The Internet of Things is enabling healthcare leaders to achieve objectives through better collection and reporting of data.
This article appears in the June 2014 issue of HealthLeaders magazine.
Technology is now in the process of not only tracking many everyday objects in healthcare, but also allowing those objects to sense and report things in a connected way to unprecedented degrees.
This technology is informing applications such as patient wayfinding, robotic transfer of supplies, interactive or informational displays throughout hospitals, and badges that employees or patients can carry or wear to optimize patient care and patient experience.
Wayfinding is essential in large medical facilities such as 395-bed Boston Children's Hospital, which built its own mobile phone application, MyWay, to help patients physically navigate their way through a campus consisting of 12 interconnected buildings with 150 total floors.
"It can be a bit of a maze, particularly when patients were going to a new doctor, clinic, or lab they hadn't been to before," says Naomi Fried, PhD, chief innovation officer of Boston Children's Hospital.
The app provides a step-by-step guide for a patient who may be walking from a parking garage to a particular doctor's office, a capability particularly important while the hospital is undergoing renovations, Fried says.
The app provides turn-by-turn directions much as an in-car navigation system does, and in its next incarnation, with the help of Cisco in-building technology, will also put a blue dot on the map indicating present location, hospital officials say.
"We see the Internet and the capability to leverage technology very broadly defined as a game-changer in the hospital," Fried says. "We are expecting to leverage technology to enhance the patient experience."
Patients aren't the only ones carrying mobile devices that sense or report their location in hospitals. For several years, hospitals have used network-connected robots to deliver meals, medicines and supplies, and to remove trash and soiled laundry using autonomous robotic tugs made by companies such as Aethlon.
Over time, such tugs have allowed newer hospital buildings to be redesigned so that not as much staging space is needed to temporarily store trash and laundry, but rather to be continuously picked up, according to officials at El Camino Hospital, a two-campus system with 300 beds in Mountain View, California, and another 143 beds in nearby Los Gatos.
"Being in the heart of Silicon Valley, we do have many examples of the technologies that are used, such as palm scanners for registering patients," says Ken King, chief administrative services officer at El Camino Hospital. "We have robotic CyberKnifes. We have da Vinci robotic surgery systems. We have robotic systems in our lab. So most of these things are integrated to work well with one another in the facility."
Featured in a report on 60 Minutes in January 2013, El Camino has 20 robot tugs deployed in multiple departments. "We made the decision early on to use robots because our prior hospital building was a vertical building of about 1,100 gross square feet per bed," King says. "Our new hospital building is about 2,300 square feet per bed, and it's very horizontal. In our old building we had trash chutes and linen chutes and vertical transportation that allowed us to move products."
Eighteen months prior to occupying the new building, El Camino's leadership team had considered adding 12.6 full-time equivalent employees, but by opting for the tugs instead was able to save $377,000 in 2008 dollars, King says. "That has significantly grown as our cost of labor has increased over the last five years, so the savings continue to be realized," he adds.
The tugs can also navigate portions of the old El Camino Hospital still in use, King adds. Implementation was very simple and relatively inexpensive, he says. "We had to install relays at doors and elevators and integrate it with our wireless infrastructure that was already designed, so that made the decision a lot easier to use the tug robots," King says. "The CAD plans that we had designed that guided the building of the building were also used to guide the tugs." Along with their preprogramming, the tugs use an array of sensors to notify operators if they get blocked, a rare occurrence.
"They do take control of the elevators. That was something that took a little adjustment for our staff, and we did make adjustments," King says. "We were fortunate in our building design that we had a significant amount of elevator capacity.
"The robots do communicate as they travel down the hallway, and they announce their arrival when they get to a point, and staff are very adept now when a robot arrives at the nurse's station—the staff just grab what they need out of it and send it right back to home, and they go back and automatically charge on the battery stations."
As the Internet of Things rolls out throughout healthcare, it is incorporating the next generation of real-time location services, traditionally used to track critical assets such as wheelchairs or infusion pumps, as well as movements of staff.
At Nemours Children's Hospital, a 100-bed facility in Orlando, Florida, that opened in 2012, the Versus ID badges worn by providers are now integrated with technology provided by GetWellNetwork, which supplies the interactive patient care and entertainment systems for the hospital.
Nemours collaborated with its technology providers to integrate the badges and the patient TVs so that when a provider enters the room, the TV displays a picture of the caregiver plus his or her credentials. "They're able to quickly know, 'That's my nurse; that's who's supposed to be here,' and again bring that sense of comfort, that this person really does belong here and that's who they are," says Jackie Gustafson, director of IT applications at Nemours.
"When we went into the contracting phase with GetWellNetwork, we threw at them a lot of ideas that we had, and they agreed to put up a portion of their own R&D dollars to help move this forward, because it was one of the firsts," Gustafson says.
Another integration links the nurse call system with the Versus badges, so that when a nurse enters a room on any sort of call, including code blues, the badge cancels the call. "They can go immediately to the patient's bedside and begin work without having to stop and cancel that call," Gustafson says. "To be able to just walk in and take care of business without having to cancel the call, or have to work with an alarm going off in the background makes it efficient for the caregiver and reduces disruption to the patient and family."
Another benefit of this integration is that a child who may have befriended another patient on the floor is less upset because the code blue down the hall gets canceled quickly, Gustafson says.
Behind the scenes, nurses coming on shift assign themselves as the nurse providing care for that room, so not just any nurse's badge entering the room will silence the alarm. At shift change, the nurse signs off being assigned to that room and the next set of caregivers signs in, Gustafson says.
Although this system is in use only in private rooms, an extension of the technology will eventually allow use in oncology settings with multiple patients per room. "The next iteration of this technology will improve the sensor specificity beyond the room level to the bed level," Gustafson says. Sensors at the head wall of each bed would properly record events at that bed without recording events at any of the other beds in that shared space, she says. "That is something that we're looking at for those additional spaces," she says, citing preop, postanesthesia care units, the emergency department, and infusion areas. "We're not there yet, but that's coming."
Gustafson also notes that every time a caregiver crosses a threshold that cancels an alarm, that event is recorded. "If there is ever a situation where a parent should say, 'I pushed that call button an hour ago and nobody has come,' we can pull that report and we're able to review it and potentially share it with the patient or the parent to say, 'Here's the time the nurse call button was pressed.' "
Nemours doesn't precisely know the return on investment of these innovations, but the innovations are aligned with the business mission of the hospital.
"For us it really was about that patient experience, that patient- and family-centered care model," Gustafson says. "We were really looking at our Family Advisory Council and saying, 'What would make this experience ideal for you?' "
The Internet of Things is also making inroads in ambulatory care. Aided by embedded digital technology, a simple piece of paper can serve multiple duties.
Sanford Health, an integrated health system with 39 hospitals, 140 clinic locations, and 1,360 physicians, uses these pieces of paper to keep tabs on patient flow through its facilities.
At Sanford's newest clinic, which opened in April in Moorehead, Minnesota, patients receive such a paper at registration. The paper indicates the room assignment and includes a map. "We're going to allow a patient the option to go straight to their own room rather than waiting for an escort or waiting in the lobby," says Jeff Hoss, vice president of clinical operations, Sanford Clinic Fargo.
The paper has a badge attached to it that sends a signal to certain sensing receivers in the clinic, and also activates timer algorithms to monitor patient flow. For instance, when the patient reaches the exam room, that time gets logged.
"We're trying to provide the staff who work in this environment with an indicator of, 'Are you in flow?' " Hoss says. " 'Are you just outside of the variation that we would want to see within the flow? Do we need additional resources?' It gives us a little bit of predictive opportunity." These milestones can also build in waiting time when necessary, such as allowing a patient to sit calmly in an exam room so as to get an accurate blood pressure reading, Hoss says.
"Everything is standardized. We've removed as much variation as we possibly can in this process. We're hoping that the days that patients come in and say 'I had to wait an hour to see my doctor' is something in the past, rather than a common standard practice."
As the Internet of Things continues its spread through healthcare, Hoss notes that providers will continue to learn as they go.
"Going blindly into this type of process is a very difficult task," he says. He recommends collaborating with technology partners such as the one Sanford uses, Intelligent InSites, which specializes in real-time operational intelligence solutions for healthcare workflow.
"They're a local business that has developed the architecture for operational intelligence which works with various different tags and badge providers from other vendors," Hoss says. "They're the real platform of this. It's the database. It's the real guts to the software that will help us with this whole thing."
Reprint HLR0614-7
This article appears in the June 2014 issue of HealthLeaders magazine.
IT leaders at healthcare providers are under siege. ROI, legacy systems, cloud software, and the EHR wars are a few of their current concerns.
I'm at the annual Health Datapalooza in Washington D.C., where executives from provider organizations are few in number and the vibe is all about payers, app and website developers, patients, physicians, and government regulators feasting on the latest batch of hospital cost data. The event appears to have doubled in size from last year. From this vantage, it's hard to view traditional healthcare providers as anything but under siege. Here are a few concerns bubbling up:
1. When hospitals install fancy hardware such as a da Vinci surgical system, it doesn't look good for the ROI on that system if it isn't getting used. CMS' 2012 batch of hospital payment data may bring to light evidence that surgical procedures that could be done well enough without such gear are deliberately being crowded out by procedures using the magical technology at hand, in order to justify someone's return on investment for purchasing the fancy hardware in the first place. If they are not already doing so, hospitals and payers must deploy oversight systems to make sure that high-tech intervention isn't conducted unnecessarily.
2. At the same time, outdated gear such as infusion pumps will continue to haunt hospitals if those legacy systems prove to be underperforming or unsafe. Last weekend, I attended the Association for the Advancement of Medical Instrumentation conference in Philadelphia and was shocked to learn that many facilities do not have accurate inventories of the gear they do possess. When medical equipment faces a product recall, too many facilities have to scramble or guess if they have such equipment and where it might be. A good real-time location services (RTLS) system will permit such inventories to happen quickly. Consider investing in one if you haven't already.
3. Cloud software is now starting to surpass on-premise software in capabilities. Even Microsoft Office 365 now has features that are not available on classic Microsoft Office. The time will come, sooner rather than later, when health information systems in the cloud will also surpass equivalent on-premise systems. Get ready for it by understanding what the cloud already can do, and ask your classic EHR vendors about their cloud strategy.
4. Having said that, there will continue to be pushback on moving large chunks of healthcare to a virtual infrastructure. At the recent American Telemedicine Association show, for the first time, two large healthcare providers had booths—Intermountain and Mercy. They weren't just touting telemedicine, but a whole new level of virtual care, with remote monitoring services for sale to rural and community hospitals.
Think of it as an extension of the eICU model into medical/surgical, post-ICU, and home healthcare. Back at AAMI, however, Johns Hopkins Medicine was talking about ripping out virtual care in favor of giving nurses the most advanced possible intelligently managed alarm system yet developed—a move many nurses may applaud. As for those remote monitors, Hopkins officials say the trick is getting caregivers to pay attention to someone in a command center far from the bedside. Expect more debate on this topic.
5. Apple yesterday re-created a bit of the push they made with leading universities when the company launched the Macintosh in 1984. The company is working with a select group, led by Mayo Clinic, to wire up Health, its new consumer-focused iPhone app to electronic medical records and connected sensors, sending alerts to doctors based on a set of app parameters. Samsung is doing something similar for the Galaxy phone. Health systems who want to keep on top of this big-business push need to step forward.
6. Any provider out there who believes that a place exists for the open-source VistA electronic health record should get ready to rally to its defense. In the wake of the departure of VA Secretary Eric Shinseki last week, makers of proprietary EHR software are claiming that part of the VA's housecleaning will be a wholesale rip-and-replace of VistA with a proprietary system, based on assertions that VistA is too hard to use, is falling behind the times, and must be at least partly to blame for the VA's current patient scandal.
But I suspect few if any of the VA's present troubles can be laid at the feet of VistA. It is simply being used as a scapegoat. VistA does have its problems, but it has also done a lot of good within and outside of the VA. Even so, a forthcoming massive EHR procurement effort by a combined VA and Department of Defense could mean curtains for VistA.
7. The Epic juggernaut rolls on at large academic medical centers. University of Arkansas recently went live, and University of Michigan goes live at the end of this week. And Partners Healthcare in Boston, which I visited last week, will replace its two home-grown inpatient EHRs with Epic starting next year. Meanwhile, competitor Cerner suffered a black eye last month when doctors at Athens (GA) Regional Medical Center issued a vote of no confidence in CEO James Thaw, which led to Thaw's resignation, followed six days later by the resignation of CIO Gretchen Tegethoff, a member of CHIME's board. A botched Cerner EHR rollout was the apparent culprit for the shakeup. CHIME officials had no comment.
As if healthcare technology and IT executives didn't have enough worries, this is no time for complacency.
Data made public by CMS includes information comparing the average hospital charges in 2012 for the 100 most common Medicare inpatient stays at more than 3,000 hospitals.
With the release of 2012 Medicare hospital charge data Monday, the Centers for Medicare & Medicaid Services jumpstarted the two-day annual Health Datapalooza conference in Washington, D.C.
CMS released its first annual update to the payment data comparing the average amount hospitals bill for services. Now data for 2012 and 2011 is public.
The data posted Monday on the CMS Web site includes information comparing the average hospital charges for services that may be provided in connection with the 100 most common Medicare inpatient stays at more than 3,000 hospitals in all 50 states and Washington, D.C.
With two years of data now available, researchers can begin to look for trends in hospital charges.
CMS also expanded its offering of online query tools interactive dashboards for the cost data, as well as CMS Chronic Conditions Data Warehouse and geographic variation data.
But due to the size of the CMS data files now being released, data analysts should not expect to be able to load the files into Microsoft Excel or Access software. Instead heavier-duty data analytics software such as SAS will be required in order to perform analytics, CMS acting director of enterprise management Niall Brennan said.
During a breakout Datapalooza session on the newly released data, Brennan said that recently approved federal regulations mean that his office will now look at releasing similar data relating to Medicare Part D bills.
In a separate announcement, the Food and Drug Administration launched openFDA, an open data initiative providing developers and researchers with access to high-value FDA public data through Web-based application programming interfaces and structured file downloads.
"These public data resources provide a better understanding of Medicare utilization, the burden of chronic conditions among beneficiaries, and the implications for our healthcare system and how it varies by where beneficiaries are located," said Bryan Sivak, HHS chief technology officer.
"This information can be used to improve care coordination and health outcomes for Medicare beneficiaries nationwide, and we are looking forward to seeing what the community will do with these releases," Sivak said.
"Additionally, the openFDA initiative being launched [Monday] will for the first time enable a new generation of consumer-facing and research applications to embed relevant and timely data in machine-readable, API-based formats."
Why is it that so few healthcare providers take information technology software and services vendors to court when projects run late, yield incomplete results, or fall below the assurances of a contract?
When car repairs go poorly, customers can and do regularly sue auto mechanics. When surgical procedures go poorly, patients or their families can and do sue surgeons and hospitals. It happens all the time.
Given that software development and deployment is so much more complex than fixing a car or even doing an appendectomy, why is it that so few healthcare providers (or corporate IT customers in general) take software and services vendors to court when projects run late, or yield incomplete results, or fall below the assurances of a contract?
Writing software and deploying technology services is hard, of course. Fred Brooks, architect of the IBM System/360 family of mainframe computers in the 1960s, codified just how hard in his 1975 magnum opus, The Mythical Man-Month.
One of his contributions to the field is Brooks' Law, which refutes laymen's logic of getting this done faster by adding more resources. Brooks' Law says, in essence: Adding programmers to a software project running behind schedule only puts it further behind.
I would suggest that deliberate neglect of Brooks' Law by IT professionals plus the stranglehold that technology vendors maintain over their customers, explains the rare occurrence of what occurred last December, when Trinity Health of Minot, ND succeeded in obtaining a $102 million arbitration award against Cerner Corp.
Because the details in this case are not being made public, it is impossible to know what exactly went wrong. The possibilities range from unrealistic assurances made by Cerner to unrealistic requirements made by Trinity Health for Cerner.
Recently, I spoke with an attorney for Trinity, Michael Dagley, lead attorney for the case at Bass, Berry & Sims, a Nashville-based law firm. "It was not a settlement. It was an arbitration award, so the arbitration panel heard the evidence over three weeks and unanimously decided this case in Trinity's favor," he told me.
An Unprecedented Action "What's remarkable about this case is that no hospital has ever done this before. No hospital system has ever successfully litigated against a software vendor for any significant amount of money, and the reason is because the vendor's contract always has very strict limitation of liability provisions, which typically hold the damages to just the amount paid for the software," he says.
Generally, what attorneys representing hospitals do is not look at these episodes as a breach of contract action. Instead, they look at the representations that the vendors made about the software when it was sold, and then determine whether those representations were true, and whether the vendors knew that they were untrue at the time that they were made.
"If that is the case, then the hospitals can pursue actions under consumer fraud statutes in each state, or under common law fraud statutes in many states," Dagley says.
"What we see repeatedly, consistently, is [that] software vendors make representations about these products, about their capabilities, and about their functionality, which is clearly not true, and if they know that there are problems with the software, they seem to feel emboldened to sell the software even though it doesn't work well, because they can hide behind their contracts. Or at least they could until recently," he says.
Seemingly lost to history during the current burst of news coverage of the Cerner settlement is the long tradition the software industry has had of trying to strip IT customers of their rights to sue.
During the 1990s and early 2000s, the industry made a push to update the Uniform Commercial Code by passing a Uniform Computer Information Transactions Act in all 50 states. The effort ultimately failed in 48 states (except Virginia and Maryland), in large part due to an outcry from consumer advocacy groups such as the Electronic Frontier Foundation.
Had UCITA passed, the "clickwrap" agreements we all accept when we install software would have indemnified software vendors for virtually all the bad behavior they exhibit such as Trinity apparently alleged.
The Trinity judgment may finally open the floodgates for other hospitals to bring forth complaints about bad IT vendor behavior, and could lead to a general enlightenment of how defects in software and services get rectified.
'We're All a Little Bit Bullied' Many software vendors still contractually prohibit their customers from publicly reporting bugs. It's usually only when a bug rises to the level of a serious security vulnerability such as Heartbleed, that the public is alerted.
But if a bug or flaw doesn't rise to that level of severity (or notoriety), any discussion about it is discreet or even confidential.
"I have had calls from colleagues and peers across the country whom I've never met," says John M. Kutch, president and CEO of Trinity Health. "We have healthcare executives who have read about or heard about this case. They are relieved to know that there is recourse, there is action that can be taken, because I've always sensed, whether it was myself or through colleagues or peers of mine, that to some degree, we're all a little bit bullied by the IT companies, because they represent that they have the solution."
Ultimately, the Trinity suit may mean that IT vendors will be held as accountable as the healthcare providers themselves are for the care they provide, Kutch says.
Not being deeply versed in the technology of health IT, Kutch was unwilling, as some vendors will be inclined, to point to the demands of the federal government's Meaningful Use program as a scapegoat for all of health IT's ills.
Certainly, last week's notice by CMS of proposed rulemaking to push stage 2 implementation of Meaningful Use out one more year is another sign that hospitals and IT vendors are in over their heads.
But while we gnash our teeth about just how far Meaningful Use may or may not have gone astray, let's not forget the very real ripple effect that the Trinity Health judgment will have on all EHR vendors to get their acts together, temper the hype, and redouble their efforts to deliver quality products and services on time.
Healthcare providers, too, should remember that Brooks' law still applies, and deploying EHR software and services is not at all like taking your car to JiffyLube. In an age of Google Glass and iPhones, healthcare leadership would also do well not to forget that.
The proposed rule would give healthcare providers more flexibility in how they use electronic health record systems to meet Meaningful Use requirements and would formally extend the timelines for Stage 2 and Stage 3.
CMS' meaningful use adoption timetable, recently bombarded by more bad news, is getting some breathing room.
On Tuesday, CMS published a proposed rule that would provide eligible professionals, eligible hospitals and critical access hospitals more flexibility in how they use electronic health record systems to meet Meaningful Use requirements.
The proposal from CMS and the Office of the National Coordinator for Health IT would let providers use 2011-certified EHRs, or a combination of 2011- and 2014-certified EHR technology, for the 2014 reporting period in Medicare and Medicaid EHR incentive programs.
Beginning in 2015, all eligible hospitals and professionals would still be required to report using 2014-certified EHR technology.
"We think this gives us the flexibility we've asked for," said Russ Branzell, CHIME president and CEO. Branzell cautioned, however, that the government must usher its proposed rule through the usual process without delay, lest providers and physicians be reliant on the outcome of their previous requests for hardship exemptions, or else face penalties for not attesting for MU stage 2 in 2014.
"From what we know of normal NPRM reporting, with 60-day comment periods and all the minimum requirements, if they push through everything, you're still talking late summer, early fall," Branzell said.
The proposed rule also includes a provision that would formalize CMS and ONC's previously stated intention to extend Stage 2 through 2016 and begin Stage 3 in 2017.
"Increasing the adoption of EHRs is key to improving the nation's health care system and the steps we are taking today will give new options to those who, through no fault of their own, have been unable to get the new 2014 Edition technology, including those at high risk, such as smaller providers and rural hospitals," said Karen DeSalvo, MD, national coordinator for health information technology.
At May's meeting of ONC's health IT policy committee meeting, it was revealed that only four eligible hospitals had attested for stage 2 of Meaningful Use through the first five months of HHS' fiscal year. "That was really the wake-up call for them," Branzell said.
"People aren't attesting. They're having problems getting their software," Branzell said. "Even if they get their software, they're having very difficult times getting it implemented. They're not having time to put in the process improvement that they need. So we really do believe that if they can get this through the governmental process, then it will help a vast majority of our membership."
Branzell does not believe that CMS's latest actions indicate that the Meaningful Use program is in serious trouble.
"I don't personally believe that," he said. "We rushed into this so fast, and all people knew we did that. Government knew that. The industry knew that. The vendor community knew that. Some people can go fast, some people can go medium, and some have to go slow. We'll be trying as hard as we can to get people through, but now we know we won't be leaving people behind, but letting them work at the pace that's reasonable for their organizations."
CMS held the first of two listening sessions Tuesday morning to gauge current provider concerns with the current meaningful use timetable. Last week, John Halamka, CIO of Beth Israel Deaconess Medical Center and co-chair of HHS' HIT standards committee, predicted that only 20 percent of eligible hospitals would achieve Stage 2 of meaningful use in 2014.
In a blog post Tuesday night, Halamka welcomed the proposed rule. CMS and ONC "have proposed a rule that elegantly allows Meaningful Use attestation flexibility for 2014 while keeping the momentum going for product upgrades and 2015 attestation," he wrote.
The new book by athenahealth's Jonathan Bush offers few ways out of the current healthcare mess, despite the importance of technological fixes. But liberated data is a bright spot.
Jonathan Bush, CEO and co-founder of athenahealth
"My fondest wish, my highest hope, is to inspire a small clan of crazy ones in every substrata of the healthcare system. A small strata of crazy medical school deans, a small strata of crazy health system CEOs, a small strata of community hospital CEOs, a small strata of crazy primary care docs. Each one of them says, I am going to be the guy who marches the wrong way. I am going to be the guy who stops protecting my flank and starts attacking her flank. And the great news is, I don't need many of them, because the point is, we've got about 50% excess capacity in our system, so frankly, if everyone did it, it wouldn't work."
So says Jonathan Bush, CEO and co-founder of the prominent ambulatory EHR software maker athenahealth. In my Q&A with him last week, Bush took aim at complacent large healthcare organizations who expose their flank to disruptors, but fail to use technology effectively to expose others' flanks, instead relying on an older generation of technology to lock in physicians and patients.
Now I admit, it can be extremely difficult to write a book about the ever-shifting landscape of information technology. I should know—I tried to write one for several years. It's like trying to nail Jell-O to a wall. The technology flavor-of-the-month may be totally irrelevant by the time the book comes out.
For some reason, Bush fails to mention athenahealth's own participation in the CommonWell Health Alliance. He deplores the practice of health systems withholding patient data from each other and from patients, to improve care coordination, but misses an opportunity to lay out specific proposals to kick-start health information exchange.
For CIOs and other healthcare leaders looking for takeaways from this book—from the vendor who most pointedly offers physicians an escape route from assimilation by hospital systems dominated by Epic—they get a few too many polemics and too few tech tips they can use.
A prime example is Bush's suggestion that a way to fix spiraling healthcare costs is to have terminally ill patients share in the savings achieved if they should refuse care, with their heirs benefitting. The Wall Street Journal book reviewers termed this suggestion "disquieting." I'm sure other critics will use stronger words.
Bush says he could have written another whole book about the problems caused by healthcare payers. "I don't rail against the software problems in insurance companies, because I've basically written off the insurance companies for dead, because dead and regulated within an inch of your life aren't that different," he says.
In our conversation, Bush shared an interesting story of athenahealth's own struggle to obtain claims data from Medicare.
"We've been working with Medicare for four years now to release data," Bush says. "We're a covered entity under HIPAA. We have access to millions and millions of claims. And yet Medicare won't give us back the claims data for the patients our doctors serve, which is astonishing."
Bush and I agree that the prospect of more and more such liberated data is one bright spot in healthcare's current predicament.
"All of that stuff is finally becoming visible, and as more and more data becomes available, and as the possibility to profit from doing better care grows, you'll see the possibility of product management," Bush says. "You'll see a hospital say, 'Well, I don't care if there's a third-party payment for this. I'm going to do it anyway, because I'm going to get so much bonus money on the back end from the reduced ED admissions that it's going to be worth it to me.' That kind of ROI-based product management is what's primarily missing from hospital and downstream medical care in the country."
One question that inevitably rises out of the book is whether Bush's own company will lead the way to the innovations so necessary to fix healthcare. Despite a general recent dip in tech stock prices, Wall Street seems enamored of athenahealth's prospects to provide truly disruptive change. Its cloud-based EHR software is a few generations ahead of your average EHR in terms of the kind of flexibility software requires to keep up with ever-changing demands of the healthcare business.
But due to the tremendous regulation healthcare faces, the cost a technology vendor such as athenahealth pays to stay a player in the game is staggeringly high and a real barrier to entry to future software innovators. "We've easily blown $50 to $100 million worth of R&D and product work on rules that have been evaporated at the final hour," Bush says.
I think it fortunate for our industry that Wall Street remains willing to pour even more money into software to solve healthcare's woes, despite years of setbacks in adoption, regulation, and dominant market players.
If and when Wall Street gives up on healthcare IT innovation, we may be in a situation far more troubled even than Bush describes in his book.
One doctor attending the eHealth Summit in Baltimore challenged electronic health records system vendors to simplify their implementations, saying "things that should be very simple… get very complicated when they get handed off to the vendor."
Simplification of everything from quality measures to physician workflow in electronic health record systems turned out to be a main theme of CMS's fourth annual eHealth Summit in Baltimore Monday.
An official of the HHS Office of the National Coordinator for Health IT said the agency recently pared down a list of 60 diabetes measures to five measures to be implemented agency-wide.
"Some of that is going to take a while for the rest of the world to see, because if you follow federal rulemaking cycles, you know that when we make decisions like this in the government, it takes two or three years for those to end up being the ones that you've living under," said Kevin Larsen, MD, medical officer for meaningful use at ONC.
Last week, ONC met with a group called the Buying Value Coalition, a project of the National Quality Forum, to align quality measures across federal, state and private sectors, Larsen said.
"The ultimate goal of that measurement is a low-burden exercise and it's an attribute of the EHR you have. So you spend most of your time improving care, but you have the tools in your lap or in your office to actually see the care that you're giving and understand where your opportunities and care gaps are," Larsen said.
Another speaker at the summit, Margot Savoy, MD, challenged EHR software vendors to simplify their EHR implementations.
"What vendors say and what vendors provide are not the same thing," said Savoy, a physician with Delaware-based Christiana Care Health System Family Medical Centers, who was selected by ONC's Health IT Vanguard Program to be a member of the spring 2014 health IT fellow class.
"Things that should be very simple, from my standpoint, they get very complicated when they get handed off to the vendor," Savoy said.
For instance, what had been a two or three-page patient sheet of instructions for patients "has now turned into a six-page document full of stuff that I don't think most patients actually want to read or care about. My instructions are now the very last thing on the document, because that's what the vendor thinks that you thought that you wanted them to say somehow."
When patients receive the longer instruction sheets, they sometimes throw it away, figuring if the instructions had said anything important, the physician would have said something to the patient.
Other patients cannot understand why they have to log into a patient portal, why instructions can't just show up on their mobile phones or in a text message, Savoy said.
"I grew up with computers, so for me, the computer's not that big a deal, and having one in my pocket doesn't really bother me," Savoy said.
She also challenged current guidelines implementing use of EHR care measures.
"Do you really want me to check off a box that says I gave a patient a patient instruction sheet, or do you want the patient to actually understand what the instruction were at the end of the visit?" Savoy asked.
"Because they're not the same thing, and sometimes, I can get so wrapped up in trying to click off all the boxes to make the instruction sheet look correct that I don't have enough time to sit and talk to you about what I actually wanted to say. I think that's the part where patients are complaining that we're not really engaged with them."
The summit also highlighted some innovative uses of EHR technology.
"We recognize that you can't expect to get clinical data from all the places that care is given, and so we actually also access the claims data on our patients and load those directly back into the EHR, not just the data warehouse."
"But we take the claims data and populate our EHR on a weekly basis, so we're not waiting for it to be staged somewhere, and six months behind," said Larry Garber, MD, chief medical information officer of Reliant Medical Group, a Worcester, Massachusetts division of Atrius Health.
"Prescription claims we load on a nightly basis, and with this, we populate medication lists," Garber said. "I know when patients are filling their prescriptions the day after they've actually picked it up. We also have population health maintenance, so if someone gets a mammogram or a colonoscopy across town, even though I may not be interfaced with them, that shows up automatically in the electronic health record."
Garber added that immunizations are automatically populated regardless of where they're given. The last diabetic eye exam is also automatically recorded in Reliant EHRs. "By doing this, when I get an alert, or when a registry shows up that a patient's overdue for something, they truly are overdue for that, and we focus our energy on making sure that those are taken care of."
Healthcare leaders are finding value in Direct messaging, but transferring information remains a challenge.
This article appears in the May 2014 issue of HealthLeaders magazine.
Still too often in healthcare, transition of care information chases caregivers. Patients often don't possess it or fail to bring it with them to subsequent encounters. Unanswered phone calls pile up in voice mailboxes, and faxes sometimes fruitlessly pursue physicians and specialists moving from practice to practice. The burden imposed upon staff and doctors alike is widely cited as one of the reasons healthcare costs continue to rise and gaps in care persist.
But with many providers facing deadlines to implement meaningful use Stage 2 this year, and the availability of a series of technologies including the Direct protocol, that is starting to change.
"Prior to Direct, what was happening was the case manager in the hospital would make a phone call," says Laurene Vamprine, CIO of Erlanger Health System, a five-hospital health system with more than 800 beds in the Chattanooga, Tenn., region.
"It ends up being this phone tag thing, back and forth," Vamprine says. "With protected health information, you can't leave the information in voice mail. You can't send it through regular email, so it becomes difficult to actually go ahead and tell the other person what you need to have done on a specific patient."
In October 2012, Vamprine heard about a new form of health information exchange being adopted by a coalition of public agencies in southeast Tennessee that would employ the Direct protocol to connect acute care hospitals with health coaches.
"Instead of coaches having to go to the hospital to pick up discharge papers or wait for a fax to come from the hospital, it can be transmitted immediately and securely through email," says Thomas E. Preston, assistant director for the Southeast Tennessee Area Agency on Aging and Disability in Chattanooga. "Also, the same transmission can be sent to several different people or several different locations that have a Direct account at the same time, instead of sending out three different faxes to three different people at three different places."
Preston says the agency's health coaches are able to check their Direct mail from wherever they are—on their phone, laptop, or tablet, "not having to wait until they get back to the office to pick up a fax to do it."
The value of secure messaging is one that consumers have understood and enjoyed for years in areas outside of healthcare. Yet, its integration into healthcare has been bumpy, and the experience in southeast Tennessee provides one example why.
For hospitals such as Erlanger, sending and receiving such Direct messages as currently configured does not yet count this year toward the meaningful use Stage 2 requirement that hospitals provide a summary of care record using electronic transmission for more than 10% of transitions of care and referrals.
"One of the things we're having to evaluate is, is there a way to tie that into the electronic medical record capabilities to generate something out of the EMR through that protocol," Vamprine says.
"I'm not sure that forcing that work that the health coaches are doing through the EMR is really the best way to do that," she says. "Sometimes you can make a process less efficient by forcing it through a technology or a technology process that really doesn't meet workflow."
When a health coach is talking to a patient by phone and hears something, or is visiting the patient and sees something, and the coach needs to quickly send an email, Vamprine says it's not going to be most convenient to do that by logging into an electronic health record software system.
As for the Stage 2 requirement of doing such communications within Erlanger's Siemens-based EHR software, "the industry as a whole is reaching this bolus where we're driving all these meaningful use requirements and functionality with our EMRs and forcing people to do them, but it's creating a tremendous amount of work effort for the clinicians that is not conducive to efficiency in the workflow," Vamprine says. "It's creating additional work, slowing them down, and impacting their productivity, and increasing costs to the organization. I believe that's temporary, but temporary for how long depends on when can we move into the next phase of this and really begin to reap some of the benefit of what we're seeing."
Meaningful use Stage 2 is an ambitious step forward in care coordination. Most "payloads" of Direct secure messages are structured as consolidated clinical document architecture (CCDA) documents, allowing transitions of care around problem lists, medications, allergies, and lab results and more to be shared upon discharge or referral between caregivers.
"It's the ability to package key data into a report that has codes inside to help computers decipher what each thing means, and then send it off to where your next care will be, or to your personal health record," says Joseph Schneider, MD, vice president, chief medical information officer, and medical director of clinical information of Baylor Scott & White Health, a 46-hospital system based in Dallas, with more than 500 patient care sites, 36,000 employees, as well as 6,000 affiliated physicians. "I really do see that this might eventually be the way that things will be done, rather than the health information exchange databanks at, say, a state or a regional level."
Meeting meaningful use Stage 2 this year means submitting a 90-day attestation of compliance with the Centers for Medicare & Medicaid Services. That 90-day period will vary depending upon health system and practice, and applies only to those eligible providers who attested for meaningful use Stage 1 in 2011 or 2012, leaving those who attested last year or this year to attest in future years.
At Baylor Scott & White, some physician practices will attest in July, August, and September. Hospitals will attest starting in October. At least one Direct message must travel between one vendor make of EHR and another. For those lacking such diversity, CMS has set up a test server that will randomly receive a provider's test Direct message.
At Baylor Scott & White, diverse EHR technology is a given. The organization's central Texas division runs Epic software, and its north Texas division runs Allscripts and GE EHR software, Schneider says.
"We're trying to set things so that they happen, I'll call it, automagically," Schneider says. "At the end of the visit, what we want to have is to whom should this information be sent, and build that right into the EMR, so that when the visit is closed or the discharge takes place, that it automatically goes out to those people."
However, Schneider concedes that for now, sending CCDAs using Direct will probably involve hiring personnel in order for the organization to achieve its required meaningful use numbers. "On the receiving side, as a hospital, it actually is even more interesting, because we'll be receiving Direct messages from all over the country, potentially," he says. "Routing those becomes a huge challenge, and so initially what I'm envisioning is that the same person that I'm using to help send things out would also be monitoring the inbound queue, and then looking at each one of those and then figuring out sort of where these go."
The capability to send and receive Direct messages also lays the groundwork for a nearly endless flow of secure electronic exchanges of health information not only between providers, but also between providers and health information exchanges, public health departments, and other government agencies concerned with everything from disease control to medical research—and in the process, allows physicians to remain autonomous.
In northeastern Massachusetts, the 225 physicians in the Whittier IPA will be able to use Direct to transmit secure patient information to the statewide health information exchange, says Joe Heyman, MD, CMIO of Whittier IPA, as well as a gynecologist running his own solo practice.
"Regardless of what network we happened to be associated with, we didn't want to be forced into just using that network," Heyman says. "Just in our little area there are four different contracting networks for hospitals and doctors. There's Steward Healthcare, Partners Healthcare, Beth Israel Deaconess Medical Cooperative, and Leahy Healthcare.
"Patients, when they go to see us as doctors, they have absolutely no idea that we're in one health network or another. They just go to the doctor, and we wanted to be able to see everything that happened to that patient, regardless of which network they were seeing at the time. We wanted the physicians who were in many different networks to be able to look at the entire picture for every patient. So the whole thing is centered on the patient."
Whittier IPA has also contracted with Alere to develop a health information exchange for its service area. The exchange, called Wellport, will issue Direct addresses to IPA physicians and act as a health information service provider, or HISP.
From the patient record on the Wellport HIE, Whittier IPA physicians by the end of 2014 will be able to pull anything off that health information exchange, such as a lab report, progress note from a physician, or a hospital discharge summary, and send it to whoever needs to receive it, Heyman says.
The role of HISPs throughout the meaningful use Stage 2 program is to provide identity verification via a chain of trust. Such a chain requires each HISP to enter into a set of legal agreements with other HISPs via certifying organizations such as DirectTrust or others. In this way, secure messages can eventually find their way to any provider participating in such a chain of trust.
As 2014 progresses, providers say the pricing of Direct messaging services will be determined largely by market forces. Some HISPs are being operated by EHR software vendors, others by HIE technology vendors, and still others operated by state health information exchanges. Some hope to charge by transaction, particularly with hospitals, or by number of Direct addresses provided, particularly with physicians.
Some providers think all Direct services will eventually be free or virtually so. "There will be significant resistance to having to pay for this in the early stages," Schneider says. "While the benefit to many of us is clear, I already have my fax machine and it works quite fine, thank you very much, and while eventually this might be able to replace it, for a while I have to have a fax machine, a phone line, and a person there. If you add costs to my cost structure, again, speaking as a small practice physician here, I'm not terribly happy to do that."
Reprint HLR0514-5
This article appears in the May 2014 issue of HealthLeaders magazine.
HIT leader and now author, Jonathan Bush, doesn't mince words. Hospital chiefs are almost all "facing in exactly the wrong direction," he says, when they should be in "assault mode" against "that which is bigger and more sclerotic" than themselves.
It's National Hospital Week, and while many hospital and health system leaders and staff may be celebrating, healthcare IT leader and presidential cousin Jonathan Bush is lobbing a bombshell of a new book into the lobby.
"Where Does It Hurt? An Entrepreneur's Guide to Fixing Health Care" rolls hits the street Thursday, May 15. I will have a full review next week, but this week, the CEO and co-founder of the ambulatory EHR software maker Athenahealth tells me why he co-wrote the book, and why hospitals as we know them, due to technology and other factors, are as endangered as the traditional department store. This is an edited transcript of my conversation with Bush.
HLM: My readers are hospital executives primarily, and large healthcare systems and large practices and payers. What's your biggest piece of advice for them?
Bush: You have to be on a path to disrupting that which is bigger and more sclerotic than you, and you have to do it in a way that is ultimately going to be viewed as on society's side. And as you get bigger and more established and get more pricing power as a hospital executive, that becomes a more momentous task. But for every institution in the United States, it is possible, because you can take out the health plans.
You can take out tertiary care that's going on in other regions that should be super-regionalized, and so today, the Stone Age nature of healthcare, the largest institutions that we have, are actually relatively small at something that could be operated on a much larger scale.
[Leaders] need to move and really, by and large, almost all of them are facing in exactly the wrong direction. They're charged by their boards these days, either tacitly or explicitly, with preserving an asset, preserving market share, preserving price, preserving physician relationships.
They are not charged with destroying some other asset of someone else, and I don't mean a direct competitor. I mean a giant category larger than they.
And most hospitals, even though they operate on a social mission, they don't operate for profit necessarily, most of them. You know, they are populated by incredibly well-meaning people. When they don't try to destroy that larger obstacle that to progress, to lower cost, they are actually the problem.
So that idea of getting out of positional defense and into an assault mode is what those leaders need to try to do.
HLM: So the strategy of buying all those primary care practices up is doomed to failure?
Bush: Absolutely. I expect a lot of hospitals to rage against the dying of the light, or to explode. All the contracts are void. The doctors spin off into the community, end up admitting patients to hospitals but not be paid by them.
You can see that kind of explosion. And if they're able to cut costs drastically enough, [and] quickly enough, just the losing of the doctors will save them a lot of money. But yeah, they are aiming for a wall, and picking up speed.
HLM: Let's talk about interoperability. Epic gets its share of shots in this book, but you also mention working with Memorial Sloan-Kettering to build a connection to Athenahealth. What's the status of that? Is this book going to adversely impact that? Talk about the front lines of interoperability.
Bush: Yeah, I'm a little worried that the book, which is by me and not by Athenahealth, might punch Athenahealth in the nose a little. I hope not. I am a shareholder, so I did try to act with some grace and maturity.
Epic is not wrong. Epic works in the service of its customer, and its customer is the board of directors of hospitals, who are facing the stern of their ship. And they're saying, I need to make it harder and harder and harder for doctors to do anything else but operations in my hospital.
I don't want them to choose no operation, and I don't want them to choose operations in someone else's hospital, and so forcing them all to be on a big piece of iron that only points at me feels like a good idea, feels like a good fiduciary duty to the community of stakeholders that own that hospital.
Plus, you can spin it to where you look like a good guy, like you're focused on quality and cost. So I don't blame Epic for that. If you want to drive your car into a wall, it's not the car company's fault. If you want to buy a closed piece of big iron to keep referrals from leaking out, it's not the guy who's making the big iron's fault. That's good.
Listening to your customer and doing what they want is not bad. It currently is flying in the face of what society largely wants, and so there's a little cosmic dissonance there, but I blame Epic least, hospitals second least, and our larger culture of kind of unimaginative safety netting most.
Bush: That is exactly right. The whole reason there was a book on healthcare, The Innovator's Prescription, is because as he looked into healthcare, [and] he was like, well, why isn't healthcare acting? The Innovator's Dilemma wasn't the non-healthcare innovator's dilemma. It's the innovator's dilemma full stop.
So why on Earth does he need another book just for healthcare? This is the vexing thing. What is it about healthcare that is making the basic functioning of a demand curve and of human agency not function?
Why don't assets gravitate toward higher utilization? The most broken industries in the world, even car plants, try to utilize their lathes more efficiently every year. And hospitals, they don't do a lot of the basic things. If a hospital cuts the cost of a mammogram, they don't get more mammograms next month, and if they raise the cost of a mammogram, they don't get fewer mammograms, so of course, you've got underutilized, marginally overpriced mammograms rattling around inside of every market in the country.
Next week: My book review, and a few more thoughts from Bush.
ICD-9, envisioned in 1975 and oblivious to all that has occurred in the ensuing 39 years of medicine, needs to go. Everyone in healthcare knows it.
This weekend, in a park in Palo Alto, California, TCP/IP will have its 40th birthday party. The communications protocol that undergirds the Internet is just a few years younger than ICD-9, the ninth revision of the International Classification of Diseases.
ICD-9, envisioned in 1975 and oblivious to all that has occurred in the ensuing 39 years of medicine, needs to go. Everyone in healthcare knows it. Last week, CMS once again tried to put a stake in the ground, announcing its intent to publish a rule that implements ICD-10 for billing codes on October 1, 2015.
And yet, at the same time, CMS called off long-planned ICD-10 testing over the summer to let providers, billing companies, and clearinghouses a chance to see if CMS can accept their ICD-10-coded claims even though numerous providers want the testing to go forward as scheduled, and extended to a much wider range of participants.
The whole thing resembles that classic Peanuts comic strip where Lucy invites Charlie Brown to kick the football, only to snatch it away at the last minute, leaving poor Chuck flat on the ground in pain.
"I was hoping to have it done," says Linda Reed, vice president and CIO of Atlantic Health System in New Jersey. "We had a lot of things already in the pipeline. I just wanted to put it behind us. A lot of organizations, us included, did put a significant amount of money into the getting ready…"
We had training already, she continues, "we had training schedules, and we had made commitments with companies who were going to come out and do some training. We had a coder strategy. So there were some resources already put into that which we're going to have to now kind of slow down and then ramp up again in '15."
AMA: ICD-10 'AnUnfunded Mandate' Contrast that posture of readiness with the continuing stance of the American Medical Association—to the AMA, ICD-10 is just an annoyance it wishes would go away.
"The AMA has long considered ICD-10 to be an unfunded mandate that comes at a time when physicians are being asked to make a number of other significant changes to their practices," says AMA president Ardis Dee Hoven, MD.
"While the AMA did not support the legislation that extended the ICD-10 deadline because it failed to reform Medicare's flawed payment formula, we believe a delay would have been inevitable for a coding system that has not completed end-to-end testing. The postponement will give physicians extra time to work with vendors on necessary system updates, train their staff, and test the ICD-10 changes with payers, clearinghouses and others."
Even ICD-10 stalwarts such as Reed concede that extra time will be useful to some. "I know that our health information medical records people are probably relieved, because there was a lot to do in a little bit of time," she says. "One good thing is a lot of organizations did go out and start looking at some computer-assisted coding products, which should help. For some folks now it's going to give you some additional time to get those things in and work with them."
Atlantic Health selected such technology from Nuance and will be implementing it in the next year, Reed says.
As bad as things are, the damage from the SGR fix-spawned ICD-10 delay would have been worse if any more time had elapsed. "Whether you have three months or whether you have a year and three months, you'll wait until you have two months" to train coders and physicians, Reed says.
Unfortunately we haven't heard the last of the ICD-10 holdouts. The CMS NPRM spelling out the new ICD-10 date of 10/1/15 may seem like a formality, but it allows all manner of objections to be raised once again by the AMA and others.
CHIME CEO Weighs In Kudos to those organizations which are going ahead with ICD-10 anyway. Their numbers are growing, according to CHIME president and CEO Russ Branzell.
"Most of our organizations essentially don't take their foot off the pedal, because if it really is October 1 of next year, then there's no reason for them to slow down" Branzell says. "Mainly because they've already installed the software. In some cases, their related software only works on ICD-10. There's really not a lot of choice in the matter."
"Now we do another year's work, people advance even more," he says. "They've built all their supporting systems, research, academic profiling, all the things they need to do, and it gets delayed again? What does that tell the industry?... That's very concerning."
CHIME and the 50+ organizations, including AHIMA and many payers, who urged CMS to proclaim October 1, 2015 as the new go-live date will not be caught napping again. Vigilance will be the watchword.
"We will go on an aggressive path for the next 15 months to ensure that there really is no way for this to occur again," Branzell says.
Two prominent EHR vendors also need to get their ICD-10 compliance in order and now have the chance to do so, Branzell says. While he will not name them, their installed base represents 5 to 10 percent of CHIME's membership.
Test for Worst-case Scenario Now that the coalition of ICD-10 supporters has coalesced, I suggest they not wait too long to press their case. A good place to start would be to move up CMS's new delayed testing schedule to this fall, catch the momentum that had been building for testing already this summer, and broaden that testing to all comers, including those two holdout EHR vendors.
We need not look any further than last year's healthcare.gov debacle for the imperative to test early and often.
"What's absolutely a standard within the CIO community is, you test for worst-case scenario, not for best-case scenario," Branzell says.
We won't get this chance again to get ICD-10 right. If the healthcare industry can succeed in holding Congress and the government to the October 2015 date, and it ends up going badly anyway, healthcare will have no one but itself to blame as ICD-9 celebrates its 40th anniversary.