Healthcare Informatics

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Harnessing EHR Data

The Cloud: Hazy Outlook?

When Radiologists ‘Google’

January 2012

Volume 29, Number 1

MEANINGFUL USE www.healthcare-informatics.com

A ROCKY PATH AHEAD?

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CONTENTS January

DEPARTMENTS 4

INSIDE

6

EDITOR’S PAGE

28

HARNESSING EHR-DERIVED DATA

CLINICAL IT PERSPECTIVE For the first time in healthcare, three physicians at Lucile Packard Children’s Hospital have leveraged aggregate data from an EHR to help make a real-time diagnosis and treatment decision on a rare pediatric condition BY MARK HAGLAND

MEANINGFUL USE UPDATE

30

COVER STORY 8

14

IMAGING PERSPECTIVE

32

BY MARK HAGLAND RIS PERSPECTIVE

36

FINANCIAL UPDATE

40

ICD-10 UPDATE

44

BY JOE MARION

TRANSITIONING TO ICD-10 IN A MULTI-HOSPITAL SYSTEM G. Daniel Martich, M.D., CMIO of the University of Pittsburgh Medical Center, talks about the challenges the health system is facing in planning for the transition from ICD-9 to ICD-10

CARDIOVASCULAR INFORMATION SYSTEMS How relevant is CVIS in a healthcare landscape being transformed by meaningful use and ARRA? Healthcare leaders are split on whether EMRs will make departmental systems redundant or CVIS will remain essential to the cardiovascular workflow. Here’s an account of both sides of the issue

THE ‘NEW NORMAL’ REFLECTED IN HIT INVESTMENTS Despite tight budgets, a large percentage of healthcare provider organizations expect their largest capital investment over the next year to be in health information technology and telecommunications, according to a recent Premier healthcare alliance poll BY GABRIEL PERNA

BY JENNIFER PRESTIGIACOMO

23

MEANINGFUL USE SPURS RIS UPGRADE PLANS A recent survey suggests that the HITECH Act’s focus on stimulating the adoption of electronic health records is having a ripple effect on planned radiology information system investments as well BY JOHN DEGASPARI

BUILDING STAKEHOLDER TRUST IN HIEs What are the best governance models to ensure the long-term viability of HIEs? At a recent gathering hosted by the National eHealth Collaborative, HIE directors and state and federal officials set about the task of answering just that question

WHEN RADIOLOGISTS ‘GOOGLE’ A group of enterprising radiology informaticists at the University of Pennsylvania Health System have developed a highly innovative radiology search engine that enables radiologists to search their databases with ‘Google-like’ ease

A HAZY OUTLOOK FOR CLOUD COMPUTING Despite its promising potential for data storage, cloud computing has been off to a slow start in healthcare. CIOs, CTOs, and other healthcare leaders weigh-in on cost, security, and performance concerns in the emerging debate over the value of the cloud BY GABRIEL PERNA

20

Meaningful use was a hot topic at the recent AMIA annual conference, where presenters discussed challenges of meeting requirements, as well as sophisticated ways of using IT tools that go beyond digitizing paper records BY DAVID RATHS

TAKING THE NEXT STEPS TOWARD MEANINGFUL USE The turn of the New Year presents an ideal vantage point from which to examine meaningful use under the ARRA-HITECH Act, both for an assessment of Stage 1 and for guidance as policymakers plan for Stages 2 and 3. In this month’s cover story, hospital CIOs and other healthcare leaders speak about the challenges they have faced so far and what CMS could change to provide more clarity and flexibility, and to reduce the reporting burden BY DAVID RATHS

AMIA REPORT: BEYOND ELECTRONIC VERSIONS OF PAPER CHARTS

BY MARK HAGLAND CAREER PATHS

48

CAREER ADVERSITY Most people have dealt with adversity in a former job. Here is advice, for both candidates and hiring managers, on how to handle the issue during an interview BY TIM TOLAN

Healthcare Informatics (ISSN 1050-9135) is published monthly by Vendome Group, LLC, 6 East 32nd Street, 8th Floor, New York, NY 10016. Periodicals postage paid at New York, NY and additional mailing offices. POSTMASTER: send address changes to HEALTHCARE INFORMATICS, P.O Box 2178, Skokie, IL 600767878. Subscriptions: For questions or correspondence about a subscription, phone 847-763-9291 or write to HEALTHCARE INFORMATICS, PO Box 2178, Skokie, IL 600767878. 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 January 2012 • www.healthcare-informatics.com

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Healthcare

Informatics

INSIDE

Healthcare IT Leadership, Vision & Strategy

Meaningful Use Next Steps, Cloud Computing Outlook, HIE Governance

M

eaningful use has been a challenge for even the best-prepared provider organizations. In this month’s cover story, which begins on page 8, Senior Contributing Editor David Raths asked CIOs and other healthcare leaders to take a look back at their experiences with Stage 1, and to give their views on elements that the Centers for Medicare & Medicaid Services could change to provide more clarity and flexibility, as well as reduce the reporting burden, as the industry moves ahead with Stages 2 and 3. At a time when electronic health records and the digitization of diagnostic images are putting pressure on hospitals to explore new data storage alternatives, a debate has emerged over the value of cloud computing. Assistant Editor Gabriel Perna examines both sides of this issue—including cost, security, and performance—in the article on page 14. As health information exchanges gain a stronger foothold in U.S. healthcare, the question of how to build effective governance is becoming increasingly important to their long-term viability. On page 20, Associate Editor Jennifer Prestigiacomo digs into the details of a recent gathering of healthcare industry leaders and government officials, and explains why inclusive involvement of all stakeholders—clinicians, consumer groups, payers, and state representatives—is crucial for HIEs’ success over the long haul. This issue’s Clinical IT Perspective on page 28 presents the inside story of a groundbreaking project at Lucile Packard Children’s Hospital that leveraged the use of aggregate patient data from an EHR and used it to make a real-time diagnosis and treatment decision in the context of a rare pediatric condition. Editor-in-Chief Mark Hagland interviewed Christopher A. Longhurst, M.D., the hospital’s CMIO and a member of the three-physician team behind the achievement, who describes how the process works and its implications for patient care more broadly. Meanwhile, two articles this month focus on imaging. In the Imaging Perspective on page 32, Mark Hagland takes a look at an exciting development from a team of radiologists from the Hospital of the University of Pennsylvania, who developed Montage, a “Google-like” radiology search engine. In this month’s RIS Perspective on page 36, Managing Editor John DeGaspari presents the results of a recent survey that suggests that the Health Information Technology for Economic and Clinical Health Act is having a significant impact on planned purchases of radiology information systems.

2012 EDITORIAL BOARD Marion J. Ball, Ed.D. Professor, Johns Hopkins School of Nursing Fellow; IBM Center for Healthcare Management; Business Consulting Services, Baltimore Lyle L. Berkowitz, M.D., FHIMSS Medical Director, Clinical Information Systems Northwestern Memorial Physicians Group, Chicago William F. Bria II, M.D. CMIO, Shriners Hospital for Children, Tampa, Fla. Adjunct Associate Professor, University of Michigan Tina Buop CIO, Muir Medical Group IPA, Walnut Creek, CA Bobbie Byrne, M.D. VP for HIT, Edward Hospital, Naperville, IL Erica Drazen, Sc.D. Vice President, Computer Sciences Corporation, El Segundo, CA Suresh Gunasekaran CIO, University Hospitals, UT Southwestern Medical Center, Dallas W. Reece Hirsch Partner, Morgan, Lewis & Bockius LLP, San Francisco

4 January 2012 • www.healthcare-informatics.com

Christopher Longhurst, M.D. CMIO, Lucile Packard Children’s Hospital, Clinical Assistant Professor of Pediatrics, Stanford University School of Medicine, Palo Alto, CA Chuck Podesta SVP and CIO, Fletcher Allen Health Care, Burlington, VT Stephanie Reel Vice President and CIO, Johns Hopkins Health System, Baltimore 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 Lynn Witherspoon, M.D. System Vice President and CMIO, Ochsner Health System, New Orleans

EDITORIAL EXECUTIVE DIRECTOR OF EDITORIAL INITIATIVES Charlene Marietti [email protected] EDITOR-IN-CHIEF Mark Hagland [email protected] MANAGING EDITOR John DeGaspari [email protected] ASSOCIATE EDITOR Jennifer Prestigiacomo [email protected] ASSISTANT EDITOR Gabriel Perna [email protected] SENIOR CONTRIBUTING EDITOR David Raths [email protected]

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EDITOR’S PAGE

Are You Past-PresentFuture-Balanced? HEALTHCARE IT LEADERS FACING 2012 COULD USE A GOOD DOSE OF POSITIVE PERSEVERANCE

I

’ve been reading a fascinating book from 2008, The Time Paradox: The New Psychology of Time That Will Change Your Life, by Philip Zimbardo and John Boyd. The authors, psychologists, have created a schematic with different psychological types, based on how people perceive their past, their present, and their future. Essentially, the authors say, to be an emotionally healthy person, you need to create Mark Hagland a balanced attitude and approach towards your past, present, and future, in order to be happy and productive. So, after taking “The Zimbardo Time Perspective Inventory” quiz, you can determine which “type” you are in all this. Based on your responses to such statements as “Familiar childhood sights, sounds, and smells often bring back a flood of wonderful memories,” “Fate determines much of my life,” “Spending what I earn on pleasures today is better than saving for tomorrow’s security,” and “I keep working at difficult, uninteresting tasks, if they will help me get ahead” (and I’m guessing that the last one will resonate with more than a few healthcare IT leaders!), you can find out which of seven different psychological types you are. You might be “past-negative,” “past-positive,” “presentfatalistic,” “present-hedonistic,” “future,” or “transcendental future,” depending on your tendencies. What’s particularly important, the authors argue, is not to get “stuck” in having an over-emphasis on either the negative or positive aspects of either the past, present, or future. Essentially, they argue, you should think positive thoughts about the past, and enjoy the present while building your future, but while avoiding future-obsession. All of this is intricately interconnected, they note, with people who have positive attitudes towards their pasts being better able to appreciate their lives in the present, and with people who can enjoy the present moment being better able to avoid being overly obsessed with the future (while still adequately preparing for it). 6 January 2012 • www.healthcare-informatics.com

All of this made me think a bit about what healthcare IT leaders are facing right now, with regard to the demands, challenges, and opportunities involved in meeting the requirements under meaningful use and under the three mandatory and two voluntary healthcare reform-driven programs that are directly affecting their work. For example, healthcare IT leaders who tend to be “past-negative” people—who often dwell on the struggles of the past—will find meeting all the data reporting and data infrastructure management challenges in these programs immensely daunting, because they will all feel intensely burdensome to them. At the same time, because of the tremendous breadth of all of this, being too future-obsessive could prove highly problematic, too, because managing change across all these programs will demand staying in the moment and not allowing the enormity of it all to overwhelm oneself and one’s organization. On the other hand, being overly “present-hedonistic” could backfire just as much, if one decides one’s organization can take the slow boat to MU and healthcare reform, for obvious reasons. So the book’s subhead, “Reclaim Yesterday, Enjoy Today, and Master Tomorrow,” sounds virtually tailormade for healthcare IT leaders hoping to move forward into the future at just the right pace and with the right attitude. So as we look back at 2011 and forward to 2012, taking a healthy, balanced approach to change management will be vital, as healthcare IT leaders move forward, organization by organization, to create the healthcare system of the future. It will all be immensely challenging, no doubt; but as Philip Zimbardo and John Boyd might say, taking the right attitude towards all of this will reap healthy, satisfying rewards.

Mark Hagland Editor-in-Chief

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COVER STORY 8 January 2012 • www.healthcare-informatics.com

Taking the Next Steps Toward Meaningful Use CIOs ARE LEADING THEIR HOSPITALS FORWARD ON THE PATH TO MEANINGFUL USE BY DAVID RATHS

EXECUTIVE SUMMARY: Even the best-positioned hospital and health system organizations have been struggling with some aspects of meaningful use. What are the implications of their struggles for the path forward into Stages 2 and 3? A look at the current challenges on the ground, and the path ahead.

A

t about the same time this issue of Healthcare Informatics hits your inbox, so will the Notice of Proposed Rulemaking for Stage 2 of meaningful use under the American Recovery and Reinvestment Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act of 2009. And if the pattern from Stage 1 holds true, there will be several months of tension as provider and vendor organizations push back against regulators, advising the Centers for Medicare & Medicaid Services (CMS) that the new measures are too heavy to lift. Because of the tight timelines they were facing, the advisory committees of the Office of the National Coordinator (ONC) didn’t have the benefit of much provider feedback on Stage 1 before they had to make proposals for Stage 2. But with more time at their disposal, CMS officials will no doubt weigh both what providers are saying about Stage 1 and the number of hospitals and physicians participating. (Only 10 percent of the 778 hospitals in a September 2011 HIMSS Analytics survey reported having the capability to address all 14 core measures and at least five of the 10 menu items. Another 31 percent of the hospitals should be prepared to meet Stage 1 of meaningful use shortly, reported HIMSS Analytics, a division of the Chicago-based Healthcare Information

and Management Systems Society.) The turn of the New Year provides a good vantage point from which CIOs and other healthcare IT leaders can take a look back at Stage 1, and as they begin to ramp up for Stage 2 apply some of the lessons they’ve learned. We asked a few CIOs where the pain points are and if there are things CMS could change to provide more clarity and flexibility and reduce the reporting burden.

DEVIL IN THE DETAILS Perhaps the biggest surprise to come out of 2011 is the relative difficulty even some of the most sophisticated users of health information technology reported having in working to attest to MU in Stage 1. At the recent American Medical Informatics Association symposium, Len Bowes, M.D., a senior medical informaticist for the 22-hospital Intermountain Healthcare in Salt Lake City, Utah, described the difficulty his organization is having with software and workflow changes around its homegrown electronic health record (EHR) systems. Intermountain, which has received numerous industry awards for e-health innovation, has to both certify its own EHR systems and get hospitals and physician groups to achieve meaningful use. Its meaningful use project team identified 105 items in a gap analysis. “From a high level, the list doesn’t look too challenging,” Bowes says, “but the devil is in the details.” Intermountain has bolstered its meaningful use project team to 22 full-time-equivalent employees working on issues ranging from medication reconciliation to problem lists. But reworking computerized physician order entry (CPOE) is the largest challenge, Bowes says. Officials dewww.healthcare-informatics.com • Healthcare Informatics 9

COVER STORY

THE PATH AHEAD

COVER STORY

cided that Intermountain had to make widespread changes to get every physician using CPOE in the hospitals, and that is taking time to implement. “We want to get them something that works and doesn’t have redundant workflow,” he says. Intermountain postponed its Stage 1 attestation for hospitals until mid-2013. “If we get half of our hospitals to achieve meaningful use then, it will be good,” Bowes says.

CLINICAL QUALITY MEASURES: ‘PREMATURE, NON-STANDARD’ “Simplify and clarify.” That’s Denni McColm’s mantra for meaningful use going forward. The CIO of Citizens Memorial Healthcare (CMH) in rural Bolivar, Mo., is optimistic about the potential value of meaningful use, as well as an outspoken critic of how some of the measures were rolled out. CMH’s 76-bed community hospital attested to meeting Stage 1 at the end of May 2011 once federal officials signaled that Stage 2 would be postponed for those hospitals achieving meaningful use in 2011. In October, McColm testified before ONC’s Meaningful Use Workgroup about CMH’s experience. In that presentation and in a recent interview with Healthcare Informatics, she noted that although her organization has achieved Stage 7 on the HIMSS EMR adoption model, it had some serious

Although four-hospital patient to another facility, NorthShore attested officials there were unsure to meaningful use for about which transitions of both its hospitals and care to include in the sumphysicians on day one, mary care record measure; Smith has stressed to or what format or content policymakers that the the summary care record program requires too should include; or how to much reporting. He report that the summary estimates that approxicare record was provided. mately 70 percent of the There seems to be a 36,000 employee hours consensus among CIOs spent on Stage 1 has been that the clinical quality Denni McColm on reporting and not on measures are potentially quality improvement. the most important aspect “Seventy percent of the of meaningful use, but effort shouldn’t be on rethey have also been by porting. They require us far the biggest challenge to use a certified EHR that in Stage 1. McColm calls passes certain minimum the measures “premature, requirements and that non-standard and unmakes sense,” he says. owned.” She says the But EHRs in general are measures do not appear not designed to do mass to have been piloted or reporting, he notes. CMS field-tested and don’t could have made some include any guidance for sort of exception for data implementation. “Some Thomas Smith warehouses to do the of the clinical quality measures are half-baked and number crunching. “We there is no one to ask about them, no could use the EHR for collecting and stewards,” she adds. The Joint Commis- using the data but then use a calculatsion should be the owner, she suggests. ing machine that is 10 times stronger. “I think CMS should have waited a year Instead, some of these monthly reports to do clinical quality measures. They take 12 days to run and we have people would have been better off if they had here on weekends.” That data warehouse certification issue is an example of something that should be relatively easy for ONC to go back and revisit, says Kevin identified stewards.” Burchill, a director at Beacon Partners, Thomas Smith, CIO at NorthShore a consulting firm in Weymouth, Mass. University HealthSystem in Evanston, “Hopefully, as in Stage 1, what comes Ill., agrees with McColm about the out after the public comment period need to improve the clinical quality will be better for it and will reflect these measures. “I talked to our quality staff, types of concerns.” and they felt the meaningful use definiAnother common refrain from tions were not well thought out,” he CIOs is that CMS has to do a better job of harmonizing all the quality-reporting programs it has in place, including meaningful use, those related to the medical home and to the says. “ONC needs to work with other accountable care organizations proagencies. CMS has whole divisions that gram, and Medicare’s Physician Quality have spent years working on this.” Reporting Initiative (PQRI), as well as

SOME OF THE CLINICAL QUALITY MEASURES ARE HALFBAKED AND THERE IS NO ONE TO ASK ABOUT THEM. —DENNI MCCOLM challenges qualifying for meaningful use in Stage 1, and that other rural hospitals just beginning that journey to EHR adoption have a lot of work ahead of them. For McColm, several of the Stage 1 items were problematic because they were poorly defined or confusing. For

SEVENTY PERCENT OF THE EFFORT SHOULDN’T BE ON REPORTING. SOME OF THESE MONTHLY REPORTS TAKE 12 DAYS TO RUN AND WE HAVE PEOPLE HERE ON WEEKENDS. —THOMAS SMITH example, although it is standard practice at CMH to provide a summary care/ transfer record upon any transfer of a 10 January 2012 • www.healthcare-informatics.com

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COVER STORY

A Busy 2012: A Look at Developments Scheduled for This Year ➣ HIPAA: Privacy, security, breach notification, and enforcement rules expected by Jan. 1. ➣ Accountable Care Organizations: Starting Jan. 1, ACOs can coordinate patient care to improve quality, help prevent disease and illness, and reduce unnecessary hospital admissions. ➣ Meaningful Use Stage 2: CMS is expected to publish a Notice of Proposed Rule Making on Stage 2 requirements in late December 2011 and a final rule by mid-year. The Stage 2 demonstration period is currently scheduled to begin in October 2012, but the demonstration period for those who attested to Stage 1 in 2011 is expected to be moved back to Oct.1, 2013.) ➣ HIPAA 5010 Electronic Standards: In January 2012 health IT departments must be ready to submit claims electronically using the upgraded HIPAA 5010 standards. ➣ ICD-10: Education begins or continues in preparation for the implementation of ICD-10 on Oct. 1, 2013. ➣ Electronic Prescribing Incentive Program: Penalties go into effect in 2012 for those providers that are eligible but not utilizing e-prescribing. ➣ Patient Safety: Health & Human Services is expected to publish a plan in 2012 on how it will minimize patient safety risks associated with health IT.

the requirements coming out of the have a team dedicated to meaningful Washington, D.C.-based National Com- use and have developed a tool to track mittee for Quality Assurance (NCQA), our progress on all fronts. We also have and other programs. Each program has an informatics office to help define its own specific goals, Smith says. “On workflow requirements.” the surface they may look exactly the same, but when you get into it, what gets STAGE 2: included and excluded in the measures ‘AGGRESSIVE AND AMBITIOUS’ is slightly different, so it is a difficult Even though providers that attested to thing for IT to write reports for each. It meaningful use in 2011 are expected to might be smart to have some sort of CMS have until 2014 to phase in Stage 2, they portal where we submit all will still be kept busy, bethis quality reporting data,” cause many of the new he adds, “and they sort it measures are ambitious. out on their end.” First, all Stage 1 menu Hospitals that are implemeasures would become menting new systems or core measures, and would switching vendors in 2012 be required of all providto meet meaningful use ers. Medication orders are doubly challenged, says must be automatically Burchill. The provider ortracked via electronic ganizations get in queues medication administrawith vendors, but then have tion record (eMAR) in at to line up both internal and least one hospital unit. Curt Kwak consulting resources when (That requirement has planning implementahuge patient safety imtion. “So there are capital planning and provement implications, but is an imoperating expense considerations, and plementation challenge to introduce, matching those up is an art,” he adds. McColm notes.) Hospital labs must proCurt Kwak would agree. The CIO for vide structured electronic lab results to Providence Health’s Western Wash- outpatient providers for more than 40 ington region, which encompasses percent of electronic orders received. three hospitals and a service area that Other new measures in Stage 2 involve includes 65 Providence-owned clinics, is patient engagement, care coordination, in the midst of switching EHR vendors. and a greater reliance on health infor“It will be a challenge to get to Stage 1 mation exchange (HIE). For instance, next year,” he admits, “but we plan to get hospitals would be responsible for through Stage 2 by the end of 2013. We requiring that more than 10 percent of 12 January 2012 • www.healthcare-informatics.com

patients actually view information about a hospital admission. And more than 10 percent of all discharges must have care summary information sent electronically to a provider or post-acute care facility. But some CIOs are nervous about how care coordination, patient engagement, and HIE are being addressed. McColm says policymakers have expressed disappointment that more provider organizations haven’t been choosing patient engagement menu items in Stage 1. “We have both a portal and personal health records, and it is still hard for us because of how the measures were defined,” she says. “That should tell them something.” The patient engagement aspects of Stage 2 are aggressive and ambitious, she adds. “I think that when the proposed rule is announced, some of us should pilot those and get back to them about how hard it is to do. Some may sound easier than they are.” Smith says NorthShore can probably meet Stage 2 requirements to exchange data with three other hospitals by using Verona, Wis.-based Epic Systems’ tools for exchanging data with other Epic customers in the Chicago area. But for Stage 3, the goal is to exchange with 30 percent of eligible providers in the area. That would be hundreds of doctors on dozens of disparate systems. There is no regional HIE in operation. “We are dependent on a statewide HIE being formed, but Illinois is pretty far behind,” he says. “There is widespread

skepticism about whether the HIEs will be sustainable.” Looking at the proposed Stage 2 objectives, Providence’s Kwak sees challenges around the proposals to develop a list of “care team” members and create more virtual communication among those pro-

cess of clinical transformation and can focus on how to best use these tools,” Lance says. “They are adapting their workflows and hiring chief medical information officers and chief nursing officers to drive the change. They are on the good end of the bell curve.”

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A CARE TEAM CAN BE ESTABLISHED USING PERSONNEL FROM THE DISPARATE ENVIRONMENTS. HOWEVER, GETTING THEM ACCLIMATED TO A STANDARDIZED SET OF MEASURES AS WELL AS A STANDARDIZED METHOD OF PRACTICING AROUND THE NEW MEASURES WILL TAKE TIME. —CURT KWAK At the same time Lance says, “There viding services to each patient. In his organization, there’s a lack of clarity around are a lot of hospitals in the center of that clinical and nurse informatics roles and curve still struggling to meet the first responsibilities, as well as their function stage. They can’t yet put any strategic focus on Stages 2 and 3.” within information services, The good news is he notes. This is especially that the providers are difficult in a complex sysdefinitely engaged and tem of hospitals and clinics moving forward on in which you are dealing meaningful use goals. with multiple standards Thirty-two percent of and environments. “A care CIOs surveyed in Septeam can be established tember 2011 believe their using personnel from the organization can achieve disparate environments,” he Stage 2 objectives with explains. “However, getting or without a delay in the them acclimated to a stanstart date, and another dardized set of measures Fletcher Lance 25 percent believe their as well as a standardized organization can meet method of practicing requirements under Stage around the new measures 2 if the planned Oct. 1, 2012, start date will take time.” Organizations such as CMH, Inter- is delayed, according to the College of mountain, Providence, and North- Healthcare Information Management Shore seem to be in relatively good Executives. For ONC, the trick will be shape to address their own weaknesses to keep the focus on that progress so it in meeting meaningful use goals. But doesn’t stall after the meaningful use many other organizations are strug- dollars are gone. “You won’t have the

THERE ARE A LOT OF HOSPITALS IN THE CENTER OF THAT CURVE STILL STRUGGLING TO MEET THE FIRST STAGE. THEY CAN’T YET PUT ANY STRATEGIC FOCUS ON STAGES 2 AND 3. —FLETCHER LANCE gling to pull together the resources, says Fletcher Lance, vice president and healthcare lead in the Nashville office of the Atlanta-based consulting firm North Highland. “Large organizations with the wherewithal are in the pro-

carrot anymore, but you don’t want to do it with a stick either,” Lance observes. “You want to keep the momentum going as healthcare providers do the hard part of cultural change. You don’t want them to get stymied.” ◆

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A Hazy Outlook for Cloud Computing WHEN IT COMES TO ADOPTING CLOUD-BASED SOLUTIONS, MANY HEALTHCARE IT LEADERS REMAIN HESITANT BY GABRIEL PERNA EXECUTIVE SUMMARY: Because of competing priorities as well as cost, security, and implementation concerns, cloud-based storage development has gotten off to a slow start in healthcare. CIOs, CTOs, and other healthcare IT leaders are adopting a variety of strategies in this area, based on their organizations’ needs, resources, and priorities.

W

ith healthcare data set to spike over the next few years due to the advent of electronic health records (EHRs) and the ongoing digitization of diagnostic images, a new debate has emerged in the industry over the value of the cloud. While a considerable number of healthcare providers are turning to cloud computing as an alternative to traditional servers for storage purposes, others remain skeptical. Cloud computing gives providers the opportunity to store data on a virtual server, and can be either public (operated by a third party vendor) or private (kept strictly in-house); or it can be created as a hybrid, using a combination of both public and private clouds. There’s no doubt that the cloud has become a trendy idea to solve storagerelated cost issues. Consulting firms like Accenture (Chicago, Ill.) say cloud computing can save up to 50 percent 14 January 2012 • www.healthcare-informatics.com

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FEATURE vironment is ready to acof a provider’s hosting costs commodate and support on an annual basis. healthcare,” he says. “I However, a look inside the wish it were, because I see front lines of the healthcare a lot of benefits from it. industry shows that CIOs Things like HIE [health inand other technology leadformation exchange] and ers aren’t fully sold on the other community needs concept. Questions about can be hashed out and reits security and reliabilsolved by a good, efficient ity have cropped up while cloud-based solution, but a multitude of other, more we haven’t seen that yet.” pressing IT issues have kept Curt Kwak According to Kwak, the cloud development on the cost factor has also kept backburner. Even its cost savings have come into question. In him leery of the cloud. He says he hasn’t short, when it comes to the cloud, there seen any solid proposals or strategies that prove it can cut costs. Even if there seems to be more doubt than certainty.

SECURITY CONCERNS Chuck Christian, CIO of the 232-bed Good Samaritan Hospital in Vincennes, Ind., has his own reasons for doubting the cloud. For Good Samaritan, he has chosen to virtualize his traditional servers rather than go for a public cloud solution. Christian says there are six servers on one farm running 65 to 70 virtual servers and three servers running 15 to 20 virtual servers on another. He considers this solution a type of private cloud, because both keep operations in-house. For Christian, the reason to keep everything in-house has to do with security more than anything else. “We’re a hospital and we’re very concerned about keeping this data as safe as we possibly can,” he says. “I’m concerned with the idea of turning that data loose.” He notes how under federal regulations, data breaches are the responsibility of the healthcare provider, not the cloud operators or other third parties. “If it’s in our data center, I know where it is,” he adds. “If it’s in the cloud, then I’m not sure where it is. The only thing I can be assured of is that we have a really good contract in place, but that doesn’t ensure that the data will or will not be compromised.” According to Jeff White, principal at Aspen Advisors (Pittsburgh, Pa.), the fact that most vendors won’t sign a business associates agreement (BAA) with healthcare providers is a strong deterrent for the cloud. Without a BAA, data breaches, as Christian says, would fall under the jurisdiction of the provider and the provider only.

IT’S HARD TO DO THIS WITH OTHER COMPETING PRIORITIES, GOVERNMENT MANDATES, MINISTRY REQUIREMENTS AND BUSINESS REQUIREMENTS, WHICH TAKE AWAY FROM INNOVATION. YOU JUST HAVE TO KEEP YOUR PULSE ON IT AND EXECUTE WHEN THAT OPPORTUNITY COMES. —CURT KWAK are some operational savings, Kwak says the return on investment is not nearly Curt Kwak, CIO of the Northwest and enough to justify a full-fledged shift to Southwest Regions of Providence Health the cloud. “There might be some savings, & Services, could be a poster boy for but at the end of the day we only have a those who have expressed doubts about finite amount of resources on hand,” he says. public clouds. Kwak’s parAdditionally, between ticular region of Providence the ongoing conversion to Health & Services, which ICD-10 and the streamlinis a 27-hospital network ing of its health informatencompassing the Pacific ics systems, Kwak says Northwest, uses a traditionthere are a lot of priorities al data center with physical that come ahead of infraservers that are currently structural needs, which being virtualized. are pretty good as are, in Kwak, who notes his his view. Often, Kwak tells opinions are not necessarothers in the industry to ily reflective of the other reproceed with caution regions of the Renton, Wash.Chuck Christian garding the cloud. “If you based Providence Health have a tough time articu& Services, is not ready to switch to a public cloud anytime soon. lating your value proposition, don’t do it “I’m not convinced yet that the cloud en- for the sake of doing it,” he says.

COST DOUBTS

16 January 2012 • www.healthcare-informatics.com

TEST CLOUD Brian Comp, chief technology officer of the 2,000-bed, eight-hospital Orlando Health System, also thinks that security is a drawback to the cloud. Comp’s

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FEATURE Orlando Health has some cloud-based experience to draw on if its leaders choose to adopt such a solution in the future. The organization previously worked with Symantec (Mountain View, Calif.) to create a cloud-based imaging storage system that would allow physicians who worked outside of Orlando Health to connect and access images. Comp says the

Brian Comp

on the market, and determine whether or not it’s right for us, but at this point there is no timeline,” says Comp. This “wait until later” attitude seems to be reflective of many in the industry. For all of his reservations, Good Samaritan’s Christian says in the future he would like to look at a cloud-based backup system, where

storage availability, and limited capital expenditure funds, the MED was practically forced into adopting a cloud solution for imaging purposes, he says. The DRCMI system provides a long-term storage base for any image created at the MED. According to Harrison, it has more than worked out. “It was almost like they had a custom, tailor-made solution for us,” he says. “Come to find out, that’s really just the DRCMI solution as a whole. But it really fit what we were trying to accomplish.” Harrison says the system is so lowmaintenance that the MED’s IT professionals often forget it’s in place. He says the system bailed out the MED when the organization lost 400,000 image-based studies from its database. While the MED’s Carestream (Rochester, N.Y.) imaging system couldn’t recover the studies, the DRCMI was able to restore all but 2 percent of those studies. Even the leaders in the MED’s radiology department, who were skeptical at first about a cloud-based solution, have been won over by the DRCMI, Harrison says. “They have done the biggest about face. They were skeptical at first, but now they believe, especially since we had lost those studies. This solution that we had engineered a yearand-a-half earlier, it ultimately saved the day.”

IF IT’S IN OUR DATA CENTER, I KNOW WHERE IT IS. IF IT’S IN THE CLOUD, THEN I’M NOT SURE WHERE IT IS. THE ONLY THING I CAN BE ASSURED OF IS THAT WE HAVE A REALLY GOOD CONTRACT IN PLACE, BUT THAT DOESN’T ENSURE THAT THE DATA WILL OR WILL NOT BE COMPROMISED. —CHUCK CHRISTIAN system was a test project for both Symantec and Orlando Health, with both having reservations about the project

data could be duplicated. He’d also like to eventually treat storage as a pay-peruse commodity. White of Aspen Advi-

WE WILL CONTINUE TO INVESTIGATE AND KEEP OUR FINGER ON THE MARKET, AND DETERMINE WHETHER OR NOT IT’S RIGHT FOR US, BUT AT THIS POINT THERE IS NO TIMELINE. —BRIAN COMP even during the development stage. Symantec ended up shutting the project down, likely because of cost concerns, says Comp. “My perception was that they didn’t perceive there was going to be a worthwhile return on investment,” he says. With diagnostic image-based volume growing by approximately 40 to 50 percent annually, Comp says, Orlando Health will continue to look at cloud solutions in the future. However, the organization is not under much pressure to adopt the cloud, since it has recently made a capital investment with an archive hardware provider. “We will continue to investigate and keep our finger

sors says this is one of the most likely uses for a public cloud in healthcare.

A SUCCESSFUL IMPLEMENTATION Brad Harrison, executive director of technology for The Regional Medical Center of Memphis (the MED), is a bit of a rare breed when it comes to technology leaders in healthcare. His organization not only uses an offsite cloud solution, but Harrison himself is extremely pro-cloud. The MED, a level-one trauma center that takes in patients from multiple states in the south, uses Iron Mountain’s (Boston, Mass.) Digital Record Center Medical Images (DRCMI) solution. Due to aging technology, a lack of

A CLOUDY LONG-TERM VIEW The apprehension in healthcare surrounding public cloud solutions is very real and it comes from multiple reasons, according to Aspen Advisors’ White. There are the security/ data-breach concerns that Christian and others have expressed, and there are other legitimate concerns with performance, he says. There’s also the (continued on p. 22)

18 January 2012 • www.healthcare-informatics.com

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FEATURE

Building Stakeholder Trust in HIEs INDUSTRY LEADERS DISCUSS HOW TO BUILD EFFECTIVE GOVERNANCE MODELS BY JENNIFER PRESTIGIACOMO

EXECUTIVE SUMMARY: At a recent gathering, healthcare industry leaders and public officials discuss the best governance models that will be necessary to ensure the long-term viability of health information exchanges.

I

n a webinar hosted by the Washington, D.C.-based National eHealth Collaborative (NeHC) in November 2011, several HIE directors and federal and state officials discussed how to create effective trust and governance models to build sustainable health information exchanges (HIEs). Overwhelmingly, industry experts say that inclusive involvement from the community’s stakeholders—which may include clinicians, consumer groups, payers, and state representatives—on the HIE board instills the confidence to drive effective information exchange. Mark Jones, COO and principal investigator of SMRTNET, a publiclyowned network of affiliated HIEs spanning the state of Oklahoma, says that rather than building one single network, SMRTNET built upon already trusted and established networks like the Oklahoma State Medical Association, Native American tribes, the Greater Oklahoma City Hospital Council, as well as others. Not only did this breed trust, but each of the eight exchanges defines its own goals and parameters around gover-

20 January 2012 • www.healthcare-informatics.com

nance and sends two members to sit on a central SMRTNET management committee. “We define governance as being organizational and consensus based in nature, with common legal documents: a security policy, a sus-

tainability plan, and a clinical clarification on what the purpose of the network is,” Jones says. Jones adds that each network can have different data sharing agreements and different technologies, but

FEATURE cians, and the security and integrity of the data in the HIE, you have literally nothing.” HIE governance is a way to set the “rules of road,” so providers are assured that data transfer is secure and in a standard format, says Mary Jo Deering, Ph.D., senior policy advisor of the Washington, D.C.-based Office of the National Coordinator (ONC). These standards set by the HIE governance also allow entities to know they are exchanging with other reputable entities. “Quite reasonably, localities and states TRANSPARENCY AND look to HIPAA as a cerCOMPLIANCE tain baseline for those Tom Deas, M.D., CMO, covered entities,” DeerSandlot LLC, an HIE ing says. “On the other services and solutions hand, states themselves provider in Fort Worth, play a significant role in Texas, believes that trust establishing their own within an HIE is largely Mike Smyly privacy policy. There has built through transparalways been a balance ent communication and and a blending between compliance with all regua federal regulatory aclatory processes, such as tivity around trust and the Health Insurance Porthe states’ powers and tability and Accountabilauthorities.” ity Act (HIPAA), to protect Deering says that patient information and health IT leaders should make sure that the stakefollow the work of the holders, board members, ONC HIT Policy Comand users understand all mittee, which develthe effort that is invested oped recommendations in making that informaat the end of 2010 advotion protected and secure. cating the need for HIEs Sandlot, which is a wholly Mark Jones to establish core condiowned subsidiary of the tions around privacy, Fort Worth-based North Texas Specialty Physicians (NTSP), interoperability, and validation prohas a governance board that includes cesses for entities. She says that the practicing physicians, healthcare busi- ONC is evaluating privacy recommenness leaders, and consumer and com- dations from the Privacy and Secumunity leadership. “Trust is essen- rity Tiger Team, as well as standards tial in sustaining an HIE,” says Deas. recommended in September 2011 for “Without the trust of our patient and the Nationwide Health Information community population and the physi- Network (NwHIN) handed down by each network shares a common technology to link up with the other SMRTNET networks. Giving each network a voice in the management committee breeds trust and a common goal. “What we found here was that whether it was optometrists, physicians, or many of the Native American tribes in the state,” Jones says, “once they have a governance board like them, they are much more encouraged to join. They have common interests that they can share with each other, and even some data elements.”

the HIT Standards Committee. Deering also urges HIEs to examine the NwHIN data use and reciprocal support agreement (DURSA), which has been signed by three states and 10 regional HIEs—five states and eight HIEs will be signing soon. Chris Muir, state HIE project manager, ONC, who manages 27 states and territories in the State HIE Cooperative Agreement Program, says that ONC can’t make a federal data sharing agreement template, but it can provide helpful tools for states. The ONC has been listening to how states are struggling and are providing them with tools and technical assistance from Deloitte (New York City). “We do some match-making between the states,” he says. “So, if we see one state struggling with something, and we know another state has figured that issue out, we bring those states together and encourage them to talk.”

COMMUNICATING VALUE Mike Smyly, chief business development officer, Inland Northwest Health Services (INHS), says that new participants need to understand the financial viability of the exchange and its business model, so they understand the long-term investment for their organization and can feel comfortable from the outset that value will be delivered. INHS, based in Spokane, Wash., started its HIE as a HIT collaborative in 1994 with an advisory structure made up of hospitals, community physicians, community business leaders, and members of the state HIE. Smyly recommends that HIEs have new member discussions about federal, state, and exchange guidelines (HIEs should also provide those in written format); data sharing agreements; and all the complexities involved. “There’s a great deal of comfort for your new HIE members in opening up [the discus-

www.healthcare-informatics.com • Healthcare Informatics 21

FEATURE sion] for existing members to be appreciated.” SMRTNET’s Jones reto have the opportunity to members a presentation discuss their experience he gave five years ago and help share the trust they have had [in the exin front of a large group change],” says Smyly. about the benefits of HIE, “I think the other part and how the tenor of the of building trust is comdiscussion changed once municating the success of a physician stood up to the information exchange encourage his colleagues and how it has impacted to get involved because, care delivery, how it’s imas he said, “‘patient care Chris Muir proved the quality of care, was on the line.’ The mesand perhaps limited some sage and the messenger of the cost,” says Sandlot’s are so important here, and Deas. “To share those stories in an open we have to rely on the participant and fashion allows the value of the system particularly the clinicians, to be the

messenger,” he says. “It’s up to us to find the right words to communicate that.” Jones says that his system tracks its patient opt-outs—which are normally in the 2- to 3-percent range—closely for patterns. In the past, opt-outs usually clustered around a staff person who felt uncomfortable with the HIE process; but once that person was engaged with training, they usually felt better, he says. Smyly says that the INHS physicians have become champions for the exchange, and educate their patients about the HIE with collateral materials. INHS also runs local TV ads to promote the value of its information exchange. ONC’s Muir believes that the most successful ways to share the value of information exchange to patients are through stories about real patients. He says many HIEs have developed YouTube videos that communicate these stories. ◆

FEATURE

WE DO SOME MATCH-MAKING BETWEEN THE STATES. SO, IF WE SEE ONE STATE STRUGGLING WITH SOMETHING, AND WE KNOW ANOTHER STATE HAS FIGURED THAT ISSUE OUT, WE BRING THOSE STATES TOGETHER AND ENCOURAGE THEM TO TALK. —CHRIS MUIR (continued from p. 18)

fact that vendors are for the most part not able to guarantee complete 100-percent space availability. Even guaranteeing 99.9 percent availability isn’t good enough for healthcare providers White says. In addition, White says that vendors are holding back on the cloud, because of platform specific issues. He says a lot of healthcare providers use certain

This specific code, he says, may not necessarily run on cloud computing. “There are so many infrastructure things like data transfer and performance that need support,” he says. “There’s no guarantee for performance sitting out in these cloud services. People know that it works, but is it really designed for high-transactional environments? Not really.”

the cloud may end up as a viable solution for smaller, community-based hospitals that don’t have large investment funds. Others, like Providence’s Kwak, say there will be a place for the cloud once organizations figure out how to leverage its positives. He says organizations should build it into their long-term strategy. “It’s hard to do this with other competing priorities, government mandates, ministry requirements, and business requirements, which take away from innovation,” he adds. “You just have to keep your pulse on it and execute when that opportunity comes. That’s the hardest thing, though, for any CIO, healthcare or otherwise.” ◆

THERE’S NO GUARANTEE FOR PERFORMANCE SITTING OUT IN THESE CLOUD SERVICES. PEOPLE KNOW THAT IT WORKS, BUT IS IT REALLY DESIGNED FOR HIGH-TRANSACTIONAL ENVIRONMENTS? NOT REALLY. —JEFF WHITE platforms for their core systems that are reliant on certain technologies. For instance, any group that uses Meditech (Westwood, Mass.) systems relies on Dell (Round Rock, Texas) platforms. 22 January 2012 • www.healthcare-informatics.com

White doesn’t foresee widespread cloud-adoption any time soon based upon the nature of healthcare and the industry’s move to integrated systems. Some, like Comp of Orlando Health, say

IS CVIS RELEVANT IN AN ARRA/MEANINGFUL USE WORLD? BY JOE MARION

EXECUTIVE SUMMARY: The ARRA/HITECH Act has made electronic medical records a front burner issue, and many believe that EMRs will make departmental systems redundant. Some cardiologists beg to differ, arguing that cardiovascular information systems are deeply clinical and essential to the cardiovascular workflow. Here’s a look at the evolution of CVIS, EMR, and their roles as the healthcare landscape is being transformed by meaningful use.

T

oday a lot of attention is focused on addressing electronic medical record (EMR) systems to meet the needs of American Recovery and Reinvestment Act (ARRA) and meaningful use legislation. In the words of some EMR vendors, the EMR will act as the aggregator of necessary clinical and operational information, enabling the physician, in one system, to access all relevant patient information across a number of clinical services. No doubt this is true. The approach has its supporters and its detractors. Robert Cecil, Ph.D., a staff member with The Cleveland Clinic Foundation in Ohio, believes the EMR is the right environment to manage patients, making departmental systems redundant. He believes that the EMR will evolve to fill this role, as the aggregator of patient information. This will leave

departmental systems to focus on what is important, which is acquisition and reporting. Dean Cheatham, enterprise manager of cardiovascular technology at PeaceHealth, Bellevue, Wash., echoes

this sentiment. He considers a cardiovascular information system (CVIS) to be “another data silo laid flat across the cardiovascular service line,” and not a “clinical-facing” system.

www.healthcare-informatics.com • Healthcare Informatics 23

FEATURE

Cardiovascular Information Systems

FEATURE Not everyone feels that strongly about the EMR. Tom Lonergan, executive operations director, Hoag Heart and Vascular Institute, Newport Beach, Calif., feels that “EMRs are still evolving, and they are not all-encompassing at this time, so there is still a place for a CVIS. An EMR is not disease or department-specific in the way it presents information—both important to a cardiovascular physician.” For James E. Tcheng, M.D., professor of medicine and professor of community and family medicine at Duke University Health System in Durham, N.C., the EMR’s focus is on patient management and not procedure management, and therefore the EMR is not specific enough for the cardiovascular workflow.

PROPOSED DEFINITION FRAMEWORK Understanding the differences between an EMR and a CVIS can be simplified by means of a framework as proposed in Figure 1. Initially, departments focused on what can be referred to as cardiology picture archive and communications system (CPACS) to address image

Source: Healthcare Information Strategies

24 January 2012 • www.healthcare-informatics.com

acquisition. Cardiac catheterization lab images from the fluoroscopic X-ray system and cardiac ultrasound images from the ultrasound cart are captured and stored in a central viewing and archival system. Cath lab procedures involve case documentation of supplies and medications, as well as a record of the procedure, while study parameters and measurements are captured on a cardiac ultrasound cart. In early CPACS, such documentation was usually printed out and used along with the images from the CPACS to produce a dictated report. Subsequently, CPACS vendors expanded their offerings to include structured reporting tools that enabled the cardiologist to produce a report directly from the CPACS while viewing images. Interfaces to hemodynamic and ultrasound systems enable directly capturing the documentation and measurement information into the structured report. Unlike radiology, where reports are usually dictated, a cardiovascular report would require a significant amount of dictation effort to include documentation and measurements—hence the

benefit of structured reporting. Capturing information directly from the hemodynamic system or ultrasound cart eliminates the need to manually transfer the information into the report and prevents possible typing errors. Thus CPACS evolved into an image management and reporting solution. Over time, cardiovascular departments realized that their workflow could be simplified if additional administrative and study management functions could be automated. Directly capturing information for registries from the reporting database could speed reporting to the National Cardiovascular Data Registry (NCDR), patient demographic consistency could be improved by passing order work lists to supported imaging equipment, inventory/billing accuracy could be enhanced through tighter integration with documentation equipment, and department management could be enhanced by management reports. These functions emerged into CVIS. Note that depending on vendor and development evolution, there is an overlap between CPACS and CVIS in the area of study documentation and reporting. Some vendors encompass both CPACS and CVIS functionality in one product, while others offer distinctly separate products. More recently, EMR systems have gained importance for ARRA/meaningful use (MU) compliance. EMRs are positioned to be the focal point for clinical information, and most encompass patient and study management processes. A patient study originates within the EMR with the collection of relevant patient information, and diagnostic exams are ordered through computerized physician order entry (CPOE) applications. Many facilities favor central scheduling for a consistent schedule across service areas. Results are aggregated within the EMR for a patient-centric view. As such there is overlap with a CVIS in terms

FEATURE of managing the patient and the exam. But as the aggregator, the EMR usually does not overlap in terms of the level of detailed clinical data captured and the physician review process. Today,

CVIS DIFFERENTIATORS Both CVIS users and vendors have vested interests in clearly defining the difference between a CVIS and an EMR. One viewpoint is that cardiovascular

a CVIS represents a specialized view of the data optimized to the cardiovascular physician’s needs.” Workflow is another major differentiation. “Cardiologists are more case involved, whereas a radiologist’s focus is on diagnosis,” according to Robert Cecil of The Cleveland Clinic. Echoing his sentiment is Robert Schallhorn, vice president, clinical solutions at Chicagobased Merge Healthcare, who believes “today’s CVIS emphasis is on workflow and reporting capabilities, data mining, and accreditation support, while image review capabilities are a commodity.” Similarly, Lobo of Lumedx adds that “workflow management during a procedure such as chest pain management or heart failure is important, as it spans the course of treatment, which is not

IN THE CASE OF THE CARDIAC CATHETERIZATION LAB AND CARDIAC ULTRASOUND, THE CONCEPT OF AN ‘ORDER’ JUST DOESN’T EXIST. —JAMES E. TCHENG, M.D. the EMR is typically not the primary vehicle for data acquisition and clinical report generation across the cardiovascular service line. With the EMR’s role expanding, the question arises as to whether there will be less need for departmental systems to manage the order and exam process. Given the CVIS’s overlap, how then might it be differentiated, and what if any role will it play in the changing IT landscape?

services tend to be unique among image generating services (radiology, cardiology, pathology, GI, etc.). In the words of Praveen Lobo, senior vice president of business development at Lumedx Corp., Oakland, Calif., “Cardiology takes a more holistic view and is focused on the morphology of the disease, as represented by multiple modalities, labs, EKGs, etc., before making a diagnosis.” Lobo further states that “EMRs may not be of the proper ‘granulation’ of data, whereas

www.healthcare-informatics.com • Healthcare Informatics 25

FEATURE the prime purpose of the EMR.” Regarding order management and scheduling, cardiovascular exams don’t lend themselves to enterprise order and scheduling processes, according to Tcheng. “In the case of the cardiac catheterization lab and cardiac ultrasound, the concept of an ‘order’ just doesn’t exist.” Tcheng likens a cardiac catheterization study more to a “consultation” than a diagnostic exam, and as such it is difficult to prospectively determine what the “order” is for. Cardiac catheterization procedures can be unpredictable in their length, making it difficult to “schedule” the lab for a fixed time slot.

ligence tool instead of a clinical facing system.” Cheatham believes that a CVIS cannot assimilate all of the information an EMR can with respect to the patient, and believes that the future will be a “cardiologist template” within the EMR. Yet, Tcheng believes that EMRs are focused primarily on addressing ARRA/ MU needs, and it will be at least 2015 before they can turn their attention to clinical needs, presenting a window of opportunity for the CVIS data integration and management. From the perspective of a large EMR vendor, the early phases of technology began with a tremendous amount

changes (HIEs), and to physician office integration, particularly as more physician groups are acquired into providers. Because the cardiovascular physician’s emphasis is on treating the disease process, they frequently need to manage data across multiple provider entities. A patient initially seen in a cardiologist’s office may receive an EKG or cardiac ultrasound procedure. Subsequently, the patient may have additional studies done at a primary care or specialty referral facility. Ideally, the physician would like to “manage populations such as chronic heart disease through the entire cycle, including inpatient, outpatient, and home care,” according to Lobo of Lumedx. Lumedx’ s HealthView application is an example of the ability to aggregate information to better manage chronic cardiac conditions, and bridge multiple provider services. Hoag Heart and Vascular Institute in Orange County, Calif., encompass two hospitals and nine clinics. The challenge, according to Lonergan, is how to tie them all together for a continuum of care. Hoag is planning a form of internal HIE at a layer above an EMR to connect physicians at all facilities. In the opinion of one large EMR vendor, interoperability is tantamount to addressing accessibility beyond the EMR. It believes that all the capability exists to support interoperability—the government just needs to decide on one approach. The result may negate the need for the HIE per se, if all locations can interoperate to share data. It states that in the instance of its EMR, 35 million patients across 71 sites involving 79,000 physicians can share data with no “hub,” or HIE. If sufficient standards come to fruition, the ability to “plug and play” may negate the need for data repositories such as HIEs. Conversely, many of the imaging

TODAY’S CVIS EMPHASIS IS ON WORKFLOW AND REPORTING CAPABILITIES, DATA MINING, AND ACCREDITATION SUPPORT, WHILE IMAGE REVIEW CAPABILITIES ARE A COMMODITY. —ROBERT CECIL, PH.D. Tcheng adds that a cardiac catheterization study is “the epitome of chaos!” Another factor in terms of order and scheduling discipline is raised by Robert Cecil, who points out that cardiovascular procedure volumes are considerably less than radiology volumes. “In the case of radiology, volume is the driver and time limitations favor an order/schedule discipline. Whereas with lower volumes, greater dollar value per case, and greater staff resource availability in cardiovascular services, there is more ability to ‘clean up’ the order post exam.” Craig Scott, M.D., founder and CEO of Flexible Informatics LLC, Bala Cynwyd, Pa., believes that “physicians interact with EMRs and CVIS in different ways.” The EMR is accessed during the patient encounter, or as new information is acquired, whereas the CVIS is typically accessed by the staff while performing and interpreting the procedure. Another perspective is Dean Cheatham’s view that the CVIS “is a business intel26 January 2012 • www.healthcare-informatics.com

of data stuck in departmental systems that didn’t get to an EMR. But physicians are looking for a way to bring the data together, similar to the way paper represented the “great communicator.” The EMR represents a higher degree of integration than departmental clinical systems, and a means for correlating data that may not be present in individual systems such as the CVIS. Henri “Rik” Primo, director of strategic relations at Siemens Healthcare, Malvern, Pa., notes that “historically each cardiovascular sub-specialty had its own sub-systems for reporting results. It was the cardiologist’s brain that integrated all this information to make a final diagnosis and treatment plan. The increasing complexity is the justification for a CVIS. Logical rules in the CVIS can now guide the cardiologist thru the diagnostic cycle to make sure that all results are included in a comprehensive diagnostic reporting workflow.” There are those who are looking beyond the EMR to health information ex-

FEATURE interoperability standards that exist today have come from organizational, not governmental efforts. Consider Digital Imaging Communications (DICOM) and Integrating the Healthcare Enterprise (IHE) initiatives that have been prospered by organizations such as the American College of Radiology (ACR), National Electrical Manufacturer’s Association (NEMA), and the Radiological Society of North America (RSNA). While these standards provide the format for image sharing, they do not directly address the management of the process for sharing data between two or more locations that need to be addressed as part of an HIE. In addition to the clinical need, there is also the data analytics need for aggregation. The ability to expand information beyond a single provider with the objective of improving outcomes is a key driver of accountable care organizations (ACOs). Providers participating in an ACO may be able to better manage a patient based on a broader base of study analytics. Siemens’ Primo summarizes it well. “The technology to share information across the Enterprise in an ACO or regional HIE is readily available, and there are no technical reasons why this isn’t done more often. The real stakeholders are the care providers and policy makers. Their commitment to eradicate the internal information silos will be the decisive element to create a true continuum of care.”

IT IMPLICATIONS AND THE FUTURE While not totally unique, cardiovascular services are indeed different. Information technology services need to be sensitive to those differences and department needs. According to Harry Comerchero, national director, strategic accounts at Philips Healthcare, Andover, Mass., “CIOs need to manage two relationships: the EMR

for hospital systems, and the CVIS as a deep clinical system.” Comerchero believes that the past fragmented nature of cardiovascular services will give way to more integrated CVIS solutions for cardiovascular services to integrate into the EMR. The question is: how many people are ready for that level of CVIS integration? Comerchero believes that cardiovascular services need a “visionary” in the cardiovascular department who has a service line perspective, and who appreciates the value of having a single point of access to a comprehensive patient record that spans the patient’s entire cardiovascular continuum of care. In the past, “CPACS and CVIS components were at a departmental level with no IT involvement,” according to Schallhorn of Merge, but today IT has a seat at the table. But Cheatham of PeaceHealth questions how many places have a dedicated IT resource for cardiovascular services. A dedicated resource may not be essential, but what is important is IT’s involvement as IT initiatives become more pervasive to imaging systems’ integration with the rest of hospital information systems as ARRA/MU takes hold. Cardiovascular services may not perceive that they have a need for integration. It is up to IT management to demonstrate the value of such integration. In the view of a large EMR vendor, it is all about where one draws the line. Companies that offer EMR and clinical system functionality will offer a high degree of integration, whereas clinical information system companies that don’t offer an EMR by necessity need to offer greater functionality and integration capabilities as part of the clinical system, and excel in interfacing to the EMR. So, is there a role for both an EMR and a CVIS? Probably, but each institution needs to assess its own circumstances

to make that decision. Factors to consider include: • The state of EMR implementation, and objectives for CPOE, central scheduling, billing services, automated physician data entry, etc.; • Other enterprise system initiatives that might impact cardiovascular and EMR system integration; • Plans for involvement beyond the institution, such as participation in an HIE, the level of system compatibility, and the scope of information sharing expectations; • The extent of current CVIS implementation, and the level of integration across cardiovascular service lines; • Current physician reporting practices and compatibility with EMR strategy; • Extent of existing management reporting tools, and their importance to administrative objectives; • Institutional plans for physician group integration, including cardiovascular physicians, and the need to absorb their IT infrastructure; • The state of image sharing across imaging services and the opportunity for enterprise initiatives such as the Vendor Neutral Archive (VNA); and • Business continuity and disaster recovery plans and their application across diagnostic services. In the words of author Bill Gray, “A lot of what appears to be progress is just so much technological rococo.” Tremendous progress has been made in terms of cardiovascular information systems. As healthcare continues to evolve, there will likely be systems overlaps. But the forces demanding greater information integration and utilization will determine the ultimate CVIS and EMR functionality and interoperability. Let’s hope it’s not just “technological rococo!” ◆ Joe Marion is founder and principal of Healthcare Integration Strategies LLC, Waukesha, Wis.

www.healthcare-informatics.com • Healthcare Informatics 27

CLINICAL IT PERSPECTIVE

Harnessing EHR-Derived Data PHYSICIANS AT LUCILE PACKARD CHILDREN’S HOSPITAL LEVERAGE DATA FROM THEIR EHR FOR PEDIATRIC CARE BY MARK HAGLAND

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or the first time, aggregate patient data from an electronic health record (EHR) has been used to help make a real-time diagnosis and treatment decision in the context of a rare pediatric condition; and in an article published online on Nov. 2 , 2011 in the New England Journal of Medicine (and on Nov. 10 in its print edition), three physicians from Lucile Packard Children’s Hospital (LPCH) at Stanford University, Palo Alto, Calif., describe how the process worked, and what the implications of that development are for patient care more broadly. Jennifer Frankovich, M.D., Christopher A. Longhurst, M.D., and Scott M. Sutherland, M.D., authored the article, “Evidence-Based Medicine in the EMR Era.” The authors, a pediatric rheumatologist, the hospital’s CMIO, and a pediatric nephrologist, write that there are frequently situations in pediatric care in which there is not enough—or even any—evidence in the medical literature that can guide unusual patient cases. “We recently found ourselves in such a situation as we admitted to our service a 13-year-old girl with systemic lupus erythematosus (SLE),” the authors report. “Our patient’s presentation was complicated by nephritic-range proteinuria, antiophospholipid antibodies, and pancreatitis. Although anticoagulation is not standard practice for children with SLE even when they’re critically ill, these additional factors put our patient at potential risk for thrombosis, and we considered anticoagulation. However, we were unable to find studies 28 January 2012 • www.healthcare-informatics.com

pertaining to anticoagulation in our patient’s situation and were therefore reluctant to pursue that course, given the risk of bleeding.” Instead, leveraging a platform called the Stanford Translational Research Integrated Database Environment (STRIDE), which acquires and stores all patient data contained in the electronic medical record (EMR) at LPCH and provides immediate textsearching capability, the article’s authors were able to perform an automated cohort review and come to a diagnostically valuable

CLINICAL IT PERSPECTIVE

a digital repository is already outdated. What’s more, everyone who’s seen by a doctor, their data should be available for clinical decision-making. HCI: Some physicians still resist losing the freetext narrative. So there is this tension between allowing physicians to produce unlimited free text in their documentation, and moving too fully toward drop-down menus, to the point where the “patient story” is lost. What are your thoughts A MAJOR SHIFT on that issue, in this context? Searchability was Healthcare Informatics: This was a fascinating clearly an element in this mix. case, and what appears to be a perfect example Longhurst: Yes. We could identify all the kids of the gains in patient care quality that can be made by fully leveraging electronic health re- Christopher Longhurst, M.D. who had lupus through discrete data. But we didn’t have the data discretely documented cords [EHRs]. Christopher A. Longhurst, M.D.: What this is really about from around clots. So we did a search across charts for a variety of my perspective, is that lots of people talk about secondary terms associated with clotting. It was a partially automated use of the EHR for clinical research. And a lot of talk is taking search, searching for terms. I agree with you, that is an issue. place around the use of business intelligence and analytics. And in fact, there have been some really good publications out This is the first instance in the literature in which aggregated of Vanderbilt [Vanderbilt University Medical Center, Nashville, Tenn.] around what they call the tension between free-text and discrete documentation. And most people are coming down on the side of, give people free-text when possible, use discrete data when necessary, data culled from the EMR has been used for real-time clinical and then use tools like natural-language processing to fill in decision-making. That’s the key concept. I would call it the first the gaps. sign of a shift from evidence-based practice to practice-based evidence. MAKING GOOD DECISIONS IN REAL TIME HCI: The patient case that you and your colleagues described HCI: When clinicians and clinical informaticists read this arin your article involved just too rare a situation for any clinical ticle, will it provide a kind of “lightbulb” moment for them? trials-based literature to turn to, correct? Longhurst: Well, I hope so. And the quicker we get to this, Longhurst: Yes, that’s right. And another way to think about the more lives will be saved. We need to think about providing it is that we’ve made this remarkable progress in curing child- tools within these systems to allow for using local data to help hood cancer. In the 1970s, Hodgkin’s lymphoma had a mortality improve decision-making. It’s the Holy Grail—the ability to rate of 90 percent; now it’s down to 10 percent. And the reason facilitate having the average doctor using this combination of that happened was that every kid with lymphoma was involved tools to make good decisions on a real-time basis. in a trial, and we learned from every patient’s case. With adult HCI: What would your advice be to CIOs and CMIOs, based cancer, fewer than 10 percent of patients are on trials. But on this? what we’ve learned is that what is key is not only collecting Longhurst: I would tell them that, to whatever extent is feasible information on every patient, but also using the data from the they should decentralize and federate their analytics tools. warehouse. And we have collected data using the Cerner and HCI: Because that will help spark a certain kind of creativity or ingenuity, right? Epic EMRs. Longhurst: Yes, because the more you keep these tools reHCI: There are a lot of clinicians who still tend to think of the stricted to a centralized group of experts, the less innovation EHR as a one-way repository, right? Longhurst: Yes. And the concept of the EMR/EHR as simply you’re going to get. ◆ conclusion about the patient in question. Dr. Longhurst, LPCH’s CMIO, spoke with HCI Editor-in-Chief Mark Hagland on the eve of the publication of the NEJM article and shared his perspectives on the implications for automationassisted patient care from this development. Below are excerpts from that interview.

THIS IS THE FIRST INSTANCE IN THE LITERATURE IN WHICH AGGREGATED DATA CULLED FROM THE EMR HAS BEEN USED FOR REAL-TIME CLINICAL DECISION-MAKING. THAT’S THE KEY CONCEPT. I WOULD CALL IT THE FIRST SIGN OF A SHIFT FROM EVIDENCE-BASED PRACTICE TO PRACTICEBASED EVIDENCE. —CHRISTOPHER LONGHURST, M.D.

www.healthcare-informatics.com • Healthcare Informatics 29

MEANINGFUL USE UPDATE

Report from AMIA: Beyond Electronic Versions of Paper Charts PANELISTS DESCRIBE GOING BEYOND ESTABLISHED USES OF EHRs TO TRANSFORM CARE BY DAVID RATHS

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he impact of meeting meaningful use requirements was one of the hot topics at this year’s Annual Symposium of the American Medical Informatics Association in Washington, D.C. In an Oct. 24, 2011 session, Len Bowes, M.D., a senior medical informaticist for 22-hospital Intermountain Healthcare in Utah, described the difficulty his nonprofit organization is having with changes around its homegrown electronic health record (EHR) and CPOE. The effort has required both software and workflow changes that are taking longer than expected. Intermountain decided to postpone its hospitals’ attempts to achieve Stage 1 until mid-2013. “If we get half of our hospitals to achieve meaningful use then, it will be good,” Bowes said. On the other hand, some other integrated delivery networks experienced with clinical information systems question the value of meaningful use to their organizations. Amy Compton Philips, M.D., associate executive director of quality for the Permanente Federation, which represents the national interests of Kaiser Permanente’s eight Permanente Medical Groups, said meaningful use is great for the country at large, but it is “doing things we were doing 10 years ago. It is requiring us to do some work crossing i’s and dotting t’s that we’re not certain adds value.”

SOME SEE OPPORTUNITIES FOR REFINEMENTS On the same panel, several presenters spoke about ways their organizations are moving beyond digitizing paper records 30 January 2012 • www.healthcare-informatics.com

and processes to use IT tools in a more sophisticated way. Mary Goldstein, M.D., director of the Geriatrics Research Education and Clinical Center at the VA Palo Alto Health Care System, described her team’s work developing a clinical decision support system for hypertension management known as Athena CDS. It combines patient information from the VistA EHR with an automated knowledge base about hypertension to generate patient-specific recom-

MEANINGFUL USE UPDATE

mendations for managing hypertension. patient care experience, and the patients really Michael Kanter, M.D., medical director notice,” he said. “It helps create a partnership of quality and clinical analysis for Southern between the patient and the health team.” California Permanente Medical Group, talked Paul Tang, M.D., chair of the Meaningful Use about how IT systems are at the heart of an efWorkgroup of the Health IT Policy Committee, fort to make office encounters more proactive. spoke on a panel about clinical quality measure “We are embedding processes to support predevelopment. Tang described the challenges of ventive and chronic care needs into standard creating clinical quality measure concepts for workflows, and utilizing IT tools for identificaStage 3 when the measures themselves don’t exist tion of patient care gaps,” he said. Physicians yet. Proposed core measures, he said, could deal and medical assistants develop and sign team with medication reconciliation and closing referagreements about which tasks each would ral loops. Others may deal with the patient experido before, during, and after office visits. The ence itself, such as patient and family experience Paul Tang, M.D. computer system scours the patient records of care across transitions of care. Still others may and comes up with a checklist specific to the be longitudinal to track how well providers are patient, such as when to order lab tests. The medical group helping individuals over time. “That is a different mindset for measures and provides feedback on how each office is do- quality measurement,” Tang said. “Clinical quality measures will ing. Kanter said screening levels are up considerably since be a focal point for healthcare delivery and payment. We need the program’s inception a few years ago. “We are activating to develop clinical quality measures that are meaningful to all members of the healthcare team in providing a proactive clinicians and patients and captured as a byproduct of care.” ◆

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IMAGING PERSPECTIVE

When Radiologists ‘Google’ THANKS TO SOME ENTERPRISING RADIOLOGIST INFORMATICISTS AT PENN, RADIOLOGISTS CAN NOW SEARCH THEIR REPORT DATABASE WITH GOOGLE-LIKE EASE BY MARK HAGLAND

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here are a lot of exciting things going on these days at the Hospital of the University of Pennsylvania (HUP) and the health system of which it is the flagship facility, the University of Pennsylvania Health System (Penn Medicine). And among a constellation of forward-looking initiatives, one particularly fascinating one is in the imaging informatics area, where Woojin Kim, M.D., associate director of imaging infor32 January 2012 • www.healthcare-informatics.com

matics at HUP, has led the development of a highly innovative radiology search engine called Montage, which first went live in 2009. Prior to Montage, Dr. Kim and colleagues, including Dr. Khan Siddiqui, Dr. Nabile Safdar, and Dr. William Boonn, were behind the creation of Yottalook, which was made publicly available to radiologists, other physicians, and medical researchers, now being accessed in more than 170

IMAGING PERSPECTIVE

based on radiology reports. So here’s an analogy: If I wanted to go out to a restaurant tonight and be within a certain geographical range, and wanted a certain cuisine and look up some reviews, I could Google all that and find a restaurant that I want to go to, right? But if I wanted to do similar things with radiology reports where I’m looking at a case, and I say to myself, I had a case just like this, but I can’t remember the patient’s name, for example, what do I do? The ability to rapidly search radiology reports didn’t exist. Woojin Kim, M.D. So I created a Google-like search engine that can be used at Penn. We had an old rudiQUICK AND EASY SEARCH TOOL Healthcare Informatics: How did the idea for Montage mentary search tool, but it was very slow, limited, and the user interface was cumbersome to use. It wasn’t like Google, emerge? Woojin Kim, M.D.: The thing that I worked on when I first which works in less than a second with a very simple user came to Penn was that I had trouble finding my own radiol- interface. Now, if it took more than a second to do a Google ogy reports. In the world of radiology, our main product is search to get results, you’d think there was something radiology reports; everything hinges on that—the quality, wrong with your Internet service, right? The expectations the value we have for referring physicians, those are all have completely changed among search engine users. countries. Like many good ideas, the concept for Yottalook emerged organically out of a set of problems to be solved. Its name, by the way, came out of International System of Units (SI) where, as Kim points out, “Yotta is the largest accepted SI.” It is also a play on the phrase, “you outghta look.” Kim spoke recently with HCI Editor-in-Chief Mark Hagland and shared the story behind the development of Montage, and of his leadership in that development. Below are excerpts from that interview.

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IMAGING PERSPECTIVE

So we created an application that works like Google. For example, at Penn, we have over 13 million radiology reports digitized since the late 1980s. And that amount of data gives you a tremendous amount of possibilities. So that’s how it got started. And I said, why don’t I make this vendoragnostic in terms of its backend, so that I can plug it into other specialties within medicine, like pathology? So now I can search pathology reports as well as radiology reports within the same institution; and what’s more, I can also do pathology-radiology correlation searches. And that’s how we came up with the idea for Montage. Over a weekend, I created a prototype version on my own laptop and showed it to my IT guys, and they really liked it. So they said, go ahead, tap into the entire report database. They gave me my own server, and the very first version of this search tool was born. It was initially called PRESTO (Pathology-Radiology Enterprise Search Tool); Dr. Boonn [William Boonn, M.D., a radiologist and radiology informaticist at HUP] came up with that name. Now, we have over 300 users, which include radiologists, administrators, non-radiology physicians, and research coordinators. And it’s already in use by many different physicians and others, within the U.S. and even abroad. Whenever I gave presentations at national meetings on search and data mining, after each presentation, people would come up and ask me, how can I get this? As a result, we ended up commercializing it, and created a company with Dr. Curtis Langlotz, Dr. Rajan Agarwal and Dr. William Boonn. The commercial product is called Montage. In radiology, everybody focuses on images, but the product really is the radiology reports. And I started incorporating other specialties within medicine, like pathology and

of medical document. There are numerous nuances around the ways that radiologists dictate and write their reports, so we’ve created a tool that accounts for that. For example, let’s say that you’re searching for a report that discusses pneumothorax, which simply is a hole in the lung, causing presence of air between the lung and the chest wall. Now, many radiologists dictate absence of pneumothorax in chest radiography reports routinely. However, if you are doing a search for “pneumothorax,” you are likely looking for positive cases of pneumothorax and want to exclude all those reports that say, “there is no pneumothorax.” Well, you can perform “negation searches” to remove all such cases so that you are left with only positive cases of pneuomothorax. Understanding such unique elements in any medical specialty are very important; this is why it is crucial to have domain expertise when creating search and data mining tools in medicine. That is also what makes Montage unique; it’s developed by physicians for physicians. We have also created various dashboards and analytics with quality assurance capabilities like error-checking within radiology reports to improve report quality and patient safety.

MINING DATA, GAINING INSIGHTS HCI: What lessons have you and your colleagues learned so far? Kim: One thing is, when you give end-user physicians the ability to data mine and search their own reports, the ideas they come up with are absolutely fantastic—in particular, some really neat quality improvement projects have come out as a result. And you engage the younger guys; and by doing so you also promote academic research and quality improvement. So they’ll come up with things like, how many malpositioned catheterizations have there been in the past year? Or, how many times is the endotracheal tube being placed in too deeply? Or how many times a feeding tube is put into the airway instead of the esophagus? I’m sure the hospital has its own procedure and incident report database, but how often are radiologists identifying malpositioning? How about how many times has a radiologist made a mistake and identified the wrong side of the body in his reports, such as a fracture of the left hand instead of the right hand? People really come up with creative ideas and solutions. Having this ability to search and data mine really empowers end-users.

WHEN YOU GIVE END-USER PHYSICIANS THE ABILITY TO DATA MINE AND SEARCH THEIR OWN REPORTS, THE IDEAS THEY COME UP WITH ARE FANTASTIC—IN PARTICULAR, SOME REALLY NEAT QUALITY IMPROVEMENT PROJECTS HAVE COME OUT AS A RESULT. —WOOJIN KIM, M.D. cardiology; there is really no limit; we could go into surgical operative notes, discharge summaries, progress notes, etc. And that’s what folks are interested in at Penn. A lot of hospitals are building their own data warehouse or buying one so that they can federate their databases and mine them. So this is a nice application that can sit on top of such system, where it’s easy-to-use interface allows for powerful searching capability across multiple different databases. Going a step further, radiology reports are a unique type 34 January 2012 • www.healthcare-informatics.com

IMAGING PERSPECTIVE

Speaking of the left and right issue, I have created a whole dashboard just on laterality errors—and when I first created this, the error rates were higher than I’d expected. But when I started sending out these error reports to physicians and when the physicians found out this was being monitored, the error rate dropped by almost 50 percent; purely the awareness that someone was watching dropped dictation error rates by more than half. Such behavior modification has been well documented so it’s no surprise, but it is nice to see such tools can be used to improve quality and patient safety. HCI: And radiology is one of the specialties where a lot of people haven’t yet thought about quality improvement, right? Kim: They have, but not enough. And this is just one specialty in medicine. But if you give this ability to do search, in a HIPAA-compliant fashion, the kind of information you can get is absolutely fantastic and mind-blowing. HCI: What thoughts would you like to share with CIOs and other IT leaders? Kim: People like to say in the healthcare IT world we’re

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many years behind everyone else [outside healthcare] in terms of IT, such as financial/banking services. Now if you were a product in WalMart, WalMart knows exactly where you are and have been at all times. Yet how many times a day do we lose lab test results or have studies that go unread in healthcare? So if you look outside healthcare for potential paths forward, that will help. Take for example the whole concept of dashboards and business analytics; those tools have been used for decades outside healthcare. That’s why I like to look outside healthcare for ideas and implementation strategies. So the simple comment I would make to CIOs and CMIOs is, what do you do every day when you go online? Half of the time, you are searching for something. Imagine what you can do if you could do that inside your own hospital. Right now, if I took Google away from you, you’d feel pretty limited. We are living with just such limitations but don’t know just how much. The fact is that we don’t have Google-like search capabilities when it comes to patient care right now. But imagine what could happen if we really did have that ability. ◆

RIS PERSPECTIVE

Meaningful Use Spurs RIS Upgrade Plans SURVEY POINTS TO AN INTEREST IN MORE ROBUST RADIOLOGY INFORMATION SYSTEM SOLUTIONS BY JOHN DEGASPARI

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recent survey suggests the Health Information Technology for Economic and Clinical Health (HITECH) Act, whose focus is to stimulate the adoption of electronic health records, is having a ripple effect on planned radiology information system (RIS) purchases as well. The 2011 U.S. Radiology Information Systems Study by CapSite, a healthcare technology consultancy in Williston, Vt., polled leaders at 360 hospitals across the U.S., distributed among small, medium, and large organizations. (Of the respondents, roughly

cent of respondents are aware that meaningful use incentive payments apply to radiologists as eligible physicians under the HITECH Act, with 51 percent of participants saying they had either already applied for MU incentive payments or will be applying in the near future. In addition, 53 percent of recent RIS purchases were part of a broader enterprise clinical EHR procurement, representing a shift in RIS procurement practices compared to several years ago. The market is mature: 61 percent of RIS systems installed in hospitals today are at least five years old. Gino Johnson, CapSite senior vice president and general manager, notes that “Almost threequarters of respondents are now aware that meaningful use incentives apply. We were not expecting it to be that high.” He says efforts among RIS vendors to raise MU awareness among radiologists have been successful. “That group was a little

AS THEY GET COMFORTABLE AROUND STAGE 1, AND ARE LOOKING AT SOME OTHER ASPECTS OF THEIR IT INFRASTRUCTURE THAT MAYBE HAVE BEEN NEGLECTED OVER THE PAST FOUR OR FIVE YEARS, THEY ARE IN SOME CASES REALIZING THAT THEIR RIS SOLUTIONS ARE GETTING LONG IN THE TOOTH. —GINO JOHNSON 200 were hospitals with fewer than 200 beds, 100 with between 200 and 400 beds, and the remainder with more than 400 beds.) Among the survey’s highlights is the finding that 71 perVOC: Which of the following functions do you use your RIS for?

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36 January 2012 • www.healthcare-informatics.com

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Save the Date! Healthcare Informatics Executive Summit 2012 May 5–8, 2012 Marriott Orlando World Center Resort

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RIS PERSPECTIVE

VOC: Which of the following best describes your recent RIS purchase?

Stand-alone RIS purchase 23%

VOC: Which of the following approaches would you prefer when purchasing a RIS?

Stand-alone RIS purchase 4% RIS purchased as part of a broader enterprise (EHR) clinical system 53%

RIS purchased in combination with PACS solution 24%

No preference 17%

RIS purchased in combination with PACS solution 12%

RIS purchased as part of a broader enterprise (EHR) clinical system 39%

RIS purchased in combination with HIS 28%

© 2011 CapSite

© 2011 CapSite

behind; there was so much focus on EHRs that RIS and PACS were in the periphery,” he says.

SHIFT IN RIS PURCHASE PLANS A shift in trends around the purchasing of EHR solutions brought about by meaningful use criteria has resulted in a shift in how hospitals plan to make their next RIS purchase. When asked to describe their most recent RIS purchase, 53 percent of respondents said it was as part of a broader enterprise EHR system purchase; the remainder was about evenly divided between those who purchased a standalone RIS, and those who purchased a RIS in combination with a PACS solution. When questioned about their RIS preferences, only 4 percent indicated they preferred a standalone system. Most indicated that they prefer to purchase RIS as part of an EHR clinical system. The survey puts hard numbers behind a trend that has been underway for several years, Johnson says. Johnson also notes that hospitals with aging RIS solutions may VOC: Which of the following best describes your facility’s/organization’s strategy to achieve and document MU with your RIS/PACS?

4%

We are working with our current RIS/PACS vendor to optimize the use of our current RIS/PACS solution We are in the process of evaluating vendors for a new RIS/PACS solution

5%

5%

We expect to initiate a search process for a new RIS/PACS solution

11%

5% 61% 9%

We have already engaged with a consultant to assist us in optimizing the use of our current RIS/PACS solution We expect to engage with a consultant to assist us in optimizing the use of our current RIS/PACS solution We have achieved MU and have already received stimulus money from the government Achieving/Documenting meaningful use is not a primary concern for our organization

© 2011 CapSite

38 January 2012 • www.healthcare-informatics.com

be at the point of replacing the systems. Many of those providers have kept RIS replacement as a back burner issue as they focused on meaningful use. Some hospitals may be ready to move on, Johnson notes. “As they get comfortable around Stage 1, and are looking at some other aspects of their IT infrastructure that maybe have been neglected over the past four or five years, they are in some cases realizing that their RIS solutions are getting long in the tooth,” he says. In fact, according to the survey, 45 percent of respondents said they were considering planning to either purchase a new RIS or upgrade the one they already have.

SEEKING GUIDANCE ON MU Many organizations are looking for guidance when it comes to meaningful use and RIS. When asked about their organization’s strategy, 61 percent said they were working with their current RIS/PACS vendor to optimize the use of their current RIS/PACS solution. Other respondents were employing a number of different strategies, including engaging or considering the engagement of a consultant to assist in the process. Another 10 percent were either initiating a search process for a new RIS/PACS solution or were in the process of doing an evaluation of a new solution. Only 9 percent said that achieving or documenting meaningful use was not a primary concern for their organization. When asked if they would be applying for meaningful use incentives, 50 percent said either they would in the near future, or that they already had; and 46 percent said they were unsure at this time. Only 4 percent said no. Johnson notes that respondents expressed an interest in more robust RIS solutions that would encompass additional functions like order entry and management reporting, which in many cases are non-RIS solutions. If the RIS also included automated critical results notification and various marketing tools, this would make an even more compelling case for a hospital to replace its current RIS for one that is more robust, he says. ◆

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FINANCIAL UPDATE

The ‘New Normal’ Reflected in HIT Investments EVEN DURING A TIME OF ECONOMIC UNCERTAINTY, MORE ORGANIZATIONS ARE INVESTING IN HEALTHCARE IT TO KEEP PACE BY GABRIEL PERNA

H

ealthcare IT is quickly becoming the most significant economic investment for patient care healthcare organizations, according to a recent survey from the Charlotte, N.C.-based Premier healthcare alliance. In a survey of 743 healthcare providers, approximately 40 percent of the respondents said they 40 January 2012 • www.healthcare-informatics.com

expect their largest capital investment over the next 12 months to be in HIT and telecommunications. The survey is a part of Premier’s semi-annual Economic Outlook report, which discusses the economic trends in healthcare. In Premier's March 2011 Survey, 34 percent of healthcare

Healthcare

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FINANCIAL UPDATE

providers said HIT would be their largest capital investment. The jump over the past six months, according to Premier Chief Technology Officer Denise Hatzidakis, is proof of the ever-changing landscape in healthcare. HIT investing has

data that makes up the full view of the patient?” Coordinated care has lagged, because of a lack of connectivity, Hatzidakis says. Varying pieces of patient data spread across different repositories that can’t communicate with each other results in a less-than-full view of the patient. This could lead to problems with prescribing, and doesn’t allow doctors to get past episodic care, she says, but adds that the evolution of integrated technologies is permitting coordinated care that is addressing those past mistakes.

ACROSS OUR MEMBERSHIP, WE SEE A WHOLE CONTINUUM. THERE’S A BELL CURVE. THERE ARE THE TWO ENDS, AND THE MIDPOINT IS PROBABLY DOING JUST ENOUGH. THE MAJORITY OF ORGANIZATIONS ARE JUST STARTING TO KICK THE TIRES, ASK QUESTIONS, AND TRY TO UNDERSTAND WHAT EVERYTHING MEANS. —DENISE HATZIDAKIS become a necessity even during a time when most healthcare organizations are trying to reduce costs and 69 percent of the survey’s respondents say their capital budgets have hit a plateau.

TIMING IS EVERYTHING As the healthcare industry begins to advance into the digital age, the federal government is pushing it along with incentivizing regulatory acts such as the American Reinvestment and Recovery Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act. Meanwhile, healthcare delivery that relies on connectivity is becoming more mainstream. This has added up to significant HIT investments for providers. “The stars are truly aligned to move the HIT/telcom focus forward,” Hatzidakis says, breaking it down into two key

LEVELS OF TECH INVESTMENT According to Hatzidakis, not every organization in Premier’s membership of approximately 2,500 hospitals and 78,000 other healthcare sites is on equal footing when it comes to HIT investments. There are early tech-savvy adopters making large investments into more complex, innovative systems; and there are other organizations that are limiting their investments to meet regulatory or day-to-day requirements, she says. “Across our membership, we see a whole continuum,” Hatzidakis says. “There’s a bell curve. There are the two ends, and the midpoint is probably doing just enough. The majority of organizations are just starting to kick the tires, ask questions, and try to understand what everything means.” As more organizations move beyond regulatory based investments, Hatzidakis expects the investments in technology to move beyond the walls of the provider. She also sees a lot of investments in data analytics. “It makes information actionable,” she says. “It’s how you turn data into something that can help people make better decisions.” ◆

THE STARS ARE TRULY ALIGNED TO MOVE THE HIT/TELCOM FOCUS FORWARD. THE REGULATIONS AND REIMBURSEMENT IS A SIGNIFICANT DRIVER. THE INCENTIVES ARE TO GO WITH HITECH; IF YOU DON’T HAVE AN ELECTRONIC HEALTH RECORD, YOU DON’T GET REIMBURSED. THE OTHER DRIVER IS THIS COORDINATED, CONNECTED CARE. —DENISE HATZIDAKIS factors. “The regulations and reimbursement is a significant driver. The incentives are to go with HITECH; if you don't have an electronic health record, you don't get reimbursed. The other driver is this coordinated, connected care. Getting that information together, how do you integrate all the 42 January 2012 • www.healthcare-informatics.com

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ICD-10 UPDATE

Transitioning to ICD-10 in a Multi-Hospital System THE CMIO OF PITTSBURGH’S UPMC HEALTH SYSTEM DISCUSSES THE LONG PATH AHEAD BY MARK HAGLAND

M

oving forward to make the transition from the ICD-9 coding system to the ICD-10 system, as mandated by federal authorities, is no easy feat. Indeed, even the largest and most sophisticated patient care organizations face multiple challenges as they navigate the numerous issues embedded in the change. At the 20-hospital University of Pittsburgh Medical Center (UPMC) health system in Pennsylvania, CMIO G. Daniel Martich, M.D. is helping to lead his fellow clinicians, informaticists, and others at the UPMC organization to move through the transition. HCI Editor-in-Chief Mark Hagland spoke recently with Dr. Mar44 January 2012 • www.healthcare-informatics.com

tich regarding the transition process taking place at UPMC. Below are excerpts from that interview. Healthcare Informatics: Where are you right now in terms of your ICD-10 preparation? G. Daniel Martich, M.D.: In late spring, we kicked off our executive management steering committee on ICD-10, which is being chaired by the system CFO, but includes individuals from every one of our business groups. I’m on the steering committee. There are about 10 of us altogether, including, for instance, the COO of the health plan, the CFO for the system, the CFO for the hospital and community services division, a representative from our long-

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ICD-10 UPDATE

term care, etc. And our health system CIO Dan Drawbaugh is on the committee, too, of course. HCI: How often are you meeting? Martich: Right now, the executive committee is meeting monthly. Working under its oversight are four main workgroups, whose work spans all the task areas, with subgroups of various types. For example, we’ve got an education/communication workgroup, with representatives from every group that does anything with education or communication, and I chair that group. We also have a process workgroup that is focused on understanding the workflow changes needed in each particular business unit and area, including assessing opportunities for process improvement as we transition, as well as any risks. And we have operational managers who are the enterprise project managers for the project in toto. On the process side, the COO of our health plan is the chair of that workgroup. HCI: And then there are other levels of workgroups, correct? Martich: That’s right. We’re a matrixed organization, so for example, within the physician services division, we have another set of workgroups, covering the academic sites, the non-academic sites, and Children’s Hospital of Pittsburgh. Altogether, there are four workgroups within physician services, and another four within the hospital division. Some of those are specific to location and some are specific to position. Each of the subgroups addresses the needs of particular groups of clinicians and others, for example, hospital-based coders; and we have a nurse education workgroup.

PROGRESS SO FAR HCI: Where are you overall in terms of your progress? Martich: We’ve probably taken a few steps forward so far on the ‘journey of a thousand miles’; we’ve kicked off each of the working groups, and the sub-working groups have kicked off. Have we rolled up our sleeves? No, not yet. We’re in the midst of vendor selection right now related to computer-assisted coding solutions, for example. One area where we’ve made progress is with something called Intelligent Medical Objects, which is a tool that can be embedded into Epic, Cerner, or any EMR. Ten days ago, we installed IMO into EpiCare. And what it does is says, for example, this patient has diabetes with eye involvement; and IMO goes into the database and finds the appropriate ICD-9 code; and the promise is that eventually it will help clinicians search for the appropriate ICD-10 codes. Everyone using it loves it. We’ll probably be going live with it in Cerner, our inpatient EMR, starting next spring, while we’re live now already on the physician practice side. And [computerassisted coding] helps in the visit coding, and has been quite beneficial so far. [The solution we’re using] doesn’t do the fancier parts of the computer-assisted coding; we’re working through 46 January 2012 • www.healthcare-informatics.com

those discussions now, and we’ve already demoed each of the products we’re interested in. HCI: What do you see as the biggest challenges right now, both for UPMC and across the industry, as you talk to other CMIOs? Martich: I actually think that the biggest challenge is educating the users about how this will improve productivity. Most physicians don’t have a full awareness of ICD-10, or even if they’re aware of ICD-10 coming in the next couple of years, they fail to connect the dots on how this will affect them. And we hope to do concurrent coding, so that on the back end, an inpatient coder can say, Dr. A or Surgeon B, you need to clarify this point for us, and not put a fist through the computer or go down and punch that person in the nose. We need to get to efficiency so that we’re prepared for Oct. 1, 2013.

A GAME CHANGER? HCI: It seems to me that there’s great potential for care delivery improvement with ICD-10, right? And perhaps this isn’t clear to a lot of people in healthcare yet? Martich: I think you hit it on the mark; organizations that are used to doing data analytics are saying, perhaps this might be another tool in the tool belt around data analytics, yes. But what it really does is that it creates a bit of a game changer in terms of what insurers can do around data; it will allow our largest insurer, the government, to understand what the highest-volume diagnoses are; it will allow a certain amount more of granularity with regard to procedures. So I think it will provide on a macro level a greater ability to do data analytics, and it will be a game changer for CMS and other large insurers, to better understand where their dollars are going. HCI: What would your advice be to other CIOs and CMIOs right now? Martich: It goes back to the ‘get started’ talk. You’ve got to get started; because even if the AMA was successful—and I can’t imagine they would be—in getting the date changed [referring here to the American Medical Association’s petitioning the federal government to delay the Oct. 1, 2013 required transition date], people have got to get going on this. So I don’t see the U.S. government changing their requirements at all. To a certain extent, this is an ‘aha’ moment, and some people get cold feet at that moment. But unless there’s the pressure of the deadline, things don’t happen. Of course, there are a lot of things being thrown at us at the same time, and it’s a lot of changes to deal with. And certainly, on a micro level, my colleagues and friends the doctors, feel as though this is yet another thing added to their to-do lists. But we want to give them the tools to make them more successful in their practice, and ease them into this. And you’ll see, as we draw closer to 2013, computer-assisted coding technologies and products will become more and more prevalent. ◆

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www.healthcare-informatics.com • Healthcare Informatics 47

CAREER PATHS

Career Adversity WHY IT’S BEST TO DEAL HONESTLY WHEN ASKED ABOUT HOW WE HANDLED BAD JOB EXPERIENCES BY TIM TOLAN

M

ost of us have “been there” and “done that” when it comes to dealing with adversity in a former job or organization. I see far too many candidates that have a blemish on their resume hoping somehow that the topic never comes up. None of us want to go back in time and open old wounds and relive a bad experience. Let’s face it—it’s not fun to talk about for most of us. Tim Tolan I happen to be in a different camp altogether. I really appreciate hearing how a candidate had a bad working experience in a former life and, more importantly, how they overcame the obstacles, removed the barriers, and made things happen before they moved on. Hiding behind the employment dates on a resume without fully explaining what happened in a bad situation or organization does you no good. In fact, I will submit to you that by reliving the details in an open and honest conversation, you may find out some-

the best healthcare CIO we can be. If we choose to, we can drink our own Kool-Aid and steer the interview back to our comfort zone of career success metrics. It’s human nature to shed the best light possible on why we feel we are the best candidate for the role. This concept is also true as you interview talent to join your organization. You should try it! Add a few questions to your next interview to get a better picture of how an individual dealt with adversity. Here are a few you may want to add to your arsenal: • Tell me about a very difficult decision you had to make where the outcome did not turn out the way you planned. Tell me why you made the decision and what you would do differently if you could do it all over again. • Give me a situation where you were asked to compromise your integrity. What was the outcome? • Tell me about the worst boss you ever worked for and how you were able to be an effective employee. How were you able to maintain your focus on the goals and objectives of the job? I have many more, and I’m sure you can think of a few questions yourself that will help you understand how a candidate dealt with adversity in a prior role. You will get a glimpse into how they are wired and perhaps their future behavior. Adversity and failure make us stronger and that’s been proven over and over throughout history. Anyone who has read about Thomas Edison knows what I’m talking about. The story goes that Thomas Edison failed more than 1,000 times when trying to create the lightbulb. The number of times he tried is up for grabs and depends which version you read. When asked about it, Edison allegedly said, “I have not failed 1,000 times. I have successfully discovered 1,000 ways to NOT make a lightbulb.” Adversity can be our friend if we learn from it. ◆

HIDING BEHIND THE EMPLOYMENT DATES ON A RESUME WITHOUT FULLY EXPLAINING WHAT HAPPENED IN A BAD SITUATION DOES YOU NO GOOD. thing about yourself that you take for granted. You may also find that by telling your story, the person on the other side of the desk will give you high scores for how you handle adversity as much (or more) than for your career achievements and accomplishments. A very famous person once said “Every adversity, every failure, every heartache carries with it the seed of an equal or greater benefit.” I could not agree more. Talk about how you handled your situation, what the outcome was and what you learned from it. In today’s world, that’s all that really matters. We all learn through adversity and failure, and that is what helps shape us into being 48 January 2012 • www.healthcare-informatics.com

Tim Tolan is a senior partner at Sanford Rose Associates Healthcare IT Practice. He can be reached at [email protected] or at (843) 579-3077 ext. 301. His blog can be found at www.healthcare-informatics.com/tim_tolan.

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