Health information technology buyers have been demanding interoperability for some time, yet too many IT vendors have too often kept the door to interoperability locked tight, denying the industry $30 billion in potential savings.
On his first comedy album, Bill Cosby did a timeless bit called The Pep Talk where a football coach gets his team all fired up in the locker room before game time and then sends them forth… only to be stopped by a locked door.
This bit came to mind as I read a new report from the Gary and Mary West Health Institute, which along with the Office of the National Coordinator for Health Information Technology, held a one-day conference on healthcare IT interoperability last month.
In the report, the authors urge all buyers of healthcare IT, that's healthcare systems, hospitals, practices and patients, to insist that technology vendors make their products work well with each other, share data, and support open standards.
But when I talked to the report's author, Joseph Smith MD, chief science and medical officer at the West Health Institute, I was somewhat taken aback when he told me that healthcare IT buyers have yet to make it clear they want interoperability.
"Part of the mission we have in front of us is to make the buyers aware that there's something you can ask for, and that the vendors can innovate and provide it," Smith told me. "I don't think there's been an adequate focus from the buying side of the equation to understand that if they do specify that [products] talk using open standards, the vendors, because they're trying to sell their wares… will follow that requirement."
I would argue that buyers have been like that pumped-up football team in Cosby's comedy bit. They've been fired up and loudly demanding interoperability for some time, yet too many IT vendors have too often kept the door to interoperability locked tight, denying the industry $30 billion in potential savings, according to West Health's estimate.
During the February event, organizers asked the audience what was preventing functional interoperability in medical devices and information systems. "Their dominant answer was, [it was] purposeful strategies to maintain market share and increase switching costs," Smith said.
"The assembled audience was dominantly of the opinion that this was kind of a market failure, as opposed to not having the technology available, not having sufficient standards. They were saying that this was kind of a vendor-driven reality."
Guidance is Only a Start My continuing concern is that just asking for interoperability without specifically naming the products that should interoperate, or the standards with which to do it, continues to give vendors a big excuse to continue their ways. Otherwise, vendors may simply say the calls for interoperability are too vague for realistic implementation.
FDA officials will have draft guidance this year on medical device interoperability. But draft guidance is not the same thing as interoperability – far from it. True interoperability is often a mixture of shared demand, technical sophistication, dogged testing and a dollop of diktat. The weaker the combined power of the stakeholders involved, the less likely they will even be at the table when the big decisions get taken about what will work with what, and how.
Another thing about healthcare that sets it apart from some other IT interoperability challenges is that it is never sufficient to simply get data from one place to another. It is also necessary to integrate that data into the workflow of those who receive the data, in such a way that the imported data practically feels like data entered by someone in the next exam room or next cubicle.
That workflow integration is itself another compromise that IT systems and stakeholders have to make, because when you get right down to it, much modern software is differentiated by the experience it affords its users – an experience expressed in the workflow of the software.
None of which is to say we should despair of striving for healthcare IT interoperability. I am pleased that West Health Institute and the Gary and Mary West Foundation have formed the Center for Medical Interoperability to drive this cause.
"We've got real people hired into these jobs, many with very deep technical chops to try to push us, because we do see this as a bit of a campaign. It's not going to be over at one meeting or with one paper," Smith said. The list of participating health systems has yet to be released, and time will tell how successful this new center will be.
ONC's Role One thing, however, is pretty ironic about the ONC's participation in this new interoperability push. Not only did ONC deliberately pull away from issuing specific guidance of its own on health IT interoperability in 2013, it also could be argued that the meaningful use program which so far has funded $22 billion of HIT technology in the U.S. is partly responsible for our current tower of IT babel.
By only requiring a minimum of interoperability in Stage 1 of meaningful use, and marginally more in Stage 2, and meanwhile not addressing the workflow issues I've described, ONC is probably singlehandedly responsible for institutionalizing a certain level of incompatibility between systems, if not on the device side, then certainly in the EHR space.
Perhaps it couldn't be helped, but critics continue to lambast meaningful use as too much of a stimulus program, and not enough of a true systems-based approach to sharing healthcare information in this country.
I realize it's easy to sit and take potshots at meaningful use these days. The recent announcement that extensive hardship exemptions will be considered for achieving Stage 2 compliance in 2014 is a concession by CMS that the program is struggling.
But that will not stop critics, especially on Capitol Hill, from continuing to pound the table, perhaps overly simplistically, demanding the interoperability that they thought their billions were buying.
For many small and rural providers, Regional Extension Centers have been a low-cost or no-cost lifeline through the process of acquiring EHR technology and participating in the Meaningful Use incentive payment program. What happens to the stragglers as the RECs wind down?
Consider the plight of the nation's Regional Extension Centers, which serve as serve as support and resource centers to assist providers in EHR implementation and Health IT needs around the country.
Until late last year, the RECs' funding was due to run out. Recently, unspent portions of that previously allocated funding was freed up through February 2015 through an ONC ruling known as a "no-cost extension."
For many small and rural providers, RECs have been a lifeline of low-cost or no-cost source of advice and support through the daunting process of acquiring EHR technology and participating in the meaningful use incentive payment program.
But as we enter the fifth and final year of the RECs' life, there is a palpable sense that the assistance the RECs have given to healthcare's "last wagon" is still about to be snuffed out, leaving those at the rear of the technology adoption trail to fall further and further behind the leading edge of the IT-fueled transformation of healthcare.
For one thing, the RECs did not suddenly snap to life in Year One of the program. "They spent the first year letting contracts," says Bobby Gladd, author of the independently-published HHS Regional Extension Center Blog. "The second year was going out and recruiting. They've really only done boots-on-the-ground for two years, and the phrase was 'one and done'" meaning, just enough time and resources to help providers implement Year 1 of meaningful use Stage 1.
For those providers who attested early, say in 2011, had collected 70 percent of the money they were eligible to obtain through the Meaningful Use incentive program, by the end of that milestone, Gladd says.
A Long and Rocky Trail
Yet, that still left Year Two of Stage 1; and all the challenges of implementing Meaningful Use Stage 2, with all its disruptive changes to healthcare's workflows in order to effectively implement such objectives as coordination of care, patient engagement and health information exchange.
Without the help of the RECs, small and rural providers would be even more dependent on pricey consultants or EHR software vendors who might see such an opportunity as a sure way to lock in and lock up providers in their technology.
Gladd is more than just a blogger; until last year, he worked for the Nevada/Utah REC. And he recounted this story not just to me, but to the assembled press at the very conclusion of HIMSS, where new ONC chief Karen DeSalvo MD had agreed to take questions.
How did DeSalvo respond? The answer to that later. But first, a little more data to ponder.
According to Ryan Sandefer, chair of Duluth, MN-based College of St. Scholastica's department of healthcare informatics, as of last summer, only three percent of rural and critical access hospitals who could have performed their second year of Stage 1 attestation had done so. Sandefer had collected this data nationwide as part of his work with REACH, the Regional Extension Assistance Center for HIT, which serves Minnesota and North Dakota.
The same research found that only 20 percent of rural, non-critical access hospitals had only done 20 percent of second-year Stage 1 attestations.That's certainly better than 3 percent, but still nothing to celebrate.
Many of these hospitals are stuck in a queue waiting for vendors to upgrade to the 2014 certified version of their EHR software. Some of those providers are luckier than others, because their EHR software vendor does indeed have 2014 certified software to install, or even has the Stage 2-certified versions available to install.
Others are truly the last luckless wagons on the trail, as they can witness daily by visiting HHS's Certified Health IT Product List (CHPL), only to see once again that the EHR vendor they chose is still not compliant with Stage 1 2014 Edition, or with Stage 2.
'A Waste of Resources'
In January, Sandefer told me 3,000 vendors had Stage 1-certified products, but fewer than 100 vendors had certified for Stage 2. I'm sure the Stage 2 numbers are up since then, but the gap could not possibly have been narrowed that much.
REACH recently got its no-cost extension on the REC funding, and will be able to help many in its area cross various finish lines in the next 11 months. Still, REACH's ability to offer one-on-one advisement to its clients is more constrained than in earlier years, as it simply gets to spend more of the money it originally got, without any additional funding, other than what it can scrape together by expanding into other paying services such as IT consulting to healthcare organizations.
Other RECs, such as in Kansas, have also been the recipients of no-cost extensions recently. But come February 2015, any REC monies left unspent— and the requirements for spending the money is closely monitored— will no longer be available for those providers still bringing up the rear of the wagon train. "I just find it a waste of resources," Gladd says.
Now, back to that HIMSS press Q&A. DeSalvo acknowledged the role that her own local REC had played in helping clinics in New Orleans get up to speed with health IT.
"I'm a fan and I'm a supporter, and I'm trying to sort out whatever I can do to see that kind of support continue, because I don't think our work is done," DeSalvo told the press. "I don't think we quite understand how to do delivery right yet, and how to pay for it properly, and what are the workflow adaptations, and we're not going to decide that at 200 Independence [Avenue in Washington D.C.] entirely."
The answer, as former ONC chief Farzad Mostashari often suggested, probably lies a few blocks away, on Capitol Hill. Without more funding from Congress, the RECs will lose their ability to help those who need it the most. In this election year, let's see if that funding can be found before the money runs out for good next February.
The electronic health record is at the heart of efforts to improve clinical documentation. One effort strives to get disparate EHR software programs—and the physicians using them—to encode problem lists in a common way.
This article appears in the March 2014 issue of HealthLeaders magazine.
With the October 1 activation date for ICD-10-coded payments and the end-of-year move to meaningful use stage 2, this will be a watershed year for clinical documentation improvement.
Technology is playing a big role in both efforts. To an unprecedented degree, and with significant cost and effort, the electronic health record is becoming the heart of clinical documentation improvement—prompting doctors to enter more specific diagnoses, reducing the need for labor-intensive coding, and propagating a common vocabulary between disparate care coordinators to enhance decision support.
"Clinicians are taking care of patients, doing their documentation as they always have, but interface terminology actually gives them phrases or other things that they can use, and those are mapped to SNOMED and often to ICD," says Rita Scichilone, who until recently was senior advisor for global standards at the American Health Information Management Association.
SNOMED CT—the Systematized Nomenclature of Medicine Clinical Terms—is required to be generated by EHRs in order to be certified under the meaningful use stage 2 program. "SNOMED CT is a terminology, actually the language of medicine, which makes it very different than a classification system" such as ICD-10, Scichilone says.
One of SNOMED CT's great benefits is it requires disparate EHR software programs—and the physicians using them—to encode problem lists in a common way, Scichilone says. Prior to the SNOMED CT requirement, EHR software supported a variety of encoding schemes, which often made interoperability and sharing of problem lists impractical.
"Clinical quality measures that CMS is developing are leveraging some of the SNOMED vocabularies to define the numerator and the denominator of a particular patient that has a particular kind of diagnosis or condition," says Doug Fridsma, MD, PhD, chief science officer and director of the office of science and technology in the Office of the National Coordinator for Health Information Technology.
"For example, if somebody has a fractured right leg, SNOMED would have three concepts—a right concept, a leg concept, and a fracture concept—and you'd put all three of those together to create the right leg fracture," says Fridsma. "ICD-10 will have a right leg fracture and a left leg fracture and a right leg fracture complex, so it has to have unique codes for each one of those things. SNOMED actually is designed a lot more in terms of how doctors and clinicians might think, and so they can kind of take the codes that represent the things that they care about—right leg fracture—click on those concepts, and it automatically then generates those three codes together to represent the diagnosis or whatever is there.
"So SNOMED is tremendously powerful, particularly as you want to think about ways to use the structured information to provide better care. It allows you to do things like clinical decision support," he says.
"Continuous documentation improvement works with the doctor to advise them to add language to let their diagnosis tell the story," says Robert Leviton, MD, chief medical information officer and physician advisor at Bronx (N.Y.) Lebanon Hospital Center, a 972-licensed-bed healthcare system.
"CDI allows us to query the doctor about their patient's condition when they cannot document all of their concerns in the EMR because they are very busy and must see the next patient in their roster of patients," Leviton says. "We obtain more detailed diagnostic information. We are able to identify the severity of illness and the risk of mortality so that a patient's assessment, plans of care, and their principle diagnoses can be reported more accurately to impact reporting to regulatory agencies, assist research, and provide specific information to healthcare plans impacting our hospital's revenue cycle management."
CDI technology embedded in EMRs is beneficial in that it can provide guidance to achieve diagnostic specificity required by ICD-10 coding, Leviton says.
"Doctors are not coders," he says. "They know how to care for patients and determine the best diagnoses. We are structuring our ICD-10 solution to have the doctor select a root diagnosis and then also provide coding qualifications to achieve the most accurate diagnosis. If the doctor selects ankle fracture, for example, we will provide coding qualifiers. Is it the left, right, or bilateral ankle? Is there a component of delayed healing, or nonunion healing? What's the encounter—is it an initial or subsequent one? Each detail adds to the ICD-10 diagnosis meeting the required detail of the coding system," says Leviton.
As physicians are prompted to answer these questions, EMR software, in the background, picks the codes that best match the physicians' answers. CDI coding specialists can then refine or ask for even more specificity from physicians to further optimize this coding, Leviton says.
SNOMED coding facilitates sharing of problem lists, procedures, and diagnoses in ways that reduce the differing number of terms physicians use for the same things, says George Hickman, executive vice president and chief information officer of the 734-staffed-bed Albany (N.Y.) Medical Center, an academic health sciences center.
"It gives you a better chance to logically operate on that data in ways that others need to do things of a computing nature with that data," Hickman says.
Despite this, "the vocabulary that they use to express things is somewhat different than the vocabulary at my place, and, therefore, I have to always have my translation thing turned on inside my own head to figure out the differences. So yeah, all these vocabularies are intended to bring us to something in common in understanding," Hickman adds.
Hawaii Pacific Health, a nonprofit, four-hospital integrated healthcare provider, still relies upon an extensive physician coding group, but it utilizes tools built into its Epic EHR software to make it as easy as possible for the coding to occur, says Steve Robertson, executive vice president and chief information officer. "There's an ICD-10 diagnosis calculator where the physician enters the diagnosis, but if [the] ICD-10 terms are not quite specific enough, it'll prompt the physician to add a little bit more specificity."
Still, Robertson cautions that such computer-assisted coding technology remains somewhat unproven. "It's still somewhat new, and all these promises of improved productivity may be a pipe dream, depending on how well your engine has been tuned," he says. "We have bought a product from Dolbey and it is installed. We're in the process of doing the tuning, so it's still too early to say what kind of an impact it will have."
Other providers are pleased with the latest CDI improvements in the EHR software they are using. "It's all part of the doctor's work then, and the note and the description and the work that they've done in the earlier part of the documentation builds toward using an electronic and computer-based method, builds toward that final code, rather than the doctor having to initiate a whole separate part of engagement, which is just to do the coding," says Peter Plantes, MD, CEO of Christus Physician Group, which employs more than 150 physicians and other healthcare providers in family practice, internal medicine, pediatrics, OB-GYN, and other multiple medical and surgical specialties, such as orthopedic trauma and cardiovascular surgery. The group operates more than 70 medical clinics throughout Louisiana and Texas, and provides staffing for several hospital-based programs.
Christus uses athenahealth's EHR software across its approximately 70 outpatient clinics to generate appropriate SNOMED CT and ICD-10 codes, Plantes says. "It's much more accepted and much better appreciated than athena's prior internal tool for coding," he says. "If we had to do this all by intensive training alone, without the SNOMED tool, then the reliability [of] any individual physician through the manual method of what they used to do with ICD-9 would just not have worked at all. This is a huge step forward, and we are supplementing the tool with education."
In effect, the technology required to achieve both ICD-10 compliance and meaningful use stage 2 attestation has arrived in time for both to occur in 2014, Plantes says.
"Being in approximately 70 different communities across two states, we need and absolutely require Internet-based clinical solution tools to be able to execute our strategies that are both required by things such as meaningful use as well as what we want to do with advancing our quality program," he says.
While providers such as Christus are able to rely upon the efforts of vendors such as athenahealth to supply CDI technology, other large providers have different strategies.
Kaiser Permanente had an existing set of clinical terms that were mapped to ICD-9 CM and SNOMED for use in diagnosis and problem list entry. In 2011, the Kaiser Permanente Convergent Medical Terminology team began an effort to transition this set of clinical terms to ICD-10-CM. The effort was referred to as a "graceful transition" based on the strategy to implement the changes in small increments over the course of several years, rather than making one significant change on October 1, 2014. This required that new clinical terms added to production be mapped to both ICD-9-CM and ICD-10-CM.
Initially, Kaiser's team performed a preliminary evaluation of ICD-10-CM to determine the areas with the most potential impact to end users, according to Moon Hee Lee, director of convergent medical terminology at Kaiser Permanente. The existing set of clinical terms was then divided into logical groups based on medical specialties, such as cardiology. "We began with groups of terms having the least impact to end users, which meant the terms in noninjury categories," Lee says. "We first mapped the existing terms to ICD-10-CM, and then compared them to the ICD-10-CM code ranges to identify any gaps."
When Kaiser's team uncovered gaps, a team of terminology modelers consisting of physicians and nurses reviewed each of the ICD-10-CM codes in the gap to determine what clinical concept was implied by those ICD-10-CM codes. They then created new clinical terms to add to the diagnosis and problem list term set, and mapped them to equivalent SNOMED concepts.
When equivalent SNOMED concepts were not available, the team would model new SNOMED concepts following the SNOMED editorial guidelines. These concepts were then mapped to both ICD-9-CM and ICD-10-CM by two independent coders, Lee says.
"When a group of terms is completed, we determine what would be useful as a problem list subset and then donate that problem list subset to IHTSDO and the National Library of Medicine," Lee says. IHTSDO, the International Health Terminology Standards Development Organisation, is the Denmark-based not-for-profit association that owns and maintains SNOMED CT.
The subsets donated to date include the Clinician Display Names, as well as associated Patient Display Names, ICD-9-CM mapping, ICD-10-CM mapping, and existing or new SNOMED concepts modeled by Kaiser Permanente.
"As we enter 2014, we have made significant progress in this work and are well-positioned to complete the transition activities ahead of the October 1 implementation date," Lee says. The progress made to date, she says, is in part due to a strong level of collaboration with the Kaiser Permanente terminology working group, which consists of physician users from seven Kaiser Permanente regions who review the clinical terms created by CMT for end-user usability.
The extent to which Kaiser Permanente has had to blaze trails in CDI points out the tremendous cost that can be incurred—cost often incurred by vendors, but also providers themselves if they develop their own EHR software.
Beth Israel Deaconess Medical Center is one such provider. At the November 13, 2013, meeting of HHS' Health IT Standards Committee, John Halamka, MD, who is CIO and senior vice president of information systems for the Boston-based 649-bed teaching hospital, revealed that the cost of its clinical documentation improvement project has skyrocketed.
"The regulation originally assessing the impact of ICD-10 suggested that Beth Israel Deaconess should spend $600,000 and would achieve everything that was necessary," Halamka said. "I'm now $10 million into the project and we're not quite done yet. It's not the retrofitting of the financial and the clinical systems to hold an alphanumeric code that's seven characters long; it's reengineering the clinical documentation processes to effectively support the code that you have to specify. That's hard work.
"We'd hoped that SNOMED could inform the ICD-10 selection so that you would link the problem list, the documentation, and the billing into one workflow. And we have yet to see products that really do that."
Reprint HLR0314-5
This article appears in the March 2014 issue of HealthLeaders magazine.
As healthcare leaders continue to pour money into electronic health record systems, many (but not all) find that their return on investment remains elusive.
This article appears in the January/February 2014 issue of HealthLeaders magazine.
Of all the capital investments made by healthcare leaders, none appears more unproved than the move from paper to electronic health records. In the past decade, billions in public and private money, boosted by nearly $20 billion in federal incentives over the past three years, have been poured into EHRs. What has that money bought?
On Capitol Hill last summer, with healthcare's cost curve just barely starting to bend, patience was in short supply. Concerns about lack of interoperability among purchased EHRs mounted. Lawmakers grilled providers and vendors, seeking hard numbers on EHR return on investment—numbers that remain in short supply.
For their part, most healthcare leaders maintain the investment is worth it, pointing to a vast array of anecdotes and scattered studies showing the value of the EHR. In a few relatively isolated cases, they say, tangible ROI is achievable within five years. And yet others caution that true ROI requires even more patience and say the bulk of the rewards can take up to 10 years to achieve.
Still, disagreement persists on how the healthcare industry is going about the move to EHRs. Critics say the existing generation of EHRs, built for billing in a fee-for-service world, is ill-suited to delivering value-based coordination across the continuum of care. Patients, newly empowered by a plethora of apps that help them manage their own care, still struggle to access their EHR-based records, stymied by technological limitations and the same lack of interoperability that frustrates clinicians. And the federal government, just now deploying stage 2 of meaningful use, must still craft guidelines that move from basic interoperability to measures that truly impact patient outcomes.
Thus, instead of the nation reaching a goal next year—first set out by President George W. Bush in 2004—of every American having an interoperable electronic health record, it could take as long as another decade before healthcare can hang its mission accomplished banner on the EHR.
"If you asked me the question in 2007, as we were installing an electronic medical record and starting a health information exchange, 'How long do you think before you will have a functional, smooth health information system?' I might have been bold enough to say, 'Well, 2012,' " says William Park, MD, senior general surgeon and former chief medical officer at North Hawaii Community Hospital, a 20-staffed-bed rural hospital in Waimea. The facility, which reported 2012 net patient service revenue of $47 million, is a participant in the Hawai'i Island Beacon Community, one of 17 such nationwide programs developing advanced health information technology through federal funding.
"But at this point I would say I'm skeptical about 2014, and certainly not courageous enough to say 2016," Park says. "I think it's going to take a decade before we have a truly intelligent, connected system that will benefit patient healthcare. We have bits and pieces of success. I think we have little silos of effort. There seems to be some general understanding about where we need to get to, but it varies depending on who you speak to."
A big obstacle for Park and others is the lack of a national health information exchange infrastructure. This project is being worked on actively through a variety of public and private efforts. But for now, the biggest EHR success stories usually involve the efforts of individual providers, and of those, only a few have already crossed the chasm between older fee-for-service payment models and newer value-based-care payment models.
Hunting for real ROI
One such provider is Sentara Healthcare, the Norfolk, Va.–based system of 11 acute care hospitals that reported 2012 net patient service revenue of $2.8 billion. From the outset of its efforts to implement its eCare EHR at seven hospitals in the Hampton Roads area of Virginia from 2008 to 2010, Sentara leaders have had return on investment in mind.
The key to ROI is to start with a baseline and "redesign your thought system and processes to leverage the value of electronic records, or any IT solution," says Howard Kern, president and chief operating officer of Sentara.
Kern draws inspiration from information systems first used more than a decade ago to improve manufacturing and business processes in the auto industry. An oft-cited 1990 Harvard Business Review article, "Don't Automate, Obliterate," described how Ford first implemented information systems and ended up with an accounts payable department head count reduction of 20%, but when it redesigned the department's processes around IT it was able to reduce head count by 75%.
"Ford simply overlaid the IT system on top of their existing process and automated an inefficient process," Kern says.
Thus, when Sentara began its electronic record work with Epic Systems in 2007, it started 18 process redesign teams, focusing on everything from clinical delivery to medical records.
"We had clinical leaders and management leaders working side by side with Epic technical staff before we implemented anything," he says. "We had done complete redesigns around each of these major areas, so when we implemented the system, it was with a design that was built to drive value in the healthcare environment, both in inpatient and outpatient environments."
Although Sentara organized separate teams for the medical office and its hospitals, leaders also designed the system so that processes would look and feel the same in the inpatient and the outpatient environments, Kern says.
"The value there is that we got much more efficiency and much more value from the way physicians and nurses were able to interact with the system, and from continuity of care with respect to how the patient experience would be with the system."
To measure ROI, the most important metric watched was inpatient length of stay. Because Sentara has largely left fee-for-service payment behind, the shorter the length of stay, the more money the system saves. Kern says Sentara has a combination of DRG and per case reimbursement. "Very little is fee-for-service in our world anymore, and we have a fair amount capitated in the sense that we have our own health plan, and that's probably about 20% of our business," he says.
"We were able to document in a way directly attributable to the electronic medical record how length of stay was reduced in a range of areas," Kern says. In the first year, savings were difficult to measure. "We had to sort things out and make sure we had all our systems stabilized," he says.
But after the second year operating the redesigned system, Sentara has seen a $54 million annual cost savings over operations across the seven hospitals, compared to operations before implementing Epic. Inpatient length of stay only accounted for $15.5 million of that savings. According to Sentara, the rest was achieved through increased outpatient procedures, increased unit efficiency and retention of RNs, and reduced costs associated with transcription services, medical record supplies, medical records personnel, health plans, and IT maintenance.
On the investment side, Sentara's total equipment and systems cost was around $180 million, Kern says. "Our total going-in cost in terms of implementation, training, and support for the back office function from the old system totaled up to about $250 million overall," he says.
Thus, at the current rate of operating cost reductions, Epic will have paid for itself completely at Sentara before the company reaches the end of the fifth year of the $54 million annual savings—2014 at the latest.
"If we didn't do the baseline process redesign and really made sure we were harvesting the value, two things happen," Kern says. "One is you don't really redesign, and there's no pressure then, or burning platform, to redesign the processes to get to that value. Two, you're layering on a lot of cost, from an expensive electronic record, and you don't have anything to show for it, other than the depreciation, maintenance, and licensing fees. Whether you're cost-reimbursed or reimbursed per case or capitation, that's just not good to do from a good business and clinical operation perspective."
The July 2013 HealthLeaders Media Intelligence Report found that 16% of healthcare leaders saw no clinical quality improvement from EHRs, and the leaders interviewed for this story believe that those systems must not have implemented the kind of process redesign that Kern and others speak of.
"Just to give you an example, we avoided 117,400 potential medical medication errors due to the medication bar coding element of the electronic medical record," Kern says. New processes and the EHR reduced medication verification from a 59-minute process to a 5-minute process, and overall medication administration time dropped from 132 minutes to 38 minutes.
Under the pre-Epic system, "we had to actually photocopy the physician's written order, even after the nurse entered it into the nurse order entry system with the old system that we had," Kern says. "The nurse had to then take a photocopy of that physician's written order, send it to the pharmacy, and the pharmacists had to enter the order after reviewing the physician's written order.
"When we redesigned the system around the physician order entry, all of a sudden all that went away, because the physician's order is already in the system and the pharmacist doesn't even have to verify it. It streamlined so much, and from a quality point of view it also took out a huge number of errors and potential errors."
Redesigning EHRs
Skeptics continue to point fingers at inadequate EHR software. One notable physician practice startup recently decided to write its own EHR instead.
"With our system, I can drill down and see if one doc is doing better than the other," says Rushika Fernandopulle, MD, CEO of Iora Health, a Cambridge, Mass.–based primary care practice that manages 7,000 patients in six locations around the United States. The same is true for patients, he says. For instance, Iora's EHR software can also quickly identify patients whose hypertension is under control. Clinical averages are around the 50% mark in the United States, while good practices achieve 60% or 70%, he says. At Iora Health, 90% control is achievable.
The net result at Iora Health's clinics, within a one-year time frame: "We've seen [a] 50% drop in emergency room visits, 40% drop in hospitalization, 25% drop in specialty visits," and a 10% total drop in healthcare spending, Fernandopulle says.
"The big caveat is very few if any of the EHRs out there in the market do any of what I just talked about because they're so focused on this coding and billing stuff," Fernandopulle says. "We've had to build our own, which does things from a completely different point of view."
Iora Health's experience highlights the fact that the definition of ROI is different for fee-for-service systems than for value-based healthcare. In fee-for-service, an EHR that bills most effectively is the one with the greatest ROI, while just the opposite can be true in accountable care.
In Iora Health's business model, insurers such as the Culinary Health Fund of Las Vegas pay a flat per-member, per-month fee to Iora Health. "We don't have to ever submit a claim or a bill," Fernandopulle says. The payer power of the Health Fund is such that Las Vegas hospitals are compelled to report hospitalizations of Iora Health patients to the clinic, thus helping engage primary care physicians in controlling hospitalization costs and reducing readmissions.
Fernandopulle's belief that the better ROI lies in discarding existing EHR software entirely is definitely a minority opinion. The vast majority of healthcare leaders continue to emphasize the greater importance of process redesign.
"We often talk about how important it is to redesign workflows and improve your processes before you automate them," says Gary S. Kaplan, MD, chairman and CEO of Virginia Mason Medical Center, a Seattle-based integrated health system with 2012 net patient service revenue of $875 million, a 336-bed acute care hospital, a multispecialty group practice of more than 450 employed physicians, and a network of regional clinics. "In fact, we jokingly say that if you don't do that, you're really just moving garbage at the speed of light, and you're magnifying inefficiency and accelerating it in some respects."
At Virginia Mason, though, a thorough evaluation of the ROI of EHR technology is simply not a priority, Kaplan says. "We view our investment in the technology as really a cost of doing business," he says.
"In general, we don't use ROI for a lot of our capital expenditures," adds Suzanne Anderson, executive vice president, chief information officer, and chief financial officer at Virginia Mason.
"We have a much larger capital appetite than we can afford, as most healthcare providers do, and so being good stewards of our resources, we need to really evaluate what it's going to do for our business in general, and not just what the economic return is," Anderson says.
And yet Kaplan regards the Virginia Mason Production System, in conjunction with Cerner EHR software, as contributing to higher-quality care that is both safer and more efficient, such as providing timely diagnosis of a curable colon cancer. A key enabler is Cerner's health maintenance module, the EHR screen that greets primary care physicians and call center operators.
"They can actually use that technology to help ensure that our patients have appropriate previsit testing, are up to date, and compliant with all of the recommended screening guidelines," Kaplan says. "We think of this entire wired system as a way of facilitating integrative, coordinated, seamless, appropriate care."
"One of the things that we say here is that our IT projects are really only 20% technical, and the other 80% is adaptive change and integrating the operational systems with the technology," Anderson says. "We spend much more time on that operational technology integration, so that when we go live, it's just a seamless part of our system."
An example occurred when Virginia Mason implemented bar code medication administration. Up to 18 months of preparation ensured that nearly all medications could be scanned by bar code readers that compared the codes to previously entered physician orders stored in the EHR, she says.
Because the bar code process worked the first time, "the nurses were not going to do some of the common workarounds that might otherwise lead to unsafe care," she adds.
Although Virginia Mason chooses not to focus on ROI, Kaplan does share that because of the combination of Virginia Mason Production System's redesigned Toyota-inspired workflows, underpinned by EHR technology, "at least double-digits [of] millions of dollars have been saved."
"We've been on this EHR journey for more than a decade," Anderson says. "EHRs are not in their infancy but are probably in their teen years, and are not fully developed the way that they will need to be in the future to manage new ways of looking at value and population health. We've made a conscious decision not to be a developer, but to work with vendors, so that we don't get out of sequence with the rest of the country. We continue to work closely with Cerner to move to more mobile applications with them, and we will continue to push them in that direction."
Enabling improvement and value
Take the EHR's ability to manage a population and add its capacity to stop duplication of radiology, lab, and genetic tests; to suggest less expensive medications to a prescribing physician; and to track readmissions at scale, and the savings add up, says Marlon Priest, MD, executive vice president and chief medical officer at Bon Secours Health System, a Marriottsville, Md.–based not-for-profit Catholic health system that reported 2012 total net revenue of $3.4 billion and owns, manages, or has joint-venture oversight of 19 acute care hospitals across six states, along with long-term care, assisted living, and retirement communities.
"If you use the EHR right, the record will remind you that Mrs. Jones has a Foley catheter on day one, she had a procedure yesterday, and by protocol it should come out on day two," Priest says, "but it often gets left in because nobody looks under the sheets."
Reduce the amount of time those catheters are left in, and it is possible to realize cost savings from exchanging a hip replacement with no infection for the same procedure with an infection, Priest says.
"Did the electronic health record do it all? It didn't do all of it, but we never argued that," he says. "We argued that the record makes your ability to recognize and transform care better. But we started our transformation journey just before we started our electronic record journey."
In Bon Secours' case, that journey began in 2006 with the assembly of order sets and care plans, "things we know we need to do, that we've never really been able to do in paper well," Priest says. "Let the EHR be an enabler."
As for hard numbers, Priest says, "We've spent to date probably $350 million total, and if I do the math, we've got our money out of it."
In 2012 alone, Priest's team was responsible for generating $50 million in savings through ConnectCare, Bon Secours' EHR. He estimates the savings in 2013 could be $60 million.
A small example illustrates why. Nurses starting blood transfusions, IV fluids, or chemotherapy are supposed to record both the start time and stop time of treatment. A DRG fee gets paid regardless of the stop time, but that only covers the drug itself, not its administration.
Now suppose that the procedure takes place during a shift change. In a paper-based record system, the new nurse is reluctant to record a new stop time for fear that the first nurse already recorded a stop time and that the entry of a second stop time could have the appearance of double-billing for the administration. In that paper system, if no stop time is ever recorded, the administration billing cannot occur, and the hospital leaves money on the table. If, instead, all the recordkeeping is captured electronically, the transfusion/administration stop time always gets captured, which allows for an accurate billing of the administration, Priest says. "We built a system so no matter how many times people record the stop time, it took the first one," he says.
Net revenue gained from this change in just one of Bon Secours' markets was $1 million per year, Priest says. Overall revenue increase in 2013 due to better coding and documentation compliance will top $25 million, he adds.
Coordination around the C-suite has been essential to transforming Bon Secours through technology, Priest says.
At the start, Bon Secours President and CEO Richard Statuto and Priest realized the system had the cash to go any number of ways. They realized they wouldn't be gaining much market share just by adding hospital capacity.
Instead, Bon Secours drove clinical and financial innovation by assembling multigenerational teams and tackled critical issues. In the clinical setting, sepsis was the first target and the EHR was key to defining, measuring, and communicating the problem throughout the care team, Priest says.
The first goal, in 2007, was modest—to save $4 million annually by reducing the costs caused by avoidable charges due to sepsis. "As a $3 billion company, it's pocket change," Priest says, but nonetheless, "everybody thought it was a great idea." And the efforts continue.
"Six months into the year, nobody is on target. Finally the CFO and I wrote a communication to the unit CEOs: 'Guys, this is 10% of our bonus this year. This is an expectation the board has, and you know they're going to ask us to talk about people who died, so why don't we get on with it.' They hit the number."
Still, at many providers, the balancing act is to provide these kinds of EHR-driven savings without cannibalizing systems that still rely on fee-for-service for the bulk of their revenues, until they reach the tipping point and switch entirely to value-based care.
"You've got to have a way to give docs a chance to make the same amount of money that they were making last year, but doing something better for their patients," Priest says.
Part of the answer is surrounding those doctors with a knowledgeable healthcare informatics team. "We just hired a young man who was a surgeon and gave up his career entirely to get a master's in health information, because he was convinced this was the next wave," Priest says. "He's doing a lot of our decision-support work now. He's beginning to put together technical people, particularly pharmacists and nurses, to think about care."
When EHRs collide
Mergers and acquisitions of hospitals and healthcare systems—a trend that shows no signs of slowing down—can confound the gains an EHR can achieve. Incompatible EHRs in a merged organization must either be ripped out and replaced by the acquiring system's EHR, or integrated through health information exchange technology or enterprise data warehouse technology. Neither course is easy, as many technology leaders can attest.
Virginia Mason's stand-alone growth enables it to have a clearer picture of the value of its IT enhancements. "Most of our growth has been organic growth," Kaplan says. "Where people may not have had the same sort of systems, we just integrated them into our Cerner platform."
One place where multiple EHRs exist today, and will continue to do so for some time, is North Shore-LIJ Health System, which reported 2012 total revenue of $6.6 billion and includes 16 hospitals and nearly 400 ambulatory physician practices.
"Most of our hospitals are either deploying or have deployed Allscripts' Sunrise suite," says Michael Oppenheim, MD, vice president and chief medical information officer of North Shore-LIJ. "Most of our medical group is deploying Allscripts Enterprise." Two hospitals that joined the system were already using the McKesson platform when acquired by North Shore-LIJ.
"Because of the scramble to get all of our hospitals that are still on paper onto the core platform, at this point those two hospitals are continuing to move forward with their McKesson deployments," Oppenheim says.
To leverage interoperability between the different vendors' EHRs, North Shore-LIJ is also deploying InterSystems health information exchange software.
This HIE software's notification capabilities can alert primary care physicians when one of their patients has arrived at an emergency department or a specialist somewhere in the system, Oppenheim says.
"It's been very effective at getting the practice to communicate with the hospital," he says. "It's also raised a lot of interesting questions that we're struggling with around the volume of patients who are using the emergency departments during business hours and could potentially be handled in an office."
In the final analysis, whether ROI is measurable or not, whether it is sufficiently fast or not, many healthcare leaders agree that the EHR remains the essential platform that will drive the Institute for Healthcare Improvement's Triple Aim: improving patient experience of care, improving population health, and reducing the per capita cost of healthcare.
"We know the consequences if we don't make the investment," says Lloyd Dean, president and CEO of Dignity Health, a 21-state network with FY 2013 net patient revenue of $10.5 billion, 39 acute care hospitals with 8,400 beds, 9,000 active physicians, and 55,000 employees.
"We know that in the current systems, the fact is that system A doesn't talk to B, patients have to input data multiple times, physicians have to wait to get critical data to help make decisions in terms of the patient care; we know also that we get into rebilling and we get inefficient information if we don't change the status quo," Dean says.
"If you look at moving data to a place where either the patient, the physician, the clinical team, [or] the provider teams can make decisions, then it's a good investment. I think we absolutely have to continue."
Like any system implementation, some providers have had immediate successes while others have not, Dean says.
"Some people have stumbled because the planning, the system, or the culture environment wasn't right, or the software just did not do what it had hoped to do," Dean says. "But is that sufficient enough to throw the whole system out, or to condemn the investments that we're making in EHRs? I think not. There are enough pilot indications that say it is scalable."
Reprint HLR0214-2
This article appears in the January/February 2014 issue of HealthLeaders magazine.
The SXSW conference demonstrates that technology and innovation are leading the way in healthcare while regulators struggle to keep up. Everyone is trying to answer one question: "Who provides care, and how?"
After barely recovering from HIMSS, I hustled down to Austin, Texas this past weekend to take a look at healthcare IT at South by Southwest Interactive. I hadn't been to this conference since 2012, and in those two years the health track moved from a venue across town to the Hilton right across the street from the main convention center.
Seating capacity is up, and so is attendance, with many sessions near full capacity. Here are my five biggest takeaways:
1. Wearables are hot.
A session sponsored by Rock Health an incubator for healthcare technology startups, created a line around the block that made some think that Daft Punk was making a musical appearance. The first 100 attendees received a wearable Misfit Shine physical activity monitor, and the session itself generated plenty of tweets.
In general, however, wearables aren't very wearable, or fashionable, yet.
The "geek factor" of having a conspicuous health sensor in the form of a wristband isn't cracking the fashion barrier yet. These devices need to get a lot smaller and sleeker before they break into widespread acceptance. Also, many devices don't like being wet in the shower or at the pool, and designers have to overcome that limitation (Misfit apparently has).
Fitness buffs too, are able to overlook some of these limitations, but the general public is going to wait another generation or two, at least. For now, the best consumer healthcare apps rely on data collected by mobile phones, not just wearable sensors.
2. Developers and providers need to resolve who owns apps and tools that result from joint hackathons.
This year, for the first time, the team from MIT's H@cking Medicine brought a mini version of its popular weekend-long healthcare hackathon to SXSW Interactive. I will have more to say about this in a future column, but suffice it to say that organizations such as MIT have already worked with major healthcare institutions on these hackathons and understand that providers have a stake in the game.
The brainstorming phases of these events are when pain points are identified. Participating teams, including startups and established health IT companies, try to match up their own proprietary solutions with the particular workflow needs of healthcare providers.
The hackathon format is conducive to rapid prototyping, and over the course of a weekend, different teams can join forces to rapidly create more comprehensive solutions to a problem. It was exciting to see this at work at SXSW, where collaborating and give-and-take are as natural as using social media.
3. Patients may own their data, but services are providing diagnoses along with the data, and that concerns physicians.
At another session I attended, it was obvious that physicians still feel challenged by the rapidly expanding smorgasbord of online services and apps that diagnose and recommend as well as record and report.
I even heard that some lab companies attach diagnoses to the lab results they return to clinicians – which is fine, except those same lab results also get reported to patients. I had not realized that some labs crossed into delivering diagnoses or interpretations of the results.
Physicians naturally get antsy about this, and I wonder if the labs may find themselves facing some sort of crackdown, particularly in instances where lab and clinician disagree on exactly what the results mean.
4. Doctors still haven't entirely bought into the notion of team-based care.
Leslie Saxon MD, executive director and founder of USC's Center for Body Computing, gave the SXSW Interactive healthcare keynote on Saturday morning. She touched off a Twitter controversy by saying that she didn't want to provide care to healthy patients, only sick ones, which prompted some physicians to respond that only the doctor knows how to spot the telltale signs that a healthy patient is trending toward sick. This prompted still more caregivers to say that only a team-based care approach can provide that kind of watchful care in a scalable fashion.
But Saxon was also willing to consider such controversial notions as paying patients for their medical data to further advance research. Saxon's ideas remind me that much of the innovation driving wearable devices comes out of the sports, military and even entertainment worlds, with regular old healthcare playing catchup. It should be interesting to watch those worlds collide again and again as the technology goes through its usual generations.
5. What if HIT were to follow the PayPal model?
One speaker at SXSW pointed out that when the PayPal online payment service started, it was with the full knowledge that many of the things it enabled – such as sending money electronically across state lines – were tightly regulated by the federal government.
PayPal overcame this by starting with small merchants in a single state, California, and by the time state regulators had discovered what state regulations PayPal was violating, the company had a base of small business supporters. They were willing to lobby the legislature to change the laws to accommodate PayPal, in California, and eventually across state lines as well.
In healthcare, apps and services that diagnose (see #3 above) are acquiring their own constituencies so quickly that by the time the FDA tries to crack down on them, there will be growing pressure in Congress from consumers and the new service providers to allow more lenient regulation.
That has to be one of the most disruptive possibilities of healthcare IT—the capability to break down the licensing requirements of who provides care, and how. This power is sure to fly in the face of medicine as it has been practiced ever since our current system came to be.
I am certain that the AMA and a host of other interested parties will fight it, but just like the bankers who tried to stop PayPal and are now trying to stop Bitcoin, the battle may be lost before they realize there was one.
Some revelations made at the HIMSS 2014 conference illustrate how difficult this period of transition is for healthcare executives charged with bringing compliant, interconnected electronic health records systems online at their organizations.
On the last day of the event, CMS announced it would grant more hardship exemptions to those who cannot meet their end-of-2014 attestation dates for Meaningful Use Stage 2. The announcement was a clear victory for CHIME, the College of Healthcare Information Management Executives, whose leaders had lobbied hard along with the American College of Physicians for some leeway during a difficult year. More on that in a future column.
Earlier at HIMSS, the CommonWell Alliance demonstrated its patient ID service operating across different vendors' electronic health record software on the show floor, and arranged for some of its pilot sites to meet with the media. But this was a lower-key event than I would have imagined a year ago. Still, the announcement of a major commitment to the work of the alliance by Tenet Healthcare was evidence of some solid momentum.
Seemingly in response, Epic and a number of partners active in the Care Connectivity Consortium, including government-assisted Healtheway, announced Carequality, a collaborative bringing together EHR vendors, HIE vendors, care providers, and IT organizations together to address the remaining challenges involved in inter-network exchange.
Meet Carequality
Carequality's goal, announced also in low-key fashion at the very start of last week, is to facilitate agreement on a common national-level set of requirements that will enable providers to access patient data from other groups as easily and securely as today's bank customers connect to disparate banks and user accounts on the ATM network.
The following 26 organizations have signed up as founding members: California Association of Health Information Exchanges, CareEvolution, Community Health Information Collaborative, CVS MinuteClinic, eClinicalWorks, Epic, Greenway Health, HIElix, Hyland Software, ICA, Intermountain Healthcare, InterSystems, Kaiser Permanente, lifeIMAGE, MDI Achieve, Medfusion, Medicity, MedVirginia, Mirth, Netsmart, New York eHealth Collaborative, Optum, Orion Health, Santa Cruz Health Information Exchange, Surescripts, and Walgreens.
At HIMSS, I approached CommonWell leader and RelayHealth vice president of strategy Arien Malec for a comment on Carequality, and he seemed fairly certain that there can be a meeting of the minds between CommonWell and Carequality at the appropriate time.
What About Deliverables?
Setting an April 1 deadline to become a founding member, Carequality was a bit vague on deliverables, saying it was just beginning its activities on a common interoperability framework. But it seems that in this pivotal year where healthcare interoperability has to take more definite shape, stakeholders are certainly filling their calendars with commitments to once again see if work by committee can trump the forces of free-market competition.
In its lengthy announcement, an additional 16 organizations have also expressed support for the Carequality vision and mission: AEGIS.net, Alaska eHealth, Care Connectivity Consortium (CCC), etHIN, GE Healthcare, Guthrie Health, Healthbridge, HEALTHeLINK, Marshfield Clinic, Medical University of South Carolina, MEDITECH, Michigan Health Information Network, National Association for Trusted Exchange (NATE), OCHIN, Premier Family Physicians and RSNA.
I also spent time last week with Jacob Reider, MD, chief medical officer of the Office of the National Coordinator for Health Information Technology. Here too, the choices facing healthcare vendors and customers alike seem to be proliferating. A new 2015 Edition Proposed Rule, published in last Wednesday's Federal Register, is sowing its own seeds of confusion.
The 2015 Proposed Rule serves a lot of different purposes, but practically speaking, it has no impact on providers' efforts to achieve Meaningful Use Stage 2 attestation this year. It has some important objectives, nonetheless, including bringing long-term post-acute care providers into voluntary compliance with the Meaningful Use standards, although with no incentive money to accompany it.
ONC 'Not Working On' National Patient ID
One big takeaway from my conversation last week with Dr. Reider was to understand the limits of both Meaningful Use software certification, and ONC's recent effort to help providers in the tricky area of patient identity.
In our conversation, Reider indicated that nothing ONC has recently undertaken amounts to any progress toward a national patient identifier.
"ONC is not working on national patient ID," Reider says. "ONC is working on understanding best practices regarding patient matching. They're two different topics. One topic, national patient ID, is a proposed solution. Other countries have employed that solution. That solution does not address all of the challenges of patient matching. Even in countries where there is a national patient ID, matching this patient to this record is still something that's necessary."
Instead, ONC's work is already producing a set of best practices for patient matching. It's still up to non-governmental U.S. organizations, such as CommonWell, to champion their own patient ID proposals, perhaps using ONC's work to get there a little faster.
No Software Without Bugs
The limits of ONC's software certification may be one of my biggest causes for concern given something I heard multiple times at HIMSS—that certified Meaningful Use Stage 2 software is currently riddled with bugs keeping implementations from proceeding smoothly.
"There is no such thing as software without bugs. No such thing," Reider says. "That's not a secret. The question is, how serious are those bugs? The certification program isn't a thorough, deep quality assurance process."
Reider likens ONC certification to getting a car "smogged" to ensure that emissions are below a set level. "At the end of that analysis, the machine says 'yes, this passes,'" he says. "But it's not testing whether the windows go up and down properly. It's not testing whether the seats go backwards and forwards, or whether the radio works perfectly."
Some critics say ONC should test the software more than it does. Some say it should test less. "We're in the middle of that," Reider says.
It's also true that healthcare providers are caught in the middle, in this most difficult of years, squeezed by the golden handcuffs of incentive programs now entering the penalty phase, squeezed by vendors distracted from eliminating bugs in their software by the need to choose partners in elaborate jockeying to appear to be more interoperable than the next company.
Let's hope the next HIMSS conference doesn't leave us with quite so much confusion and uncertainty.
Despite its sophistication in healthcare IT, the CIO of Intermountain Healthcare says the organization is unready and will forgo incentive payments and trigger penalties. Federal officials acknowledge that many health systems take issue with the meaningful use deadlines.
Update: CMS Administrator Marilyn Tavenner, speaking at the HIMSS 2014 conference in Orlando Thursday morning, announced that CMS has decided to permit flexibility on how hardship exemptions will be granted for meeting 2014 Meaningful Use Stage 2 attestation deadlines. "I must stress we expect all providers to meet requirements in 2015. I urge you to meet the requirements this year."
In an exclusive interview with HealthLeaders Media, Intermountain Healthcare CIO Marc Probst says the organization is planning not to attest for meaningful use Stage 2 in 2014, forgoing a sizable incentive payment and triggering penalties in 2016 from CMS.
"We don't feel confident we can attest in 2014 and maintain our current level of patient safety," Probst says.
Intermountain has begun transitioning from its own homegrown electronic health record software to software provided by Cerner, but that transition is such a lengthy process that only three of Intermountain's hospitals will be running on the new EHR by the end of the year, Probst says. He spoke with HealthLeaders Media at the HIMSS 2014 conference in Orlando.
The remainder of those hospitals will continue to run Intermountain's own EHR, which the health system will certify for MU Stage 2 this year. But the attestation will take place next year, Probst says.
The buzz at this week's HIMSS annual conference in Orlando was that some large providers could miss their 2014 attestations, although there were few public acknowledgements. The topic has also been of great interest recently on the member-only list serve of the Association of Medical Directors of Information Systems, according to Lyle Berkowitz, MD, a Chicago-area physician leader.
Elsewhere at the HIMSS conference, numerous physician practice leaders interviewed by HealthLeaders Media indicated their confidence in meeting the 2014 attestation deadline, reaping incentive money and avoiding penalties.
Another large hospital using homegrown software is better positioned than Intermountain to attest this year. "The short answer is we are finished with our certification at Beth Israel Deaconness [as of] March," says John Halamka, CIO of Beth Israel Deaconess Medical Center in Boston.
"We'll use April through June as our attestation period, and then we'll attest in July," Halamka told HealthLeaders. "Of course we do this to avoid penalties, and it's unclear whether an extension will be offered to the attestation timeframe, although certainly there are many organizations that require such an extension.
"It's touch and go, and the only reason that we are able to achieve the timeframe is because we self-build the software and therefore are very agile. If we would have had to depend on vendor software, chances are we would not have been able to hit the deadlines that are currently in force for Stage 2."
Halamka echoes the hope that many other CIOs at HIMSS expressed: that the Department of Health and Human Services and its Office of the National Coordinator for Health Information Technology will give significant consideration to a letter sent by many organizations to HHS Secretary Kathleen Sebelius earlier this week asking for relief from pending meaningful use deadlines.
In another exclusive interview with HealthLeaders Media, ONC Chief Medical Officer Jacob Reider acknowledged that Intermountain had been warning the agency for some time that it would miss the 2014 attestation deadline, and that other large healthcare systems were in similar straits.
"A number of organizations have expressed to ONC and CMS their concern about the trajectory of the program," Reider says.
"What's the next step of the value stream?" Reider says. "It's implementing certified product, and I think that's where you're hearing from…many [leaders] that in order to incorporate all of the workflow changes and the use of new functionality that's in new certified product, this isn't a flip-the-switch, especially for a large care delivery organization."
"When we talk to vendors of products that serve small markets, and we talk to the users of those products in small markets, they're not as concerned. They're concerned, but they're also not quite as sophisticated as an organization like Intermountain," Reider adds.
"A small practice is thinking, what's going to happen next month. Intermountain is thinking 6, 12, 18 months in the future. So I think we heard ahead of time and we're hearing now that they're concerned that this too high a hill to climb."
Reider says that if providers fall short of the 2014 deadlines, it should not mean that the meaningful use program is a failure.
"Some may characterize this as a failure. I don't see it as a failure," Reider says. "I see it as a challenge, because we want them to get their incentive dollars. We want them to avoid a penalty. We want those things to happen, and so we want them to attest to meaningful use. Don't get me wrong. If they, for various reasons, make choices not to, we still don't see that as a failure of the program. We don't see that as a failure of health information technology. We're still on the path."
Cleveland Clinic is increasing its ROI on the EHR infrastructure it has invested in by working toward becoming, in effect, the new data center for a growing number of other, otherwise non-affiliated, providers.
Traditionally, information technology has been one of healthcare's more expensive cost centers. But for some large players, and even a few smaller ones, that is changing, and at HIMSS this week we are seeing birth of healthcare IT as a revenue center for those providers.
The first clue I received this week was when I was briefed on an announcement between Cleveland Clinic and Dell made at the show in Orlando.
Cleveland Clinic will provide practices and smaller hospitals help with planning, implementing and customizing electronic health record software, as well as training those practices and smaller hospitals.
Growing out of its experience with some regional practices, Cleveland Clinic is now taking it national, and leveraging Dell's HIPAA-compliant cloud to become, in effect, the new data center for a growing number of other, otherwise non-Cleveland Clinic affiliated providers around the U.S.
You've heard of software as a service. Maybe we should call this hospital IT as a service.
"Over the last few years we've had more and more requests for other organizations to help them with their own implementations to offer advice on how to optimize and build strategies to best utilize EHRs," says Mitchel Krieger, MD, associate chief information officer at Cleveland Clinic.
"My practice, Health Care Solutions, was really developed out of that need, and essentially it's a practice to provide sort of a suite of solutions for other organizations that range from strategic guidance to design, implementation, even the actual provisioning of software for their own use in their own health systems," Kreiger says.
Over the past 8 years, Cleveland Clinic has performed a large number of ambulatory installations for its local partners. In the past four years, Cleveland Clinic expanded this work to non-affiliated physicians, and 18 months ago, did the same for a freestanding, nonaffiliated 200-bed hospital in northern Ohio. Currently, Cleveland Clinic is also doing some work on the ambulatory side with a hospital in upstate New York.
"We get a lot of inquiries from systems all over the country to offer assistance with their own planning and design," Kreiger says. "We're just starting to test the waters."
In effect, it's not only a way for Cleveland Clinic to increase its ROI on the EHR infrastructure it built in the past decade or so. It's also a new model for revenue growth, and possibly growth in influence as well.
I also learned at HIMSS this week that the move apparently has the blessing of Judy Faulkner, CEO of Epic Systems, maker of the EHR software that Cleveland Clinic runs.
I learned this from an ex-Epic employee, who I met in one of HIMSS's long taxicab lines. This person told me that Faulkner hopes to see others replicate Cleveland Clinic's enterprising initiative.
Coming as I do from the old world of client/server software, I find it amusing that a software customer, which in a bygone age would be dinged for exceeding the provisions of its software license agreement by subletting its infrastructure to others for a profit, instead may be getting a nod of approval from the publisher of said software.
I haven't contacted Epic yet for an official comment on Cleveland Clinic's announcement, but if true, the Epic chief's favorable view could be a nod toward a world where Epic technology, like all other healthcare IT infrastructure, moves into the cloud, albeit a private one at first.
As for Cleveland Clinic, I am certain the system would not mind in the least if these new customers spur the number of referrals of patients from other areas of the country to receive specialized care at Cleveland Clinic. Kreiger says such synergies may come to pass.
He also notes that Cleveland Clinic will only install those Epic applications that it has experience with, which leaves out, for instance, Epic's Cogito business intelligence software. Cleveland Clinic had already developed its own such software, which the company spun out a while back into a company known as Explorys. The software remains in use at Cleveland Clinic.
As for Dell, it is only too happy to add Epic installations to its ever-growing stable of data centers it runs for hospitals nationwide. "Very soon, as the leading-edge organizations like Cleveland Clinic who work with genomics, you're talking about terabytes of information for one individual patient, that will quickly overrun most data centers that are currently being built, and certainly within the next couple of years," predicts Cliff Bleustein, MD, who leads the global healthcare consulting practice for Dell Services.
Another megatrend this may represent is the movement of provisioning of health IT services away from strictly the domain of companies such as Dell and toward those organizations that best know how to provide those health IT services, namely, the large hospitals and health systems who have to live with this technology on a daily basis.
A similar trend may be underway in the operation of private health information exchanges. In the past couple weeks I've come across two large medical practices standing up their own HIEs as part of ACO models, appealing to physicians and patients alike that medical records should still be entrusted to doctor-led organizations, just as they were when they were on paper.
Recent concerns about the security and privacy of personal health information stored by organizations not governed by physicians may be helping this trend along. And those concerns may hamper the efforts of any number of other tech companies attempting to act as the HIEs of choice for ACOs.
It is too early to tell whether all these shifts will have a lasting effect on the way large healthcare organizations view their healthcare IT assets. Economics of scale in the cloud could still disrupt things further. Who is to say that at some point, Amazon cloud storage won't be cheap enough, secure enough, and simple enough to trump all these offerings?
But I will leave that portion of the great cloud computing debate for another day. In the meantime, I'm eager to see how many providers opt to bring their information management assets under Cleveland Clinic's wing, or those of other players of a similar size.
CIOs heading to the biggest health IT event of the year will encounter a vast array of new platforms and protocols promising health information exchange interoperability. Whether there's room for much optimism amidst the complexity remains to be seen.
As the healthcare industry prepares to head to Orlando for next week's HIMSS conference, should we be optimistic about the state of healthcare IT interoperability?
I'm not sure. So far this month, the healthcare IT news hasn't been all that promising. According to industry buzz, CMS found its Meaningful Use attestation Web site overwhelmed by traffic that made the Web site unusable from time to time, so much so that the agency postponed the deadline for 2013 attestations for 30 days to March 31, 2014.
Pessimists will point to this flub as one more foreshadowing of 2014's Stage 2 attestation requirements as a train wreck in the making. After months of pleading, CHIME has been unable to prevail upon CMS to push back the basic requirements for those providers who attested in 2011 or 2012 to attest for Stage 2 this year, and this month's CMS postponement changes nothing about that.
And there's plenty more than can go wrong. I continue to hear persistent reports that although certified Stage 2 software has now been released by most major EHR software publishers, providers remain queued up in long lines waiting for their numbers to be called by those publishers so their software can be upgraded.
I even hear that some EHR software certified to be Stage 2-compliant makes some basic tasks, like sending a document via the Direct protocol, convoluted. That should be remedied when the software gets patched later in the year.
All these upgrades are necessary for providers to even begin practically preparing their Stage 2 attestations. And only recently have I begun to understand how rudimentary the Stage 2 requirements are, and how even once those attestations are in hand, providers will have some distance left to go to get to cost-lowering, care-enhancing coordination of care.
Disruption as Close as Your Pocket And yet, again and again, I hear that technology is not the key. Governance is. Even in an age when there are incentives for providers to share information and thus put the patient back at the center of healthcare, it is undeniable that information is still power. Yet too many payers and providers are still nervous about sharing that information, for fear they will lose patients, customers, volume, and market share.
I also continue to hear fundamental questions about the electronic health record model defined by the Office of the National Coordinator, source of $19 billion already spent. Disruption is coming to the EHR model we know and occasionally love. For instance, a company called Docbook MD is offering a mobile phone app that lets doctors share patient information with full HIPAA security by taking pictures of records with their smartphones and emailing them to each other.
Now, if you're carrying around a phone that's three or four years old, that might sound goofy. But having just recently gotten an iPhone 5C and seeing the incredible photos its camera can take, this app sounds quite plausible for acting like a document scanner you are always carrying. It could even transmit detailed X-rays from doctor to doctor.
Compared to the byzantine way Meaningful Use defines the protocols, standards, and services required to share a simple medical record, this sounds like a much simpler way to go, and one that didn't require $19 billion.
Yet, because providers are enrolled in the Meaningful Use incentive program, and because shared cell phone photos alone can't fix healthcare, providers are on a conveyor belt headed into fulfilling the requirements for Stage 2, Stage 3, and beyond, or face penalties. I don't doubt that some of those requirements will fit the need to coordinate care. But I also know that the devil, as always, is in the details.
Many, Many Services Based on my discussions with providers and vendors prior to next week's HIMSS, it's clear we're entering a truly confusing period of not knowing which platforms and pieces will be the right ones for providers trying to achieve true interoperability. Consider that the HIMSS Interoperability Showcase will have a growing plethora of technological services and solutions for accomplishing basic health information exchange:
Direct protocol, a kind of secure paperless fax that works much like secure email must be supported by Meaningful Use Stage 2 EHR software, like healthcare's own "Intel inside."
Healtheway, descendent of the federal government's Nationwide Health Information Network, is a series of application program interfaces that allows all the secure transfer of Direct plus more sophisticated variants, such as query-based exchange, to provide more targeted information to support everything from coordination of care to preventing 30-day readmissions.
Epic CareEverywhere, is used by large health systems running the industry-dominant Epic EHR to exchange health information with each other, and, due to an alliance between Epic and eClinicalWorks, with physicians running the eClinicalWorks EHR for small practices.
CommonWell Health Alliance is a vendor-based consortium whose invitations to Epic have been rebuffed for the entire year of its existence. CommonWell technology, now in early pilot testing, will also be on display at HIMSS exchanging information. CommonWell lists these vendors in its opening lineup: Cerner, Allscripts, McKesson, athenahealth, Greenway, CPSI, Sunquest Information Systems, and HIE service provider RelayHealth.
DirectTrust is a service for HIEs to talk to other HIEs, who must sign legal agreements and pay to establish trust relationships with each other. Not every HIE has joined DirectTrust yet, but the list is growing.
The National Association for Trusted Exchange (NATE) is an organization trying to tie together state HIEs across the U.S., but has some distance to go to enroll all the states. The success of NATE may determine the long-term viability of some state HIEs.
SureScripts, a new entrant, is traditionally known as the HIE limited to, but very successful in, exchanging e-prescribing health information in a trusted network. Recently, SureScripts announced a Record Locator Service, to be available this fall, built on the same provider directory that powers its e-prescribing network.
Some of these HIE systems, such as DirectTrust and SureScripts, are partnering with each other, and as mentioned, some are not. A number of vendors are setting up their own HIE infrastructures. All who are endpoints of health information are considering their options, trying to pick partners, and, if they can afford, placing some side bets.
How Good is EMPI? Also at HIMSS, you'll hear a relatively new term: HISP, or health information service provider. Some HISPs are also HIEs, and some are not. If they're not, they may be exclusively moving Direct messages from EHR to HER. In other cases, they may be moving other kinds of information, in addition to or instead of Direct data.
All of these HIE building blocks, and many more on display at HIMSS, also rely to a greater or lesser degree on patient identification technology, often based on IBM's Initiate technology. And yet, while enterprise master patient index (EMPI) is pretty good technology, is it good enough?
(For the answer to that question, you might want to attend Overview of Identity Systems and Identity Technologies, a HIMSS pre-conference panel in which I will be participating, on Sunday, February 23 at 10:15am in Room 207C of the Orange County Convention Center in Orlando.)
All in all, the complexity of the HIE haystack will make finding the right solutions every CIO's headache this year. At HIMSS, let's keep asking how the many players can make interoperability simpler, not more complex. Talk about a challenge.
Putting business intelligence in the form of cost accounting data directly into the hands of physicians can start rich dialogues within or between service lines to make healthcare more predictable, more consistent, and less expensive.
John Kenagy, PhD,
CIO of Legacy Health
In this year of Meaningful Use Stage 2 and ICD-10 deadlines, CIOs are consumed by the effort of meeting the high bars set by government to achieve compliance with these mandates. Wouldn't it be great if technology could also control escalating healthcare costs?
It might happen sooner than anyone thinks.
John Kenagy, PhD, CIO of Legacy Health, may just be the catalyst to making that happen, not only at his own five-hospital system in Portland, Oregon, but far beyond those walls.
A year ago at HIMSS, Kenagy conducted a kind of shuttle diplomacy between Epic and Strata Decision, two vendors with large installed bases. Epic's reputation precedes it, and its own new business intelligence software, Cogito, is being adopted widely. Strata Decision is less well known, but its financial management and cost accounting software is installed in one of five hospitals in the U.S., more than 170 healthcare systems overall.
Kenagy's big audacious goal: to get a unified view on healthcare costs down to the physician level, while overlaying clinical outcomes and patient satisfaction data. Kenagy is a man on a mission, and as a result of his legwork at last year's HIMSS, he recently convened a summit at Legacy where all the stakeholders, including clinical leaders and finance chiefs, all worked in unison on Legacy's big goal.
"It's not like we're looking at quality data in isolation of cost data, [or] in isolation of patient satisfaction data," Kenagy says. "That conversation at HIMSS kind of snowballed into this effort where Legacy is not a development partner, but certainly bridging" the efforts of both vendors, he adds.
As a HIMSS EMR Adoption Model Stage 7 site, Legacy is an advanced user of electronic health record software. The system chose not to adopt earlier business intelligence solutions, such as Oracle or Cognos, but instead waited for more cost-effective solutions. "We're really working with our vendors to develop the tools that we need, instead of bolting on other products," Kenagy says.
The big huddle last month included a data architect Legacy had hired from Intel and other members of Legacy's BI team, as well as more than a dozen representatives combined from both Epic and Strata. Over the course of two days, input came from more than 100 people inside Legacy, including service lines, pharmacy, care transformation, and Legacy's CEO, George Brown MD.
"We were actually able to demonstrate some of the tools, because we did that in our test environment," Kenagy says. Feeding in the various forms of cost—fixed, variable, labor, supplies—from Strata's StrataJazz technology into Epic's Cogito, meeting participants were able to quantify value as an equation with clinical outcomes as the numerator and cost as the denominator.
"It was wonderful," Kenagy says.
Having installed StrataJazz, there are payoffs already coming this spring for Legacy. "This year is the year where we implement Cogito in production," Kenagy says. "In April, not only does our budget year start, we'll also be upgrading to Epic 2012. Managers now have access to their costs on a monthly basis, and I know they [will be] using that information as they make budgetary decisions."
For instance, the cost accounting information will allow managers to break out a gross figure of cost of supplies, attribute it to various clinics, observe variations, and address the variations in next year's budget.
"It will be wonderful if a year from now we are doing our fiscal year 2016 budgeting [and] making amazing use out of the data systems to inform that, that we're just making sharper decisions on what we think our patient volumes will be, what we think the growth will be," Kenagy says.
Along with other efforts to eliminate waste, such as Lean, Kenagy expects a return on investment in this business intelligence push within the next two years. "The proof of the pudding is healthcare becomes cheaper for the people of Portland, because Legacy has done this and then created a competitive excitement around lower cost," he says.
One thing I've observed covering analytics technology is just how wedded some places are to using Excel spreadsheets to try to do the kind of work that Legacy is doing with StrataJazz. After digging into the tools themselves, CIOs inevitably come to the decision that an investment in a true business intelligence solution, while costly, is far superior to trying to achieve these insights via traditional spreadsheets.
I am also now convinced that business intelligence will help healthcare systems figure out how to fit themselves into newer, innovative emerging care delivery models. Cost accounting technology can show which service lines have higher costs than industry averages. Leadership might try to bring those costs down, or instead, it might decide to form a strategic partnership with a competitive provider in that area to enter an ACO or other arrangement, to leverage the lower costs of the competitor's service lines while maximizing those service lines within their own organizations where cost is lowest and quality highest.
I also keep hearing that physicians love to see the data, and it's entirely possible that systems such as the one Legacy is building can put cost accounting data right in the hands of those physicians – evidence that may start rich dialogues within or between service lines to make healthcare more predictable, and more consistent.
"Physicians are very data-oriented," Kenagy says. "They're trained to be really skeptical of information, inquisitive, wanting to discover the truth. Doctors don't like to be outliers, and there's kind of a moderating impact that just the transparency of information presents."
As a physician colleague of Kenagy's once told him, physicians can remember their most recent case, their best case, and their worst case, but usually have no clue about their "average" case.
"Meaningful Use is creating the databases and data structures to collect order entry information and some outcomes information to be able to run the cost accounting and more importantly take that cost accounting and compare it to outcome," Kenagy says.
Even more promising is Kenagy's attitude toward sharing this work with other providers who also run Cogito and StrataJazz. "There's nothing proprietary in this for us, no competitive weapon," Kenagy says. "Let's make this something that Epic and Strata customers can benefit from [on] day one."
With the collaborative attitude of leaders like John Kenagy, there is much reason to be optimistic about technology's ability to truly bend healthcare's cost curve.