More Good EMR Implementation Advice Coming from the Top

Standards group offers 10 guidelines to make HIT adoption easier
November 20, 2009 | Diana Manos, Senior Editor
HeathcareIT News

Below are the main points from the above reference:

1. Start small and simple.
2. Don't let perfection be the enemy of 'good enough.'
3. Keep cost as low as possible by eliminating royalties, licensing fees and other expenses.
4. Make adoption easy for providers from small practices.
5. Don't try to create a one-size-fits-all system that adds burden and complexity.
6. Separate content and transmission standards.
7. Create publicly available vocabularies and code sets that can be easily downloaded.
8. Leverage standards that already work on the Internet.
9. Position quality measures so they motivate standards adoption and strive for the automation of quality reporting.
10. Support the implementation. – give HIT adopters readable guides and open-source reference implementations.

It is thrilling to see more and more of these more practical and effective approaches in the press. The current alternative that most enterprises are selecting appear to be just about the opposite.

1. Start with too much functionality and complexity so that the technologies interfere with patient care.
2. Choose systems that match the most functions in an RFP rather than select systems that best serves patients and the physicians deservng of their trust.
3. Purchase exorbitantly expensive solutions that silo health information and makes interoperability unaffordable.
4. Make adoption a nightmare for small practices lacking implementation resources.
5. Try to force an inflexible approach to workflows (primarily driven by non-clinicians) into the point of care.
6. Buy into a vendor's initial sales pitch that they can provide whatever information transfer is needed.
7. Choose products that can only update their vocabularies and code sets via expensive and intrusive, bulk upgrades.
8. Adopt systems that are only supporting awkward and overly complex, standards that are proprietary to the current, medical-industrial complex, rather than those that are widely used by all other industries on the Internet.
9. Try to force clinicians to change their workflows to capture data that theoretically will allow "quality reporting" tomorrow while degrading the patient care process today.
10. Expect EMR vendor training, alone, will be adequate to on-ramp clinicians into the systems.

Laying bare the ARRA Stimulus Bill and its pitfalls

John Moore at Chilimark Research has again summed up the current situation

PHAT: Mash-Up on Healthcare IT

November 19, 2009 by John

I want to include one of his quotes, below...


Bell: “There has been plenty of talk on HIT standards but woefully little on implementation guidance, i.e., how to bring data in, incorporate it into workflow, make it actionable and facilitate efficiencies in care.” Amen.

He pretty much sums it up by implying that it may likely end up being the taxpayers that end up out in the cold when the health information technology industry's emperors are discovered to have no clothes.

Meanwhile, hundreds of doctors are being forced into purchasing lots of expensive EMR pumpkins that will never make it into any meaningful use pies. The insanity will only end when the doctors get more involved in the process and demand a more sane and proven approach that improves, not impairs, their ability to care for patients.

What’s in a Metaphor :-?

In an earlier blog post, I alluded to a metaphor that the fashion in which many clinicians are currently transitioning to using EMR’s are akin to going from walking to riding bicycles at a time they need airplanes. The fashion of use of most EMR’s is little more meaningful than moving paper to be behind glass. This certainly has some advantages, and there is some evidence that many users of these systems are often quite happy. After all,they have transitioned from walking and obtained “airplanes” of sorts. These clinicians tend to report amazing cost savings compared to what others are spending on airplanes.

It appears I was also in error by implying that today’s more “comprehensive” EMR offerings tend to expect clinicians to walk out on the tarmac, jump into a plane, and take off with often disastrous results. I have found evidence of clinicians literally powering through their charts using comprehensive systems. It appears that some implementations that are limited to “training” are sometimes adequate for flight after all. It has been widely reported, with comprehensive systems, that younger physicians tend to go higher and further. Some of these systems even facilitate that all scripts can be transferred electronically at the same time that general electric bills in the practice actually fall. Why wouldn’t all practices partner with one of these?

To top it off, some appear to believe there is a wise, Greek goddess somewhere that can almost magically guarantee to deliver meaningful information technology use to clinicians at the point of care. Unfortunately, being unable to find any evidence, in the real world, I will assume it to be myth.

Health Data Exchange - The New Health Internet vs. the Old NHIN Models

November 16, 2009
The Health Internet vs. the NHIN -- A Matter of Control, Cost, and Timing
By DAVID C. KIBBE and BRIAN KLEPPER
The Health Care Blog

Below are summary quotes from the above blog post:

“…Now is a good time to re-visit the plans for a National Health Information Network (NHIN), since we can finally observe and compare different health data sharing and exchange models in the marketplace. NHINs represent an older model that tries to use regional health information organizations (RHIOs) to establish secure networks, privately owned and operated by large provider organizations, mostly hospitals and health systems. The idea was that, over time, each private regional network would develop a gateway to other networks, creating a "network of networks" that would allow Stanford to talk to Partners Health, or Kaiser to Mayo. This communications model was enterprise/provider-centric. Patients/consumers were relegated to depending upon each RHIO's policies for access to their health information. It was also a massively expensive and time consuming - think decades - way to build a health data network…”

“…The Health Internet, on the other hand, has the obvious advantage of not "re-inventing the wheel." As former Intel CEO Craig Barrett famously said, "We already have a network for health data, it's called the Internet." Proponents of the Health Internet argue that, while health data and privacy and security are very important, the data themselves are inherently no different from financial data or the kinds of personal information routinely -- and very securely -- transported over the Internet using fair market encryption and other security technologies to protect it from intrusion, capture, or breach. So why go backwards to create the equivalent of Prodigy or AOL in every state? It could take forever.

We want to give credit to David Blumenthal, the Obama health team members and the folks at HHS who are taking a hard look at how best to create a secure and efficient method for health data transfer in this country…”

Also, see - Covisint Jumps onto PaaS Bandwagon by John at Chilimark Research.

Another article showing little benefit in current EMR implementations

Little Benefit Seen, So Far, in Electronic Patient Records

By STEVE LOHR
Published: November 15, 2009
New York Times

More of the same… the current approaches to EMR in the U.S. deliver little benefit. Some quotes from the article


…“The way electronic medical records are used now has not yet had a real impact on the quality or cost of health care,” said Dr. Ashish K. Jha, an assistant professor at the Harvard School of Public Health, who led the research project…”

“…The differences, Dr. Jha said, were “really, really marginal.”
To Dr. Bell, the results of the study suggest that government policies should focus on helping physicians, hospitals and the public health system use the technology more effectively.
“It’s not going to be easy or quick,” Dr. Bell said, “but the better information at the point of care, the better health care we will have.”

How much more evidence is it going to take?

Physicians… take your time and beware.

Fascinating Week!

This week has seen several announcements that are very encouraging for those of us that want to see our health care system evolve from one that is industry centric to one that is patient centric. Particularly exciting is this letter from David Blumenthal at the ONC, who is leading the government's effort to transform our healthcare information systems. He stresses the need to break down barriers to data exchange. Subsequently, Mark Leavitt announces he is leaving the helm of CCHIT. I do have great respect for Mark, but, as I have blogged in the past, I have not felt CCHIT has always represented the best interests of the larger community. Commentaries on recent events by people I greatly respect are below:

Further on the US Healthcare IT Standards Debate – Wes Rishel at the Gartner Group

Blumenthal Beats HITECH Drum – John Chilimark at Chilimark Research

Mark Leavitt Leaves CCHIT - John Lynn at EMR and HIPAA

The Genius of the AND by John Halamka.

John Halamka’s Stunning 180: “Dogs and Cats Should Live in Harmony” by Vince Kuraitis at e-CareManagament

Conspiracy theory Friday (FDA & CCHIT related) by Matthew Holt at The Health Care Blog

For those of us who see the current direction of health care “reform” legislation as fundamentally flawed, this commentary is most intriguing - Will Business Force Reform Back To The Drawing Board? – by Brian Klepper and David Kibbe at the Health Care Blog.

I have spent much of the last month traveling to the East coast, and meeting with leaders in the industry, government, and professional organizations. Particularly, the time I spent in D.C. was most fascinating. There are some cracks appearing in the Bastilles of special interests.

Listen to Muffin

I was blessed in my youth to have had many great mentors. One of the greatest was a beagle named Muffin.
I no longer hunt rabbits, but I have fond memories of the days when the beagles and I would team to chase the wily rodents. Nobody, who has not had the experience, can quite understand just how connected and integrated one can become with the dogs and the world. It is a real delight to let out the dogs, watch their noses go to the ground, and anticipate the excited yelps once a rabbit’s trail is discovered. One quickly learns to determine, based on the level of excitement in the yelp, how convinced the dog has become that he/she is on a fresh trail soon to lead to the prize.
It can be a very rewarding experience, just as long as there are not too many inexperienced dogs involved. You see, inexperienced dogs will get a faint whiff of something/anything that smells somewhat interesting, and then they will go to howling and yelping so loud that they will even get the more experienced dogs, who should know better, all distracted. If inexperienced dogs are allowed to lead the effort, it leads to lots of howls and yelps, but few prizes. More often than Muffin and I want to admit, he would glance over at me and just shake his head in disgust. He knew that he and I should have known better than to listen to a bunch of inexperienced beagles who were often in error, but seldom in doubt.
The decision-makers in this industry are too often very similar to a bunch of inexperienced beagles. They are quite capable of getting all excited and distracted, and less capable of delivering. This is only going to worsen.
So... physicians... perhaps it would be wise to take Muffin’s advice, and not succumb to intense-misguided yelps and howls. If you have not already, you will likely experience someone showing up promising that if you will just follow their nose, you will end up with a bunch of rabbits.
Stick to the evidence rather than the hype, and follow your nose. Sometimes, the kindest response to hype/yelps and inexperienced decision-makers is a gracious "no thanks" until the path meets your own sniff test.

Who Notices the Difference Between the Pumpkin and the Pie?

http://www.healthcareitnews.com/blog/meaningful-use-explained

Here is another picture that can reveal far more than words. Way too many still do not understand the meaning of “meaningful use” as defined by the ARRA Stimulus Bill. Why this is important is that medical practices will theoretically be able to benefit from bonuses for “meaningful use” of a certified EMR in 2011. Please notice this subtle, but extremely important separation of what is necessary for practices to receive the ARRA bonus.

1. Acquire an HHS/ARRA certified EMR (this is not the same as CCHIT certification)
2. Report “meaningful use” of the EMR.

Both the HHS/ARRA certification and meaningful use criteria will be defined in the coming months. Entities, other than CCHIT, will be offering this certification.

• Today, no EMR systems are HHS/ARRA certified!
• By 2011, when practices can qualify for bonuses, SOAPware will be just as HHS/ARRA certified as any other EMR.

Using the picture containing the pumpkin and the pie as a metaphor, SOAPware will be just as much of a pumpkin as any other EMR system. However, that is not the end result that is sought. In order to have the pie, the pumpkin has to be put to meaningful use. Lot’s of EMR vendors are lining up to supply medical practices with pumpkins. However, few are delivering much as to the pie-making process itself. Most EMR vendors would have practices and decision-makers believe that the pumpkin and the pie are the same. It is only after physicians are delivered a pumpkin does it become apparent what the difference is between the pumpkin and the pie. At this point, the chefs-clinicians are typically told that before they can have a pie, they must open the pumpkin and individually point-and-pick out every individual seed. Never mind that it should not be necessary for clinicians to personally do this in order to have a tasty pie. This is just how it must be done if the clinicians want to turn a vendor’s particular pumpkin into a pie.
Hopefully this current phase where certain EMR vendors are promising that practices will receive meaningful use pies using their pumpkins can soon be seen for what it really is.

Physician beware!

Who is deciding your "solutions?"

Survey: U.S. physicians lag behind those in other countries in IT use
November 05, 2009 | Bernie Monegain, Editor
HealthcareIT News

http://www.healthcareitnews.com/news/survey-us-physicians-lag-behind-those-other-countries-it-use

"The patient-centered chronic care model originated in the U.S., yet other countries are moving forward faster to support care teams including nurses, spending time with patients, and assuring access to after-hours," she added. "The study underscores the pressing need for national reforms to close the performance gap to improve outcomes and reduce costs."

I have been to several of the nations referenced in this article (i.e. New Zealand, Sweden, Denmark) and seen their information technologies in action.

In these successful nations, the approach is upside-down to what continues to be happening in the U.S. The patient’s primary physician groups were largely the final decision makers. In the U.S. it is largely politicians and various administrator-experts of some type deciding the “solutions.” Until we, as a nation, can learn the very simple, proven reality that decisions have to be patient-centric, it is only going to get worse.

Hopefully, this phase of blaming doctors for not adopting systems that are not designed by them, for them, will soon become obvious for what it is.

EHR use falls short

Survey: electronic health records not getting full use

http://www.mlive.com/business/west-michigan/index.ssf/2009/11/survey_electronic_health_recor.html

By Mark Sanchez | Business Review West Mich...
November 04, 2009, 2:00PM


Hopefully the entities making EMR purchasing decision for clinicians will start to get more of a clue as an increasing number of these types of articles and reports are published. Below are quotes. Click the above link to get the full story.

">There’s still a lot of work to be done to fully utilize these systems,” he said. “They (EHRs) could be a lot more help there in terms of how they (doctors) could take advantage of what they have….”

“…Part of the problem is that health care lags other industries in the use of I.T. for business operations, Hamilton said. To get the full benefits an EHR and other I.T. systems offer, physicians have to re-engineer their businesses practices, as well — and there are some doctors who aren’t always able or ready to make those kinds of changes in how they run their practice….”

“…As a result, “the whole health care industry is way behind adopting business practices that others businesses around the globe have long adopted,” Hamilton said….”


“…A PricewaterhouseCoopers Health Research Institute report estimated that a typical medical practice with three doctors could spend as much as $296,000 over two years to acquire and maintain an EHR system….”

“…Like any major strategic move in business, transitioning to an EHR is a significant undertaking for medical practices, Hamilton said….”

“… “It’s a real challenge for physicians to try to implement this on the fly,” he said….”

“…But for those able and willing to make the investment and alter their business practices and models, there is a return on investment over the years through improved efficiencies and productivity on a number of fronts, Simpson said….”

“… “It’s a big investment up front, but there is a payoff that will come over time,” she said.

The federal government is pushing doctors to fully adopt and integrate EHRs into their practices to improve quality and patient safety and generate cost savings. Funding of up to $44,000 is available to doctors through federal economic stimulus money beginning in 2011, though doctors will have to make “meaningful use” of EHRs and comply with federal standards by 2015 or risk having their Medicare reimbursements reduced.

“It has to do more than just have a data base of patient records,” Hamilton said. “They have to implement it in a networkable type of environment”….”

The real challenge continues to be that even for the EMR vendors willing to help practices address the necessary change in business practices, this continues to not be budgeted. It is just too easy for an EMR vendor to accept payment to throw in a bunch of technology because some misguided decision makers decide that is what the practice needs. The practice ends up with little more than an expensive pile of bricks and bags of mortar with no masons around.

EHR Disruptions

Here is yet another article that is getting out the message...

Physicians still worried about EHRs disrupting work
November 04, 2009 | Patty Enrado, Contributing Editor
HealthcareIT NewsDay


http://www.healthcareitnews.com/news/physicians-still-worried-about-ehrs-disrupting-work

Below are quotes with my emphasis added. Visit the link above for the full story.

...While financial incentives and penalties drive physicians to adopt health IT, the survey showed, they continue to be worried about upfront cost and workflow disruption...

...Not surprisingly, cost and workflow disruption were listed as the two greatest risks for EHR deployment, with 82 percent citing cost and 74 percent citing workflow disruption...

...The industry needs to educate the independent physicians who have not had a compelling business case to adopt in the past, LaFontana said. The legacy vendor community has largely focused on the multi-specialty, complex healthcare systems with deep pockets, she said.

With ARRA and a larger market of small physician offices, vendors have an incentive to develop innovative next-generation electronic health records, she said. Hosted EHRs with monthly subscription fees are providing much-needed new business and technology models for independent physicians...

...The way physicians are educated on health IT and EHRs also needs to change, LaFontana said, adding, "This is an opportunity to start talking about capabilities in the physician's office."

Technology should be seen as an enabler that brings new capabilities and efficiencies to a physician's office, she said. Physicians will be more receptive to health IT if the conversation is around better care and more efficiency of the whole system. For instance, physicians would value an EHR with its ability to identify their diabetic patients who have not had a hemoglobin A1c screening test in the past year.

The primary care physician's world is changing rapidly, LaFontana said. Fee and reimbursement schedules are changing, models of care such as the patient-centered medical home are being introduced, reporting quality meausures is required for participation in pay-for-performance programs. The small physician offices are overwhelmed with administrative complexity, clinical protocols and revenue cycle management issues, she said.

Legacy vendors have under-invested in the small group practices in the past. "You have to look at the entire physician's office," LaFontana said. Vendors and independent physicians need to establish the foundational capability in the office and the workflow around that in order to reap the benefits of health IT implementation...

Polititcal Digression

Pardon me again as I go on record. It is important to me that our children and grandchildren can see that some of us publicly asked some tough questions at this point in time.

Could the following, written in 1787 be proving to be prophetic?

"A democracy is always temporary in nature; it simply cannot exist as a permanent form of government. A democracy will continue to exist up until the time that voters discover they can vote themselves generous gifts from the public treasury. From that moment on, the majority always votes for the candidates who promise the most benefits from the public treasury, with the result that every democracy will finally collapse due to loose fiscal policy, which is always followed by a dictatorship."

Please help me understand how this is untrue. The evidence might help me sleep a little better. Are we, as a nation, already fiscally irresponsible?


Now, for a little satire, click on the video - The Government Can.

Patient-Centric vs. Industry-Centric Information Sharing

November 03, 2009
Back to Basics: Toward a Core Set of Relevant and Portable Personal Health Information

By DAVID C. KIBBE


http://www.thehealthcareblog.com/the_health_care_blog/2009/11/back-to-basics-toward-a-core-set-of-relevant-and-portable-personal-health-information.html#comments

…the reason why we as citizens lack routine access to even the most basic summary of our personal health information, and therefore can't put those data to work for us as individuals or as a society, is that we lack the political, cultural, and professional will to unite these disparate and unconnected bits and pieces of information together into a Continuity of Care Record.

But ARRA also states, in part, "...the individual shall have a right to obtain from such covered entity a copy of such information in an electronic format and, if the individual chooses, to direct the covered entity to transmit such copy directly to an entity or person designated by the individual, provided that any such choice is clear, conspicuous, and specific." This is, essentially, a re-statement of the requirements of HIPAA that patients/consumers have a right to their health information, and adding the obligation to make this information available in electronic (digital) format. Finally!
What is encouraging is that the definition of Meaningful Use issued by ONC, by way of turning the legislation into federal regulation, includes amongst its set of specific activities health care providers need to undertake to qualify for incentives from the federal government, a requirement that doctors and hospitals must do the following:
• Provide patients with an electronic copy of their health information (including lab results, problem list, medication lists, allergies) upon request.
• Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies).
• Provide access to patient-specific education resources.
• Provide clinical summaries for patients for each encounter.
Source: Health IT Policy Council Recommendations to National Coordinator for Defining Meaningful UseFinal- August 2009
http://ncvhs.hhs.gov/090518rpt.pdf ...

The growing interest and support for the CCR standard is another glimmer of hope that we are finally on the path to more of a patient-centric, rather than an industry-centric view of health information.

Staffing Issues with EMR Implementation

The quotes below are pearls from - How electronic medical records affect staffing

http://www.ama-assn.org/amednews/2009/10/05/bisa1005.htm

Staffing needs will change after medical practices adopt electronic record systems. Some practices may be able to cut staff. But others may hire, and some may shuffle responsibilities.

By Pamela Lewis Dolan, amednews staff. Posted Oct. 5, 2009.

...One practice installed an electronic medical records system and cut 12 staff members. Another practice added two full-time employees.

These two very different scenarios help underscore one truth: The only definite aspect about determining post-EMR staffing needs is that there is no magic formula.

A variety of factors come into play, including practice size, scope and, most importantly, the practice's goals. What happens in terms of the number of staff -- and how the EMR changes what that staff does -- will largely depend on the problems the practice is looking to address with automation.

If the goal is to reduce costs, the end result will look much different than if implementation is to improve quality of care or to change a practice's branding, ...

...Other changes are not so easy to predict, and could depend on how willing your employees are to adapt and learn new skills.

...Mike Doyle, CEO of Carlsbad, Calif.-based Medsphere, which installs the VA-created VistA EMR in hospitals and physician practices outside of the Dept. of Veterans Affairs system, said he strongly believes that the more specific a practice's goals, the better the outcomes...

..."Some have this vision of Xanadu. That they just drop the thing in and somehow things are going to get a lot better. Unfortunately, I think some were sold a bill of goods from the EMR vendor about how easy it is and how seamless it is. Most underestimate [the transition process] greatly, particularly in the way of staffing," Kerr said...

..."If the practice isn't already spinning like a top, it can get ugly" after EMR implementation, said Dr. Pifer, who worked as an informatics officer for the University of Pennsylvania Health System when it rolled out EMRs to its outpatient practices...

...Mullins said practices that achieve buy-in from staff members early in the process will be able to set specific staffing goals more quickly. When the staff is excited about the impending implementation, they can then help define how their job responsibilities will change...

...Training staff to learn new skills can help grow the practice, Mullins said, as employees take a role in defining how the practice will operate moving forward. "If they are engaged in something, they will adopt and embrace it willingly."...

...A locally hosted system, the type often used by large practices, would likely require IT staff, either in-house, or via an on-call support contract. But many small practices are going with application service provider models, which means the server and data are stored online instead of in-house...

...Communicating with staff can help curb anxiety...

...Being open about expectations with employees from day one will make the transition smoother and ensure no one is blindsided, Dr. Donnersberger said...

...When employees feel they are a part of the process, they can help shape their post-implementation roles, even if it means that role is played out elsewhere...

...Bob Kleinbauer, chief operating officer of Community Care Physicians, a multispecialty group in Albany, N.Y., said constant communication with his 30-member office staff raised the interest level.

Some of the physicians became so excited about the project that they pursued new career paths within the practice, and now serve as health information technology leaders...

Great Image at the HealthBlog Sums it Up

The first image on this blog post really sums it up:



See Why clinicians fear electronic medical records and what we can learn from Toyota and Disney for the story. by Bill Crounse, MD Senior Director, Worldwide Health Microsoft at http://blogs.msdn.com/healthblog/archive/2009/10/29/why-clinicians-fear-electronic-medical-records-and-what-we-can-learn-from-toyota-and-disney.aspx




Below are quotes from Dr. Crounse:

"...Have you ever wondered why so many physicians resist going “electronic”? Trust me, it is not because they fear technology..."

"...It is not because doctors and nurses are Luddites when it comes to using computers. It is because they fear losing time. It is because they resist using technology if it doesn’t, or they perceive it doesn’t, add value. Even if “meaningful use” of electronic records translates to fewer errors, safer care, and higher quality; unless it also fits like a glove into clinical workflow, saving time and saving money, the trade-off just isn’t worth it in the minds of most clinicians..."

The Comments on this blog post contain some gems:

"...You make a very valid point; for providers, you can't have "meaningful use" without the word "use" (any EMR/EHR has to be easy to implement and adopt) and from a consumer perspective, it's not about "meaningful use" at all but about "meaningful results" ..."


"...One size does not fit all – Each specialty has unique requirements for medical documentation and information viewing. The design of any system should begin with this premise, not have it discovered later. How information is displayed on the screen, how images are displayed and stored, how quickly certain items are retrieved for viewing and what items should always be displayed needs to be determined at the outset otherwise usability suffers..."

"...Easier on the other hand saves me time and helps me do my job documenting more quickly and efficiently so that I can focus on the important aspect of medicine, which is taking care of patients..."

"...we have to dramatically improve clinical workflow, care quality, patient satisfaction and even the cost of care..."

"...I think this stems from experience of too many poorly thought out systems which were introduced by managers without thought for the clinicians using them and their specific needs..."

"...Besides, while we all can appreciate what Toyota has done for cars, medical care is far from assembly line processing. In fact, my effort at using IT in practice has actually been to get rid of an assembly line type process, and reintroduce meaningful interaction between patient and clinician..."

"...The glaring omission I see is that IT companies have not utilized the expertise of clinicians in the trenches to build/improve systems that can actually work in clinical medicine..."