HCI Blogs

Could Ten Percent Be About Right...?

Fri, 17 Jul 2009 00:00:00 EST

I’m going to step out on a limb here and comment on the CPOE element of the revisions announced yesterday to the recommendations of the Meaningful Use Work Group of the ONC’s HIT Policy Committee, per the ARRA-HITECH funding (my colleague David Raths wrote an excellent blog report on the announcement of the overall revisions yesterday). So here’s the thing: I think that whatever requirement gets set in stone regarding the 2011 requirements for CPOE as an element in meaningful use, would be criticized by one faction or another in the industry. Some will say that the 10-percent-of-orders requirement is far too weak a requirement; others, that any firm requirement for 2011 will be impossible for most hospitals to achieve. I’m going to take a middle-of-the-road view here (or at least, what I consider to be a middle-of-the-road view!) and say that, in a situation that is going to require that we all accept imperfection to begin with (after all, this whole process is going to be like asking a thousand archers to try to hit a bull’s-eye on a moving target, I think!), 10 percent sounds more or less about right to me. Why is that? Well, to begin with, just requiring some level of implementation of CPOE by 2011 will indeed be a rigorous demand for the majority of U.S. hospitals. For one thing, it means that, if this revised set of recommendations is solidified, the vast majority of hospitals will have to rush—and I do mean, rush—just to get their CPOE implementation to that level in time. In fact, if hospital CIOs around the country aren’t moving right now to budget for CPOE implementation and beginning at least the first stages of its planning (vendor evaluation, internal multidisciplinary working group planning and preparations, etc.), they won’t make it. And I’m talking about now, meaning this week or this month. And yes, some might say the 10-percent requirement is too lax; but basically, what it does is to compel hospitals to get the core CPOE functionality live on at least one significant unit within a hospital. In my reporting on CPOE, I’ve found that the most common unit for hospitals to go live in is one of the ICUs, for a variety of reasons, including the smaller number of clinicians regularly working on that unit; the smaller number of patients; the close physician-nurse communications required in an ICU; and other clinical and operational reasons. In any case, if a hospital goes live on one significant unit or one floor, it means that at least an important portion of the groundwork has been laid for the ongoing rollout of a CPOE system. What’s more, the feds will almost certainly raise that level for 2012, and thus, will be compelling hospitals forward in an important area. My September cover story on CPOE will give HCI readers a look at what some of the CPOE pioneers have done to leverage the power of CPOE. What I can say now is that those organizations that are at least two or three years out on CPOE go-live (and thus by definition ahead of 90 percent of their peer organizations nationwide) have terrific stories to tell. All of those I interviewed for the September cover story approached CPOE not as an IT project, but as one strongly facilitative component in an overall drive towards improved patient safety, clinical care quality, and clinician workflow. And aren’t those the areas that all the purchasers, payers and policymakers want healthcare to move forward on, anyway? I’m glad that the feds are going to compel CPOE forward; and I hope they figure out a way to move the pace car forward at a reasonable pace, one that neither causes hospitals to fail through rushing nor lets hospital leaders think they have forever to get going. The right pace would also mean acknowledging the pressure that will be put on vendors and consultants to help hospitals implement so much, so quickly, en masse. There’s no perfect solution here, but with the right combination of carrots and sticks, the feds could maybe get the pacing of this whole thing just right after all.

NG was right! We need a clear HCIT vision or HealthCare costs will continue to rise

Fri, 17 Jul 2009 00:00:00 EST

There's a must read in today's (7/17/2009) WSJ: Budget Blow for Health Plan Congress's Chief Fiscal Watchdog (CBO) Warns of Overhaul's Cost; Ammunition for Critics http://online.wsj.com/article/SB124775966602252285.html CBO's Elmendorf "We do not see the sort of fundamental changes that would be necessary to reduce the trajectory of federal health spending by a significant amount," Douglas Elmendorf, director of the Congressional Budget Office, told the Senate Budget Committee. "On the contrary, the legislation significantly expands the federal responsibility for health-care costs," he added. As usual, the Comments tab is as important as the article. The premise stated is that the core healthcare problems and solution that preceed "the two main objectives (of policy) are: - expand access to health insurance, and - curb runaway costs , not just for the government, but the economy as a whole." Going back to Neal Ganguly's " What's a community hospital CIO to do? " post, the shared HCIT vision must clearly address costs. And must do so in a way that's both plausible and transparent for the CBO. For example, reducing non-value-add redundant procedures, and waste due to lack of care coordination. Regular readers of these blogs understand, and have seen the data that indicate, we can reduce wasteful spending associated with poorly coordinated care. See my Leap of Faith post for a recent example that CMS agrees with, i.e. addressing readmissions will help control healthcare costs. Similarly, better communication between care providers and patients is another large HCIT opportunity. This translates into fewer duplicated services, which drives down the costs generated. This can be measured today and going forward with episode grouping of services. Neal is right. We need to up our game in communicating a cogent, shared HCIT vision. Otherwise, the arguments laid out in the CBO analysis (today's WSJ article) will ultimately document how we failed to advocate for rational HCIT.

And the Sign Said, "Long-Haired Freaky People Need Not Apply"

Thu, 16 Jul 2009 00:00:00 EST

My role as a matchmaker between Healthcare IT job seekers and the recruiters and/or employers who seek them is always fascinating, sometimes humorous, and occasionally gut-wrenching, all rolled up into a day’s work. As you can probably imagine, I get some really thought provoking queries via email, from members of both camps. It can be a stressful time – one is seeking a new opportunity, perhaps in transition (aka unemployed), and the other is tasked with finding and securing the best possible teammate, leader, or visionary. So the questions can sometimes be . . . shall we say. . . wince-inducing. Why do you think I didn’t at least get an interview? Why in the world would this candidate lie about her degree? What do I need to do to be more competitive? And then there’s this one I received over the weekend. The hopeful Healthcare IT candidate had emailed what appeared to be a very simple question, along with two files attached to his message. “Greetings! I’m applying for a Healthcare IT position I saw on your site, and saw the option to upload a photo. I don’t have a current business photo since I’ve worked from home for the past several years - will this one be acceptable? Thanks – I’ve attached my resume, too, for your review.” A quick scan of the resume revealed a very promising candidate. Experienced, educated, and credentialed. And I could tell from his email that he was friendly, polite, and articulate. So far, so good! Oh, yes, the simple question still needs to be answered – is this photo acceptable? I click on the attachment and up comes. . . this: Well, okay. Not this exact photo, but one very very close to it. (I don’t want to embarrass the guy). Hmmmm. So much for a simple question. Sure, it would be great if we all were judged solely on our talents and experience, and not by the way we looked. It would be nice if we ourselves could judge others that way, too. And I suppose in years past, IT professionals could hide out in cold basement server rooms and stay there for days until someone in Accounting, or Marketing, or HR did something really lame to illicit the “blue screen of death,” and then up would come the IT Guy. But those times? Long, long, gone. IT professionals are no longer on the periphery of a company’s success. Today, IT professionals DICTATE a company’s success. From the simple tech support position all the way up to the hospital CIO, IT professionals have now been moved to the forefront, required to interact with all facets of an organization. In other words, IT has gone (cue gasp!) mainstream. So, what does this mean for the long-haired freaky people? Do they need not apply? That’s a tricky question. So, tricky, in fact, that I put it out there for my fellow Twitterers to answer: Tweet: Quick question for Healthcare Informatics blog post - would you hire a male IT professional w/ extremely long hair? Reply Tweets: “If he doesn't have to face customers, yes. If customer facing is required certain hospitals are too conservative.” “Depends on qualifications AND what culture does he originate from? In some of them LONG hair is the rule rather than exception.” “Long hair if it is clean and groomed, no problem. It is what the person brings in personality and knowledge.” “I get away with it because I work at an Indian clinic :> Our COO has longer hair than I do.” Personally, I can see good points on both sides of this issue. I’ve known more than a few extremely inept yuppie (boy, I’m really dating myself with this post!) “professionals.” On the other hand, can a guy who looks like he’s the missing member of ZZ Top get the respect his IT talents deserve in a room full of suits? Not sure. What I do know for sure is, I can’t get this song out of my head now, and misery loves company, so here you go:

Work Group Doesn’t Budge on Patient Access

Thu, 16 Jul 2009 00:00:00 EST

In several of the revisions to its recommendations announced July 16, the Meaningful Use Work Group of ONCHIT’s HIT Policy Committee demonstrated flexibility and a willingness to compromise in order to gain wider acceptance. But on a few fronts, it’s likely that some hospital executives and physician practices are still going to see the bar for achieving “meaningful use” as set too high. And the work group didn’t budge on its stance that patient access to their electronic health data must come sooner rather than later. ONCHIT’s proposed rule will be published by the end of the year and will be implemented by the Centers for Medicare and Medicaid Services. Some clarifications and details offered up by co-chair Paul Tang, M.D., chief medical information officer at the Palo Alto Medical Foundation, will no doubt ease some concerns about earlier proposals. For instance, many comments the work group received stated that a 2011 CPOE requirement was unrealistic. Tang said the revised suggestion is that at least 10 percent of all orders processed in a hospital must be entered through CPOE to qualify the institution for CMS incentives under the HITECH Act. That figure may come as a relief to many hospitals, although ones that haven’t started on a CPOE implementation may still have difficulty achieving it by 2011. But concerning patient access to health record information, the committee stuck to its guns in suggesting e-copies of health information should be part of the 2011 definition. Despite the current lack of progress industry-wide on patient portals, it actually suggested moving up “real-time” patient access to that data in a personal health record from 2015 to 2013. (It’s not clear what the definition of “real time” is.) Tang said the work group believes it is important to stress that consumer access should become part of the equation right away. Many written comments had stressed that the timeline for giving patients access to electronic health data is too aggressive and should be scaled back. At the July 16 meeting, Neil Calman, M.D., of the Institute for Family Health, restated his position that asking practices to develop a patient portal in their first year of EHR implementation is impractical. And Calman expressed the concern that practices with no technology experience will see the bar as set impossibly high for them to reach. But the work group clearly disagreed. The work group also sought to address the problem of calendar year vs. adoption year. Because of what ONCHIT has set out to describe as meaningful use in 2011, 2013, and 2015, the longer an organization waits to begin an implementation, the higher the bar is in terms of what they must achieve in the very first year. The work group proposed having the 2011 requirements be renamed Adoption Year 1 requirements and 2013 requirements renamed to Adoption Year 3, no matter when you start. But Tony Trenkle, director of CMS' Office of e-Health Standards and Services, noted that, by statute, in 2015 funding disincentives start kicking in, so a three- or four-year implementation process encouraged by incentives really can’t be extended out for those starting later. So it’s not clear how much this proposal would help. The work group also addressed concerns about language regarding HIPAA violations. The recommendations initially stated that organizations under investigation for violations would not be eligible for incentive money. Recognizing that organizations could be under investigation but be completely innocent, the work group changed this proposal. The recommendation was changed to say that organizations with proven violations must resolve them to HHS’ satisfaction before incentive payments would continue. Organizations had expressed concern about requirements for participating in health information exchanges when so few are actually up and running. The revision suggested the 2011 standards involve requiring the capability for exchange, and to take part in one where possible. Then the 2015 guideline would include required participation in an HIE. What will these proposals mean to your organization? Do you find the proposals for 2011 realistic?

What's a community hospital CIO to do?

Wed, 15 Jul 2009 00:00:00 EST

The Stimulus Bill and the billions of dollars it directs have hospitals and physicians scrambling to qualify as ‘meaningful users’ in order to collect significant incentive payments. Many community hospitals are working feverishly to develop EMR strategies that would link physician offices to hospitals in order to promote the exchange of patient information. The ability to exchange data was a requirement of the first draft definition of meaningful use, and there is no reason to think that it will not remain a requirement. So, what’s a community hospital CIO to do? Let’s take the case of a mid-sized community hospital with an entirely voluntary medical staff of over 450 physicians, roughly half of whom practice primarily at the hospital. Mix in the fact that the environment consists primarily of small practices of 1 – 3 physicians with a very low penetration of EMRs to date. The stimulus bill woke up a number of physicians, who began to knock on the doors of administration looking for help. Of course, the physicians did not agree on any particular EMR , each citing particular features that they would require, or other concerns that emphasized their independence. So what kind of help did they want? What were their goals? Wants were easy. They wanted subsidies to help purchase EMRs. They wanted advice on which EMR to purchase, but did not want to be restricted to a few choices. They wanted information on how to get their stimulus incentive money. The more thoughtful among them also wanted to know who would help them install, and maintain the technology, and who they would call when they had a problem. Ultimately, they were wanted assurance that they would be able to collect the stimulus dollars and end up in a better position than they were today (or at least not be in a worse position). Goals were, unfortunately, very aligned with the wants. Few, if any, talked about the goal of using technology to improve their practice workflow – whether that is measured in terms of patient volume, or charge capture. Few, if any, talked about the value of being able to have a more complete picture of the patient available for review at the point of care. No one talked about the efficiencies that would accrue from less duplicative testing. The goal was money – saving money – making money. Okay, so the physicians were struggling to understand why they should do this beyond incentive money. What about the hospital? The administration believes that an EMR strategy will be valuable to improving the quality of care and increasing the efficiency of that care. But what is that worth in terms of measurable value to the hospital? How can administrators determine how much to invest in an EMR strategy, and how can they measure success? These questions are landing on the desks of most CIOs and represent real strategic questions. Operational questions are also facing the CIO. Should the hospital contract with and build interfaces to a limited number of vendors, or support a mini-HIE environment that would allow a wider range of EMRs to connect? Should the hospital support a hosted model for small practices? Who will the physicians call when they have a problem? The EMR vendor or the hospital helpdesk? Or will the EMR vendor punt to the hospital anyway? What will it cost to support this operation? There sure are a lot of questions – I'll let you know if I find any answers...

HITECH Mega-monopoly

Wed, 15 Jul 2009 00:00:00 EST

Dr. Blumenthal's committee deciding what defines "meaningful use" to qualify for stimulus funds is unfortunately dominated by giant facilities like John Glaser's Partners and John Halamka's Beth Israel. These facilities have hundreds of FTEs in their IT departments and IT budgets in 7-8 figures. Yes, they are easily the most knowledgeable and articulate spokesmen for HIT, but they live in a rarefied atmosphere far from the reality of the typical community hospital, with but a handful of IT staff and an annual budget measured in thousands , rather than millions. These mega-facilities may define "meaningful use" in a fashion that is only achievable in their super-sized world. Take CPOE: they alone can achieve a high percentage of use thanks to: • Teaching environmen t, where interns and residents can be ordered to use it or not graduate, versus community hospitals where admitting physicians have little incentive to learn or use CPOE... • CMIOs - know what the average doctor makes per year? How can a typical community hospital of 150 beds afford to hire a full-time MD to build screens and alerts, train other MDs, man a help desk, etc. • RN Informaticists - the last few large hospitals I have been in had teams of nurse informaticists (3 or more) working full-time on assessments, care plans, BMV, eMARs, etc, to build their EMR. How many RNs can a Critical Access Hospital under 25 beds devote full-time to screen-building? Per an AHA data base we purchased a few years ago for mailings, the median hospital bed size in America is 168 beds. That means there are about 2,500 under that number, none of whom are being represented on the DC committees. That's as fair as letting HUMVs set crash standards for Toyota Priuses. We need to get normal hospitals voices heard. If you have time to answer these "calls for comments" or know any of the mavens in Washington, please, tell them about the small hospitals who need the stimulus funds far more than AMCs and IDNs, but aren't having their voices heard!

The Strategy—the Only Strategy

Sun, 12 Jul 2009 00:00:00 EST

I had a hard time finding hospital CIOs to talk about chronic disease management. Well, it suddenly dawned on me why: Most CDM takes place in the primary care setting. Duh. Why should that be such a problem? Bad or non-management of CDM often lands these patients in the hospital (or back in the hospital) —needlessly. Isn’t the hospital’s job to make sure this doesn’t happen? This isn’t just an opinion--the way things are looking in Washington, this hospital-centric model is going down the tubes, fast. And it made me stop to think about the CIOs I talk to, all the time. What is their ultimate IT strategy? If it doesn’t include primary care, that CIO is living in the past. Unfortunately, for the majority of CIOs I talk to, their IT strategy is mostly about hospital-centric IT—an EMR, CPOE, EDIS, PACS. Sure, there are places where CIOs are doing great work linking their community docs in a variety of ways, including HIEs. And of course, IDNs like Kaiser et al have been doing this for years. But mostly, these hospitals are the exception. Now, I know our CIOs have a lot on their plates right now. In too many cases they are just trying to keep the dike from breaking. But HITECH dollars are on the table already. Are you thinking about using them to link primary care to your hospital? If primary care is not at the top of every IT strategy meeting you hold, I think the strategy is doomed.

CCHIT Run!

Sun, 12 Jul 2009 00:00:00 EST

Or is it "See Spot..."? Anyway, only two vendors have made CCHIT certification for 2008: • Epic - what's new? • Opus - who? If you're a regular reader of this blog, you may remember an entry from last October entitled "Best Kept Secrets:" Every now and then we run across a new HIS vendor with a hot product, reasonable price, but an unknown name. In honor of my 1969 start at SMS, which back then was little more than 3 guys in a phone booth, I'm going to help spread the word about a few upcoming firms who deserve more recognition and RFPs than they'll ever get as "best kept secrets..." First is "Opus," a small firm from Waco (pronounced "whackoo"), Texas, who have an amazingly functional set of clinical apps centered around a web-based EMR and CPOE. We just learned about them at a system search in the Midwest this summer, where Opus partnered with another vendor for financial systems. The other vendor bombed, but the physicians and nurses rated Opus as better than 3 "leading" vendors' clinical offerings! Their biggest client is UHS from Phila., for whom Opus has installed about 20 acute care hospital on their clinical suite. Biggest drawback: no financial systems, so you'd have to interface. But, if your AR days are low and financial users are happy, why risk the pain of a conversion? Building an interface might be far less trouble and cost... Hottest feature: being web-based, MDs can use handheld devices (Palms, Blackberries, even iPhones!) to inquire into patient EMRs through a browser. HIPAA treat: no PHI is left on the device, as its only a web page surfed by IE, Safari, etc. Yes, they're small and unknown, but so were SMS and HBOC in the days of King of Prussia and Walt Huff's garage!" Opus may really fill the bill for hospitals with a decent financial suite and a CFO who has the sense to not risk rocking his AR boat with a total HIS conversion. Just buy new clinicals from Opus, and interface them to your financials, like the "big boys" do with Cerner, Soarian, Epic, etc. Other vendors in this clinical-add-on category to consider include IntraNexus and MedSphere, who also offer very modern clinical systems that can be plugged into other vendors financials. But then, how many hospitals do you know who want to be sensible in spending their piece of the $34B stimulus funds?

A Leap Of Faith

Fri, 10 Jul 2009 00:00:00 EST

A Leap Of Faith Discharges, Re-Admissions, and Post-Acute Care I was chatting with the chief hospitalist at a major medical center yesterday and he reminded me of something I understood all-too-well. As a doctor, you can't keep a sick patient in the hospital forever. There can be a big difference between stabilized and stable enough that you're confident that the patient won't "bounce back" and be re-admitted. Discharging patients is often a leap of faith, faith that they'll continue to improve after hospital care. There were lots of articles in yesterday's newspapers like this one: And this one from USA Today and Baylor: The CMS study of Medicare records showed Baylor University Medical Center in Dallas has the lowest readmission rate for heart failure in the country, at 15.9%. Baylor invested some $20 million in measuring and improving performance at all 15 of its hospitals. Part of the success comes from intensive follow-up after discharge to ensure patients are complying with treatment regimens. USA TODAY (07/09) The national re-admission rate according to CMS is about 20% within a month of discharge, and readmission rates have been added to hospitalcompare.hhs.gov. Here is an example : Hospitals, whether the physician involved is a hospitalist or a private physician, are driven to discharge patients who are stable, presuming that their post-discharge care is adequate. Organizations like Baylor, above, have stepped up to the challenge of effectively offering post-discharge care in various ways, away from the hospital. Last month at the first annual X3summit, Johns Hopkins's CIO Stephanie Reel and her team detailed a variety of dramatic programs to deliver care outside of the hospital. The implications for CIOs and other readers of these blogs is pretty obvious. The walls of the hospital are coming down. And that's a great thing!

Can’t we all just get along?

Fri, 10 Jul 2009 00:00:00 EST

And if we can’t, can’t we just talk to each other? Let’s just say I have a friend who had been trying to get a physician’s office to do some paperwork in regards to getting approval for a special medication. Let’s just say then, for argument’s sake, that after taking nearly two months to do so, said office finally completed the task. And yes, the clinician’s staff is likely overworked and underpaid. And while to err is human, what followed wasn’t. You see, the staff member who finally completed the necessary paperwork used made a few clerical errors (three of them) by using old and outdated patient information. The patient’s insurance provider (the plan had terminated six months prior and the patient had a new policy with another company), the patient’s phone number (which had changed two years earlier) and the patient’s home address (as the apartment number was omitted). And while to err is human, what transpired wasn’t. You see the correct data was there — somewhere. It had to be. The patient’s updated insurance company was picking up the tab, the patient was receiving phone calls from the physician’s assistant to reschedule appointments, and the patient was receiving correspondence at home regarding missed co-pays. I’m not suggesting that people stop making mistakes in their day-to-day lives, what I am is that HIT systems not function in silos. If the data is there in one way or another, it must be easily located so that staff members can execute their jobs effectively because it really does matter.

HP’s Top 10 Trends in BI (and HIT) for 2009: #5 BI – Keep It Simple, Stupid

Thu, 09 Jul 2009 00:00:00 EST

Sometimes vendors do get it (mostly) right. Hewlett-Packard put together a brief white paper in February of this year laying out their view of Business Intelligence (BI) for 2009 (and beyond). I think that they got it largely right. Their #5 trend is a rising demand for a new performance dimension, namely, simplicity. Below is a summary of the trend, my thoughts on whether HP got it right and what the trend may mean for HIT. HP predicts : a potentially disruptive innovation arising from several IT and BI trends, such as data warehouse appliances , outsourcing , Software-as-a-Service (SaaS), Service-Oriented Architectures (SOA), and the economic commoditization of BI. The Verdict : Yes and no. As long as I have been in BI (a little over a decade now), BI vendors have been touting their simplicity. As long as I have been in BI, using and implementing BI tools has been anything but simple. Again, perhaps I am the jaded grognard here, but I very firmly believe there is a direct relationship between the value delivered by a BI implementation and the complexity of that BI implementation (the simplest way to think of this is as a linear relationship y = mx + b , where y is the value delivered and x is the complexity of implementation; b represents the inherent initial value of the implementation and m is the proportionality constant. Of course in real-life there is a least one other dimension, z for time and m, x and b are all likely to be functions of z). While a truly simple tool to implement and use is the holy grail of BI, I’ll take the liberty of mixing my metaphors here and say that such a tool is closer to the leprechaun’s pot of gold at the end of the rainbow . After all Galahad did find the grail demonstrating his holiness in the process, while no one ever came out the better searching for the leprechaun’s gold. HIT Impact : Essentially nil. BI is an analytical tool first and a reporting suite second. Canned reports with simple prompts, pre-defined drill-downs and hard-coded links to other canned reports are not BI. Presuming the requirements for such reporting applications are well-spec’d, they are trivial and cheap to implement with sufficiently talented developers and engineers, presenting minimal barriers to adoption. BI in the HIT context requires subject matter, analytical and clinical expertise to collect and interpret ambiguous requirements, to derive and/or validate algorithms to implement those requirements and finally to assess the clinical relevance of any findings and to initiate necessary process improvements from those findings. Simplicity simply isn’t an option. Disclaimer: The opinions expressed herein are my own personal opinions and do not represent my employer's view in any way.

The true measure of an all-star

Thu, 09 Jul 2009 00:00:00 EST

Next week, Major League Baseball will hold its annual all-star game, an exhibition that lets the best players in the game — as voted on by fans — showcase their skills while competing alongside their league rivals. It’s a very cool concept, and the games are often entertaining. But some (including myself) believe that the teams selected aren’t necessarily an accurate portrayal of the game’s top players. The reasoning behind this is that those who play for big-market teams, with large fan bases and deep pocketed-owners, tend to get the most media coverage, the most all-star votes and the most recognition. Meanwhile, the guys on the small-market teams are often over-looked; that is, until they’re gobbled up by one of the big boys, leaving places like Kansas City for the bright lights of New York or Los Angeles. For example, someone like Derek Jeter, who has been coasting off a strong reputation (and the fact that he plays for the Yankees) for years, gets the nod, while someone like Miguel Cabrera, who has been tearing the cover off the ball in Detroit, gets bupkis. Those who are lucky enough to play for a top organization — with general managers that utilize seemingly endless resources to surround them with top talent — are at a distinct advantage over someone from a small organization who is just as, if not more, skilled, and can bring more to the table. The same could be said about the health systems and hospital leaders that often get recognized for successful IT roll-outs, groundbreaking initiatives and other accomplishments. Why is the industry more likely to heap praise on the large health systems that have the resources to pull off bigger implementations and can take more risks? If we really want to learn what it takes to deploy EMR systems, shouldn’t the discussion include places that had less to work with and more to lose? Don’t get me wrong, I think there are many valuable lessons to be learned from large health systems, and that they do indeed deserve praise on a project well-done. But I also believe it’s important that the smaller organizations don’t get lost in the shuffle. In the two months, HCI has profiled two CIOs at hospitals with less than 100 beds (both of which are HIMSS Stage 6 hospitals) — Denni McComb of Citizens Memorial Healthcare in Bolivar, Mo., and Bill McQuaid of Parkview Adventist Medical Center in Brunswick, Maine. Both interviews received hundreds of hits from our readers, who were intrigued by how much these small organizations have achieved. It just goes to show that when it comes to being an all-star, it should be less about who has the most funds and the most fans, and more about who is doing the most with what they have. (And it also shows that I can relate any issue to sports if I try hard enough.)

Ego and Metrics Gone Awry

Wed, 08 Jul 2009 00:00:00 EST

It's not good karma to take pot shots at someone after they pass away, but I started this blog several months ago and never finished it, so I find at least some relief in that. The core message in this post: Beware the leader too comfortable in the role, too adept at eluding the grasp of humility. Robert McNamara died last Monday. For those interested in studying and learning about leadership and management, independent of industry or purpose, he's a character worth knowing. My father, brother, uncle, and cousin all served in the McNamara War; my father at the most senior levels of the Air Force. And, of course, in my own Air Force professional education, we studied his style, strategies, and outcomes in-depth. Bless him and the hearts of his left behind family, his life offers poignant and painful lessons in leadership that we should all note. He had all the right academic credentials, corporate pedigree... and haircut. He was a data wonk before it was fashionable. He came into his role as Secretary of Defense with an ego only rivaled in modern times by characters such as Patton and MacArthur. He created a dream team at the Pentagon and set out to change the stodgy US military. To that end, he had remarkable vision and management skills, and his thinking and fingerprints remain to this day in the DoD. But... his great successes fed his great ego and the egos of his aides and staff. Like an engine of pride consuming itself for fuel, it was only a matter of time before it all came apart. Ironically, for truly great leaders, their successes lead to successively greater connections to gratitude and humility. They see that, were it not for the grace of God and subtle random events to their favor, their great successes would have been great disasters. In McNamara's War, number crunching, organizational theory, "systems engineering", academic credentials, and money were all trumped by the heart and will of a culture not inclined to change from the influence of a superpower consumed by its own self-righteousness. One of McNamara's metrics-gone-wrong legacies: The Daily Body Count, mandatorily reported up-channel from the lowest level troops in the field. Can you imagine being a 20-year old platoon leader, pausing after a jungle battle to count bodies (the enemy's and your own troops) and coldly radioing them into headquarters to ensure that the numbers made it to the next morning's briefing for the Pentagon? Do you really think those metrics were accurate or reflected anything meaningful about success or failure? McNamara's ego convinced him that his pedigree could out-think, out-manage, and out-measure the lowly peasant Communists. But, as they say, not all things can be measured and not all things measurable should be measured. The best leaders walk the thin line between confidence and uncertainty... between egotism and humility. You want a leader who shows evidence of falling to both sides of the line because all of those behaviors are appropriate at the right time and right place. Beware the leader too comfortable in the role, too adept at eluding the grasp of humility.

HP’s Top 10 Trends in BI (and HIT) for 2009: #4 No ROI, No BI

Wed, 08 Jul 2009 00:00:00 EST

Sometimes vendors do get it (mostly) right. Hewlett-Packard put together a brief white paper in February of this year laying out their view of Business Intelligence (BI) for 2009 (and beyond). I think that they got it largely right. Their #4 trend is increased pressure on BI projects to deliver more value more quickly. Below is a summary of the trend, my thoughts on whether HP got it right and what the trend may mean for HIT. HP predicts : BI and DWH projects will neither be approved nor funded without defined business objectives, quantified business value and analyses demonstrating rapid time-to-value (TTV). Further, contrary to all the buzz, HP states that Software-as-a-Service (SaaS) will not provide rapid TTV for BI due to data management, integration, security and control issues; instead managed, hosted and outsourced services will serve user’s needs while reducing risk. The Verdict : Amen, brother! I have long been a proponent of explicit ROI and TTV analyses – a rarity in the BI world. Yea, verily! Perhaps my opinions are beginning to ossify in architectures of the past, but I just do not believe that SaaS is anywhere near production-ready for large, complex, high data volume, analytically demanding, tightly SLA driven, mission-critical applications like today’s DWHs. This is especially true as DWHs begin to reach deeper and deeper into the operational and transactional systems (or perhaps it is that the operational and transactional systems are expanding borg-like into the ivory tower world of DWH). And right on! Managed services, although I believe more around hardware, virtualization and analytics than HP’s prediction of data integration, reporting and data modeling, will be on the rise. HIT Impact : In 2009, minimal. HIT budgets are already tight, enacting ROI and TTV discipline can only be a good thing, but it is hardly new. By the beginning of 2011 though, look for SaaS packages bundled with light-weight management consulting and cultural transformation services which will provide a complete, turn-key, and therefore rapid to deploy, ARRA compliant web solution. These solutions will be targeted at small- to mid-size practices and clinics first, and gradually work their way up-market. Disclaimer: The opinions expressed herein are my own personal opinions and do not represent my employer's view in any way.

40th SMS Reunion

Wed, 08 Jul 2009 00:00:00 EST

Hard to believe it's been 40 years since pioneers like SMS and Meditech started this industry in 1969, but "tempus fugit!" In honor of SMS' 40th anniversary, we are holding a reunion bash this November. I guess we should be magnanimous and allow any old "Magicians" from Meditech come, but I fear we won't understand their Boston accents. So, if you spent any quality time in King of Prussia, SMS' home in the 70's, here's the details: Who – Originally intended for SMS-ers who worked in King of Prussia during the 70s, we’ve broadened the invites to include “Malvernians” from the 80s that can stand hearing about the good old days at 650 Park Avenue… Click Here for the contact-list What – SMS’ 40th Reunion will consist of: A cash bar Sit-down dinner with 4 entrée choices: Chicken, Mahi-Mahi, Prime Rib, Vegetarian Some entertainment (TBD – not sure who will embarrass whom yet…) Dancing to music from those wonderful 70s played by an SMS DJ (Ben Gay will be provided…) When – Saturday, November 7, 2009 5:00pm - 7:00pm – Appetizers & Cash Bar 7:00pm - 8:00pm – Dinner 9:00pm - 11:00pm – Dancing & Entertainment Where – Based on a review of property damage insurance, we picked the Crowne Plaza Hotel 260 Mall Boulevard King of Prussia, PA 19406 610-265-7500 (damn – that’s close: we were 265-7600!) www.crownplaza.com We’ve got a discounted rate of $99, so mention be sure to mention the “SMS 40 Year Reunion.” Why – There has been a series of sad emails about former colleagues passing away lately, so we better kick our heels while we still can. Who knows, with this “Great Recession,” this may also be the last time we can afford to get together… How Much – RSVP by sending a check made payable to “Anthony Sammartino - SMS Reunion” for $65 per person (that’s $130 for a couple in case your math is as bad as the old Controllers report…) , and either on the memo line of the check or on a separate sheet of paper indicate your meal preferences: Chicken, Mahi-Mahi, Prime Rib, Vegetarian (or cash bar only…) and mail it to: Tony Sammartino 1379 Branch Hill Court Apopka, FL 32712-2410 Once Tony receives your check and preferences, he’ll email confirmation to you. So let's start those emails and checks humming! 40 years - are we really that old?? Then let's celebrate!!! Vincent Ciotti , Principal H.I.S. Professionals, LLC 21 Centaurus Ranch Road Santa Fe, NM 87507 505.466.4958 www.hispros.com

Will They Lower the Bar?

Wed, 08 Jul 2009 00:00:00 EST

Mark July 16 on your calendar. It could be a very interesting day. That’s when the Meaningful Use workgroup of the HIT Policy Committee makes public the next draft of its advice to the Office of the National Coordinator on the definition of meaningful use. A lot is at stake. ONCHIT’s proposed rule will be published by the end of the year and will be implemented by the Centers for Medicare and Medicaid Services. Yesterday I attended two virtual meetings featuring members of the HIT Policy Committee. The first, a regular meeting of the National eHealth Collaborative, featured Paul Tang, M.D., chief medical information officer at the Palo Alto Medical Foundation. The second, a webinar put on by the eHealth Initiative (eHI), included Christine Bechtel, vice president of the National Partnership for Women and Families. Both made strong cases for why the committee proposed an aggressive timeline for reporting clinical data from EHRs and for including patient access to health data in the definition. When pressed during Q&A sessions, neither felt it was appropriate to comment yet on how the workgroup’s second draft might be influenced by the public comments from healthcare organizations and feedback from federal agencies, although Tang and Bechtel noted that ONCHIT has received more than 900 comments. Although not all of those comments are public, it is clear that there is widespread concern that very few physicians and hospitals will be able to meet the criteria the first draft established for 2011. For instance, the American Hospital Association said its members, including those with significant previous HIT investments and CPOE, consider a 2011 CPOE requirement to be unrealistic. Many comments also have stressed that the timeline for giving patients access to electronic health data is too aggressive and needs to be scaled back. They basically see patient access as the last step in a successful implementation process. The AHA also noted that “the expected release of a final definition will be past the 2010 budget cycle for most hospitals – making the definition proposed for 2011 unmanageable. A rush to implement the draft definition, combined with the lack of capital and personnel, could result in many hospitals choosing not to, or being unable to, participate in the incentive program.” In fact, during the eHI webinar, Michael Shabot, M.D., chief medical officer of the Memorial Hermann Healthcare System in Houston, said that even a huge organization like his, which has spent almost 10 years and more than $100 million on EHR implementations, would have trouble reporting all the quality information the first draft proposed in its Meaningful Use Matrix. “In our current state, we could not meet the 2011 objectives as outlined,” he said. Part of the problem, he continued, is that the meaningful use measures are ill-defined, and he went through a few examples from the matrix, asking how his hospitals would determine what the denominator population is in equations about percentages of patients getting certain types of treatment. Shabot also noted that the physician practices his organization is helping implement EHRs are very patient-focused and not set up to do this type of statistical reporting. But even in his hospital setting, which is incredibly computerized, a larger issue is that the quality reporting Memorial Hermann does now often involves manual data abstraction because the systems in place do not have the hooks built in to report on those quality measures. Joseph Heyman, M.D., Chair of the Board of Trustees of the American Medical Association, also spoke at the eHI webinar. He said physicians have to be confident that if they make the investment in health IT, they will be able to meet the criteria. He stressed that any physician who had no idea how to start on automation would look at the first draft’s criteria and feel that finding products to make that possible by 2011 is an insurmountable challenge. Heyman said AMA suggests starting at a much more rudimentary place in 2011 to get greater acceptance going in. The eHI webinar’s moderator, Lou Diamond, M.D., vice president and medical director for Thomson Reuters Healthcare, began the session with two questions that loom large: 1. How much will the public comments affect the committee’s decision-making process? 2. What will happen if very few providers are able to meet the definition of meaningful use once it is established?

Crystal Balling Image Visualization

Tue, 07 Jul 2009 00:00:00 EST

Recently, a client of mine was wrestling with PACS vendor differentiators, and we had a discussion of potential image visualization advantages. It gave me a chance to reflect on over thirty years of imaging technology, and how far we have come. It also reminded me of the reversal in the proverbial “chicken and egg” scenario! In the early days of imaging technology, there were no video games, high definition TV, etc. upon which to develop. Imaging requirements far exceeded anything that was commercially available, and consequently, imaging paced commercial developments. For example, the earliest image displays for Computed Tomography (CT) were 256 by 256 pixels, or a whopping 0.07 megapixels! GE pioneered a 320 by 320 pixel display with the development of its earliest CT scanner, and that was revolutionary. CRT (Cathode Ray Tube) displays were also custom, as they needed to be high quality non-interlaced gray scale, and commercial TV was typically interlaced color, so even they were unique. And, image manipulation controls were all custom developed as well, as they initially preceded even the lowly track ball! All of these technologies were custom development and their cost reflected it. Fast forward to today. Now, commercial developments seem to be pacing imaging technology, and “COTS” (common-off-the-shelf) technology has driven down the cost of imaging equipment. Yet, it seems commercial developments are outpace imaging, which still hasn’t caught up. In some respects, requirements are still somewhat unique. Commercial HD TV is still 1080 pixels, while imaging displays utilize high-end graphic flat panel technology that can range from 3 megapixels up to 9 megapixels. When it comes to image manipulation, commercial technology still outpaces imaging. Witness the iPhone and other smart phones that have ushered in hand gestures as a means of control. I recently became an adopter with the Palm Pre, and now would have a hard time readapting to a Palm or Blackberry format where one cannot manipulate the image size when viewing the internet or a mail message. The Nintendo Wii ushered in a whole new video gaming experience by interjecting normal hand movements to gaming control, thereby simulating natural motions such as swinging a baseball bat, or rolling a bowling ball. Slowly these technologies are beginning to emerge within imaging. Over the past several years, vendors have shown “works-in-progress” applications of hand motions and large display formats for image manipulation. And researchers are experimenting with gaming controllers to control the display and navigation of images. But to date, there is no commercially available application of the technology, and the 3 megapixel flat panel and mouse continue to dominate. One area remains open as to who is the chicken and who is the egg! 3D visualization has long been a promise for both imaging and gaming, but to date, it has not become a major factor in either. I’m not speaking to the 3D software visualization tools that present 3D representations on 2D displays. I am speaking to the full-scale 3D visualization. Granted, there are some high-end gaming 3D glasses, and holographic 3D projectors, but nothing has caught on in the mainstream. Personally, I believe this is the game changer for diagnostic imaging displays. Imagine a radiologist having the ability to view the entire body in true 3D, and then being able to zoom in on specific areas and view in any cross sectional plane desired! Instead of taking valuable time to view thousands of cross sectional images and build up the 3D representation in their mind, the diagnostician could begin with the entire visualization, and then concentrate on suspect areas. Such technology could easily make use of the more advanced control technology such as hand motions to provide a more interactive experience. So how far off is “Buck Rogers” technology for healthcare? In today’s environment, it is hard to say. Some things are probably a given under current conditions. It is highly unlikely that diagnostic imaging can support custom development for its limited application. Changing healthcare policies just won’t allow it. Therefore, it seems we will be dependent on how fast such visualization technology is adopted for commercial use, and how applicable it would be for imaging application. Might there be some compromises along the way? Most certainly. For example, ask any old timer from radiology as to whether an x-ray developed on a glass plate was superior to wet chemical processed film, and they will tell you it was the gold standard. But, volume and throughput demands hastened the acceptance of the wet chemical 90 second processor. So, might a holistic 3D display compromise image quality for visualization productivity? And will this eventually become the norm? My crystal ball is still a bit hazy, but I venture to say, the future looks promising!

HP’s Top 10 Trends in BI (and HIT) for 2009: #3 Data Quality and Governance are key to BI Impact

Mon, 06 Jul 2009 00:00:00 EST

Sometimes vendors do get it (mostly) right. Hewlett-Packard put together a brief white paper in February of this year laying out their view of Business Intelligence (BI) for 2009 (and beyond). I think that they got it largely right. Their #3 trend is that as BI increases in importance and impact, data governance and data quality become more critical than ever. Below is a summary of the trend, my thoughts on whether HP got it right and what the trend may mean for HIT. HP predicts : “a bad economy provides a good opportunity” for those companies willing to invest in BI, Master Data Management , Data Governance and Data Quality. The Verdict : This prediction is axiomatic , that any BI implementation ever got off the ground without a thorough analysis of data quality and data governance issues is an embarrassment. HP is correct that formal Data Governance committees and Centers of Excellence which define standards, disseminate best practices and establish processes will be increasingly present on the departmental, enterprise and industry scales. HIT Impact : Immense. Intra- and Inter-entity data governance is the foundation of “ meaningful use ”. In the absence of standardization (or at least cross-referenced indexing) of terminology, data elements, transformation algorithms, metric formulas and report definitions, the result is GIGO . Where, after all, is the usefulness of sharing meaningless reports? Disclaimer: The opinions expressed herein are my own personal opinions and do not represent my employer's view in any way.

The Who, What, Where of Regional Extension Centers

Mon, 06 Jul 2009 00:00:00 EST

The written comments flowing into the Office of the National Coordinator for Health Information Technology about the proposed Regional Extension Center program demonstrate the vast array of opinions about how many extension centers should be created, who should run them, and how broad their focus should be. In a non-scientific survey of the eHealth Initiative’s members and organizations in May, 49 percent said the centers’ coverage areas should vary to meet the need; 26 percent said they should be statewide; 15 percent said they should cover multi-state regions; and 8 percent said they should cover sub-state regions. When asked how many centers should be created, 41 percent said 10 to 50, while 24 percent said 50 to 100. Many organizations are already involved in the work of helping clinics and physician offices with technology adoption, so they naturally see themselves as logical candidates to lead extension center efforts. Some have argued that existing CMS Quality Improvement Organizations should take the lead. The Network for Regional Health Improvement suggests that ONCHIT give preference to regional health improvement collaboratives and chartered value exchanges for designation as regional extension centers. NRHI leaders argue that connecting health IT to quality improvements is critically important. “The strategy should demonstrate how the assistance given to providers will help to improve the quality and/or improve the efficiency of healthcare delivery in the region,” NRHI wrote. The National Association of Community Health Centers Inc. argues that Health Center Controlled Networks (HCCNs) and Primary Care Associations (PCAs) already provide an array of services to health centers and safety net providers, including health IT-related efforts listed as objectives of the regional centers. The National Rural HIT Coalition is concerned the extension center effort may not place enough focus on rural providers. It proposes that at least one regional extension center be provided the funding to serve as a national rural HIT technical assistance and knowledge center. It also suggests that rural health clinics should be specifically noted as a prioritized provider to receive assistance from extension centers. One thing these organizations seem to agree on is that the funding limits suggested could be harmful. They argue that the award amount averages of $1 million to $2 million may be insufficient to provide the on-site support described as the purpose of the regional extension centers. And the proposed maximum amount of $10 million to any one center may be too low. The New York eHealth Collaborative noted that the New York Primary Care Information Project and the Massachusetts eHealth Collaborative estimated that effective adoption required support services in the range of $10,000 per provider. “In light of this experience, the proposed maximum award of $10 million per regional extension center would limit the scale of operations and scope of clients that any single center can serve and would undermine its ability to effectively deliver the support services detailed in the draft description,” the New York collaborative suggested. In a recent interview, Phyllis Albritton described a multi-stakeholder collaboration forming in Colorado. Albritton is executive director of CORHIO, the statewide health IT entity that would play the role of umbrella organization. “We were struck by the language that these should be shovel-ready. We have a number of quality initiatives in the state that are already working with the physician community on technology adoption,” she said. “Rather than one organization being responsible, our intention is to apply through a collaboration of seven to nine groups that already have this expertise.” Those groups include the Colorado Foundation for Medical Care, the Colorado Clinical Guidelines Collaborative and the Colorado Community Health Network, a primary care association. “We have heard from the feds that they want this to get to work as quickly as possible and to engage as many stakeholders as possible, so this is the model we think will work,” Albritton said. “Many of these groups will need funding to expand their capabilities, but they are already engaged.”

A Computer Savvy User-base is Critical to Organizational Effectivess with IT

Mon, 06 Jul 2009 00:00:00 EST

Continuing with the series on elements of Organizational Elements of Effectiveness with IT, we have come to “Computer Savvy of the User-base”. Savvy-ness is not simply knowledge and it is not exactly acquired through training alone. When you look up “savvy” in Wikipedia, you get referred to “intelligence” and “common sense.” Somewhere between those two references lies a pretty good definition of savvy. A person with Computer Savvy understand computers well enough to readily ingest the knowledge you send their way through training and can quickly adapt to changes in the “mechanics” of a computing process or interacting with the computer (re: joystick to Nintendo Wii or keyboarding to “thumbing” a Blackberry). Most importantly, a computer savvy user has a comfort-level using the computer that empowers them to think beyond the particular computer-based tool that happens to be in front of them to more robust critical thinking about how the tool fits/could fit/should fit into their work-life. They also make it all look pretty easy. A computer‐savvy user base is highly important to the success of IT, if for no other reason than the fact that a good computer user can make up for a lot of mistakes by system implementers. If few mistakes are made in an implementation, which is the goal, a computer‐savvy user base is important to quickly using a system and getting the most out of it. They can also help speed up business cycles, by being able to take-in changes to the computing aspects of the overall work-o-sphere quickly. A computer-savvy user base is critical to being able to react quickly as a organization. Savvy computer users can also be integral to optimizing a system, and assisting in problem solving to generate more utility from each dollar invested in IT. A computer savvy user-base can be created. To get there, it is best to think of the creation of computer-savvy-ness as a goal unto itself. Use every opportunity to grow computer-savvy in your organization. These opportunities can include very small things like putting meeting materials out electronically and using the projector instead of paper, to larger issues like hiring for computer skills, training at multiple-levels of intensity for users of all skill-levels when updates or system optimizations occur, or through extensive training campaigns that stand on their own or in combination with major implementations. Anything you can do to make your organization full of computer-savvy users will be an important element in using information technology highly effectively as an organization.