The EHR vendors have not been sharing HOW their products are being certified. Currently, it is a black box. This is VERY frustrating. Especially since hospitals and doctors are supposed to be using the EHRs as cerified. Often there are many ways for an EHR to accomplish a testing objective. The current certification just produces a check box and a pretty certificate.  How do we deploy and use the product in a certified way is a mystery. My EHR vendors have not been forthcoming with this informtation (slippery is a term that comes to mind).

During a HIMSS meeting with an ONC official, it became apparent to me that ONC now realizes this is a problem. There was a discussion that the vendors should provide screen shots for each step to share this with their customers. ONC can compel them to do this, but I would like to see the vendors do this on their own.

For me, this is one more reason to take the self certification route.

In the world of hospital information technology, automated care planning is as under-appreciated and Computerized Physician Order Entry is over-hyped. Typically care planning software was used outside of the care process to produce documentation for Joint Commission (JCAHO) surveys. This is not the promise of good care planning software.

The care plan should be the plan produced by all disciplines, and led by the physician, that defines the goals of the patient stay and ensures that all of the key interventions take place at the optimal time in order to achieve those goals as quickly as possible (shortest length of stay) with the least amount of resources (lowest cost). The care plan is the hospital’s assembly line. I believe it is the most important element of nursing informatics.

Focusing on medication process automation and Computerized Physician Order Entry (CPOE), to the exclusion of good care planning automation, is like a car company that wants to build really good tires and engines, but does not have a way to build a car in a timely, defect-free manner.

I believe nurses, no – all care givers, need a single dashboard where they can see every intervention (including administering post-operative antibiotics, ambulating patients, assessing skin, patient education, etc,). That dashboard can function as the caregivers worklist presenting the tasks to be completed in the most efficient sequence by the most appropriate member of the care team

Additionally, all of the care plans could be monitored centrally to identify key interventions that have been missed (think population management for inpatients). This would allow interventions of key quality indicators before it is too late, as opposed to the status quo where the quality indicators are available 6 weeks after the patient is discharged and coded.

Why isn’t care planning an element of meaningful use? In my opinion, It holds more promise to manage cost and achieve outcomes than CPOE.

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.