NeoTool — Singular Focus, Healthcare Integrated

Tim Gee with the Medical Connectivity wrote a great review of the recent Healthcare Unbound conference that was held in San Franciso. Tim did an excellent job of providing good detailed insights from the conference.

The Center for Business Innovation hosts the conference, and they describe Healthcare Unbound in the following manner:

Innovative technologies are driving opportunities to serve consumers in new ways and in new settings. Forrester Research coined the term “Healthcare Unbound” to encompass the trends toward technology-aided self-care, mobile care and home care. More specifically, Forrester describes “Healthcare Unbound” as “technology in, on and around the body that frees care from formal institutions.”

As healthcare IT evolves and changes, it is interesting to read the thoughts and activities happening at the consumer level.

As noted in HIS-Talk, Former Meriter Hospital CIO Peter Strombom has written an interesting article on Wisconsin’s progress towards a regional health information exchange (RHIO). Peter’s history and thoughts are very pragmatic and, IMO, on target; I thought I would share some quotations.

The motivation behind Peter’s article is that, like many areas of the US, Wisconsin has been talking about building a RHIO (or two) for a long time. The current challenge is architecting the system and ultimately paying for it. The state has issued an RFP asking for help designing the architecture. Costs for the total deployment are estimated at $1.2B and are, presumably, to be funded by the providers.

Peter makes some great points about:

1. The fact that we’ve been at this “regional interoperability game” for a long time.
2. RHIOs are the latest name for an old idea
3. Peer-to-peer communication (rather than centralized “control”) has a better chance of success
4. Good discussion of political v. economic v. quality of care motivations for interoperability
5. Providers must be using electronic records before they can be exchanged, well, electronically
6. On-going work to firm up standards will help with interoperability

Two counter points I would make to Peter’s thoughts:

1. I do not think that the banking analogy Peter uses is a good one. The banking world has (effectively) centralized control over the SWIFT and related networks. A better analogy would be peer-to-peer file sharing networks — heck, if we can share MP3s in an ad-hoc-yet-organized-way, surely we can share healthcare records.
2. IMO, the CCHIT is not the total driver for peer-to-peer interoperability. HL7 (among others) has been working on this problem for a long time and, again IMO, CCHIT is effectively profiling existing standards rather than creating new standards.

Selected quotations from Peter’s article:

[In November 2005 Wisconsin’s Governor] called for “a statewide eHealth infrastructure […]. [P]resident Bush’s State of the Union Address [in January 2004] stated that “By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.”
…
The statements were both politically appropriate at the time, but as of June, 2008, little has been achieved in Wisconsin.

We have been at this for a long time. The CHINs (community health information networks) of the mid-1990s were an idea that had merit but was not adequately supported by the technology of the day. The RHIOs (regional health information organizations) of later times were also a great attempt at interoperability but suffered from lack of community acceptance and viable business plans to sustain them. It is telling that only a handful of RHIOs continue in business from the several hundred that were founded on initial seed money only to fail when those funds became exhausted. The poor support from the healthcare providers and the payer community, and the absence of inspirational insight into the opportunity being presented to us by the technology, contributed to the lack of success of what I will call the second generation of this approach at interoperability.

Presumably, the healthcare provider and payer will bear the cost of this process. […] Importantly, to be viable, the plan further assumes that all healthcare providers in the State of Wisconsin will maintain patient records electronically. This is not the current or the foreseeable situation, as many small hospitals and physician practices do not have the available funding to achieve this goal with only their own resources.
…
Application (systems) vendors in healthcare are working together under the auspices of the Certification Commission for Healthcare Information Technology (CCHIT) to develop standards for interoperability. By working together it is planned that their output will become accepted as was the HL7 interface standard. A peer-to-peer network with communications between healthcare providers using software from the same or different software vendors and based on the CCHIT standards could follow a model based on the Banking system model.
…
This peer-to-peer network lends itself to progressive growth and expansion, as warranted as additional providers implement electronic medical records systems. Importantly, a sustainable business plan at the operations level is not needed to finance the exchange of key clinical information in a time of need.

The National Alliance for Health Information Technology (NAHIT) recently released new definitions of certain healthcare IT terms. This project was completed for the Office of the National Coordinator of Health Information Technology; this office was created by the President on April 27, 2004 to promote the adoption of electronic health records by most Americans by 2014.

Outlined below are the definitions published by NAHIT. These healthcare IT definitions were published in the report entitled Defining Key Health Information Technology Terms (PDF).

• Electronic Medical Record: An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one healthcare organization.
• Electronic Health Record: An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.
• Personal Health Record: An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual.
• Health Information Exchange: The electronic movement of health-related information among organizations according to nationally recognized standards.
• Health Information Organization: An organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards.
• Regional Health Information Organization: A health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community.

The greatest understatement in the report is: “Interoperability is the common thread running through health IT terms. Interoperability is the essential factor in building the infrastructure to create, transmit, store and manage health-related information.”

For more definitions, check out our healthcare interoperability glossary.

A recent Radinformatics article entitled CIO at the Table highlights the fact that most radiology practices have not welcomed their CIOs to sit at the executive committee table. Nevertheless, research indicates that having the CIO at the management table will facilitate the practice’s growth more effectively.

Creating a competitive advantage for your radiology practice is critical in today’s market. Healthcare IT is a critical strategic element that can automate, streamline, enable, etc. radiology workflow. Having the CIO present at the business level can only help your radiology practice meet the growth and operational goals.

Many of the radiology practices we work with have a CIO who has a strong involvement in the operational discussions, and they have produced impressive results. The results can include improved turn around times (TAT), improved billing cycle times, or other elements of the radiology workflow.

The Radinformaticsarticle highlights some important insights about radiology CIOs, including the valuable role they can play and the skills they can bring to the management table.

In a previous post, I highlighted several healthcare IT perspectives on the Stark Law changes and the impact on EMR implementations through hospitals. A recent article in Inside Electronic Medical Records is an interesting edition to this topic; the article is entitled:  Hospitals Take Tentative Start EMR Steps, Struggle with Charging Overhead to Doctors.

A few interesting points in the article:

• Different approaches are being taken by hospitals. In the article, one hospital is offering just a single EMR offering to their physicians, and another hospital is offering 3 to 4 EMR application options. The primary reason for the multiple EMR offerings is that “We realized that one size doesn’t fit all.”
•  Integration is essential. The reason for the one hospital to offer single (hosted) EMR offering to their physicians is so that the patient has one medical record in their system. In the other hospital’s case, clinical integration is still essential. As they stated, “You have to have clinical integration between multiple entities. If you are not sharing data, you are losing the real benefit of EMR.”
• EMR certification also plays a role in the selection process by the hospital. In one case, only CCHIT certified EMR vendors are considered.
• The amount of the hospital subsidy varies. One hospital is covering 60% of the EMR services while the other seems to be taking advantage of the full allowable amount of 85% of the covered services.
• Trust is a factor with physicians. If a physician practice is going to take advantage of a hospital supported EMR, they will need to trust that hospital.

Forward progress? Time will tell which approach will work the best, or it may be that the approaches do vary… select the approach that best fit the needs of the connected healthcare objectives being pursued. As long as everyone involved trusts the objectives, it may work.

An article in FierceHealthIT highlighted a recently published paper (PDF) on how Electronic Medical Record (EMR) adoption is driving the need for more Healthcare IT (HIT) jobs. A key statement from the report:

“While hospitals with basic implementation are utilizing about 0.1 IT staff per bed, this rises to around 0.2 IT staff per bed as hospitals advance from Stage 1 to Stage 4 implementation based on the HIMSS EMR Adoption Model. If our data represent a correct sampling of the entire US, then the current IT staff workforce is about 108,390 FTE. However, if the US HIT agenda is fulfilled and hospitals move to higher levels of adoption, an additional 40,784 FTE will be required.”

Characterizing the Health Information Technology Workforce: Analysis from the HIMSS Analytics Database, April 2008.

In the EMR adoption model as defined by HIMSS, the various stages are succinctly defined. Stage 1 includes basic systems in place - radiology, laboratory, pharmacy - while moving to Stage 4 includes implementation of a Computerized Practitioner/Physician Order Entry (CPOE) system.

The key point of the paper and discussion: Adopting new technologies in hospitals require additional IT personnel to support and ensure success. In selecting new technologies, it is important for hospitals to evaluate the type of IT skills required to support the required new applications. Balancing the type of skills required with the associated costs is essential.

Just recently, I wrote about how workflow discussions are frequent, and sometimes it is easy to lose sight of what needs to be simply done. In the current issue of Health Management Technology, there is an interesting article of how Meadows Regional Medical Center applied lean manufacturing principles to their workflow. The article is entitled Leaning Towards Efficiency, and is written by the hospital CEO, Alan Kent.

The hospital worked with Georgia Tech’s Enterprise Innovation Institute and focused on improving the Emergency Department (ED) workflow.

In healthcare IT, it is great to read about how workflow projects are undertaken in a straightforward way and achieve significant results in a short time period. As the article states:

“The lean team at Meadow’s developed 44 action items for reducing lead time to admit, treat and discharge a non-critical ED patient, 18 of which were determined to be low cost and high impact.”

The results, according to the Georgia Tech press release:

“… a 44 percent reduction in average length of stay per patient, a 10 percent boost in patients served and a 92 percent patient satisfaction rate.”

Great work!

As reported in Health Data Management, the FDA is proposing that Medical Device Data System (MDDS) software be reclassified from a Class III to a Class I medical device. A Class III medical device is the most stringent and expensive regulatory classification and must receive pre-market approval from the FDA. Class I classification is the least stringent classification.

 The FDA report summary states:

SUMMARY: The Food and Drug Administration (FDA) is proposing to
reclassify, on its own initiative, the Medical Device Data System
(MDDS) from class III (premarket approval) to class I (general
controls). This action does not include medical device data systems
with new diagnostic or alarm functions. FDA is also proposing that the
MDDS be exempt from the premarket notification requirements when it is
indicated for use only by a healthcare professional and does not
perform irreversible data compression.

The entire report can be found as document ID fr08fe08P, Devices: General Hospital and Personal Use Devices.

The Stark Law is potentially changing the landscape in the adoption of healthcare IT in physician practices in communities across the US. What change actually happens is still up for debate.

A recent article in Government Health IT entitled Picking Up the Check for EMRs does a good job of outlining the differing perspectives:  hospital, physician practice, and vendor. Outlined below is a brief summary of each perspective.

Hospital Perspective.  Although some hospitals may implement strategies and programs to offer EMRs to physician practices, there is skepticism that it will work. Hospitals like Partners Healthcare System do not have plans to start paying for local systems. Other hospitals note that they would have to offer physician practices more than one EMR option in order to meet the differing requirements. The bottom line, though, is that many hospitals are not in the financial position to fund EMR adoption in physician practices.

Physician Practice Perspective.  Doctors are independent and do not want to take hospital incentives which may compromise their independence. Also, what if a physician practices at more than one hospital and each hospital has a different supported EMR application? There is also some concern about patient data security.

EMR Vendor Perspective.  Essentially, the vendors like the possibility of additional funding to support EMR adoption. However, there are concerns this would benefit the larger EMR vendors more than the mid-to-small sized ones.

A recent HIS Review blog post also provides a good overview of recent updates to the Stark Law and what hospitals need to be considering.

The most detailed outline of what a hospital will need to do around the Stark Law changes comes from a hospital CIO blog post. In Life as a Healthcare CIO, John Halamka describes the top ten planning items for hospitals to consider as they implement a strategy and program that leverages the Stark Law changes.

Obviously, how this all plays out is still up for debate. There are many elements to consider, not the least of these being how to integrate the patient data flow together between the different EMR applications, physician practices, and hospitals. In many respects, the debate is happening at the right level – the local level.

If healthcare IT is to be adopted by physician practices, the issues and plans will need to be resolved between the players in the communities.

Or, as is being done in some instances, the connections are being made between the different healthcare providers and their applications by leveraging interface engine technology.

The driving forces in these electronic transaction interactions are streamlined workflow, increased referrals, and faster turn around times to support quality patient care. There are several case studies that highlight specific providers connecting to various EMRs successfully and exchanging patient information. Business or operational drivers, not the Stark Law, are moving “connected healthcare” forward in these examples.

The technology used in imaging centers and radiology practices is rapidly evolving. These technology changes affect both the front-end and back-end radiology workflows. The front-end workflows are affected by ever changing imaging and modality technology advancements while the back-end workflows are affected by advancements in information technology (IT). Keeping up with the changes can be a challenge.

The focus of this blog is the IT back-end radiology workflow changes. The goal of healthcare IT is to make all the systems work smoothly together or interoperate for organized, seamless data flow. The first step to achieving such goals is to understand your current workflow.

In an example imaging center, the workflow might be:

• Schedulers enter orders manually on the radiology information system (RIS) or orders move into the RIS electronically from external referring physicians or hospital systems.
• Those orders flow to various internal systems such as the picture archiving and communication systems (PACS) and Voice Recognition (VR).
• The images are acquired:
  • Modalities query the modality worklist manager (PACS).
  • Once the procedure is completed, images are returned to PACS.
• A radiologist reads the images and dictates the results into VR.
• A radiologist self-corrects and approves the reports.
• The reports are distributed to RIS, PACS, Billing and the applicable referring locations.

As is possible to observe in the example radiology workflow, in an imaging center, clinical data must move to and from multiple systems. Even though the workflow is unique for each imaging center, the need to transfer clinical data is not. The moving of data is where HL7 interfaces can make the most headway towards bridging the gap for interoperability and creating that organized, seamless data flow.

Using an HL7 integration approach to move clinical data between applications helps:

• Optimize information systems
• Reduce errors in multiple, manual entries
• Maximize radiology workflow
• Facilitate growth through an efficient workflow

Whatever applications and systems are used to perform the tasks necessary in your imaging center, there is still a need to make the data flow to the right place at the right time based on the capabilities of those systems. With greater requirements for RIS-driven workflow and data exchanges with referring physicians, the HL7 Standard plays a prominent role in automating the radiology workflow.

For addition information, read an interview with the CIO at Radiology Consultants of Iowa and watch a 15-minute web seminar on what role HL7 messaging can play in radiology workflows.