by connection, some have third party costs.  As with any purchasing decision, be sure to consider the hidden costs with implementing a vendor solution.  These include:  hardware, third party development software, training, consulting, source control, annual support, database licensing, connections, etc.

Support

When the integration environment goes down, you need help immediately.  When you have questions or problems about the product, you can’t afford to halt an implementation for a week or more.  How effective a vendor supports its clients is critical in the selection process.  Evaluate the vendor’s various support options and associated cost.  Talk with other similarly sized organizations and their personal experience.  Ask the vendors what support metrics they internally track and what their goals are.  In the new era of the “electronic hospital”, the interface engine is the central hub of business process activity, and you must feel confident that vendor can support the organization adequately. 

Each of the leading middleware vendors can get an HL7 message from point A to point B.  That is where the similarities end.  The vendor’s focus and strategy, product architecture and functionality, ability to support their customers, and cost differ significantly.  There is a best choice for each organization, understanding these aspects can help your organization make the right choice.  

Santa Rosa provides expert assistance in assisting our clients in making the right technology choices. Please let us know if we can be of help to you organization.   

Dan Rounds, Associate Partner

The industry is buzzing with anticipation and almost giddy at the prospect of the billions of dollars available in American Recovery and Reinvestment Act of 2009 (ARRA), perhaps better known as stimulus money. Specific to Healthcare Information Technology (HIT), ARRA provides approximately $19 billion for Medicare and Medicaid Health IT incentives over five years (with estimates of $36B over 10 years) as well as $1.1B for Comparative Effectiveness Research (CER) – certainly those dollar figures have the potential to put a smile on many Health IT corporate faces. 

Overarching the ARRA money is the Meaningful Use Matrix.  This matrix will lay out a series of requirements and measurements to assure meaningful use of the HIT and compliance with meaningful use and thus the money.   So what is the big deal about meaningful use, well it is the government’s financial stick to improve healthcare.

Here is a very short overview:

·     Authorizes ONCHIT to provide competitive grants to states for loans to providers.

·    Medicare incentive payments would be based on an amount equal to 75% of the Secretary’s estimate of allowable charges, up to $15,000 for the first payment year.  Incentive payments would be reduced in subsequent years: $12,000, $8,000, $4,000, and $2000, after 2015. 

·    Physicians who report using an EHR that is also capable of e-prescribing would be eligible for EHR incentives only.

·    Early adopters, whose first payment year is 2011 or 2012, would be eligible for an initial incentive payment up to $18,000.  In 2014, the payment limit would equal $12,000

·    For eligible professionals in a rural health professional shortage area, the incentive payment amounts would be increased by 10 percent.

·    Physicians cannot take advantage of the incentive payment programs under both the Medicare and Medicaid programs

·    Physicians who do not use a certified Health IT system would face reduction in their Medicare fee schedule of -1% in 2015, -2% in 2016, and -3% in 2017 and beyond. 

·    Allows HHS to increase penalties beginning in 2019, but penalties cannot exceed 5%. 

If you made it past all these criteria, the real question is much bigger – the point of all this is to improve the quality of care in our healthcare system, improve patient satisfaction and drive down costs.   The Meaningful Use Matrix requires a myriad of reports to support the meaningful use claims.  In any case, the concept is fantastic although is it realistic?

You can say it has to be, but historically incentives like these may not be the drivers especially if the use of EMRs does not save a clinician time or enhance their decision-making capabilities.  Additionally, perhaps the hardest component of the Meaningful Use Matrix is not adoption of HIT, but the reporting requirement associated with HIT.  Let’s focus on one seemingly easy report that is a required measure of meaningful use in 2011 (as specified in the meaningful use matrix).  The measure requires reporting quality measures to CMS such as percent of diabetic patients with A1c under control.   Seems relatively easy.  From a human perspective it is, but meaningful use requires use of HIT – this presents a huge increase in complexity.  Let’s pick it apart:

1.      If the are multiple systems how do we track what a A1c test is, it maybe be denoted as Hemoglobin A1c, HbA1c, diabetes blood glucose test, diabetes blood test, blood test for insulin levles, diabetic blood glucose test just to name a few.  This is a complex and expensive issue to program a computer to recognize all these different semantics.

2.      Reference ranges - these vary by age, sex, race, and even ethnicity, but are required in order to build the report.

3.      What is a diabetic patient, again easy for a human to understand – massively complex for a computer.  Is it a diagnosis code, a DRG from the billing system, a compilation of lab results, how do you tell a computer what the profile for a diabetic patient is?

4.      Under control – this is a potentially ”fuzzy” objective call for even a human, let alone a computer.

So how meaningful is meaningful use?  The example above is just one of many, many reports each with a level of complexity of at least this magnitude.  One component that may help is interoperability.  Interoperability comes in two basic flavors, semantic and syntactic.  Semantic interoperability is the ubiquitous use of standardized vocabularies so data can be exchanged and the meaning kept intact.  In out A1c example, LOINC codes would help significantly.  Syntactic interoperability is the standard formatting for machine-to-machine exchange of data, i.e., HL7.  The challenge for syntactic interoperability is that the power and beauty of HL7 comes in its flexibility.  Flexibility is the archenemy of interoperability.  Flexible, interpretable formats introduce complexity and variability – exactly what is not needed.   The semantic challenge is tha the industry as a whole has wrestled with standard vocabularies for decades with some progress, but no generalized acceptance.   Moving forward interoperability of all kinds will be required, but is it realistic to have implemented by 2011 – most likely not.

In any case, these reporting requirements of Meaningful Use have the true potential to dampen, diminish or even nullify the industry attempts at Meaningful Use.  Does this mean we should just save ourselves the headaches and fold up the tent and go home - absolutely not!  What it means we, as industry professionals,  proceed with the caution and care demanded by the situation.  Meaningful Use is indeed meaningful, perhaps just not in the compressed timeframe.  The reporting requirements of meaningful use are the elephant in the room and we all know how to eat an elephant – one small bite at time.  So get your knife and fork ready and start finding the perfect spot for that first meaningful bite.

Dale Will

Associate Partner

Photo Source: http://chilmarkresearch.com/2009/06/26/our-meaningful-use-comments/

With all the discussion surrounding the ARRA and HITECH legislation one cannot help but wonder – what about all those on the “early adoption curve” for their EMR?  When systems were installed in the late 90’s and To Err is Human had not yet been published – it was impossible to build for standards that had not yet been developed or even identified?  In the intervening years as the pressure has built to further develop our information system environments the competing priorities have been overwhelming at times.  The regulatory environment has imposed the “un-funded” mandates and the easy patch for these needs have been manual chart review and abstraction to answer the call for information.

In early 2009, I worked with a client on an engagement that allowed for a review of some of these challenges.  There was one hospital with a well established CIS installed with default design decisions that force patient safety measures to be abstracted from the manual chart.  An example was noted in the Emergency Dept where the time frame from patient arrival to antibiotic administration in instances of community acquired pneumonia is measured.  The default time documented as the ED nurse charts is the time the medication was ordered – not the time administered or even the time charted.  This means for reporting this important JCAHO Core Measure/CMS quality measure is reviewed by hand!   There was not the opportunity to explore how many instances of this type of decision exist but it seems obvious that the potential is there to uncover more?

The opportunities presented by ARRA and HITECH require organizations to optimize their installed systems for meeting the new meaningful use measurements.   One would hope there will be comparisons of patient safety and quality standards with meaningful use standards and develop methods to meet both.  This is work that can lead to decreased time by the quality staff and also help the organization to meet meaningful use standards.  This is work that can be done to both assist in accomplishing both meaningful use and quality and patient safety standards by optimizing the current environments of the far sighted early installers of EMR applications and systems.  Santa Rosa Consulting is helping our clients do just as I suggest.  Please contact us for more information.

Karen Hollingsworth, RN, MS, CPHIMS
Associate Partner
Santa Rosa Consulting

Photo Credit: Redwood Area Hospital Copyright © 2009 http://www.redwoodareahospital.org/patient%20safety/mha.htm

I recently returned from the inaugural Medical Connectivity Conference held in Boston from September 10-11. It was a good conference, but it can make a person’s head spin with all of the Use Cases, updates from industry standards development groups (IHE-PCD, Continua, ICE, HITSP), an alphabet soup of communication and connectivity standards (DB9, DB22, RJ45, ASTM F29, iS77,ZigBee, 802.11n), and new compliance mandates for managing networks connected to bedside medical devices. It’s a jungle out there.

What does all this mean to our clients considering patient care device integration (PCDI) and other point-of-care technology? Let’s start with the obvious. This stuff is complicated. There are, as yet, no plug-and-play solutions for device integration in the acute care environment. However, there are very tangible patient care and patient safety benefits to be derived from PCDI and the overall convergence of medical and information technology.  There are also external drivers accelerating the adoption of new integrated systems, not the least of which is the ONC’s 2015 target objective to achieve medical device interoperability as part of “meaningful use.” If you add to that the expected publication in 2010 of the IEC8001 standard, which defines best practice for managing risk associated with enterprise networks incorporating medical devices, it becomes obvious that hospitals need to start planning now. The convergence of medical and information technology will bring a sea of change to how we select, test, implement and manage point-of-care technology and the wired and wireless networks on which it resides.

So, how to begin? Always a good place to start is to have a road map for point-of-care technology in your organization. Envision the future; asses your current environment; develop tactical plans for acquiring and deploying technology to achieve your patient safety and patient care goals; and determine your tolerance for risk. Engage nursing leadership to understand how workflow can be optimized at the patient bedside with stationary and mobile technology, and how it can be integrated with the hospital’s enterprise network and clinical applications. Bring in clinical engineering to learn how they’ve managed risk associated with life critical and life support networks. Encourage biomedical engineering to educate your team about how medical devices are increasingly incorporating PC-functionality and how equipment management systems are evolving. And, last but not least, have your information systems professionals bring to the table their competencies and knowledge of network management, clinical information systems, data integration, and project management.

It’s time to get started. In future point-of-care technology blogs we’ll discuss market ready components of PCDI, how to interrogate vendor offerings, which standards development organizations you should watch and how to get involved, how biomedical and IT departments need to rethink Help Desk and field support services with PCDI, and many other related topics. Let us know which ones are vexing you the most. For more information about Santa Rosa’s PCDI and point-of-care technology advisory and implementation services, click here.

Marilyn Hailperin

Associate Partner

Hopefully this slide from the thought leaders at Sg2 makes you laugh? But the reality of it makes me cry… The truth is that the incentives and motivations of healthcare IT vendors are not aligned with their customers, and this particular vendor achieved their objective, getting paid for a shipped system.  It is not the fault of the vendors or their customers, "it is just the way it is."

After reading the book Freakonomics, I was able to understand the problem better. Among other great insights, Freakonomics posits that many systems and economies are inefficient and are built on misaligned incentives. The fact is that the Healthcare IT Vendor economic model is built upon vendors obtaining transactions with customers. However, customers do not need transactions, they need the latest functionality available with optimized workflow, maximized adoption and agile infrastructure. The bigger problem is that vendors create the illusion that they will give customers what they really need by obtaining a transaction and many customers experience years of frustration after signing a contract.

The “system” at vendors is designed and optimized around obtaining a transaction, getting you to sign the contract. Customers see large quantities of “suits” from a vendor prior to signing a contract, but once a customer has signed a contract the vendor is incented to do as little work as necessary to get a customer to accept the system so they can start reaping the benefits of maintenance revenue for years. The suits are swiftly replaced with a project manager that is responsible for many other customers concurrently, a few days of a “workflow specialist” and a “train the trainer” briefing.

I am sure by now that vendors have stopped reading and those of you at healthcare organizations are vigorously shaking your head in agreement. I wish that I could simply be labeled a pessimist and an exaggerator, however, I have participated in hundreds of negotiations and implementations between healthcare organizations and vendors, and what I describe is the norm, not the exception. Even though I have grown used to this, it still disturbs me thoroughly.

So, what is a healthcare organization to do? For years I tried to help my clients change the system, but after reading Freakonomics, my team and I started creating solutions and services that would exploit the current economics and systems, to make it easier for Vendors to get transactions and to make it possible for customer to get optimized, adopted and agile implementations. I will continue to blog about our approaches and how they will revolutionize the healthcare IT industry here on our blog and I hope you will follow along so that we can work together to make the best use of ARRA stimulus dollars toward implementing your EMR/EHR, Imaging and/or HIE systems.

Until next time,

Joe Lavelle  Partner and National Practice Leader, Healthcare Provider Consulting Services

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Slide Credit: Sg2 ©2004