Healthcare Informatics

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Healthcare I.T.’s CIO of the Year

Keeping Data Safe

Smoking: Hot-Button Issue

March 2014

Volume 31, Number 2

Top Ten Tech Trends 2014: N E DS R T

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T E P CH O T

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The Big Picture

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CONTENTS March 2014 37

COVER STORY TOP TEN TECH TRENDS 2014 How are policy, industry and technology developments remaking healthcare? In this year’s annual Top Ten Tech Trends package, experts weigh in on 10 areas of sweeping change that will have a profound effect on the way healthcare is delivered for years to come. 8

INTRODUCTION: GETTING THE BIG PICTURE

TECH P O T 10

PERSONALIZED MEDICINE

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STANDARDS DEVELOPMENT

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IMAGING AND HIE

ENDS TR

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SOCIAL MEDIA

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PATIENT-GENERATED HEALTH DATA

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MOBILE AND MESSAGING

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EHR OPTIMIZATION

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SMART DEVICES

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DEPARTMENTS 4

INSIDE

6

EDITOR’S PAGE

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CIO PERSPECTIVE UPBEAT ON HEALTHCARE I.T. Edward Marx, CIO of Texas Health Resources and recipient of the 2013 John E. Gall, Jr. CIO of the Year award, discusses opportunities and challenges for the industry BY RAJIV LEVENTHAL

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IMAGING PERSPECTIVE BEYOND INTERPRETATION How one 109-year-old radiology group is taking steps to survive in a value-based care model

BY RAJIV LEVENTHAL

READMISSIONS REDUCTION

24

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KEEPING DATA SAFE

In healthcare, as in every other major industry, data breaches are a fact of life and an area of growing concern. Hospital CIOs and security experts offer their perspective on preventative strategies BY RICHARD R. ROGOSKI

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A St. Louis payer achieves healthcare’s triple aim in terms of cost, quality and population health—plus physician satisfaction BY RAJIV LEVENTHAL

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DATA INTEGRATION UPDATE INTEGRATION COMES TO LIFE IN MICHIGAN How one hospital brought together brought together many disparate information systems, laying the foundation for integrated care delivery

BY GABRIEL PERNA

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SECURITY AND PRIVACY

ACO PERSPECTIVE A COLLABORATIVE PAYER MODEL FLOURISHES

CAREER PATHS NEW HIRING RULES Is smoking the new taboo in Florida hospital hiring practices? BY TIM TOLAN

Healthcare Informatics (ISSN 1050-9135) is published 9 times per year by Vendome Group, LLC, 216 East 45th Street, 6th Floor, New York, NY 10017. Periodicals postage paid at New York, NY and additional mailing offices. POSTMASTER: send address changes to HEALTHCARE INFORMATICS, P.O Box 2178, Skokie, IL 60076-7878. Subscriptions: For questions or correspondence about a subscription, phone 847-763-9291 or write to HEALTHCARE INFORMATICS, PO Box 2178, Skokie, IL 60076-7878. If you are changing your address, please enclose entire mailing label and allow 6 to 8 weeks for change. Subscription rate per year (U.S. Funds): U.S. $58.00; Canada/Mexico $82.00; all other countries $109.95 (includes air delivery). Single copy rate (U.S. Funds) except September and January: U.S. $8.00; Canada/Mexico $12.00; all other countries $15.00. September 100 and January Resource Guide: $50.00 (U.S. Funds) includes shipping/handling to all countries. Add state and local taxes as applicable. 2 March 2014 • www.healthcare-informatics.com

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EDITORIAL

INSIDE

Healthcare

Informatics

EDITOR-IN-CHIEF Mark Hagland [email protected]

Healthcare IT Leadership, Vision & Strategy

MANAGING EDITOR John DeGaspari [email protected]

Top Ten Tech Trends

SENIOR EDITOR Gabriel Perna [email protected]

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ith each March issue, Healthcare Informatics brings its signature Top Ten Tech Trends cover story package, which focuses on the major issues that are profoundly remaking the world of healthcare. How is the new healthcare shaping up? Turn to page 8 for this year’s analysis. Personalized Medicine: Senior Contributing Editor David Raths reports on the progress researchers are making on decision support and uncovers remaining gaps in standards, integration and workflow. Standards Development: Raths investigates FHIR (pronounced “fire”—shorthand for Fast Healthcare Interoperability Resources), a new HL7 draft standard that, it’s hoped, can ease IT bottlenecks and offer more granular data access. Imaging and HIE: Editor-in-Chief Mark Hagland takes a look at a critical challenge— as technology connects patients to clinicians and clinicians to clinicians, it’s becoming clear that an information superhighway for images will be a necessary, and still missing, component. Readmissions Reduction: Hagland uncovers reasons for optimism that the mandate for reduction of avoidable inpatient readmissions can be met. Social Media: How are providers harnessing social media to engage patients and collaborate with each other? Senior Editor Gabriel Perna reports. Patient-Generated Health Data: Perna explains how the advancement of patientfacing connected technologies will allow providers to track patients on a daily basis. Mobile and Messaging: Assistant Editor Rajiv Leventhal reports on texting, which is on the swift uptake among the nation’s nearly one million physicians—and along with it, increasing concerns about security. EHR Optimization: Leventhal interviews leaders of major healthcare organizations on how they have been moving forward with their EHRs. Smart Devices: Managing Editor John DeGaspari reports on technology advancements that are promising better patient care, and why some experts are concerned that the industry is moving too fast. Security and Privacy: DeGaspari explains how a perfect storm of evolving technology, policy developments and industry consolidation is putting new security demands on provider organizations. MORE ONLINE:

ASSISTANT EDITOR Rajiv Leventhal [email protected] ASSOCIATE EDITOR, READER ENGAGEMENT Megan Combs [email protected] SENIOR CONTRIBUTING EDITOR David Raths [email protected]

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Visit www.healthcare-informatics.com for the latest in healthcare IT coverage: “Big data” collaborative research and innovation center; Stage 3 meaningful use objectives; “Big bang” EMR implementation; and best-selling author Malcolm Gladwell on interoperability.

2014 EDITORIAL BOARD Marion J. Ball, Ed.D. Professor, Johns Hopkins School of Nursing Fellow; IBM Center for Healthcare Management; Business Consulting Services, Baltimore, MD William F. Bria II, M.D. Chairman, Association of Medical Directors of information Systems (AMDIS) Tina Buop CTO, La Clinica de La Raza, Oakland, CA Bobbie Byrne, M.D. VP for HIT, Edward Hospital, Naperville, IL W. Reece Hirsch Partner, Morgan, Lewis & Bockius LLP, San Francisco, CA Christopher Longhurst, M.D. CMIO, Lucile Packard Children’s Hospital, Clinical Assistant Professor of Pediatrics, Stanford University School of Medicine, Palo Alto, CA G. Daniel Martich, M.D. Chief Medical Information Officer, UPMC Pittsburgh, PA

4 March 2014 • www.healthcare-informatics.com

Brian D. Patty, M.D. Vice President and CMIO, HealthEast Care System, St. Paul, MN Chuck Podesta SVP and CIO, Fletcher Allen Health Care, Burlington, VT Wes Rishel VP and Research Area Director, Gartner Healthcare, Industry Research and Advisory Services, Alameda, CA Benjamin M.W. Rooks Principal, ST Advisors, LLC, Evanston, IL Rick Schooler Vice President and CIO, Orlando Health, Orlando, FL Patricia Skarulis Vice President and CIO, Memorial Sloan Kettering Cancer Center, NY, NY Fran Turisco Director, Aspen Advisors, Denver,, CO Ferdinand Velasco, M.D. Chief Health Information Officer, Texas Health Resources, Arlington, TX

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EDITOR’S NOTES

Who Will Be Our Georges Méliès Figures in 21st-Century Healthcare? A FILMMAKER AHEAD OF HIS TIME AT THE TURN OF THE LAST CENTURY CAN BE A MODEL AS HEALTHCARE LOOKS TO ITS FUTURE

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here were many wonderful elements in the 2011 film “Hugo,” directed by Martin Scorsese, with a screenplay by John Logan. The movie is based on the novel The Invention of Hugo Cabret, by Brian Selznick, with cinematography by Robert Richardson, and starring Ben Kingsley and numerous other wonderful actors. The writing, direction, acting, and of course, amazing cinematography, made “Hugo” a truly beautiful and inspirMark Hagland ing film; it’s no surprise that it won five Oscars, including for best cinematography and art direction, along with 11 Oscar nominations, including for best film. Beyond all those elements, I personally was particularly entranced by the fictionalized elements of the storyline around a real person—Georges Méliès (1861-1938; portrayed by the fabulous Ben Kingsley in the movie)—the French filmmaker who led many important technical and artistic innovations in the earliest days of cinema. Indeed, excerpts from Méliès films, most famously the 1902 “A Trip to the Moon,” in which a spaceship capsule hits the Moon right in the face (this is an image that many, many people have seen, but few realize where it came from). Fascinatingly, between 1896 and 1913, Méliès directed 531 films, ranging in length from one minute to 40 minutes. As Wikipedia notes of him, “In subject matter, these films are often similar to the magic theater shows that Méliès had been doing, containing ‘tricks’ and impossible events, such as objects disappearing or changing size. These early special effects films,” the article notes, were essentially devoid of plot.” But what they did have was tremendous inventiveness and verve, as the earliest filmmakers literally felt the sky was the limit, experimenting technically and artistically in myriad ways. Above all, Méliès and his fellow pioneers were figuring out what film was for—what the cinema could do, literally and figuratively. It was an extraordinary time, peopled by extraordinary visionaries. 6 March 2014 • www.healthcare-informatics.com

Would it be too much of a stretch to compare the turn of the previous century in European filmmaking to the current period of transformation in healthcare? Perhaps so; but let’s look at a few of the parallels, shall we? Just as French cinema in 1900 was undergoing a period of intense ferment, so is the U.S. (and global) healthcare system right now. Just as 1900 in European cinema was also a time in which many experiments of many different kinds were taking place, so is the present day in healthcare, particularly in the United States. Importantly, now is a perfect time to look at the long-term trends shaping U.S. healthcare, as many of the most important are becoming clearer, in the wake of federal healthcare reform, the meaningful use process under the HITECH Act, and other key developments. So this month, as we have every March for the past several years, we at Healthcare Informatics are delighted to bring to our readers our Top Ten Tech Trends for 2014 (page 8). How will the fusing of genomic and clinical data reshape patient care delivery? Where will the diagnostic image reside in the new, connected healthcare? How will mobile technology and innovations in messaging transform the physician-patient relationship? And what’s going on with this new interoperability standard called “FHIR” (and pronounced “fire”), anyway? Our ten articles will address those important questions, and more. As we move forward into the healthcare future, it can be very useful to take a step back, and look at the bigger picture—and to think back to people like Georges Méliès, and to understand how wide-open the future of healthcare really is, and how much possibility there is for all of us in figuring out how to shape it going forward!

Mark Hagland Editor-in-Chief

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HCI’s Top Ten Tech Trends 2014: Getting the Big Picture

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ith the influence of policy, regulatory, industry, and technological developments accelerating change these days, there really has never been a time of greater ferment in U.S. healthcare. As a result, it’s more vital than ever for healthcare leaders to get the big picture when it comes to what’s going on 8 March 2014 • www.healthcare-informatics.com

right now. Accordingly, we at Healthcare Informatics are delighted to bring you, our readers, our annual Top Ten Tech Trends, for 2014. From the flourishing of the availability of genomic data to inform clinical decision support at the point of care, to the hard slog forward among the pioneers in healthcare to apply data analytics to reduce avoidable inpatient readmissions, to the shift among physicians strongly away from the use of pagers and towards the use of texting for mobile communications, things are moving fast these days—very fast. Just take for example the rapidly progressing development of the FHIR specification for the transport and sharing of patient care summaries and records. The combination of the deployment of FHIR and the REST web application programming interface could really revolutionize the quick sharing of patient information among clinicians, possibly creating a new path forward that could change the landscape around health information exchange. Meanwhile, patient-generated data is a rapidly emerging consumerdriven trend thanks to the rise of connected devices. Yet as quickly as things are moving along certain dimensions, it is also becoming clearer by the day how long-term many challenges will be in the coming years in healthcare. For example, even leaders at the very most pioneering patient care organizations in the U.S. are struggling in some ways to put into place the ideal data and information infrastructures to effectively lower readmissions rates; and the data security situation is only becoming more and more complex, as data breaches continue to explode in healthcare. We hope that these Top Ten Tech Trends articles will be useful to you, our readers, going forward, at a time of unprecedented change and dramatic developments—because the big picture is more important these days than ever. —The Editors of Healthcare Informatics

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www.healthcare-informatics.com • Healthcare Informatics 9

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Trend: Personalized Medicine

PUTTING GENETIC DATA IN CLINICIANS’ HANDS RESEARCHERS MAKE PROGRESS ON DECISION SUPPORT, BUT GAPS REMAIN IN STANDARDS, INTEGRATION, WORKFLOW BY DAVID RATHS

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or the last several years, Healthcare Informatics has significant genes. If they find them, they need to inform the made personalized medicine one of its top technology clinicians. trends, and we are doing it again this year because the Today, clinicians don’t want a lot of the details about the stakes are so high. As Christopher Chute, M.D., a Mayo Clinic genetics. “They say, ‘Tell me the clinical significance and the bioinformatics researcher, told us in 2012: “Many of us believe drug I should use based on this patient’s genetic makeup.’ They that genomic information will inevitably transwant targeted answers in plain English,” Wells form healthcare beyond recognition. It will be a explains. bigger breakthrough than antibiotics—not imSome clinicians want that information to apmediately, but in the next decade or two.” pear as clinical decision support reminders and Even if the commonplace use of a patient’s some don’t. “We have not built the infrastructure personalized genetic risk information to make in informatics to take it out of the genetic seclinical care decisions is still a decade away, the quencing process and pipe it right into the EMR pace of progress is accelerating, with research[electronic medical record]; and there aren’t reers at academic medical centers studying the ally standards in the industry for how you would integration of genomic data into the electronic communicate genetic results. It’s not like typical health record (EHR) with relevant clinical decistandards for most lab results,” Wells says. sion support. “At Penn Medicine, we believe it all ought to The early efforts of Penn Medicine in Philadelreside outside the EMR,” he says. “You click on a Brian Wells phia are illustrative of the challenges and opporURL and get a dynamic picture that is constantly tunities of moving into personalized medicine. changing about what’s significant and what isn’t. On the clinical side, all the data is integrated into You want the genetics to be a snapshot, but the a data warehouse, explains Brian Wells, associsignificance is a moving target. That’s why we ate CIO of health technology and research combelieve it ought to be a web service or externally puting. But on the research side, there are islands provided result that is dynamic.” of data that are not yet linked together. “We are Josh Peterson, M.D., M.P.H., director of working to combine that research data, includhealth information technology evaluation in ing genomic, biobank and clinical trial data, and the Department of Biomedical Informatics link it back to the phenotype data in the clinical & Medicine at Vanderbilt University Medical data warehouse,” Wells explains. Researchers Center, says his organization has been expericould find all the patients with a specific gene, menting with offering clinicians pharmocogeand then see those patients’ clinical data; or they nomic information at the point of care along could find all the patients with a particular cliniwith clinical decision support. First the inforAndrew Litt, M.D. cal profile and then look at their genetics, he says. matics researchers tried putting the clinically Penn Medicine has created a Center for Persignificant drug-gene interaction information sonalized Diagnostics to do somatic gene testing of solid tu- in the labs section of the EHR. “Eventually it was put in the mors and blood-borne tumors. Researchers might look for patient summary adjacent to a medication list,” he says. 30 or 40 genes that they know are highly predictive, clinically Vanderbilt also added a decision support tool within the 10 March 2014 • www.healthcare-informatics.com

SECURITY, INNOVATION AND FLEXIBILITY FOR A CHANGING INDUSTRY.

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EHR as well as a surveillance effort by pharmacists who can help interpret the finding for physicians. The fact that many parts of Vanderbilt’s EHR are homegrown makes modifying it easier, “but we still have challenges getting the right data in the right place at the right time,” Peterson says. “For many of the clinicians, this is fairly new to them, and they say they don’t want to worry about the raw results. They want a distillation of what it means.” The patient portal also provides a notification to patients that their genetic disposition may have implications if they take certain drugs. Patient education is another area that needs research and improvement, Peterson says.

A HOST OF DATA MANAGEMENT CHALLENGES Health systems will have to consider what type of infrastructure changes personalized medicine will require, says Andrew Litt, M.D., chief medical officer for Dell Healthcare & Life Sciences. His company is building the IT infrastructure to support an FDA-approved personalized medicine clinical trial

ers at 16 different centers could easily access the data. Health systems will need new ways to manage all the data involved in personalized medicine, Litt says. “They already have storage issues today and genomic data is an order of magnitude greater,” he says. “Hospital CIOs have to ingest it, store it, and then present it so clinicians can make use of it.” They also need appropriate clinical decision support at the point of care, he adds. “Most current EHRs have no way to present this data, so hospitals have to make a choice whether to build that in or link to an external source. I think it’s more likely they will do the latter. This is not an area of expertise for the EHR vendors. I think for all these reasons, the topic scares the heck out of most CIOs.” If progress is being made in terms of presenting clinically relevant genetic information at the point of care, many gaps remain in terms of standards, integration, decision support and work flow. Speaking at the AMIA Symposium in Washington, D.C., last fall, Kevin Hughes, M.D., co-director of the Avon Comprehensive Breast Evaluation Center at Massachusetts General Hospital in Boston, described some of these gaps in greater detail. In the ideal world, he said, a clinician would pull structured data out of the EHR to support a genetic consultation. That would include access to decision support and risk algorithms to determine what might be needed for an individual patient. The clinician could send genetic test requests as structured data, including a structured family history, and get back a structured result, which could help feed a rapid learning health system. “We don’t have any of this,” Hughes told the AMIA audience. Genetic lab tests are being sent back and forth on paper, he added. All that information is being stored as free text in the EHR, where it becomes unmanageable. He noted that although his EHR at Mass General may show in its notes section that a patient tested positive for the BRCA1 mutation, the clinical decision support section says the patient has no increased risk of breast cancer. “In the absence of structured data, the decision support has no idea that this patient is a mutation carrier,” he said. “Not only are EHRs not interoperable,” he added, “they can’t even talk to themselves.” “We need clinical decision support, we need knowledge bases, and we need a rapid learning health system, and unless the data is standardized we will not get there,” Hughes stressed. “Health IT solutions must collect, receive and transmit standards-based family history and genetic data.” Guidelines and knowledge bases must be machine-readable and deployed as web services. “Closed, proprietary systems that are not interoperable are holding us back.”

WE HAVE NOT BUILT THE INFRASTRUCTURE IN INFORMATICS TO TAKE IT OUT OF THE GENETIC SEQUENCING PROCESS AND PIPE IT RIGHT INTO THE EMR; AND THERE AREN’T REALLY STANDARDS IN THE INDUSTRY FOR HOW YOU WOULD COMMUNICATE GENETIC RESULTS. IT’S NOT LIKE TYPICAL STANDARDS FOR MOST LAB RESULTS. —BRIAN WELLS using gene-expression-guided therapy for pediatric cancers. The Translational Genomics Research Institute is using its genomics technology to determine the gene expression of children’s tumors and make the data available to teams of specialists who consult on treatment options. Dell built a supercomputer to get the computational time from three weeks to four days, Litt says, and it created a genomics cloud so that research-

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Trend: Standards Development

CATCHING FHIR A NEW HL7 DRAFT STANDARD MAY BOOST WEB SERVICES DEVELOPMENT IN HEALTHCARE BY DAVID RATHS

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tandards development work in healthcare noon,” he said in a recent e-mail exchange. “FHIR is a challenging, often thankless task, and hides the complexity of the HL7 Reference Infordefinitely more of a marathon than a sprint. mation Model but enables HL7 to curate standards based on a model its experts understand.” It isn’t often that a proposed standard garners In an interview at the 2013 HIMSS conference, genuine enthusiasm among people working on Australian software developer Graham Grieve, interoperability issues, but that is what is happenwho has spearheaded the FHIR project, said that ing with HL7 Fast Healthcare Interoperability Reno matter how hard developers have worked on sources (FHIR). interoperability, the costs have remained too Proponents of FHIR (pronounced “fire”) are high. “It is really hard to take one piece of inforworking on a specification that could ease health mation and share it consistently across a lot of IT bottlenecks and offer more granular data accontexts,” he said. “With FHIR we are defining a cess. Rob Brull, the product manager for Dallassingle simple-to-use format that can be used from based Corepoint Health, which offers a health Arien Malec the back office all the way to personal health redata interface engine, told me that his company cords and social web and mobile phones. That executives are amazed at the activity level around is a really compelling picture. We are taking the it at HL7 work group meetings. “They haven’t seen best bits of HL7 version 2 and the stuff we learned anything like it in 10 years, in terms of enthusifrom version 3 and putting it in really modern asm,” Brull says. “Everyone is talking about FHIR. technology that is making it easy to use.” HL7 struggled with version 3, so this is a big opportunity to create something that will be widely VENDOR SUPPORT FOR adopted.” WIDER ADOPTION Healthcare has lagged behind other industries Arien Malec is vice president of data platform in the use of web technologies, Brull adds. “Healthsolutions for McKesson subsidiary RelayHealth, care has relied on IHE [Integrating the Healthcare Atlanta, a founding member and service proEnterprise] protocols and SOAP [Simple Object vider for the CommonWell Health Alliance. He Access Protocol] for transport, which can be cumJohn Halamka, M.D. says that FHIR is appealing for several reasons. bersome. FHIR uses RESTful [Representational “We have HL7 version 2 for sending messages State Transfer] web APIs [application programfrom one system to another and CDA [clinical document archiming interfaces]. It is more lightweight.” The combination of FHIR for content summaries and the tecture] is good for documents, but neither of those work well REST standard for transport would bring healthcare into align- for exposing a service or granular data,” he explains. “If instead ment with the more modern web services approach used by of sending a document, I want to expose a medication list to companies such as Yahoo, Facebook and Google: simple XML authorized parties, the current systems are not designed to do and simple transport, notes John Halamka, M.D., CIO of Beth that and it takes a lot of extra work.” Malec says a good use case example would be offering mobile Israel Deaconess Medical Center in Boston and co-chair of the federal Health IT Standards Committee. “Content summaries app developers access to patient data. “If you are going to do should use simple XML that any developer, even one without that, using FHIR is going to be cheaper, faster and better than HL7 or healthcare expertise, should be able to create in an after- rolling your own.” www.healthcare-informatics.com • Healthcare Informatics 13

SPECIAL ADVERTISING SECTION

Cloud Control: How Velocity Technology Solutions Is Helping the Healthcare Industry Accelerate Meaningful Use Are cloud providers ready to host electronic health records?

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t’s a question that many healthcare chief information officers (CIOs) are asking. Cloud computing has moved mainstream for many types of applications and data. And, in the past few years, healthcare organizations who have joined the cloud have realized key benefits from converged infrastructure and shared services: notable savings on upfront information technology (IT) costs, increased technology environment resiliency, rapid deployment of new clinical applications, accessibility independent of location, and, perhaps most importantly, the ability to quickly reallocate and redeploy resources in an ever-changing clinical and revenue cycle environment. Velocity Technology Solutions, a leading cloud application hosting company, has been hosting applications in its virtual private cloud for more than a decade. Its experience has shown that a one-size-fits-all approach does no one any favors. Velocity works closely with each customer to ensure that any cloud-based solution meets the organization’s unique needs— and, in doing so, helps accelerate attainment of meaningful use, gives hospitals costs that are both lower and fixed and achieves the goal all hospitals are striving for: improved outcomes.

Understanding the cloud “Cloud” is no longer simply an IT buzzword: it will underpin the majority of technology investments moving forward. Simply defined, cloud computing is all about moving away from costs and management of physical servers and hard drives. Instead, key applications and data are stored, accessed and controlled over the Internet, allowing for a more flexible, scalable and efficient technology approach. While cloud-based computing

started as more of a consumer phenomenon, big business recognizes its advantages. McKinsey & Company, a global management consulting firm, estimates that 80 percent of large companies in North America are looking at the cloud to help them with their IT goals. The healthcare sector is no exception. Paul Cioni, Velocity’s Chief Technology Officer (CTO), says that, despite the benefits, many hospital CIOs have some serious misconceptions about the cloud, namely concerning security and capabilities. “We hear that ‘the cloud is not secure’ a lot. But we also hear that it’s fully secure. CIOs should understand that neither is exactly true,” says Cioni. “The most important thing to know is that the cloud, for any organization, has to be designed with security and compliance woven in from the beginning. It’s not something that can be added as an afterthought. And, on that same note, they should understand that not all clouds are equal. There are some clouds that are public, there are some that are private, and there are some that are a hybrid. Choosing the right flavor of cloud for your organization is key to realizing the benefits—and getting the services that you need.” Cioni also notes the misperception that the cloud services companies are nothing more than infrastructure providers. “There’s a lot more to it than that. When your cloud provider has expertise specifically around cornerstone healthcare applications, it is evident that you get a lot more than just infrastructure. They can help with performance tuning, management, monitoring,

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adding interfaces, healthcare exchange, upgrades, fault resiliency—there’s a lot to choose from. When you have access to the right knowledge and services, you’ll find your organization moving into the realm of fully managed applications, and, from there, rapidly moving towards achievement of meaningful use.”

Example: Using the cloud to accelerate meaningful use When the Brookdale University Hospital and Medical Center, one of Brooklyn’s largest voluntary nonprofit teaching hospitals, was faced with an aging technology infrastructure that needed to be updated to support its strategic objectives, it reached out to Velocity to help with an extremely rapid application and infrastructure overhaul. And that’s what made the difference in getting Brookdale’s systems up and running under an accelerated timeline. Velocity was able to deploy Brookdale’s new IT infrastructure, supporting nearly 60 applications, in just 10 months, enabling the hospital to adapt to changing healthcare requirements and regulations at a pace it could not have achieved without Velocity. “Brookdale had an extremely complicated set of needs, including implementation of clinical applications to achieve ‘meaningful use’ of electronic health records as set forth in the Health Information Technology for Economic and Clinical Health (HITECH) Act. The hospital realized that, in the current regulatory environment, it needed to get this done faster. Brookdale required a knowledgeable, experienced partner to bring ready skill sets to the table and to support the variety of application platforms it currently had and was deploying,” says Mike Tsontakis, Velocity’s Healthcare Solutions executive. The hospital wanted to ensure it was making the best use of healthcare technology to manage costs and increase the spectrum and quality of care it offered the community. And so the hospital called on Velocity. Cioni says that Velocity’s unique service offerings allow it to assist in big transformations during a customer’s technology lifecycle, whether it’s rapid deployment of a new system, a major upgrade or the loss of a staff member with a specific (and necessary) skill set. “We don’t throw a one-size-fits-all solution at our customers. We listen carefully, find out what they really need and then align the business needs and the service level specifically to those needs. That ability to listen, challenge and then map out the right solution for an individual organization is what really separates us from our competitors.”

How the cloud can benefit your bottom line It would seem that there are no products or services in the IT world that don’t promise healthcare organizations cost savings. But how many can accelerate the deployment of clinical applications and meaningful use? Few, but the cloud can. “A well-engineered, purpose-built cloud solution can help our customers save a lot of money—on the order of 20 to 40 percent,” says Cioni. “The cloud allows executives to look into the operations of their applications and see who is running them when. We reduce the risk of catastrophic failure, the risk that the one guy who knows this one specialized application might get up and leave. And, on top of all that, we provide them with a level of service, operational expertise and functional support that they can’t get anywhere else. Velocity makes sure that customers have a full view into operations and performance, and that helps them make the most of what the cloud has to offer.” Velocity sees its service as evolutionary. As applications become more complex, specific application knowledge is more critical, and the cost to train and retain staff rises. “Health systems are inundated with requirements for new application deployments and existing application upgrades,” says Tsontakis. “This comes at a time when their competitors in the local market are recruiting their best people as fast as they can train them on the new technology.” Velocity solves this by including all of the specialized skill sets in its services, both precluding the need to train across multiple specialties and also enabling hospital staff to focus on user and patient-facing initiatives—not technology deployments and upgrades. In sum, Velocity offers its customers a fully-managed virtual private cloud solution that spans the continuum of applications offerings. Velocity ensures that cloud computing goes beyond the buzz, tailoring each cloud solution to support an organization’s needs. But its commitment to success does not end there. After deployment, it remains a dedicated partner managing the cloud environment, making sure that hospitals and other healthcare organizations are making the most of their IT infrastructure and applications— improving patient care and their bottom line. How should you be using the cloud? Velocity can help you define the right approach for your organization.

For more information, email [email protected]

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Even though FHIR is only a draft standard at this point, CommonWell is already using it in a patient identification and authentication effort involving multiple providers and health IT platforms. “We turned to FHIR and quickly got to 80 percent of what we wanted, and the other 20 percent wasn’t that hard to

ed? Each EHR vendor will make its own decision, but Mandel believes they will have strong motivation. “Creating an apps platform is a compelling target,” he says. “EHR vendors are getting requests from hospitals for new features, but those take a long time to build into new versions. They would like to build apps platforms. For instance, at Boston Children’s Hospital, we have built apps that work with their Cerner EHR; but once built, these only run in one place. The real trick is to build those in a way that they could be used anywhere someone wants to use them.” Not everyone is enthusiastic about FHIR. Eliot Muir, CEO of the Toronto interface engine developer Interfaceware, was initially quite positive about the FHIR standard, “since at a high level the message is very positive,” but he says that when you look closely the standard is too complex and overly prescriptive. “I think manufacturers and software companies can build better RESTful web service APIs into their products, which will be simpler and more cost-effective that trying to follow the FHIR standard,” Muir says. “My own economic interests are served best in an environment with lots of APIs with useful data, which increases the usefulness of good integration technology. Clunky standards inhibit my business model.”

IN HEALTHCARE WE HAVE AN INNOVATION DILEMMA BECAUSE MEANINGFUL USE HAS BEEN DRIVING THE DEVELOPMENT ROADMAPS OF EHR VENDORS. AT THE HIT STANDARDS COMMITTEE WE THINK ABOUT WAYS TO BREAK THAT CYCLE, AND I HAVE A STRONG BELIEF THAT FHIR IS A PROMISING TECHNOLOGY APPROPRIATE FOR INNOVATION. —ARIEN MALEC do,” Malec says. “The disadvantage is that FHIR is still evolving and CommonWell is still evolving. But overall the tradeoff of the flexibility it offers versus it being a moving target was worth it.” Another effort that has turned to FHIR is Substitutable Medical Applications, reusable technologies (SMART), a collaboration between Harvard Medical School and the Office of the National Coordinator (ONC) to create an application program interface (API) for substitutable health apps that run across multiple electronic health records (EHRs). Initially, SMART created its own data model because it couldn’t find one that was developerfriendly, says Joshua Mandel, M.D., the project’s lead architect, “But we were excited to see the FHIR group follow the same principles: developer friendly, open license and extensible,” he says. To support the FHIR effort and highlight its potential for providing a robust, open health API, the SMART team built a prototype it calls SMARTon-FHIR. “We ripped out our data model for query and changed to one that knows how to talk FHIR,” Mandel says, “and the process went smoothly.” How quickly could FHIR be more widely adopt-

MY OWN ECONOMIC INTERESTS ARE SERVED BEST IN AN ENVIRONMENT WITH LOTS OF APIS WITH USEFUL DATA, WHICH INCREASES THE USEFULNESS OF GOOD INTEGRATION TECHNOLOGY. CLUNKY STANDARDS INHIBIT MY BUSINESS MODEL. —ELIOT MUIR But Malec, who has worked as coordinator for the Standards and Interoperability Framework for ONC, and still sits on the HIT Standards Committee, is optimistic about FHIR. “In healthcare we have an innovation dilemma because meaningful use has been driving the development roadmaps of EHR vendors. At the HIT Standards Committee we think about ways to break that cycle, and I have a strong belief that FHIR is a promising technology appropriate for innovation. I will be supportive of FHIR as one way out of our innovation dilemma.” Adopting FHIR will require some up-front work by system vendors, admits Corepoint’s Brull, but once that work is done, “it promises to open up opportunities to work on doing bigger and better things with the data.

Healthcare

Inlorma ICS xecu Ive ummit Healthcare IT Leadership. Vision & Stratef!)!

APRIL 30 MAY 2,2014 -

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Presentations and panel discussions from leaders of innovative healthcare organizations

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topics as: � Pioneers of Population Health and Data � HIE Opportunities and Challenges � IT Implications of Population Health, HIEs, and Readmissions

Russel P. Branzell, President and CEO,

Marc Probst,

George "Buddy" Hickman,

College of Healthcare

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VP and Cia, Albany Medical

Information Management

Intermountain Health­

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Trend: Imaging and HIE

PICTURE SHOW IN THE NEW, CONNECTED HEALTHCARE, WHERE WILL THE IMAGE LIVE? BY MARK HAGLAND

E

veryone in healthcare these days is talksystems] has been a very separate area, though ing about the new connected healthof course, cardiology, gastroenterology, and care—a U.S. healthcare system that will other –ologies are becoming involved.” seamlessly connect patients to clinicians, cliGiven all that, Shrestha says, “Going forward, nicians to other clinicians, all kinds of patient I think it’s going to be more of an enterprise care organizations to each other, and the payplay. We need to get a fuller picture of what’s ers and purchasers of healthcare to everyone going on with the patient. So that story of conelse. Yet even as health information exchange necting the dots will need to continue to grow, (HIE), patient engagement, and coordinaand will need to embrace imaging in a big way.” tion of the transitions of care move forward, Importantly, says Chris Deible, medical direcwhat to do about diagnostic images remains tor of radiology informatics at UPMC Presbyfor most healthcare leaders something of a terian, the system’s flagship facility, “I largely conundrum. As much as we in healthcare are agree that we’re definitely going to have to Russell P. Branzell awash in diagnostic images of all kinds—not bring things together in a patient-centered only from radiology and cardiology, but also way.” Indeed, in that regard, Deible says, movfrom pathology, gastroenterology, dermatoloing forward on health information exchange, gy, pediatrics, and other medical specialties— when it comes to images, means this: “I think how to create an information superhighway that globally, a lot of aspects of HIE will be govfor images as well as documents, remains an erned by local policy and hospital interactions, unresolved challenge. so part of this comes from everybody realizing Still, at some of the most advanced integratwhat they have to benefit from it.” ed health systems, leaders are moving towards Similarly serious discussions are taking place some level of clarity. One of the most advanced at the eastern end of the state, among the folks with regard to imaging informatics is the 20at Penn Medicine, the four-hospital integrated plus hospital University of Pittsburgh Medihealth system based in Philadelphia, where a cal Center (UPMC) health system in western whopping 7.2 million diagnostic imaging studRasu Shrestha, M.D. Pennsylvania. There, leaders are focusing on ies are done annually in radiology and cardiolhow to make images move seamlessly, with a ogy. There, Jim Beinlich, the system’s associate patient-centered focus. Rasu Shrestha, M.D., the organiza- chief information officer of entity services, has been helping tion’s vice president of medical information technology and to lead transformative work, via the convening of a Medical its medical director for interoperability and imaging infor- Imaging Steering Committee, which came into existence last matics, puts it this way: “If you look at the healthcare land- summer, and which has been overseeing the selection and scape at large, we essentially have three buckets of data: you implementation of a vendor-neutral archive (VNA), and othhave structured information, unstructured data, and then er capabilities (as of press time, VNA vendor selection was imaging data. And up ‘til now, you’ve had all these EMR de- set to take place by around April). The goal at Penn Medicine, ployments involving structured data; and interoperability he notes, is to seamlessly integrate the VNA with the orgaefforts; and then natural language processing initiatives. nization’s electronic health record (EHR), its patient portal, Historically, PACS [picture archiving and communications and its provider portal, as well as its HIE capabilities that are 18 March 2014 • www.healthcare-informatics.com

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around patient identification. The images are going to ride on the same rails. These are large data content files, and the speed and the performance have to be there. And, too, each of the COMMUNITY-WIDE VIEWS participants has a small investment; they need AND BEYOND to set up a staging server so we’re not hitting up It’s important to note that most U.S. communitheir native PACS. The system rides outboard, ties are still not live with regular image-sharing so that exchange doesn’t impact production even as most health information exchanges radiology functions.” have been live with data-sharing for several All of these issues also inevitably lead to a years now. The governance, process, and techpolicy-level discussion of the place of the diagnological issues are all factors, say HIE leaders. nostic image in the new, connected, transparDaniel Chavez For example, Daniel Chavez, executive director ent, accountable healthcare. Russell P. Branzell, of San Diego Health Connect (SDHC), is cura former CIO and the president and CEO of the rently leading preparations for a go-live of image-sharing Ann Arbor, Mich.-based College of Healthcare Information there, whose activity spans 19 hospitals, 125 clinics, 9,000 Management Executives (CHIME), asks, “Who really owns physicians, and three million lives across the far southwest the image? If you look at most people who move through a continuum of care, they have image management in multiple locations— cardiology, radiology, pathology, whatever the case may be, and even old hard film converted to digital images. I think that what will occur is, there’s going to be this ubiquitous aggregation of images. It may well be not organization-specific, but rather, patient-specific, and how they gather and garner those images across that.” Importantly, Branzell says, “There’s still the holy grail that’s corner of the state of California. SDHC has been live with missing here, which is appropriate patient-matching and patient records exchange for over a year, but Chavez notes identification. Kudos to ONC [the Office of the National Cothat it will have taken two years of preparation to go live ordinator for Health IT] for starting the dialogue and the with images, because of the complexity, and thus, the HIE discussion, but in some cases, there should be fairly clear will not be live with image-sharing until sometime next year. ability to do this, through electronic authorization. I recent“It takes time to ramp up properly to image-sharing,” ly tried to get my daughter’s images from Colorado, and they Chavez says bluntly. “It’s a function of our own resources, wanted to send me a form via fax,” he notes (Branzell and and the resources of our participants. his family recently moved from Colorado to Georgia). “And We have to prioritize, the priori- I said, I don’t own a fax machine: it’s 2014! And this was my ty was to bring up the virtual own former organization, which was balking at creating an record first. It’s a board- electronic pathway to send me images for my family.” approved project to In the end, Branzell says, “It’s time to look for new techshare images, but nology and create innovative solutions. And I think we’re they want to make not far from that but it’s like fee-for-service healthcare— sure the images can we’ve still got a lot of people addicted to the current techride on the same nology. But you see a few people every now and then who network, and the are really pushing the envelope.” And clearly, with just the challenges have right new technological innovations, as well as process inbeen around the novations, and collaborations across entire communities, anticipated speed the future of image-sharing is wide-open—and ready for of the network, and transformational change.

connecting Penn to other patient care organizations. The goal is an ambitious one, and will take some time to execute, he says.

THERE’S STILL THE HOLY GRAIL THAT’S MISSING HERE, WHICH IS APPROPRIATE PATIENT-MATCHING AND IDENTIFICATION. KUDOS TO ONC FOR STARTING THE DIALOGUE AND THE DISCUSSION, BUT IN SOME CASES, THERE SHOULD BE FAIRLY CLEAR ABILITY TO DO THIS, THROUGH ELECTRONIC AUTHORIZATION. —RUSSELL P. BRANZELL

iHT² Health IT Summit Boston, MA May 13-14 2014

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Topics Include: • The Future of U.S. Care Delivery: A Horizon of Opportunity • Analytics: The Backbone of New Care Delivery Models • Data Security in the Cloud: Leveraging the Low-Cost Advantages while Managing Risk • Achieving Quality Improvements with the Next Generation of EHRs • Tools and Strategies to Engage Your Patient Population

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John D. Halamka, MD, MS Chief Information Officer Beth Israel Deaconess Medical Center Professor of Medicine Harvard Medical School Chairman New England Healthcare Exchange Network (NEHEN)

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Chuck Podesta SVP & CIO Fletcher Allen Health Care

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Bruce Metz, PhD SVP & CIO Lahey Clinic

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Trend: Readmissions Reduction

HARNESSING ANALYTICS A LONG, COMPLEX JOURNEY AHEAD, BUT THERE IS REASON FOR OPTIMISM BY MARK HAGLAND

T

he mandate embedded into the AffordNow, of course, there is a scramble underway able Care Act (ACA) for hospitals to to figure out how to harness the analytics and reduce their avoidable inpatient readreport-writing tools and the data warehouse infrastructure, to reduce and eliminate avoidable missions has proven to be a major—if predictreadmissions. On the Medicare side, hospitals able—shock to the U.S. healthcare system. Major, because already last August, the Centers are receiving publicly reported data from CMS for Medicare & Medicaid Services (CMS) notito help them sort things through, while on the fied the executives of 2,225 hospitals across 49 private side, health insurers are beginning to share claims data with hospitals and physicians, states that they would lose up to 2 percent of while ramping up their plans to emulate the their Medicare reimbursement in 2014, based on ACA readmissions reduction program in their CMS finding too many avoidable readmissions contracts. for heart attack, heart failure and pneumonia Meanwhile, the stakes continue to be raised on patients at those facilities. (Hospitals forfeited Ferdinand Velasco, M.D. the federal side, with CMS preparing to raise the up to 1 percent of Medicare reimbursement in maximum penalties to a 3-percent reduction in fiscal year 2013, and 18 hospitals are expected overall Medicare payment for admissions beginto see the maximum 2 percent reduction in ning Oct. 1, 2014, and preparing to expand the Medicare reimbursement in 2014. Predictable, number of conditions covered to include chronic of course, because such measures had been obstructive pulmonary disease (COPD) and eleccleared by federal authorities as punishments tive hip and knee replacements. At 3 percent of for poor performance when the ACA was passed Medicare revenues, some hospitals operating on back in March 2010.) very slender margins to begin with, and which are If hospital executives have known for nearly also facing penalties under the value-based purfour years now that these penalties were potenchasing program and healthcare-acquired conditially coming to their organizations (and indeed, tions program also mandated by the ACA, could the first penalties were already applied in October 2012, based on 2008-2011 data), why does Steven J. Klasko, M.D. ultimately face shuttering. As Chas Roades, the chief research officer at The Advisory Board, told avoidable readmissions work remain one of the Kaiser Health News last August, “The financial biggest challenges facing healthcare leaders now? A complex knot of reasons is involved, say experts, but penalties aren’t huge right now, but hospital leaders recognize fundamentally, it all boils down to this: under the fee-for-ser- that the penalties will get bigger, and that scrutiny over readvice (FFS) reimbursement system, there had never been (prior missions rates will continue to grow.” (http://www.advisory. to 2010) much motivation for hospital executives to try to fig- com/daily-briefing/2013/08/05/cms-2225-hospitals-will-payure out, let alone fix, the “problem” of avoidable readmissions readmissions-penalties-next-year.) for common diagnoses, given that all the incentives under FFS payment have always been towards filling beds. As a result, AN UPHILL CLIMB, EVEN FOR PIONEERS development of both analytics tools and analytical processes, Why is this all so hard? Just ask the leaders of pioneering organizations in this area, like the 25-hospital, Arlington-based around this issue has until recently been severely delayed. 22 March 2014 • www.healthcare-informatics.com

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Texas Health Resources (THR), which has been using data analytics for readmissions work for at least a few years already, and which has been working with neighbor Parkland Hospital on a collaborative initiative. Ferdinand Velasco, M.D., THR’s chief clinical information officer, puts it this way: “I do think it is going to be a journey; and this will be a top tech trend for many years. I think this will be a similar transition around data analytics as the EHR transition was. We now have a tremendous amount of data, but it’s going to take a long time” to consistently be able to apply analytics, using that data, to readmissions work. Up in Philadelphia, Stephen J. Klasko, M.D., president and CEO of Thomas Jefferson University and the Thomas Jefferson Hospital System, says of his health system, “We’ve recognized the burning platform to get this done. We have to promote not over-utilization or under-utilization, but optimal utilization, for the first time. We’ve recognized at Jefferson, and what David [David Nash, M.D., founding dean of the Thomas Jefferson University Jefferson School of Population Health] in his school has recognized, is that 90 percent of the reason that people get readmitted is that they have symptoms and don’t know what to do.” Connecting patients with their physicians electronically through mobile connectivity, Klasko believes, will be one of several keys to reducing readmissions, as will increasing patient engagement through such motivators as enrollment in high-deductible health plans. What’s more, as a November 2013 Health Policy Brief from Health Affairs (https://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=102) noted, “A study by Yale University researchers identified six strategies that were modestly successful in lowering readmission rates for patients with heart failure. These included partnering with community physicians, partnering with local hospitals, having nurses reconcile medications, arranging follow-up appointments prior to discharge, sending discharge papers to patients’ primary care physicians, and assigning staff to follow up on test results after discharge. Hospitals that implemented more of these strategies,” the brief went on to say, “had substantially lower readmission rates. However, the study also found that several strategies intended to reduce readmissions actually increased readmission rates, potentially because they reduced informational and logistical barriers to hospitalization.” How does all this translate into “next steps” for healthcare IT leaders? “To me, the most important thing is having a system and an infrastructure that allow you to get reliable data,” says Scott Tongen, M.D., a director for the Pittsburgh-based Aspen Advisors consulting firm. “The next important thing,” says the St. Paul, Minn.-based Tongen, whose clinical background is as a hospitalist physician, “is being able to demonstrate that the data is accurate and means what it means. Too

often, physicians have a tendency to question the data if they don’t look good.” When it comes to physician engagement and buy-in, Tongen says, the key is “being able to use the data to identify physician best practices, and then use the data in places where you’re not getting best practices. We worked on readmission for congestive heart failure” at Allina Health System in the Twin Cities when he was there, Tongen notes. The core of the challenge around physician buy-in, he says, was helping to guide physicians past data findings that were not helpful, such as data around “readmissions for any reason,” and leading them forward around data they could accept and take action on.

PROGRESS IN PHILADELPHIA At Penn Medicine, the four-hospital integrated health system in Philadelphia, considerable progress is being made in leveraging data and analytics to reduce avoidable readmissions, reports Christine VanZandbergen, associate CIO of clinical applications for the system, where, she says, “We are driven from a clinical outcomes and quality perspective by our CMO, P. J. Brennan, M.D., and his partnership with a variety of operational and clinical leadership, per our ‘Blueprint for Quality and Safety.’ Our overarching goal,” VanZandbergen says, “is eliminating preventable mortality, and eliminating preventable readmissions.” Indeed, the folks at Penn Medicine have an explicit goal of eliminating all avoidable readmissions for several conditions by July 1 of this year. While Penn isn’t yet willing to publicly share results to date, VanZandbergen says that considerable progress has been made, using sophisticated analytics-driven processes, and focusing on patients determined through analysis to be at the highest risk for readmissions. Not surprisingly, she says, a bottom-line result of all the analyzing taking place in her organization is that the single strongest predictor by far of a readmission is a recent admission. What the folks at Penn, Jefferson, and Texas Health Resources are all learning is that working across systems, and indeed, ultimately, community-wide, will be essential to real progress in readmissions reduction, as with the Texas Health Resources-Parkland Hospital ongoing collaboration. Penn’s VanZandbergen says, “I hope that we’ll be able to expand our data to include outside organizations, since all we have access to right now is internal data; and so that means claims data. We’re in the process of negotiating relationships with more than one of our payers, to look at these high-risk populations, and work with claims.” Will this be a long, complicated journey going forward? All those interviewed for this article agree that it will. Yet all are also optimistic that the U.S. healthcare system will eventually get to where it needs to get on this journey of 1,000 miles. www.healthcare-informatics.com • Healthcare Informatics 23

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Trend: Social Media

THE SURFACE IS BEING SCRATCHED PROVIDERS ARE USING SOCIAL MEDIA TO ENGAGE PATIENTS, COLLABORATE WITH EACH OTHER BY GABRIEL PERNA

I

t’s beginning to happen, slowly, but surely. cause people use this stuff everyday in all asSocial media use in healthcare is beginpects of their lives—it’s only natural that it ning to scratch the surface. will [continue] to make the jump to healthcare The UCLA Health System live-tweets brain itself. When you can order a plane ticket, orsurgery, including short video clips to reduce fuder a pizza, and deposit your paycheck from ture patients’ fear of a procedure. Johns Hopkins a phone, you’re going to want to access your uses Facebook to generate a 21-fold increase of health records, schedule a doctor visit, get your people who registered themselves as an organ lab results, and you are going to want to ask a donor in a single day. Texas Health Resources health question,” says Jeff Livingston, M.D., a in Arlington is using social media internally and physician at MacArthur Obstetrics, Gynecolexternally, for knowledge-sharing, team buildogy, and Infertility in Irving, Texas. ing, education, and employee recruitment. Out Drex DeFord A PATIENT ENGAGEMENT TOOL of the organization’s 21,500 employees, 3,500 are Livingston has spearheaded the organization’s active social media users. avid social media efforts, connecting with paThis is just a small sampling of how healthtients through these mediums, for approxicare organizations, specifically leading promately 10 years. This dates back to the days viders, are beginning to embrace what many, when he would go on MySpace and answer and some likely still, dismiss as a passing fanquestions from his young patient demographic cy. For many, the use of social media is no lonabout their pregnancy concerns. One look on ger just being passed off as a marketing effort. the MacArthur Ob/Gyn social networking sites Leading providers are even integrating it into and the fruits of his labor will be in clear view— clinical operations and overall efforts to imnumerous likes, retweets, questions and comprove patient engagement. Others are using it ments, and overall, engaged patients. to collaborate with others to better navigate His strategy differs from many larger organithe tricky, regulatory waters upon which IT zations. Doctors, not the marketing people, are leaders in healthcare are facing. David Fleming, M.D. the ones using the networks. “Finding a doctor An April 2012 report from Pricewaterwho likes a particular network is so important houseCoopers’ (PwC) Health Research Institute (HRI) found that 60 percent of consumers would trust to success,” Livingston says. Recently, one of Livingston’s health information posted on social media by their doctors, doctors took over the organization’s Pinterest page and was 55 percent would trust a hospital, and 56 percent would able to gain more than 100 followers on the network overtrust a nurse. The same study found that one-third of all night. “This is not about practice marketing. This is a tool consumers use social media for healthcare information. to engage patients in their health.” MacArthur also focuses hyper-locally, looking to serve Since then, social media in healthcare has only grown and the patients of the Irving area and their concerns. To Livmany say it will continue to grow. “[Social media] is too much of a natural process—be- ingston, this is how the organization can build effective, 24 March 2014 • www.healthcare-informatics.com

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have a certain standard to act professionally, intimate relationships with their patients and sometimes that filter is not there to enable through social media. us to do that appropriately,” says David FlemFor bigger hospital provider organizations, ing, M.D., the President-elect of the ACP, who such as Mount Sinai Health System, a sevenserved on ACP’s Ethics, Professionalism and hospital system based in New York City, the Human Rights Committee. “Sometimes things hyper-local concept might not fly as well when can slip out on a Facebook post, a tweet, a blog. serving a city of eight million. Still, the orgaSuddenly, you have private information from nization, which has been recognized for being patients, it may have been put out there innoone of the friendliest hospitals for social media cently or educationally…but there it is.” in the U.S., works to ensure there is a meaningWhen it comes to interacting with patients ful connection with patients. digitally, Fleming advises providers to use To do this, John Ambrose, the social media John Ambrose a secure patient portal. He also says digital director at Mount Sinai, says his team meets tools should be used to strengthen and enwith physicians, nurses, and department heads multiple times per week. They’re mining for information hance face-to-face relationships. Ultimately, Fleming says providers need to establish guideon what patients want to learn about and will create campaigns based on that research. In that vein, it promoted a lines for social media and other forms of digital communicafree skin cancer screening on Facebook and had a line out tion with patients. Others in the industry are instead focusing social media efforts on provider-to-provider communications. the door at the dermatology department. Drex DeFord, the one-time CIO of Steward Health Care, “It’s really about word of mouth, speaking to the doctors, speaking to the nurses. These are the people who are sitting the Boston-based integrated health system and chairwith the patients every single day and know what these pa- man of the board of the Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME), shifted to the vendor side in 2013, accepting a job as CEO of the Seattle-based Next Wave Connect. Next Wave is a social media platform that tients need, and from that, we can create meaningful cam- allows healthcare professionals to collaborate internally paigns,” Ambrose says. In addition to this, Mount Sinai has and externally, in a private or open setting. It relies on adcreated 50 or so social media channels, many of which are visory council experts, community advisors, and community managers to contribute to conversations and facilitate specifically for a certain disease population. collaboration. CONCERNS WITH HIPAA To DeFord, these elements are where the value of social Many on the provider side have shied away from connect- networking for healthcare providers can come into play. “I ing from patients altogether, citing concerns with poten- think the ability to create real and persistent collaboration tial violations of the Health Insurance Portability and Ac- over time is a real opportunity for healthcare that isn’t ofcountability Act of 1996 (HIPAA). The Philadelphia-based fered in any other way today,” he says. American College of Physicians (ACP) has provided an ofDeFord says there is a real opportunity for growth in social ficial series of ethical guidelines for physicians using social media for healthcare providers and patients, as soon as they media and other electronic means of communication. The recognize this collaborative potential, and not just see the guidelines advise them to keep a distance from patients on medium as a “time waster.” This includes, he says, taking pathe networks and schedule an appointment if they are ap- tient-generated data from social apps and feeding it into cliniproached through electronic means for clinical advice. cal portals. “Figuring out ways to use social to make people “I encourage physicians to not even use Facebook and ar- healthier is really something that will become a reality, and is eas where they put personal content in there, because of the a reality today, but will come more commonplace in the com(potential) for miscommunication. We are observed and we ing years,” he says.

WHEN YOU CAN ORDER A PLANE TICKET, ORDER A PIZZA, AND DEPOSIT YOUR PAYCHECK FROM A PHONE, YOU’RE GOING TO WANT TO ACCESS YOUR HEALTH RECORDS, SCHEDULE A DOCTOR VISIT, GET YOUR LAB RESULTS, AND YOU ARE GOING TO WANT TO ASK A HEALTH QUESTION. —JEFF LIVINGSTON, M.D.

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Trend: Patient-Generated Health Data

TRANSFORMING DATA INTO DECISION SUPPORT THE ADVANCE OF PATIENT-FACING CONNECTED TECHNOLOGIES WILL ALLOW PROVIDERS TO TRACK PATIENTS ON A DAILY BASIS BY GABRIEL PERNA

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o Joseph Kvedar, M.D., it’s time to change the way 30 percent of consumers were eager to use smartphones healthcare provider organizations have given care, and tablets to manage their health. which he says has basically stayed the same since This interest has created a burgeoning market for perthe ancient days of Hippocrates. sonal health and wellness devices. According to the Con“You come to visit a doctor for a 10- to 15-minute period of sumer Electronics Association (CEA), more than 40 million time a couple of times per year, maybe more of these kinds of devices sold in 2013. By 2018, if you are sick. During that time, I’m supthat number is expected to jump up to more posed to extract a chronology of your illness than 70 million sold, reaching $8 billion in total from you and then I measure a few things, get sales. a few lab tests, and that’s the package of data INCLUDED IN STAGE 3? points I use to make a decision about you. We By 2018, these technologies could also be very don’t need to do it that way anymore,” says well could be integrated with clinical data at Kvedar, who is the founder and director of provider organizations across the country, espethe Center for Connected Health, a division cially if Chuck Parker has his way. Parker is the of Partners Healthcare in Boston that focuses executive director of the Continua Health Allion non-traditional medical interventions, ofance, a 200-member nonprofit organization that ten in underserved areas, through the use of is working to establish interoperability within connected devices. Joseph Kvedar, M.D. the personal connected health space. The forward advance of patient-facing Continua is one of eight industry groups that connected technology, Kvedar surmises, will sent a letter to the Vice Chairman of the ONC’s allow these healthcare providers to track Health IT Policy Committee (HITPC) asking to patient-generated health data (PGHD), and formally require eligible providers and eligible thus the patients themselves, on a continuhospitals to use and integrate PGHD into the ous basis. For the patients, use of these tools, electronic health record (EHR) as part of Stage be it a remote monitor connected to a device, 3 of meaningful use. “The desire of the patienta phone or mobile application with a sensor, generated data is that it’s a richer data set, it or even a platform that allows patients to allows us to connect and follow the individual self-report data, is becoming more common. much more closely, it becomes easier to manage Accenture, a New York City-based global because it’s machine to machine,” Parker says. management consulting company, recently The members of the HITPC, for their part, conducted a survey of more than 6,000 peohave recommended the inclusion of PGHD ple in six countries, and found that more than Jodi Daniel in Stage 3. When pressed on whether or not it half are interested in buying wearable techcould be in Stage 3, Jodi Daniel, the director of nologies such as fitness monitors for tracking physical activity and managing their personal health. the Office of Policy and Planning at ONC, says the office Another survey, quoted in a data brief put out by the Office is waiting on the formal recommendations from HITPC on of the National Coordinator for Health IT (ONC) found that this inclusion. She says the HITPC’s Consumer Empower26 March 2014 • www.healthcare-informatics.com

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ment Workgroup and the Consumer Technology Workgroup are providing input on what standards could be used and future opportunities. “We’ve been working closely with folks on those committees to think about what the next steps might be,” Daniel says. Before that happens, certain elements still need to be worked out, those aforementioned standards being priority number one, according to Mary Griskewicz, senior director of health information systems at the Health Information and Management Systems Society (HIMSS). She says there needs to be reconciliation between the provider community and the patients with what’s possible and doable based upon those standards and interoperability of the data. Parker says, however, that from a technical standpoint, the standards are there through the consolidated care document (CCD), an HL7 clinical document architecture (CDA) standard that enables connectivity between the two sources. While some personal health data device compa-

conjunction with clinical data. While many in the industry are doing this through patient portals, a select few are going beyond that. Banner Health, an integrated health system based in Phoenix, which operates 23 hospitals and other healthcare entities in seven states, is remotely monitoring a population of high-risk patients with tablets and various devices that track vital signs like blood pressure on a long-term basis and send them to a hub that connects to the Banner EHR. The tablets are designed to keep the Banner physicians updated on the patients continuously and in frequent contact. The project, called iCare, has been ongoing since June. Though it’s early, Edward Perrin, M.D., who works as a primary care intensivist with the Banner iCare project, says that PGHD, when properly organized, can be unquestionably be useful to physicians. “One [measure] of blood pressure does not equal how [the patient’s] blood pressure is trending over the course of weeks and months. The snapshots and cross sections we get from a hospital setting are very abnormal and atypical for what a patient is doing at home. That’s what you need to focus on, managing them at home and what they are doing there,” he says. At Connected Health, Kvedar and his team patients are using PGHD to engage underserved patients. Using data from a pedometer to track a patient’s activity, paired with data based on a questionnaire they filled out and where their doctors are located, the Connected Health team created a series of automated, motivated text-message interventions designed to keep them active. While many are still trying to understand the true clinical value of what this kind of data can accomplish, those like Kvedar recognize its potential worth. “It’s not clear yet how you enter steps counts into an electronic record, except to say that clinicians will all tell you if you have diabetes, are overweight, have metabolic system, it’s better if you are more active. Just being able to assess person’s activity is a new and exciting tool for preventive care,” Kvedar says.

THE DESIRE OF THE PATIENT-GENERATED DATA IS THAT IT’S A RICHER DATA SET, IT ALLOWS US TO CONNECT AND FOLLOW THE INDIVIDUAL MUCH MORE CLOSELY, IT BECOMES EASIER TO MANAGE BECAUSE IT’S MACHINE TO MACHINE. —CHUCK PARKER nies are using propriety architecture (such as FitBit from San Francisco), many are using that CDA standard. Furthermore, he says Continua is working with the Food and Drug Administration (FDA) to craft standards requirements and guidance around mobile medical devices. In a sense, a lot of the success of this integration hinges on practicality. “Realistically, 90 to 95 percent of this data is not really relevant on a daily basis,” says Parker. This means provider organizations will have to get physicians on board and promise that this won’t just create an “avalanche” of new, useless data. He says this means having them work within the EHR with clinical decision support tools to understand that data at a larger trend level and with the care teams to find the most pertinent data points. In that sense, ONC’s Daniel says, there are also concerns from the provider side with how this data would integrate into a physician’s workflow. Others, including ONC within that data brief, have expressed apprehension over the privacy and security of transmitting this data.

PGHD IN ACTION Despite the hurdles that exist and lie ahead, there are examples of provider organizations already using PGHD in

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Trend: Mobile and Messaging

GREEN LIGHT ON CLINICIAN-TO-CLINICIAN TEXTING HEALTHCARE ORGANIZATIONS ARE GIVING THEIR PROVIDERS THE ABILITY TO TEXT EACH OTHER, BUT SECURITY REMAINS A CHALLENGE BY RAJIV LEVENTHAL

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here are nearly one million physicians things going on, and ask him or her to contact a in the U.S., many of whom constantly certain physician. “That physician isn’t exactly move between their offices, clinics, and waiting by the phone for me to call them,” Levy says. “So I go off and do my thing, and it’s likely various departments and other facilities in and that I’m involved in doing something very diffiaround affiliated hospitals. They possess a concult for me to extract myself from when the call stant need to access clinical information and to comes back in 10-60 minutes. Needless to say, it’s communicate with colleagues and care team an inefficient process.” members. With callDR, continues Levy, physicians can It was not too long ago when these physicians now navigate through a quick menu and provide would be checking their pagers for messages from other doctors, but times are changing, some written information—via text or speaking and those pagers have turned into smartphones into the phone—as well as take images, and then Michael Levy, M.D. send the whole thing as package. “The physician with text messaging capabilities. In fact, in 2012, on the other end gets a ‘ping,’ and this helps solve a survey from the Lexington, Mass.-based Imprivata, a healthcare IT security vendor, found that what I think is a huge problem in being able to more than 70 percent of IT decision-makers in work efficiently and accurately,” he says. “We’re some of the busiest guys around—you can’t exhospitals in North America said they expected secure text messaging to replace paging in the pect to call your CEO and expect to talk to them next three years, as smartphones become more right at that second, and that’s the level at which of a tool in the hospital environment. we’re operating at.” Three years have not yet passed, but the trend Meanwhile, at the six-hospital integrated deis coming more quickly than even the industry livery system, Orange Coast Memorial Medical Center (OCMMC), based in Fountain Valley, Camight have expected—the transition from pagers to text messages has already begun among lif., communication among providers is especialdoctors, and most are finding the switch seamly crucial due to the distance between facilities, says Scott Raymond, executive director, informaless and efficient. Scott Raymond In Anchorage, Alaska, Michael Levy, M.D., tion services. “We aren’t trying to solve one single emergency physician at Alaska Regional Hospiproblem, but rather the global problem of getting tal, was so motivateed to improve his communications with care to patients quicker, which we call unified clinical collaboother physicians, he helped create Fractal OnCall Solutions. ration,” he says. The company, formed in April 2013, has since developed a To this end, OCMMC has tapped the Knoxville, Tenn.-based product for the iPhone and iPad called CallDR, a multimedia PerfectServe for its unified communications platform. Similar consultation and secure messaging system for mobile tele- to Levy, Raymond also makes note of the organization’s “stone age” methods of communication before deploying Perfectmedicine, says Levy. Levy says that he needs to talk to other physicians regard- Serve. The back-and-forth loop of communication sometimes ing their patients on a daily basis, so prior to callDR, he would took as many as six hours to close, says Raymond, who did a have to break what he’s doing, go to a secretary who has other time motion study to get the specific numbers. 28 March 2014 • www.healthcare-informatics.com

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Right after PerfectServe, the average time it took to close the loop from the first line of communication to the last was 15 minutes, while the median was six minutes, Raymond says. “The greatest outlier we had after PerfectServe was 100 minutes, and we had very few outliers because almost all of our target physicians for this app were utilizing it at this point,” he says. “I call it the 50 percent initiative, because right off the bat, we had a 50 percent improvement in all areas.” A few thousand miles away, in the southeast, Quality Independent Physicians (QIP)—a group of more than 1,000 physicians in private practice working together to care for their patients in the Louisville and Lexington, Kentucky areas as well as the Southern Indiana counties of Clark and Scott— started a Medicare Shared Savings program accountable care organization (ACO), employing nurses to hospitals and nursing homes to follow those Medicare patients around who were attributed to the organization, says Tom Samuels, QIP’s CIO. “At the time, we were struggling with a way to communicate with our doctors in a quick and real-time fashion, and still be HIPAA [Health Insurance Portability and Accountability Act]

CONTROLLING PHI Indeed, physicians’ adoption of smartphones has become near universal. According to a recent Spyglass Consulting Group report, 98 percent of physicians interviewed said they own and regularly use smartphones. However, text messaging by physicians and other clinicians poses serious potential patient privacy risks. But with security controls in place, some healthcare organizations are giving a green light to texting. OCMMC is one organization that has taken these measures, although Raymond says when people ask him what keeps him up at night most, it’s the risk of information leaking out of the hospital, be it unsecure texting or any unsecured communication. Raymond feels the organization has made great strides in taking care of that information. “Our network is locked down, every machine is encrypted in our enterprise, and we have filters looking for PHI leaks,” he says. “But then with clinical communication, that door has been opened even wider with smartphones.” The chance a nurse who is carrying an iPhone could text a physician with patient information in the message is real, and if they aren’t provided with an avenue to do it securely, it will happen unsecurely, Raymond says. Another organization that has given its providers the texting green light is the Lubbock-based Texas Tech University Health Sciences Center (TTUHSC), which is using Imprivata’s HIPAA-compliant text messaging application, Cortext. But even with the app, controlling protected health information (PHI) is a huge challenge, say both Shauna Baughcum, institutional privacy officer, at the academic center, and Ed Gaudet, general manager of the Imprivata Cortext products group. A doctor or nurse may log into his or her app or desktop 10 or 15 times an hour—rather than a whole day like employees in other industries—Gaudet notes, adding that a few years ago, he began to see a trend where doctors and nurses were texting insecurely—and of course with PHI involved, that’s a HIPAA violation. While it’s easy to say you’re not allowed to text, that’s quite difficult to implement, says Gaudet. “You cannot 100 percent control it, as there is no such thing,” agrees Baughcum. “But the idea is to put tools like this in place to mitigate it as much as you can. People in everyday use don’t realize exactly how much information floating out there is sensitive; and even though they’re exchanging it via an unsecure line, they don’t realize that they’re violating anything,” she says. At TTUHSC, there are intimate details of what needs to happen to discharge a patient, says Baughcum, and in the past, pagers and landline phones were used. But now, as long as the physicians are doing the texting inside Cortext, they

WE AREN’T TRYING TO SOLVE ONE SINGLE PROBLEM, BUT RATHER THE GLOBAL PROBLEM OF GETTING CARE TO PATIENTS QUICKER, WHICH WE CALL UNIFIED CLINICAL COLLABORATION. —SCOTT RAYMOND compliant,” Samuels says, adding that QIP also needed a solution that would be easy enough for physicians to use. QIP ended up choosing Louisville-based startup Red e App, a real-time private mobile messaging platform, to allow onsite clinical staff to communicate back to the in-office doctors. “It looks and feels like texting or like an email, and we can communicate directly to the doctors about patient information to get real-time feedback, get status on a patient, or let doctors know what is going on with a patient,” Samuels says. One way QIP uses the app in the clinical setting is with care coordinators, who are in the hospital with patients, says Samuels. “The nurse might text a doctor, ‘Mrs. Jones is being discharged to a nursing home for rehab. Can she come to your office in 14 days?’ And the doctor might say yes, or might say he or she will visit the patient in the nursing home,” Samuels explains. “The Center for Medicare and Medicaid Services (CMS) wants us to see 70 percent of patients within 30 days of discharge, and we have moved that standard to 14 days. Now, we are looking for movement on those percentages because of the app—we’re able to notify office managers and doctors when patients are discharged from hospital. So in this respect, it fosters better transitions of care,” he says.

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can put everything they want about patients and then some, she says. “If you want to keep in compliance with regulations and best serve your patients, you need HIPAA-compliant

messaging, and it won’t be getting easier as we continue to move in the environment we are heading to in healthcare,” he says.

Trend: EHR Optimization

POST-IMPLEMENTATION ADVANCEMENTS LEADERS FROM VARIOUS HEALTHCARE ORGANIZATIONS EXPLAIN HOW THEY HAVE BEEN MOVING FORWARD WITH THEIR EHRS FOLLOWING IMPLEMENTATION BY RAJIV LEVENTHAL

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ealthcare organizations are faced with eter removal by a nurse within 48 hours of inserincreasing pressure to deliver clinical tion, if no physician order has been placed. “We and financial results that demonstrate then modified and tested changes to 1,639 order the benefits of their implemented electronic sets within the system’s EHR, and deployed the health records (EHRs). Because of this, healthchanges to the entire health system. We were also care IT leaders are realizing more and more that able to identify high-risk readmission patients, success in their work will be measured by the and sent them home with technology, which they work that happens after EHRs have been fully applied. As a result, readmissions have been reimplemented. In that context, the race is on to duced by 25-30 percent,” he says. fully leverage EHR implementation for genuine INTEGRATING DATA IN ILLINOIS population health and care management. In Illinois, the Evanston-based Northshore Uni“It’s one thing to implement the EHR, but it’s versity HealthSystem, which recently saw its more about, ‘How do we optimize it?’ How do Steven Smith ambulatory clinics become the first group of amyou move the needle on your quality outcomes?” bulatory facilities to reach Stage 7 on the HIMSS says Edward Marx, senior vice president and Analytics Ambulatory EMR Adoption Model, has CIO of the Arlington-based Texas Health Rebeen making data—specifically its data waresources, an organization that has reached Stage house and analytics teams—its biggest priority of 7 (the final stage in the HIMSS Analytics Eleclate, says Steven Smith, Northshore CIO. tronic Medical Record Adoption Model) in 10 of “One of the terms we use is ‘turning data into its 14 wholly-owned hospitals. actionable information,” he says. “So we are opAt Texas Health, one example of EHR optitimizing across different departments, using the mization was through the reduction of venous EHR to improve workflows, cut off steps, putting thromboembolism (VTE), or blood clots, which in clinical decision support where appropriate are the biggest killer of people once they come (including predictive analytics to help our cliniinto hospitals. “We put alerts in the EHR to help reduce the risk of getting blood clots during George Reynolds, M.D. cians know what to test), following up on health maintenance reminders, and making sure all this hospital stays, and in a few years, post-operative data gets to our back end enterprise data wareVTE rates were less than half of pre-program house. For us, optimization is really about the growth of our rates,” Marx says, of his organization’s VTE prophylaxis work. Marx gives another optimization example involving cathe- warehouse and our analytics capabilities. We have been doing ter-associated urinary tract infections, the most common in- it for about eight years now, and it really takes the EHR and an fection people get once they are admitted to hospitals. In that optimized functionality in the front end to feed that back end area, Texas Health first established criteria for urinary cath- warehouse and analytics,” Smith says. 30 March 2014 • www.healthcare-informatics.com

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Northshore has been able to use predictive analytics as a way to identify undiagnosed hypertension, Smith says, explaining that the health system was able to look at patient data across the care continuum. For example, Smith says, a patient might have elevated blood pressure in a single visit with a physician, and while that might not trigger an alarm, if the data across all of the patient’s encounters is brought together, and predictive analytics are done on it, you can identify patients who might be at risk for hypertension. “Then, you can feed that back into the EHR where clinicians can follow up with patients, call them in, re-test them with more advanced blood pressure devices, and thus improve their care,” Smith says.

CONVERGING IN PITTSBURGH At the 20-plus-hospital University of Pittsburgh Medical Center (UPMC) health system, the idea is to think “above the EHR level,” says Rasu Shrestha, M.D., vice president, medical information technology at UPMC. “It’s one thing to go from paper to paperless and film to filmless—we have been there and done that. But we aren’t hanging the ‘mission accomplished’ sign up just yet,” he says. “It’s one thing to go live and a completely different thing to see it through.”

convergence is thinking about how we would be able to bring the patient’s story to life,” he says. “Right now, I’m supposed to navigate through a window, scroll through screens, go from application to application. I’m playing the role of detective rather than clinician,” says Shrestha. With the convergence platform—what Shrestha calls a “revolutionary approach to healthcare”—UPMC is approaching interaction with its data silos that it has come to love and implement, but also is continuing to push collaborative care and value-based healthcare forward. “With convergence, how do we bring that patient story to life?” asks Shrestha. “One place we can go to is where it can basically speak to me in the context of the clinician that I am. That leads into contextualization, the other big theme. For any clinician, how would that view be pertinent to me in terms of information that I need around that patient story? That has been pieced together from multiple different systems interoperating with each other in the back end.” The platform also centers around communication and care collaboration, Shrestha says. “Looking at care teams, there is a need for us to approach patient care as more of a team-based approach rather than a singularity approach that traditional EHRs propagated quite a bit of. We’re enabling that level of intelligence and care collaboration on the convergence platform.”

IT’S ONE THING TO GO FROM PAPER TO PAPERLESS AND FILM TO FILMLESS —WE HAVE BEEN THERE AND DONE THAT. BUT WE AREN’T HANGING THE ‘MISSION ACCOMPLISHED’ SIGN UP JUST YET. IT’S ONE THING TO GO LIVE AND A COMPLETELY DIFFERENT THING TO SEE IT THROUGH. —RASU SHRESTHA, M.D. The focus at UPMC is on the core clinical workflow at an enterprise level, where the workflow can be taken to above the EHR to where the action really happens in terms of the core interactions between the care teams, care collaborators, and across populations of patients, Shrestha says. “As we move things forward in terms of accountable care and value-based healthcare, we wholeheartedly believe that’s where the energy needs to be focused on, and that’s where you have the promises of the things accountable care is really pushing.” By “rising above the EHR,” Shrestha explains that UMPC is embracing things such as natural language processing, and going after nuggets of information that are hidden away in unstructured notes, radiology reports, post operative notes, and picture archiving and communication system (PACS) notes. “We are continuing to connect the dots, and our vision with

OPTIMIZING IN OMAHA

In Nebraska, at the Omaha Children’s Hospital and Medical Center, George Reynolds, M.D., CIO and CMIO, says that at the end of the hospital’s EHR golive, the team promised itself that project wouldn’t end with the go-live, and would instead continue with training and optimization. To help with this, the team gave its project a baseball theme, says Reynolds. “We had cute names—for example, go-live was opening day, training sessions prior to go-live were batting practice, training post go-live was extra innings, and we have another round of training coming up next month. We also have tip sheets, both video and written, called “fundamentals of the game,” he says. Failing at planning for optimization is likely one of the biggest mistakes that organizations make, Reynolds says. “People fail to plan making an ongoing commitment to training end users and keeping current with the operation,” he says. “Something that drives me crazy is the idea of upgrading an application where you don’t actually turn on the new features in the new version, but instead just put in the new version. It makes no sense at all.” The way to prevent this potential failure is with constant communication and setting the appropriate expectations, Reynolds continues. “Tell people what you’re going to do, how www.healthcare-informatics.com • Healthcare Informatics 31

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it will impact them, show them how it will work, and then walk them through it,” he advises. “Then remind them what you told them afterwards. It takes several undertakings for change to become part of workflow and culture of the organizations. You can’t turn it on and hope for best.” Reynolds says he told everyone on day one that not everything is going to go right. In fact, he says, hundreds of things will need to be fixed, and they will be fixed as time moves along. “You have to set those expectations at the front end, as it will keep people from being anxious. I liken it to being at an airport—if they tell you what’s going on with the plane and tell you why you’re stuck, you will feel better than if they didn’t tell you anything at all.” That’s why while technology is undoubtedly a big component to improved outcomes, a lot of it is centered around put-

ting people in the room and saying, “We have this tool, now let’s change clinician behavior.” So while there is an EHR component, Reynolds feels that “It’s really about people, workflow, and getting all of the information in the hands of people to take care of their patients.” As such, according to Reynolds, the key to his organization’s success is dependent on the level of engagement of its physicians. They key is to turn the conversation from, “What do I have to do with the EHR?” to “What can the EHR do for me and my patients?” He adds: “That will be the point in which we succeed in population health management and patient engagement. Someone other than me once said that installing an EHR for meaningful use dollars is like having children for the tax deduction. If the EHR is seen as a tool to help them do a better job, then we are going to get there.”

Trend: Smart Devices

PAVING THE WAY TO THE FUTURE TECHNOLOGY ADVANCEMENTS ARE PROMISING BETTER PATIENT CARE, BUT IS THE INDUSTRY MOVING TOO FAST? BY JOHN DEGASPARI

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Administration) for approval, but they do have an ulian Goldman, M.D., attending anesthesiinterest in better data acquisition. At a time when ologist at Massachusetts General Hospital many hospitals are still adopting and expanding and medical director of Partners Healththeir use of electronic health records (EHRs), Care System Biomedical Engineering in Boston, those efforts are shining a light on the inadequahas a vision for the next generation of medical cies of medical device interfaces, he says. devices working in clinical environments: those Presently, it’s possible to start a transfusion on devices will interconnect freely with each other a patient knowing that the patient could have a and will readily integrate with medical systems. transfusion reaction, but the best one can do is The result, he says, will greatly improve patient monitor the patient, says Goldman. “We still care and reduce medical accidents. don’t have a way to stop the infusion pump usThat vision is a far cry from today’s clinical ing additional data,” he says. Stage 3 meaningful environments, but the industry has reached a Julian Goldman, M.D. use talks about knowing which devices are on the critical threshold for connectivity, says Goldpatient, which means that it will be necessary to man, who is also director of Medical Device Plug and Play (MD PnP), a group that was formed 10 years ago to read the device ID through the network. Goldman has taken a systems engineering approach to promote medical device interoperability. He says technology is moving toward smarter sensors and actuators, but believes device interoperability, encompassing the acquisition of the the real driver will be connectivity technology, which will open data, where it is being transmitted, and existing barriers to its deployment and implementation. Much of his work as foup new categories of devices. Goldman notes that hospitals are not in the business of cused on focus medical body area networks (MBANs), which building these devices and filing with the FDA (Food and Drug are low-power wide area networks that consist of multiple 32 March 2014 • www.healthcare-informatics.com

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is able, in the device itself, to handle some of the basic worksensors, worn on the body that transmit data to controllers. The technology has been gaining momentum since the Fed- flow functions. According to Gee, the next big milestone in Stage 3 meaneral Communications Commission (FCC) allocated a spectrum for MBANs in May 2012. Among the vendors that have ingful use from a connectivity standpoint is interoperability of infusion pumps. “One of the problems of a drug been developing MBAN-based technology are error reduction system is supposed to solve is GE Healthcare and Phillips Healthcare, accordthat you misconfigure the pump because you are ing to Goldman. doing it manually,” he says. Yet automating comGoldman considers MBAN technology an plex workflows has proven to be very difficult. enabler of miniature smart devices. Localized Historically, third-party vendors have been devices can, for example, provide better bed dequicker to respond to market demands than tratection for the patient who gets out of bed and ditional medical device manufacturers, many of starts wandering. “We will have better sensors which view connectivity and workflow beyond that enable patients to get up soon after an inthe direct use of their products to be outside their jury or surgery, and see if they are ambulating comfort zone, Gee says. Yet medical device mansafely. We can do some of those things today; it’s ufacturers that have done so have distinguished just that those devices are more cumbersome themselves and helped transform their segment and more limited,” he says.” Tim Gee of the market. One example is Alaris, a brand of Mainstream devices such as activity sensors San Diego-based CareFusion Corp., which develconnect to platforms—smartphones or laptop computers—that have been designed from the ground up to oped the first drug-error reduction system for infusion pumps. Other areas where Gee has observed a lot of development accept them. That can serve as a model for their clinical counterparts, which don’t yet exist, but are under development, he activity include alarm notification systems, devices that monitor for routine tasks performed at the bedside, and ventilator says. Goldman says that progress has been made in laying the systems. He notes that major ventilator companies are introfoundation for an ecosystem for interoperable medical prod- ducing new products this year and next year, and he suspects ucts. The FDA has issued mobile medical application regu- that those products will have more connectivity on them. latory guidance, which he sees as a pathway to implement medical applications on standard off-the-shelf computing IS TECHNOLOGY OUTPACING hardware. He notes that there is a demand among hospitals to PATIENT SAFETY? drive open interfaces as a means for them to swap equipment. Mac McMillan, co-chair of the HIMSS Policy and Security He adds: “We are starting to see some convergence, and we Policy Task Force and CEO of Austin, Texas-based CynergisTek, Inc., is concerned that technology has leapt ahead of the controls that need to be in place to what they do in a safe manner. This is especially a problem with medical devices that interconnect or support a patient’s health directly, he says. Medical devices weren’t networked or able to be remotely controlled until 2006, are no longer hearing large companies say, ‘our hospitals, our and by 2014, 98 percent of the devices can be networked or customers, don’t want this.’ Two years ago, that’s what I heard. communicated with, he says. McMillan says there is a large number of devices that That’s progress.” were never designed to communicate within a network, but VENDORS ADVANCE TOWARD are doing it now. “They are not engineered securely and SMART DEVICES often are not implemented securely,” he says. He sees two Tim Gee, principal at Medical Device Connectivity, Beaverton, basic issues: one is the integrity of the device itself and the Ore., says there a strong market demand for workflow auto- platform it runs on; and the other is the communication mation and integration of medical devices. He defines a smart link between the device and the middleware or the device device as one that knows the patient it is associated with, and and the back end. There are no regulations that say the

WE ARE STARTING TO SEE SOME CONVERGENCE, AND WE ARE NO LONGER HEARING LARGE COMPANIES SAY, ‘OUR HOSPITALS, OUR CUSTOMERS, DON’T WANT THIS.’ TWO YEARS AGO, THAT’S WHAT I HEARD. THAT’S PROGRESS. —JULIAN GOLDMAN, M.D.

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medical device operating system has to be supportable or upgradable, he says. The problem has engulfed three groups, which McMillan says have yet to arrive at a consensus on how to address the issue: provider organizations, device manufacturers and the FDA. McMillan sees three possibilities to fix the problem. First, manufacturers decide on their own to establish standards for building devices that are compliant with privacy and security requirements. Second, hospitals influence the market with their buying decisions. Third, and most likely in McMillan’s view, the FDA, which has the authority to implement a rule, does so.

So far, the agency has been reluctant to do that, but that may be changing, McMillan says. Last year the FDA issued two sets of guidance: One concerned things that should be considered in pre-market development and post-market implementation of the device. The other lists things to consider from a radio-frequency perspective. Both are guidelines only, not enforceable as law. “The bottom line is that the FDA could take that guidance and turn them into rules, and the medical device vendors would no choice but to follow them,” McMillan says, which he believes is a possibility. “If we all know it’s a problem that we can’t agree to do something about, if the providers aren’t capable and the vendors aren’t willing, Uncle Sam, that’s when you get involved,” he says.

Trend: Security and Privacy

PERFECT STORM RAPIDLY EVOLVING TECHNOLOGY, POLICY DEVELOPMENTS AND CONSOLIDATION ARE PUTTING NEW SECURITY DEMANDS ON PROVIDER ORGANIZATIONS BY JOHN DEGASPARI

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here’s a storm brewing in the healthcare security and Meeting security challenges and protecting patient data privacy arena that will stretch the resources of even will require extra vigilance, as well as rethinking how technolthe most nimble healthcare provider organizations, ogy and policy decisions can help minimize those risks, acas they face challenges on multiple fronts. On the policy side, cording to security professionals interviewed. providers will face steeper fines for breaches, backed up with COMPLIANCE ISSUES COME TO THE tighter enforcement. Meanwhile, rapidly evolvFORE ing medical devices, coupled with the emerCompliance in general is going to a big issue gence of mobile devices in the workplace, are reacross the board for all CIOs, according to Micky quiring that providers reevaluate their security Tripathi, founding president and CEO of the policies. At the same time, new care delivery and Massachusetts eHealth Collaborative (MAeHC), communication models, such as accountable Waltham, Mass., who has also named co-chair care organizations (ACOs) and health informaof the Office of the National Coordinator Tiger tion exchanges (HIEs), are remaking the healthTeam, a workgroup on privacy and security iscare delivery landscape—and the security and sues. He notes that the Health Information Porprivacy policies that go with it. tability and Accountability Act (HIPAA) Omnibus As if this was not enough, these developments Rule has raised the penalties for breaches signifihave been taking place at a time when data cantly—to as much as $1.5 million per incident. breaches at healthcare provider organizations Micky Tripathi Tripathi expects to see more compliance audits are on the rise. In 2013, medical identity theft from the Department of Health and Human Serwas up 20 percent compared to the year before, according to a report released last September by the Traverse vices’ Office of Civil Rights (OCR). “Starting with the passage City, Mich.-based Ponemon Institute. Malicious attacks have of HIPAA Omnibus, they have upped their diligence around increased in number as well as the level of sophistication, say these audits, because they realize that with these electronic systems, there is a different type of exposure they need to be experts. 34 March 2014 • www.healthcare-informatics.com

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on top of; and as these rules are getting more stringent, they need to do more audits,” he says. Mac McMillan, co-chair of the HIMSS Policy and Security Policy Task Force and CEO of Austin, Texas-based CynergisTek, Inc., agrees, noting that the heightened HIPAA requirements have strengthened the bond between covered entities and their business associates. Formally, business associate agreements are required; but informally, the risk is much higher, because if business associates have a breach, they are going to be investigated, he says. If a provider’s vendor experiences a breach, the covered entity must make all of the notifications to the affected parties and media; and when a vendor is investigated, the OCR is going to want to know how the relationship is defined and managed by the covered entity. The upshot: “You can’t just give the vendor a business associate agreement and say, ‘I’m done.’ You have to have more visibility into what they are doing and whether they can meet their obligations,” he says. In addition to all of this, the rapidly increasing level of consolidation and affiliations taking place in healthcare today, as the result of trends such as accountable care and HIE, is putting extra security demands on organizations. This has raised

sure the diligence is applied to the smaller practices under your umbrella.” Tripathi offers this advice to organizations: first, consider the nature of the affiliations involved, and the nature of the information that is going to be exchanged to support the clinical and business models that are being put in place. If the nature of the relationship is limited—such as jointly sharing some specialists who will work part time at each hospital—it may be possible to enable technology to support only that limited type of integration, which will limit the risk of the organizations involved, he says. Second, take a look at the orchestration of technology and policy controls. In some cases, technology can implement the policy—for example, allowing physicians to see only the patients with whom they have a care relationship, by locking down areas of the electronic health record. Policy controls should be strengthened where technology can’t be used as an enforcement mechanism, he says.

KEEPING TECHNOLOGY CURRENT McMillan observes that technology is an essential tool against security threats, but can also be a significant vulnerability if it is not kept current. As a tool, encryption will be one of the top security issues for the foreseeable future. “We are still losing devices that are not encrypted,” he says. Within the enterprise, healthcare provider organizations need to do a better job of privacy monitoring—“paying attention to what people are doing ion our system. We still have way too many incidents occurring where authorized users are looking at things they are not supposed to, or getting involved with medical identity theft with the access they have,” he says. Fortunately, data-loss prevention (DLP) technology has proven effective in helping CIOs enforce their security policies and avoid breaches before they happen. “We are just beginning to see DLP become recognized for the benefit it provides to healthcare in avoiding a lot of these things,” he says. Yet McMillan sounds the alarm on end-of-life or obsolete operating systems—particularly Microsoft’s announcement that it will cease to support the XP operating system in April. He points to factors that make this a bigger issue than normal. One is that there is increasing evidence of malware, both in terms of the frequency of directed attacks as well as more malicious and sophisticated forms of those attacks. At the same time, anti-virus solutions that organizations have relied on to protect themselves from malware are only about 60-percent effective. “That means that 40 percent of the stuff they don’t even see it anymore; so the more systems you have in your environment that are not up to date, the higher the risk,” he says. This is happening as the normal refresh rate of operating

THE ISSUE OF END-OF-LIFE SYSTEMS AND THE WAY WE PROTECT AGAINST MALWARE TODAY IS A BIG ISSUE THAT HOSPITALS ARE GOING TO HAVE TO START THINKING ABOUT DIFFERENTLY IN ORDER TO ADDRESS EFFECTIVELY. —MAC MCMILLAN significant technology challenges, according to Tripathi. In some cases, hospital systems try to wipe the slate clean of disparate systems and put everyone on the same network with a single set of technology controls around security and uniform policies around them, he says. Most often, the result of such efforts is a hodgepodge of different acquired platforms, raising the challenge of enforcing uniform security across disparate systems. In fact, consolidation and acquisitions raise a host of issues around the need to control access to patient records for physicians from affiliated organizations—a challenge that becomes especially acute in the ambulatory world, with organizations that are setting up private HIEs. “Ambulatory tends to be a whole different world,” Tripathi says. “How do you bring all of those users under the same security and policy umbrella, where they have a different system and they have been operating under less formal policies? Now they are part of a bigger enterprise, and you have to extend your policies out to make

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systems is compressing, from the once-typical three-year refresh cycle to 18 to 24 months. “Everything is happening so much faster, so end-of-life is happening so much faster,” he says. “The issue of end-of-life systems and the way we protect against malware today is a big issue that hospitals are going to have to start thinking about differently in order to address effectively,” he says. George Bailey is the senior advisor of security at Purdue Healthcare Advisors, a not-for-profit organization in West Lafayette, Ind. Among his clients, many small- and mediumsized provider organizations have opted to stay with Windows XP well after the April cut-off date, he says, adding that some use specialized applications that are vendor-bound to XP. He acknowledges that traditional security vendors will continue to support XP, so organizations that have a management system for their XP systems are in a better position; and they can further protect themselves by isolating those systems where possible. On the other hand, he says, that fix doesn’t address the related issue of browsers such as Internet Explorer, which someday will also face end-of-life. He points out that Explorer is the primary browser for many web-based clinical

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applications, so those machines will be inherently susceptible to compromise. He recommends that organizations that have the ability to move away from XP should so, and those that don’t should restrict devices running XP, either with content filtering, putting them a segmented guest wireless network, or prohibiting Internet connectivity. Bailey also cautions that medical devices, which are increasingly networked, often run on embedded Microsoft Windows or Linux operating systems, and can’t be updated very easily. Those devices aren’t maintainable within the same ecosystem as desktops and laptops, so they aren’t running malware protection and generally don’t have security controls enabled on them, he says. Yet even those medical devices run within the hospital clinical electronic network, so have some level of protection. Another potential red flag is the “bring-your-own-device” trend, in which personal smartphones are making their way into the clinical environment. That can be a point of vulnerability in hospitals that haven’t fully segmented their BYOD and guest wireless networks, he cautions. ◆

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36 March 2014 • www.healthcare-informatics.com

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THE THREAT OF SECURITY BREACHES CAN FUEL PREVENTIVE STRATEGIES BY RICHARD R. ROGOSKI

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he inability of retail giants like Target and Neiman Marcus to protect customer data from an alleged foreign hacker got national attention recently. But when a large healthcare system experiences a security breach that puts the protected health information (PHI) of thousands of patients at risk, it is often the case that few outside of the industry ever hear about it. While healthcare IT security breaches have been increasing over the past few years, they are being detected much more quickly. Mac McMillan, co-founder and CEO

of Austin, Texas-based consulting firm CynergisTek Inc. and co-chair of the HIMSS Privacy & Security Policy Task Force, sponsored by the Chicago-based Health Information & Management Systems Society, says a growing awareness within healthcare organizations and higher levels of security put in place between 2000 and 2014 have helped reduce the number of major breaches. Although a number of the breaches now being reported are the result of lost or stolen mobile devices like laptops, tablets or smartphones, targeted attacks are on the rise. “There’s an increase in the use of malware looking

for specific types of systems,” McMillan says. Unfortunately, the adoption of newer technologies is putting more data at risk, he notes. “Healthcare has more information digitized now. Over 90 percent of patient information is in digital form.” That includes medical ID numbers, addresses, and medical history. “Patient information is more valuable now than credit card information,” he says. “If someone steals your medical identity, you can’t cancel your medical history.” Typically, this type of identity theft is used to set up false claims so that the

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Keeping Data Safe

FEATURE

person can receive expensive medical that can put personal data at risk, says care while the victim’s insurance com- McMillan. The younger generation, pany pays for it. which uses social media outlets like Leon Hoover, CIO of Hendry Region- Facebook and Twitter, tends to view al Medical Center in Clewiston, Fla., privacy differently than the older genpoints out that whatever care the thief erations that fashioned the current prireceived is also entered vacy laws. “Because they into the victim’s health share everything about record, which could rethemselves and share sult in non-payment by information liberally the insurance company with others, they don’t if the identity theft victim perceive a personal ever had to undergo the ownership of informasame procedure. tion,” he says. Aside from the ease RECENT BREACHES with which digital data Cottage Health Syscan be compromised, are tem in Santa Barbara, the emerging trends in Calif. reported in early managing and deliverMac McMillan December that a thirding IT services, McMillan party vendor appeared says. These include cloud services, mobile apps, social media, tex- to have removed electronic security ting and the use of third-party service protections from one of its servers without informing Cottage, resulting in the providers. Nader Mherabi, senior vice president, exposure of patient information stored

OVER 90 PERCENT OF PATIENT INFORMATION IS IN DIGITAL FORM. PATIENT INFORMATION IS MORE VALUABLE NOW THAN CREDIT CARD INFORMATION. IF SOMEONE STEALS YOUR MEDICAL IDENTITY, YOU CAN’T CANCEL YOUR MEDICAL HISTORY. —MAC MCMILLAN vice dean and CIO of NYU Langone Medical Center in New York, agrees. “As healthcare services move online and patients become more directly engaged in their care processes, security and safety issues loom ever larger. At the same time, the proliferation among our faculty, staff and students of sophisticated devices such as smartphones and laptops, and the necessarily collaborative practices of our research and educational missions pose additional challenges.” Mike Fleck, CEO of CipherPoint Software, Inc., Denver, notes, “There is pressure to make more information available to patients. But anytime you have a new way of doing business, you’re going to increase the risk of exposure.” There may also be a generation gap 38 March 2014 • www.healthcare-informatics.com

on a server. The information that may have been compromised involved patients treated at Goleta Valley Cottage Hospital, Santa Ynez Valley Cottage Hospital, and Santa Barbara Cottage Hospital, between September 29, 2009 and December 2, 2013. While no one from Cottage Health agreed to be interviewed for this article, a press release dated Dec. 11, 2013 says the file contained information on approximately 32,500 patients including “the name, address, date of birth, and very limited protected health information for some patients related to diagnosis, lab results, and procedures performed. The file did not include any Social Security numbers, driver’s license numbers, health insurance numbers, bank account numbers or any other fi-

nancial information.” Cottage Health removed the server from service; conducted a review of all other servers; began an audit of its security protocols; and mailed letters to each of the affected patients. Steve Fellows, executive vice president, COO and chief compliance officer at Cottage Health, states in the press release, “We deeply regret this incident. Cottage takes its obligation to protect health information very seriously and is taking aggressive steps to safeguard against this type of incident in the future.” Another recent breach occurred at AHMC Healthcare Inc., a six-hospital system in Alhambra, Calif. In this case, two laptops were stolen from a secure office on Oct. 12, 2013. The laptops contained information on approximately 729,000 patients—one of the largest HIPAA privacy breaches on record. Again, officials at AHMC declined to be interviewed. But a press release dated Oct. 21, 2013 says the laptops contained data on patients treated at Garfield Medical Center, Monterey Park Hospital, Greater El Monte Community Hospital, Whittier Hospital Medical Center, San Gabriel Valley Medical Center and Anaheim Regional Medical Center. The press release also states: “The protected health information contained in the laptops includes patient names, Medicare/insurance identification numbers, diagnosis/procedure codes, and insurance/patient payments. “At this time, AHMC Healthcare Inc. has no evidence that the information has been accessed or used in any manner, but because this cannot be ruled out, this notice is being provided out of an abundance of caution and in order to comply with the legal obligations of the hospitals.” It further states: “AHMC Healthcare Inc. had recently engaged a third-party auditing company to perform a security risk assessment and is working through its recommendations, and in that connection will be expediting a policy of encrypting all laptops.” A major breach also has also been reported by UW Medicine in Seattle, Wash.

PREVENTING A BREACH Although McMillan doesn’t believe patient information belongs on a personal mobile device, he says the growing use of these devices and the use of texting as a primary means of communication demands that efficiency be balanced with protection. “We need to work with the workforce to make it easier to do their job but to secure their texts,” he says. “The simplest way is to encrypt it.” The same is true for email. “The average email encryption solution costs less than $100,000,” he says. “Everything costs money, but if you look at overall costs, a breach can cost a lot more than the protection.” Ed Ricks, vice president of information services and CIO of Beaufort Memorial Hospital in Beaufort, S.C., admits that a majority of his hospital’s physicians use their mobile devices for texting, but he says, “We now have an app to encrypt their text messages, which is HIPAA compliant.” Protecting email is a little different. “We do have an encrypted email system. Internal email is on our secure network,

but those going offsite protect sensitive messagare not always encryptes and data residing on ed,” Ricks says. portable devices such as While Fleck views enlaptops, phones (includcryption as one security ing end user-owned desolution, he says there vices) and USB drives,” he also needs to be controls says. “We continually rein place to follow the view our technology posdata. “It’s trying to conture and policies to meet trol the use of informaand minimize threats to tion by a certain number the Medical Center’s enof users, but if you can’t vironment and data. It is Ed Ricks actually follow the data, NYU Langone policy that you can at least know storing PHI on any unenwhere the information crypted mobile device is goes,” he says. unacceptable. Hoover agrees. “A “Because we are comlot of people focus on mitted to protecting the what’s coming into the privacy and security of network, not what’s goour patients’ medical ing out,” he says. He information and other adds: to ensure true sensitive information, we data security, you have have taken affirmative to address data in rest, steps, including moving data in use and data in protected health informotion. mation from desktop In some cases, computers to secure netLeon Hoover though, information work drives and retrainthat needs to be shared ing staff regarding proper among many entities safeguarding of private creates what Fleck calls patient information.” a “cultural” challenge. As for offering advice “Many big hospitals are to CIOs concerned about linked with educational data breaches, Ricks says, systems, and some re“The best thing is to be search is linked to the open to visibility. UnderNational Institutes of stand your vulnerabilities Health,” he says. “Folks and understand where aren’t trying to change your risks are.” that culture, but to put Adds Hoover: “It’s all controls on that culabout discovery and preture—to be aware of vention. It’s about watchNader Mherabi what is going on with all ing that data in motion that information.” and knowing who is acThat hasn’t been a problem for NYU cessing that data.” Langone, which, according to Mherabi, Fleck says he’s pleased to see the efhas instituted strict policies concern- forts being made to protect patient ining the storage and transmittal of data. formation, but he says more needs to “The NYU Langone Medical Center em- be done. “If this is not a top priority, it ploys various technologies to secure should be.” He also says that most CIOs information at rest and in transit on its now have an actionable strategy to prenetwork, including firewalls to control vent breaches. “Some look at it in terms inbound malware, digital loss-preven- of building blocks—devices, networks, tion systems to control outbound PHI applications. Encrypt your devices, en(protected health information) and crypt your networks and secure inforother sensitive data, and encryption to mation in applications,” he urges. ◆ www.healthcare-informatics.com • Healthcare Informatics 39

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Although officials declined to be interviewed, a press release dated Nov. 27, 2013 explaines how the breach occurred. “In early October 2013, a UW Medicine employee opened an email attachment that contained malicious software (malware). The malware took control of the computer, which had patient data stored on it. UW Medicine staff discovered this incident the following day and immediately took measures to prevent any further malicious activity. “Based on the results of an internal investigation, it is believed that patient information was not sought or targeted. However, the malware accessed the data files of roughly 90,000 Harborview Medical Center and University of Washington Medical Center patients.” The press release further states: “Data about patients may have included: name, medical record number, other demographics (which may include address, phone number), dates of service, charge amounts for services received at UW Medicine, Social Security Number or HIC (Medicare) number, date of birth.”

CIO PERSPECTIVE

Edward Marx, CIO of the Year, ‘Bullish’ on HIT AWARD HONOREE DISCUSSES OPPORTUNITIES, CHALLENGES FOR THE INDUSTRY BY RAJIV LEVENTHAL

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n Jan. 13, 2014 Edward Marx, senior Edward Marx: It’s really an external validavice president and CIO of the Arlingtontion of our organization, and how we have levbased Texas Health Resources, was eraged IT. I get it, it required leadership, and selected as the recipient of the 2013 John E. Gall I’m very honored and humbled, but certainly I Jr. CIO of the Year, an award given by the College don’t think of it as an individual achievement. of Healthcare Information Management ExecuInstead, it’s about what our organization has tives (CHIME) and the Healthcare Information been able to do over the last six years, with and Management Systems Society (HIMSS). leveraging technology to improve clinical Marx’s distinguished career in the healthcare outcomes. industry spans 24 years, 16 of which have been A LONG-TERM INVESTMENT IN I.T. spent as CIO.  Concurrent with his career in HCI: What has Texas Health been able to do to healthcare, he served 15 years in the Army leverage IT? Reserve, first as a combat medic and then as a Edward Marx Marx: Well, it’s funny, because they call the combat engineer officer. award CIO of the Year, but it’s really about Marx has been leading the 14-hospital Texas Health Resources’ innovative technology services profession- what you have done year after year in the industry. At Texas als in developing and implementing strategies to enhance Health, we have demonstrated how to master the art of EHR the patient and provider experience through the application implementation and optimization. We were one of the first to of IT since 2007. Prior to joining Texas Health, Marx was CIO successfully implement, and now we’re going through multiple of University Hospitals Health System of Cleveland. He previ- stages of optimization. It requires the entire health system, ously served in a variety of IT leadership roles with healthcare including leadership and culture, to make that work. We were also [one of the first] organizations to [receive organizations such as Hospital Corporation of America (HCA, Nashville, Tenn.; Parkview Episcopal Medical Center, Pueblo, incentives] for meaningful use; we are now at Stage 7 [in the Colo.; and Poudre Valley Health System (now University of HIMSS Analytics Electronic Medical Record Adoption Model] in all of our hospitals; we received the 2013 HIMSS Enterprise Colorado Health), Fort Collins, Colo. Recently, Healthcare Informatics Assistant Editor Rajiv Lev- Davies Award; and we have won numerous other awards for enthal spoke one-on-one with Marx about his contributions to innovation and technology. It’s an accumulation of things that the industry, why his leadership approach has been successful, have led to this recognition, and that’s why I call it an enterchallenges he has overcome as CIO, and the current and future prise award. Personally, I have been very involved with CHIME and HIMSS on a national level too, and that has helped further state of healthcare IT. Healthcare Informatics: First of all, congratulations on this the cause of healthcare IT. It all blends together. HCI: How important is it to plan for EHR optimization postrecognition. What is the significance you take out of the implementation? award? 40 March 2014 • www.healthcare-informatics.com

CIO PERSPECTIVE Marx: It’s one thing to implement the EHR, but it’s more about, “How do we optimize it? How do you move the needle on your quality outcomes?” For us, one example was the reduction of venous thromboembolism (VTE), or blood clots, which are the biggest killer of people once they come into hospitals. In fact, it kills more people each year than breast cancer, AIDS, and auto accidents combined. We put alerts in the EHR to help reduce the risk of getting blood clots during hospital stays, and in a few years, post-operative VTE rates were less than half of pre-program rates. The other was catheter-associated urinary tract infections, the most common infection people get once they are admitted to hospitals. Texas Health established criteria for urinary catheter removal by a nurse within 48 hours of insertion, if no physician order has been placed. We then modified and tested changes to 1,639 order sets within the system’s EHR, and deployed the changes to the entire health system. We

Marx: Well, they certainly add to everything else, don’t they? Like it’s not hard enough to do what we do without this other layer! But we prepare for it, we fit it into our schedules, and we work through it. With all of these regulations adding to the auditing, you’re looking at a good percentage of your time taken up by administrative, regulative activities. That’s a bummer, but we try to get through it as efficiently as possible so we can focus more on strategies. When challenges are presented, you handle them by learning from them. It’s never fun in [the moment], but if you take time and reflect, learn, and apply those lessons to the future, they become valuable. We take two-day retreats to reflect and also look forward. It’s your reaction to the challenges that are really important. HCI: You have been very humble and modest so far. Tell me about your most significant contributions to the industry, from a personal perspective. Marx: For me, it’s really all about leadership. Somehow you have to multiply yourself. I think I borrowed this from [author] John C. Maxwell, but, “One is too small a number for greatness.” You can do great things, but if you really want to have a greater impact, you need to multiply yourself. I have been grateful and humbled that [several] of my former employees have moved on to be CIOs or COOs. They are all making big impacts in their organizations. I am also a faculty member of the CHIME Healthcare CIO Boot Camp (a three-and-a-half-day education program taught by CIO health leaders). The idea is to keep the ball moving forward for healthcare IT, and I think in a few different ways I have done that. HCI: This past year in healthcare IT has been full of passion, but also sprinkled with gloom. How would you characterize the state of the industry? Marx: One of the coolest things that have happened to me recently is becoming a grandparent. My grandson is now eight months old, and can grab onto something and pull himself up. And that’s where we are in healthcare IT. We have finally got our legs; we are past falling, and are now able to pull ourselves up. But we are not walking yet, as this is a transitional state. Until we all have EHRs, we have a long ways to go. Fifty-seven percent of us are there now, so that’s what I mean by pulling ourselves up. There are organizations that are beyond that—they are walking, doing mobile health, advanced analytics, population health management. Overall, it’s an exciting time, and the stock valuations of a lot of these companies have gone up. Much more important than that though, we’re trying to have a demonstrative impact on quality outcomes. I’m a believer in healthcare technology impacting people’s lives, and that is what gets me going in the morning. I am very bullish on 2014. ◆

I SURROUND MYSELF WITH ABOVE-AVERAGE PEOPLE; SO TOGETHER, WE ARE ABLE TO MOVE THE BALL FORWARD. IT’S AMAZING WHAT A COLLABORATIVE APPROACH COULD DO, ACCEPTING AND EMBRACING THE INPUT OF OTHERS. —EDWARD MARX were also able to identify high-risk readmission patients, and sent them home with technology, which they applied. As a result, readmissions have been reduced by 25-30 percent. We’re never done optimizing; those are just three examples. We’re very fortunate that we have progressive leadership, people who said a few years ago that we needed to prepare for down the road now. We took a lot of steps to get ready, we were a pioneer accountable care organization (ACO), we were involved in several other ACOs, and we were very active in care management, connected health, and population health. The future is here now and you have to prepare for it.  

A TEAM-BASED APPROACH HCI: How would you describe your leadership approach to IT management? Marx: There are many styles that work, so it’s really about the culture of the organization. I am very collaborative. I know I’m not the smartest person; in fact, I am probably an average person. I surround myself with above-average people; so together, we are able to move the ball forward. It’s amazing what a collaborative approach could do, accepting and embracing the input of others. HCI: Your job is obviously a highly stressful one. How are federal mandates adding to the burden?

www.healthcare-informatics.com • Healthcare Informatics 41

IMAGING PERSPECTIVE

Beyond Interpretation HOW RADIOLOGISTS CAN SURVIVE IN A VALUE-BASED CARE MODEL BY RAJIV LEVENTHAL

A

t last December’s Radiological Society of North value-added matrix, which is a copyrighted document that America (RSNA) conference, Mary C. Mahoney, M.D., identifies 36 categories of value that have nothing to do with chair of RSNA’s Patient-Centered Radiology Steer- film interpretation, says Patel. “All of the radiologists have ing Committee, said that radiologists must be portrayed “as scorecards, and any time someone performs a value-added knowledgeable physicians—the imaging experts—and show activity, they fill out a piece of paper and send it to the centhat we’re patient advocates by demonstrating concern and tral billing office, which then gets tabulated into a database,” knowledge about safety and risks. Many patients don’t even says Patel. “We can quantify all the different value-added know we exist. We can’t just be a name on a bill.” activities that we do, such as hours spent on conferences, Optimizing the entire patient experience means that on committees, transcription time, teaching, and research.” radiologists need to go beyond image interAt Elkhart General in 2012, the team of rapretation and get involved before and after diologists documented 3,000 hours of valueexams. This is the idea behind Imaging 3.0, a added services to the hospital. In 2013, the call to action—led by the 36,000 members of organization took this to the other hospitals the American College of Radiology (ACR)—to it covers, and through the first 10 months of all radiologists to take a leadership role in last year, has documented more than 6,000 shaping America’s future healthcare system. hours of value-added services within the Additionally at the RSNA conference, Bibb group. “We presented this to administration. Allen Jr., M.D., vice-chair of the ACR Board of The value management program, to sum Chancellors said in a presentation, “It goes up, is invested, aligned, citizenship actions beyond interpretations. It’s about assuring optimizing value-added patient-centered appropriateness, documenting the quality outcomes,” says Patel. “The idea is basically to and safety radiologists provide, actionable quantify, document, and present all the nonSamir Patel, M.D. reporting with evidence-based follow-up, interpretation services we do, and present to and empowered patients. We would have a our customers—the hospitals—what we’re measurable role for radiologists in improving population doing.” health and we would have a calculation of radiology’s value Patel says he recently presented this information to in reducing per capita cost.” leaders at the Beacon Health System (an affiliation of Elkhart General and the South Bend, Ind.-based Memorial HONING SKILLS FOR VALUE-BASED CARE Hospital), and they are now beginning to see the true value One organization that has begun to make strides in this area of the services radiologists provide. Radiology is unique in is the north central Indiana-based Radiology, Inc., a 109-year that many other specialties are behind it in terms of being old independent radiology group. Samir Patel, M.D., leads able to measure its services, Patel says. “No other specialty the team of 28 radiologists, and stresses the importance of is providing this quantification of all of the other [things] current and next-generation radiologists building out their that we have to do. This is something that I have not seen skills sets beyond report interpretation in order to survive anywhere else,” he says. in a value-based care model. “Other specialties need to not only perform, but to Last year, Radiology, Inc, which services Elkhart General document, quantify, and present everything they do to their Hospital in Elkhart, Ind., two other hospitals in the state, customers, who will primarily be hospital administrators and several outpatient centers, began to implement a and referring physicians,” Patel continues. “Here, many of 42 March 2014 • www.healthcare-informatics.com

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that-rather than me just saying what we do, we can now quantify it. Health systems that have been presented with this now have a better understanding [about radiologists], which is important because most physicians think all we do is read films:'

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show hospitals what services the radiologists are providing, but to demonstrate what the customer is getting out of it. "Last year, we provided the hospital with the outputs, or outcomes, which were 105 key performance indicators on what it received from our services. An example of this was turnaround time metrics that we monitored to them, as well

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as 20 national imaging accreditations and designations that partly came from our work;' says Patel. Additional value included more than 4,000 critical test

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more than 400 hours of transcriptionists' time, according to Patel. "The 3,000 total hours were on the input side, while these were things on the output side;' he says. Moving forward, Patel sees increased pressures on radi­

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ologists as the industry moves to a value-based care model. "Not only will we see radiologists having to interpret images at a very high level, but they will also have to document and perform all these other activities. I don't think this will be an option, but a requisite for survival;' he says. However, if these services are performed, quantified, and documented, then the outcomes will be improved, Patel says. "The ultimate judges are our administration and our referring providers;' he says. "[Elkhart General] just recently did an internal survey of physicians, and the radiology

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department scored the highest in terms of quality service and accuracy of interpretation. That told us we were on the right path:' Disproving the many misconceptions about imaging is also important to the future of radiology, Patel feels. According to him, people think there is an overutilization of imaging in certain aspects, as well the perception that radiologists recommend too many studies, and the idea that anyone can read a film. Further, Patel says, there is a misconception that medi­

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cal imaging is the only reason for high health costs and is a major reason for spiraling health costs. "These are myths without support;' he says. "It is significant for radiologists to educate everyone on the outside on what exactly the field is and all of the benefits we provide. Radiologists need to be engaged at all levels:' •

www.healthcare-informatics.com

•

Healthcare Informatics

43

ACO PERSPECTIVE

Flourishing as a Collaborative Payer Model in Missouri ESSENCE HEALTHCARE IS ACCOMPLISHING HEALTHCARE’S TRIPLE AIM ‘PLUS ONE’ BY RAJIV LEVENTHAL

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s reimbursement cuts and other payment changes put intensifying pressure on physicians and medical groups, accountable care offers new opportunities for collaboration between payers and providers. Over the 44 March 2014 • www.healthcare-informatics.com

last decade, health insurers across the country have been practicing aspects of accountable care through the collaborative payer model, a care delivery innovation jointly developed by a payer and provider in which operational

ACO PERSPECTIVE support tools, information, and technology pharmacy, lab, and other available data. It help manage patient populations. rationalizes that data to establish a unified, accurate view of patient care and population In Missouri, Esse Health—a group of about health, she explains. 70 primary care physicians in the St. Louis area—started Essence Healthcare in 2004, an “As CMO of Essence, I use the ADSP every insurer that offers coverage under the Mediday to evaluate performance on quality, cost care Advantage program, and serves more and utilization measures, and look for both than 40,000 members. Essence Healthcare clinical and financial improvement opporprovides its network of providers a collaboratunities,” Zimmerman says. “My care mantive payer model. agers use the platform to manage high-risk Essence was an early adopter of the cloudpatients and close gaps in care. My director based accountable delivery system platform of quality improvement uses the platform (ADSP) from St. Louis-based Lumeris, which Deborah Zimmerman, M.D. to monitor performance on quality metrics.  provides operational support to Essence Our networked physicians use the ADSP to Healthcare and Esse Health. ADSP was purmanage the health of their patients to view pose-built for population health management, and helps care reminders to close gaps in care, as well as to stratify the plan integrate claims and patient data from across the their patient populations by needed interventions, outcontinuum of care to create a holistic and accurate view of reach score and disease state.” plan performance against various cost, quality and utilization metrics, says Deborah Zimmerman, M.D., who is chief PHYSICIAN EMPOWERMENT PAYS OFF medical officer of both Lumeris and Essence Healthcare, a The underlying key to success, says Zimmerman, is phyrole that allows her to focus on clinical quality. “This posi- sician engagement and satisfaction, something that she tion suits me perfectly as a physician, because I get to help strives for as Lumeris’ CMO. “Through the right incentives, tools and information, we empower physicians to change other providers succeed in value-based care,” she says. their behavior and make better-informed, value-based DATA ACROSS THE CARE CONTINUUM decisions. The results that we’ve achieved with Essence Via the ADSP, Essence pinpoints opportunities for improve- Healthcare map well to the Triple Aim ‘plus one’ in terms ment in these areas and then engages primary care physi- of cost, quality and patient plus physician satisfaction,” she cians in the network to address them via a host of web- says. based platform applications and tools. There are more than In terms of cost, Essence has seen a 30-percent reduction in 150 quality metrics in the platform, including the 33 met- cost when compared to fee-for-service Medicare, reports Zimrics that are part of the Medicare Shared Savings Program merman. In terms of quality, the health plan has maintained (MSSP) accountable care organization (ACO), Healthcare Centers for Medicare and Medicaid Services (CMS) 4.5-star ratEffectiveness Data and Information Set (HEDIS), National ing for three straight years, and in terms of patient satisfaction, Committee for Quality Assurance (NCQA), payer-driven ratings for the health plan are consistently above the national average in Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, and 95 percent of patients are seen annually. “Our plus one—physician satisfaction—is reflected in more than 80 percent of physicians rating that they are satisfied with Essence,” Zimmerman says. While accountable care involves risk and reward sharing, and is a departure from the feefor-service, volume-based care that the industry and other evidence-based care measures. “Our commit- is used to, Zimmerman believes it is truly the nation’s best ment to collaboration and information transparency has hope for achieving better health outcomes, lower costs, and enabled the plan to achieve significant reductions in over- improved patient plus physician satisfaction. “As the market all costs while improving quality performance, as well as evolves from fee-for-service to value-based care, [we are] helpmember and physician satisfaction,” Zimmerman says. ing providers assume more risk for managing their patients According to Zimmerman, ADSP aggregates and ana- and populations,” she says. “And [to do that], technology-enlyzes data from across the continuum of care—includ- abled solutions [are needed] to solve some of the industry’s ing electronic medical record (EMR) encounters, claims, biggest challenges.” ◆

THROUGH THE RIGHT INCENTIVES, TOOLS AND INFORMATION, WE EMPOWER PHYSICIANS TO CHANGE THEIR BEHAVIOR AND MAKE BETTER-INFORMED, VALUE-BASED DECISIONS. —DEBORAH ZIMMERMAN, M.D.

www.healthcare-informatics.com • Healthcare Informatics 45

DATA INTEGRATION UPDATE

Integration Comes to Life in Michigan HOW ONE HOSPITAL BROUGHT TOGETHER MANY DISPARATE PLAYERS TO LAUNCH A HIGHLY INTEGRATED ‘INTELLIGENT’ CARE DELIVERY SYSTEM BY GABRIEL PERNA

I

n southeastern Michigan, St. Joseph Mercy Oakland, a 443-bed facility in Pontiac that is part of CHE Trinity Health, a Catholic-based healthcare system, has laid down an impressive foundation for integration, bringing multiple information systems together. Integration at St. Joseph’s came about because of a convergence of events. First and foremost, the hospital announced in 2011, that it was building a $150 million, technologically advanced patient tower. Around the same time, it began shifting its philosophy to a more private environment for its patients, 46 March 2014 • www.healthcare-informatics.com

focused particularly on safety. “One of the things that the board said to our CEO, Jack Weiner, was that we had to do something that was different. If we were investing the money to build this tower, we had to do something that was really going to improve patient safety, quality-of-care, and benefit the patients coming into our facilities,” explains Robert Jones, the director of IT at the hospital. Leaders at St. Joseph’s recognized that the demands being put on caregivers were, in Jones’ words, “astronomical.” With the mounting number of tasks that clinicians were being

DATA INTEGRATION UPDATE required to do, the hospital’s leadership wanted make sure the clinicians were at the patients’ bedside—where they need to be for patient care and safety, he says. St. Joseph Mercy Oakland formed a collaborative team, with both IT and clinical representatives, and tried to determine what kinds of technologies could be implemented to improve a caregiver’s workflow. “We wanted to involve our caregivers in the process as we looked for this technology,” Jones says. As the team at St. Joseph Mercy Oakland began to search for a system, they determined that integration was going to be vital if they were to improve workflow and patient safety. It was then that idea of the Intelligent Care System began to take shape.

INTELLIGENT CARE SYSTEM 101 The Intelligent Care System, St. Joseph Mercy Oakland’s homegrown integration engine, is comprised of multiple vendor products. This includes a Cerner EMR and connectivity platform, Voalte’s voice over IP computing (VOIP), Hill-Rom’s nurse call and “smart bed” system, a real-time location system (RTLS) through CenTrak, GetWellNetwork’s patient education and entertainment system, Sotera’s wireless vital sign monitoring technology, and vital sign analysis interpretation from Visensia. The Intelligent Care System uses iBus from Cerner as middleware to bring these various technologies together and act as the connectivity architecture. The hospital takes information from these various systems, sending it through the iBus, and integrates it at the point of care. For example, through iBus, the hospital is able to send information from its smart bed system to a caregiver’s phone. As Jones tells it, when a patient who is a falls risk starts to get out of bed, an alarm goes off. The alarm is sent from the HillRom system, through the middleware, to an alert link ( from Cerner), which then sends it to the appropriate caregiver. The caregiver, gets that information sent to his or her iPhone through the Voalte platform. “Before that patient starts to exit that bed, that nurse [who is not in the room] can say, ‘Mr. Smith, please do not get out of bed. Will you stay in the bed? I’m on my way there.’ So you now you start to minimize and reduce falls related to that,” Jones says.

NOT A SINGLE TECHNOLOGY St. Joseph Mercy has integrated the various vendor systems with the Intelligent Care System in other ways, incorporating nurse call, patient education and RTLS technologies to detect specific performances of its staff as it relates to hand hygiene and infection prevention practices. The hospital is also working on automatically recording and transferring vital sign and other data into the EMR. Ultimately, through this integration, Jones says the possibilities are endless.

“The beauty of it is it’s not one single technology that we have. Having this middleware in place allows us to grow the technology. That was one of our drivers. With this technology, we’re not looking at just today. Technology will change. Technology today will be different where we are a few years from now. We decided to select a platform that will allow us to be able to grow. This technology is not going to become obsolete, it will grow with all of the changes that take place from a technology perspective,” Jones says. Down the line, Jones and his colleagues at St. Joseph Mercy Oakland have ideas for expanding the platform to include other technologies. He says the hospital would like its physicians to connect and share information with each other, regardless of the device they are using. It also would like to get into patient and asset location tracking, and have it interact with the nurse call system.  In the immediate future, when that new patient tower opens in May, the Intelligent Care System will be implemented for all 198 beds. Already, Jones says, it has been implemented in 90 beds. It has shown various degrees of success in a short period of time, with increased patient satisfaction and a reduction in falls.

GETTING VENDOR ALIGNMENT Getting multiple vendors, some of which compete against each other, to play nice was not the easiest of tasks, reveals Jones. He says one of the biggest challenges the hospital faced was simply bringing those vendors to the table and getting them to work together. “We were told that no one had tried to do what we’ve done. There have been bits and pieces. But no one has taken it to the point of integrating all of these technologies like we have. It was new from our standpoint and it was new from our vendor’s standpoint,” Jones says. “There were no lessons learned that we could use, we had to learn these things ourselves.” In addition to vendor cooperation, Intelligent Care System represented a paradigm shift for the St. Joseph Mercy Oakland staff. In that sense, Jones says the organization had trouble getting them to change their thinking and buy into the new environment. With the precedent now in place, Jones can offer advice and lessons learned. He says the most important thing to know is that collaboration is essential in order for a project like this to succeed. “This is not just an IT project. It has to be owned by the business unit. It’s really a clinical project, but it’s a project that touches all phases of your organization. You have to have a team that’s willing to work together, and you can’t become territorial. You can’t work in a silo approach,” Jones says, adding that this philosophy should be shared with vendors as well. “You have to sit down with them very early and share your vision.” ◆ www.healthcare-informatics.com • Healthcare Informatics 47

CAREER PATHS

New Hiring Rules CAN A PERSONAL HABIT BE A DEALBREAKER FOR HIGHLY QUALIFIED CANDIDATES? IF YOU ARE A SMOKER IN FLORIDA, MAYBE SO BY TIM TOLAN

T

he world of hiring in the healthcare IT is definitely changing. Recently, a new policy was implemented at a hospital in northeastern Florida to screen for smokers during the hiring process. As of Jan. 1 of this year, this hospital no longer hires tobacco users. You heard it. The local newspaper here reported that all new hires will be tested for a nicotine byproduct during Tim Tolan the hiring process—and sign off to remain tobacco-free throughout their employment. The policy has some wiggle room in that it does not apply to volunteers, medical staff or some of their employees already working at the hospital. This seems to be a policy that works well for existing workers but not for new recruits. Talk about a strange twist. This policy could help the hospital with improved tenure with their current employees who smoke. The hospital became smoke-free in 2009. It started charging $25 per paycheck for smokers who elected to take health insurance as an added reason to quit. All new employees hired after Jan. 1 who test positive for the nicotine byproduct are subject to disciplinary action—including possible termination. That’s a game-changer. The hospital offers free tobacco-cessation counseling to employees and their families to help them kick the habit! Flashback: It still bothers me to no end to visit a physician or hospital and see the medical staff gathered in groups smoking outside the office knowing they have to present a much healthier message once they are back inside visiting with their patients! I have unpleasant memories of our family’s primary care physician openly smoking in his office during a medical exam in during my younger days. When I think back to how wrong that was it makes me shake my head! For me, it was up for debate on which odor was worse—the cigarette smell that reeked throughout his office or the strong smell of rubbing alcohol that hit you 48 March 2014 • www.healthcare-informatics.com

like a ton of bricks the minute you walked into his waiting room. Let’s face it: the data on the risks of smoking have been around for years, but now all of the sudden the risk of being a smoker and getting hired in a healthcare system could change forever—at least here in Florida! As a hiring manager you have lots of things to think about when considering a new hire. In addition to the IT skills the candidate has you also have to think about how they will fit in with your team. Then there is the on-boarding process to make sure they feel connected with your organization as they get up to speed. Let’s not forget to check out your potential new hires on social media before you pull the trigger on an offer. Often you will be surprised or shocked at what they do when they are not working! Now (at least at this medical center in Florida) you have to know if they use tobacco products during the screening and interview process. A candidate’s health history is protected information for the most part—unless you are financially impacted by their bad habits. In many ways I get that. So what’s next? Do we add a “Do You Use Tobacco Products?” field to the application, or better yet, does that become part of the search firm’s responsibility to vet in advance of presenting them? The answer is, it does. Our firm was hired a couple of years ago by a healthcare organization in Texas that refused to hired smokers. We had to determine if a candidate used tobacco products during our screening process. We had to eliminate dozens of highly qualified candidates because of personal choices they made that would impact the employer’s healthcare costs. The world of hiring in healthcare is definitely changing. With 10,000 Americans retiring each day, the candidate pool for great HCIT talent will no doubt become much smaller and the fight for talent will surely heat up. Choosing not to hire employees that use tobacco will definitely drain the talent pool a bit more.◆ Tim Tolan is senior partner of Sanford Rose Associates-Healthcare IT Practice. He can be reached at [email protected] or (904) 875-4787. His blog can be found at www.healthcare-informatics.com/tim_tolan.

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