Thinking of adding a chief medical information officer to your IT staff? You can't just pluck anyone from the doctor's lounge and consider the job filled. Here are five key attributes that should be part of the job description for any CMIO.
1. Must have leadership, communication skills
It might seem a little obvious, but CMIOs can't effectively champion electronic health record systems if their peers won't listen to them. "This physician has to be more than just a clinician, they have to be a leader," says Edward Marx, CIO at the 13-hospital Texas Health Resources in Arlington, TX. "That's what helps make an excellent CMIO."
Jon Morris, CMIO at WellStar Health System in Marietta, GA, agrees that the CMIO must be more than a spokesperson. "Don't misunderstand: I'm out there selling a lot of the time, but I also act as an interpreter [and] facilitate engagement of other providers."
Morris' communication skills and the fact that he has the respect of his peers is what makes it work, says Ron Strachan, senior vice president and CIO at WellStar. "Physicians need to be involved and they need to be involved from working with a peer, a respected peer, because I or any other CIO that's not a physician can stand up and essentially preach all day long about values of their involvement in various projects and process change, but I'll never have the credibility with the physicians at large when compared to one of their peers. There's no replacement for that," Strachan says.
2. Must work well with others
The ideal candidate should also have a collaborative and innovative spirit. "I like to be innovative in our use of information technology and finding ways to use technology to drive better performance from the healthcare system, whether that's in terms of the clinical outcomes or patient safety or efficiency," says Ferdinand Velasco, MD, THR's CMIO.
Marx, he adds, has a similar viewpoint. "He complements me from the standpoint of being very innovative, very focused on continually raising the bar. Those are the attributes that have contributed to our successful working relationship."
3. Must have a passion for IT
A CMIO should also have more than a passing interest in technology. Velasco says he has long been passionate about IT and using it to improve healthcare.
"Even back in the days when I was a medical student, I was doing research and finding ways to use data and information systems, as rudimentary as they were back then, to automate the research process or the clinical processes. And that's something that continued into my residency and in my fellowship," he says. "It was a natural transition to go from that into a formal role as the physician leader for informatics."
4. Must be part of a diverse team
If one clinician in the IT department is good, more than one is even better. At THR, 30% of IT staff members are certified clinicians—and the system recently added its first chief nursing information officer. A CNIO can help build a relationship between technology leaders and nursing leaders and, in turn, reach nurses, who are usually a healthcare organization's largest group of employees.
5. Must show results
At THR, physician engagement is particularly important—because most physicians are not employed, EHR adoption is voluntary. And although it didn't happen overnight, physician adoption is now "essentially universal," Velasco says. At the 12 hospitals with live EMRs, physicians document more than 90% of their progress notes, CPOE adoption exceeds 80%, and 65% of its order sets are standardized.
"We're very well positioned for meaningful use because of those adoption rates," Velasco says.
Adds CIO Marx: "We would not have achieved the level of success without the CMIO."
You can read more about the CIO-CMIO teams at Texas Health Resources and WellStar Health System here, in this month's issue of HealthLeaders magazine.
Health workers around the world are using mobile devices and wireless technologies to track infectious diseases, conduct research, treat patients, and bring access to modern healthcare to patients in developing nations, remote regions, and rural villages in ways never before possible. So what's keeping the U.S. from doing the same?
Bureaucrats who won't invest in unproven programs, policy wonks who fret about lack of regulation, and a widespread skepticism and lack of understanding of the benefits of mHealth, for starters, according to an international panel of experts and government officials at the mHealth Summit in Washington, DC, this week.
"American doctors don't know anything about mHealth," said K. Ganapathy, PhD, president of the Apollo Telemedicine Networking Foundation in India. And while that might be a bit of an overstatement, the general consensus among panel members is that if the U.S. wants to catch up with the rest of the world, it had better start paying better attention to mHealth—and building upon some of the many pilot programs taking place in other countries.
"To some extent it's true that scaling up is an important part but I think we've got a long way to go," said David Gustafson, PhD, director of the center for Health Enhancement Systems Studies at the University of Wisconsin Madison.
Like search results on the Internet, there are still an overwhelming number of health applications for patients and clinicians to choose from with no good way to determine which ones are helpful—and no guarantee they won't actually be harmful. Interfaces and devices are not always user-friendly, especially for older patients who might have trouble seeing small cell phone screens or punching tiny cell phone buttons, he added.
And he agrees that the U.S. healthcare system and healthcare consumers still haven't embraced mHealth and don't necessarily understand its potential benefits. "Right now there is skepticism except for a few enthusiasts like us," he said.
The world doesn't have time for large, randomized control trials that could take years to show whether mHealth can improve outcomes and further stall implementation, panelists said.
But governments will be reluctant to invest in mHealth technologies without that kind of data. The problem is compounded by the lack of awareness of potential for mHealth among bureaucrats and other stakeholders, said Ganapathy.
Public-private partnerships and commercial ventures could help speed things along. "In my country we are in a position to make mHealth private," said Mwendwa Mwenesi, MD, who coordinates the Phones for Health program for Tanzania's Ministry of Health and Social Welfare. "We are seeing that is the only way we can move forward."
"India is very open to public-private partnerships and this is a reality—not just a slogan," said Ganapathy. But Gustafson said the U.S., at least, should proceed with caution. "I don't think we can just turn it over to the private sectors and say 'Go for it,'" he said.
Another solution is to publicize the many mHealth success stories, said Allen Wade Hightower, chief of data management activity at the Centers for Disease Control's Center for Global Health. The task ahead, he said, is to win the confidence of senior management at agencies such as CDC. "Once they see that this technology is working and helping them do more with fewer resources, they'll buy into it," he said.
And, he added, forums such as this one, which organizers said attracted about 2,400 registered attendees from nearly 50 countries, is one way to do just that.
Prosthetics technology has been advancing rapidly of late, with a number of breakthroughs or emerging technologies that will help those with artificial limbs feel sensations such as pressure and heat and, as a result, move more naturally with more exact dexterity. Grasping a small item such as a cup of coffee, for example, would be much easier if there were a two-way interface between brain and fingers.
The Department of Defense has such high hopes for the technology that they’ve granted researchers at Dallas’ Southern Methodist University’s Lyle School of engineering $5.6 million to create a research facility to work on lightning-fast connections between robotic limbs and the human brain for injured soldiers and other amputees.
The key, researchers believe, is light. More specifically, fiber optic links that would send signals seamlessly back and forth between the brain and artificial limbs.
“Currently available prosthetic devices commonly rely on cables to connect them to other parts of the body for operation—for example, requiring an amputee to clench a healthy muscle in the chest to manipulate a prosthetic hand. The movement is typically deliberate, cumbersome, and far from lifelike,” according to SMU. “The goal of the Neurophotonics Research Center is to develop a link compatible with living tissue that will connect powerful computer technologies to the human nervous system through hundreds or even thousands of sensors embedded in a single fiber.”
Every movement or sensation a human being is capable of has a nerve signal at its root. "The reason we feel heat is because a nerve is stimulated, telling the brain there's heat there," Marc Christensen, center director and electrical engineering chair in SMU's Lyle School of Engineering said in a report on the new technology.
Unlike experimental electronic nerve interfaces made of metal, fiber optic technology would not be rejected or destroyed by the body's immune system.
The center formed around a challenge from the industrial partners to build a fiber optic sensor scaled for individual nerve signals: "Team members have been developing the individual pieces of the solution over the past few years, but with this new federal funding we are able to push the technology forward into an integrated system that works at the cellular level," Christensen said.
Stanford University researchers in Menlo Park recently published the results of their work on creating artificial electronic skin that would be flexible and sensitive to even minor touches, such as the weight of an insect. Such a touch-sensitive material could be used for human prosthetics, sensory input devices for robotics, and applications where the biologic and electronic communicate, according to the report. That project is supported by the Department of Energy.
Researchers placed a thin sheet of rubber between even slimmer electrodes to make flexible and (you guessed it) thin pressure sensors. To make the rubber sheet more spongy and pressure-sensitive, millions of little structures were molded into it. As the rubber film deforms on exertion of pressure, the electrodes change proximity resulting in a change of charge that can register as “feeling.” The researchers found their material to be sensitive enough to detect a fly and fast enough to provide fluid reaction times when perceived by people.
What’s next?
Researchers from SMU, Vanderbilt University, Case Western Reserve University, the University of Texas at Dallas, and the University of North Texas are also investigating the possibilities of man-to-machine applications that extend far beyond prosthetics, leading to medical breakthroughs such as brain implants for the control of tremors, neuro-modulators for chronic pain management, and implants for patients with spinal cord injuries. "This technology has the potential to patch the spinal cord above and below a spinal injury," Christensen said. "Someday, we will get there."
Healthcare organizations have been investing heavily in the latest diagnosis and treatment technology in order to show that they are state-of-the-art facilities. They tout the technology in advertisements and annual reports to boost their reputation among patients and referring physicians. They buy machines to keep up with competitors and to recruit the best specialists, who want to practice in a facility that has the equipment they trained on. And patient demand drives purchases too—even if patients don't actually need high-tech care, hospitals that have it still bring them in the door.
But as the healthcare landscape changes, and a greater emphasis is placed on efficiency and cost reduction, that may no longer be the case.
Specialization is a strategy that will likely become more common in the reform-era world, says Stephen Wunker, managing director of New Markets Advisors, a consulting firm in Washington, DC. Hospitals must find their competitive advantage by examining what makes them indispensible and what services are dispensable.
One results of such specialization may be a cooling of the so-called technology arms race. Now, many hospitals feel pressure to invest in clinical technology even if they won't often use it because of the reasons cited above. But specialization as well as increasing transparency about quality and outcomes data may mean hospitals do not need the technology to prove their worth, Wunker says.
How organizations choose to specialize depends on several factors, chief among them market dynamics. On the East Coast, for example, Massachusetts-based Partners Health System is well poised to dominate with advanced IT systems and a large stable of physicians.
Cancer technologies are one area where hospitals may start to look at the cost of technology and weigh it against its ability to impact outcomes and whether or not market demand justifies purchasing the latest piece of equipment, such as stereotactic radio surgery systems, which cost hundreds of thousands of dollars.
Hospitals that invest in high-cost cancer technologies do not do so lightly. It is, they argue, not only critical to their mission of offering patients the best possible care, but it is also a business imperative.
Andrew Pecora, MD, chairman and executive administrative director of the John Theurer Cancer Center at Hackensack (NJ) University Medical Center, says it should not be taboo to question a treatment that is no better or only marginally better than others but costs much more. The trick, he says, is defining what is marginally better.
Pecora cites four steps to making a decision about investing in new technology. "First and foremost, we have to believe that it's materially better than the existing technologies for the patients," he says. "Then we do a financial analysis to determine whether or not the cost of capital will be offset by an appropriate return on investment, like any other business makes a capital investment business decision." Access is another consideration—are there geographic or regulatory barriers? Finally, the technology should be one that the clinicians who would use it want and are excited about, he says.
Any organization with the money and resources to do so can buy cancer diagnosis and treatment technologies, says Anurag Agarwal, MD, chief of radiation oncology at Broward Health, a seven-hospital integrated system in Fort Lauderdale, FL. "But to utilize the technologies properly is very important."
To read more about weighing the costs and benefits of investing in technologies to diagnose and treat cancer, read The Complex Calculations of Cancer Care, one in a three-part series on the cost of healthcare technologies.
There are plenty of benefits to using cloud computing to share health data. Of course, the cloud isn't perfect. When it comes to diagnostic imaging, for instance, massive file sizes make even online access tricky.
But when you pair benefits such as ease of use with improvements such as greater efficiency and lower costs, it's easy to see why more organizations are turning to cloud computing solutions to gather and share digital records.
It's easy to access
Online sharing can solve the interoperability problem—the challenge of communication between healthcare providers, including physician's offices, hospitals, and specialty practices, which often have different computer and software setups and use a variety of external devices to store and share images. With cloud computing, resources, software, and data are stored and accessed online—all that's needed is an Internet connection. (And, really, who doesn't have Internet access these days?)
It's cost-effective
Although government stimulus money will help some healthcare organizations pay for EMR systems, the cost of achieving meaningful use of health information systems is still a big issue. Independent practitioners, in particular, are worried. Similar to a data plan on a smartphone, with cloud computing solutions, organizations only pay for what they use. And another boon to small physician practices, in particular: They don't have to pay for software or hardware or keep data storage onsite—and they don't have to pay for special IT staff to manage, maintain, and service it.
It improves efficiency
With more than 500,000 outpatient visits per year at Yale-New Haven (CT) Hospital, it is critical that medical imaging records are captured and shared as efficiently as possible and that exams are instantly available to clinicians. "The ability to load and access imaging information in advance of the patient's appointment [improves] productivity and patient care," says Michael Matthews, director of clinical imaging and information systems at Yale-New Haven, which will use a cloud computing platform to collect and share diagnostic imaging information in its new 168-bed Smilow Cancer Hospital and within its trauma unit during emergency transfers from remote locations.
It puts patient information where it needs to be
Healthcare leaders and clinicians often talk about the importance of having data available at the right place at the right time. Cloud computing can collect and organize data from a variety of sources—from EMRs to pharmacy records to claims. And it puts it in the hands of primary care physicians, specialty physicians, nurses, other hospital employees, and patients. "It's literally available anywhere, anytime. If you have a Web-based link and an account, you can get in," says Richard Mohnk, vice president and chief information officer at HealthAlliance Hospital in Leominster, MA.
It's user friendly
It takes time to learn a new system, input data, and adjust to changes in workflow—these are all common grievances among physicians when it comes to electronic health systems. "The more you can make it so that it's something people can teach themselves, the better off you're going to be," Mohnk says. And clinicians who have pet devices such as iPhones or iPads can use devices that they're already familiar with to access data. New Wi-Fi channels can handle greater amounts of data than earlier versions. The Wi-Fi protocol (802.11n) allows sharing of radiology images, video, and other multigigabyte files on more kinds of devices.
To read more about how a number of organizations, including The Moffitt Cancer Center in Tampa, FL, Memorial Sloan-Kettering Cancer Center in New York City, and Massachusetts General Hospital Cancer Center in Boston are using cloud computing to transfer diagnostic images, read Data in the Clouds in the October issue of HealthLeaders magazine.
The business models that will emerge in the era of healthcare reform are still unclear, but leading hospitals and health systems are already positioning themselves to adapt when they do come into focus. They're taking the first steps toward becoming accountable care organizations even before anyone knows for sure what an ACO will look like—or even if they'll ever come to fruition. They're figuring out how to reduce costs while improving quality and efficiency ahead of reimbursement changes. And they're looking to strengthen their market positions through partnerships, collaborations, or mergers and acquisitions. Why? Because even though it's not yet entirely clear which strategies will be most successful in the next five years, organizations can't afford to take a wait-and-see approach.
"The ones who are not feeling the pressure [to change their business models] right now are going to be the last ones in, but eventually everyone will feel some pressure. It's just a matter of what they can tolerate," says Peter A. Pavarini, partner at the Columbus, OH, office of the law firm Squire, Sanders & Dempsey LLP. "If you are going to survive in an accountable care world, you have to have a degree of coordination that only comes from affiliation. You can't have it in the free market."
Hospitals that do not conform, collaborate, and work together will suffer, says Frank M. Lee, MD, vice president of medical affairs at The Exigence Group, an Amherst, NY-based urgent care and ED management firm. "And you'll see some close, just like in any industry," he predicts.
An eye to the future
The good news is that there is opportunity ahead for all healthcare organizations—from small community and critical access hospitals to large integrated systems. Among the many changes experts predict will take place in the new healthcare landscape: increased collaboration, even among competitors; an uptick in partnerships with alternative care, ancillary service providers, and outpatient clinics; more mergers and acquisitions of hospitals and other healthcare organizations, such as long-term care facilities; a trend toward specialization; and hospitals and health systems that are no longer the center of the healthcare universe but instead work with patients and physicians as those patients move along the continuum of care.
To take advantage of those opportunities, however, healthcare organizations will have to take some risks-changing or modifying business strategies based on predictions about where the market will go.
"The real question is, what do you want to be ten years from now?" Pavarini says. An independent hospital with geography in its favor can survive, with a caveat: "Some of those will have a longer timeline to determine where they fit, but they, too, will reach a point where independence is not a long-term strategy."
The healthcare industry, of course, is not known for its ability to swiftly implement change-let alone make those changes in advance of final government rules. "Disruptive innovation" might be a trendy topic, but can hospitals and health systems really shake things up in any significant way?
In healthcare, change tends to be incremental, says Stephen Wunker, managing director of New Markets Advisors, a consulting firm in Washington, DC. In some respects, incremental improvement has worked extraordinarily well for the healthcare industry--such as improving operational efficiency and safety.
The ability to achieve significant change depends on the type of organization, Wunker says. For example, a health system in a small rural town has enough market power that it has to stay in business--it is, in effect, too small to fail.
"But when it comes to business strategy, for a lot of healthcare systems that's not going to cut it," he says.
Moving forward no matter what
Premier, the Charlotte, NC?based performance improvement alliance, has gathered together 40 organizations that are betting that collaborative care coordinated by a hospital or health system is the healthcare business model of the future.
The collaborative's aim is to help each member develop its own skills, team, and operational capabilities needed to become an effective ACO "capable of lowering costs by improving care coordination, efficiency, quality, and patient satisfaction," according to Premier.
The collaborative will build the knowledge and expertise needed to transform a healthcare system from one that treats illness to one that delivers health and wellness, improving healthcare outcomes at the most cost-effective price for patients and taxpayers, says Susan DeVore, Premier president and CEO.
Aurora Health Care in Milwaukee joined the collaborative in August. The 13-hospital system says it is committed to creating ACOs in its markets and accepting accountability for the care delivered to patients by improving care coordination, efficiency, quality, and patient satisfaction.
"There's no question that meeting the demands of healthcare reform will require providers to assume greater accountability for community health," says Nick Turkal, MD, president and chief executive officer for Aurora Health Care. "Keeping people healthy is the best way for health systems to add real value, control healthcare costs, and increase overall satisfaction. We truly believe that ACOs are the future."
That future will include a number of components, from patient-centered health homes to physician compensation models that reward care coordination, efficiency, and productivity. Among the organization's goals: to build integrated relationships with specialists, ancillary providers, and hospitals; to negotiate provider-payer partnerships and reimbursement models that incent improved outcomes and reward value over volume; and to create a population health information infrastructure, including health information exchanges, to enable care coordination across provider networks.
As an integrated delivery system, Aurora is well-positioned to meet those goals, says Patrick Falvey, senior vice president and chief integration officer. That means pulling together all of the pieces that make up the delivery system along the continuum of care, he says, from home health to pharmacies to physician practices to hospitals. And Aurora has begun crafting deals with ancillary providers to fill some of the gaps in the system, such as long-term care facilities.
Aurora will pursue the model whether or not ACOs come to fruition and even if healthcare reform is repealed, Falvey says. "If it does change, I think we're agile enough to [respond]," he says. "Whether it comes or not, this is a direction we've been moving in for years."
Quality affiliations
Like Aurora, the Rocky Mountain Hospital for Children in Denver (the pediatric arm of the 325-staffed-bed Presbyterian/St. Luke's Medical Center) is betting that its strategy will position it for success in the reform era marketplace. That strategy includes affiliations with community hospitals and a somewhat unusual philosophy that the hospital is not the center of the patient's universe.
Each of the six full-service hospitals in the Denver-based HealthONE Presbyterian/St. Luke's Medical Center health system went through a rigorous affiliation process that included an evaluation of clinical services, quality and outcomes, staffing, equipment, community relations, relationship with primary care providers, the scope of pediatric subspecialty services on site, and ED capabilities. The process was led by the chief medical officer to ensure that the review focused not only on administrative capabilities but also on clinical competencies.
Those hospitals that made it through the affiliation process must adhere to strict quality standards based on demonstrated best practices, contained in a 6-inch-thick binder. "We regularly assess that what we say we're doing is what we're actually accomplishing," says Rocky Mountain President and CEO Mimi Roberson. "You don't put the binder on the shelf."
Rocky Mountain coordinates care with its six affiliated community hospitals so that patients can be moved closer to home as soon as they are stable, allowing them to continue treatment closer to family and friends, improving patient satisfaction, and also strengthening ties with the affiliated community hospitals and referring physicians.
"We don't consider ourselves the home hospital," Roberson says. "The important thing for us to do is recognize that people choose their community hospitals because there's a level of trust there." The relationship between patient and primary care physician is similarly personal, she adds. That's why it is so important to return patients to their home hospitals and their primary care physicians as quickly as possible. "We support wholeheartedly them retaining their relationships."
Physicians should get used to this kind of collaboration and coordination of care, Wunker says. "Physicians need to drop the historical aversion to hierarchy and having others coordinate care. The train has left the station and the old model of Marcus Welby coordinating care may work in a handful of isolated communities but is not what payers, ACOs, and health systems are going to desire. The evidence is pretty clear that more coordination is needed," Wunker says.
You can have a physician who is totally out of line with the systemic approach you want to take with a service line, says Pavarini. "It's better to have an independent physician who shares governance and oversight and is with the program than an employed physician who is there to pick up a paycheck and doesn't give a hoot. We've fallen in love with employment, but to me it is a limited model."
At Rocky Mountain, says Roberson, the relationship with providers—whether physicians, specialists, affiliates, or competitors—is one of trust. "And we have never betrayed that trust," she says.
"I don't think good medical care should be proprietary," Roberson says. "I don't own patients. Nor do I own the physicians. Whether physicians are employed or not, patients deserve choice. And if we can create and support choice, the humanitarian part of healthcare has been accomplished."
Parts of Rocky Mountain's strategy echoe CMS' initial description of ACOs, which will, according to CMS, "facilitate coordination and cooperation among providers to improve the quality of care for Medicare beneficiaries and reduce unnecessary costs." CMS also says ACOs must demonstrate that they are patient-centered and that they must pay attention to both clinical and administrative systems--two aspects of the Rocky Mountain model.
Although she is not quite ready to say whether the organization will pursue an accountable care model since it is still unclear how ACOs will "play out," Roberson says the organization is refining the business model it has developed over the two decades that the hospital has been open, with a renewed focus on quality and outcomes and a mission to deliver what patients, physicians, and the community need and expect. "Our strategies are solid and flexible, which allows us to be nimble," she says.
Cooperation with competition
Rocky Mountain doesn't just maintain relationships with its affiliated hospitals and physicians—it also does so with other hospitals in its market, even those with which it competes. An outreach program provides resources to rural hospitals and hospitals in underserved areas, including on-site clinician training programs, for example. And any hospital in the region can call Rocky Mountain for free advice on a patient, day or night, regardless of affiliation. "The right thing to do is to support the community where those patients live and work," Roberson says. "Because of our collaboration and affiliation, we're all working toward a united goal."
And to skeptics who say this strategy is all goodwill and no ROI, Roberson says, "When you do the right thing, the business usually follows." Working with rather than against physicians and other hospitals not only boosts patient satisfaction and positive word of mouth, but also supports appropriate referrals, since physicians and organizations know you won't try to "steal" their patients. Further, it allows the hospital to focus on the most acute cases.
Hospitals are used to working with referring physicians and physicians are used to working with specialists, but the next phase of integration will be linking all specialty services, such as cardiology programs and even, eventually, specialties that have traditionally been independent, such as urology, even if they are competitors, Pavarini says. Key specialties will likely be a part-ownership or employment model, or will at least form very close relationships with hospitals (within the limits of state regulations, of course).
Another reason to work with competitors: bundled payments shared among hospitals and postacute care facilities with no additional payments for patients who are readmitted within a certain time frame—a structure that will create a strong incentive for providers to ensure coordination of care and high quality of care all along the continuum. "That's a radical change," Pavarini says. "If providers want to reduce costs and maximize reimbursement, they'll have to work together."
Specialize to compete
Specialization is a strategy that will likely become more common in the reform-era world, Wunker says. Hospitals must find their competitive advantage by examining what makes them indispensible and what services are dispensable. Some hospitals may differentiate themselves by being low-cost providers and more hospitals may vie to become destination providers. There could also be an increase in organizations that seek market domination through mergers and acquisitions.
Another result of such specialization: The so-called technology arms race may begin to cool. Now, many hospitals feel pressure to invest in clinical technology even if they won't often use it because their competitor down the street has it. Owning the latest piece of equipment is a shorthand way to show your organization is cutting edge. But specialization as well as increasing transparency about quality and outcomes data may mean hospitals do not need the technology to prove their worth, Wunker says.
How organizations choose to specialize depends on several factors, chief among them market dynamics.
A consolidated system with a large chunk of market share has more ability to succeed by creating change in the healthcare system, Wunker says. On the East Coast, for example, Massachusetts-based Partners Health System is well poised to dominate with advanced IT systems and a large stable of physicians. "They should push those advantages as far as they can," he says. But, he adds, in some crowded markets with many different independent organizations, it would be difficult for one dominant force to emerge. "If we're talking about South Florida, then it may be that trying to become the colossus there is too difficult—it's too fragmented."
Meanwhile, the big brand-name players are expanding into new markets through acquisitions and affiliations—they'll continue to do so and will likely succeed with that strategy, he adds.
JOINT FORCES
Joint ventures with ancillary service providers is another way for hospitals to focus on their core business as well as improve efficiency and reduce costs.
One of the toughest challenges facing hospitals today is ED overcrowding, which is predicted to get worse when roughly 30 million new patients are insured under healthcare reform.
If a pessimist sees the difficulty in every opportunity and an optimist sees the opportunity in every difficulty, Jim Greenwood, CEO of Concentra, an urgent care provider based in Addison, TX, that runs 300 clinics, is surely the latter. There is a "tremendous opportunity" for urgent care models to help alleviate ED overcrowding, he says. And they won't necessarily be stealing patients from hospitals—especially if the hospitals partner with them.
Founded in 1979, Concentra originally partnered with larger employers to care for employees who had sustained work injuries. But, Greenwood says, the company recently realized that there was a need to control rising healthcare costs due in part to unnecessary and expensive ED visits. (A trip to the clinic costs about $125 while an ED visit costs an average of $600 for the same type of condition.) The company partnered with three school districts that wanted to put more focus on health, wellness, and preventive care for their combined 25,000 employees. "We need to get people to the right care, at the right time, for the right price, and we need to focus on prevention," he says.
The business doesn't necessarily compete with hospitals, he says. In fact, it has entered into 10 joint ventures with hospitals. Concentra manages and delivers care in the clinics; inpatient care is a collaborative effort with the hospitals.
Such models—with closer collaboration between providers and employers in an outpatient setting or on the job—will continue to thrive, Greenwood predicts.
Increasingly, hospitals and health systems have begun to align with facilities beyond outpatient clinics--especially those that provide postdischarge care, including long-term care facilities, home health agencies, and outpatient clinics, in part to prepare for payment changes that will penalize readmissions and reward quality.
One of Pavarini's firm's clients is a large long-term care provider that delivers postacute, hospice, home, and nursing home care. The firm is working to connect the organization with hospital systems to perform these services for them under accountable care—a far stretch from simpler models such as bed reservations. At one time, a request for such an extensive partnership would have "fallen on deaf ears," he says, but a large hospital quickly expressed an interest.
"Collaboration is now not theoretical. It is real and present, and I think we're going to see more traction than ever before," he says.
Virtual ICUs got a bad rap: That's what early adopters of remote intensive care unit monitoring systems said in response to a study published last year in the Journal of the American Medical Association. The authors of the JAMA study said they found "no association between implementation of telemedicine technology and adjusted hospital or ICU mortality, [length of stay], or complications." And, the authors noted, the systems are expensive, easily running to seven figures a year for software, hardware, two-way video and audio equipment, clinical salaries, and licensing fees.
But more recent evidence suggests that the technology could, in fact, be an antidote for the high cost of providing care in ICUs and other healthcare settings. Further, telemedicine advocates say, the programs can help alleviate the shortage of intensivists, improve access to care in remote or rural areas and across large systems with many hospitals, reduce mortality and length of stay, and even reduce ICU nurse turnover.
For example, the three-hospital Lehigh Valley Health Network (LVHN) compared the outcomes of 954 patients who received care in the ICU for 16 months prior to its remote ICU launch and 959 who received care from intensivist physicians using the remote ICU. Mortality dropped from about 21% to nearly 15%. LVHN, located in Bethlehem and Allentown, PA, uses an advanced ICU system to monitor about 120 beds overnight.
LVHN's remote ICU, which includes an EMR, a computer-assisted physician order entry system, medication bar-coding, and a picture archiving and communication system, costs about $1.7 million a year—an expense that is not reimbursed. But LVHN leaders say that reduced mortality and length of stay as well as increased capacity to treat critical patients covers their costs.
Resurrection Health Care, a six-hospital system in Chicago, has also found success—both financial and in improved outcomes and reduced length of stay—with its remote ICU. Resurrection's return on investment in the program—which monitors 182 beds and costs the system about $6 million a year—is calculated using a variety of metrics, including length of stay.
In the past two years, the organization saved about 9,200 ICU days. Using a conservative formula of $1,250 a day, that's a savings of about $11.5 million over two years, says Rebecca J. Zapatochny Rufo, RN, Resurrection's eICU operations director.
The system has seen a decrease in length of stay after a patient is released from the ICU, she adds, saving about 18,500 non-ICU days over two years. At $300 per day, that's an additional $5.6 million in savings.
But the most important bottom line, Rufo says, is that the virtual ICU has saved an estimated 1,090 lives in that two-year period. Yes, the infrastructure and technology are expensive, she says. But the cost of poor quality, complications, and death are greater. "That's your return on investment," she says. "There's no price tag that can fit that. Quality of care is priceless."
To read more about the eICU programs at LVHN and Resurrection Health Care, see Virtual ICUs: Big Investment, Bigger Returns, which is the third in a three-part series on how technology impacts the cost of healthcare.
The best physician can make a mistake when writing a prescription, the best nurse can fail to remove a catheter on time, the most organized medical records staff can misplace a file, and even top hospitals have areas of waste and inefficiency. But electronic health records systems are supposed to make all that go away, right?
Well, not exactly.
Whatever you may hear from Washington policy-makers, EHR is not going to solve all of healthcare's quality and patient safety problems. HIM professionals at last week's meeting of the American Health Information Management Association in Orlando made that much clear.
In one session, aptly titled The Top Ten Urban Myths of an EHR, presenters Ann Meehan and Julia Kendrick, health information administrators at Ardent Health Services, a seven-hospital system based in Nashville, talked about their organization's journey to EHR—and the lessons they learned along the way about the futility of pursuing perfection.
In 2009, Ardent Health Services had a piecemeal approach to electronic access to medical records data in its acute care and rehabilitation facilities. Ardent knew it needed to standardize information systems across acute care and rehabilitation facilities in its markets and recognized that having one system would improve patient care, processes, data reporting, flexibility, and information systems support. After months of planning and hard work, McKesson's STAR system was implemented, using Horizon Patient Folder to convert paper medical records to electronic.
But when the successful implementation ended, Meehan and Kendrick said, they began to uncover some myths about EHRs.
Here are five of the myths they encountered and what they discovered about them:
Broken HIM processes will be fixed: In fact, broken processes become more apparent in an electronic environment, where reports provide solid data relative to backlogs, timeliness, and ownership.
Chart reconciliation will be over: Nope—with the implementation of an EHR, chart reconciliation is even more important than in the paper world, where the lack of a record is physical evidence of the charts needed for processing, they said. In the electronic environment, varying percentages of charts are interfaced into the electronic health record. Without chart reconciliation, the speakers noted, you are “working in the dark.”
No more missing charts: This is simply not the case, Meehan and Kendrick said. Charts can be scanned to the wrong account number or the documentation may be split across many account numbers. Patient Access registration errors, interface issues, ancillary department errors or providers who do not want to “let go” of charts can also cause trouble.
No more paper: Very funny. Clinicians and providers still love paper and want it in hand. In a hybrid environment, dictated reports are printed and placed in binders on nursing units, despite the fact that the same reports are available electronically, they said.
Greater efficiency: Well, maybe. While an EHR provides significantly increased efficiencies, there are also some inherent inefficiencies. One information system does not meet all needs, regardless of how thoroughly evaluated or how extensive the client base.
The point of all this is not to say that EHRs are evil. In fact, the speakers agreed, they are necessary—for patient care, for sharing information internally and across the healthcare continuum in a timely and efficient manner, for expeditiously tracking and reporting quality indicators, for meeting regulatory requirements, and for timely billing and payment.
But to overlook the potential problems caused when you implement electronic health records is to miss an opportunity to use the system to its fullest advantage. It's important to share information among HIM, IT, and senior leadership, paying attention to problems and solutions. Only then can an organization really understand the power of the EHR.
U.S. Surgeon General Regina Benjamin, MD, speaks about the importance of electronic health record systems to America's public health and whether consumers are ready to access and share electronic health data with their providers through EHRs, patient portals, or health information exchanges. "People have real concerns, and that's where government comes in to protect that information," she says, in an exclusive interview with HealthLeaders Media during the American Health Information Management Association's annual conference in Orlando last week. [Sponsored by McKesson]
An increasing number of organizations are implementing computerized provider order entry (CPOE) systems in order to help physicians make decisions based on evidenced-based best practices. There are a number of benefits to such systems, from streamlined ordering of clinical tests, labs, and medications, allergy and drug interaction alerts, and, of course, an end to the errors caused by physicians' notoriously poor handwriting.
But there are a number of pitfalls, as well. Improperly deployed systems are at risk to cause more harm than good. Here are five common pitfalls of CPOE and how to avoid them.
1. Make it easy to use
Look for graphic displays that are easy to read and understand says Ron Short, vice president of operations at Good Shepherd Medical Center in Longview, TX. Physicians like "touch, enter, and go" software, he says.
2. Avoid alert fatigue
When it comes to CPOE, it is possible to have too much of a good thing: Too many screens and alerts can cause clinicians to start clicking through them on autopilot, a phenomenon known as alert fatigue. To avoid it, review drug and allergy alerts and remove those that are not absolutely necessary, suggests Mary McNichol, senior director of information systems at Thomas Jefferson University Hospital in Philadelphia. Weigh sets carefully and avoid those that have only narrow applicability to a few specialists.
"If we put in an alert for anything that could possibly go wrong, they may never get through the order set," says Stephen Tranquillo, vice president and CIO for Thomas Jefferson.
3. Double-check it
In a recent study by the Washington, DC-based Leapfrog Group, 214 hospitals used a Web-based simulator to test their systems for common medication errors, including potentially fatal errors. The CPOE systems on average missed half of the routine medication orders and a third of the potentially fatal orders.
That sobering statistic is a strong reason to run such tests, monitor for missed alerts at least monthly, and perform a root cause analysis any time there is a medication error, says Leapfrog CEO Leah Binder.
4. Don't set it and forget it
Simply having a CPOE system in place isn't nearly enough."The belief that simply buying and installing health information technology will automatically lead to safer and better care is a myth," Binder says.
Organizations must start with good content, get plenty of input from clinicians, and then customize the product, says Jeff Rose, MD, vice president of clinical excellence and informatics at Ascension Health.
5. Share best practices
Healthcare organizations are putting aside competition to share best practices in CPOE adoption. Developing evidence-based order sets is expensive, Rose notes. Ascension is working with two other large systems to create a set that is 80% complete—then organizations can tailor the remaining 20% to its own needs with input from its physicians.
You can read more about how to create an effective, safe, and easy-to-use CPOE system in the September issue of HealthLeaders magazine article Strategies Toward Simpler, Safer CPOEs.