Candid CIO

For year’s EHR vendors created EHR shells with  functionality that lacked all of the creamy goodness of evidence based medicine.  Instead they have left it up to the hospitals to do this.

This has not worked well. Who wants to buy the cream puff shells at the bakery then go home to make your filling? I just want a damn cream puff. Adding the evidence-based medicine to an EHR is an amazing amount of work that literally takes a decade before the average health care organization can scratch the surface.

I read this blog post today that describes Cerner’s plans to use British Medical Journal (BMJ) clinical content: http://bit.ly/9vJEfb. Dale Sanders, CIO, Cayman Island Health Authority has written an excellent post with exuberance.

This seems to be much more connected and thought out than the pseudo-partnerships we see today between EHR vendor’s and tools such as Zynx.

This is the kind of thing that can be disruptive to the EHR market. That is, it could knock Epic off the top of the mountain.

I was speaking to some of the folks that head up admissions and registration at Affinity Health System this week. They shared with me that recently it has become very common for patients to have to look up their home phone numbers when registering. Usually they look it up on their cell phones.

I can think of a couple of times recently when I could not rattle off my home phone number like I had my entire life. I am glad to hear that this is the result of the shift in reliance to mobile phones, rather than my approach to age 50 (at least that is my claim).

In the future we will all be like Einstein.

On July 13, 2010 the Center for Medicare and Medicaid Services released their Final Rule regarding the Electronic Health Record Incentive Program, known within our industry as the definition of “meaningful use” of an EHR.

Senator Russ Feingold’s office contacted Ministry Health Care to get our reaction to the regulations. We greatly appreciate the Senator taking the time find out how such rulings impact our organization and our ability to live out our mission of improving the health of the patients we serve, especially the poor. Here is our response:

Thank you for asking for Ministry Health Care’s reaction to the Final Rule on HIT – Meaningful Use.

Our overall reaction is favorable.  While there may still be challenges associated with timing and certification, we do believe some specific comments from Ministry Health Care and others were heard and addressed in the Final Rule.

Under the Draft Rule, we viewed the Meaningful Use regulations as a disincentive, requiring too-much-too-quickly for an entire healthcare industry.  Given the changes in the Final Rule, we are re-evaluating our plans with an eye toward accelerating Electronic Health Record plans at many of our hospitals.  This is good news for our patients!

The true measure for us is Ministry Saint Clare’s Hospital in Weston.  Under the Draft Rule, Ministry was challenged just to reach Stage 1 meaningful use in Weston, where Ministry Saint Clare’s is Wisconsin’s first all-digital hospital and the only hospital in the state recognized by The Leapfrog Group as having fully implemented Computerized Physician Order Entry (CPOE) (by the way, the invitation for the Senator to visit Ministry Saint Clare’s to see this firsthand is always open).  This was a sign that the originally-proposed incentives were not rational.  Under the changes in the Final Rule, the path to Stage 1 meaningful use is more easily accomplished for Ministry Saint Clare’s: Wisconsin’s most IT-advanced hospital that has been perfecting its EHR since opening in 2005.

Likewise, Ministry Medical Group would not have been able to easily achieve Stage 1 meaningful use despite our project to deploy the Marshfield Clinic’s EHR (CattailsMD). We were not sure that the 1,000 Wisconsin doctors were going to be able to receive EHR incentives using that system.  Under the Final Rule, we feel there is an achievable effort to reach Stage 1 Meaningful Use, which is an incentive to start improving the system in order to meet Stage 2.

Our only significant concern at this point in time is the EHR certification process.  We are now nine weeks from the October 1, 2010 start of the EHR Incentive Program, and none of the EHR products on the market today are certified to meet Stage 1 meaningful use criteria.  As of today, ONC has yet to identify an Authorized Certification Body.

Ministry could implement the most sophisticated and beneficial Electronic Health Record in the world and still be denied EHR incentive payments due to the EHR certification requirements.  These requirements, in our opinion, have not been well defined or well conceived.  The certification process does not seem to take into consideration that a large sophisticated health system, such as Ministry, implements EHRs using a combination of commercial products and internal software development.  While no single piece of the puzzle is a certified EHR, the combination of these solutions result in an Electronic Health Record that exceeds the certification requirements.  The uncertainty over the certification process is now a much greater concern than the final meaningful use requirements.

On July 6, 2010 the The Office of the National Coordinator for Health Information Technology (ONC) sent written guidance to states and state designated entities regarding HIEs:

Executing Strategy for Supporting Meaningful Use

Operational plans shall describe how the state will execute the state’s overall strategy for supporting Stage 1 meaningful use including how to fill gaps identified in the environmental scan.  Specifically, states and SDEs shall describe how they will invest federal dollars and associated matching funds to enable eligible providers to have at least one option for each of these Stage 1 meaningful use requirements in 2011:

1. E-prescribing
2. Receipt of structured lab results
3. Sharing patient care summaries across unaffiliated organizations

I first heard about this guidance to the states about a month ago. At the time I was puzzled how ONC thought state HIEs would ever be involved in ePrescribing. Providers do not need assistance from the HIEs to implement ePrescribing.  This is solely the domain of the provider EHR and the existing Pharmacy exchange managed by SureScripts. I thought that they would realize this and back away, but surprisingly it made it to writing.

So, what does ONC expect the state-designated HIE to do regarding ePrescribing? If you read the entire Program Information Note there isn’t any sort of clue. Does anyone have any insight regarding this?

I used to think that change management was something you did for the auditors. I now realize that my attitude was undermining the value and that Change Management is the most important control in an IT department.

Kevin Behr (kevinbehr.com) opened my eyes. In Visible Ops Behr, et. al. state that 80% of all IT problems are the result of something we changed (shooting ourselves in the foot). Creating a culture that values successful changes and backs out bad changes rather then “fixing” the problem creates a more efficient IT organization.

I could continue plagiarizing from Visible Ops, but this note from our Exchange guru says it all:

Change management saves the day and my vacation! I have been working on a pesky issue  today that I thought was limited to one resource mailbox but turned out to affect other mailboxes of that type. While working closely with the impacted users we were able to determine the problem started last week.  I reviewed my changes from that time frame and there it was!  A minor change made to correct one issue caused another issue.  Before finding that change documentation I was worried there was a larger issue going on that would require resolution before I could leave for vacation.  Long story short, issue resolved.  The extra time taken to document changes pays off big time and  I’m outta here! Have a  great 4th of July.

As each state prepares to launch Health Information Exchanges (HIEs), it is important to keep in mind the goals of the effort.  I believe this is more difficult than one may think at first blush. But, trustees of these HIEs need to move beyond a “motherhood and apple pie” approach of saying the purpose of an HIE is to reduce cost and improve quality and safety.

The cost question is very complicated. After all, one stakeholder’s expense is another’s revenue. Is the goal to reduce the cost to the State? The Patient? The Payors? The Providers of healthcare?

Take duplicate testing. Certainly an HIE has the ability to enable the reduction of duplicate testing by giving providers instant access to results stored in other providers Electronic Health Records. That is a win for the Patients, States and Payors. But, that will have an impact on provider revenue. If the HIE requires all parties to mutually support initiatives there is a strong potential for stalemate.

To complicate this even further…just because a provider has access to the results from another provider does not prevent the provider from ordering a duplicate test. I have overheard other organizations leaders suggest that they should not trust results from other providers and that re-ordering expensive tests is the best care. Unless the HIEs tackle that concern they may not achieve the benefits that they seek.

After 14 months ONCHIT has still not been able to define the EHR certification process. It is time to kill it dead.

The original intent of certification, as I understand it, was to ensure that purchasers of EHRs would buy systems that met a certain level of capability (presumably meaningful use). Now ONCHIT is contradicting the original spirit of that concept by encouraging healthcare providers to proceed with their meaningful use projects on products without certification criteria. Providers are understandably reticent since they don’t want all of their efforts to go to waste if they cannot be assured that their products are certifiable.

It is possible, maybe even likely, that providers will achieve meaningful use with a combination of applications. So why should any one of them have to be certified as having the ability to meet all of the meaningful use criteria?

Certification is blocking EHR progress.  There is one rational solution: BANG.

What do you think? Do I have my facts right?

I am a skeptical person by nature. It turns out that has served me well in my field. For over 25 years I have listened to people proclaim how information technology will transform health care in the near future.

Usually I am the one trying to temper expectations. But, today I found myself claiming that we are on the verge of some really interesting things in healthcare technology. For a long time we have lacked the standards and networks that exist in in the financial sector. But, I believe we are close to implementing early versions of these at the state level. This is due to the federal stimulus funds and the hard work of state agencies partnering with the private sector.

Some aspects of the meaningful use are frustrating.  I believe we are still chasing a list of functionality that does not have a clear line of sight to specific and prioritized goals. I once heard this referred to as planning by the cover of Modern Healthcare.

But, I believe 5 years from now we will see interoperable heathcare systems at the state level. I am optimistic.

It’s December and I am excited. Sure, I am excited for the holidays, but I may be more excited to see the official ARRA “meaningful use” guidelines.  The HIT Policy Committee’s draft is simply not detailed enough to use to develop a good IT strategy. There are so many vendor assertions being made that have multi-million dollar implications.  Here are my top questions I am wishing will be answered when the the first draft of the rule is published:

1. Is the hospital CPOE standard for inpatient orders, or all orders in the hospital? A number of sellers of Emergency Department vendors are asserting that hospitals will not be able to accomplish meaningful use without their software.  Implementing an Emergency Department system before October 2011 is a big deal.

The meaningful use matrix does state that the 2013 standard for meaningful use is “CPOE for all order tpye.” But it also states that the measure for CPOE is “%  of all orders entered by physicians  through CPOE [EP, IP].” Can I presume that IP means inpatient and that the measure applies to order entered on inpatients?

2. In writing the official rule, have those charged with setting the standards realized that the original standard is not acheivable by the vast majority of hospitals?  Given that it has taken the writers of the rule a year just to describe what they want done, it is probably going to take more than 21 months for us to do it?

3. If niche vendors are required to achieve meaningful use, like the ED system mentioned above, do they need to be CCHIT certified? Or, does the certification requirement only apply to the core HIS? If so, what is the definition of core HIS?

Please post a comment if you think these questions have been clearly answered, or, you have questions of your own to add.