It's too early for a victory lap yet, but health systems and physician groups that prepared for ICD-10 are faring well. Revenue cycle implications are yet to be seen, however.
Having stared at tables full of ICD-10 reference books last week at AHIMA's annual convention and flipping through a few code books myself, I can sympathize with those clinicians and coders who are looking up all the new billing codes on paper.
But why would anyone put themselves through that?
It is too early to take anything like an ICD-10 victory lap—and there are future implications of the new code set that I address later in this column. But the initial reports are that those who prepared, and armed themselves with a technology assist, are doing okay with ICD-10 so far.
John Showalter, MD
"No major surprises," says John Showalter, MD, chief health information officer of the University of Mississippi Medical Center, writing to me at the start of the week in an email. "Systems are functioning well, and with a little extra effort, coding days are still at pre-ICD-10 levels. We have submitted a few claims where the remittance has already come back, and all of our major payers have accepted a claim submission.
"It has mostly been a non-event (still need to make sure we get paid though)," Showalter says. "When there isn't a one-to-one mapping, we need to manually make the best selection. We started with about 12,000 and will be down to about 2,000 by the end of the day. Luckily, we have been able to do most in large batches because it is primarily affecting providers with a narrow clinical scope, like transplant."
The medical center's primary technology assist comes from M*Modal's natural language processing, which converts unstructured text or narration into structured data. Another tech assist offers prompts within the healthcare system's Epic EHR from Intelligent Medical Objects, suggesting ICD-10 billing codes.
"Since March, all our physician billing has been ICD-10-level," Showalter says. Until October 1, these codes were backtracked to ICD-9 codes for submission to payers.
The medical center also did three rounds of testing with Medicaid in the state of Mississippi. And analytics dashboards help Showalter and his team keep on top of it all.
A day after the ICD-10 transition date, I spoke with Chris Kean, chief operating officer of San Antonio (TX) Orthopaedic Group, to see how her group was faring.
"We're doing just great, as if nothing ever happened, honestly," Kean says. "We're doing really, really well."
The group's 27 surgeons, practicing across eight locations, are doing all the coding. The practice is otherwise free of ICD-10 coders. The EHR is provided by athenahealth.
In explaining the group's success, Kean says the surgeons started by hitting the books.
"We did a coding class, brought in somebody to teach us about the code, learned how to use the books—exactly as if you were doing it in the ICD-9 world—brought all the providers in, all the billers," she says. "We had several evening meetings in order to make sure that everybody was able to grasp it."
Around that time, athenahealth launched a portal to offer a way to learn ICD-10 online instead of focusing on book learning, Kean says. The group decided to finish the book-oriented course because "if something goes wrong, we're going to need to refer to the book to figure it out," she adds.
"So we taught the book, taught how to use it, but then at the very end of the class, after all the doctors were freaking out thinking they were never going to ever survive this, we said, Now athena's developed a tool to show you how this is going to work," Kean says.
"The relief that was on their faces when we showed them that—they said, 'Why didn't you just show us that in the very beginning? We wouldn't have been freaking out,' " she recalls.
On day one last week, the group's administrators fanned out to all the offices. "We just supported the doctors as they tried to figure out their codes using the athena product," Kean says. "We created cheat sheets for them on their top codes in ICD-9 before, to show them how it would convert over into the ICD-10 world, but they really didn't need the cheat sheets at all. They really just started right away within the athena product and started clicking off the codes, and they got to where they needed to be. It was such a relief for someone like me not to have to worry about that."
The pivotal day for the organization turned out to be the next day, October 2. "The administrative folks were not even in the clinics," Kean says. "We went back to our offices and said, 'Call us if you need us.' " There were very few calls.
Kean is certain that any physician just trying to look up ICD-10 codes in a book, without the technology assist of an athenahealth or other technology provider, will definitely get bogged down.
"That's probably true for anybody who's using that book, I am sure. Because I would think that it would take at least five minutes to look up a code—if you're proficient at it at that point; right now, they're not proficient at it—so maybe it would take them 10 minutes to look up a code, times the number of patients that you're seeing."
Revenue Cycle Implications Are TBD
Like Showalter, Kean is still waiting to see how her organization's revenue cycle plays out in the weeks and months to come. Because San Antonio Orthopaedic Group's payer mix is 16% workers' comp, she expects a rise in initial claims denials, as the workers' comp insurers use ICD-10's more specific information to determine that someone else should cover the medical bills for an injury.
"If this is a fall from a ladder, now they know, on a code, real quick, it's a fall from a ladder," Kean says. "Now [if] I'm an insurance carrier, I'm looking at that going, 'Well, is that my responsibility as an insurer? Did it happen at your home? Did it happen at work? Did it happen at somebody else's property?' So what will happen, I believe, is that will trigger an ability for the insurance carrier to quickly identify that, send that letter to the patient to say, 'How did this injury happen? Where did it happen?' And if it happened at somebody else's property, they're going to say, 'We're denying the claim. Go after the homeowner.' "
So an unexpected outcome of ICD-10 could be not just more work for physicians, but also more work for patients as well as property owners, who will have to provide better documentation of the circumstances of certain injuries.
I am sure there will be numerous other ripple effects on healthcare from ICD-10, if Kean's story is any indication. I'll be keeping an eye on them in the weeks and months ahead.
Lynne Thomas Gordon, CEO of the American Health Information Management Association, says high turnout at the organization's annual conference is an indication that hospitals feel "pretty confident we're ready to go. If not, I don't think we'd have anybody here."
Will ICD-10 be the Big Easy?
This week, all eyes are on New Orleans, where the American Health Information Management Association has gathered for its annual convention. The event will conclude mere hours before the cutover from ICD-9 to ICD-10 for hospitals—and the one-year grace period for physician practices to adjust to the new coding system.
On Tuesday I spoke briefly with AHIMA CEO Lynne Thomas Gordon here in New Orleans about the transition to ICD-10. The transcript below has been edited for clarity.
HLM: Do you think that we'll know early on if CMS is processing ICD-10 claims correctly? How much of a concern is it to you that we won't know on October 1 how things are going? I wasn't reassured by the CMS press call last week. What's your thought on how responsive it can be in letting us know things are going all right with ICD-10?
Lynne Thomas Gordon
Gordon: Great question. You're going to start coding when the bill drops. So you've got patients in the hospital and you're only going to start coding those patients that are discharged after October 1. Your bills are going to go in, and then I think you'll first know if you first start getting rejections, if you get denials, unless something just catastrophic happens, and course they've done the testing.
They feel things are good to go. So the quickest way [to know [if there are problems] is, if I were a hospital, I'd send in my bill, and I'd start getting rejections, rejections, rejections, and problems. That would be my first red alert. Of course, most hospitals are going to know their typical rejection rate. What do we send in? How does it come back? So that will be the first red flag.
HLM:And how long do you think it will take before we start to know if that is even a big problem?
Gordon: I don't know the exact answer. I am thinking it's going to be 30 days. It would depend on how long it takes them to adjudicate and get it back out, and I don't know how fast they are. I hate to say the government takes 30 days, because I don't know the real answer to that.
HLM:When you're working on a slim cash margin, like many providers are, 30 days can be an eternity—a long time to know you've got a problem.
Gordon: I think it depends on the provider, too. How clean are their claims going in in the first place? What's their track record? Are they getting things through normally with ICD-9? I used to work in revenue cycle, and on the back end, you're always looking at why did this get rejected, what happened here? You're looking for different things, not just the ICD-10 code.
HLM: It's not always as simple as yes or no.
HLM:Some people are worried that certain payers will find [the ICD-10 implementation] a convenient excuse to delay payment. Have you heard that?
Gordon: I think hospitals think that all the time. It's just one of the things they always say. It could be possible. I'd like to be optimistic and think that people are trying to be fair and square. The problem is, if they do that, they're just chasing things down the road.
I would think, if I were a payer, I would want to make sure things were working well before I used [ICD-10] as a delay tactic. We've got this big change, and we've got to make sure we've got our act together before we start doing shenanigans.
HLM: How would you even prove the shenanigans anyway?
Gordon: You wouldn't. I will say, if you are a well-run organization, you do have benchmarks. You're looking at your A/R all the time. You're looking at your denial rate. You're looking at your coding quality. You're looking at your coding productivity. You have an eye on the ball.
So when something goes askew, you're going to know it, and people are going to be even more fanatical than usual, because they're going to be going, 'okay, this is a change.' So if we have been looking at our metrics closely before, we're going to be especially careful to be analyzing what's coming back in, [and] how are things going out.
I think hospitals are going to be on high alert to say, 'we don't want to have any cash flow problems, so we're going to make sure we're doing everything on our end.'
I have to say, we've got a great turnout at the convention. That tells me hospitals are ready. They feel pretty confident we're ready to go. If not, I don't think we'd have anybody here. I think it says a lot for the healthcare industry.
HLM: I'm impressed by the longer-term vision of this HIM community, which is how coordinated care happens, and how the coordination with long-term care happens. This is a vital component of health IT that doesn't always get the credit it deserves, but boy is it important.
Gordon: We used to be able to really manage the patient's story. We could make sure it was trusted. We could make sure it had integrity when it was on paper.
Now that we've put in all these electronic health systems, what we're saying is, you have got to have information governance. You have got to make sure that you've got principles in place and framework and people that are being held accountable.
We feel like we're the water that flows through the pipes, and IT, they're the pipe. And you don't want your water corrupted. You want it to be safe. You want it to be secure. You want it to be there on time.
That's our job.
People just assume their information is correct. What they don't realize is there is a whole profession that's out to make sure that we're taking care of the patient's story and can be trusted. Our members are very technical and very well-trained. It is hard to explain to people what we do. We believe strongly that not only does it help patient care, but we also believe it helps with patient safety. We've been in discussions with the Joint Commission, and they get it big time.
While governments and groups gnash their teeth and craft future policy concerning electronic health record usability, providers are turning to overlay software to recast EHR workflow.
This article first appeared in the June 2015 issue of HealthLeaders magazine.
Electronic health records are doing more than ever, but providers are challenged like never before to find ways to make them easier to work with and more productive; in short, more usable.
In January, the American Medical Association, joined by 34 other medical professional organizations including the College of Healthcare Information Management Executives, told government regulators there is an urgent need to change the current federal EHR certification program to better align end-to-end testing to focus on EHR usability, interoperability, and safety. CMS has even recommended enhanced user-centered design principles in the 2015 EHR certification criteria proposed in conjunction with meaningful use stage 3.
"A lot of the traditional design in a lot of these legacy systems was never really built to encompass the full range of physician documentation and order entry."
While governments and groups gnash teeth and craft future policy concerning EHR usability, providers are turning to overlay software—some of it powered by speech input, some of it running on simplified tablet-based desktop or mobile user interfaces—to recast EHR workflow.
"A lot of the traditional design in a lot of these legacy systems was never really built to encompass the full range of physician documentation and order entry," says Brian Yeaman, MD, chief medical information officer of the Norman Physician Hospital Organization at Norman (Oklahoma) Regional Health System, a multicampus system with more than 3,000 employees.
Brian Yeaman, MD
Many EHR vendors resorted to numerous overlays or additional pop-up screens, but these often just compounded usability issues in the interest of fulfilling some requirement of meaningful use, Yeaman says. "They are very destructive in terms of workflow, thought process, and how we're moving through the EHR to evaluate data and to evaluate a patient."
Repetitive typing and mouse-clicking are also causing eyestrain and prompting carpal-tunnel surgeries for clinical staff, Yeaman says.
Two years ago, Norman installed Nuance's Dragon NaturallySpeaking in its 4,000-square-foot, 39-bed emergency room. To prevail in this noisy environment, Norman uses noise-canceling microphones with the software, along with Nuance's macros to input significant amounts of information via simple commands.
A limitation of many speech-input technologies is the need for a clinician's voice profile to be present at the point of speech. While deploying dedicated dictation computers can help, Norman has yet to make the investment in infrastructure that would allow such voice profiles to move with the clinician, Yeaman says.
A common tension runs through any EHR usability improvement in healthcare. On one end are those pushing for totally standardized user interfaces and workflows, for reasons ranging from simplicity of training and help-desk support, to larger issues such as implementing quality measures. At the other end are those who want flexibility, either because it conforms to previous workflows or physician preferences, or because a particular specialty's EHR workflow is much different than the workflows of other specialists.
A neurologist and a nephrologist are going to evaluate a patient in a significantly different way, Yeaman says. "One is heavily numbers-driven. The other is heavily exam-driven and imaging-driven. How those templates set up and how those macros would work are significantly different, and as a health system, we can't slow down our providers by forcing them to do a one-size-fits-all in significantly different specialties."
Saving work for later
Many clinicians fume about EHRs that force them to complete lengthy structured notes during or immediately after a patient encounter. New technologies sitting on top of EHRs not only allow such notes to be saved in draft form and completed later, but they even permit clinicians to complete the notes on a mobile device or start on a mobile device taken into the exam room and then finish later on a desktop device.
Paul Richardson, MD
In April, 165-bed Conway (South Carolina) Medical Center, in order to finish migrating its last physicians from paper, standardized on one such technology with physician workflow software published by PatientKeeper, a company acquired by HCA in 2014.
All Conway physicians are now required to enter their orders through the PatientKeeper portal and to enter notes using PatientKeeper NoteWriter, says Paul Richardson, MD, vice president of clinical informatics and utilization, and chief medical information officer at Conway.
Prior to April 1, some of those physicians still used paper charts, even though Conway had a separate Meditech Magic EHR since 1998, and continues to use Meditech as its EHR. In 2009, Richardson, who is also a practicing internist, and a few other Conway physicians, started using PatientKeeper to perform computer-assisted order entry with Meditech Magic.
"I particularly like that they're able to integrate multiple systems, to pull the x-ray reports and the films themselves right into what I need and incorporate it all into one platform," Richardson says.
PatientKeeper allows Richardson and other clinicians to be more efficient than they were on paper, despite conventional wisdom he had heard from colleagues at other organizations who found EHR order entry and note-taking slower than on paper.
Recently, PatientKeeper began reconciling medications at discharge time at Conway. "CMS is mandating through meaningful use that this facility needs to have a 60% usage of CPOE," Richardson says.
So, as of this spring, rather than Meditech, Conway physicians "live in" PatientKeeper NoteWriter all day long, he says. "I personally don't know why a practicing physician would need to go back into Meditech. I can't see a workflow where that would be necessary."
Donald Abrams, MD
On the standardization versus flexibility issue, "customization cannot circumvent some core quality items. These are evidence-based guidelines, and no physician should really disagree with these guidelines. In my opinion, those are non-negotiables," Richardson says. "Beyond that, there's something to be said for some workflow tweaking and customization."
However, Richardson shudders at tales of hospitals with up to 6,000 order sets. "But you do have to have a little bit of flexibility, because not everybody's workflow is the same."
"Customization cannot circumvent some core quality items. These are evidence-based guidelines, and no physician should really disagree with these guidelines."
Richardson also points out the weakness of allowing physicians to save draft notes, returning later to complete them. "If you come back two hours later, how fresh is your memory of that interaction?" he asks. "Are you going to miss something? That worries me. Now, there may be physicians able to do that, but that makes me a little bit uncomfortable."
And yet "obviously, emergencies are going to happen," Richardson adds. "I'm doing a note, then a patient's crashing. Again, patient safety and patient care come first, always. So I need that ability to be able to walk away and not have my computer time out and losing everything I was doing."
One shortcoming of PatientKeeper: Right now it is targeted at physicians, but not at nurses, who must instead struggle with the older EHR's user interface.
"I've told the folks at PatientKeeper I wish it were there for nurses," Richardson says. "It would be very helpful for nurses to tee up orders for the physician."
Rethinking usability via iPads
The advent of tablets such as the iPad have sparked a once-in-a-generation opportunity to rethink how clinicians interact with EHRs, with implications far beyond the core usability debate,such as unexpectedly advancing preparedness for ICD-10.
The Electronic Medical Assistant from Modernizing Medicine is one EHR that several providers have used to tap the intuitive interface of the iPad, although the technology is limited to the practice of several lines of specialist medicine, rather than being aimed at general practitioners.
At Coastline Orthopaedic Associates, a six-physician Fountain Valley, California–based group with 35 employees, the patient encounter begins with the clinician carrying an iPad to the exam room—no PC in room, no laptop, no paper chart. By using the iPad screen to touch, pinch, and zoom in on different displayed anatomical features on the iPad screen, clinicians can access the EMA database, where more than 75,000 anatomical locations are revealed graphically in layers. If a patient reports pain or popping, the clinician can paint the location of the report in this database, which under the covers can generate appropriate diagnostic codes, even in ICD-10, which is due to become a U.S. standard later this year.
"It combined my vision of what an electronic health record should be, and has made it much easier for us in the office, actually spending less time in the office, getting better reports out, and complying with governmental regulations," says Daniel Stein, MD, founding orthopedic surgeon at Coastline. Yet clinicians can still add traditional notes in EMA by touching to open a text box—and even dictate those notes using the iPad's Siri voice transcription feature.
Coastline implemented EMA in August 2014, and within a few weeks, all its physicians had made the transition from paper, Stein says. "We did it slowly purposefully, because there's always going to be something to be dealt with," he says. But, "we lost no time, and we lost no charges to the patients."
Another EMA user is Donald Abrams, MD, chief of ophthalmology and director of the Krieger Eye Institute. He is also the chair of the Graduate Medical Education Committee for Sinai Hospital in Baltimore. The department of ophthalmology employs 11 ophthalmologists and more than 60 employees overall.
Six years ago, the hospital's IT department implemented the ophthalmologic version of its EHR. "It was a system that was heavily customized to meet our practice, but after a year of customization, the actual use and output was so terrible that we had to abandon it after about six weeks," he says. "Our productivity dropped to 25% or 30% [of usual patient visits], and we could never recover from that. We had very upset clinicians, technicians, and patients. It was very laborious to sit there in front of a massive computer or even carry around a big laptop to get the data in, and ophthalmology has a lot of data points. There's vision, pressure, all sorts of eye measurement, and it's very difficult to do that with some of the traditional electronic medical record software programs."
After the department returned to paper and witnessed another disappointing demo of the same EHR in 2014, the department received approval not only to implement EMA in June of that year, but also to avoid interfacing with the hospital's EHR for the 2014 meaningful use reporting period. (The interface is being implemented for this reporting year.)
The transition from paper to iPads running EMA was speedy, Abrams says. "I started on a Monday, where I did maybe more than half of my patients, and by Wednesday I was at 100% of my patients," he says. "From a practice standpoint, we had ratcheted back to between 25% and 50% of the normal number of patients, and we were back at over 100% by August; so within five to six weeks, we were as productive or even more productive using the electronic system, and I don't know any electronic system where you can say something like that."
The capper came when the hospital IT team met with ophthalmology department leadership to discuss conversion to ICD-10. "I said, 'I don't really know what you're talking about, what you want me to do, because I kind of think we're ready,' " Abrams says.
When the IT team asked for an explanation, Abrams demonstrated using EMA to chart a patient, and then changed the date of exam to October 15, 2015. "Immediately it gave me the CMS 1500 form and all the summary fields with all the ICD-10 codes in it, and I showed it to them, and they said, 'I guess you'd like us to cancel all the rest of our time with you for the rest of the year, right?' And I said, 'It's up to you.' So that kind of blew them all away."
A few pioneering healthcare providers have figured that because customer relationship management apps are so good at the people-oriented workflow details necessary for care coordination, the effort to customize CRM for healthcare is worth it.
The more I look into the status of meaningful use—it's a source of distress—the more I find beleaguered care coordinators using notebooks, Excel spreadsheets, and sticky notes to keep track of risk-stratified populations.
The reasons why they are not using EHRs to do this are varied, but fall into two general categories:
Too many EHRs either require care coordinators to adopt unfamiliar workflows.
EHRs require too much time, effort, training and retraining to provide workflows which are sufficiently tailored to the provider's way of doing things, or to the workflows that make the most sense for care coordinators.
All around, we see efforts to solve these problems. Some providers simply lay down the law that the EHR shall be used, even though it may not be anywhere near optimized for care coordinators. The low attestation rates for meaningful use in 2014 are evidence this approach has been unsuccessful.
Throwing Software at the Problem Every year at HIMSS, we see a growing number of sprung-from-nowhere population health software applications designed to fill the gap in a best-of-breed fashion. At next year's HIMSS, a whole host of those will likely have vanished, replaced by other startups.
For my money, the most battle-tested care coordination software emerging is likely to be the customer relationship management (CRM) software represented by Salesforce and Microsoft Dynamics, which sales forces have been using out in the field for more than 15 years.
A few pioneering healthcare providers over the past decade figured that because CRM apps are so good at the kind of people-oriented workflow details which customers across many industries respond to so well, that the effort to customize CRM for healthcare would be worth it.
Thus, the care coordination crisis afflicting meaningful use is putting more and more CRM software on desks alongside EHR software. This "two panes of glass" approach is even prompting one provider, the University of California San Francisco, to purchase larger monitors, so care coordinators can have the EHR and the CRM open and side-by-side to get work done more efficiently.
Last week, Salesforce boiled down some of the early work of UCSF and other pioneering healthcare customers into its newly announced Health Cloud, a specific version of Salesforce optimized not only for care coordination, but for the kind of lead generation and call center productivity enhancement which are foreign to EHR software, but necessary to all businesses today, healthcare being no exception.
One reason healthcare can turn to these types of CRM solutions is that (with some effort) EHR data can now find its way out of EHRs into CRM systems via HL7 feeds and a growing selection of connecting middleware.
Another reason: Salesforce is comfortable signing hundreds of business associate agreements assuring that data stored in the Salesforce cloud is compliant with HIPAA regulations.
The popularization of CRM technology in healthcare is somewhat analogous to the way analytics technology has made the leap into healthcare. Vast and growing talent pools of analytics experts seasoned from tours of duty in the financial services sector, and legions of CRM rapid-application-development experts are increasingly at healthcare's beck and call.
The modern, application program interface (API)-based nature of cloud platforms mean projects are developed in weeks or months, as opposed to the years that such projects can take in traditional healthcare IT.
More Efficient Care Coordination For example, at City of Hope National Medical Center in Duarte, California, a single nurse is now managing 150 to 200 cancer patients on their journey from diagnoses to outcomes, using a single Salesforce-built care coordination software system. Care coordinator positions, launched this year, allow staff to risk-stratify those cancer patients to determine which patients need additional support, says Shirley Johnson, senior vice president and chief nursing and patient care services officer at City of Hope.
City of Hope, UCSF, and a handful of other Salesforce healthcare customers are piloting Health Cloud before its general availability next spring.
"We knew there had to be a better way" than sticky-note reminders, Johnson says to an audience at Dreamforce, Salesforce's annual user convention, which brought more than 160,000 registered attendees to downtown San Francisco last week. "And that better way didn't take a year to develop."
CRMs, which typically could allow sales reps to track progress of sales prospects along a timeline, are being adapted to display to the entire care team episodes of care along a timeline. Johnson's team fine-tunes what Salesforce now calls "patient relationship management" workflow in collaboration with its new team of care coordinators.
One of the ways CRM turn the traditional EHR world topsy-turvy is the way the relationship between a prospective patient and a provider can begin. Instead or originating as a medical record number, a lead is generated in a prospect pipeline, much like any sales prospect.
Centralizing Key Data Elements 'in Context' At Johns Hopkins Medicine International (JHI), a 450-employee unit of Johns Hopkins Medicine providing personalized, culturally-appropriate care for patients traveling to Hopkins from outside Maryland and the United States, an application built in Salesforce's Support Cloud manages coordination of patient visits where each day in the U.S. is a day of extraordinary patient expense and separation from distant loved ones.
"We are trying to centralize key data elements in context," including information drawn from the Hopkins Epic EHR so such coordination happens smoothly, says Fedor Vidal, IT director of JHI.
Yet another Health Cloud pilot site, Centura Health in Colorado, is using Salesforce for utilization management and referral management, and to receive notifications from the Colorado Health Information Exchange when a patient has been getting treatment outside the Centura network, which is about to go full-risk on 175,000 patients.
If it all sounds like things you thought the EHR was supposed to do on its own, well, that's what I think as well. That presents a challenge and an opportunity to CRM technology vendors such as Salesforce, and an equal challenge to traditional EHR vendors.
Lack of Data Flow to EHR For one thing, what Salesforce does technically will not get anyone over the meaningful use attestation finish line. This is in no small part because data in CRMs, even HIPAA-protected data, has no easy way to flow back into the EHR.
The growth of APIs for EHRs has largely been restricted to read-only access so far. Where this all gets really interesting is that companies such as Salesforce are considering applying for certified modular EHR status for technologies such as Health Cloud.
If they succeed, the legacy EHRs may find themselves under enormous pressure from government and providers alike to allow technologies such as Health Cloud not only to read data out of EHRs, but to write data back in. That would require even more of an open kimono on the EHR vendors' parts – something in short supply so far.
A true ecosystem of sharing between the two worlds would allow UCSF and others to stop requiring dual-entry of care coordination data first into the CRM and then into the EHR.
For now, customers of CRM providers such as Salesforce has seem quite happy just to leave their Excel spreadsheets and sticky notes behind in order to have a simple second screen for unified care coordination, sitting alongside the EHR as necessary.
The next step, and it won't be long, will be to merge those two screens into one. This will allow CRM technology to help EHR technology do what it was supposed to be doing all along: Coordinate and manage longitudinal patient care at the population health level, while engaging patients at all points of their relationship with healthcare.
Measuring the value of healthcare and using the data to influence outcomes isn't a distant goal. It's happening now and physicians are starting to get the message.
The message to physicians and healthcare executives couldn't be any clearer: Since your outcomes performance is more and more a matter of public record, you had better get a handle on the value you deliver before the public does.
After attending the Health Catalyst Analytics Summit last week in Salt Lake City, I am convinced that health leaders are not just talking about measuring value sometime in the future. They are doing it today and driving better outcomes, using that data transparency to get through to recalcitrant physicians and healthcare executives.
Jay T. Bishoff, MD
One such leader is Jay T. Bishoff, MD, director of the Intermountain Urological Institute at Intermountain Healthcare. He has to convince his fellow urologists and surgeons to pay attention to a series of dashboards displaying prostate cancer patient outcomes, including not only the cancer's progress or control, but also side effects such as incontinence or impotency.
Fellow urologists "get really sensitive about it," Bishoff told conference attendees. "They say, why are you doing this? I say, 'I'm doing this to help your patients have a better outcome because somebody is going to measure that, and they're going to put it online, whether you like it or not. So let's work together now to get better outcomes.'"
Out in Front
To get ahead of public reporting of these outcomes, Intermountain is working quickly to publicly report its prostate cancer treatment potency and continence rates, individually by surgeon, Bishoff says.
Intermountain's "obligation to deliver a measured experience" also translates into fewer biopsies for prostate cancer, saving money and reducing unnecessary discomfort and pain to patients.
The effort starts by constantly scouring medical literature for evidence-based, but as-yet unimplemented protocols, some more than a decade old. Intermountain urologists perform 65,000 prostate-specific antigen (PSA) tests per year. Taken in isolation, a PSA measurement of 3.0 wouldn't seem to indicate a need to do a biopsy. But when clinicians risk-stratify, considering factors such as race and age, risk of an aggressive prostate cancer can rise to where a biopsy is definitely in order.
"There's only one other integrated healthcare system in the United States who's interested in incorporating that same logic," Bishoff says. "That is something that [other] healthcare systems could do."
Risk Stratification By stratifying risk, Intermountain was able to drop its number of biopsies by 30%, while still finding those patients whose PSA might be 3.0, but "we want to find it when his PSA is 3.0, not when it's 30," Bishoff says. "We will spend less money on that guy by screening him and identifying his progressive cancer early than when we're trying to treat him later."
The patient also gets a say in the treatment conversation after the risk stratification. "So we have a meaningful conversation, and we let patients decide," Bishoff says. "Our own insurance company loved it."
Drawing this line between transparency, technology, and value is the top takeaway from conferences such as these.
"One of the things we find here, what has become pervasive in the industry… is lending more structure to how clients find that value," says Vi Shaffer, research vice president and global industry services director for healthcare providers at research firm Gartner.
While the knowledge transfer is getting a bit more organized, trying to keep on top of the firehose of case study-sharing at conferences such as this can still drive healthcare executives crazy.
"It feels like a zillion knowledge clouds out there with independent networking and no cohesion to it," Shaffer says. "That's going to happen for a while. I'm certain it's going to happen with the explosion of genomics and all these other use cases, now that people have clinical data in their warehouses and there's more benchmarking and more collaboration and it's easy to do technically."
Frederick C. Ryckman, MD
A Vigorous Response The response of many organizations at last week's event was to swarm the conference by sending entire analytics-savvy teams.
"We have now trained in our organization over 500 people in quality improvement and analytics, and they all understand what annotated run charts look like, and control limits," says Frederick C. Ryckman, MD, interim chief operating officer and senior vice president of medical operations at Cincinnati Children's Hospital Medical Center.
That figure represents 15% to 20% of the hospital's workforce. "More than that [percentage] from a clinical point of view are highly trained in analytics, so it's made the journey easier, but the early days were really an uphill climb," Ryckman says.
Reducing variations in care through analytics-driven process change allowed Cincinnati Children's to pass along $25 to $30 million worth of savings to families last year, with a total of $50 million in savings across the institution, he says.
"Our goal in our strategic plan for the next five years is to decrease our costs by 2% per year and make sure that that we keep the cost of patient care at exactly the same or 2% less per year over the course of the next five years while we improve outcomes by no less than 2 to 3% per year."
Curbing Costs While many health systems have similar aspirations to cut costs, few are as under-the-gun as providers in Massachusetts, where legislation mandates the rate of cost growth in healthcare to no more than 3.6% per year, says Tim Ferris, senior vice president of population health at Massachusetts General Hospital Partners Healthcare in Boston.
"Given [that] the national inflation rate of healthcare in the 5% range, [makes it] a distinct challenge for us," Ferris says. "I'm more optimistic. We do have the data now. Data that is real-time and data that is clinically accurate. Our clinicians appropriately demand that we show them data, that data is accurate, that data is attributable, and the data is risk-adjusted."
Partners has signed different risk contracts with six different payer entities. "Each one of those contracts provides different methods for calculating the benchmark," Ferris says. "They provide different measures for assessing the quality. So our performance is different, but we don't treat patients differently depending on whether they come in with one commercial health plan or Medicare or in the Medicaid program.
"So as long as we don't have a national standard for how to do performance-based risk contracting, providers are going to live in a world where they are chasing multiple targets at the same time. It sounds like a full employment act for analytics."
"That was supposed to be a joke," he quips, and the audience laughs.
As providers chase elusive value goals which constantly get moved and increased by payers, including the government, I have no doubt that anyone in healthcare with analytics tools at the ready will have plenty to think about and do.
Leaders at Mercy have developed an inclusive and expansive technology program that focuses on human relationships and partnerships inside and outside the organization.
This article appears in the September 2015 issue of HealthLeaders magazine.
Telemedicine is not merely cables, computers, cameras, displays, software, and sensors. It starts with relationships between people, between the organization providing telemedicine and those providers who benefit from and help direct the evolution of telemedicine efforts, and ultimately the provider-patient relationship itself. Those human relationships also extend to the vendors supplying technology to providers, and, in the case of one health system, Mercy, a brand-new standalone virtual care center to extend its relationships to other healthcare systems looking to partner with it, rather than independently build their own telemedicine nerve centers.
So says the telemedicine team at St. Louis–based Mercy, a 35-hospital system spanning Arkansas, Kansas, Oklahoma, and Missouri that has become a national leader in implementing telemedicine. To Mercy, virtual care represents the opportunity to extend person-centric care delivered by expert teams beyond the traditional institutional setting.
Christopher Veremakis, MD
The organization started its telemedicine efforts in 2006 with an eICU program, but with a plan even then to incorporate those efforts throughout Mercy's care system. Today, Mercy Virtual is progressively integrating across the entire system. "We believe virtual care will be integrated into the full spectrum of care and health optimization," says Randall S. Moore, MD, MBA, president of Mercy Virtual.
"Because we partnered with primary care from the very beginning, we knew [that] to live within a construct of population health and risk management, we needed a program that was married very closely with primary care," says Janet Pursley, vice president of care management.
"The technology can be the easy part," says Christopher Veremakis, MD, medical director of Mercy Telehealth Services. "It's all about establishing relationships with people. Much of the work I've done is change management work, getting people to accept [that] the world of medicine is changing, that technology can play a role. Technology is just another tool, and a key part of what we have to do is learn how to use our new tools to build care solutions we could not offer before, while recognizing that relationships are still really important. You can develop different kinds of relationships with patients than you did in the face-to-face world."
A key turning point occurred when one-way video to the bedside was replaced with two-way. "When [we] made that transition and when we went from being the stranger know-it-all from the big city far away to knowing people on a first-name basis, and we were just another provider, like them, who was up all night trying to take care of patients—that's when we went from being the outsider to just one of the team, and the acceptance really developed," Veremakis says.
Even where Mercy first employed telemedicine, in its hospital-oriented tele-ICU and telestroke programs, it was "helping people to retrain themselves on how to deliver better medicine with this new tool and make them understand that some things have to change, but some things can't change and shouldn't change," Veremakis says. "Whenever you're dealing with groups of physicians who you're leading through change, there's politics and relationships, but that's true even of administrators and nurses and other coworkers."
As an example of things that can change, Veremakis cites new technologies that permit physicians to get the same information as they would from a regular physical exam (e.g., heart rate, respiration, and ECG waveforms) without necessarily having to see a patient in person. "Basically," Moore adds, "what we cannot do is touch or smell."
Wendy Deibert, RN
Also, Veremakis says, "everybody thinks that when you start doing telemedicine you are giving up the personal relationship with the patient. We're learning that that's absolutely not true. Number one, with two-way audio-video, you can look at someone face-to-face and have a conversation with them. You often pick up facial nuances and body language more than when in person. That's been surprising."
Mercy psychiatrists, who also use Mercy telemedicine technology, have learned that the distance created by the physical separation actually gives their patients a feeling of safety, Veremakis says. "They're more open and they actually say more, and therapeutic relationships can work better."
"People who need procedures and more intensive care will require face-to-face, but I think an increasing majority of cognitive care can be done via telemedicine," says Wendy Deibert, RN, vice president of telehealth services at Mercy. "So that leaves more time for bedside providers to be face-to-face with their patients."
Mercy Virtual went through a substantial learning curve. New implementations consisted of technology deployment and an introduction to the program and how it would work.
"We learned successful programs required much greater change management than we anticipated," Deibert says. "Based on lessons learned, new implementations now include assessment of current workflows, clinical and operational process reengineering, alignment of incentives, and many more change management activities. Nursing and physician staff turnover leads to reiteration. You've got to constantly be educating, training, updating, educating everybody about what you're doing and why."
When implementing telemedicine in a Mercy practice, "for each individual program or location that we build, we go in and assess the culture and what telemedicine will help them solve," Deibert says. "Once you design around that, the buy-in and the relationships build. You get a long-lasting effect of your program."
Choosing the correct technology partners and vendor relationships is another element of this. "We worked closely with our vendors to develop shared solutions, because part of it is a joint effort," Deibert says.
"Integrating our telemedicine program with our electronic health record platform was critical. Our EHR partner teamed with Mercy Technology Services to make the integration process successful," she says.
"Integrating and transforming a health system is an expensive, complex, and intensive process," adds Moore. "We believe there are many advantages for systems to partner together, learn from each other, and advance virtual-enabled care faster, better, and at less expense for each system."
Integration affects every part of delivery, all the way down to physician quality of life. "By adding physicians to the Mercy telephonic nurse-on-call program, we reduced patient triage to the emergency department from 25% down to 19%," Pursley says. "In addition, Mercy reduced the number of phone calls primary care physicians receive at home by 70%."
HealthLeaders Media LIVE from Mercy: Telemedicine; Healthcare's Nerve Center, will be broadcast on Thursday, October 22, 2015, from 11:00 to 2:00 p.m. ET. Mercy Health System reveals underlying reasons for their successful implementation of telemedicine. How telemedicine has enabled them to improve outcomes, reduce costs, provide their clinicians better quality of life, and made them an increasingly attractive value proposition to payers.
The forces that are making health information exchanges essential include exchanging summaries of care when EHR integration is not yet present and responding to business pressures such as accountable care.
This article appears in the September 2015 issue of HealthLeaders magazine.
As the industry turns its attention to interoperability, the nation's health information exchanges—some regional in nature, some statewide—are helping clinicians avoid productivity-sapping phone calls and faxes, and meet some challenging meaningful use requirements.
The forces that are making these HIEs essential include streamlining workflow utilizing Integrating the Healthcare Enterprise's EHR-to-EHR integration and Direct secure messaging connectivity built into meaningful use–compliant EHR software, exchanging summaries of care when EHR integration is not yet present, and responding to business pressures such as accountable care.
Pennsylvania: Making the transition
The Keystone Health Information Exchange connects 20 hospitals, 239 physician practices, and 30 home health locations primarily located in 31 counties in central, northern, and northeastern Pennsylvania, as well as 69 long-term care facilities spread throughout the state.
"We first went live in 2007 with a pretty rudimentary system of just connecting a few provider portals that were being offered by different healthcare systems and making it available through a single platform," says Jim Younkin, director of KeyHIE. Younkin is also IT director for external customer relations at Geisinger, a system that operates and participates in KeyHIE and itself serves more than 2.6 million residents throughout 44 counties in central and northeastern Pennsylvania.
In 2009, with funding from the U.S. HHS Office of the National Coordinator or Health Information Technology's Beacon Communities program, KeyHIE enabled a registry and information repository based on Cross Enterprise Document Sharing (XDS), a health IT standard developed by the nonprofit organization IHE, for storing and retrieving documents for providers who belonged to KeyHIE.
In fall 2013, use of KeyHIE leapt when it activated a notification service. "Any time a patient presented at a hospital or emergency department participating in KeyHIE, either as an inpatient or at an ED, we would send those alerts," Younkin says.
At the same time, KeyHIE successfully connected EHR software that had the ability to consume records via IHE's XDS protocol and present these records to clinicians as part of their regular workflow—a marked improvement from traditional HIEs, which require separate log-in via a physician portal to access information. In May 2015, 559 users of the HIE accessed information via the portal, with 461 using XDS-powered access within the EHRs themselves.
Those users include one of Geisinger's area competitors, Susquehanna Health, a four-hospital integrated health system, Younkin says. From within Susquehanna's Cerner Soarian EHR, clinicians can click on a link that will connect them to KeyHIE and bring back a list of documents associated with that patient. "My understanding is that that is just at a document-level consumption at this point, but we have similar functionality with customers using Allscripts; Epic does consuming, and there's a regional EHR called Medent, and we have set up with that as well," Younkin says.
KeyHIE is just in the process of finishing a multiyear migration of its HIE technology platform from an earlier technology offering by Caradigm to Orion Health HIE technology, he says.
One challenge for KeyHIE has been the varying degrees to which participating organizations obtain consent from patients to release their records to other members of the HIE. For instance, Geisinger asks registering patients to sign an authorization allowing Geisinger to share their information with other members of the care team. But those patients would have to sign the same authorizations at other organizations where they registered.
"The challenge is that some organizations were good at asking patients to sign this, and some were very lax, and as a result, the organizations that were good at getting them signed were the ones who were frustrated, because when they went to access data from organizations that were lax at getting them signed, they found many times the data wasn't available," Younkin says.
Another KeyHIE feature helps participating healthcare organization bridge an oft-criticized gap in care coordination by connecting data from long-term care facilities and nursing homes to inpatient and ambulatory EHRs.
Those facilities often lack EHRs of their own, which prompted KeyHIE to offer them its Transform service, a low-cost software tool that allows nursing homes and home health agencies—with or without an electronic health record—to contribute patient assessment information to any HIE.
"Transform allows us to take patient assessment data from a nursing home or a home health agency that normally would be sent to CMS or their billing process," Younkin says. "We've used the HL7 standards as well as IHE profiles to generate a Continuity of Care Document from the nursing home and home health settings." CCDs facilitate transitions of care that are required for providers participating in the meaningful use EHR incentive program.
Four hospitals and four group practices in KeyHIE saved money by using the organization's patient portal to fulfill meaningful use stage 2 requirements to have a patient portal, despite efforts by the EHR vendors of those organizations to sell them separate patient portals, Younkin says.
New Jersey: Pockets of success
Four regional HIEs divide the state of New Jersey, says Linda Reed, RN, vice president of behavioral and integrative medicine and CIO at Atlantic Health System a Morristown, New Jersey–based system with multiple hospitals and more than 1,599 licensed beds, which is a founding member of Jersey Health Connect, one of the four HIEs. Providers in the state hope to bring all four together but face funding and technological challenges.
Now integrating 30 hospitals, Jersey Health Connect uses RelayHealth technology and, at the end of 2014, says it saw a sharp increase in providers contributing health summaries via the HIE, rising from around 100 in November to nearly 900 in December.
One reason Jersey Health Connect has grown rapidly is that the HIE was set up so patients had to explicitly opt out of the HIE; if they didn't, their records would be available throughout the HIE, Reed says. "It looked like our governor at one point was going to go after opt-in, but we all rallied, got our government people involved, and he did just let it ride as an opt-out. Otherwise, we would have just had to close up shop."
Linda Reed, RN
Jersey Health Connect's success so far has been driven by the hospitals because they collectively realized it was the right thing to do for patients, Reed says.
"New Jersey is a small state," she says. "We've got a hospital on every corner. As a patient, you could be at an Atlantic Health facility today, you could be at a St. Barnabas facility tomorrow, and you could get Robert Wood Johnson the next day."
The CIOs of the respective hospitals realized that the best patient care comes from sharing results, Reed says. "We then convinced some of our colleagues in our facilities that it was the right thing to do, and I think some of them still are concerned that maybe it's not; but when the accountable care organizations started coming around, they now needed to know what's going on down the street: 'Because now I'm the accountable party for this care, and I didn't know that they were in the Robert Wood Johnson ED two weeks ago,' " he offers as an example.
Also, 14 participating hospitals were able to use Jersey Health Connect in 2014 as a means to meet the meaningful use stage 2 requirement for patients to view, download, and transmit records.
Now New Jersey as a state is facing the challenge of integrating three other regional HIEs into a shared infrastructure to handle, among other things, the typical HIE challenge of patient IT matching, but across a state of nearly 9 million people.
The New Jersey Institute of Technology, which itself runs a small HIE based in Newark, hopes to model a new overall statewide health information network after Michigan Health Information Network Shared Services, an HIE hub that oversees and coordinates information from seven regional HIEs in Michigan, Reed says. "It's not unlike the conversation about interoperability in electronic medical records," she says, "except that you have a bigger issue with the patient matching, especially because of the multiple medical records."
The elephant in the room, Reed says, is that vendors now power many HIEs, just as they power EHRs. "They are still going after proprietary stuff, and we see similar things moving into HIE technology," Reed says.
Some vendor-introduced differences are as mundane as whether a vendor takes one identifier in a data field instead of two. Reconciling these differences makes the job of an HIE that much more difficult, Reed says. Even in supposedly well-defined data standards, "There was enough wiggle room for them to interpret some of these things differently."
Another challenge all HIEs face is to go beyond the usual utilization metrics they publish, to much more difficult-to-capture metrics of how the HIE has affected patient outcomes, Reed says.
And finally, the new statewide initiative faces funding challenges. New Jersey is applying for a federal grant but will need more resources. "That's been one of my concerns," Reed says. "We don't want to put any more financial requirements on our members."
New Mexico: Reboot marks rebuilding phase
The New Mexico Health Information Exchange grew out of the state's HIE Cooperative Agreement Program originally funded by ONC in 2010. Operated today by nonprofit firm LCF Research, the HIE faced a major setback in 2012 when a vendor discontinued the product powering the HIE, although the HIE was able to get by until it transitioned to a new technology vendor.
Through a combination of continuing to run that older technology while migrating to new Orion technology, New Mexico's HIE has avoided the fate of some other states, whose HIEs completely shut down.
"We've been fortunate here that the state Medicaid program, Centennial Care, has been a great supporter of this, and they help through their managed care organizations to participate in this," says Thomas East, CEO and CIO of LCF Research. "They're using the HIE for care management for the Medicaid population, so we've been able to spread the costs out to not just healthcare organizations and providers but also payers."
The NMHIC HIE contains 1.2 million uniquely identified persons out of a total state population of just over 2 million. "We make sure the New Mexico Centennial Care Medicaid population is all represented in the master patient index," East says.
In its current rebuilding phase, NMHIC has been able to gain commitments of participation from a statewide diagnostic imaging organization, and the New Mexico Primary Care Association is funding participation for 15 federally qualified health centers, East says. "There's a number of different organizations in the state, and records don't always easily flow when patients move from care setting to care setting, so folks are anxious to get access to records that haven't made their way very effectively the traditional ways via paper or fax," he says.
A challenge NMHIC and other HIEs face is the lack of comprehensive patient records among participating healthcare practices. "We'd ideally like to see folks move closer to a meaningful use 2 transition of care record," East says.
One New Mexico medical practice that finds value in NMHIC is ABQ Health Partners, a 220-physician, multispecialty group based in Albuquerque. ABQ Health Partners was acquired by DaVita Healthcare Partners in 2012.
"The exchange is our only way of getting information easily across systems," says Robert White, MD, MPH, medical director of informatics and quality at ABQ Health Partners.
White recalls seeing a patient "a couple years ago where I was able to see documents that drastically changed what I did with the patient. Compared to asking the patient or calling somebody else and having something faxed, it's far, far better."
While White and his fellow physicians have been able to exchange summaries of care over NMHIC, moving documents via Direct messaging has been difficult. "In the HIE, it's sort of designed to give me the document as well as discrete test results and discrete vital signs," he says. "It's the note about the exam the patient had that I want to see that tells me what to avoid or what needs to be done in follow-up."
As the HIE matures, much of its power will simply live inside EHR software, White says.
"We're going to continue to work with our HIE to embed it in our EHR so clinicians are not having to think about two different systems," he says.
But White also echoes the importance of the New Mexico approach versus HIEs powered exclusively by EHR software itself.
"The payers and the state are really critical, because the HIE doesn't have an automatic business case," White says. "In fact, a lot of people, including some imaging centers and hospitals, don't want to see it succeed, because sequestering data makes their lives easier and more financially productive."
The Digital Doctor by Robert Wachter, MD, is the book that will have the most long-lasting impact on health IT, and perhaps all of healthcare. Here are five takeaways.
Last winter, two health IT books dominated the discourse: Where Does It Hurt? An Entrepreneur's Guide to Fixing Health Care by athenahealth CEO and cofounder Jonathan Bush; and The Patient Will See You Now: The Future of Medicine is in Your Hands by Eric Topol, MD, cardiologist and chief academic officer of Scripps Health.
But the 2015 book that will have the most long-lasting impact on health IT, and perhaps all of healthcare, has to be The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age by Robert Wachter, MD, who directs the 60-physician division of hospital medicine at the University of California, San Francisco.
Robert Wachter, MD
As evidenced by its frequent mention by attendees at HealthLeaders Media's own Population Health Exchange in June, The Digital Doctor is this year's required reading. About health IT, Wachter has said "We were bound to be disappointed." As we all return from summer vacation, I thought it would be timely to highlight my top five takeaways from Wachter's book.
1. When patient safety is at stake, it leads to powerful examinations of faulty EHR design. Wachter extensively interviewed more than 100 sources, including a few on the UCSF team who erroneously delivered a near-fatal overdose to a patient in 2013, due to what looks to me like design in Epic's EHR which could stand improvement (and since then has been modified). In fact, this overdose inspired Wachter to write the book.
To its credit, Epic permitted publication of the faulty EHR screens in question in Wachter's book. When I spoke recently with Epic president Carl Dvorak, he conceded that Epic customers are normally prohibited from publishing such screens in talks or publications, which he says does not materially differ from the policies of other EHR software publishers. In the case of Wachter's book, "We said, 'yeah, you can publish these screens, even though you're going to be disparaging, because we think it's an important message about safety, and we think there's something to be learned about that,' " Dvorak says.
2. Compliance officers and malpractice jitters are making infeasible the task of dividing EHR workload among team members, forcing already overworked physicians to work even harder. Wachter tells the story of a primary care physician, Christine Sinsky, MD of Dubuque, IA. At her clinic, compliance officers interpreted federal regulations such that nurses or clerks cannot sign a chart for later review by physicians; instead, the doctor must do everything.
When you pile those sorts of internal policies on top of well-known alert fatigue, usability, regulatory, and patient safety issues created by EHRs and other healthcare IT systems, it is no wonder that a recent survey showed physician dissatisfaction with EHRs is actually rising, not falling, in 2015.
3. The clinical quality measures collected as part of meaningful use and other compliance programs have a huge shortcoming, in that they fail to assess the quality of diagnoses. At length, Wachter discusses the advances and limitations of artificial intelligence to provide diagnoses by computer. Like him, I've been expecting this advance since I was young, but instead have wading through, as Wachter says, "the junkyard of failed computerized diagnostic programs built in the 1970s and 1980s." As a result, we live with a healthcare system where, according to one report, major diagnoses may be overlooked in nearly one in five patients.
Wachter does describe Isabel, a promising technology for augmenting physicians' ability to arrive at a diagnosis. But due to a lack of a business incentive or quality metrics, hospitals have no imperative to improve their diagnoses, whether or not technology can help, Wachter says. A cause for optimism, though, is a change in physician attitude that says there is no shame in doing a Google search, even in front of patients. After another generation, that will be profoundly true.
On a troubling note, Wachter notes (as do others) that anything that can assist in diagnoses or computer-assisted coding can also be used to increase the occurrence of "upcoding" which costs insurers and the public dearly in higher costs and premiums.
4. The iPhone, touted as an exceptionally "open" platform by many healthcare IT evangelists, actually derives much of its value from being quite closed. Wachter characterizes Apple's platform as "extraordinarily closed (or at least brutally prescriptive) about who and what plugs into its system." On the other hand, he says, "that's why your apps work so well. Epic is trying to do the same thing as it gradually opens up to third-party programs. That's what I want in my hospital, at least for the foreseeable future."
Perspective is everything. When Epic did not allow much application programming interface (API) access, then of course practically every other health IT platform looked open by comparison. EHR vendors, and customers such as UCSF and Wachter, realize they must strike a balance between control and freedom for developers to innovate, so that they do not get locked into a slowly changing base platform.
But opening up the electronic health record to outside apps is a double-edged sword. It raises all sorts of issues about the trust and reliability of what is being added to the record, either from external data sources or from patients. Don't expect the kind of rapid innovation explosion that occurred when Apple agreed to open up the iPhone. At least with the iPhone, there is essentially only one gatekeeper: Apple. With healthcare, expect overcaution from not only EHR vendors but from clinicians as well. Wachter alludes to the "hold harmless" clauses that technology vendors often hide behind. As long as a physician or a healthcare system is ultimately liable, innovation in healthcare IT will proceed at a relative snail's pace.
5. Although many physicians I speak with say that they can learn technology more easily than geeks can learn medicine, not everyone agrees. "It may be easier to teach a techie healthcare than to teach a doctor tech," says Nate Gross, cofounder of Rock Health, a healthcare IT startup incubator in San Francisco, interviewed by Wachter for his book.
No one is suggesting that tech types can actually practice medicine, but Wachter's book is a reminder that the many aspects of software design alone are simply beyond the training of physicians. Let doctors and nurses do what they are good at, and let software developers pay attention to precisely what it is that clinicians do, to arrive at intuitive EHRs and related systems.
Wachter will be one of the keynoters at the Health 2.0 Fall Conference, October 4-7 in Santa Clara, CA. I will also be there, moderating a panel on patient apps, with speakers James Madara, CEO of the American Medical Association, and Michael Tutty, PhD, AMA group vice president. I look forward to many good conversations there on the combination of technology and healthcare.
The cumbersome process of scheduling interviews between medical residency programs and candidates usually involves a torrent of emails and phone calls between exasperated candidates and equally exasperated residency program directors. That may be about to change.
Scheduling interviews between residency applicants and medical education residency program coordinators is about to get easier, if one startup's promise to automate the process holds true.
Each summer, a bit of computer science commences which optimizes U.S. healthcare behind the scenes. The Electronic Residency Application Service (ERAS), operated by the Association of American Medical Colleges (AAMC), starts accepting fourth-year medical student applications for residency programs starting the following July. Candidates submit their transcripts, grades, letters of recommendation, personal statements, and an application fee, and hope for some good responses.
Invitations to interview follow from residency programs, and then a round of in-person interviews between residency programs and candidates. Then a second service, the National Residency Matching Program (NRMP), accepts the rankings of both the interviewers and the interviewed, and via an algorithm recognized with a 2012 Nobel Prize in Economics, produces the final matches, which are released on Match Day, usually the third Friday in March.
As wondrous as this process is, there has been a cumbersome productivity-drain and stress-inducing process in arranging those interviews. That is because ERAS produces a list of candidates for each residency program, which then invites potentially hundreds of candidates to choose from perhaps 20 potential interview dates, but it's left up to the prospective residents to arrange the actual dates and times of each interview.
Believe it or not, at least one residency program still uses the U.S. postal service to arrange the entire thing.
Mostly, administrative officials at each school are besieged by a flood of nearly-simultaneous emails and phone calls from hundreds of applicants trying to confirm their preferred dates and times. "We interview about a 170 to 200 people, so you get all those emails back, trying to get everybody scheduled in, so it's hundreds of emails and phone calls and stuff," says Amy Matenaer, anesthesiology medical education residency program coordinator at the Medical College of Wisconsin (MCW) in Milwaukee.
Clearly, there was a need to more efficiently match available times to candidates and interviewers, and even to establish waiting lists, since in the scrum of candidates trying to reach their most desired interviews, there was bound to be variations in interview demands based on the prestige of the residency program.
Last fall, MCW's anesthesiology program became one of a handful of residency programs which turned to Thalamus, a service open to all specialties, which charges programs a modest fee, $250 to $1000 per year, and in return offers an online interview reservation and scheduling system, including wait lists, not unlike some airline reservation systems.
Thalamus is the creation not of some venture capital-based startup, but of an exasperated residency candidate and an equally exasperated anesthesiology residency program director.
The service's founder and CEO Jason Reminick is that former residency candidate. He describes the problem: "It becomes this big email race… So everyone emails back as quickly as they can. They arbitrarily just pick a few dates. And then a coordinator on the other side is going email by email, filling out a date planner, filling out an Excel spreadsheet, a completely manual process until they hit a roadblock."
"The idea for this came when I actually got stuck in New York City during Hurricane Sandy, and several of my interviews were cancelled," he says.
Suzanne Karan, MD
After Reminick returned home to his medical school, the University of Rochester School of Medicine and Dentistry, and met with his mentor (and Thalamus co-founder and secretary), Suzanne Karan, MD, vice chair of education and residency program director for anesthesiology, she told him of her own frustrations with arranging interviews from the program side of the process.
"We sat down and came up with this idea of trying to hit it from all sides to make this one-shop stop for everyone." Reminick says. "I was completing a combined MD/MBA degree and I had one more course that I needed to complete for my business degree, so we decided that together we would write the business plan as part of that course, and Thalamus is what came of it."
"We're not so much reinventing the match process, but there's a byzantine process that precedes getting to the match that we are making into a more modern process," Karan says. She and Reminick used their network of residency program directors, interviewing physicians, administrators, and applicants who needed a solution for this problem. Last year, the Thalamus community included Stanford, Mount Sinai, and the University of Miami.
One beauty of Thalamus is that candidates can select interview dates that allow them to minimize the amount of cross-country travel during interview season by coordinating interviews within a particular geographical region, instead of just arbitrarily picking dates and then facing stiff travel costs and too much time in airports.
Then there is the waiting that is eliminated. Under the old email-and-phone call system, residency administrative personnel spend hours and hours thumbing through paper calendars or spreadsheets, and might respond to a candidate with an interview time three or four weeks later. Using Thalamus, they can reduce this process to under a minute.
In addition, Thalamus accommodates those students who are left without their most-preferred prospects at the end of the early round of interviews in January, says Michael Wadja MD, vice chair for education and residency program director for the NYU School of Medicine Department of Anesthesiology.
Trimming Fat from the System
"Some applicants are spending between $10,000 and $20,000 just on the interview process in terms of travel costs," says Reminick, who eventually chose Stanford University Hospital and Clinics/Lucile Packard Children's Hospital and just completed his second year of combined residency in pediatrics and anesthesiology there. Reminick cites an estimate from Forbes that the entire process wastes between $300 and $400 million.
Considering that medical residents don't exactly rake in the big bucks in terms of salary— another controversy entirely—anything that can cut costs of these programs is obviously good for those programs in light of widely reported physician shortages.
And those wait lists? Thalamus handles them automatically as interview candidates change their plans and interview slots open up. "They actually get an email saying this date just opened, would you like to move your date to here?" Matenaer says. "So it's more of an automated system, versus the manual going back and forth and everything like that."
"There's fat in the system, and some of the fat in the system is the administrative cost of running these residency programs," Karan says. "Being able to take a third of one person's job and cut it into minutes is a huge time and cost savings for our department. So I was thrilled, my chair was thrilled, and my other program director friends were thrilled."
Another Thalamus believer is Brian Tse, a 2015 UCLA Medical School graduate who began his anesthesia residency at Stanford last month.
"Several of the programs I interviewed at started to use Thalamus, which didn't take away the anxiety of emailing back ASAP, but did eliminate the lag time of emailing back in order to confirm dates," Tse says. "I started to look forward to those programs that sent out interview invitations through Thalamus and loved how simple the process is."
This fall, Thalamus continues to gain traction, much of it by word of mouth. There is also the possibility of integrating it with travel services, or even analyzing prior application data and telling applicants what their probability of matching at a particular program might be, Reminick says.
AAMC also deserves some credit for freely sharing necessary data with Thalamus and other programs while it works on enhancing ERAS' own capabilities in this regard. Such openness and cooperation is admirable, and could be better emulated throughout the healthcare IT field.
Twin shocks have upset conventional wisdom: Epic failed to nab a coveted Department of Defense contract to supply electronic health records system technology, and along with other contenders, failed to appeal the federal government's decision.
EHR vendors' big ambitions include wanting to be every provider's health information exchange intermediaries, and replacing basic state-run and private HIE functions, that is: requesting patient records, and transmitting updated records after episodes of care.
Until now, these ambitions looked lopsided depending on the market share of the EHR vendor. Epic has claimed to have more than half the U.S. population under its EHR management. Kaiser and Geisinger led the Epic wave years ago. More recently, large academic medical centers in particular have skewed toward Epic.
Aligned with prime contractorIBM, Epic was the odds-on favorite to win the Department of Defense's Defense Healthcare Management System Modernization(DHMSM contract to supply EHR technology) for 55 hospitals and more than 350 clinics worldwide. But twin shocks upset conventional wisdom in the past month.
First, the DoD awarded the contract to rival prime contractor Leidos, Inc. and its EHR partner Cerner. Then, more surprisingly, on Friday the Kansas City Star and others reported that the losing DHMSM bidders had decided not to protest the Leidos/Cerner award.
From my years of watching federal technology procurement as far back as 1985, I can say that protesting federal IT awards has been the rule, not the exception, when it comes to awards which are this lucrative. The default has been to protest, usually at minimal expense, and hope for a discrepancy to be found somewhere in the complex RFP and bidding process.
But for reasons the five other bidders have yet to reveal, none appealed.
Now we have to see how smoothly Leidos and Cerner can implement the DHMSM contract. It will take time, and as with any contract of this size, it will be challenging to execute it without making a mistake or two.
"The Partnership is fully prepared to meet the staffing requirements of DHMSM, and our globally deployed team stands ready to support the DoD and the DHMSM Mission," Cerner president Zane Burke said during an August 4 earnings call. "We believe this is a positive development for our clients, and they should have confidence that Cerner will continue to execute to meet all of our current and future commitments."
Leidos was awarded a contract for $4.3 billion over 10 years, consisting of a two-year initial ordering period, two 3-year option periods, and another two-year option period. The DoD cited a higher potential figure of $9 billion, but Burke pointed out that this higher figure represents total DoD estimated program costs over an 18-year lifecycle, not the value of the contract awarded.
To delve further into the interoperability implications of this award, which could be many, I visited the Leidos web site set up for the DMHSM bid. In addition to Leidos and Cerner, the other two core partners are the management consulting services firm Accenture and Henry Schein, which bills itself as "the world's largest provider of healthcare products and services to office-based dental, animal health, and medical practitioners," which includes practice management software.
Surrounding this core are more than two dozen other "large partners" and "small-business partners" supporting various aspects of the contract.
More interesting is the impact this award has on various ongoing EHR interoperability initiatives.
In my research for an upcoming HealthLeaders magazine story on interoperability, it became clear that one pillar of meaningful use stage 2 interoperability, the Direct Project secure messaging protocol for "pushing" Consolidated Clinical Document Architecture (CCDA) from one provider to another, is somewhat of a paradox.
It got off to a rough start. An official at Epic told me that Direct was primarily imposed on meaningful use by a handful of vendors.
"'Pull' was the accepted pathway, and then ONC took a sharp left turn, and it was really at the behest of a few special interests, and developed this Direct Project," Epic president Carl Dvorak told me during an interview. "People are now realizing that was probably a bad thing to do."
And yet, although Dvorak calls Direct "a detour on a bumpy road," which a story I reported last year seemed to bear out, more recent reports show Direct usage has surged dramatically. My recent interviews with Epic customers show this growth is occurring not only within Epic's own CareEverywhere network, but also is fueled in part by the recent growth in membership and usage of DirectTrust, a consortium of vendors and service providers who enable a trust framework that moves Direct messages between different vendors' EHR in a truly interoperable way that compels participating members to share and share alike.
Cerner kick-started Direct's growth and inclusion in the meaningful use stage 2 EHR certification requirements by contributing more than 180,000 lines of open source code to Direct, code now used in many Direct implementations.
While I don't know DoD's plans to use Direct, it stands to reason that its choice of Cerner's EHR will mean another surge in Direct usage. Due to Direct's simple messaging-based model, it may also play a role in DoD's ongoing struggle to interoperate with the Department of Veterans Affairs' VistA EHR, a struggle detailed in the just-released Government Accountability Office report on this topic.
Likewise, the DoD award probably means bigger things for the Commonwell Health Alliance, the national record locator service established by Cerner, Allscripts, Athenahealth and others two years. The Alliance now claims that 75% of the EHR vendor industry has joined. It is taking longer for Commonwell members to actually deploy its services within their products and services. Although activated in some regional pilots, Commonwell has yet to really experience a surge in nationwide use.
Direct use is surging everywhere, but record location/query/retrieval may eventually dominate the same way Web traffic numerically dominates email traffic on the Internet today. Only when we see the final rules for meaningful use 2016 and years beyond will we know to what degree pushing records or pulling records is the regulatory favorite, outside of the DoD.
There are still problems with Direct. Physicians can easily end up with multiple Direct addresses, which can be just as complicated to deal with as having multiple email addresses. And the payloads those Direct messages contain—the CCDAs—vary so widely in what they contain, and how they are formatted, they may create more work than they save for clinicians.
The DoD must wrestle with all these issues. But that will all take place outside of Epic CareEverywhere. Sooner or later, through some mechanism, even Epic will have to adjust to this new reality. Epic customers will be receiving more Direct messages than ever. Epic could choose to respond by joining DirectTrust, or the alternate CareQuality trust framework announced at HIMSS and supported by Epic. Then CareQuality and DirectTrust need to hammer out reciprocal use agreements, if enough customers demand it. This looks like the new interoperability reality.