The ICD-10 Leap
EMRs and the Bottom Line
ACO How-To
September 2011
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Volume 28, Number 9
What Are You Doing to Support M.D. Mobility?
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CONTENTS September ✪ ✪ SPECIAL SECTION ✪ ✪ 28
TWEAKING THE PACS MARKET How well are vendors of picture archiving and communication systems meeting the expectations of hospitals? Hospital CIOs and experts from KLAS give their perspective, drawing on the latest KLAS research BY RICHARD R. ROGOSKI
DEPARTMENTS 6
INSIDE
8
EDITOR’S PAGE
FINANCIAL MANAGEMENT
32
COVER STORY 10
M.D. MOBILITY EXPRESS With new technologies rapidly making physician mobility a reality, the time is now to plan for the changes in how physicians care for their patients. What are healthcare IT leaders saying about the strategies and vision to make the mobile future a success for all involved?
CLINICAL IT PERSPECTIVE
36
SMART SYSTEMS, SMART CARE DELIVERY Carol Scholle, R.N., whose team was the third place winner of the first Healthcare Informatics/AMDIS IT Innovation Award, describes how she and her colleagues implemented an ensemble of “SmartRoom” technologies to improve care delivery at the University of Pittsburgh Medical Center health system BY MARK HAGLAND
BY MARK HAGLAND
18
EMRs AND THE BOTTOM LINE As hospitals take on the task of selecting and implementing electronic medical record systems, they are confronting two key issues: what funding strategies are available, and what value can be expected. Hospital CFOs, bankers, and consultants weighed in on the issue at the HFMA ANI Conference in Orlando, Fla., in June BY JOHN DEGASPARI
RAMPING UP As the deadline for ICD-10 approaches, how are CIOs and HIM directors laying the groundwork to smooth the way to the transition? BY JENNIFER PRESTIGIACOMO
CAREER PATHS
24
ACTIONABLE ACCOUNTABLE CARE GOALS Pinning down the IT requirements to achieve accountable care is a difficult undertaking. An expert offers advice on strategies, systems, priorities—and pitfalls for CIOs BY DANIEL J. MARINO
48
TOUGH INTERVIEW QUESTIONS For better or worse, job applicants today should expect tough interview questions. Here’s advice for knocking the real hardball questions out of the park BY TIM TOLAN
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Healthcare
Informatics
INSIDE
Healthcare IT Leadership, Vision & Strategy
M.D. Mobility, ICD-10 Deadline, and Action Items for Accountable Care
T
he rapid pace of technology development is opening up a broad range of ways to meet physicians’ needs for mobile computing as never before, while fueling a host of issues around cost, interoperability, security, and patient privacy. In this month’s cover story, beginning on page 10, Editor-in-Chief Mark Hagland looks at what medical group, hospital, and health system leaders are saying about the strategies and vision needed to make the mobile future a success for all involved. As the Dec. 13, 2010 deadline for ICD-10 approaches, hospital CIOs and HIM directors are laying the groundwork for a smooth transition. In the article on page 18, Associate Editor Jennifer Prestigiacomo takes a look at critical care assessments, training programs, and costs that will be required to make the changeover a success. The push for accountable care has left many CIOs uncertain about the IT requirements to make ACOs a success. On page 24, healthcare expert Daniel J. Marino provides guidance on strategies, systems, priorities in the form of action items, which taken together point to the importance of developing an integrated IT plan. As more and more hospitals take on the task of selecting and implementing an electronic medical record system, all are grappling with issues of funding while weighing the value propositions that EMRs provide. Hospital CFOs, bankers, and consultants weighed in on the issue at the HFMA ANI conference in Orlando in June, as highlighted in this month’s Financial Management story, beginning on page 32. This issue’s Clinical IT Perspective shines a spotlight on Carol Scholle, R.N., whose team at UPMC was the third-place winner of the first Healthcare Informatics/AMDIS IT Innovation Advocate Award. Beginning on page 36, she describes how she and her colleagues implemented “SmartRoom” technologies to improve care delivery. Last but not least, how should prospective healthcare CIOs handle tough and uncomfortable questions that are bound to come up in a job interview? On page 48, Career Paths columnist Tim Tolan takes on the role of coach, and tells you how to knock hardball questions out of the park.
2011 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
6 September 2011 • 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
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EDITOR’S PAGE
Can You Trust Your Intuition? MORE AND MORE, PHYSICIANS ARE TURNING TO MOBILE COMPUTING SOLUTIONS TO ACCESS INFORMATION THAT CAN HELP THEM PRACTICE BETTER MEDICINE
I
n their 2010 book The Invisible Gorilla: And Other Ways Our Intuitions Deceive Us, co-authors Christopher Chabris and Daniel Simons, cognitive psychologists, “reveal the numerous ways that our intuitions can deceive us…” and “explain why we succumb to…everyday illusions,” according to their book’s self-description on its book jacket. Chabris and Simons provide a fascinating look at how a lot of the mental Mark Hagland processes we take for granted, under the dangerously broad umbrella of day-to-day intuition, are actually exercises in illusion and selfdelusion. It’s the kind of book that makes one question a lot of assumptions about how the human mind works. Interestingly, the authors open their third chapter by relating a personal healthcare experience that Chabris had several years ago that left him “a little unnerved.” Suffering a lingering headache, body aches, and exhaustion, Chabris was initially diagnosed by a clinician at the university health service at Harvard University (where he was attending graduate school at the time) with some kind of flu-like virus, and told to go home and rest. When the symptoms persisted, and Chabris discovered a sunburst-shaped red rash on his left calf, he limped off to the school’s after-hours clinic, where a physician there diagnosed Lyme disease, and prescribed a 21-day regimen of the antibiotic doxycycline for him. Chabris writes that while the diagnosis of Lyme disease was unsettling, “even more unsettling was the doctor’s open consultation of reference books during the session” (after informing him that he had Lyme disease, she had gone into another room to retrieve a medical reference book with information on its treatment). “Chris had never seen a doctor do this before, and this one did it twice. Did she know what she was doing?” Even as he rushed off to fill the prescription, Chabris questioned why a seemingly competent physician would turn to a reference work 8 September 2011 • www.healthcare-informatics.com
in his presence in order to prescribe treatment for a well-known disease. Ultimately, though, Chabris and Simons use the anecdote not to condemn this unnamed doctor, but to vindicate her, weaving together compelling, true stories and evidence in the literature that demonstrate that the more confident-appearing a person is, the more we believe them—sometimes with disastrous consequences. In reality, the world is becoming more and more complex, and ultimately, more patients are coming to understand that, as the practice of medicine, too, becomes more complex and demanding, physicians will need to rely more and more extensively on clinical decision support at the point of care, on evidence-based order sets, and on other informational tools that can help them where they need it most—at the point of care or consultation. And how can physicians most readily benefit from all the electronically based solutions out there in these areas? The easy phrase—as difficult as it is to execute—is just two words long: mobile computing. The question is, what do physicians want, and how—and where—do they want it? And what’s possible? As this month’s cover story (p. 10) notes, medical group, hospital, and health system leaders are finding a very broad range of ways to meet physicians’ needs for mobile computing, even as they work to balance out issues around cost, comprehensiveness, interoperability, user-friendliness, patient data privacy and security, and compliance with federal mandates, such as those emerging out of the HITECH Act and healthcare reform, going forward. Exactly how each patient care organization delivers mobility to its doctors will inevitably vary by individual organization; but the reality that mobile computing will soon be an assumed part of healthcare—well, that’s just intuitive.
Mark Hagland Editor-in-Chief
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COVER STORY
M.D.Mobility
EXPRESS
10 September 2011 • www.healthcare-informatics.com
EXECUTIVE SUMMARY:
COVER STORY
ARE YOU READY TO FACILITATE TOTAL PHYSICIAN MOBILITY? BY MARK HAGLAND With new technologies erupting across the IT landscape, physician mobility is expected to leap forward in the coming years. But healthcare IT leaders and industry experts say thoughtful strategies and clear vision will be needed to make the mobile future a successful one for all those involved.
M
ark Musco, M.D., remembers clearly what life was like in the pre-mobile-computing days for physicians. “It must have been in 2005 or 2006,” he recalls. “I was at a party with a bunch of friends from college, and two friends had Palm PDAs, and they were checking their e-mails, and I looked at them doing that with longing. And I realized in that moment how owning a mobile device would allow me to be connected to my practice, but also be with my family, or be at the park, or anywhere else—in other words, how it could untether me from a fixed workstation.” Not long after that, Musco began using his BlackBerry for some functions, and then switched to an iPhone just under two years ago. And if Musco glimpsed the future of physician mobility several years ago, he’s also someone who, in his role as CMIO of the Walnut Creek, Calif.-based Muir Medical Group IPA, has been charged with helping his 700-plus physician colleagues create the environment they want in order to facilitate the anytime-anywhere computing capabilities they need these days. So Musco, a family physician who practices two days a week in a three-doctor practice in nearby San Ramon, also spends two days a week at the Muir corporate headquarters, working with Tina Buop, the organization’s CIO of clinical integration, and others, to help move everyone towards the new world of mobile computing. (The fifth day every week Musco devotes to managing a mix of administrative and personal activities.) Musco himself currently performs many tasks in a mobile fashion—“coordinating care, taking calls, updating a patient’s status with another provider—a lot of that I’m doing is via textmessaging now,” he notes. He also texts fellow physicians briefly regarding patients before receiving documents within the IPA’s electronic health record (EHR) or a fax. Meanwhile, within his own three-doctor, one-physician assistant office practice, “All the people with direct patient care responsibilities are mobile,” using tablets for core clinical documentation and other functions, he notes. As CMIO, what is he seeing? “The physicians have a few major concerns,” Musco says. “Number one, they’re often driven by total cost. Number two, the physicians are very excited about instantaneous provider connectivity to ancillary services and other providers in the community; so basically, they want to be connected to a community of doctors collaborating and coordinating care on an e-community kind of platform.” The third and fourth levels of priority, he says, are “ease of use” of any www.healthcare-informatics.com • Healthcare Informatics 11
COVER STORY Mark Musco, M.D., CMIO of Muir Medical Group, is helping to move his physician colleagues toward the world of mobile computing. Source: Muir Medical Group
platforms and devices “relative to their particular clinical needs”; and making
practice are all struggling over questions around physician mobility, as
factors that could potentially support increased physician computing mobility are also weighed down by issues of cost, implementation scheduling, prioritization, and return-on-investment value. How to decide? Tina Buop, Muir’s CIO, is clear in her mind about all of this. “As a CIO, I’m constantly prioritizing in four key categories,” she says. “Number one, are we up, are we available, are we secure?” In other words, core maintenance, operations, and availability. The other categories are new projects and product development; implementation, training and adoption activity; and work that supports the vision and mission of the IPA’s board. What is key about all the developments taking place around physician computing facilitation at Muir, she says, is that “We’re constantly evaluating whether what’s being requested is aligned with what the board is envisioning. So if you want an iPad, that’s great, but would you like an iPad, or a new bidirectional interface for the lab?” The key, in other words, is IT prioritization and governance. At Muir, that translates into an EHR physician advisory committee of 13 doctors, which meets at least three times a year, with Musco as chairman and Buop facilitating. Among the questions she, Musco, and their colleagues at Muir are continuously trying to answer are the same ones their colleagues nationwide are looking at these days. Among those are: • What strategies make sense from the organizational standpoint of a medical group, hospital, or integrated health system leadership level? • How can strategizing around mobility be successfully harmonized with overall clinical IT strategy development? • What kinds of analysis and trendwatching can be brought to bear, both in terms of the mobile, web, and infrastructure technologies themselves, and in terms of the policy, regulatory and reimbursement developments taking place that will in effect mandate cer-
THERE’S GOING TO BE AN ENTIRE GENERATION OF ADOPTERS WHO NEVER KNOW WHAT IT’S LIKE TO HOST THEIR OWN SERVERS, BUT WHO INSTEAD WILL BE LOGGING INTO WEB-BASED, HOSTED SERVICES. —MARK MUSCO, M.D. sure that “the instrument that they’re policy, regulatory, industry, technogoing to deploy in their oflogical, and societal defice is going to help them velopments continue to meet evolving mandates swirl forward in a heady or requirements, such mix of change. Far more as related to meaningful than even a few years use, healthcare reform, or ago, there now exists the managed care needs.” technical capability to What’s patently clear, provide physicians with Musco says, is that in a unprecedented capabilicollaborative environties in mobile computment such as exists in ing. But just because IPA-based organizations something is technilike Muir, “The idea of cally capable of being Tina Buop maintaining something done, does that mean yourself in clunky servers it should be facilitated? in your office is going by CIOs, CMIOs, and other the boards.” Instead, he says, “There’s healthcare IT leaders are faced with an going to be an entire generation of almost bewildering array of choices to adopters who never know what it’s make, knowing that choosing correctly like to host their own servers, but who could boost physician productivity and instead will be logging into Web-based, potentially optimize reimbursement, hosted services.” while also enhancing patient safety and care quality and boosting patient MANAGING A SWIRLING MIX and family satisfaction. Nationwide, CIOs, CMIOs, other But no one can have everything; healthcare leaders, and physicians in and the same industry and policy 12 September 2011 • www.healthcare-informatics.com
EXAMINING USABILITY One thing is patently clear: physicians are becoming mobile very quickly—perhaps more quickly than many in the industry might have anticipated even a few years ago. This fact is documented in a recent survey conducted by QuantiaMD, a Waltham, Mass.-based mobile and online physician community. In the survey of 3,798 physicians, conducted online in May, more than 80 percent of doctors surveyed said they own a mobile device capable of downloading applications—a percentage far higher than that among the general public. For more details on the QuantiaMD survey, including results made available exclusively to Healthcare Informatics, see “Mobile Device Adoption Speeding Forward” (sidebar, p. 14). The data on accelerating mobiledevice adoption is obviously very clear. But one researcher who has done recent work in this area cautions that there is a flip side to the current wave of interest in mobile computing among physicians, and that has to do with the mobile applications currently being developed. Fran Turisco, a researcher in the Waltham, Mass.-based Global Institute for Emerging Healthcare Practices, a division of the Falls Church, Va.-based CSC, has been
examining usage of mobile apps in healthcare. “What’s interesting,” says Turisco, “is that while there are something like 17,000 mobile health, or ‘mHealth,’ apps out there, and they range from free-of-charge to some expensive, very sophisticated solutions, what we’re seeing is that in many cases, physicians and other clinicians are trying out mobile apps, but not sticking with them very long.” She cites a recent industry survey that found that only 26 percent of mHealth
apps retain end-user loyalty beyond about 10 uses. “What I think that shows is that there are a lot of apps out there addressing certain needs; the question is what the value proposition is for them,” Turisco continues. “Our view is that something has to become the preferred way of doing something, or has to provide a unique way of accomplishing a task, for it to be adopted beyond the very short term,” she says. “These solutions are being built by physicians with a specific
COVER STORY
tain clinical computing requirements? • How can the vendor development elements be managed, and can vendors move forward to more optimally partner with patient care organizations going forward? While there are no simple answers to any of these questions, all those interviewed for this article agree that one of the numerous pressing challenges of the next few years for CIOs and CMIOs at all types of patient care organizations will be to figure out how best to facilitate mobile computing for physicians in ways that make sense for all the stakeholder groups involved, without breaking one’s organization’s bank or vaulting off a tech-fad cliff.
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www.healthcare-informatics.com • Healthcare Informatics 13
COVER STORY
Mobile Device Adoption: Speeding Forward Just how quickly are physicians adopting mobile devices for clinical use? Pretty quickly, in fact, as the results of a survey conducted by QuantiaMD, a Waltham, Mass.-based mobile and online physician community, confirm. In QuantiaMD’s survey of 3,798 physicians, conducted online in May, more than 80 percent of respondents reported that they already own a mobile device capable of downloading applications. And among those who already possess such a device, 59 percent had an iPhone; 29 percent had an iPad; 20 percent had an Android smartphone; 14 percent had a BlackBerry; 3 percent had an Android tablet; and 7 percent had some other device (and of course, many had more than one mobile device). And a full 44 percent intended to buy a mobile device this year. 10%
7%
12%
8%
10%
11%
83%
78%
81%
Group Practice
Inpatient
Outpatient, Hospital-Based
N = 1013
N = 744
N = 458
Significantly, 19 percent of survey respondents are already using a tablet device clinically, while another 65 percent say they will likely or very likely do so in the next few years (only 15 percent said it is unlikely they will do so, and only 2 percent said they absolutely won’t).
Percent of respondents
At this publication’s request, QuantiaMD researchers have shared additional statistics exclusively with Healthcare InformatHow did you acquire your mobile device? ics. Among those findings: 12 percent of group practices, 10 percent of inpatient I bought it personally hospitals, and 11 percent of outpatient, My institution supplied it as part of my work hospital-based organizations have proI have two or more devices—personal and institution-provided vided physicians responding to the survey, Figure 1. About one in five group practices and institutions give their physiwith mobile devices (see figure 1). In the cians a smartphone or tablet device. Source: Quantia Communications Inc. vast majority of cases, however, doctors are buying those devices themselves. In addition (see figure 2), it is interesting to 100% note that there appears to be no correlaChristopher Longhurst, M.D. Purchased personally, mean = 3.9 tion between whether organizations have purchased mobile devices for physicians or Institution-provided, mean = 4.0 they bought them themselves, and their level of interest in using those devices. Also, significantly, a minority of “super-mobile physi41% 43% cians” identified in the study—doctors who use both smartphones and tablet computers 27% 26% 20% 21% in their practice—are performing such tasks as “accessing patient information and re7% 5% 5% 5% cords,” “learning about new treatments and 0% 1 2 3 4 5 clinical research,” and using their devices Not interested Somewhat interested Very interested to aid in patient diagnosis, at significantly N = 2205 higher rates than other doctors. Figure 2. Physicians who have purchased their own mobile devices are just as interested in connectivity to EMR data as those with institutionprovided devices. Source: Quantia Communications Inc.
What does all this mean? “I think the most surprising finding was around these superuser physicians,” says Mary Modahl, QuantiaMD’s chief communications officer, and the author of the survey report. “We found that once a doctor had acquired both a tablet and a smartphone, they started using their devices overall at a higher rate than those physicians with only one of those types of devices,” she says. “And certainly the speed with which the tablets are coming on” is another noteworthy finding of the survey. “Of course, physicians have incomes that allow them to buy tablets easily; but the level of interest also reflects a growing level of interest in mobile applications that serve the healthcare field,” she says.
need, or by organizations with specific needs,” she adds, “and they’re infiltrating care organizations, and that really puts the onus on organizations to get ready, to catch up—they’re already behind, as 14 September 2011 • www.healthcare-informatics.com
doctors and patients are already using these technologies. So the broader question,” she says, “is really, how do you catch what I call the mHealth train speeding through your organization?”
A COMPLEX INPATIENT ENVIRONMENT While the mHealth express may be speeding through the physician office and outpatient environments, within
access to a small subset of data in the EMR,” which makes such apps highly limiting at this point in time. But, he adds, “I think that because of the ubiquity of mobile devices, there will be increasing pressure on the software vendors to support them and you’re already seeing some of that pressure having an effect now. Still, for more intensive and comprehensive data entry purposes, he says he sees physicians in inpatient hospitals continuing to rely on COWs (computers on wheels) in a
majority of situations. If the inpatient environment is somewhat clouded by complexities around documentation tasks, adequately supporting the infrastructure for mobility remains a key ongoing challenge for medical groups, says Les Clemmer, CIO of Quincy Medical Group (QMG), a 95-doctor group in the Mississippi River town of Quincy, on the far western frontier of Illinois. With himself and six other IT staff (out of a total medical group staff of about 600)
COVER STORY
the inpatient hospital setting, physician mobility remains a distinctly local train for now. The fact is that there are a number of complex inhibiting factors that are keeping many physicians from becoming fully mobile, at least at the tablet and smartphone levels, says Christopher Longhurst, M.D., CMIO at Lucile Packard Children’s Hospital (LPCH) at Stanford University, Palo Alto, Calif. “Whether or not doctors are going fully mobile” at the level of tablet use, Longhurst says, “has to do with the use case: are they doing data review or data entry? The fact is that doing rounds involves a lot of data entry— you’re writing a lot of notes, doing e-signing, you’re doing electronic billing, and doing electronic order entry. And so the reality is that a device that doesn’t allow for facilitation of those tasks falls short.” In other words, without a dedicated keyboard, physicians are finding iPads and their brethren inhibiting when it comes to any significant data entry tasks. LPCH has provided iPads to some of its physicians, including in its neonatal ICU. “But our early experience shows that if you want to provide those devices, you need to provide software that optimizes such use,” Longhurst says. “You can load [Cerner’s] PowerChart or the Epic EMR right up there, but what you get is not the simple, intuitive interface you’ve come to expect from an iPad app, right? Most of the EMR products are really still meant to be used in a Windows 32 environment, even if you’re working on a tablet,” he notes. “So the question is, how rapidly can the Windows-based EMR vendors rewrite their platforms to accommodate tablets? And the newer vendors, like PracticeFusion, are on modern technology where the data layer and the presentation layer are separate, and they can rewrite the presentation layer pretty easily. But the core big-box software vendors have a lot of legacy software code that makes it much harder to extend these applications.” Meanwhile, Longhurst says he is highly critical of the “basic iPad apps” from some of the core-clinical vendors. “They give you very basic
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www.healthcare-informatics.com • Healthcare Informatics 15
COVER STORY
supporting their EHR full-time, Clem- as they contemplate how to strategize mer reports that “We are a Citrix shop, around mobility. “My mantra is that as well as a full VMware workflow trumps everyenvironment, with about thing,” says Dan Imler, 90 servers, mostly virtual,” M.D., a second-year peand with full Citrix Access diatric emergency mediGateway availability for cine fellow at Boston Quincy Medical Group Medical Center. “I don’t physicians from anywhere. care what device I use or QMG doctors have total where it comes from or anytime/anywhere access anything; all I care about is managing my workto all the key EMR and other flow in the most efficient clinical IT capabilities the and effective manner group offers (including full possible.” PACS—picture archiving James L. Holly, M.D. In fact, Imler says, and communications sys“There are times when tem capabilities), Clemmer a mobile device is not reports. The key to success across the many medical specialties nearly as good as a PC in certain setinvolved, he says, has been forging tings. For instance, if I’m in an office consensus on supporting core clinical setting, there’s no need for me to have solutions that work broadly across the a mobile device. Now, in the ER, that’s
organizations in California, Nevada, and Florida, Davis has been working closely with the organization’s CIO, Zan Coulson, to create and maintain the infrastructure to support mobile computing for doctors in very diverse settings across a far-flung multi-state organization. As at Muir in Northern California, the leaders of HealthCare Partners are using an IT governance structure, including in their case an interoperability workgroup, in order to develop strategies that are sustainable and optimal. “How do you make data accessible to the physician at the point of care? The art of the future is going to be getting all this information together, but making it relevant to the time and place needed,” Davis says. In this view, he is supported by James L. “Larry” Holly, M.D., CEO of Southeast Texas Medical Associates (SETMA), a 26-physician, 12-nursepractitioner medical group in Beaumont, Texas. SETMA has received numerous awards and recognitions for its pioneering work in developing the patient-centered medical home and focusing on care management for patients with chronic diseases. “What mobility does for us that is key is that it allows numerous clinicians and staff to be contributing and sharing data and information about patients simultaneously,” Holly says. That, he contends, will be the basis for ongoing breakthroughs going into the future, as physicians and other clinicians in patient care organizations will increasingly become truly interconnected in real time, with obvious benefits to patients and families. Will support for physician mobility continue to pose challenges going forward? Obviously. But, all those interviewed for this story agree, with the right strategies, mindsets, and collaboration, the mobility express is set to turbocharge forward in ways that will significantly improve patient care for everyone. ◆
DOING ROUNDS INVOLVES A LOT OF DATA ENTRY; YOU’RE WRITING A LOT OF NOTES, DOING E-SIGNING, YOU’RE DOING ELECTRONIC BILLING, AND DOING ELECTRONIC ORDER ENTRY. THE REALITY IS THAT A DEVICE THAT DOESN’T ALLOW FOR FACILITATION OF THOSE TASKS FALLS SHORT. —CHRISTOPHER LONGHURST, M.D. entire spectrum. Or, as he puts it, “The challenge to a multispecialty group is, you don’t get to buy best-of-breed for every ‘ology.’ I’ve got 28 different specialties here. So I have to let everyone know I understand that this system is not perfect for everyone, but we need to share, and provide that common
somewhat true, but surprisingly, mobility does matter there—for example, to show a patient something on an iPad, or to check on something when I’m just a few feet away from a workstation.” The bottom line for him? CMIOs and CIOs need to think in terms of physician needs in order to get clear on what
I DON’T CARE WHAT DEVICE I USE OR WHERE IT COMES FROM OR ANYTHING; ALL I CARE ABOUT IS MANAGING MY WORKFLOW IN THE MOST EFFICIENT AND EFFECTIVE MANNER POSSIBLE. —DAN IMLER, M.D. platform to everybody.” Given ongoing consensus on that level of uniformity, supporting mobility is highly sustainable over the long run, he says.
FOCUS ON FUNCTION, DOCTORS SAY Regardless of the specific decisions that are made around infrastructure for mobility and support for mobile clinical apps, physicians in practice want CMIOs and CIOs to understand their mindset 16 September 2011 • www.healthcare-informatics.com
their mobility strategies should be. Steven Davis, D.O., a family physician in Southern California, agrees with Imler. And, like Muir’s Musco, Davis is both a physician in practice and a medical informaticist. As medical director of clinical information services for the Torrance, Calif.-based HealthCare Partners organization, which encompasses physicians practicing in both group-model settings in Southern California, and doctors in IPA
FEATURE
Ramping Up HEALTHCARE IT LEADERS BEGIN THE SERIOUS WORK OF PREPARING FOR THE TRANSITION TO ICD-10 BY JENNIFER PRESTIGIACOMO
EXECUTIVE SUMMARY: CIOs and HIM directors are laying the groundwork for the ICD-10 transition by performing critical risk assessments, beginning training programs for clinicians and coders, and figuring out what all this is going to cost.
L
ast October, Stephen Stewart, the CIO of Henry County Health Center, got a major wakeup call after he attended an ICD-10 sunrise session at the College of Healthcare Information Management Executives (CHIME) Fall Forum, which emphasized that the compliance deadline was quickly advancing. Before then, his 74-bed hospital in Mount Pleasant, Iowa, had, as he puts it, been “plodding along” on creating an ICD-10 plan, but after hearing the session, he sprang into action and called his health information management (HIM) director to start the ball rolling on a plan to tackle this multi-faceted project. If your organization has been hearing similar calls to action, you’re not alone. IT leaders and HIM professionals across the country are pursuing parallel paths that will eventually dovetail as the Dec. 13, 2013 ICD-10 transition date nears. These two departments will be joining
18 September 2011 • www.healthcare-informatics.com
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FEATURE identify which informaother organizational leadtion systems would be ership to work out detailed affected by the transiassessments of what systion and what hardware tems will be affected and and software upgrades extensive ICD-10 training, would be necessary. “It’s all the while overcoming amazing when you start common challenges includlooking at the tentacles ing budget, bandwidth, and human resources. As many of ICD-10 and how it rehave asserted, the technical ally cuts across all parts issues of the ICD-10 transiof your organization: fition are not that great; it’s nancial, clinical, HIM, IT,” Janice Jacobs the training of clinicians says Chuck Podesta, CIO, and coders that will be the Fletcher Allen Health significant obstacle. Care. “Depending on Because the ICD-10 tranwhat type of systems you sition cuts across all dehave in place, it can be partments, Janice Jacobs, even more challenging director, regulatory complifrom an IT perspective if you’re a best of breed verance practice at IMA Consus an integrated shop sulting (Chadds Ford, Pa.), because you have more says that every organizasystems.” tion might take a different approach, but that, howevMany in the industry realize that considerer they approach it, healthable challenges will arise care IT leaders “absolutely, Chuck Podesta from physician docupositively have to have an mentation issues. Stewexecutive steering committee.” At the very least, steerart acknowledges that ing committees need to have represen- physicians, when building problem tation from IT, revenue cycle, HIM, and lists at intake, will be confronted with clinicians to create a comprehensive more choices and clinical vocabulary communication plan to coordinate soft- with ICD-10. His strategy is to advise ware upgrades and training, she advises. clinicians to document by their best Organizations like CentraState Health- practices, and HIM will review and corcare System, a 282-bed hospital-based rect the codes afterward. Over time, he organization in Freehold, N.J., and the says, his team will educate physicians 562-bed Fletcher Allen Health Care in on what additional coding they might Burlington, Vt., have gathered together be missing. Lahey Clinic, a health system that multi-disciplinary taskforces to develop work plans and organize organizational includes a flagship 317-bed hospital in Burlington, Mass., as part of its clinical assessments for their ICD-10 journey. documentation improvement program SYSTEMS INVENTORY AND for capturing quality data for benchPHYSICIAN DOCUMENTATION marking, did a risk assessment with the All of the organizational leaders inter- help of the St. Paul, Minn.-based 3M a viewed for this story note that a ma- year ago that identified ICD-10-driven jor component of their work plan has documentation requirements for diagbeen a complete systems inventory to nosis codes and procedure codes, as 20 September 2011 • www.healthcare-informatics.com
well as what service lines required additional documentation specificity. Three hundred records were reviewed, says Lori Jayne, Lahey Clinic’s HIM director and privacy officer, to target subspecialties and diagnosis-related groups (DRGs) that were lacking in documentation for the specific codes for ICD-10 translation. The risk assessment revealed common threads that were lacking in physician documentation that included identifying the specific diagnosis or procedure involved. Another need that was identified was making sure laterality is documented for the site of joint replacements, cataracts, neoplasms, arthritis/ osteoarthritis, hearing loss, and visual loss. Other items noted in the assessment include procedure codes needed in ICD-10 when none was required in ICD-9, and increased specificity needed in ICD-10 for some routine procedures that only had one code in ICD-9, such as for infusions/transfusions. Lahey Clinic will also be focusing on specialties like cardiology, orthopedics, and radiology, where coding guidelines and further training will be given.
BUDGETARY CONSTRAINTS One area of uncertainty in all of this is how much an ICD-10 transition will cost. Among those who are scratching their heads are leaders at CentraState Healthcare. During budget planning last year, HIM Director Judy Gash put a preliminary figure into the budget for ICD-10 services, but it was quickly blown out of the water after ICD-10 risk assessment requests for proposal came back. The quotes from the five vendors that submitted ranged from $100,000 to $600,000 and left Neal Ganguly, vice president and CIO, as well as the state’s CHIME StateNet vice chair, perplexed. His committee is now drilling down into the proposals to see how much of what’s
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FEATURE Five Things You Can Do to Start Your ICD-10 Transitionn CIOs and HIM directors cite several things that you can do to begin egin your ICD-10 journey today: • Perform a comprehensive impact assessment and systems in-ventory to identify which information systems will be affected by the transition and what hardware and software upgrades will be needed. • Decide if you have the internal talent to manage this multi-disciplinary project or if you have to outsource a projectt manager. • Educate a super user on the clinician and the coding side withh a program like AHIMA’s Academy for ICD-10. • Identify the top diagnoses and procedures within your organization and create “before and after scenarios” that show the specific wording and codes necessary for ICD-10. • Be realistic about future coding needs and be creative about recruiting and retaining your human capital.
recommended really needs to be done. have the strong, disciplined project At last year’s CHIME Fall Forum, Gan- management expertise inside your guly remembers being astonished when doors, or not, because that’s where hearing quotes of an ICD-10 transition you’re going to need the help because costing in the millions for a community ultimately this has a direct impact on hospital. “We’re trying to validate some reimbursement which makes all the of that because that just seems way difference in the world,” Ganguly says. off the mark from our perspective,” he says. “There’s a lot of work that needs to IMPLEMENTATION AND TRAINING be done, but I don’t know if it’s at that Podesta says that the key to ICD-10 scope. One of our concerns is, are we training is to start physician awareness and education early. His missing something?” team has created “beAnother wrinkle relatfore and after scenarios” ed to budgetary issues is for specific procedures whether to outsource the and diagnoses that show management of an ICD-10 the specific wording and transition, or marshal the codes necessary for ICDresources internally. “Orga10. “We’re doing that nizations are realizing now with a small group now that they can’t pull their to gauge the impact,” he existing pool of resources says. “But we think it’s and devote them to work going to be huge because on ICD-10 all the time,” says all the systems downJacobs. “More and more orstream will be affected ganizations are outsourcNeal Ganguly by how well that docuing to outside vendors.” She mentation is done.” says that in the past month Not only will clinicians need to be she has gotten more requests for protrained in ICD-10 documentation, posal than all last year put together. “The key thing is identifying if you coders will also need significant edu22 September 2011 • www.healthcare-informatics.com
catio cation. “The big difference with ICD10 is that it’s not just expanding a ffield two digits; it is a completely d different coding methodology,” sa says Jacobs. SSome organizations, such as CentraS traState Healthcare, are already providin viding anatomy and physiology training for f their coders. CentraState also sent several physician informaticists and executive e team members to a fourday ICD-10 boot camp sponsored by the New Jersey Hospital Association. Future plans are for a high-level coder to be trained by the American Health Information Management Association (AHIMA) as a certified ICD-10 trainer to help prepare the organization’s other coders. Jacobs says 2011 is the time for awareness-building, but still too early for ICD-10 coding training, as coders won’t be able to actually start coding till 2013. She recommends starting to train six to nine months before the transition, so codes are fresh in coders’ minds. With the knowledge of a possible shortage nearing as older coders retire before the ICD-10 transition and with the industry’s competitiveness, Jayne recommends organizations be creative in sustaining their coding resources. Her organization, Lahey Clinic, has established a remote coding program to recruit and retain coders that gives them several tools to infuse into their daily work. One tool, a crosswalk methodology, allows coders to see how today’s ICD-9 codes will translate into ICD-10. Lahey Clinic has also implemented a clinical assistive coding application to assist with abstraction of the entire medical record, which abstracts key medical terms and allows coders to validate the information. Other organizations, like CentraState, plan to hone in on their top diagnoses to see how much they will change from ICD-9 to 10, which will then guide future physician education. ◆
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FEATURE
Translating Accountable Care Goals into IT Action GUIDANCE ON STRATEGIES, SYSTEMS, PRIORITIES, AND PITFALLS FOR HOSPITAL CIOs BY DANIEL J. MARINO
EXECUTIVE SUMMARY: A healthcare consultant offers concrete steps that CIOs can take when creating an IT foundation for accountable care.
T
he push for accountable care has created a new vocabulary for healthcare leaders: clinical integration, longitudinal records, ambulatory networks, patient registries, care protocols, and more. Many hospital CIOs are uncertain how to piece it all together, and they are having trouble pinning down the IT requirements for making accountable care a reality. The solution is to break the problem down into functional objectives and concrete steps. Following is a quick guide to translating the goals of accountable care into specific action items for CIOs.
GOAL #1: COORDINATE PATIENT CARE ACROSS MULTIPLE SETTINGS Coordination is the watchword of accountable care, but from an IT perspective it’s often easier said than done. To create the infrastructure for coordinated care, hospital CIOs should focus on three steps. First, select a platform for exchange that ensures interoperability. True sys24 September 2011 • www.healthcare-informatics.com
tem interoperability takes disparate medical data maintained in different formats and transforms it into integrated multidisciplinary patient care
information. Many large healthcare organizations are faced with the challenge of connecting 100 to 400 different information systems, including both internal
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FEATURE systems and those of community partners. The key is exchanging patient information in a continuity of care record (CCR) or continuity of care document (CCD) format, aggregating the data from major clinical systems and semantically organizing it into viable medical information for providers. Second, establish an agnostic application strategy. Individual clinical systems need to interface with other applications, but “integrated” enterprise solutions also pose a challenge. An integrated hospital/ambulatory solution has many benefits and will make implementation easier, but some vendors discourage connecting outside
GOAL #2: IMPROVE QUALITY AND OUTCOMES The opportunity is clear—using electronic medical record (EMR) technology to push evidence-based care and quality improvement. The challenge is that there is no cookie-cutter approach. Again, three action items are key. First, focus on “tailoring” structured data. Where will hemoglobin A1c labs for diabetic patients appear within the EMR? How will consult notes map into the system? While many EMR systems are pre-loaded with structured data, “out of the box” data sets rarely work well. CIOs need to make sure structured data are individualized to the organiza-
CDSS functions need to support the specific clinical quality and improvement goals of your organization.
GOAL #3: REDUCE COSTS AND UTILIZATION The government has already decided how much money it will save thanks to accountable care. Whether hospitals will maintain profitability depends on their ability to manage costs. The job of the CIO right now is to build the IT infrastructure for identifying “cost of care,” quality-of-care thresholds, and revenue metrics. The important thing to realize is that traditional business information systems are not up to this task. Instead, put resources into creating or enhancing a data warehouse system. The goal is to be able to integrate system-wide cost, utilization, and revenue data and stage it for reporting. Hospital IT also needs to acquire or develop advanced analytics capabilities. Look for a system versatile enough to tie clinical outcomes to revenue cycle claims data. Functionally, the goal of a data warehouse/analytics system is to identify opportunities to reduce waste, reduce spending, and improve operational efficiency.
MAKE SURE PHR DATA FEEDS INTO KEY INFORMATION SYSTEMS, INCLUDING THE HOSPITAL REGISTRATION SYSTEM, THE ACUTE CARE EMR, AND THE AMBULATORY EMR. the integrated platform. This will undermine coordination of care and true interoperability. CIOs need to select an integrated solution that allows full connectivity—or specify within the vendor agreement that outside interfaces will be allowed and supported. Third, connect to or build a health
tion’s clinical goals. Second, build a patient longitudinal record. To manage quality, physicians need a composite patient record within the ambulatory EMR. Customization is essential. Work with physician leaders to make sure patient information is mapped to
CIOs NEED TO SELECT AN INTEGRATED SOLUTION THAT ALLOWS FULL CONNECTIVITY—OR SPECIFY WITHIN THE VENDOR AGREEMENT THAT OUTSIDE INTERFACES WILL BE ALLOWED AND SUPPORTED. information exchange (HIE). Several options are available. The critical question for IT executives is: what is your hospital’s strategy? Does the hospital intend to lead its own ACO, develop clinical integration, and drive decisions about data collection and sharing? If so, you probably need to develop your own HIE. If, on the other hand, your hospital plans to take part in a community accountable care strategy, consider connecting to your state or regional HIE. 26 September 2011 • www.healthcare-informatics.com
the right place within the EMR. (This will often be determined by physician workflows.) Also, work with clinicians to standardize terminology for tests, lab values, diagnoses, etc. This is critical to ensuring the system has useful semantic data. Third, implement clinical decision support systems (CDSS). Technology can drive better care through automated alerts and reminders. Once more, however, avoid prepackaged solutions.
GOAL #4: INTEGRATE PATIENTS INTO COMMUNICATION
There are a growing number of personal health record (PHR) systems on the market. Most hospitals are looking at ways to use these systems to provide patients with access to their health data. But under accountable care, patient integration is about more than just information access. IT executives need to focus on using PHR systems to build patient engagement and support chronic care. One priority is technical. Make sure
FEATURE PHR data feeds into key information systems, including the hospital registration system, the acute care EMR, and the ambulatory EMR. The second priority is strategic. CIOs need to guide PHR design based on high-level decisions about what information will be captured and exchanged and how it will be used. The overall driver is strategy. For example, if a hospital is launching its accountable care effort with a clinical integration project for asthma management, the IT department should configure the PHR to allow patients to log their medication use, record lung function measures, and receive seasonal asthma reminders.
GOAL #5: CREATE MANAGED CLINICAL VALUE Right now, accountable care is being driven by the promise of higher government payments. Before long, however, leading accountable care organizations will work proactively to identify en-
hanced clinical value and get paid for it. Here, the most precious commodity is patient medical information. What many hospital leaders struggle with is that an EMR system is not enough. EMR is a tool for capturing and retrieving patient information at the point of service. For CIOs, the core action item is to build a model of system integration that allows for the capture of clinical data within a data repository. A clinical data repository (also called a patient disease registry) is a database that stores and coordinates clinical information for an entire population of patients. It allows an organization to report off clinical data, which is needed for calculating actual clinical quality outcomes and comparing them against industry benchmarks. By tracking clinical quality outcomes and accurately measuring the cost of care, hospitals will be in a position to identify savings—which will then lead to evidence-based reimbursement
opportunities. A clinical data repository also creates an infrastructure for joint clinical decision making about population care. This is essential for achieving clinical improvement across the enterprise to meet performance goals and therefore payment goals.
HOSPITAL STRATEGY IS KEY The common theme that runs through all these action items is the importance of an integrated IT strategy. The key to designing an effective IT infrastructure is to focus on your hospital’s clinical and business goals. In almost every case, strategic goals determine how to configure technology to support accountable care. ◆ Daniel J. Marino is president and CEO of Health Directions, LLC, Oakbrook Terrace, Ill., a national consulting group that provides business solutions for healthcare organizations. He can be reached at (312) 396-5414 or dmarino@ healthdirections.com.
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www.healthcare-informatics.com • Healthcare Informatics 27
SPECIAL SECTION
Tweaking the PACS Market FUNCTIONALITY, INTEROPERABILITY, AND CUSTOMER SERVICE ARE KEY TO KLAS’ ‘READ ON PACS’ BY RICHARD R. ROGOSKI
W
vendor has found a niche among hospitals of between 200 and 500 beds. Among the larger, multi-site hospital organizations, vendors like McKesson, Philips, GE, and FUJIFILM still dominate mindshare for PACS deals. But Brown is quick to point out that this market segment is already 95 percent to 98 percent The report, “A Read on PACS: Hospital Expectations Rising,” saturated and is well past the initial go-live stage. As a result, examines a market that is highly mature along these organizations are now concentrating on a number of dimensions, from the level of upgrading existing PACS or contemplating a saturation to the level of expectations among future system replacement. end-users. KLAS researchers and CIOs alike However, given the up-front costs, the econagree that, given the expectations of hospital omy, and the potential effects of meaningful healthcare IT leaders and end-users, the comuse on radiology, Brown says he has seen a petition for market share will only continue to limited number of these hospitals pull the trigintensify. ger on placing an order. Replacement activity is It is in that context that the PACS vendor increasing, especially at the high end of the PACS market. He also observes that there is a disthat was most highly ranked by CIOs and othcernible difference between large hospitals and ers surveyed by KLAS was founded by a radismaller community hospitals when making that ologist and has become known for valuing the feedback of its customers. According to leap. “In the large hospital market, technology Ben Brown the report, which was published in November is the driver. Price is probably a close number two. In the community hospital market, price is 2010, DR Systems Unity took home the honors number one, ” he says. for acute-care with an overall performance score of 86.0 out Product availability also is a factor in market share. “There of 100. (Coming in at number two was McKesson Horizon are only a handful of vendors that compete at the highest end Medical Imaging, with an overall score of 83.2.) of the market, ” Brown says. “There are quite a few vendors For DR Systems, capturing the number one spot in the that are very successful in the smaller market, but provider acute-care arena indicates that the company has adapted to its rapid growth and has renewed its focus on customer ser- confidence in their ability to scale up limits the number of vice and support, according to Ben Brown, who is KLAS gen- vendors that typically compete in the high end of the PACS eral manager for medical imaging and medical equipment. market,” he says. The fact that DR Systems was founded by a radiologist also gives the company an edge, Brown believes. “It’s really been a ACHIEVING INTEROPERABILITY radiology-focused company,” he says. One persistent problem, especially for large hospitals that have DR Systems solicits input from its customers, as well. User tended to purchase best-of-breed systems, is achieving interopergroups are regularly asked to submit lists of upgraded features ability across disparate platforms. In Brown’s view, interoperabilthey would like to see incorporated, and the company priori- ity issues have even been a challenge for vendors that offer intetizes the items on the wish lists, says Brown, who adds that the grated systems, which often come up short in the PACS arena, he
hen it comes to picture archiving and communication systems (PACS), most clinicians in an acute-care setting prefer a system designed by radiologists for radiologists. That’s one of the key findings of a report from the Orem, Utah-based KLAS (www.KLASresearch.com).
28 September 2011 • www.healthcare-informatics.com
SPECIAL SECTION
HOW DO THE VENDORS STACK UP? Figure 1: Overall Performance Scores
RANK
Positive Trend – Performance score increase of 3 or more points above previous score. No Significant Change – Performance score is within 3 points of previous score. Negative Trend – Performance score decrease of 3 or more points below previous score.
---RANK
This study is divided into two main segments, Acute Care and Community. Acute Care refers to hospitals over 200 beds. Community refers to hospitals with between 1 and 200 beds.
------
PACS – ACUTE CARE DR Systems Unity PACS McKesson Horizon Medical Imaging FUJIFILM Synapse Philips iSite PACS GE Centricity PACS-IW Carestream PACS Merge Healthcare PACS (AMICAS) Sectra PACS Siemens syngo Imaging Agfa IMPAX GE Centricity PACS Cerner Millennium ProVision PACS
86.0 83.2 81.4 81.4 81.1 79.7 77.2 77.2 73.1 71.8 68.5 66.2
Infinitt PACS* Intelerad IntelePACS* NovaRad NovaPACS* PACS – COMMUNITY Infinitt PACS McKesson Horizon Medical Imaging DR Systems Unity PACS Avreo interVIEW NovaRad NovaPACS Philips iSite PACS Sectra PACS Aspyra AccessNET Merge Healthcare PACS (AMICAS) Carestream CARESTREAM PACS FUJIFILM Synapse BRIT Systems Roentgen Files Agfa IMPAX GE Centricity PACS GE Centricity PACS-IW Siemens syngo Imaging
84.1* 84.8* 77.2* PERFORMANCE SCORE 88.4 86.7 86.1 85.4 85.4 85.4 84.3 84.2 83.3 82.2 81.0 80.5 79.3 77.0 75.7 70.3
Cerner Millennium ProVision* CoActiv Exam-PACS (North)* eRAD PACS* Intelerad IntelePACS* ScImage PicomEnterprise
PERFORMANCE SCORE
53.4* 91.5* 62.8* 88.4* 70.5*
1 YEAR TREND
--
1 YEAR TREND
--
* Preliminary scores do not meet minimum KLAS Konfidence levels. Reprinted with permission from KLAS. www.healthcare-informatics.com • Healthcare Informatics 29
SPECIAL SECTION
says. “Epic doesn’t have a PACS, but it has an integrated EMR/RIS. GE Healthcare has a RIS, PACS, and EMR, but they have acquired them from other companies. Philips has a large customer base with its PACS, but it doesn’t have an EMR.”
Brown notes that “one of the reasons Epic and Cerner are successful is that they have an integrated platform.” However, he adds that “Cerner has a great integrated system, but a majority of Cerner hospitals have not gone with Cerner PACS.” Rick Schooler, senior vice president and CIO of Orlando Health in Florida, says the problem of interoperability is compounded when different hospital departments and off-site radiology groups use different PACS. “Each specialist has its own preference for a PAC system,” he says. “What they want is the functionality. But you can’t find it in one solution.” To accommodate its departmental needs, Orlando Health’s eight-hospital healthcare network uses GE Healthcare Centricity PACS in radiology; Merge Healthcare PACS in pediatric cardiology; and Medcon’s C-PACS (now owned by McKesson) in adult cardiology. It has recently purchased ThinkingPACS from Thinking Systems Corp. for use in its nuclear medicine department, Schooler says. Obviously, running this many PACS can create IT challenges. “The more technologies you have, the more interfaces you have,” Schooler says. “But you are still in the business of managing multiple platforms.” Schooler also points to the additional challenge of storing and retrieving images. Each PACS has its own short-term storage capacity, and in order for the EMR to retrieve archived images, it has been necessary to install a long-term, commonplatform storage solution on the back-end. On top of that, Schooler notes that Orlando Health is working with Symantic to ultimately roll out a cloud-based PACS image storage solution. “You’re going to see a lot of imaging going to the cloud,” he says. And while Schooler acknowledges that Orlando Health has been able to build bridges between different PACS platforms, he states: “As people like me find options that are integrated, you’ll see us buying that integrated solution.”
NECESSITY: THE MOTHER OF INVENTION Sometimes, specific needs lead to innovation around integration and interoperability. The University of Pittsburgh Medical Center (UPMC) health system, for example, needed to accommodate multiple, diverse PACS solutions, leading the organization to develop a unique solution. With 20 hospitals, 30 imaging centers and a total of about two million imaging exams per year, UPMC uses PACS from FUJIFILM, Siemens, and GE Healthcare. But it relies mainly on Philips, says Rasu Shrestha, M.D., vice president of medical information technology and a member of the KLAS advi30 September 2011 • www.healthcare-informatics.com
sory board. “The PACS solution we have here is different from the vanilla iSite solution.”
As a recognized innovator in healthcare IT, UPMC had already developed its own PACS, called Stentor, which was subsequently acquired by Philips and rolled into its iSite product. What was still needed was a way to bridge different PACS platforms, to make all images available across the entire enterprise, and eliminate duplicate tests. Two years ago, UPMC developed a solution called SingleView to address that need. In explaining the philosophy behind SingleView, Shrestha says, “A lot of PACS vendors are still focused on a silo approach. But they’re missing the point. It should not be about PACS or RIS. It’s not about an application. It’s about the clinical workspace. SingleView is our imaging interoperability platform that bridges the silos.” One of the unique features of SingleView is that it provides instantaneous access to a patient’s previous imaging studies and reports, regardless of the department or origin, he says. As a radiologist, Shrestha knows the importance of having access to previous images and reports, but his emphasis on the clinical workspace goes beyond PACS. “What we’re trying to achieve is treating the patient as a whole—a more holistic approach. I want relevant, actionable and contextual information at the point-of-care. SingleView creates a more patientcentric view of imaging. It gives us, at the point-of-care, all the imaging history of that patient,” he says.
DECISION-MAKING OPTIONS The decision to purchase or upgrade a clinical system like PACS requires buy-in from a number of stakeholders, not least the physicians who demand a system that works best for them. “This is not a CIO decision,” says Schooler of Orlando Health. “It’s a collaborative process.” For those contemplating purchasing their first PACS, or replacing an existing system, Schooler’s advice is simple: “You have to get ready to operate on multiple platforms. But if you can buy an integrated platform, why would you buy multiple platforms?”
Adds Shrestha: First-time or replacement purchasers need to spend a lot of time reviewing PACS solutions in their entirety and speak with other customers of the vendors they are considering. “Look under the sheets,” he said. “How futureproof is the vendor? Look for vendors that aren’t afraid to embrace industry standards—not just develop a proprietary system. “And analyze your workflow,” he says. “Make sure the PACS you choose will fit your workflow.” ◆ Richard R. Rogoski is a freelance writer based in Durham, N.C.
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FINANCIAL MANAGEMENT
EMRs and the Bottom Line HFMA: CFOs VIEW EMRs THROUGH THE LENS OF COST AND VALUE BY JOHN DEGASPARI
A
s many hospitals embark on the task of selecting and implementing an electronic medical record (EMR), CFOs are confronting two key questions: what funding strategies are available, and once a system is implemented, what is the value proposition that can be expected of the EMR. Both related issues were addressed in separate financial management presentations at the Healthcare Financial Management Association’s ANI conference, held in Orlando, Fla. in June. M.J. Klimas, managing director of healthcare, institutions
32 September 2011 • www.healthcare-informatics.com
and government finance, Bank of America Merrill Lynch , Wexford, Pa., led a panel discussion between healthcare providers as well as financial experts. She noted that 40 percent of healthcare providers today indicate that EMR represents a majority of their capital budget. Many hospitals will turn to banks to provide financial solutions to fund their capital expenditures in 2012, she said. According to Brad Swenson, vice president and national healthcare leader of the Minnetonka, Minn.-based Winthrop Resources Corp., a financial consultancy, the challenge of the
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FINANCIAL MANAGEMENT
American Recovery and Reinvestment Act-Health Information Technology for Economic and Clinical Health (ARRAHITECH) Act will be to implement all of the systems, pay for them today, and for the next few years, figure out how to use them in a meaningful way each year. He believes that Stage 2 meaningful use requirements should be delayed for hospitals that have already attested for Stage 1. As hospitals progress through meaningful use, they must implement EMR systems that are interoperable, and capable of exchanging data via health information exchange and bi-directional communication between physician and patient, he said. While health reform, ARRA incentives, and definitions of Stages 2 and 3 are known forces of change, hospitals will also encounter unknown issues, such as additional technological conditions for software requirements, infrastructure changes, and new integration technologies, as well—all of which have cost factors. “It’s important to have a strategic plan, but there is a lot we don’t know,” he said. Swenson advises hospitals selecting an EMR to think of its requirements in terms of “buckets”: hardware infrastructure, clinical equipment, services, and applications, and to form a financial strategy around each of those areas; for example, the kinds of maintenance costs around certain pieces of technology, he said. In addition, he said hospitals should consider the costs associated with changes to maintain acceptable technology. Tim Brooks, senior vice president of healthcare and institutions finance at Bank of America Merrill Lynch, Baltimore, said it is important to know who the stakeholders are in the hospital when forming a strategic plan around costs. He noted that an EMR is an enterprise-wide project and will be an ongoing expense. “Whether it’s the IT shop, the physicians, finance or the operators, they need to have a look and everybody buy into it. That’s the key to understanding where we need to budget and make sure that we operate within the capabilities that we say are going to happen—particularly for physicians,” he said. He said hospitals have various debt term financing options to meet short- medium- and long-term capital requirements for paying for an EMR system. Options range from a line of bank credit for short-term capital to bond issues for long-term strategy, and tax-exempt solutions and fair-market value financing for medium-term capital needs, he noted. Part of the discussion that needs to take place is the fit from a legacy perspective: how long the hospital will use the piece of equipment. “That decision that needs to be made by the operators, the finance staff, and the IT staff, is what 34 September 2011 • www.healthcare-informatics.com
makes sense from the equipment standpoint,” he said.
CFOs WEIGH IN Britt Tabor is senior vice president and CFO of Erlanger Health System, Chattanooga, Tenn., an 800-bed academic health center with 120 employed physicians. He said that getting all of the stakeholders in the hospital on board was the key to successful implementation of the system’s EMR. He added that productivity at the department level was also a concern, with training requirements and integrating certain departments. One additional challenge was certification of the software interfaces. “Erlanger has over 100 interfaces, and we realized that needed to be upgraded. It took a lot of extra set-up time and staff to do that,” he said. Tabor said that Erlanger negotiated financing that was flexible, allowing it to change equipment without being penalized. “We wanted to make sure that we were at the most effective piece of software and equipment at any point in time,” he said. Dennis Scanlon is CFO and vice president of finance of Doctor’s Community Hospital, Lanham, Md., a 200-bed community hospital with about $210 million in revenues. He said that good communication, from the president’s office down to everyone in the organization, is the key to successful EMR implementation. “Every department has its own idiosyncrasies, and we have to make sure each department is served well and their needs are met,” he said. Scanlon also said that better outcomes, and sharing information among professionals inside and outside the hospital, are key factors as the hospital moves forward on meaningful use. He said that reimbursements are projected to be $6.7 million over the next four years.
THE VALUE OF EMRs In a separate presentation, Daniel J. Marino, president of Health Directions, a consultancy in Oakbrook Terrace, Ill., noted that EMRs will prove their value to hospitals as they are integrated across their physician practices. He said the true value of an EMR is for the hospital to connect with its providers and create efficiencies. “We are seeing that hospitals are using technology in such a way that it creates efficiencies. It creates value for the patient as it relates back to the hospital organization, through coordination of care,” he said. He sees two challenges: one is interoperability, the requirement to connect sometimes hundreds of systems to the EMR, which will allow coordination of care across the physician-patient continuum; the other challenge is exchanging data in a way that is organized and that can help physicians make decisions. ◆
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CLINICAL IT PERSPECTIVE
Smart Rooms, Smart Care Delivery UPMC CLINICIAN LEADERS LEVERAGE TECHNOLOGY FOR GREATER EFFECTIVENESS IN PATIENT CARE BY MARK HAGLAND
C
linicians, clinical informaticists, and IT leaders at the 20-hospital University of Pittsburgh Medical Center (UPMC) health system have been moving forward on many fronts to improve care processes for patients and for clinicians. One of the numerous innovations at UPMC, which was developed by a corporate-level IT team, but is being implemented first at UPMC Presbyterian Shadyside (the flagship hospital facility of the health 36 September 2011 • www.healthcare-informatics.com
system) is an ensemble of “SmartRoom” technologies that together are facilitating more effective care delivery patterns among UPMC clinicians. Carol Scholle, R.N., clinical director, transplant, and dialysis services at UPMC Presbyterian, has been the clinician leading the clinician/clinical informaticist teams in their collaboration with the IT professionals on this project. For their innovative work in this area, Scholle’s team
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CLINICAL IT PERSPECTIVE
earned the third-place award in this year’s Healthcare In- excerpts from that interview. formatics/AMDIS IT Innovation Advocate Award program, Healthcare Informatics: What was the initial impetus or co-sponsored by Healthcare Informatics and by the Associa- strategy behind this innovative work? tion of Medical Directors of Information Systems (AMDIS). Carol Scholle, R.N.: It does go back one step earlier to All three winning teams were recognized in May during the Shadyside. There was a situation that occurred where a paHealthcare Informatics Executive Summit held tient had a latex allergy, and that information in San Francisco. wasn’t available at the bedside, so the patient The UPMC team’s submission to the program was exposed to latex—a kind of sentinel event. included the following: “This team impleSo some very smart people like Dave Sharmented a new bedside charting technology on baugh [who continues to lead the SmartRoom a high-acuity abdominal transplant step-down technology development at UPMC] decided unit. This SmartRoom technology utilizes an that we needed to automate the process of ultrasound-based real-time locating system, providing whiteboard-type information. So in which the nursing team wears tags that are they came up with the idea of pulling some identified by sensors located in the hallways information from the electronic patient record and in the patient rooms. and displaying it in patient rooms. When the caregiver walks into the room, the And one of the challenges was that, as the touch screen mounted on the wall announces system became more mature, there was the Carol Scholle, R.N. the caregiver by name to the patient and then desire to interact more with it, and one early presents HIPAA-compliant information to the iteration was using a light pen on the screen caregiver. The system also allows the caregivin the room—it was the television screen in the ers to do routine documentation through a touch screen room, either the patient’s or a monitor screen. That was an interface, and they can access key clinical attributes about early iteration. the patient—meds, labs, vitals, etc. Finally, the system has And then there was an engineer who kept working on a patient- and family-centered component that engages the idea, and it was determined that our CEO wanted to try this on a larger scale and in a more robust form. So at that point, we looked at Presby to see if this could be more successful. At that point, my VP, the the family in the care process, and provides education and vice president of patient care services and our chief nursing entertainment. This is a new technology built at UPMC, officer, recruited me to get involved. That was in the fall or and this unit was selected because of their leadership and winter of 2009. willingness to try new technology.” Among the numerous results attained: most routine AN IDEA TAKES ROOT documentation is now done in between 40 and 70 percent HCI: You worked with IT and others in the development less time than in the traditional system; patient satisfaction work? Scholle: We worked with IT and the SmartRoom Team. At scores have soared, because of the perceived patient- and family-friendliness of the new caregiver behaviors (includ- that point, through our Small Business Ventures division, ing both doing bedside charting, and the deployment of the they pulled together a small company that is affiliated with “announcing” technology when clinicians enter the patient the UPMC corporation. And the very first nursing unit to try rooms); and nurses have significantly cut down on the dis- it was Unit 12 North, which is an abdominal transplant steptances they walk daily, because of the increased proximity down unit. And we looked at the physical environment. We of computing devices, thus increasing their efficiency and have private rooms and semi-private rooms at Presby, and we initially wanted to focus on a unit with private rooms, which their ability to spend more time at the patient bedside. Scholle spoke recently with HCI Editor-in-Chief Mark 12 North had; and I felt very strongly that we needed to work Hagland regarding the work behind this innovation, and with a staff that would be highly engaged in developing this. its implications for the future of care delivery. Below are And 12 North had been very involved with the Transforming
WE ACTUALLY HAD THE NURSES WEAR PEDOMETERS, AND FOUND THAT THEY WERE WALKING AN AVERAGE OF 4.5 MILES PER SHIFT; AND THEY GOT THAT DOWN TO ABOUT 3.8 MILES PER SHIFT.
38 September 2011 • www.healthcare-informatics.com
CLINICAL IT PERSPECTIVE
Care at the Bedside work advocated by IHI [the Cambridge, per shift; and they got that down to about 3.8 miles per shift; so they were able to save steps. And every minute that they’re Mass.-based Institute for Healthcare Improvement]. It’s really a rapid-cycle change method—you would try walking around instead of with a patient decreases their face something new and quickly tweak it, and then spread it. time with patients. We have also had the kinds of things that So they were very familiar with this kind of concept, and nursing assistants are able to do, when they do their vital receptive to it, and were able to give us the kind of feedback signs—so there’s some ability to do documentation right at we were looking for, to improve care processes and make life easier for frontline caregivers. So we met with them formally weekly, but the SmartRoom team folks and the unit leader, Marcia McCaw, R.N., talked daily. So it was a developmental process and continues to be. We went live with this in June 2010, so we’ve been live there for a year. And then a couple of months after the implementation there, we went live in the GI surgery unit. And that was particularly interesting, because one of the physicians who admits patients there and does surgery is Dr. Andrew Watson, who is the medical director at UPMC’s Center for Connected Medicine, and who has some very cool ideas for things he’d like to do to expand communication capabilities with patients. So right now, we are live on five units, and are working on a sixth. Our campus includes the Presbyterian building and the Montefiore building, and we plan • Relevant Degree AND Certifications—Incorporates two industry certifications— to have the Montefiore building enCompTIA A+ and CIW Database Design Specialist—and prepares you for a career as a tirely live. Our hospital is called UPMC designer and developer of health information systems. Presbyterian-Shadyside, which consists • Flexible, Non-Profit, and Affordable—One of the best values in higher education, of the Presbyterian campus and the WGU gives you a convenient, cost-effective way to earn a degree. Shadyside campus. I’m on the Presbyterian campus, in the Montefiore building, • Ability to Accelerate—A competency-based approach to education that allows you to and the units that have gone live are in take (and pay for) only the time you need to complete your degree. the Montefiore building. But our goal is to have the whole Montefiore building • CAHIIM accredited—The Health Informatics program is accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM). live by the end of the year.
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REAL-WORLD IMPROVEMENTS HCI: How has this made a difference in care delivery? Scholle: Among other things, it has saved steps for the nurses. We actually had the nurses wear pedometers, and found that they were walking an average of 4.5 miles
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CLINICAL IT PERSPECTIVE
the point of care, via the touch screen monitors in the rooms. HCI: When the caregiver enters the room, the smart screen announces the caregiver by name to the patient. That seems
piece of education available through the SmartRoom technology. And that’s one of 200-some videos available. So the nurse selects the appropriate video for the patient, and then the patient can activate the video through their pillow speaker device, and then the nurse later can inquire whether the patient has viewed the video, and then once the patient confirms they’ve seen it, the nurse can document that at the point of care.
THE CAREGIVERS AT THE POINT OF CARE ARE VERY BUSY TAKING CARE OF PATIENTS WHO ARE MORE COMPLEX THAN THEY’VE EVER BEEN CLINICALLY. SO IT’S REALLY HARD TO GET CHANGE ACCEPTED. like a very strong patient and family satisfier. Scholle: Yes, and we had talked about the whiteboards, and prior to that, the nurse was supposed to come in and write their name on the whiteboard, but of course there’s the human factor, and sometimes the nurse would forget, and the previous nurse’s name would still be on there. And the patients do appreciate knowing which doctor is coming in. The doctors are electronically badged, so their names appear; and we’re in the process of universalizing that identification system across all caregivers, including physical therapy. Another really nice feature for the patients that we just went live with in January and that we’re still trying to optimize is our patient education feature. Based on the things the nurse knows about the patient, and what the patient needs to know to take care of themselves and understand their situation, the nurse can go into the smart screen and select some videos and education. And some of those can be very specific. For example, in the transplant unit, they and their patient would have to present this information to pa-
LESSONS LEARNED HCI: What have been the biggest strategic lessons learned so far? Scholle: I think that we did right by selecting that first unit. The first place that you implement a new strategy needs to be well-prepared for accepting the technology. We have had challenges as we’ve rolled forward, because we haven’t provided quite as much support on subsequent units; so that’s a lesson because those units weren’t quite as prepared for change as that first unit was. So we had to step back and say, we need to provide more ongoing support to those additional units. HCI: I think healthcare delivery will all be about change going forward; but to have that, you need a culture that is receptive, right? Scholle: Yes, that’s one of the great challenges. The caregivers at the point of care are very busy taking care of patients who are more complex than they’ve ever been clinically. So it’s really hard to get change accepted. And we’ve made some mistakes along the way. Organizations have made the mistake of saying, OK, let’s do barcoded meds administration, that’s great, and let’s do this and that, and while adding all these technologies may seem like they’re making things more efficient, and making care better and safer, but when you combine them, what you’ve done is to create a really complex working environment for caregivers, particularly when the systems can’t talk with one another. So you’ll have to have the interoperability to make these systems work together. I think that’s our biggest challenge. But what SmartRoom has done for us has been to make the systems in place work for us in a more usable manner—things like not having to log in all the time. But there are some interoperability issues between our electronic health record and our SmartRoom technology, so the SmartRoom folks continue to work on that. ◆
THE DOCTORS ARE ELECTRONICALLY BADGED, SO THEIR NAMES APPEAR; AND WE’RE IN THE PROCESS OF UNIVERSALIZING THAT IDENTIFICATION SYSTEM ACROSS ALL CAREGIVERS, INCLUDING PHYSICAL THERAPY. tients and family members right after their transplant. And we took that content and adapted it so that it could be made into a module for SmartRoom education; so in addition to attending a class, the patient has that information available at any time. Anyone who knows about transplant patients knows that compliance is a huge issue. Their care is very complex, and the medication regimes are very complex; the kinds of things you can and can’t do if you’re had an organ transplant—there’s a lot of information to know and remember. Some of these patients are taking 28 or 30 pills in the morning and have more to take later in the day. And that piece of education is so critical to their surviving and thriving, and yet is so difficult to deliver successfully, that you can’t reinforce it enough. So that’s one 42 September 2011 • www.healthcare-informatics.com
REACHING New Heights in Health Information AHIMA’s 83rd Convention & Exhibit! October 1–6, 2011 | Salt Lake City, UT Find everything you need to learn and grow as a health information management (HIM) professional—all in one place! » Network with the best and brightest individuals from around the globe » Hear the latest on ARRA-HITECH, REC, RAC, EHRs, ICD-10, and more from expert speakers » Earn continuing education units (CEUs) » And meet with more than 200 vendors in the exhibit hall.
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AD INDEX AHIMA..............................................................................................43 athenahealth ..................................................................................CVR 2 Availity ..............................................................................................40, 41 Axolotl...............................................................................................2, 3 CDW Healthcare...........................................................................CVR 3 Fujitsu Computer Products of America ..............................7 Futura Healthcare Technology ...............................................13 GCX ....................................................................................................17 Hospira .............................................................................................21 InterSystems Corporation ........................................................1 Iron Mountain ...............................................................................5 MedAssurant, Inc. ........................................................................15 Motion Computing ......................................................................33 NextGate ..........................................................................................23 Northwestern University ..........................................................27 Onset Technology ........................................................................31 Quammen Group .........................................................................44, 45 Sprint.................................................................................................CVR 4 SSI Group, Inc., The .....................................................................19 Suntrust Wealth ............................................................................37 Verizon Wireless ...........................................................................9 Vocera Communications, Inc..................................................25 Western Governors University................................................39
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CAREER PATHS
Tough Interview Questions HOW TO KNOCK HARDBALL QUESTIONS OUT OF THE PARK BY TIM TOLAN
W
hen the tough and uncomfortable questions come up during a job interview, healthcare CIOs need to be ready to answer them with absolute conviction. Most candidates are accustomed to answering “softball” questions during the course of a job interview, and most can do so without batting an eyelash. Such questions help validate a candidate’s success metrics (i.e. great leadership Tim Tolan attributes, qualities, career progress, etc.), and they are usually easy questions to answer. Most of us are proud of our accomplishments and it’s important to get them out there, as previous success can often give us a preview of upcoming attractions. Here’s the challenge: like a baseball player, you must be able to respond flawlessly to each question—regardless of how dif-
• Please describe a recent situation when your work was criticized. • What do you think of your current boss? • How would you describe your personality? • How long will you stay with our organization? • What would your boss say is your greatest strength and weakness? • Why are you the best candidate for this role? A really good interviewer will ask you the tough questions, and in many cases, the way you respond can have a significant impact on your future candidacy—just be sure you pause briefly to gather and formulate your thoughts. Spouting off a quick answer just to prove you’re quick on your feet rarely scores a home run. The interview is looking for depth and honesty in your answer, and yes, it may expose the human side of a mistake you’ve made, but that’s ok! We all slip-up now and then, and it’s important to be able to articulate and explain the lessons you have learned, and how previous experiences helped you later in your career. Of course, in order to respond properly to a question in an interview, you have to answer! Failing to answer or glossing over a question posed by an interviewer is a huge mistake. Attempting to demonstrate that you’ve never made a bad decision by ignoring a question is very risky and will most likely result in another bad decision on your part. Organizations are looking for excellent leaders, and leaders become great through experience. Overcoming and learning from previous failures make us better at what we do. Being human and admitting mistakes and what we learn from them can have a positive outcome during an interview. It demonstrates personal growth and experience. So the next time you get a chance to swing the bat, be prepared for every question that’s thrown your way, positive or negative. Pause for a moment to think about your response and then answer each question honestly and with conviction. Swing hard!
A REALLY GOOD INTERVIEWER WILL ASK YOU THE TOUGH QUESTIONS, AND IN MANY CASES, THE WAY YOU RESPOND CAN HAVE A SIGNIFICANT IMPACT ON YOUR FUTURE CANDIDACY—JUST BE SURE YOU PAUSE BRIEFLY TO GATHER AND FORMULATE YOUR THOUGHTS. ficult they may be. And you must do so with speed, accuracy, and without hesitation. What I find really interesting is why some candidates never prepare for the fast balls, curve balls, or the occasional slider. Here are a few questions that you should be ready for the next time you are up at bat: • Why are you here today? • Tell me about a time you had to make a tough decision and the outcome was not good. Why did you make that decision, and if you could do it all over again, what would you do differently? • Describe a time you had to compromise your ethics. • What is your biggest weakness as a leader? • What is your greatest career accomplishment? • What is it like to work for you and what would your people say about your leadership? • If you could improve in one area of leadership, what would that be? 48 September 2011 • 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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