What is Meaningful Blog

Part 2: What Hospitals Need to Understand about Health Reform

What is Meaningful Editor — Thu, 19 Aug 2010 15:42:00 -0400

Part 2 of What is Meaningful's spotlight on health reform and its impact on hospitals continues below with John D'Amore, vice president of enterprise performance management, Eclipsys. Part 1 of his interview pinpoints three areas that he believes hospitals can actively prepare: quality, finances and delivery change.

What is Meaningful Editor: What are the financial changes in reform, and how do health systems prepare?

John D'Amore: When reform was being discussed everyone heard the price tag: approximately $900 billion over 10 years. Politicians were quick to say, however, that health reform would not increase the federal deficit. This goal was accomplished by cutting payments and selectively increasing taxes to compensate for new spending, like subsidies for low-income families purchasing insurance. One of the biggest cuts was for hospitals and health providers. This amounts to $156 billion, estimated from the Advisory Board, a large majority of which comes from hospitals. These cuts are made as adjustments to the annual payment increases by Medicare and start this year. To prepare for them, there are a few things health systems can do.

Do More with Less
First, integrate reduced revenue assumptions for your Medicare patients in long-range planning. It’s not anticipated that lower reimbursement will cause hospitals to turn away Medicare patients since rates will exceed variable costs, but hospitals will need to find new opportunities for cost savings. Determine which services have the slimmest Medicare margins and investigate if other hospitals are able to do better. Through the use of cost accounting and government data, hospitals can evaluate their relative performance and find ways to do more with less. For example, if a hospital uses 10 different vendors for spinal implants, a better price could be achieved by consolidating to fewer vendors. If a disease specific average length of stay is well above national averages and benchmarks, there may be an opportunity to work with physicians and case managers to speed patient discharges. These types of projects aren’t new but will garner renewed attention as Medicare margins contract.

Be More Productive with the Staff You Have
Another opportunity is to get more efficient with a hospital’s single biggest expense, labor. While reform doesn’t change the way hospitals are staffed, labor shortages are forecast to continue as government revenues dwindle. Hospitals can prepare for this in a few ways. First, they need to become more effective at flexing staff to dynamic volumes. This is difficult but is often made harder by hospitals that don’t get the right information to decision makers. Departments frequently don’t need to send a nurse home if another unit is under-staffed. When managers call in personnel, having them start with nurses who aren’t already on overtime can save on premium pay. Examining patient flow patterns may reveal opportunities for unconventional staffing schedules, like a mid-morning swing shift. There are many ways to be more productive with the staff you have, but it requires the right tools and a willingness to ask tough questions. With reform, more hospitals will be forced to do so.

The Uninsured
One twist introduced by reform is how non-profit facilities treat the uninsured. While managed care companies typically negotiate steep discounts with providers, often up to 50% of charges, the uninsured may receive a bill at 100% of charges. Reform mandates that individuals who qualify for financial assistance must have charges limited to “the amounts generally billed” to individuals with insurance. Obviously, this leaves some ambiguity as to an exact amount, but the principle is clear. The uninsured with limited financial resources shouldn’t be billed $10,000 for a stay if a managed insurer would only pay $5,000. In addition, reform makes changes to how hospitals report their community benefits which qualify for tax exemption and limits some collection practices for patients identified for financial assistance. Since non-profits are about half of all hospitals nationwide, one can expect these revisions to have significant downstream effects. For this financial aspect of reform, it will be important to involve legal counsel so that practices and policies are in compliance with its terms.

Existing Incentives
Finally, as we talk about new regulations and payment cuts, I think an important element of reform is to go after the incentives that do exist. Meaningful Use will provide more than $27 billion in incentives for EHR adoption, and reform makes it important to go after that money. Projects that demonstrate new delivery models and innovation in health delivery provide an opportunity to increase margins on federally funded patients. While reform is primarily a stick for health providers, there are still some carrots available for those who are willing to push forward.

WIM: What are the delivery system changes of reform?

D'Amore: That’s a difficult question because we don’t know the full detail today. Reform only begins the process of moving healthcare delivery away from a ‘fee-for-service’ model and toward a focus on quality over quantity. It’s too early to know how these delivery changes will transpire, but several themes are becoming clear.

Clinical Partnerships
First, physicians and health systems are going to become more integrated. Integration was happening before reform, and new payment mechanisms from this legislation will only speed that transition. This shift means fewer doctors will independently operate practices and more will be part of clinically integrated networks. Health systems and hospitals need to prepare for this in two ways. They will require tools to budget ambulatory practices and new systems to manage physician performance. There is a fine line to walk here. Medical autonomy will always remain with a physician, but successful organizations will work cooperatively to achieve high quality and manage utilization for populations. Feedback and open dialogue between administrators and physicians will make this possible. Health systems that succeed and profitably manage physician practices will be well-situated for the future.

Payment Streams & Bundled Payments
Beyond clinical partnership, reform changes the payment streams. Today, payments are broken up to multiple sites and providers of care. For example with a typical labor and delivery, a mother can expect to receive at least three bills, one from the hospital, another from the anesthesiologist for an epidural, and another from the obstetrician. Would it be possible to bundle bills together so that a patient and insurer could receive a single bill for the entire delivery? Yes, but it requires physicians working with each other and hospitals in new ways. One of the possibilities here is called bundled payments, and there are already pilots underway to test how this might work. Under bundled payments, health systems would receive one amount for all services rendered to a patient associated for an episode of care. This places the burden on the system to coordinate activities and payments between providers and settings. This would provide an incentive to reduce unnecessary testing and readmissions, since the provider would now realize cost savings. In addition to saving money, this system could improve quality by enhancing communication between providers. Bundling payments, however, is just one step of how the payment streams will change.

Accountable Care Organizations
A larger change to health delivery will be the emergence of Accountable Care Organizations. With ACOs, there’s still a lot of debate about what they will actually be. At the recent annual conference of the American Hospital Association, Ian Morrison likened ACOs to unicorns. We can all describe what a unicorn would look like, but who has actually seen one? ACOs are a new term, but one that borrows many ideas long circulating in policy discussions. The idea is to create one entity to be held responsible for coordinating and managing a patient’s health over an extended period.

Existing payment mechanisms, however, do not support such an entity. While it’s easy to envision a clinician reaching out via email, coordinating care among specialists and providing phone reminders, they are not reimbursable events under the ‘fee-for-service’ model. Consequently, these are not general practice for most providers. Accountable Care Organizations could make comprehensive care possible by taking on risk, through capitation or other means, and thereby profiting by keeping patients well and lowering overall medical cost. In a recent survey, health executives rated ACO performance metrics as a number one priority for clarification from the government. Moreover, most hospital CEOs expect that they will participate in an ACO within five years from now. While health systems should begin to assemble the pieces to be positioned for ACOs when they arrive, the most important task here will be to listen and learn more about how they will work.

WIM: How can technology help manage the impact of reform?

D'Amore: Well, one overriding observation should be that health reform doesn’t reduce or alter the plans to distribute $27 billion in incentive payments to hospital and health providers who meaningfully adopt an EHR. In fact, reform only increases the need for technology. Technology provides the means for clinicians to work together in new ways and share information about patient care for better quality and less redundancy. These outcomes are going to be an essential part of ACOs and clinical integration, and I personally think that collaboration through technology is one of the few ways to control health cost growth over the long term. The standards that are adopted through ARRA-HITECH & Meaningful Use will enable that collaboration since EHRs will all use a common set of languages. It’s an exciting time to be in technology, and I’m very eager to see the innovative ways we can help providers achieve this.

Data-driven Performance
Collaboration and new care models are the future, but today we have technology that will be vital to reform. Specifically, reform will force health systems to examine their performance through data-driven lenses. To do this, health systems need to gather information and have the tools at their disposal to portray the full picture of performance. That picture must include the financial, operation and clinical aspects of executive decisions. For example, when a CFO reduces staff for the emergency department, this action is more than just a full-time employee adjustment. Fewer clinicians may mean poorer performance for wait times and more patients leaving without treatment. That effect may adversely impact volumes and customer satisfaction. In addition, several process measures used for Value Based Purchasing are based on activities in the first hours of patient care, like antibiotic administration for pneumonia patients. If fewer staff means lower performance on those metrics, then this executive would jeopardize future Medicare revenues.

Performance Management Tools
Too often, hospitals don’t have an integrated set of applications that work together to share data and comprehensive monitor performance. Many also spend too much time looking at last quarter, when the key to management is today and the future. Performance management software suites are designed for executives and administrators who want evidence driven decisions to improve results. This technology can provide actionable knowledgeable and feedback on the core functions of a hospital: delivering high quality care, satisfying patients, recruiting and retaining the best staff, growing to serve the community’s needs and managing margins for long-term success. With the mounting pressures of reform, the right technology will be a key differentiator between hospitals that struggle and ones that succeed. This is what I get to work on everyday, and it’s a very exciting time to work to improve the outcomes of health systems.

The Patient Protection and Affordable Care Act as passed in March 2010 is a watershed for the U.S. health system. It doesn’t fix all the problems, but it starts the process of improving a very fragmented and expensive system. Although opponents are keen to rally on a repeal of the legislation, it’s difficult to foresee how that would happen in the near-term. The consequence is that it’s time for health systems to prepare for real change and to position themselves for future success in an era of reform. I’m happy to see the feedback as posted on this site and also welcome people to contact me at john.damore@eclipsys.com to continue the conversation.

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Peach: Customization Is One Aspect to EHR Success

What is Meaningful Editor — Wed, 18 Aug 2010 12:35:00 -0400

In this video, Anne Peach, vice president of nursing, Orlando Health and chief operating officer, M.D. Anderson Cancer Center of Orlando, talks with What is Meaningful about using, embracing and customizing EHR technology from the start. Below is the video and a transcript of the interview.

What is Meaningful Editor: What is the key to achieving meaningful use of EHR?

Anne Peach: I think to use technology you have to embrace it right from the start. You have to own it, no matter what the product is and you have to customize it. You have to have your team on board, and the team has to be committed right from the start that they’re not only going to use the technology but they’re going to use it in a meaningful way. They’re going to identify issues that may come up with the technology and work with their partners to solve them.

WIM: How does M.D. Anderson apply its EHR, and what have you accomplished with the solution?

Peach: I’ll tell you – going to an electronic health record has been a very positive experience for us at M.D. Anderson. I remember the days, years ago, when we would have patients who would see different physicians: a medical oncologist, a radiation oncologist and a surgeon. And we would have to seal their chart so they could take it with them to the different appointments. And, then at the end, we had to figure out well where did that chart go? So we’d be sending out pages looking for charts. Now with technology, with the electronic health record, the physicians can pull up the information from visit to visit. The nutritionist can pull the information and the research team. So not only has it been positive in terms of all our patients’ data being there, but providers can look at the chart at the very same time. We work with M.D. Anderson in Houston, Texas – that is actually where our name came from – and we’ve used the electronic record in terms of what we call concordance studies looking at the quality of care that we deliver in Orlando measured against the Houston team and it’s been absolutely terrific. We have continued to move ahead looking at how we can improve the quality of care in the central Florida community and the electronic health record has been a great part of that.

WIM: To what would you attribute your success with EHRs and the relationship with your vendor?

Peach: I think our success has been because it’s been a partnership. First of all, I don’t think there’s a product that you ever take off the shelf and don’t do something to customize it. That’s not just electronic health records, that’s probably most things we do in health care. And it truly has been a partnership, sitting down, looking at what we need to do to make it work for our clinicians. And, so I think the customization of the product, on things that we needed to change has been absolutely ideal. One of the avenues that we went down was nursing documentation, besides CPOE, just documentation as a whole. And being able to have evidence-based charting has been a tremendous help not only for our experienced clinicians but for our new nurses, to be able to click and see the reason for the care, to have prompts there on things that they should document has been tremendous. And, actually last week, I was upstairs on one of our oncology floors with a brand new nurse and she was telling me how comfortable she is actually in charting – that it actually was helpful to her to have the prompts there.

WIM: Can you talk about the clinician buy-in to using EHRs?

Peach: One of the things that we did to look at success in adoption of technology in the electronic health record is that the senior executive team owned it. Actually I was one of the executives assigned to the project of implementation of the electronic health record so it wasn’t just a responsibility of the CIO, it was a responsibility of operations. And we actually talk about it every single week. We have what we call the Medical Staff Leadership breakfast so every week we talk about it. We publish the results of percentage of CPOE. We identify the issues with CPOE. At M.D. Anderson, we actually have a multi-disciplinary team that meets every single month looking at what our progress is, what are the issues and things that we need to deal with. For us, we had a big issue looking at chemotherapy order sets. We have spent quite a bit of time saying how are we going to address that because I believe that the electronic health record is key to patient safety. It’s key not only to making sure that the right care is delivered to the patient, because we all know that handwriting orders and handwriting notes is not the wave of the future. In fact, we could all tell a story of how we used to hold the chart out about three feet seeing if you could identify whose handwriting it is, what they might say. We know that’s not safe. So we know an electronic health record is better. But we also know that there’s work to do. No one likes change. And believe me, healthcare people are right in that group who don’t like change. Even though the current system didn’t work, it was their current system that they used for 20, 30, 40 years. And, so, we’ve had to deal with the change process. We’ve been through storming and we’re in norming right now saying, okay, what do we need to do to move ahead?

In terms of nursing, we established a nursing technology group that is actually a partnership with the informatics team. It is head by a chief nursing officer who I would say is as proficient as any IT person. She owns it. She embraces it. She has had staff nurses involved looking at how the system works, what we need to change, and so we’ve embraced and said we need to be part of the solution to make this work. Are we perfect? Absolutely not. Do we still have people that we’re having to drag along who don’t want to use an electronic record? You bet. But we’re committed that this is the way we’re going and we’ll be successful because of it.

WIM: How important is it to have agility in your systems and in how you operate?

Peach: Well, I think agility in systems is very, very important. I mean the government is looking not only at healthcare reform but it’s looking at transparency. It’s looking at the quality of care and patient safety. I actually sit on the Florida Hospital Association Quality and Safety Committee and one of the things we were discussing are the areas that we do need to measure in the state. We identified four areas that we want to measure. I’m pretty comfortable that Orlando Health can easily participate, because we do have an electronic health record. We can mine data, and I think the key today is to be able to not only provide the care in a safe way but be able to look at the data and find new ways to improve. So agility is absolutely key.

[End of of video transcript]

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Part 1: What Hospitals Need to Understand about Health Reform

What is Meaningful Editor — Wed, 11 Aug 2010 18:38:00 -0400

For insights into health reform and its impact on hospitals, What is Meaningful spoke with John D'Amore, vice president of enterprise performance management, Eclipsys. In Part 1 of his two-part interview, D'Amore pinpoints three areas that he believes hospitals can actively prepare: quality, finances and delivery change.

What is Meaningful Editor: What are the most important elements of health reform that hospitals and health systems can prepare for?

John D'Amore: That’s a question many experts have been working through since the bill’s passage a few months back. Many changes in reform are for the insurer market, like coverage expansion and removing preexisting conditions. Health systems can’t necessarily prepare for those. As I’ve read through the legislation and spoken to experts, I've begun to break down the things that hospitals can prepare for into three topics: quality, finances and delivery change.

Quality
First and foremost, reform brings measurement of quality into the spotlight. Over the past decade, providers have gotten comfortable with the idea that quality can be measured. Since 2002, they’ve been reporting a growing number of measures endorsed by the Joint Commission and National Quality Forum, which are now required for the full annual increase in Medicare payments. The data they report are published on the web for the public, but up until now, hospitals have not been systematically reimbursed differently based on those results. Reform enacts a major change through the adoption of what Medicare calls ‘Value-Based Purchasing.’ The idea is to pay systems with better results more over time relative to others with poorer results. This idea isn’t new to other industries. Who would expect car prices to all be the same regardless of quality? It’s a big shake-up, however, for hospitals. To go along with this program, there are two other independent reform initiatives that penalize poor quality. The first is a readmissions penalty, where hospitals with high rates of 30-day inpatient readmission will lose money in subsequent years. The readmission penalty and ‘Value-Based Purchasing’ go into effect in October 2012, not that far from now. The last one is a payment reduction for hospitals with high rates of hospital acquired conditions, like pressure ulcers and infections. This one is delayed a couple years and doesn’t start until October 2014. Investigate quality for your local hospital.

Finances
Next are the impacts to finances as part of health reform. In addition to the penalties for poor quality, reform makes a huge cut of $156 billion dollars to Medicare reimbursement over the next decade. Even though those cuts are designed to offset fewer losses from bad debt and charity, they begin this year while coverage expansion doesn’t take hold until 2014. This will place hospitals and health systems in a bit of a cash flow pinch over the next couple of years. This means managing revenues and expenses are going to be particularly important, even as organizations emerge from this current recession. In addition, reform places some new hurdles for non-profit systems to maintain their tax exempt status.

Payment for Care
Finally, reform begins the long process of reworking how the U.S. pays for medicine. Today, health systems and physicians get paid separately for individual services, like an office visit, ambulatory surgery or inpatient admission. Policy experts suggest that this payment methodology, a ‘fee-for-service’ model, causes more services to be used than are often necessary. Reform doesn’t radically change this system in year one, but it outlines future payment designs with the potential to increase quality while decreasing costs. One way, written in reform, is through bundling the payments to providers across settings for an episode of care. The idea is that making a single payment will encourage providers to better coordinate the utilization of services. A second method proposed by reform is the establishment of Accountable Care Organizations, or ACOs. Although the legislation doesn’t define them with great detail, the idea of ACOs is to broadly integrate services to manage communication, expenses, payments and quality for a large patient population. One way to conceptualize an ACO would be to examine the current models of system integration, pioneered by Geisinger or Intermountain Healthcare.

As you can tell, 2,409 pages of reform legislation make a lot of changes. Through the categorization into quality, finances and delivery change, health systems can begin to think about what taskforces and executives need to be engaged for each aspect of reform. Just within those three categories, there’s already a lot to prepare for.

WIM Editor: How do hospitals prepare for this new focus on quality?

D'Amore: Well, the good news is that many hospitals have started doing some of the right things. Since quality metrics are already publicly reported and used in national rankings, there’s been good reason to focus on improving scores. Now with dollars tied to quality, high performance is paramount.

Core Measures
A first focus with quality should be the 27 process measures, commonly called the ‘Core Measures,’ which are abstracted from patient charts. These are fundamental processes that experts agree should be completed on every eligible patient a hospital admits. For example, a smoker who has had a heart attack should be counseled to stop smoking before he or she leaves the hospital. How does a hospital make sure this happens? Some hospitals are using checklists or order sets. Others are dedicating clinical staff to manually ensure each measure is performed and documented before patient discharge. These are good activities, but I think one that may be missed is the use of technology. With the rush towards Meaningful Use, hospitals are rapidly upgrading their electronic medical records and codifying information to receive incentive payments beginning in 2011. As they make these investments, hospitals should simultaneously be thinking about how to use these new systems and data to improve their ‘Core Measures.’ For example, once problem lists, medications and laboratory data are all electronically in one system, it’s possible to screen inhouse patients for evidence of a heart attack. Then for the identified patients, reporting tools can automatically check if smoking cessation counseling has been documented. This process of electronic surveillance can be cheaper and more effective than manual reviews. I think hospitals will make investments to do so now that the technology and Meaningful Use will enable it.

Readmissions
A second focus will be on readmissions. Incredible as it may sound, over one-third of all Medicare inpatient spending is on patients who are readmitted to a hospital within 30 days of a prior discharge. While not all of those readmissions are avoidable, there is a lot of variation between providers in readmission rates. This is why reform creates a financial penalty for hospitals with high 30-day readmission rates. To prepare for this, hospitals need to track their readmissions every month and proactively put mechanisms in place to prevent readmissions. To track, it’s about optimizing patient reporting systems to scan and count medical record numbers that repeat for a facility. For proactive prevention of readmissions, there are many published studies on effective tactics, such as ProjectRED from Boston. The main lessons are to educate patients before they leave, get them on the right therapeutic course, and make sure they follow-up on prescribed outpatient activity.

Prevention of Medical Errors & HACs
A final issue for quality reform is the prevention of medical errors and hospital acquired conditions. Again, the means to succeed here come down to measurement and feedback. Are the right bundles of preventative practices being done in the ICU to prevent infections? Do nurses document skin integrity and follow-up when there’s a problem? If a hospital can reliably monitor the presence and completeness of preventative practices, it can manage quality, rather than hoping that clinicians don’t make mistakes. Atul Gawande, a surgeon and author, has written extensively on systematic processes that improve outcomes, like through the use of checklists. While humans work diligently and efficiently, the hectic nature of medicine means distractions and lapses inevitably occur. The right processes provide a fail-safe mechanism so that an oversight doesn’t become a costly or litigious mistake.

Quick Links & References:
AHRQ Statistics on Readmission
Re-engineering Patient Discharge (Project RED from Boston University)
Atul Gwande, the Checklist Manifesto

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Investing in the Future of Health Care with EHRs

What is Meaningful Editor — Wed, 14 Jul 2010 23:39:00 -0400

The Health Information Technology for Economic and Clinical Health Act (HITECH), part of the American Recovery and Reinvestment Act, provides for an unprecedented amount of funding to improve the quality and efficiency of our health care system through health information technology. The HITECH Act’s historic investment in HIT will advance health care in our country through adoption and use of EHRs and other tools of our digital age. As the National Coordinator for Health Information Technology, it is my job to facilitate this effort and help health care providers, and the American people, realize the full value and benefits of electronic health records and digital technology.

The publication of the meaningful use final rule and the standards and certification criteria final rule marks the official launch of EHRS in this country. Health care providers now have the guidelines they need to not only implement electronic health records on a widespread basis, but also to use them in a way that improves care for their patients. Standards and certification criteria help ensure that Certified EHR Technology on the market can maintain data confidentiality, share information securely, and perform a well-defined set of functions to help physicians and hospitals realize the full potential of electronic health records and health information exchange.

For those just beginning the transition to electronic health records, the change can be challenging. Providers may not see themselves as technology experts and may be anxious about learning a new system. Patients may have never thought about how their information is stored, and about how the move to electronic data could improve their health care.

I’d like to share with you a few of the many benefits I believe electronic health records can offer providers and their patients:

Complete and accurate patient information
With electronic health records, providers have more accurate and complete information about their patients, enabling them to provide the best possible care. Providers will know more about their patients and their health history before they walk into the examination room.

Better access to health information
Electronic health records facilitate greater access to health information. Providers can diagnose health problems earlier and improve the health outcomes of their patients. Electronic health records also allow information to be shared securely and more easily among doctors’ offices, hospitals, and across health systems, making for better coordination of care.

Patient empowerment
Electronic health records will help empower patients to take a more active role in their health and in the health of their families. Patients can receive electronic copies of their medical records and share their health information securely over the Internet with their families.

On a broader scale, electronic health information exchange will improve tracking of public health trends such as flu epidemics, health disparities, and gaps in health care. These data that are captured, analyzed, and shared will help us understand which interventions lead to better health outcomes and which areas need significant improvement.

Nearly 200,000 providers have already adopted EHRs and are using them at various levels of technological sophistication and ability. With the support of the President, I have pledged to help the rest of America’s clinicians and hospitals join their ranks. I am confident that the majority of adopters will agree that electronic health records have increased efficiencies and improved care.

I encourage health care providers to become a part of the future by becoming a meaningful user of certified electronic health records.

David Blumenthal, M.D., M.P.P.
National Coordinator for Health Information Technology
U.S. Department of Health & Human Services

Final Rule on "Meaningful Use" of EHR Available

What is Meaningful Editor — Tue, 13 Jul 2010 11:24:00 -0400

The US Health and Human Services Department today released the final rule on "meaningful use" of an Electronic Health Record (EHR).

The rule clarifies the requirements physicians must satisfy to earn financial incentives for automating and connecting their practices under the HITECH Act, part of the American Recovery and Reinvestment Act (ARRA) of 2009. The final rule was accompanied by a second rule setting standards, implementation specifications, and certification criteria for EHR technology in an effort to help physicians ensure their purchases will deliver the value the rule is designed to drive.

Read the HHS press release

View the final rule on meaningful use.

View the final rule on standards, implementation specifications, and certification criteria for EHR technology.

Creating the Information-Powered Healthcare Enterprise

What is Meaningful Editor — Wed, 30 Jun 2010 10:25:00 -0400

Based on proposed measures of governmental performance-based reimbursement, many hospitals stand to lose millions of reimbursement dollars for noncompliant care. Without doubt, the transition to outcomes-focused reimbursement will materially increase risks to revenue growth.

The following excerpt of the white paper, Creating the Information-Powered Healthcare Enterprise, published by Eclipsys, guides providers towards making more informed business decisions through integrated performance management practices.

Despite massive investments in enterprise systems, many hospitals still struggle to make informed business decisions. Their systems are nonintegrated and disjointed and present multiple representations of patients, encounters, products and service lines. Business intelligence (BI) dashboards and reports are a necessary component of sustaining improvement, but they fail to adequately inform healthcare organizations.

Several factors account for this shortfall. BI often centralizes access to data at the executive level and is limited in its ability to allow organizations to create, analyze and model potential solutions in a timely way across the enterprise. Also, BI’s retrospective approach to dashboards with predetermined key performance indicators are based on static assumptions. BI and data warehouse approaches are not built to accommodate dynamic prospective analysis, address “what-if” modeling, or facilitate rapid cooperation between multiple departments across an enterprise. While useful in measuring progress, BI does not provide the clarity users need for nimble decision-making and timely action.

Decision makers will require a solution that vets truly useful insights hidden in terabytes of data assets. A practice called integrated performance management (IPM) — a holistic approach to performance management from planning, budgeting and forecasting to reporting, and performance measurement — offers a new path to this insight.

IPM combines decision support software, automated reports, knowledge management, alerts and human analytics to enable organizations to pull, customize and integrate data from different systems into one place for timely analysis and response. IPM provides an up-to-date view of what is occurring enterprisewide, enabling organizations to clearly visualize how financial, clinical and operational areas perform in relation to each other.

As compared to BI solutions, IPM employs a decentralized approach to data, knowledge and accountability, enabling action at multiple levels of the organization to change existing processes, manage risk, capitalize on performance improvement opportunities, and adjust planning, budgeting and forecasting on the fly. Powerful model flexing capabilities enable users to factor in variables that can affect strategic plans such as treatment patterns, payer mix, rates, market share or cost structure.

The result is faster identification of fundamental service-line business issues to help avoid costly missteps and to achieve improved operational and financial outcomes. Hospitals guided by IPM tools can identify and anticipate patterns, strengths and weaknesses, and make informed interventions to continually calibrate their trajectory toward strategic objectives.

Provider Example: Controlling Pre-Surgical Costs

A 500-bed medical center uses IPM to alert executives whenever pre-surgical costs exceed an assigned threshold based on analysis of historical data. When monthly costs exceed the target, IPM notifies management to explore the data for the cause of the variance. In 2008, the analytic dashboard alarm went off. Management first examined data across the enterprise and discovered that pre-surgical costs for patients scheduled to receive pacemakers exceeded the cost of other comparable procedures by $200,000 monthly.

Management then drilled into the data to scrutinize pacemaker cases according to level of service (LoS). Further analysis at the procedure level evaluated individual physician performance, revealing the true causes of the cost overrun:

• Physicians not prescribing the proper procedure or using unnecessary pre-op resources

• Scheduling and capacity issues

• Surgeries that were delayed because of the patient’s condition

Armed with this knowledge, the medical center sprang into action, scheduling surgeries at appropriate intervals to ensure operating rooms were available and making sure surgeons arrived on time.

Understanding that surgeries were justifiably postponed when patients were too ill set the proper expectations and increased the perceived value of close patient monitoring prior to surgery.

Read more. Download the complete text of the white paper, Creating the Information-Powered Healthcare Enterprise.

Thompson Offers a Nursing Perspective on Value of EMRs, CPOE

Reanna Thompson — Tue, 22 Jun 2010 12:02:00 -0400

In this video, Reanna Thompson, chief nursing officer of Presbyterian Intercommunity Hospital, shares a nursing perspective on electronic medical records and CPOE with the editor of www.whatismeaningful.com. Below is the video and a transcript of the interview.

What is Meaningful Editor: Explain how CPOE enhances workflow for the medical staff at PIH.

Reanna Thompson: There are many ways that technology has helped the physician workflow with the implementation of CPOE. Some of the obvious ways are that they have access to the medical record in various units throughout the hospital, in their office, and even at their home as they need to access information and data to make better decisions about their patients. We’ve also seen decreased phone calls to physicians for clarification of orders, whether it be legibility or completeness of orders. Now we see that physicians who are reluctant to have any sort of clinical decision support through CPOE and the pharmacy system, just reluctant to have too many alerts coming into their workflow? They are now asking for those kinds of solutions to help them make better decisions and to drive them to better practice and keep us compliant with some of our issues with core measures and joint commissions. So, it’s been an enhancement to their ability to do their work.

WIM Editor: How have PIH’s technology initiatives benefited communications between clinicians, with patients?

Thompson: I think the benefit to clinicians not having to do redundant work and finding more efficient ways to communicate. It also drives communication between clinicians as they look at best practicing and coordinate and collaborate about their care. And the patients benefit also when we can share that data in a way that makes sense to them, giving them information in a visual perspective and being able to answer their questions with not only just words but sitting and looking at their data and their information in a real-time way and a way that they can use and help make decisions about their own care. I think having technology available, whatever level we are at, has enhanced our ability to communicate with each other and with our patients.

WIM Editor: What impact has CPOE had for nursing at PIH?

Thompson: It is interesting when you think about nursing and their involvement with the implementations of electronic medical record. From the very beginning, even with CPOE, nursing really had a huge part in the success of that and their partnership with the physicians. It has provided another opportunity for them to collaborate with physicians and help them use the system. I don’t mind saying that I think a nurse is a little more adaptable than the physicians but they have really been able to be a partner out there to physicians and helping them see why this is so important, for them to enter in the orders themselves and take away some of the barriers to say order entry with legibility and incomplete orders.

Nursing support of those kinds of things have really made our transition so much less painful than they would have been otherwise without their engagement. Typically, nursing is about getting the best care to the patient, providing a higher level of care to the patient, spending more time with the patient. And the physician is really their best partner in that and I have seen a real step forward in that partnership as we have been implementing technology. We’ve just recently implemented KBC (clinical documentation) in all of our acute medical/surgical units – ICU and the emergency department. And, once again, the nursing staff has risen to the occasion. They absolutely love it. They feel that it really helps facilitate communicating with each other, being able to see data as it comes across in a real time way, the visibility of the trending that they can access on KBC. It’s just been a true enhancement in their ability to see patient care in a new way - making best practice decisions using the clinical practice guidelines, and collaborate with all of their partners in respiratory, in physical therapy, in dietary, and a way for them to communicate and remove some of the redundancy in their processes.

WIM Editor: What insights can you share with other community hospitals working to implement technology goals?

Thompson: I know that a lot of community hospitals see this as unachievable and that a lot of hospitals have been able to do it because they are either an academic medical center, they have residents, whatever. We have proven that you can do it at a community hospital if the hospital sees themselves as a partner to the physician. They practice here. A lot of our physicians have been here a long time and they have been our partners over the years to provide quality of care and provide what we needed as an organization. And this is our commitment…this was our commitment to them that YES as an organization we were moving to an electronic solution. Not all of them bought in right at the front of it and a lot of them were resistant but we wanted to prove to them that as a community hospital we could be as safe and efficient and as forward thinking as some of the highest rated academic medical centers in the country. And I believe we are there.

We want to continue that partnership as we implement other best practices and other workflow efficiencies, getting their perspective, getting their viewpoint. I don’t think that is so different from any other academic medical center wherever you are at. It’s all about listening to the person who is delivering the care and finding out what they need to make their workflow efficient. I just don’t think you can underestimate the voice of the front line staff. They are doing the work, they know what the problems are, and no suggestion should go unconsidered. It’s amazing the way we’ve gotten solutions and the ideas from unsuspecting people who haven’t taken the time to just analyze and test our system and they have come up with some really creative ideas so I think we are in the forefront of finding great solutions for some of the everyday workflow problems that impact every hospital.

[End of of video transcript]

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Presbyterian Intercommunity Hospital (PIH) has experienced close to 100 percent adoption of computerized physician order entry (CPOE) within 15 months. When PIH set a goal of 100 percent adoption rate of its CPOE implementation, its strategy was a combination of strong physician and nursing leadership, and a focus toward physician workflows. The approach helped to win over any resistance among affiliated physicians and enabled the community hospital to take away all paper order forms on day one.

Summa's Dr. Ross Shares CPOE Experiences, Insights

Charles Ross — Mon, 14 Jun 2010 17:21:00 -0400

In this video, Charles Ross, chief medical information officer of Summa Health System, shares his experience with CPOE implementations and the value of meaningful use with the editor of www.whatismeaningful.com. Below is the video and a transcript of the interview.

What is Meaningful Editor: What issues were most important to Summa in selecting a CPOE system?

Charles Ross: I think, oh, seven or eight years ago when we first decided to obtain a CPOE, we looked at multiple vendors and there were a lot of things that went into this but the major thing that we were looking at was quality. I think at that time if you look at this, I think there were issues that were very, very valuable and I think one of those issues was the ability to change this application to meet our processes and policies. And the second thing was to be able to change our order sets. To put decision support within our order sets that allowed us to go ahead and get the best quality so we would improve the physician buy in.

WIM Editor: What do you attribute to your high physician adoption of CPOE?

Ross: I think, like any other organization that has been successful with this, I think there is a number of things that we did and I would think that they would answer the same way. I think one of those things that was positive certainly we had a lot of support and administrative buy in. We also had nursing buy in. We also had physician buy in although some of it was skeptical to start off with. And I think that we had a lot of nursing IT analysts and also quality people that helped us and I think that that was very, very important as we move forward. One of the things that we were really afraid of was the multiple alerts within all of these systems and as we rolled this out, it became very obvious to us that we needed to change that and so what we did is to add decision support within our order sets which would allow better quality. And having better quality, we had physician buy in. If you really take a look at this, there were many outcomes that we had and it was very important that we show these outcomes to physicians. They needed to have that buy in to really accept this and this increased their buy in as we moved along so that is very, very important. If you look at the number of order sets that we had prior to putting in the CPOE, it was still only 13%. If you look at the percentage after we put in CPOE, it was 93%.

WIM Editor: How important is it to include CPOE in the ARRA meaningful use definition?

Ross: I think it would be hard for companies making CPOE to really define exactly what they need as a certified application. I’m also not absolutely sure that an institution which is starting CPOE today can get this done within a two-year time frame. But what I am sure is that if they put CPOE in and they implement it well, that it will improve outcomes and quality.

WIM Editor: What role has CPOE played in your clinical outcomes?

Ross: It was important because we felt quality in outcomes was the reason… or the reasons that we put in CPOE. If you look at this, we improved the outcomes and we’ve shown this to other institutions and presented it around the country, actually internationally but if you look at this, we’ve improved the outcomes on pulmonary embolism. We’ve improved the outcomes on diabetes. We’ve improved the outcomes on pneumonia….stroke outcomes…and as I said before, what we have shown is that we have increased the order set use from 12% to 93%.

WIM Editor: What is the key to achieving meaningful use?

Ross: Technology is extremely important. You have to have a technical application that works well but I think the most important thing you need to move forward is that the hospital has to understand what the process policies and flows are. We have to know what those are and secondly what we have to do is make sure that the physician and nurses all agree to that before you move on. So, technology is important but understanding these policies and procedures are fine. I think if you look at what I would say are the most important things to get physician buy in, and this is whether you have an ambulatory system or whether you are putting in an inpatient CPOE, the major thing is that you really have to have is that you have to make sure that you do not effect productivity. And the second thing you have to do is you have to show the physicians that you have improved outcomes. And if you can show that you’ve improved outcomes, you’re going to get better buy in.

WIM Editor: How has Summa been able to accomplish its technology goals?

Ross: The board of trustees and the administration of Summa Health System believes that qualities and outcome are the best things that we can …the best things that we can achieve… I think that the physician buy in is the major thing that has helped this but it is also nursing buy in to support this and I think that it is this type of thing which allows us to happen. We have a lot of nurse technical analysts and these nurse technical analysts have achieved what we really need to do as far as implementing and also maintaining this product. And I think the other thing that is extremely important is that we have tied ourselves very closely to quality and I think it is extremely important that the IT part of this ties itself to quality because quality is really what we want to achieve.

[End of of video transcript]

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Steltenkamp on the Value of Enterprise-wide Electronic Prescribing

What is Meaningful Editor — Fri, 21 May 2010 16:09:00 -0400

Carol Steltenkamp, M.C., CMIO, University of Kentucky HealthCare in Lexington, recently spoke with Healthcare Informatics about enterprise-wide e-prescribing and supporting the use of it among affiliated community physicians in Lexington. Below are excerpts of her comments to Healthcare Informatics. Read the complete Healthcare Informatics article.

“Just having that information available on a give-and-take basis is huge,” says Carol Steltenkamp. “As an academic medical center, [UK HealthCare], it is our job to be teaching the physicians of the future and they need to be doing this.”

According to Healthcare Informatics, Steltenkamp cites the improved safety and access of e-prescribing as a principal reason why. Her concerns about patient safety and prescribing errors are echoed in a recent study in The Journal of General Internal Medicine. The study, funded by the Washington-based Agency for Healthcare Research and Quality, found that a group of primary care practices in New York reduced their prescribing error rate from 42.5 percent to 6.6 percent over a one year period using e-prescribing.

Steltenkamp goes further when she notes that e-prescribing alone, even when not accompanied by full EMR adoption on the part of individual physicians, is proving its merit. Though the EMR adoption rate among physicians in her community remains at around 30 to 40 percent, she sees e-prescribing alone as improving the quality of care, simply based on the fact that community physicians logging onto the hospital's physician portal are able to check the prescription information that the hospital has on their patients. In addition, the hospital can always fax a clear print out of the prescription to the physician office.

“Our challenge is to bring value to our community physicians,” adds Steltenkamp. “We want to hold out the carrot, not the stick. The message needs to be that you really need to work with the providers and e-prescribing is a way to facilitate the good care that they're giving, not hinder it.”

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No "One-Size-Fits-All" in Building Nationwide Health Information Network

What is Meaningful Editor — Fri, 14 May 2010 14:27:00 -0400

Below is a message from Dr. David Blumenthal, national coordinator for Health Information Technology.

Private and secure health information exchange enables information to follow the patient when and where it is needed for better care. The Federal government is working to enable a wide range of innovative and complementary approaches that will allow secure and meaningful exchange within and across states, but all of our efforts must be grounded in a common foundation of standards, technical specifications, and policies. Our efforts must also encourage trust among participants and provide assurance to consumers about the security and privacy of their information. This foundation is the essence of the Nationwide Health Information Network (NHIN).

The NHIN is not a network per se, but rather a set of standards, services, and policies that enable the Internet to be used for the secure exchange of health information to improve health and health care. Different providers and consumers may use the Internet in different ways and at different levels of sophistication. To make meaningful use possible, including the necessary exchange of information, we need to meet providers where they are, and offer approaches that are both feasible for them and support the meaningful use requirements of the Centers for Medicare & Medicaid Services (CMS) Electronic Health Record Incentives Programs. As with the Internet, it is likely that what is today considered “highly sophisticated” will become common usage. Moreover, users may engage in simpler exchange for some purposes and more complex exchange for others.

Current NHIN exchange capabilities are the result of a broad and sustained collaboration among Federal agencies, large provider organizations, and a variety of state and regional health information organizations that all recognized a need for a high level of interoperable health information exchange that avoided “one-off” approaches. Based on this pioneering work, a subset of these organizations is now actively exchanging information. This smaller group currently includes the Department of Defense, Social Security Administration, Veterans Health Administration, Kaiser Permanente, and MedVirginia. They initially came together to show, on a pilot scale, that this type of highly evolved exchange was possible. Having succeeded, they continue to expand the level of exchange among their group and with their own respective partners in a carefully phased way to demonstrate and learn from these widening patterns of exchange. The robust exchange occurring at this level has several key attributes, including the:

1. Ability to find and access patient information among multiple providers;

2. Support for the exchange of information using common standards; and

3. Documented understanding of participants, enabling trust, such as the Data Use and Reciprocal Support Agreement (DURSA).

Not every organization and provider, however, needs or is ready for this kind of health information exchange today. Nor do the 2011 meaningful use requirements set forth by CMS in the recent proposed rule require it. Direct, securely routed information exchange may meet the current needs of some providers for their patients and their practices, such as receiving lab results or sending an electronic prescription.

To enable a wide variety of providers – from small practices to large hospitals – to become meaningful users of electronic health records in 2011, we need to ensure the availability of a reliable and secure “entry level” exchange option that aligns with the long-range information exchange vision we have for our nation. Such an option should balance the need for a consistent level of interoperability and security across the exchange spectrum with the reality that not all users are at the same point on the path to comprehensive interoperability. In an effort to provide the best customer service possible, the Office of the National Coordinator for Health IT (ONC) will consider what a complete toolkit would be for all providers who want to accomplish meaningful health information exchange.

Broadening the use of the NHIN to include a wider variety of providers and consumers who may have simpler needs for information exchange, or perhaps less technically sophisticated capabilities, is critical to bolstering health information exchange and meeting our initial meaningful use requirements. Building on the solid foundation established through the current exchange group mentioned above and the recommendations of the HIT Policy Committee (which originated with the Committee’s NHIN Workgroup), ONC is exploring this expansion of NHIN capabilities to find solutions that will work across different technologies and exchange models.

The newly launched NHIN Direct Project is designed to identify the standards and services needed to create a means for direct electronic communication between providers, in support of the 2011 meaningful use requirements. It is meant to enhance, not replace, the capabilities offered by other means of exchange. An example of this type of exchange would be a primary care physician sending a referral and patient care summary to a specialist electronically.

We are on an aggressive timeline to define these specifications and standards and to test them within real-world settings by the end of 2010. Timing is critical so that we may provide this resource to a broader array of participants in health information exchange as a wave of new, meaningful users prepare to qualify for incentives provided for in the HITECH Act and ultimately defined by CMS. This model for exchange will meet current provider needs within the broader health care community, complement existing NHIN exchange capabilities, and strengthen our efforts toward comprehensive interoperability across the nation.

A natural evolution in NHIN capabilities to support a variety of health information exchange needs is being reinforced by trends that are leading us toward widespread multi-point interoperability. The current movement toward consolidation in health care, coupled with health reform’s encouragement of bundled payments for coordinated care, will mean more providers need it. Quality improvement, public health, research, and a learning health care system all require it. Ultimately, simple exchange will be part of a package of broader functions that allows any provider, and ultimately consumers, to exchange information over the Internet, enabled by NHIN standards, services, and policies.

Your continued input will help guide us toward and maintain a direction that is in harmony with the rapid innovations in health IT today. The NHIN Direct Project will conduct an open, transparent, and collaborative process throughout its development by using a community wiki, blogs, and open source implementation already available on the project’s website (http://nhindirect.org). I encourage you to participate through the website, via public participation at the implementation group meetings, and by deploying and testing the resulting standards and specifications. For those of you who are participants in the current exchange group, I urge you to take every opportunity to share your experiences. Lessons learned from the NHIN Direct Project and the exchange group will inform the evolution of the NHIN as new uses and users come forward, and as continued innovation occurs to meet the growing needs of our community.

As we head into the next stage in the development of nationwide health information exchange, we should all take a moment to reflect on how far we have come and evaluate our plans for the future. ONC is committed to providing resources and guidance to stakeholders at all levels of exchange through HITECH programs, such as the Health IT Regional Extension Centers, the national Health IT Research Center, and the State Health Information Exchange Program. As you assess your own needs for exchange, please take advantage of the many Federal resources available to you on the ONC website and the online resources of the programs mentioned above, as well as through the “NHIN University” education program hosted by our public-private partner, the National eHealth Collaborative.

We have done a great deal of work in the short period of time since the passage of the HITECH Act. We at ONC appreciate your willingness to stay engaged and involved in every step of our journey, and we look forward to our continuing collaboration to improve the health and well-being of our nation.

Sincerely,

David Blumenthal, M.D., M.P.P.
National Coordinator for Health Information Technology
U.S. Department of Health & Human Services