The Eyes Have It

No matter what technologies are used, the end goals for any organization are adoption and behavior change to achieve desired clinical and financial outcomes. Well-designed workflows that satisfy the needs of users lead to high levels of adoption of information systems. High levels of adoption that do not facilitate behavior change replicate systems and the undesirable outcomes achieved before technology deployment. Therefore, techniques that encourage behavior change, such as clinical decision support tools and performance scorecards, must also be embedded seamlessly in the clinical workflow to be effective.

Tools exist for achieving effective clinical workflow, although we continue to learn and refine best practices. Throughout the 1990s, payers employed clinician profiling reports or scorecards in an attempt to identify outlier providers and effect change in clinician practice patterns. Few of these efforts proved successful due to problems with data sources and the delivery and content of the scorecards.

With the expansion in the use of electronic medical records, the data source for scorecards that can influence clinician behavior moves to a much more robust data source, a data warehouse populated with clinical information gathered from multiple clinical systems. In addition, analytical tools now exist that can easily comb through enormous data sets and generate insightful results presented in attention grabbing, meaningful graphics.

Excerpts from: The Eyes Have It. PSQH, March/April 2013

Photo Courtesy of  Don Guerwitz Photography - At the Catania Market, Sicily, Italy

Next Generation CDSS: Patient-Centered Workflow

In the design of successful health IT implementations, patients matter. Although the importance of addressing the workflow needs of clinicians cannot be overstated, focusing on patient needs helps ensure newly designed workflows leverage the full capabilities of IT tools and embedded clinical decision support systems (CDSS).

In addition, this delivers the clinical and financial outcomes desired by organizations. Entities that ignore the needs of clinicians in designing health IT-driven workflows can expect to experience either low levels of health IT adoption among clinicians, suboptimal patient care results, or both.

Excerpts from: Next Generation CDSS: Patient-Centered Workflow. Health Technology Online, January/February 2013, p.10.

Photo Courtesy of  Don Guerwitz Photography – Guardians of the Gate. Angkor Thom, Siem Riep, Cambodia

We Know What to Do

Almost eight years ago Richard Hillestad and his colleagues from the Rand Corporation predicted that electronic medical record systems (EMRs) would generate cumulative efficiency and safety savings of $142 to $371 billion during a 15-year period, an average of $81 billion annually (Hillestad et al., 2005).

Just seven years later, Arthur Kellermann and Spencer Jones from Rand revisited Hillestad’s work and concluded that the increase use of health IT made the quality and efficiency of healthcare only marginally better. At the same time, yet, aggregate expenditures on health care in the United States have grown from approximately $2 trillion in 2005 to roughly $2.8 trillion today.

This Kellerman report evaluates four assumptions made in the original article by Hillestad and attributes the shortfall in observed versus projected results to shortcomings in four areas. Hillestad assumed the following in making his projections: 1) robust interoperability and interconnections of health IT systems, 2) wide adoption of health IT systems by clinicians, 3) effective use of health IT systems to impact care, and 4) changes in incentives and reimbursement systems that emphasized quality rather than revenue.

No surprises here. Anyone who toils in the health IT field knows that these four items represent the key challenges that we all work to overcome as we deploy our health IT applications. Counter to the pessimistic view that the billions of dollars spent on EMRs and other health IT systems are wasted resources, these investments offer a powerful force that, when the conditions are right, will significantly impact quality, safety, and cost.

Excerpts from: We Know What to Do. PSQH, January/February 2013

Photo Courtesy of  Don Guerwitz Photography – Temple Ruins. Sanka, Nam Belu River, Myanmar (Burma)

‘Show Me the Money’ Revisited

In the immortal words of Ronald Reagan, “There you go again.” Something that can be explained simply is twisted to look infinitely complicated with plots and subplots that would make J.K Rowling proud. The recent controversy over the use of EMRs to increase reimbursements to providers suggests intrigue, fraud, and bad intent. In contrast, if you learn how the money flows, you will better understand the true reasons for the outcomes seen in organizations using EMRs.

A New York Times report published in September 2012 documented an increase of $1 billion in Medicare reimbursements in 2010 over the amount paid five years earlier. The report partly attributed this payment increase to changes in billing codes assigned to patients in emergency rooms.

Such stories send shivers through the EMR community. To date, hospitals, EMR vendors, and the government struggle to demonstrate the value of EMRs in enhancing patient care and delivering cost savings. With billions of federal dollars earmarked to payment incentives for the use of EMRs, government officials anticipate some kind of return on this investment. Government EMR advocates did not expect to see an increase in reimbursements by public and private payors to providers through “enhanced” billing practices (code optimization [legal] or code maximization/up-coding [illegal]) activities.

Compared to paper records, EMRs allow for more rapid and complete documentation. In addition, EMRs slow the documentation process. Wait, how can EMRs both speed up and slow down documentation? It all depends upon deployment of the EMR and the constructed documentation workflows.

Unfortunately, EMRs focus on two important objectives at the same time– 1) facilitate clinical documentation to deliver patient care, and 2) facilitate clinical documentation to optimize coding for reimbursement. Documenting for patient care does not closely parallel documenting for reimbursement. As long as reimbursement is tied to documentation, EMR documentation workflow will suffer from inefficient documentation workflows, inaccurate documentation of care from global templates, and accidental (or deliberate) upcoding for reimbursement.

Excerpts from: ‘Show Me the Money’ Revisited. PSQH, November/December, 2012

Photo Courtesy of  Don Guerwitz Photography – Daybreak at the Ganges, Varanasi, India

Super-Organism Focused Healthcare

About 10 trillion cells make up the human body. The joining of eggs and sperm at the time of fertilization brings together 23,000 genes. In a healthy gut alone, more than 100 trillion bacteria thrive.

Scientists estimate that the microbiome—the term used to describe all the bacteria and other organisms that live on and within us—collectively represent more than three million genes. These bacteria live symbiotically with us, providing a variety of beneficial protections while we offer them raw materials and a nice, warm shelter in which to grow and reproduce. For most of medical history, physicians studied disease states without consideration of the microbiome. Only recently have researchers viewed the human body as a super-organism, influenced as much by the genetics of the host as by the permanent bacterial residents.

The microbiome offers humans an expanded ability to thrive within their environment by offering additional functionality—such as breaking down complex carbohydrates—that would be difficult to code within our limited number of genes. Through evolution bacteria chose us, and we chose bacteria, establishing a powerful, mutually beneficial relationship.

Even today, the new medical knowledge produced in even narrow disciplines exceeds the capacity of any physician to assimilate and apply effectively. Adding the complexity of the microbiome only makes the task of assimilating the relevant medical knowledge further out of reach.

Health information technology offers clinicians tools to manage this avalanche of information. As new knowledge is obtained, this information can be codified in guidelines, order sets, and searchable knowledge bases, relieving physicians of the impossible burden of assimilating all this new information.

Excerpts from: Super-Organism Focused Healthcare. PSQH, September/October, 2012

Photo Courtesy of  Don Guerwitz Photography – Mandalay Monk, Myanmar (Burma)

The Roberts Legacy: ACA Upheld

Thirty-seven years after the Federal government first departed on a journey to guarantee healthcare coverage to its citizens through an amendment to the Hill-Burton Act of 1975, our great country now ensures that all its citizens can obtain affordable healthcare services for their entire lives. No American will ever again be denied coverage due to pre-existing conditions or inability to pay. The United States now joins the rest of the world’s rich nations with a healthcare social compact first forged among its citizens with the passage of Medicare and Medicaid almost five decades ago.

Good for Employers and Employees

Irrespective of the rhetoric coming out of Washington, this ruling by the Supreme Court of the United States is good for both employers and employees. Cherry picking of enrollees becomes more difficult for insurers as payors now must accept all persons irrespective of pre-existing conditions. This motivates insurers, as well as providers who carry risk contracts, to focus on keeping people well rather than looking to make access to care difficult in their effort to boost profits. No longer can costly enrollees with pre-existing conditions be dropped from coverage. Payors must now take a population health point of view maximizing health while efficiently providing resources to achieve the associated clinical outcomes.

Businesses can now adequately budget for healthcare costs for their employees. A larger number of relatively healthy individuals enrolled in plans will expand the risk pool available to fund care, the underpinnings of all insurance models. This should decrease healthcare costs for businesses and employees alike. No more free rides for those who refuse to pay for insurance yet seek free care when they get sick with a catastrophic illness that they cannot afford pay for.

Businesses will benefit from the enhanced job mobility now afforded to employees. No longer will employees be trapped in jobs to ensure healthcare insurance for a family member with a pre-existing condition. Employees can now seek positions offering the best opportunity while businesses can hire the best candidates. These shackles are gone forever.

The Roberts Court

Finally, Chief Justice Roberts made a bold statement today. Although there are nine justices on the Court all with just one vote, the Chief Justice’s vote and role transcend the other eight justices. Every Chief Justice deeply understands the role of the Court in the lives of its citizens. Every Chief Justice understands his role in protecting the Court and ensuring its high standing in the eyes of its citizens.

In recent years the Court’s decisions have appeared politically motivated rather than legally forged. Whether true or not, public perception weighs heavily and a recent 44% approval rating in a recent national poll, the lowest in decades, surely unsettles Chief Justice Roberts.

This decision, decided by a conservative Chief Justice appointed by a Republican president, clearly makes a statement that Chief Justice Roberts intends to demonstrate to the American people that His Court – the Roberts Court – exists to serve the people, and decisions made by the Roberts Court are not politically motivated. The Roberts Court intends to study the law and rule accordingly to the best of its ability. The ruling wisely sends back to the Congress and the President the responsibility of governing – deciding what rules our healthcare system should function under and how to pay for it.

Five decades hence, scholars will look back on this decision the way we look back on Brown v. Board of Education. It is momentous in scope and will forever change how Americans live.

Patient-Centered Workflow

In the design of successful healthcare information technology implementations, patients matter. Although the importance of addressing the workflow needs of clinicians cannot be overstated, focusing on patient needs helps ensure newly designed workflows leverage the full capabilities of information technology tools. In addition, this delivers the clinical and financial outcomes desired by organizations. Entities that ignore the needs of clinicians in designing HIT driven workflows can expect to experience either low levels of HIT adoption among clinicians, suboptimal patient care results, or both.

The Institute of Healthcare Improvement —led by founder and former administrator of the Centers for Medicare and Medicaid Services, Don Berwick, MD—displays this mantra throughout its facility:

“Every system is perfectly designed to achieve exactly the results it gets.”

Therefore, organizations that utilize new information technologies to mimic the existing workflow of clinicians deliver results no better than outcomes previously reached. In some cases, the inherent complexity of the information technology when deployed within a paper-based workflow can deliver results worse than originally obtained.

To effectively implement HIT, organizations must understand in-depth the capabilities of the available information technology, the requirements of the practicing clinicians, and the expected outcomes of all impacted stakeholders (i.e., patient, clinician, organization). Readily available healthcare information technologies offer invaluable tools such as single sign-on (SSO), roaming desktops, location awareness, and fast-user switching to support impactful patient-centered workflows.

Patient-centered workflow requires stringing together individual steps, the linking of processes, and the bridging of activities by multiple caregivers to create an effective and efficient orchestration of resources to enhance the health of the patient.

Excerpts from: Patient-Centered Workflow. PSQH, July/August, 2012

Photo Courtesy of  Don Guerwitz Photography – Monastery Buddahs, Bangkok, Thailand

Sitting on A Cure for Cancer – 2012

Sitting on a Cure for Cancer 2012 from Barry Chaiken on Vimeo.

Short video reviewing the last three years of my Pan-Mass Challenge ride – a 2 day, 193 mile event that raises funds to defeat cancer by contributing funds to the research efforts of the Dana-Farber Cancer Institute in Boston. This year’s ride is August 4-5, 2012. To review my story and make a donation visit this link – pmc.chaiken.com.

See you on the road.

Barry P. Chaiken

Print Me a Pill

During the first Star Trek series released in the mid 1960s, the creators introduced viewers to several magical devices – the Communicator, the Padd, the Replicator, and the Transporter. Although building the latter device requires the repeal of several of the laws of physics, the other three commonly exist today for the public to use. Smart phones are the Communicator of today allowing us to speak, text, or email to anyone around the world who might have a similar device. The Padd is my Nook – it even looks like it and makes the same sound when dropped on a desk – or your iPad or similar tablet device. Finally, the Replicator is nothing other than a three dimensional (3D) printer, a device just entering the world of consumer products.

All 3D printing works from a digital file or blueprint that directs the building of the object. Some printers use tiny nozzles that deposit layers as thin as 0.1 mm in thickness from material contained in their “printer cartridges.” Other 3D printers use laser beams or tiny droplets of glue to fuse thin layers of plastic or material dust into solid objects.

Bioprinting represents the next step in 3D printing. Instead of materials, living cells fill the cartridges of the 3D printer. Cell by cell and layer by layer, these bioprinters deposit specific living cells chosen to perform a particular function in a pattern that allows them to perform a designed task.

3D printing offers the opportunity to print pharmaceuticals specifically produced to meet the needs of individual patients. A 3D printer with cartridges loaded with the pharmaceuticals required by the patient could print a pill that contains exactly the right amount of each of a patient’s medications, thereby customizing the drug treatment for the patient.

Excerpts from: Print Me a Pill. PSQH, May/June, 2012

Photo Courtesy of  Don Guerwitz Photography - Conch Fisherman, Grenada

Sensory Overload?

For many technology geeks the long march through ever more sophisticated televisions, computers and other electronic toys has run its course. The new buzz at Consumer Electronics Show (CES) drew its energy from the integration of electronics, Internet, social networking, and data analysis. The key to achieving that harmony of technology is through sensors, devises that collect vast amounts of data from an almost infinite number of sources. Fortunately, the technology arrived recently to deliver these sensors inexpensively and with very powerful capabilities. This opened the floodgates to allow entrepreneurs to utilize these unique devices in previously unimaginable ways.

Early adopters of sensors rally around the concept of “self-tracking, collecting information about one’s self to improve their lives. Whether to lose weight, sleep better, eat healthier foods, or manage chronic disease, these sensors provide an inexpensive, easy method to measure physical condition (e.g., heart rate, blood pressure) and behavior. This allows users to discover insights that can be applied to improve one’s being.

Some innovators see “gamification” as a way to encourage self-tracking. Gamification turns everyday activities into games by awarding points and merchandise, and encouraging people to compete with their friends.

Excerpts from: Sensory Overload? PSQH, March/April, 2012

Photo Courtesy of  Don Guerwitz Photography - Lead Dancer. Tiji Festival, Tibetan Kingdom of Mustang, Nepal