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‘Show Me the Money’ Revisited

‘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

The Roberts Legacy: ACA Upheld

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.

Failure is Not an Option

January 22, 2011 Healthcare Policy, PSQH No Comments
Failure is Not an Option

Healthcare could learn much from Gene Kranz. A recipient of the Presidential Medal of Freedom along with other mission scientists and crew, Kranz led his Tiger Team of experts at NASA in its successful effort to bring three astronauts on a perilous 500,000 mile journey around the moon and back home to Earth. Apollo XIII, launched in April 1970 to be America’s third manned moon landing, suffered a catastrophic explosion of its service module on the way to moon, leaving the command module without adequate power to run the spacecraft’s instruments or life support. Kranz’s lead White team, aided by three other teams of experts, inventoried the available resources and improvised all along the way to bring the three astronauts, James A. Lovell, Ken Mattingly, and Fred W. Haise, back safely. Although inaccurately attributed to Kranz, “Failure is not an option” is now associated with the unwavering commitment by the teams of scientists to find a solution to a seemingly unsolvable problem.

This past December marked the 11th anniversary of the release of the landmark Institute of Medicine study, To Err Is Human, attributing upwards of 100,000 deaths and more than 1 million injuries to medical errors caused by systematic failures of our healthcare delivery system. In response to the 1999 report, accreditation bodies, payors, providers, hospitals, and government agencies launched numerous efforts to reduce the number of medical errors, and in turn the morbidity, mortality, and wasted resourses associated with them.

Despite this great effort and investment, failure sadly remains a common occurrence in our healthcare system. According to a November 2010 article in The New England Journal of Medicine, medical errors continue to be a dangerous, common occurrence, appearing just as frequently today as they did more than a decade ago (Landrigan et al., 2010).

The authors offered cautious advice to their readers:

“…achieving transformational improvements in the safety of health care will require further study of which patient-safety efforts are truly effective across settings and a refocusing of resources, regulation, and improvement initiatives to successfully implement proven interventions.”

Although the incentives provided by the federal government through the “meaningful use” initiative foster the utilization of health information technology to improve quality and reduce errors, the use of health information technology alone will not reduce medical errors.

The meaningful use criteria evolved to encourage utilization of health information technology in a beneficial way, but it remains unclear what the true impact of the initiative will be on safety and costs. At this juncture, it is reasonable to assume those results will be mixed.

First steps begin with identifying well-defined goals and objectives (e.g., elimination of IV medication dose errors in the pediatric intensive care unit). Achieving these outcomes requires the use of proven, documented workflows built from effective processes, some of which employ health information technology tools. In addition, these tools collect data useful in monitoring the effectiveness of the workflow and identifying possible improvements to enhance results.

Effective use of information technology to reduce medical errors requires identifying the cause of the medical errors and the clinical transformation—the change in how we clinically do something—that reduces the probability of the error occurring. Transformative solutions that reduce reliance on perfectly executed human actions while shifting that burden to tireless health information technology are much more likely to consistently reduce errors than those that fail to leverage such technology.

Only through intelligent, purposeful implementation of healthcare information technology will we be able to reduce medical errors. Using healthcare information technology in a shotgun mode fails to guarantee any level of success. And failure is not an option.

Excerpts from: Failure Is Not An Option. PSQH, January/February, 2011

Photo Courtesy of  Don Guerwitz PhotographyHouse on a Hill, Pokara, Nepal

Show Me the Money

Show Me the Money

The most important lesson in medical care comes from a bank robber who stole more than $2 million and spent more than half his life in jail. Named after Willie Sutton, the one of the most prolific bank robbers in history, Sutton’s law states that when diagnosing, one must consider the obvious. Diagnosticians should first conduct those tests that will confirm the most likely diagnosis, and order them in a sequence that has the highest probability of delivering an accurate diagnosis. This approach also minimizes unnecessary tests and reduces costs.

Sutton’s law grew out of a famous response to a reporter’s question attributed (perhaps falsely) to Sutton. When asked by a reporter why he robbed banks, Sutton allegedly replied, “because that’s where the money is.” In reality, he probably said, “Go where the money is… and go there often.”

More than 20 years ago, payors and providers experimented with capitated arrangements where IPAs—Independent Practice Associations often constructed from a broad swatch of primary care and/or specialty physicians—contracted with payors to provide services to a population of insured individuals. Although numerous variations of capitation were tried during that time, capitation arrangements did not succeed in reducing costs, increasing provider compensation, or improving quality of care. Many physicians continued to over-utilize services.

Like so many ideas in healthcare, the old, after a time of dormancy, becomes the new. The excitement around accountable care organizations (ACOs) and patient-centered medical home projects is based upon much of the same thinking that excited healthcare policy makers 20 years ago. With ACOs and patient-centered medical homes, primary care physicians would be responsible for both the care and cost of care for patients assigned to them. Those physicians able to keep their patient population healthy while reducing the cost burden associated with treating their population would share in the savings to the payor.

What our healthcare system will look like at the end of 2014, when the final provisions of the Affordable Care Act of 2010 become active, may be fuzzy today, but a rough picture of it can be drawn by following the flow of financial incentives. By 2014 the effects of removing lifetime caps on medical costs, eliminating the process of denying coverage due to pre-existing conditions, emphasizing the use of proven disease treatments, and reducing reimbursement for preventable medical errors and readmissions shifts the care incentive from providing more care to providing only care that is needed.

Healthcare information technology will play a critical role in delivering these new models of care delivery and financing. Only through robust information technology can we track and report on performance, offer clinical decision support to enhance safety and quality, and monitor the health of populations of patients. Healthcare information technology offers the critical tools to move clinicians from their focus on episodic care, where financial incentives were based upon piecework, to much broader population-based care, where financial incentives promote the delivery of favored clinical outcomes that efficiently utilize resources. Therefore, to understand the current and future changes to our healthcare system, you need only to know where the money is and where it is flowing.

Excerpts from: Show Me the Money? PSQH, November/December, 2010

Photo Courtesy of  Don Guerwitz Photography Breaktime. Jokhang Temple, Lhasa, Tibet

A True Tipping Point?

A True Tipping Point?

From the signing of healthcare reform legislation to the release of final rules for “meaningful use,” events in 2010 are driving toward a true transformation in the delivery of healthcare in the United States. Optimism is high that we will finally see tangible benefits from healthcare information technology as measured by enhanced quality, improved access, and lower costs. I recently reviewed some testimony given to a subcommittee of the U.S. Senate Finance Committee that highlighted the role of healthcare information technology in transforming healthcare delivery.

Here are excerpts from that testimony.

“It is with great anticipation I approach this committee today to give testimony on health care issues and the effect new information technologies will have on the delivery of care. Clearly the swirling debate on how to restructure our health care system has raised the awareness of all Americans to this important issue. It is through the management of information, in particular its dissemination, that we can address some of our health care challenges. We need to use new information technologies to provide physicians, patients, providers and payors with the appropriate, relevant information to produce good, acceptable outcomes from appropriate cost-effective care.

“The information technology revolution is changing the way medical care is delivered. These new tools provide physicians with the opportunity to access relevant clinical information on a real time basis to most likely impact on their patient care. Using standards, guidelines, protocols, and information available from profiling using normative data bases, physicians can obtain useful information on their patterns of care. Patients can obtain understandable information on their disease process, thereby becoming an informed consumer of health care. Organizations exist to educate physicians and other health care professionals in the use of these systems. For-profit firms are developing the tools and making the investment needed to convert data into information.

“My final advice to this committee is hold on tight, the medical information superhighway has no speed limit.”

Excerpts from: A True Tipping Point? PSQH, September/October, 2010.

Photo Courtesy of  Don Guerwitz Photography A Farmhouse, Central Turkey

Is “Meaningful Use” Meaningful?

Is “Meaningful Use” Meaningful?

Now that the “meaningful use” rule has been finalized by the Office of the National Coordinator (ONC), many organizations turn their focus to a rapid deployment of electronic medical record (EMR) systems in an effort to achieve transformation of the United States healthcare system. Unfortunately, EMR adoption is just one tool used to transform health care, and not the single transformative activity so many believe it to be. Transformation of healthcare encompasses enhancing quality of care, improving patient safety, expanding access to care, and reducing the cost of care. EMRs deployed to satisfy the criteria for “meaningful use” can impact these factors, but only within a comprehensive framework that recognizes the role of incentives, clinical decision support, and healthcare information technology (HIT) in facilitating transformation.

Introduction of new technology often distracts us from our primary task. Our fascination with the technology leads us to focus on what the technology can do, rather than what we need the technology to do. This misguided use of technology also occurs when it is used for healthcare delivery. Many EMR implementations focused on the impressive features of the EMR software rather than the workflow requirements of the clinician users.

Healthcare transformation requires a comprehensive vision of care delivery that recognizes the interrelationships of the many stakeholders. Technology by itself only helps improve those interrelationships, while the underlying structure that the interrelationships are built on remains.

Therefore, the “meaningful use” criteria are meaningful in that they help ensure the use of EMRs in ways that can enhance healthcare delivery, they do not transform healthcare. The recently passed Patient Protection and Healthcare Reform Act (2010) does much to move us toward a better healthcare system, but it too does not transform healthcare. Transformation requires many factors working together in an iterative process to deliver the expected results. Some of those factors are outlined below.

Until economic incentives of all the stakeholders align, care delivery will remain inefficient and suboptimal in quality and safety. Providers are incented to provide more care, payors are incented to withhold care, and patients, detached from the direct costs of care, have been molded to always expect care. The culture of healthcare in America is based on the false belief that more care is better care.

Transformation of healthcare requires a complete disruption of our current system of healthcare delivery. Clinical roles require redefining. Workflows will change to meet the needs of these new clinical roles, allowing the HIT tools, such as EMRs, to be leveraged to improve care. “Meaningful use” criteria is a nice first step to help ensure the effective deployment of HIT tools such as EMRs. Nevertheless, it is just a very small step towards truly transforming healthcare.

Excerpts from: Is “Meaningful Use” Meaningful? PSQH, July/August, 2010

Photo Courtesy of  Don Guerwitz Photography First Light. Bhaktapur, Nepal

Regulate HIT Tools as Medical Devices? Yes and No

May 27, 2010 Health IT, Healthcare Policy, PSQH Comments Off
Regulate HIT Tools as Medical Devices? Yes and No

The Food and Drug Administration recently announced it is reconsidering its previous decision to exclude health information technology (HIT) tools from regulation as medical devices. When last evaluated in the late 1990s, this decision made common sense. At that time HIT consisted of rudimentary clinical documentation systems, electronic reference materials, and administrative applications. As even these tools were not well integrated with each other and into clinical workflow, they represented more of a digitization of paper-based activities rather than something truly transformational.

Today, HIT functionality far outstrips what was even dreamed about 10+ years ago. In addition, applications function in an integrated manner truly providing the clinician with a clinical experience much different than that offered using paper-based clinical documentation or simple clinical decision support tools.

The role of physicians, nurses, and other healthcare professionals is changing. These providers are becoming more dependent upon the clinical content within the HIT tools, often deferring to “decisions” made by these tools. Such examples include differential diagnosis, prescribed diagnostic and therapeutic treatments, choice of drug, and drug dose calculations. Although the previous rationale for not considering such HIT tools medical devices was based upon the intermediation of the provider between the recommended clinical activity and actual actions taken on behalf of the patient, the strong reliance on these very sophisticated HIT tools today puts this premise into question.

The FDA must study in detail the quality and safety issues inherent in integrated HIT applications before rushing to regulate HIT tools as medical devices. An uninformed effort to regulate HIT tools as medical devices may cause more harm than good. Applying the same standards used for medical devices to HIT tools makes little sense as HIT is neither a standalone application nor strictly a medical device. They are integrated applications that can impact quality and safety in ways far dissimilar to standard medical devices.

Regulation of HIT tools as medical devices is currently premature. Although HIT tools do directly impact patient care and therefore surely require some level of regulation, such regulation cannot be done without the requisite understanding of how HIT works within clinical workflow. The regulations must be constructed to advance HIT use while simultaneously protecting patients.

Excerpts from: Regulate HIT Tools as Medical Devices? Yes and No. PSQH, May/June, 2010

Photo Courtesy of  Don Guerwitz PhotographyRunning the Rapids, Mae Hong Son, Thailand

Keynote Adddress at HIMSS 2010 Annual Conference

Keynote Adddress at HIMSS 2010 Annual Conference

(Opening address given at HIMSS 2010 Annual Conference, Georgia World Congress Center, Atlanta, GA, March 1, 2010.)
For PDF of keynote address, click here.

Click here to watch video presentation – Part 1 of 3.

Click here to watch video presentation – Part 2 of 3.

Click here to watch video presentation – Part 3 of 3.

Click here to download and view video presentation.

Our great country is on an unsustainable healthcare cost curve that threatens our ability to bounce back from the severe economic challenges we now face. In addition, healthcare quality and safety, as well as access to care, sit at disappointing levels, especially considering the resources our nation expends on healthcare.

While these healthcare challenges are daunting, I believe the solutions to them must and will come from the professionals sitting in this room and from our colleagues across the country and around the world. Healthcare information technology is the instrument that will transform healthcare and it is we – the informaticists, clinicians, management engineers, senior IT executives, IT specialists and the diverse talents of so many others – who will create the applications, processes and workflows that will improve quality, safety, access and cost-efficiency.

I am confident that we can make this transformation happen because similar revolutions relating to technology and the workplace have happened quite recently. For example, consider the huge changes in how we communicate with each other. Throughout this week, we all will be periodically checking our e-mail inboxes to stay in touch and communicate. According to Merriam-Webster, it was in 1969 that the term “inbox” first entered the American lexicon, to describe a physical tray holding incoming mail and work documents. Over the next 40-plus years, the inbox morphed into an electronic tray where important messages and information are stored. Today, the inbox pervades our working and personal lives, present on our personal computers and mobile smart phones.

The story of the inbox is in many ways the story of the American economy over the past four decades. The inbox tells the story of how a manufacturing-based industrial economy became an information- and knowledge-based service economy driven by data and analytics. The inbox tells the story of how savvy businesses began to share information quickly and inexpensively. These businesses effectively leveraged this information to deliver higher quality products at lower costs. By meeting the needs of their customers, their profits grew while profits of their competitors’ shrank. New ventures sprouted to support these innovators with brand new knowledge-based products. Smart companies thrived in this new data—driven marketplace; others – either unable or unwilling to adapt – could no longer compete.

While most American industries became more efficient and streamlined as a result of these economic realities, healthcare in many ways remained frozen in time. Today, the cost of the American health care system, at 17 percent of GDP, is a millstone around the neck of American businesses, raising the costs of production, stealing wages from the pockets of workers, and restricting the ability of American companies to compete globally. Health care here costs at least 50 percent more than it does in any other industrial country, and according to the World Health Organization, our health care system underperforms in quality, safety, and access to care. In 2006 we ranked 39th for infant mortality, 43rd for adult female mortality, 42nd for adult male mortality, and 36th for life expectancy. According to a 2008 study reported in the Journal of Health Affairs, the United States trails every single country in the 30-nation Organization for Economic Cooperation and Development in amenable age-standardized death rates, meaning, we are worst at preventing unnecessary death in people under the age of 74. Isn’t the whole point of healthcare delivery to create wellness and prevent unnecessary death? Sadly, we are not doing very well.

In many respects, our health care system still operates like the typical business of 1969 – it is still largely paper-based, it ignores information tools that can facilitate evidence-based best practices, and it functions without analytics to qualify and quantify the care we provide. Medical decisions are made according to implicit criteria – hidden internal knowledge – rather than explicit criteria – external knowledge that can be checked, evaluated, and updated. The Dartmouth Atlas of Health Care provides documented proof of glaring, unacceptable variations in how health care is provided and sheds light on disparities existing across the country. Too many providers are not taking advantage of 21st-century technologies to access 21st century information, choosing instead to provide care the same way it was done 40 years ago.

How can we change this? While enacting healthcare reform legislation remains a critical need, any health care bill will primarily impact reimbursement policy, not the transformation of care delivery.  And, because the task of transforming our health care system to meet the challenges of the 21st century remains to those of us who work in the system, as the HIMSS board chair, I direct these three important messages to your inbox today:

One: HIMSS will play a leading role in the transformation of American health care by effecting positive change in four key areas: quality, safety, access to care and cost.

Two: HIMSS’s purpose – our reason for being – is this health care transformation.

Three: As members of HIMSS, you are the leaders who will create the solutions that will drive this transformation. Through the implementation of compelling healthcare IT solutions, you must transform the way health care is provided in this country. Not the president, not Congress, not clinicians – you. If you don’t do it, it will not happen. You must step forward and you must lead.

As I begin to make the case for why and how healthcare IT will transform health care, I’d like to take us all back to 1981, the year I graduated from medical school. Back then, people spent a good part of each workday managing paper. Upon returning from lunch, a busy executive was handed a pile of pink while you were out messages. She, or more likely he, would find a report draft on top of a bulging inbox. Attached to the report was a brand new, very popular, high-tech item of the day – a post-it note – where the boss scribbled a message to review and advise by writing comments in the margins. On his desk for his signature was a series of letters that his secretary had revised using another technological marvel – white-out. Reminded to call a key contact for advice on an important matter, the executive would quickly thumb through his rolodex to find the telephone number.

During my time as an Epidemic Intelligence Service officer with the Centers for Disease Control back in the 1980s, I do remember working this way. My first outbreak investigation was a foodborne illness on a cruise ship sailing out of Pittsburgh on the Ohio River. When investigating these type of outbreaks, my first task was to construct attack-rate tables that try to statistically identify the food that made people ill. I built these tables by doing all the calculations on a handheld calculator. No PCs were available to me at that time. Needless to say, it took me a few hours to complete the table and identify the cause of the outbreak.

Back then, we were very comfortable going about our business in this fashion and saw no need to change. Still, over the following several years and continuing into the 1990s, the workplace began to change immensely due to personal computers, e-mail and the Internet. Workers did not need to be encouraged to use this technology. They wanted to use it, even demanded to use it, because it made their jobs easier and made them more productive.

Today, in 2010, we must begin to change healthcare in the same fashion – by creating healthcare IT solutions that are so compelling, so irresistible, that people just want to use them. We cannot rely on incentive programs or executive orders.  We must create demand.

We must create electronic systems so appealing that they make physicians want to leave their paper medical records behind. We must create clinical decision support systems that make it routine for physicians to check their internal knowledge with data and evidence. We must offer workflow solutions that improve the efficiency of using health IT. We must make physicians want, yes, demand the enormous power that IT brings to the practice of medicine.

Creating this demand is important because it will improve quality, safety, access to care and cost-efficiency. Simply, we have to change a paper-based system in which most clinical decisions are made primarily by intuitive judgment – based on the ability to recall disparate facts – into an electronic system enabling decisions to be made according to data and evidence.

We must provide clinical decision support tools that reduce the burden of recalling facts and help to assess patients, form diagnoses, and choose therapeutic paths. Healthcare IT opens the door to this higher level of medical practice, one where both physicians and nurses can concentrate on examining, interacting, and motivating patients while technology handles the burdens of collecting, storing and accessing data. The knowledge of best practices and evidence-based care must be delivered to every single clinician at every point of care so that every patient everywhere receives care according this latest knowledge, rather than according to the habits of a clinician disconnected from this knowledge.

American medicine, right now, is relying too heavily on recalling facts. Perhaps the clearest example of this fact is the Pronovost checklist. Each year, about 28,000 Americans die due to I-V line infections. In response, Peter Pronovost, a Johns Hopkins physician, developed a list of five simple steps that intensive-care doctors should take to prevent the introduction of bacteria when inserting an I-V line. Physicians working at 108 hospitals in Michigan adopted the five steps and reduced the infection rate to essentially zero. A paper about their success was published in the New England Journal of Medicine in 2006. But, today, most American intensive-care doctors still don’t use the checklist. They continue to rely on their ability to remember what to do each time they insert an I-V line. Most times, they get it right. The few times they don’t, people die unnecessarily from infections. This is crazy. Every physician I know wants to help patients, not hurt them. Yet, we are hurting them.

It’s up to healthcare IT to make knowledge such as the Pronovost checklist more readily available and its discovery and use more intuitive. This work will require the design of clinical decision-support systems and other tools that merge seamlessly with patient care activities. This work will not just distribute best practices, but embed them into the workflow of medical practice. This work requires a unique multi-disciplinary effort involving not only workflow experts but also virtually any person connected with clinical care.

Bringing this level of sophistication and beyond to American health care will signify true transformation and will require all of the diverse talents represented within HIMSS. No matter who you are, whether you are a senior IT executive, a clinician or an engineer – whether you come from a hospital, a community or public health organization, a clinical practice, a payer or a pharmaceutical company – or whether your primary interest is patient safety, quality, research, privacy, or return on investment – we need you to contribute to the cause of transforming health care through IT.

HIMSS is reaching out to new groups and communities who must engage in the transformation. For example, our Life Sciences Community initiative actively engages pharmaceutical and life science companies, medical researchers, practicing clinicians, the academic community, and device manufacturers. This initiative concentrates on improving the quality, access and usefulness of data through interoperability and interconnectivity – data that can lead to new medical discoveries and treatments. With Board approval, I recently appointed Debra Bremer, Vice President at Pfizer, as an advisor to our Board to offer guidance in these efforts.

Our Payer Community initiative recognizes the shift from the payer playing the role of a transaction manager to one of a care delivery partner focused on improving chronic care management and overall patient outcomes. With Board approval, I also recently appointed Kevin Hayden, President at WellPoint, as an advisor to our Board to provide guidance in these efforts.

Both Debra and Kevin have been working hard with our staff to engage these two communities as we have engaged other industry specialty areas in our effort to transform healthcare through IT. To further involve and educate professionals we need to achieve our goal, HIMSS also has launched a Diversity Business Roundtable, created and delivered numerous distance learning opportunities, and reached out to several academic institutions.

Transforming healthcare requires the development of imaginative solutions. Cedars-Sinai Medical Center in Los Angeles did just that to improve hand-washing compliance, according to a story in the New York Times. Several research studies have reported that health care providers wash or disinfect their hands in less than half of situations where they should, with physicians being among the worst offenders. In an effort to achieve 90 percent or better hand-washing compliance in advance of a Joint Commission inspection, Cedars-Sinai first tried a campaign of e-mails, faxes and posters, but that didn’t work.  Then, a group of physicians and hospital administrators – who dubbed themselves the Hand Hygiene Safety Posse – started handing out bottles of Purell to physicians rounding on wards or as they stepped out of their cars in the parking lot. Also, the posse awarded a $10 Starbucks card as a reward to any physician “caught” washing his or her hands. This tactic improved compliance from 65 to 80 percent but still fell short of the 90 percent goal.

After delivering these discouraging results to the medical center’s chief of staff advisory group of roughly 20 doctors, the hospital’s epidemiologist handed each doctor a sterile petri dish loaded with a spongy layer of agar. “I would love to culture your hand,” she said.

The resulting cultures were photographed. The images were – in the exact words of the epidemiologist – “disgusting and striking, with gobs of colonies of bacteria.”

But here’s the best part – and where IT comes into play: the hospital harnessed the power of this disgusting image by making it into a screen saver that haunted every computer in Cedars-Sinai. Reluctance to hand washing vanished in the face of this filthy evidence, and compliance shot up to nearly 100 percent, where it remains today. Cedars-Sinai urologist Dr. Leon Bender said in the Times article: “With people who have been in practice 25 or 30 or 40 years, it’s hard to change their behavior. But when you present them with good data, they change their behavior very rapidly.”

Now, Cedars-Sinai obviously did not employ leading-edge IT sophistication to solve its problem.  But I chose to share this story with you because it’s a wonderful example of fast and practical problem solving. It shows how you can solve an important safety problem, relatively quickly, through multidisciplinary teamwork, data gathering and a little bit of IT. Oh, and let’s not forget about some good marketing. I chose to tell this story because I want you to think of what problem of a similar nature you might solve. And how you can work to gather the team and fix it.

This week we will hear about many other examples of problem solving and achievement. This year’s Davies Award winners, for example, have impressively improved access to care, quality performance, cost-efficiency and safety. The 19 hospitals that have achieved the HIMSS Analytics Stage 7 recognition represent the first of the truly paperless hospitals and give all other hospitals something to emulate.

But I have purposely crafted my remarks today to emphasize that it’s no longer about what others have done or what others are doing.  It’s now about what you and your organization are doing to transform American health care. I suspect that some of you may see yourselves clearly within this context while others may not. Let me suggest to you today that no matter who you are and what your role is, you have an important if not critical role to play to achieve transformation. You can fulfill your role by building a multidisciplinary team with the expertise needed to solve a problem. You can fulfill your role by gathering and sharing data and evidence as you go along. And you can fulfill your role by having the courage to stay the course or to change your mind – whatever the situation calls for. Great science comes from flip-flopping – it’s O-K to change your point of view as you gain new knowledge.

The challenge before us now is to help all health care organizations to achieve the standards set by the leaders. Indeed, we are succeeding in changing the culture. We have reached the tipping point. Health IT isn’t just for early adopters anymore; it is expected of all.

I send this urgent message to your inbox today: the transformation of American health care by improving access, quality, safety and cost-efficiency is a cause to which we all must dedicate ourselves. Identify a project, engage experts different from you, embrace diversity, form a team, try something unique, make mistakes, redouble your efforts, celebrate your successes, and then start again with a new idea. It is you who will discover something new. It is you who will develop the needed solutions. It is you who will effectively implement change. It is you who will transform healthcare. It’s your job to act now upon the message in your inbox and to place your contribution to a transformed American health care system in your out-box in due time. Thank you.

Barry P. Chaiken, MD, FHIMSS
2009-10 Chair HIMSS
CMO, DocsNetwork, Ltd.

Looking Back…and Looking Ahead…on the Progress of EHR Implementation

Looking Back…and Looking Ahead…on the Progress of EHR Implementation

In the December 2010 issue of the HIMSS Digital Office, leaders in health information technology share their perspective on the progress of EMR adoption in 2009…and their vision for implementation of electronic health records in 2010. Barry P. Chaiken, MD, FHIMSS, HIMSS Chair shares his vision on adotpion below. This is reprinted from that publication.

What do you think is the greatest achievement in health IT in 2009?
Advances in technology just offer new tools, while advances in politics, represented by meaningful funding levels, provide momentum for real change. The billions of dollars provided to the Office of the National Coordinator for Health IT established the ONC as a true driver of advances in health IT use. The appointment of a healthcare policy expert David Blumenthal, MD, rather than an informaticist, signals that the Obama Administration is serious about promoting the use of health IT through policy changes that impact how healthcare is delivered in the United States. In addition, recruiting John Glaser, even on his current temporary basis, partners Dr. Blumenthal with one of the country’s leading health IT experts, Therefore, solidifying the funding of the ONC, and appointing Dr. Blumenthal and Mr. Glaser is 2009’s top health IT achievement that will positively impact the use of health IT to deliver safe, high quality and cost effective healthcare.

What would you like to see happen in 2010 to help move forward the adoption of electronic medical records?
When ATMs first appeared in the 1970s, interconnected financial networks did not exist. Customers of a bank could only use their ATM cards in machines provided by their bank. There was no ATM interoperability. The banks soon realized that providing ATM interoperability was considerably less expensive than installing proprietary ATM machines throughout the country. In addition, interoperability gave all banks a national, rather than regional, presence as customers could withdraw funds from any connected ATM. To advance the adoption of EMRs, information technology vendors must honestly embrace interoperability, building their systems to easily accept and exchange clinical data. True interoperability would provide clinicians with more complete patient records allowing for better quality care. Offering a more complete record that provides more value to the clinician strongly works to advance the adoption of health IT applications.

Photo Courtesy of Don Guerwitz Photography - Rooftop Statues, La Pedrera. Barcelona, Spain.

Hospital Computerization Not a Budget Saver, Concludes Study

Hospital Computerization Not a Budget Saver, Concludes Study

By Joshua Feblowitz

The recent survey of over four thousand hospitals found no connection between computerization and reduced costs. In addition, increased computerization led to only small improvements in the quality of care.

Researchers found that more “wired” hospitals had higher total costs and more rapid cost increases. They also examined a list of the “100 Most Wired” hospitals and determined that these institutions had performed no better in terms of administrative expenses or quality of care.

These findings contradict previous anecdotal evidence indicating the benefits of healthcare information technology (IT), a category that includes systems such as electronic medical records and computerized order entry. The study has sparked significant controversy, in part because President Obama and others have widely promoted healthcare IT as a tool for saving money and improving healthcare. The 2009 stimulus bill included over $19 billion to encourage the adoption of healthcare technologies.

Using twenty-four different measures of hospital technology, researchers created a composite “computerization score” and compared this with changes in administrative costs and quality of care during the years 2003 to 2007. The only area in which they found significant improvement was in the quality of care for heart attacks.

“There’s no evidence that what we are doing is actually working,” says lead author Dr. David Himmelstein, a professor at Harvard Medical School, who calls promises of improved quality and reduced costs “propaganda of the healthcare IT industry.”

“It’s easier than saying what needs to be said,” Himmelstein argues. “We need to abolish the private health insurance industry. It’s much easier to say that there’s a silver bullet here, and all we need to do is install these fancy machines.”

However, these results, experts say, are far from definitive. Certain hospital computer systems have proven to yield substantial benefits. Computerized physician order entry, for example, a technology used to enter prescriptions and order tests, has been shown to greatly improve the quality of care. Even things as simple as adding barcodes to medications can dramatically reduce medical errors, says Dr. Barry Chaiken, chair of the Health Information Management Systems Society.

These types of improvements in quality are well documented. A study at Brigham & Women’s Hospital in Boston, Massachusetts, showed that computerized order entry systems could reduce serious errors by up to 55 percent and the overall error rate by over 80 percent.

Computerization accomplishes these improvements, experts argue, by giving hospitals the ability to manage information more efficiently. “When a facility installs software, they are looking for something that gives them better control over the chaos in their department,” says Keith Herron, representative for Patient Care Technology Systems, a healthcare IT company. “They also want to be able to document the patient encounter and document more fully.”

“If your physician has more information about your health, they are likely to make better decisions,” says Dr. Ashish Jha, professor at Harvard Medical School. “In a paper-based world, important pieces of information are often missing. Mistakes aren’t caught as easily. There are many ways in which technology if designed and implemented effectively can improve quality.”

Experts also criticize the study’s methods of examining hospital computerization. “This study is very problematic because both their measures of cost and their measures of technology have serious limitations,” says Jha.

“If you look at something and don’t find it, it could be that there’s no effect,” Jha continues, “Or, it could be that the way you looked at it didn’t make sense.” Specifically, Jha notes that the study’s “computerization score” included factors unrelated to patient care, such as accounting and staff scheduling.

Jha also says that the study’s measures of costs and quality are very broad and may not accurately reflect the benefits of healthcare information technology. Data on computerization was reported by hospitals and collected by the Health Information Management Systems Society. Researchers compiled this data into their own composite scores of quality, costs and computerization before performing statistical analysis.

Others suggest the reason for these findings is that current hospital systems simply aren’t very advanced. Although many hospitals spend a great deal on information technology, says Dr. Robert Kolodner, former National Coordinator for Healthcare IT, the number of hospitals with sophisticated electronic health records is “vanishingly small,” less than two percent.

“They are using the best data they have,” agrees Chaiken. “But I don’t think we’ve reached a tipping point as to what healthcare IT can do.”

In addition, experts say, healthcare IT is only beneficial if applied in the correct way. “It all comes down to how you implement these systems,” says Dr. Adam Wright, co-author of the study, “It’s not the technical quality of the system that you purchase but the way you use it.”

In order to benefit from these technologies, says Dr. Michael Siegel, head of the Digital Health group at MIT, we must accept new approaches to healthcare. “We’re managing the process, moving at incredible speeds, as if things were still the same. There has been lots research done that when you introduce IT and don’t change what you’re doing, it doesn’t help.”

“I would call for some patience,” says Wright, who likens the process of development to the construction of the Transcontinental Railroad. “Imagine you’re building a railroad. Laying tracks across the country. It’s very boring and very expensive. And until you hammer in the Golden Spike, you can’t actually drive a train across the country.”

Reprinted from Scope, December, 2009.

Photo Courtesy of Don Guerwitz Photography - La Pedrera. Barcelona, Spain.

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