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IOM: Continuous Healthcare Learning

Secure Image Sharing

Data Security’s ‘10,000 Club’

October/November 2012

Volume 29, Number 9

MAKING THE LEAP How are Medical Group Leaders Strategizing Toward the New Healthcare? A Vendome Publication

The Key to

Breakthroughs in Accountable Care InterSystems HealthShare® is a strategic informatics platform. It connects applications, creates a uniied view of every patient, enables rapid development of new functionality, and provides insights based on real‐time active analytics. Across a hospital network, or a community, or a nation.

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CONTENTS October/November


MAKING THE LEAP Leaders of six medical groups share their perceptions on laying the strategic IT foundations for the “new healthcare,” as the industry shifts from volume-based fee-for-service patient care delivery and reimbursement towards a healthcare system that is more measured, responsive, accountable, and transparent





What are the most significant changes from the proposed rule to the final rule, and what do they mean for providers?

Researchers at Wake Forest University School of Medicine have come up with a way to digitally and securely transfer medical images, alleviating common workflow pain points. Can this be a model for others to follow?




DATA SECURITY 101: AVOIDING ‘THE LIST’ As the number of patients affected by data breaches continues to climb, data security experts and CIOs offer advice—and lessons learned from their own experiences—for staying off the HHS list of offending provider organizations


POPULATION HEALTH PERSPECTIVE ALLINA’S PIONEERING MOVE ON POPULATION HEALTH How a groundbreaking dashboard helped this integrated health system assess readmissions risks for inpatients before they are discharged





CHRONIC CARE PERSPECTIVE FRANCHISING THE CHRONIC CARE MODEL Iora Health’s Special Care Center, a model for high-intensity care, has outperformed national indicators on chronic diseases, reduced readmissions, and generated high patient satisfaction

How three hospital systems use technology to protect their data, speed recovery and care for patients in the event of a disaster










PHYSICIAN PRACTICE PERSPECTIVE NEXT STEPS FOR THE PRIMARY CARE PRACTICE INITIATIVE CMS has selected 500 primary care practices in seven regions that will serve as a test bed for its effort to strengthen primary care




An important IOM report is aimed at making the healthcare industry become a learning industry

Useful tips to help calm your nerves so you can put your best foot forward during an interview



Healthcare Informatics (ISSN 1050-9135) is published 9 times per year 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 60076-7878. Subscriptions: For questions or correspondence about a subscription, phone 847-763-9291 or write to HEALTHCARE INFORMATICS, PO Box 2178, Skokie, IL 60076-7878. If you are changing your address, please enclose entire mailing label and allow 6 to 8 weeks for change. Subscription rate per year (U.S. Funds): U.S. $58.00; Canada/Mexico $82.00; all other countries $109.95 (includes air delivery). Single copy rate (U.S. Funds) except September and January: U.S. $8.00; Canada/Mexico $12.00; all other countries $15.00. September 100 and January Resource Guide: $50.00 (U.S. Funds) includes shipping/handling to all countries. Add state and local taxes as applicable. 2 October/November 2012 •

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Medical Group Strategies, Data Security, Disaster Recovery


his month’s cover story, which begins on page 8, presents a virtual roundtable, in which Editor-in-Chief Mark Hagland interviewed six medical practice leaders from across the country to find out where they are in laying down the foundations of the “new healthcare” that is shedding the volume-based fee-for-service model in favor of more responsive, accountable, and transparent patient care. Speaking from the front lines of change, the participants lay out their strategies for addressing the most significant IT issues facing medical groups in the emerging operating environment. On page 14, Senior Editor Jennifer Prestigiacomo reports on an intriguing technology, developed by researchers at Wake Forest University School of Medicine, which enables secure sharing of digital radiological images, eliminating workflow problems associated with compact disks. Can this be a model for other providers? Despite increased attention on security of patient data by the Department of Health and Human Services, the number of patients affected by data breaches has continued to climb. On page 18, Associate Editor Gabriel Perna takes a closer look at this seemingly intractable problem, and presents advice from industry experts and healthcare CIOs about how to better secure their records. Meanwhile, no hospital system is immune from potential natural disasters, be it floods, tornadoes or hurricanes—which have been occurring with increasing severity in recent years. In the article on page 22, Managing Editor John DeGaspari takes an in-depth look at what three hospital systems are doing to protect their data and IT infrastructure, and ensure the best possible care for their patients. Of special note in this issue is insightful coverage of two important policy developments. On page 30, Hagland presents the recommendations of a recently released report by the Institute of Medicine that defines its vision of a healthcare system characterized by continuous learning. Senior Contributing Editor David Raths distills key requirements of the meaningful use Stage 2 final rule and what they mean for provider organizations on page 34.

Informatics Healthcare IT Leadership, Vision & Strategy

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

SALES DIRECTOR OF DIGITAL & CUSTOM SOLUTIONS, WEST COAST Nicole Casement [email protected] 212-812-8416 SENIOR DIGITAL ACCOUNT MANAGER Cathleen Ryan [email protected] 646-217-8413 PROJECT MANAGER, DIRECTORIES/SPECIAL PROJECTS Libby Johnson [email protected] 216-373-1222


PRODUCTION DIRECTOR OF PRODUCTION Kathi Homenick [email protected] ART DIRECTOR James Gouijn-Stook [email protected] TRAFFIC MANAGER Judi Zeng [email protected] 212-812-8976 All ad materials should be sent to:



Make sure to visit for the latest healthcare IT coverage: integrating imaging into clinical workflows; HIEs and analytics technologies; patient interest in web-based healthcare interaction; and rural health IT challenges.

Erin Tyler 216-373-1217 [email protected]

2012 EDITORIAL BOARD Marion J. Ball, Ed.D. Professor, Johns Hopkins School of Nursing Fellow; IBM Center for Healthcare Management; Business Consulting Services, Baltimore, MD Lyle L. Berkowitz, M.D., FHIMSS Medical Director, Clinical Information Systems Northwestern Memorial Physicians Group, Chicago, IL William F. Bria II, M.D. CMIO, Shriners Hospital for Children, Tampa, Fla. Adjunct Associate Professor, University of Michigan Tina Buop CTO, La Clinica de La Raza, Oakland, CA Bobbie Byrne, M.D. VP for HIT, Edward Hospital, Naperville, IL W. Reece Hirsch Partner, Morgan, Lewis & Bockius LLP, San Francisco, CA Christopher Longhurst, M.D. CMIO, Lucile Packard Children’s Hospital, Clinical Assistant Professor of Pediatrics, Stanford University School of Medicine, Palo Alto, CA

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

4 October/November 2012 •

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CORPORATE CHIEF EXECUTIVE OFFICER Jane Butler EXECUTIVE VICE PRESIDENT Mark Fried VICE PRESIDENT, FINANCE Bill Newberry EXECUTIVE GROUP PUBLISHER Michael W. O’Donnell HEALTHCARE MARKETING DIRECTOR Rachel Beneventi © 2012 by Vendome Group, LLC. All rights reserved. No part of Healthcare Informatics may be reproduced, distributed, transmitted, displayed, published or broadcast in any form or in any media without prior written permission of the publisher.




any in healthcare remember what happened on Nov. 1, 1999 (though they may not recall the date itself): on that day, the Institute of Medicine (IOM) released a groundbreaking report, “To Err Is Human: Building a Safer Health System.” That report, which was also published in book form, initiated the first serious, industry-wide, nationwide conversation about patient safety Mark Hagland and medical errors that had reached the ears of the general public. What made the mainstream media sit up and take that report seriously was a single statistic: that somewhere between 44,000 and 98,000 Americans were dying every year, in hospitals alone, from fully preventable medical errors—the equivalent, it was pointed out, of a jumbo jet crashing every day and killing all the passengers on board. And while I’ve often criticized my mainstream media journalist colleagues for being lazy when it comes to their healthcare policy reporting—their failure to articulate fully the important policy choices facing the American people during the healthcare reform debate in 2009 and 2010 was a particularly egregious example—it’s kind of hard to ignore a statistic of 98,000 annual preventable deaths. Thus, in November 1999, Americans from all walks of life were made aware of the issue of patient safety in a new and important way, creating a watershed moment for our country. Meanwhile, Sept. 6, 2012 passed far more quietly. Yet the report that the IOM released on that date—the organization’s third major report in 13 years—is one that I would argue will have an increasingly important impact over time. That’s because “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America” was released at a particularly propitious point in the evolution of the healthcare industry in the United States, relative to the core changes it is urging. In contrast to 13 years ago when “To Err Is Human” was released, “Best Care at Lower Cost,” which focuses on the 6 October/November 2012 •

idea of compelling the healthcare industry forward on a system-wide journey of continuous learning, was published at a time when pioneering patient care organizations are already moving down a path towards sustained, continuous performance improvement. Of course, most patient care organizations nationwide are still very, very early in their journey; and the 10 core recommendations that the report makes, which would move the U.S. healthcare system toward a far more data-driven, patientcentered, community-linked, new-payment-model-facilitated care delivery model, will take years, if not decades, to fully build. But in contrast to the situation more than a decade ago, some of the care delivery models that will be required going forward are already emerging. When it comes to the efforts that leading medical groups are making in all this arena, this month’s cover story (page 8) offers a discussion among the leaders of such diverse organizations as Hunterdon Healthcare Partners in Flemington, N.J., Cornerstone Health Care in High Point, N.C., and the Physician Services Division at the UPMC health system in Pittsburgh, describing the initiatives they’re participating in, in order to lay the groundwork for what I’ve regularly been calling the new healthcare. So though “To Err Is Human” hit the U.S. healthcare industry as a shockwave in 1999, and though the release of “Best Care at Lower Cost” was a far quieter affair, there’s no question in my mind that the map that this latest IOM report lays out is one whose path the healthcare system will turn to countless times as a point of reference, as we move forward to transform the healthcare delivery system on behalf of our patients and communities.

Mark Hagland Editor-in-Chief



EXECUTIVE SUMMARY: This summer, HCI’s Editor-in-Chief Mark Hagland interviewed leaders of medical group organizations from across the country to get a sense of where their leaders are right now with regard to laying the strategic information technology foundations for the “new healthcare,” as it’s being called: the shift away from volume-based fee-for-service patient care delivery and reimbursement, and towards a more measured, standardized, responsive, accountable, and transparent healthcare system. Among the numerous emerging vehicles for that care are accountable care organizations (both within the Medicare Shared Savings Program, and between private health insurers and providers), bundled payment-based contracts, patient-centered medical homes, population health initiatives, value-based purchasing programs, and others. Fortunately, the Supreme Court’s affirmation in June of the constitutionality of the federal Affordable Care Act (ACA) has created greater policy clarity around many of these vehicles, with the ACA’s provisions for accountable care organizations (ACOs), bundled payment-based contracts, patient-centered medical homes (PCMHs), and value-based purchasing now moving forward with renewed certainty.


n this virtual roundtable, medical group leaders share their views on the challenges they face as the industry shifts from the volume-based fee-for-service model to more accountable and responsive patient care. See the participants’ biographies on page 10. Healthcare Informatics: What are you all seeing as the most significant strategic IT issues facing medical group leaders like yourselves in the current and emerging operating envi-

8 October/November 2012 •

ronment at the moment? Francis X. Solano, M.D.: We’ve been extremely successful in rolling out the electronic record, which is a wonderful tool. The next priority is to utilize that tool to the fullest, so we get maximum benefit. Personally, I think meaningful use is actually forcing us to go backwards a bit in order to satisfy government regulations. Our capabilities in report-writing are already advanced. Our challenge really is in the area of specialty care, which everyone in the industry is struggling with. You can get lots of crude data on outcomes, including length of stay, etc., but is that really helpful? In primary care, there are a lot of outcomes measures, process measures like controlling hemoglobin A1C, lipid management, blood pressure control, smoking query, anti-platelet and statin use in heart disease care, colonoscopy rates, immunization rates, etc., and we’ve actually done things like ranking our physicians on those elements. Some of the meaningful use requirements were well-intentioned. But in some cases, it’s kind of a step backward for us to spend all the time, energy, and resources, to figure out what the government wants and satisfy those wants. Jeffrey Weinstein: Our biggest challenge is taking the data that we’ve collected and starting to put it into a format so that we can use it to help manage populations, to improve the health of our communities. Glenn Mamary: At some point it’s really being predictive in our analysis as well. Because we’ve been on our EMR for so many years now, we’ve got a database that we could leverage, because the tools are so mature out there. Tim Terrell: Overall, for us, it’s the challenges presented by healthcare reform, in its broadest sense.

COVER STORY HCI: From your perspective, what unites all these healthcare reform-related programs in terms of the strategic IT foundations required for them? Terrell: Number one is analytics, and number two is integration. Those two things will be the biggest elements of it, and both are enormous. HCI: Where are you on those two elements? Terrell: We’re actually investing pretty heavily in analytics. We’re working with Teradata, one of the three biggest data

now in the medical group setting, and what IT can do to improve that performance? Solano: Getting rid of the variability in care is what’s keeping me awake at night. I just don’t realize why so many physicians are so variable in their care in so many ways, or why so many physicians are still not optimally using some of the tools in the electronic record. Some of it has to do with such elements as best practice alerts, preventive maintenance screens, and allergy-allergy checking: if you ignored them in the paper world and you ignore them in the electronic world now, you’re going to be mediocre. The thing is, this transparency train is coming, and physicians have to be ready for it and be aware that it’s coming. Also, it’s not automatically true that quality care will cost less. That conundrum is out there, and it bothers me if we’re going to be benchmarked based on quality and cost. If you happen to work in a quaternary care center as I do, your costs will be a lot higher, because you’re supporting a teaching institution. We actually did an interesting study: we took our top 50 providers and bottom 50 providers in primary care, and found that it actually cost more money to provide higher quality in a care group; so that’s out there. The newest conundrum that we face is, how do you go from a volume-based payment system, to doing the right thing in a quality-based system? That will be our biggest challenge. How do you start to align yourself to set up what you have to do. You’ll have to make some changes around utilization,

SOME OF THE MEANINGFUL USE REQUIREMENTS WERE WELL-INTENTIONED. BUT IN SOME CASES, IT’S KIND OF A STEP BACKWARD FOR US TO SPEND ALL THE TIME, ENERGY, AND RESOURCES, TO FIGURE OUT WHAT THE GOVERNMENT WANTS AND SATISFY THOSE WANTS. —FRANCIS X. SOLANO, M.D. warehouse vendors (the other two are IBM and Oracle); also, we’ve got Humedica for the clinical analytics and clinical predictive modeling. We’re in the process of implementing the OptumImpact suite from OptumInsight, to give us claimsbased analytics. HCI: Are you live on all three yet? Terrell: Right now, we’re live on one, Humedica; we’ll be live on Teradata by October, and will be very close on the Optum. HCI: Dr. Solano, your umbrella organization, UPMC, has long been a pioneer in leveraging clinical IT to address core issues in patient care delivery. Where do you see the nexus between performance improvement in care delivery right • Healthcare Informatics 9


Meet our Virtual Panel Members:

Tim Terrell, Chief Information Officer, Cornerstone Health Care, High Point, N.C., a 340-provider multispecialty group practice (nearly 240 physicians, plus physician assistants, and nurse practitioners) across 80 locations. Cornerstone is physician owned, in the Greensboro-Winston Salem-High Point Triad area of North Carolina. It was established in 1995. Tim Terrell has been CIO since 1998.

John Cuddeback, M.D., Ph.D., Chief Medical Informatics Officer, Anceta, Alexandria, Va., a subsidiary of the American Medical Group Association (AMGA). Anceta facilitates data-driven shared learning among AMGA members to enhance value in population health. AMGA represents large-sized medical groups whose 125,000 physicians care for more than 130 million Americans in 49 states (nearly onethird of all Americans).

Glenn Mamary, Vice President and CIO, Hunterdon Healthcare, Flemington, N.J. Hunterdon Healthcare Partners is a multispecialty group with more than 165 providers. It is half-owned by an independent physician association, and half-owned by Hunterdon HealthCare System, an integrated system that encompasses a 178-bed hospital, 30 patient care locations, and more than 2,000 employees, in Hunterdon County in western New Jersey.

Francis X. Solano, M.D., Vice President, Physician Services Division, University of Pittsburgh Medical Center (UPMC) health system, and President, Community Medicine Inc., and Medical Director, Donald D. Wolff, Jr. Center for Quality, Safety, and Innovation, at UPMC, Pittsburgh, Pa. Dr. Solano also continues to practice parttime in internal medicine (he has been in medical practice since 1984).

Jeffrey Weinstein, Executive Director and CEO, Hunterdon HealthCare Partners, Flemington, N.J., which works in conjunction with the Hunterdon Medical Center.

Jim Venturella, CIO, Physician and Hospital Services, UPMC, Pittsburgh, Pa. The UPMC health system encompasses more than 20 hospitals and more than 400 clinical locations across western Pennsylvania.

10 October/November 2012 •

around the use of diagnostic tests and drugs.

WHY WORKFLOW MATTERS HCI: How does that translate into what IT implementation can do to support performance improvement? Jim Venturella: It gets to the workflow and efficiency issues that Dr. Solano talked about. In some of the practices, the doctors are well-educated, and our tools may not be as efficient as they could be, so we’re trying to figure out how to make the tools more efficient; because some of the tools actually make their day less efficient. The other area is looking at devices: how do we use devices more efficiently? How will we use the new mobility tools more efficiently in the clinic setting? Terrell: Also, you can’t treat every patient the same way anymore. You basically have to divide your patients into the generally healthy versus the chronic with one illness, versus the poly-chronic, versus those in end stages of illness; and you have to treat each category differently. With poly-chronics, you have to work on poly-pharmacy and managing those patients more intensively. With the end-stage people, it will be about getting them to the lowest-cost, best-outcome setting for care. The patient who is terminal with cancer actually lives longer, and at much lower expense, in hospice, versus in the hospital. In addition, you have to create disease registries. You have to figure out who your most frequent flyers are, and why; and who your most expensive patients are, and why. You have to figure out exactly what your clinical performance is at the individual provider level. The same thing is true regarding patient satisfaction, by provider. You’ll need the analytics to understand the processes at each clinic, to know which things work for each patient and which don’t. You need analytics to determine

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how you’re performing on your qualitybased contracts.

DATA INTEGRITY ISSUES Mamary: Among other things, we’re trying to move forward on data integrity issues. Some of the issues in that area include making sure that people understand the meaning of the data we’re capturing, and that people are trained to correctly capture the data. Fortunately, we’re all on the NextGen system, so the capture element isn’t that difficult on the practice side. It’s on the hospital side where I find that we have some issues, because of multiple systems and vendors. The other thing is that, in the hos-

they don’t. We needed more analytics people to find things out. We’ve got tons of data, but we’re really trying to turn that data into information. We’re using the Ensemble solution in that area. Having a financial systems analyst, a clinical systems analyst, and also working with the customers, you need to put all those systems in place, to make sure you have good data integrity, and to make sure that all your processes are correct.

ACO CHALLENGES AND OPPORTUNITIES HCI: Dr. Cuddeback, when you talk to leaders of medical groups that are your organization members, what are you

CAPTURING A PIECE OF DATA IN A CONSISTENT WAY IS A CHALLENGE, AND IS ONE OF THE LESSONS WE’VE LEARNED. WE’VE GONE BACK AND MADE MORE FIELDS REQUIRED FIELDS, SO PEOPLE DON’T JUST SKIP BY THEM. —GLENN MAMARY pital, I have to provide data to over 30 outside sources, whether state or federal. They come up with these little state-level names of pieces of data that mean something to New Jersey, for example; and then the information systems are required by our contract to capture those data elements. Inevitably, New Jersey calls something

hearing right now? John Cuddeback, M.D., Ph.D.: Accountable care organizations are very much a focus for our member organizations, and ACOs are exactly what our association has been focused on. Of course the Medicare Shared Savings Program was based on the Medicare group practice demo that several of our member orga-

That’s essentially been the theme, just because this is so important to AMGA members. Accountable care is about medical groups working collaboratively with insurance partners—not just on their own. With regard to the infrastructure issues, it’s about being able to understand a patient’s entire healthcare experience. If you look at AMGA members, we’re seeing an increase in integrating organizations; and most of these are mergers of different groups. Five years ago, in the heart of the PGP demo [the federal Medicare Physician Group Practice accountable care demonstration, which helped create the model for the Medicare Shared Savings Program under healthcare reform], only about one-third of our members were integrated delivery systems; but now, two-thirds are. Still, data integration remains a huge focus. HCI: What should your colleagues in medical group organizations across the country be doing right now? Solano: First, you have to get an electronic record in place, one that will support your organizational and national goals, because if you pick a vendor that can’t do that, that will create problems down the road. Then you need to get a leadership group together with strong, forceful, directional leadership, so that you can try to define what your priorities are, which is crucial. You can wander into areas that will just waste your time and resources. You have to make sure you hit all the national benchmarks for quality. It’s very easy to get sidetracked into pursuing projects that bring your organization very little value and don’t fulfill any of the national objectives. Instead, you need to look at the national objectives of accountable care, the medical-centered home, and value-based purchasing, and align your organization with those, both on a national and local-area level. Aligning with those goals is crucial. Because if you fall off the path, it can be fatal. Anyone who says they’ve never fallen off the path is lying! We’ve fallen off the path many times along the way. ◆

ACCOUNTABLE CARE IS ABOUT MEDICAL GROUPS WORKING COLLABORATIVELY WITH INSURANCE PARTNERS—NOT JUST ON THEIR OWN. WITH REGARD TO THE INFRASTRUCTURE ISSUES, IT’S ABOUT BEING ABLE TO UNDERSTAND A PATIENT’S ENTIRE HEALTHCARE EXPERIENCE. —JOHN CUDDEBACK, M.D., Ph.D. by a name that is different from what it’s called in another state. There are so many points of data entry into the system. Capturing a piece of data in a consistent way is a challenge, and is one of the lessons we’ve learned. We’ve gone back and made more fields required fields, so people don’t just skip by them. We’re required to say that a patient doesn’t actually have a referring physician, if

nizations participated in. HCI: Weren’t most of the practice demo groups AMGA members? Cuddeback: Yes, nine of the 10 were, and the tenth was not an actual medical group, it was a community coalition. When I first came to AMGA five years ago, medical directors and CIOs of medical groups were talking about the issues around creating patient registries and supporting population health.

12 October/November 2012 •

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EXECUTIVE SUMMARY: A new digital technology has been developed by researchers at Wake Forest School of Medicine to allow unaffiliated institutions to transfer medical images, thus avoiding the hassle of CDs. Could the PCARE system offer a model for others to follow?


ow that health information exchange (HIE) is gaining traction in the industry and becoming a larger part of meaningful use requirements, researchers at Wake Forest School of Medicine in WinstonSalem, N.C., have been trying to figure out how to make radiological images as mobile as other patient health information. Co-investigators Yaorong Ge, Ph.D., associate professor of biomedical engineering, and Jeff Carr, M.D., radiologist and director, TSI Biomedical Informatics Center, have built the Patient-Controlled Access-key REgistry (PCARE), a set of processes that allows patients, with a swipe of a card, to digitally enable unaffiliated institutions to transfer medical images to avoid the hassle of CDs. “The idea is that the images stay where they are,” says Ge, who demonstrated PCARE at the Radiological Society of North America conference two

years ago and was recently featured in the Journal of the American Informatics Association. “That addresses a lot of concerns; not only does it address physician workflow and patient privacy

14 October/November 2012 •

concerns, but also a lot of business interests concerns, such as, why do I want to have my data lumped together with my competitor’s data?” The impetus for developing this tech-

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nology was to alleviate the bottlenecks of current workflows involved in transferring radiological images between institutions. At many organizations, patients sign paperwork to obtain their radiological images on a CD, which they then have to handdeliver to the other institution. Often times the patient forgets the CD, or the CD contains the wrong images, or the physician has trouble loading images because of compatibility or hardware issues.

facility contains encoded metadata that age cache that acts like a local image identifies the hospital where the images repository, and so physicians can use were taken, what time, the facility-gen- existing workflows to look at those imerated patient identifier, and the facili- ages,” explains Ge. “Because the images ty-specific URL that links to the actual are linked with this token that has the clinical data. When the patient goes to information about those hospitals in the second healthcare terms of their local IDs, our system aufacility, they swipe a tomatically maps [the patient] ID to the patient identity card, local hospital’s ID.” much like a credit card, PCARE leverages open-source techat a patient controlled nologies and standards like dcm4chee, portal or kiosk. The an image manager/image archive appatient is asked if they plication that contains the DICOM, HL7 want to share the speci- services and interfaces that are required fied images, and once to provide storage, retrieval, and workthat option is selected, flows; the Cross-Enterprise Document a digital signature signs Sharing (XDS) standard; and Indivo, the HOW PCARE WORKS a secure token that is patient controlled health platform that The PCARE project got then sent to that facil- allows the sharing of health informaYaorong Ge, Ph.D. its start three years ago ity’s edge server, which tion. with a Research and Retransmits the token to Ge says PCARE also leverages pasearch Infrastructure the original healthcare tient participation in its privacy and “Grand Opportunities” grant funded imaging facility’s edge server, which security practices, given that the paby the federal American Recovery and validates that token and ships the vali- tient authorizes the information exReinvestment Act (ARRA). While devel- dated token with the image links back change by being physically present at oping PCARE, Ge and Carr investigated to the second facility. both healthcare organizations. “We two main approaches for image ex“When images arrive at the new hos- can then physically link the IDs tochange: a patient-centric approach, i.e., pital, those images are found in an im- gether by the patient’s direct confira personal health record (PHR), which puts the burden on the patient; and an organization-facilitated approach, i.e., HIE where the onus is on the health system. The investigators saw flaws in each method, with the patient-centric approach not fitting into physician workflows and data having to be validated by the physician, while the organization-based approach creating challenges around patient consent. “This is the critical design feature that sets our framework apart from existing patient-coordinated sharing frameworks such as PHRs,” says Ge. “Instead of dealing with actual clinical data as in a PHR, PCARE is a collection of access keys or secure tokens that uniquely represent clinical datasets. These unique access keys are generated by a healthcare imaging facility upon patient authorization to provide a secure electronic conduit to the actual dataset.” PCARE capitalizes on the strengths of both the patient-based and organi- The PCARE architecture transmits secure tokens that represent clinical data sets zationally based approaches. The token to each node of the network that may be an independent healthcare enterprise or generated by the healthcare imaging an HIE. Source: Yaorong Ge, Ph.D.

16 October/November 2012 •


Yaorong Ge, Ph.D., PCARE co-principal investigator (in back); David Ahn, architect (seated); and Jeff Carr, M.D., co-principal investigator (right), demonstrating the PCARE system. Photo: Wake Forest School of Medicine

mation,” adds Ge, “and therefore we believe it will be much more accurate than an MPI.” “In most cases based on our survey data, and based on our anecdotal evidence, patients are very comfortable authorizing the sharing of their ongoing medical records with the healthcare providers that are part of

nization already has a broadband connection and a PACS, all that is required is a small server placed at the facility, and a kiosk or computer for patient authorization, all of which could cost the organization approximately $15,000, says Carr. “There might be a competing network or groups of physician practices and smaller players that your patients

PCARE’s next phase hasn’t been completely finalized yet. In the next three to six months, the investigators will partner with a healthcare economist to begin interviews with patients, families, and providers to ascertain what they would like to see in the PCARE platform and how much they would be willing to pay for it. There are also plans for a regional demonstration project to implement the system to document its challenges and successes. However, more funding is needed for that, and the team is currently in active exploration with interested parties. Ge emphasizes the cost and time benefits of PCARE; not only can organizations save money on the CDs themselves, but the costs of management of the CDs in storage and personnel. Ge is excited about the many possibilities for this image sharing system and how it can be applied for other purposes like sharing a longitudinal virtual electronic health record, since the token in the PCARE system can link to lab data or any other medical data, for that matter. “If you look at Stage 2 meaningful use, with the necessity to facilitate real exchange of information between providers and patients, and how that happens, I think our solution can play a role in several scenarios that are likely to be high volume exchanges of information,” says Carr. He adds that beyond enhancing interoperability, another strength of PCARE is that it can maintain an audit record, as well as document patient authorization for the exchange of their medical information, which is necessary for Health Insurance Portability and Accountability Act (HIPAA) requirements. ◆


INFRASTRUCTURE NEEDS Carr says that the PCARE system is ideal for where most healthcare imaging is performed—at small physician practices or outpatient imaging centers. The PCARE system was designed to have a small footprint, and assuming the orga-

see that you would like to collaborate with in a very rich way, and right now that is very difficult,” says Carr. “The advantage of PCARE is that you don’t have to set up an agreement between the two hospitals to open up all your databases and image archives.” A prototype was implemented during a feasibility study between the 800-bed Wake Forest Medical Center in WinstonSalem, N.C. and Lexington Memorial Hospital, a 90-bed community hospital in Lexington, N.C. The performance test • Healthcare Informatics 17


showed that, even including the slower network of Lexington Memorial Hospital, PCARE could move 1 gigabyte of data within 15 minutes, which Ge notes is satisfactory compared to most hospital wait times that are at least that long.


Data Security 101: Avoiding the List HEALTHCARE DATA MAY BE RIPE FOR THE PICKING, AND THAT’S CAUSING SLEEPLESS NIGHTS FOR MANY CIOs BY GABRIEL PERNA EXECUTIVE SUMMARY: Thanks to the rampant digitization of healthcare data, breaches have become commonplace in an industry that lacks advanced security practices. In this industry-wide report, those who have dealt with breaches implore others to shore up internal security practices and be transparent. As one CIO keenly notes, “we’re all in this together.”


ere’s something that may keep your typical healthcare CIO from getting a good night’s sleep: the growing list of data breach victims on the federal Department of Health and Human Services (HHS) website. From breaches affecting 500 patients to those that impact millions, it’s an extensive catalog, which shows how even the most sophisticated provider and payer organizations are susceptible to this growing threat. The list is part of HHS’ effort to make organizations more transparent when data has been breached. It’s existence is part of the federal Health Information Technology for Economic and Clinical Health (HITECH) Act. While getting on the list is not exactly something leaders at any provider-based organization will ever want to achieve, for many, it could be only a matter of time. Even if it’s not a breach that affects 500 or more patients, the industry-wide consensus, from analysts to CIOs, is that unless an organization is aggressive in protecting its data, vulnerabilities are inevitable.

“If you don’t believe your data is at risk, you don’t know what’s going on,” John Halamka, M.D., CIO at the Boston-based 649-bed Beth Israel Deaconess Medical Center (BIDMC), says matter-of-factly. Michael ‘Mac’ McMillan, chair of the HIMSS Privacy & Policy Task Force, and co-founder and CEO of CynergisTek Inc., a health information security and regulatory compliance firm located out of Austin, Texas, says data breaches have become a near-weekly occurrence due to three main factors, all converging around the same time. The first factor is the rapid digitization of healthcare data, thanks to meaningful use and other regulatory mandates. Secondly, he notes that healthcare entities are still using manual, outdated processes for data protection. Lastly, he says, privacy and

18 October/November 2012 •

security is not the priority it should be. “The overwhelming majority of breaches today are caused by carelessness or lack of attention to controls, or lack of attention by the organization,” McMillan emphasizes.

BREACH DATA Statistics on data breaches are not definitive, but they are revealing. While the number of data breaches affecting 500 or more patients fell this past year by 32 percent from the previous year, the number of patients impacted by those breaches doubled, from 5.4 million to 10.8 million, according to data compiled by Kaufman, Rossin, and Co., a Miami-based accounting firm. Other studies have painted an even darker picture. The Ponemon Institute (Traverse City, Mich.) found in De-


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“[Before the breach], there was a belief that the tapes were encrypted, and in fact they were not. So we put encryption practices into effect immediately,” Turnbull says. “The second thing was dealing with the transport contractors. We stopped sending them to the backup vault in the mountain for some time before we did a review of all the processes. With our own employees, we made it so they have to go to the vehicle and ensure the proper vehicle is there to transport the data.”

BE AGGRESSIVE Infograph Data Provided by Kaufman, Rossin, & Co. and The Ponemon Institute

cember of 2011 that data breaches have increased 32 percent year-over-year, with 96 percent of the healthcare organizations that were surveyed reporting that they experienced breaches during the last two years. The most alarming report may be from security firm Symantec (Mountain View, Calif.), which looked at the top 10 sectors by number of data breaches in 2011. The healthcare industry was the unlucky “winner,” with 43 percent of the healthcare organizations reporting that they had breaches, blowing away the government industry, which was second at 13 percent. Cost is another element, factoring into the weightiness of data breaches. According to the Pomenon study, data breaches are costing the healthcare industry an average of $6.5 billion on an annual basis. McMillan says the fine levied on an institution when they suffer a data breach is only a fraction of the actual cost. Using an example of a breach that cost a provider organization just over $600,000 in fines, McMillan says, “More than that fine, they spent countless man hours in remediation activities, and they’ve

reached a resolution agreement with the federal government that requires them to come up with a full time monitor for three years. That breach, between legal issues, resolution, remediation, etc. is probably costing them between $4-5 million.”

ENCRYPTION FAILURE While data breaches come in all shapes and sizes, for most healthcare leaders, the lessons learned are strikingly similar. In the case of Jim Turnbull, CIO of the four-hospital, integrated University of Utah Health Care system, the breach at his organization wasn’t even perpetrated by someone from within. Instead, a third-party organization was faulted for allowing the backup data tapes, which were being sent to a storage facility in the mountains, to be stolen. The data tapes, which Turnbull says contained information on approximately one million patients, later turned up in the house of some small-time thieves. The data, which had been backed up, was not lost. Still, Turnbull said, the healthcare system, which had immediately begun the process of notifying patients, learned some lessons, even with the positive outcome.

20 October/November 2012 •

Looking back, Turnbull says one of the most important things University of Utah Health Care did in the wake of the breach was to be transparent with patients. He adds that the worst thing an organization can do after a breach is to “try and hide it.” That sentiment is shared by BIDMC’s Halamka, whose organization has suffered two data breaches over the past two years. He says it’s important for those in the industry to share and learn from each others’ mistakes. “It’s so important for the industry to share lessons learned. We’re all in this together, and it isn’t a question who is to blame, but how does the industry get better,” informs Halamka, who has not only publicly reported the breaches to HHS and BIDMC’s patients, but also discussed them extensively on his popular health IT blog. Like University of Utah Health Care, BIDMC’s first recent breach was caused by the error of a third-party organization. According to Halamka, a personal device used by a subcontractor ended up getting stolen from that person’s car. The device had error logs on it, and in the error logs there were patient names. This year’s breach happened when the personal computer of a physician was

WORKFORCE EDUCATION Around the block from BIDMC, Brigham & Women’s Hospital, a 777-bed hospital that is also a teaching affiliate of the Harvard Medical School, also recently suffered a data breach. It occurred when a doctor, who works at Brigham & Women’s and nearby Faulkner Hospital, lost an external hard drive in a cab that stored data on 638 patients. Sue Schade, who is currently CIO of the University of Michigan Hospitals and Health Centers and was CIO of Brigham & Women’s at the time of the breach, says the incident taught her that

it’s important to ensure your policies are in place and people are trained on it. “The number of breaches right now of a large-scale magnitude that involves security within your overall infrastructure is far less common than the small ones of laptops and flash drives,” she says. “And that latter category is really about education of the workforce.”

probably the organization, and probably for financial reasons.” McMillan says these kinds of threats would be better avoided if better data security standards and practices—even with legislation from HITECH and Health Insurance Portability and Accountability Act of 1996 (HIPAA)— John Halamka, M.D. were implemented and observed industry wide. “We’re in a kind of environment where healthcare reSTANDARDS AND ally needs to step up its PRACTICES game. It needs to adopt For some, though, data a real security standard breaches are complex, like you see in other inand involve IT infradustries,” he says with structure. Take the Surconviction. geons of Lake County, Of course, as Glancy Libertyville, Ill., which and others note, it’s most recently had the server important to shore up hosting its unencrypted data security practices Mac McMillan EHR data hacked, enin house. In an era where crypted, and held for the digitization of data is ransom. The surgeons did not oblige, rampant, getting your own information and instead turned off its servers and procured and staff trained is critical. alerted authorities. To Dorothy Glancy, “Think about the law of averages. professor of law and digital privacy ex- They [providers and payers] have all pert at Santa Clara University, Santa this information or almost all, which Clara, Calif., this kind of breach repre- can identify one person, one way or ansents more serious criminal activity. other. And they have so much data per “[The hackers] were probably pros, person because of the way medicine is and not just 16-year-olds playing in practiced. So yeah, the law of averages their bedroom,” Glancy says. “I don’t says there will be a lot of data breaches. think a single person was targeted but It’s not surprising,” Glancy says. ◆


stolen from his desk. Neither device, he says, was procured or protected by the hospital’s IT department. This led BIDMC to make a major change. “Our response has been that our policy is no longer strong enough, and we actually need to ensure that data is protected by forcing encryption on every mobile device that touches our network,” Halamka says. To do this, BIDMC has begun an aggressive campaign where employees have either synced or brought in their devices to be fully encrypted. Furthermore, with every password renewal, the user of the device will have to attest that it’s still protected. “CIOs may not have a lot of authority, but we have a whole lot of accountability. How will you sleep at night knowing you’re responsible for any device at the Apple Store? The answer is you have to take an active approach, rather than passive,” he adds.

TTHE 10,000 CLUB Notable data breaches in 2012 affecting more than 10,000 patients Jan. 31-April 2: Jan. 25:

Howard University 34,503 patients

Feb. 11: Feb. 7-20:

South Carolina Department of Health and Human Services 228,435

March 16: March 10:

Indiana Internal Medicine Constituents Emory Healthcare 315,000


Utah Department of Health

April 30: Our Lady of the Lake Regional Medical Center 17,339

The University of Texas MD Anderson Cancer Center



Data provided by the U.S. Department of Health & Human Services Health Information Privacy website breach notification tool. • Healthcare Informatics 21




typically a top-down process, and is inclusive of the clinical and business units in a hospital organization. The IT department, he says, should play a central role as implementer, charged with enacting plans, making the investments in technologies, and archiisasters can strike at any tecting systems that meet the clinical time, and there is really no and business requirements. way provider organizations How is technology driving better can completely insulate preparedness? Healththemselves from uncare provider organiforeseen or large-scale zations are following natural events such as various strategies to hurricanes, floods, and prepare against unfires. Nonetheless, as planned downtime. hospitals continue on White provides a few their steady march to trends that help to becoming paperless orexplain progress in ganizations, many are the disaster recovery following strategies that arena. More hospital are minimizing their risk systems are moving of unplanned downtime. toward multiple data Jeff White Key to any disaster center environments, recovery effort is the purely for the sake of ability to protect electronic data, disaster recovery and business contiwhether the core clinical information nuity. systems or ancillary systems such as Core electronic health record (EHR) imaging or business functions, ac- systems have an architecture that cording to experts interviewed for plays into real-time or near real-time this article. Jeff White, a principal of replication of data. Data exists as a the Pittsburgh-based Aspen Advisors, single database, so can be replicated LLC, notes that disaster planning is in their entirety from a primary site

Three hospital systems provide details about how technology has influenced the way they prepare for disasters and what they have learned from their experiences.


22 October/November 2012 •

to a secondary site. Replication can be done in near real time, resulting in minimal data lost in case of an interruption. For ancillary systems, many providers are moving to a virtualized environment. Some providers, especially larger ones, have invested in storage area network (SAN) replication, with a duplicate SAN at a remote site. This can be an expensive set-up, and some mid-sized hospitals are still on that migration path. The advantage is that replication can occur very quickly. In White’s view most hospitals do a good job planning, configuring, and testing their disaster recovery capabilities, particularly with their core EHRs systems. However, he adds that many organizations struggle with their ancillary systems, because they often lack the people, bandwidth, and time to test major changes adequately on an annual basis. Disaster recovery system testing should happen annually, White says, adding that regular testing helps train the IT staff in proper procedures. In addition, disaster recovery plans should be revised whenever there is a change in the technology. “Once a disaster is declared, the staff may react differently because the technology

LESSONS LEARNED IN JOPLIN In May 2011, an EF-5 tornado slammed into St. John’s Regional Medical Center in Joplin, Mo., part of the Mercy Health System, leaving a mile-wide path of destruction. Mike McCreary, chief of services at Mercy Technology Services in St. Louis, says the hospital’s disaster planning is an integrated effort. The IT infrastructure component at the corporate level provides redundancy and connectivity; and a local component operates at the community level. “We follow both hospital emergency and state command systems,” he says. Failover drills are done quarterly, and local disaster drills are done annually in conjunction with the city.

When the tornado struck, it destroyed Joplin’s communication infrastructure. Cell towers were destroyed, removing voice communication (there remained enough bandwidth for text messaging). To fill the gap, the hospital established a command center with a satellite link to provide phone and Internet connectivity, he says. As a result, Mercy now has a mobile communication center with satellite capability and satellite phones. It has incorporated into its plans that text messaging be the primary means of communication when a disaster happens. McCreary says the hospital’s patient record systems fared well, partly the result of timing and partly due to the remote location of its data center and failover site. At the time of the tornado, the hospital had been part of the Mercy system for about two and a half years. It was in the process of moving older equipment, including hardware and a variety of systems including nursing documentation and legacy accounts

receivable systems, from Joplin to a data center in Washington, Mo., about 250 miles away. “Our model is to have a central suite of applications that is standard on the Mercy system; and the transition was complete at Joplin except for some clean-up,” he says. The hospital was already live with its EHR (supplied by Epic Systems Corp., Verona, Wis.), which was fully functional when the tornado struck. Had it struck prior to the go-live, it would have been much worse from a data standpoint, McCreary says: “We would have lost all of the systems; and even though there were backups, once something like that happens you are restoring new equipment, and there are always complications.” McCreary notes that the data center in Washington, which was up and running at the time, works with a failover site in St. Louis. He adds that there is also a local component for each of the hospitals, where local servers would be used for storage and faster access. Those were destroyed at Joplin. In the short term, the availability of

St. John’s Regional Medical Center, Joplin, Mo., in the aftermath of a tornado strike in May 2011. Photo: Mercy Health System • Healthcare Informatics 23


has changed. If they don’t have that documented, then it becomes more difficult for them to react once the disaster has happened,” he says. The following case studies discuss how three hospital systems prepare for potential disasters and the lessons learned from past experiences.

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FEATURE Florida Hospital in metropolitan Orlando has employed virtualization and a remote secondary data center as part of its disaster recovery preparation. Photo: Adventist Health System

patient data is crucial, he says. During recovery, “You want as much detail around that type of information, because you are dealing with casualties first off, and the more of that information you have available, the better care everybody gets in the beginning,” he says. After that, the hospital moved as quickly as possible to get back to a normal mode. “Our goal is one patient, one record, and that record should include every encounter he has ever had with a Mercy hospital or clinic,” McCreary says. Since the Joplin tornado, Mercy has hardened its data center in Washington, adding that it centralizes data as much as possible. In addition to running its own data centers, Mercy is also a data center vendor, selling disaster recovery advisory services to other health organizations, McCreary says. He also thinks that large healthcare organizations should look for ways to work together to back each other’s data.


which are centered on remote replication and Florida Hospital, part of virtualization. the Adventist Health SysIn 2006, the hospitem, is a 2,247-bed acute tal abandoned the use care organization with of backup tapes in faseven campuses in the vor of continuously Orlando metropolitan replicating data to a area. In 2004, the hospisecondary data center tal experienced a “hur(operated by SunGard ricane trifecta”—three Availability Services, hurricanes in one year— Wayne, Pa., which proRobert Goodman according to Robert vides all data recovery Goodman, the hospital’s services to the hospidisaster recovery coortal) located nearly 1,000 dinator. At the time, the hospital used miles from the hospital’s primary data a “tapes and trucks” process, in which center—and a safe distance from redata backup tapes were transported gional disasters. “Basically we mirror physically to a secondary data center. asynchronously to our hot site, and Although the hospital did not de- that keeps our data current,” Goodclare a disaster that season, had man says. the data center been destroyed, the In addition, Goodman reports that backed up data from the tapes would Florida Hospital has begun to virtualhave been several days old, Goodman ize its environments in both its home says. This prompted the hospital to ex- data center and its secondary site. plore alternatives for backing up data, Virtualization of its servers allows ap-

26 October/November 2012 •


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participates in the hospital’s weekly (virtual) change control meetings, where new recovery procedures are discussed resulting from changes to the system’s hardware or software. Florida Hospital runs disaster recovery exercises twice a year for the purposes of quality improvement. “We want to learn from all of our mistakes,” Goodman says. The hospital’s disaster recovery plans are stored on a server on a private cloud.


Cooley Dickinson Hospital upgraded to an enterprise data backup and recovery system to minimize unplanned downtime. Photo: Cooley Dickinson Hospital

plications to be deployed very quickly, crypted virtual private network (VPN) because they are not tied to a specific connection over the Internet, IT staff piece of hardware, he says, adding can access the recovery site and the that virtualization also home site remotely. At provides scalability, an one point, Florida Hosimportant factor bepital required 19 indicause the hospital has viduals to be on site more than 100 disaster during a recovery exerrecovery applications. cise. During its last ex“We’re getting scalability ercise it sent four techbecause we don’t have as nicians; and in the next many physical servers, two years he hopes to and replication is quick,” be able to work 100 he says. percent remotely. The hospital conducts In June, Florida Hosa business impact analpital subscribed to Kipling Morris ysis to classify which SunGard’s Managed systems get backed up. Recovery Program “We look at what the impact would (MRP), which Goodman says is in line be to the enterprise if those applica- with the disaster recovery strategies tions were down for a certain period the hospital has taken so far. Under of time,” he says. The applications are MRP, the hospital has access to a techtiered accordingly. nical team that is a counterpart to the Goodman says data is written to hospital’s IT team. The teams work disk, which is then replicated to the together during disaster recovery exsecondary site. With remote replica- ercises. tion using virtualized servers, data The bottom line, Goodman says, is replication time has gone down by a that “we now deploy very few people factor of 10. “That’s a good thing, be- in disaster recovery; we are current in cause underlying technologies are be- our backup, and our disk data; and we coming more complex,” he says. have individuals trained on the other In addition, Goodman says the hos- [MRP] end.” He notes that the hospipital has begun to use remote access tal’s IT team and its MRP counterpart for his IT staff, which he calls “virtu- team work in an integrated way to alizing the workforce.” Using an en- solve problems. The MRP team also 28 October/November 2012 •

Luckily, Cooley Dickinson Hospital, a 140-bed facility in Northampton, Mass., has never experienced a disaster in its data center. Nevertheless, several years ago, it re-evaluated its readiness to reduce the possibility of unplanned downtime. At the time the hospital did not use an enterprise backup system, according to Kipling Morris, manager of systems engineering; it took a silo approach to backup, in which each server was backed up to individal tape drives, he says. In a disaster recovery situation, the speed with which a hospital can restore its files is crucial, Morris says. “Any advantages you can get in backing up data, that’s the name of the game,” he says. The hospital decided to move to a centralized backup system, choosing a dedicated storage appliance (supplied by STORServer Inc., Colorado Springs, Colo.), which sits on top of IBM’s Tivoli system. Backup is now done on disks, and the data is spooled off to tape. “You increase the throughput on the front end, which eliminates bottlenecks and reduces the overall backup window,” he says. The underlying Tivoli system uses “Incremental Forever” technology that tracks files and file versions, so it backs up only the most recent files or those that have changed. The hospital’s business data and primary EMR for its physician practices (supplied by Westborough, Mass.-based eClinicalWorks) is backed up on the hospital’s data center on campus. Remote users access the application from the main campus database to work off site. Business and clinical systems are

stored on the hospital’s campus. The main HIS (supplied by Chicago-based Allscripts) is hosted off site by a third party. PACS is located on site, but the hospital keeps secondary copies off site. In addition to the main data center, the hospital is developing a secondary site on campus, which is used for realtime replication of the hospital’s systems. “This is not so much for backup and recovery as it is for business continuity, because that would allow us to be extremely agile in the event of lost systems at the primary site,” Morris says.

PARTING ADVICE FOR FUTURE EVENTS While there is no foolproof way to prepare for every disaster threat, each of those interviewed offered advice for minimizing the risk of unplanned downtime. Jeff White of Aspen Advisors says that hospital organizations should constantly revise their disaster recovery procedures to reflect changes in the IT systems. Hospitals need to make sure they test their recovery plans frequently. Robert Goodman of Florida Hospital says that once a hospital has made a decision to go with a paperless system, patient care depends on a hospital’s ability to recover quickly. Hospital administrators and CIOs need to think through what they need to do to bring their systems back to parity. “When you go to these systems, you need to support them from a recovery standpoint,” he says. Kipling Morris of Cooley Dickinson says that when it comes to backup and data recovery, there is no single approach that satisfies everyone’s needs. “Everyone wants to make sure they are identifying all of the appropriate use cases in their environment and are addressing them appropriately,” he says. Finally, Mike McCreary of Mercy Technology Services says the disaster recovery procedures that were in place were up to the task, adding that “it’s unfortunate that we had to put them to use.” He calls the mobile communications center a worthwhile improvement. ◆ • Healthcare Informatics 29




n Sept. 6, the Institute of Medicine (IOM), one of the U.S. National Academies and a leading nongovernmental organization in the healthcare policy arena, released a report entitled “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.” The report was produced by a committee of 18 volunteer healthcare industry leaders, including such luminaries as Helen Darling, president of the National Business Group on Health; George Halvorson, chairman and CEO of Kaiser Permanente; Mark D. Smith (the committee’s chair), president and CEO of the California HealthCare Foundation; and Brent James, chief quality officer at Intermountain Health Care, and supported by nine IOM staff members. The Committee on the Learning Health Care System in America has produced a 382-page report, with 10 core recommendations for action to create what the report’s editors—Mark Smith, Robert Saunders, Leigh Stuckhardt, and J. Michael McGinnis—call a vision of a new healthcare system: 30 October/November 2012 •

“a learning healthcare system that links personal and population data to researchers and practitioners, dramatically enhancing the knowledge base on effectiveness of interventions and providing real-time guidance for superior care in treating

POLICY PERSPECTIVE and preventing illness.” The editors added that “a healthcare system that gains from continuous learning is a system that can provide Americans with superior care at lower cost.” Reflecting on both the gains that have been made in healthcare delivery performance since the publication of the groundbreaking IOM report, “To Err Is Human: Building a Safer Health System” in 1999, and its follow-up report “Crossing the Quality Chasm,” published in 2001, as well as the obstacles that remain in improving patient safety, care quality, cost-effectiveness, and efficiency, the report’s authors and the committee offer the following 10 core recommendations: • The digital infrastructure: Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge. • The data utility: Streamline and revise research regulations to improve care, promote the capture of clinical data, and generate knowledge. • Clinical decision support: Accelerate integration of the best clinical knowledge into care decisions. • Patient-centered care: Involve patients and families in decisions regarding health and healthcare, tailored to fit their preferences. • Community links: Promote community-clinical partner-

ships and services aimed at managing and improving health at the community level. • Care continuity: improve coordination and communication with and across organizations. • Optimized operations: Continuously improve healthcare operations to reduce waste, streamline care delivery, and focus on activities that improve patient health. • Financial incentives: Structure payment to reward continuous learning and improvement in the provision of best care at lower cost. • Performance transparency: Increase transparency on healthcare system performance. • Broad leadership: Expand commitment to the goals of a continuously learning healthcare system. Importantly, the report’s authors and the committee note, “Given the interconnected nature of the problems to be solved, it will be important to take the actions identified above in concert.” They add, “To elevate the quantity of evidence available to inform clinical decisions, for example, it is necessary to increase the supply of evidence by expanding the clinical research base; make the evidence easily accessible by embedding it in clinical technological tools, such as clinical decision support; encourage use of the evidence through appropriate payment, contracting, and regulatory policies and cultural factors; and

POLICY PERSPECTIVE assess progress toward the goal using reliable ing for people is bankrupting this country. So metrics and appropriate transparency.” And, then obviously, we had to ask what we could do they say, “The absence of any one of these factors about it. And so we really focused on a couple will substantially limit overall improvement.” of things: making things available in terms of In other words, the committee and the report’s knowledge, and then capturing that knowledge authors agree, a combination of continuous perin ways that everyone could take advantage of formance improvement, increasing evidenceit. based care supports, care coordination, continuWith regard to the 10 core recommendations ous improvements in operational efficiency, and [above], you can put them in three buckets. the creation of cultures of constant learning, all One, we’ve got to create a data and knowledge supported and facilitated by significant investfoundation, a digital foundation.  Second, we’ve ment in the information systems needed to got to apply that to each and every patient and Paul Tang, M.D. create this change, will be required. to the community at large; and third, we’ve got The implications for healthcare leaders and to apply this information to the right policies. healthcare IT leaders are obvious, and most And what are the implications? Fortunately, importantly, this IOM report acknowledges the interconnect- we had this thing called HITECH [the Health Information edness of all the issues involved. Technology for Economic and Clinical Health Act] that has To sort through some of those issues, Healthcare Informat- given us a lot of the tools, and particularly the meaningful ics Editor-in-Chief Mark Hagland spoke with Paul Tang, M.D., use objectives. So the broad objectives of meaningful use are a committee member, regarding the implications for health- very well aligned with the goals of this report. For example, in care IT leaders. Tang is vice president and chief innovation the first group of recommendations, we have clinical decision and technology officer at the Palo Alto Medical Foundation, support as a key component of that group. a multispecialty group in Palo Alto, Calif., that takes care of And we’re moving towards a major emphasis on this infrastruc800,000 patients in a service area just south of San Francisco. ture, a big piece of which is the electronic health record [EHR], of Below are excerpts from that interview. course; because you have to capture all this information on the front line, and you can’t do that without an EHR. And in order to engage patients, not only should patients be able to access information, they should be able to contribute information—thus, the need for patient portals. HCI: Can you comment on the Stage 2 final rule requirement for patient engagement through patient access to and downloading of information, and the pushback on the part of the Centers for Medicare & MedALIGNMENT OF MEANINGFUL USE OBJECTIVES icaid Services (CMS) and Office of the National Coordinator Healthcare Informatics: To begin with, what seems particularly for Health Information Technology (ONC), against providers’ important about this report is that the committee is recommend- request for the elimination of that requirement? ing a broad range of continuous improvements to be tackled in Tang: Just to put that 10 percent now 5 percent requirement, concert, including patient safety and care quality improvement, into context 73 percent of our patients at Palo Alto Medical efficiency improvement and performance improvement, care Foundation are online with us; and in today’s world, 5 percent coordination, provider-community connectedness, and strategic is very achievable throughout the country. Now, 73 percent information technology implementation and leveraging. Is that a may not be achievable throughout the country, but that correct summation of the broadest goals in the report? statistic [the 5 percent requirement] just shows what can Paul Tang, M.D.: Yes, you got it absolutely right. This is why be done. The biggest progress takes place when physicians we started out two decades ago doing this; we didn’t have the personally encourage their patients to get online with them; same context that we do today, but even back in the 1980s, and the most common opportunity is during the patient we saw where our system was headed. For one thing, with all visit. It’s very easy for me to say to a patient when I’m giving the advances in medicine, in the literature, and in everything them their lab result, would you get online? It’s natural for else, doctors simply can’t keep up. And the result could be that them to say, yes, sure. The thing is, patients really love this people wouldn’t get optimal care, even while what we’re do- stuff, and get a lot out of it, and just having their informa-


32 October/November 2012 •

POLICY PERSPECTIVE tion online encourages them towards healthy behaviors. It’s really a try-it-you’ll-like-it technology, both on the patient and physician side. You do have to have a little kickstart, but it’s very worthwhile. HCI: The pioneering organizations in this country have all committed to continuous performance improvement and continuous learning, as recommended in the report. What are your thoughts on that? Tang: Well, the pioneering organizations in performance have all long ago committed to investing in the information technology needed to support their work, and invested their own money, long before HITECH. Unfortunately, when you talk about the folks whose organizations haven’t achieved that continuous learning state, it’s because they haven’t achieved the infrastructure they’ve needed. The pioneering organizations’ leaders spent the money, ahead of the curve, on the infrastructure, and then moved ahead and improved; that’s why we have that divide between types of organizations. That’s where HITECH comes in.

HAVE WE REACHED THE TIPPING POINT? HCI: Do you think that we’ve reached a turning point of awareness in our industry now, with regard to healthcare leaders’ realization of the need to engage in concerted,

coordinated performance improvement? Tang: Yes, I do. We’re reaching that tipping point on health IT now because of HITECH. But also, everyone is in touch and regularly uses a computer in their lives now, and is accessing information and knowledge. The cultures are being transformed for us because of the instant availability of data and information, and computing mobility is pushing us over that point. HCI: In the context of the report and everything we’ve discussed here, what should CIOs and CMIOs and their teams be doing right now? What are your personal recommendations? Tang: We talked a lot about the digital infrastructure in our report, so, first, get the EHRs and patient portals in place; because that is key to implementing a lot of the recommendations. The EHR and PHR [personal health record] are the foundation. Get the clinicians and patients to use them, and if you do a great job with meaningful use, you’ll be on your way to leveraging the tools. Meanwhile, the additional element that’s not in meaningful use is leadership. We’ve got to make sure that leaders understand how to use the tools and get the most out of them. So accelerate what you’re doing with the IT infrastructure, and really work at the culture of continuous improvement. ◆ • Healthcare Informatics 33




ike most people involved in the implementation of electronic health records and the journalists who write about them, I spent the evening of Aug. 23 poring over 600 very dense pages of Centers for Medicare and Medicaid Services (CMS) jargon to try to discern the flavor of the meaningful use Stage 2 final rule. My guess is that depending on your provider organization’s experience with Stage 1, you might have quickly scanned the index looking for specific topics such as “clinical quality measures” or “summary of care records” to see how you will be affected. But as someone who has followed the work of the Health IT Policy Committee pretty closely the last few years, I thought I would offer a first look at a few key items that CMS chose to alter from the proposed rule. (In cases where it finalized the proposed rule with no changes, CIOs sort of knew what to expect. My first impression is that it didn’t make as many alterations between proposed and final rule with Stage 2 as it did with Stage 1. In some cases it lowered thresholds from 10 percent to 5 percent, but I don’t see that as a huge shift. If you have to do something for 5 percent of patients, you still have to make the technology investment and make it work. So healthcare provider and vendor

34 October/November 2012 •

advocacy groups may not be too happy with the outcome.) Here are a few of the significant changes: Stage 2 Reporting Period: CMS will not delay Stage 2 until 2015, as some had suggested, but instead will use a threemonth EHR reporting period in 2014 as the first year any provider would attest to Stage 2. It agreed with comments that the use of a shorter EHR reporting period in 2014 is necessary to allow sufficient time for vendors to upgrade their technology and for providers to implement it. Patients View, Download, and Transmit their Health Information:  This is the one that drew the most negative comments from provider organizations. Many made the claim that they shouldn’t be held accountable for what their patients do. But CMS stuck to its guns, by insisting on the importance of making health information readily available to patients after a visit. It did acknowledge the difficulty of working with some patient populations by lowering the threshold from 10 percent to 5 percent. Providers will be scrambling to get their portal technology in place. Health Information Exchange Crossing Vendor and Organizational Boundaries: With the goal of furthering interoperability, the proposed rule sought to ensure that providers


were exchanging health data with users of other EHR vendor systems and with other organizations. But CMS decided that “making the determinations for the numerator was infeasible particularly in regard to the organizational and vendor limitations. Therefore, we are removing the organizational and vendor limitations from this measure

solely due to the burden of making these determinations for measurement.” Instead it will require providers to conduct one or more successful data exchange tests with a “CMS designated test EHR” during the EHR reporting period. Secure Electronic Messaging:  The proposed rule was to use secure electronic messaging to communicate with


more than 10 percent of unique patients on relevant health information. In the final rule, CMS lowered the threshold to 5 percent and added a “broadband exclusion” for rural areas with limited broadband access. Summary of Care Documents: CMS lowered the threshold

of medication orders be tracked using an electronic medication administration record (eMAR). But it also established exclusions for very small hospitals with inpatient census of fewer than 10 patients. “We are also concerned that very small hospitals may have local technical support and training issues that may make an automated eMAR solution actually less effective than other approaches. We also believe that very small hospitals will have fewer healthcare professionals involved in the process of medication administration and fewer patients for whom duplicative orders could present an issue, which would also make an eMAR solution less effective. Therefore, we believe these hospitals would not benefit from eMAR as much as larger facilities and are finalizing an exclusion for these hospitals,” it wrote. Medication Reconciliation: The proposal was to raise the measure on performing medication reconciliation during transitions of care to 65 percent. CMS noted that because most providers chose to defer this measure in Stage 1, and the lack of robust data in support of the proposed threshold, they lowered the threshold to 50 percent. CPOE:  CMS finalized the threshold for CPOE use in Stage 2 at 60 percent. It will also require that more than 30 percent of laboratory orders and more than 30 percent of radiology orders are recorded using CPOE. CMS also clarified that orders entered by credentialed medical assistants will count toward meeting this requirement. Clinical Quality Measures (CQMs): There’s a great deal of detail in the CQM section. One important point is that the proposed rule had called for hospitals to meet 24 CQMs beginning in 2014. CMS decided that would be too great an implementation burden and lowered the total to 16. It also will allow for group reporting by physician groups. ◆

MANY MADE THE CLAIM THAT THEY SHOULDN’T BE HELD ACCOUNTABLE FOR WHAT THEIR PATIENTS DO. BUT CMS STUCK TO ITS GUNS, BY INSISTING ON THE IMPORTANCE OF MAKING HEALTH INFORMATION READILY AVAILABLE TO PATIENTS AFTER A VISIT. —DAVID RATHS slightly from 65 percent in the proposed rule. In the final rule, 50 percent of transitions of care must involve sending a summary of care record. eMAR: CMS finalized the rule that more than 10 percent

36 October/November 2012 •

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he  Healthcare Informatics  Innovator Awards Program reaped a cornucopia of outstanding submissions in 2012. Indeed, the editors at  HCI  concluded that every semi-finalist entry was worth coverage, given the very high level of quality of the entries in this successful program, whose goal has been to highlight team-based achievements in informatics work in patient care organizations nationwide. One of the semi-finalist teams this year was the Patient Census Dashboard Team at the Minneapolis-based Allina Health. The 11-hospital, 90-plus-clinic, 24,000-employee, 5,000-physician Allina organization is already nationally known for its innovations in many areas of patient care delivery and operations. With regard to the organization’s Innovator Awards program submission, in 2011, staff from Allina’s Performance Resources department convened an interdisciplinary team from 10 hospitals to understand the barriers to coordinating care for patients with complex needs. The team learned of a desperate need to assist clinicians in the identification of patients at higher risk for readmission. As it turns out, clinicians were spending hours finding these patients, who require an interdisciplinary approach in order to achieve a successful transition from the hospital to the postacute setting. The team began work on designing a case-finding tool to quickly identify these patients and assist in convening the care team to create a transition plan. What was needed, the leaders of the team decided, was a tool that could quickly identify these patients while they were still in the hospital and could provide instant access to real-time clinical information and summarized key healthcare resource utilization measures for each patient. Those measures would include indicators such as how frequently a patient has visited a hospital in the past 30 days, a count of total emergency department visits in the prior year, and how many different medications a patient might be taking. 38 October/November 2012 •

After months of work on this project, the ultimate result was the Patient Census Dashboard, a business intelligence application developed internally at Allina using QlikView business intelligence technology, which provides users with an intuitive, interactive environment in which to explore these types of data points. The tool leverages established and prior investments in the organization’s electronic health record (EHR), enterprise data warehouse (EDW), and business intelligence tools. Given those advantages, the Allina team members were able to produce the tool with nominal effort and no cost in additional hardware, software, or professional services. The tool is now being used widely by Allina clinicians. HCI  Editor-in-Chief Mark Hagland recently interviewed members of the team that developed the Patient Census Dashboard. Present at the interview were the following Allina leaders: Michael J. Doyle, manager of the enterprise data warehouse; Penny Wheeler, M.D., chief clinical officer; Susan Heichert, R.N., vice president, health information systems and CIO; Karen Tomes, R.N., director of quality improvement and care management; and Jason Haupt, Ph.D., senior statistician. Below are excerpts from that interview.

GOAL: BETTER OUTCOMES FOR THE COMMUNITY Healthcare Informatics: What was the strategic impulse behind this initiative? Penny Wheeler, M.D.: We are very much on the path of, and feel that it’s our civic duty to transform healthcare for our community. All of this is about getting away from the traditional revenue generation, providing the most care to the most people, and getting towards quality-based care delivery. It’s really about pushing that Queen Mary of healthcare into a more positive direction to demonstrate that we can deliver superb outcomes to our community. For example, we’re a pioneer ACO [accountable care organization, as part of the federal Medicare Shared Savings Program].

POPULATION HEALTH PERSPECTIVE And data is really something that needs to be aggregated to help us do the right thing; and we’re really on the forefront of using some of those tools to accomplish those things. Susan Heichert, R.N.: We’ve made significant investments not only in our EHR, but also in data warehouses and other tools, and our goal is to use those tools to improve care delivery and outcomes. Karen Tomes, R.N.: The exciting outcome of this project is that the clinicians designed it, and also gave us feedback into what needs to happen in the current state, to help them succeed in terms of care transitions. The exciting part of this project was listening to clinicians, including physicians, nurses, pharmacists, case managers, and social workers. Michael J. Doyle: The investment that Susan talked about that Allina has made in infrastructure for performance measurement has really made this possible in a way that wouldn’t have happened otherwise. Second, it was an extremely gratifying project; we worked very closely with our clinicians, and it helped the front-line clinicians understand that we’re not too far removed from their concerns. It was really neat; it was very much not a “request a dashboard and we’ll build it” kind of situation; it was collaboration. Wheeler: We’ve got a ways to go, like everyone else. But when people visit and see these tools, their jaws drop; and we’ve got

something very precious here that we’re using on behalf of our community.

LESSONS LEARNED HCI: What have been the revelations and learning so far around the leveraging of IT? Tomes: I think the patient story is so intuitive in this tool, that the way it was designed has meant it takes very little training to use. It actually takes more training just to make a few clicks to get to the tool—and once you open it up it is so intuitive in terms of accessing data on the patient. The other great benefit is that this crosses the entire continuum of care. We started new relationships, quite honestly, using this tool. We still have opportunities to build on that concept. Formerly, it had been relatively hard to find information in the record; now, the entire care team across the continuum can easily find that information. Heichert: I would add, from an organizational perspective, I think it’s important that, as we’re putting in our electronic record, that’s not going to be the be-all and end-all for everything. You try to use the functionality and work with the vendor and all that, and that’s great. But at some point now, we’re starting to have to go faster and faster and faster. It’s been kind of a revelation that we can kind of figure out some of this ourselves. If

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Background on Allina Health’s Patient Census Dashboard Initiative: Organization: Allina Health, an 11-hospital, 90-plus-clinic, 24,000-employee, 5,000-physician integrated health system based in Minneapolis-St. Paul, Minn. Initiative: Patient Census Dashboard Team. Go live: Rolled out in late 2011, into early 2012. What the Patient Census Dashboard is: A business intelligence application developed internally at Allina, using QlikView business intelligence technology, and providing users with an intuitive, interactive environment in which to assess the status of patients at higher risk for readmission. Key existing information systems leveraged: Allina’s electronic health record, enterprise data warehouse, and business intelligence tools.

infrastructure should report up through the clinical reporting structure in the organization. That keeps it aligned to what Susan said is our core business. Make sure that the people who are using the tools are co-designing those tools. A big lesson learned, too, is, meet the clinicians where their passion lies. If you have a group of clinicians ready to run on, say, reducing heart failure readmissions, then dig in deep with them. Tomes: I would add that a CIO should bring clinicians in and shoot for the sun; give them that permission to dream. Sometimes, they’ve been working in an environment where they’ve been adapting to the current environment. Allow them to dream.


HCI: What has been most challenging for you so far in all this? Heichert: What’s most challenging is the frustration with having all of this data and not having great tools Results: Clinicians and researchers at Allina can now display a list in the past; I’m thinking maybe five years ago. We didn’t of patients and several key healthcare utilization metrics, including number of visits within the past 30 days, number of times seen in the have those tools. And it would be great if things were a emergency department within the past 12 months, cross-referenced lot more intuitive. We do have some limitations in that as desired with current or historical coded or clinical diagnoses, presregard. And frankly, things are very expensive; it does ence or absence of a primary care provider, current location within require an investment on the part of the organization; the hospital, etc., making readmissions risk assessment an automated and not every health system has as much capital to and highly searchable process. invest as we do. Doyle: We couldn’t have done the work we’ve done you can get these fantastic people together with the clinicians, without Susan and Penny setting up the culture to innothey can figure things out, and [make things operational]. vate towards success. Let me give you an example: a lot of this We’re learning that we need to be a little bit open-minded started because we had a data feed that went to the EDW, on about what tools to use and how to use them, and we need a shared drive, a couple of times a day. We realized that with a to be willing to fail a bit in order to learn. We have to allow little more effort, we could get that feed going every hour, but ourselves to be a little bit more adventurous in that. we had to work more closely with IT. And once we got that HCI: What kinds of lessons learned could you share with developed, we were on the path. fellow CIOs? HCI: Another possible lesson here is that one’s organization Heichert: Well, it does help that I have a clinical background. has to be willing to invest in the technology, too, correct? But it’s been Karen and Mike who’ve been doing the work. They Doyle: Yes, and these really are great multi-purpose tools. A come to me and say, here are some tools and technologies that great carpenter has to invest in a great table saw, and a great we can work with, and what do you think? Certainly, we say, set of wrenches, for example. In a similar way, Allina made the you have to make the business case for what we’re doing. We choice to invest in a great BI technology; it’s not a healthcaredon’t want to harm the infrastructure with this. Mike pushes specific BI technology. Our organization’s leaders also were the envelope a bit, but these are the challenges we need to take willing to invest in general tools at a time when we couldn’t on, or we can’t change the way we do things. find the healthcare-specific tools we were looking for at that HCI: What do non-clinician CIOs need to do? time, so we repurposed broader tools. Heichert: Well, it’s not earth-shattering; it’s something we’ve HCI: How hard is this, on a scale of 1 to 10? known for a long time: that CIOs need to know the business Doyle: If you had no EHR, it would be a 10; if you had no that their organization is in. CIOs need to knock on people’s enterprise data warehouse, it would be a 9. But given the fact doors and follow them around, and learn. that we have both means that it’s not technically difficult; Wheeler: I want to underscore something that Susan said, it’s something like a 2 or 3, if you have people trained on the and something that Mike and Karen said: that they got very tools like QlikView, Cognos, or BusinessObjects. You get down deeply involved with the clinicians from the outset, and that’s to that 2 or 3 because of the investment you’ve made in the very important. Another element is that all of this clinical IT culture, the EHR, and the data warehouse. ◆ Additional resources consumed: No additional hardware, software, or professional services consulting costs were incurred.

40 October/November 2012 •

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fter a win with the Atlantic City Special Care Center, new culture, new profits, new payment models.” primary care physician turned population health One practice, the Culinary Extra Clinic, opened this Janupioneer Rushika Fernandopulle, M.D., is replicating ary in Las Vegas serving the hotel and restaurant workers its care model of intensive primary care management ser- who participate in the Culinary Health Fund, and a month vices, aligned incentives, and actionable analytics, across later, Iora opened Dartmouth Health Connect, a joint practhe country. His guiding principle is to target the small tice with Dartmouth College and Dartmouth-Hitchcock in group of patients who generate the most healthcare costs, Hanover, N.H. Another practice will be opening this fall in and treat them using a global budget, rather than fee-for- downtown Brooklyn with the Freelancers Union, and one is service infrastructure. being planned for Boston. “We have fidelity to the design, and quite frankly, I think its franchisable,” says Sandy Festa, administrative director, TEAM-BASED CARE AtlantiCare. “There’s a method to how much space we need, The Special Care Center operates on the principle of focusing how many staff we need, the routine of actions that occur that on the small group of patients with an average of two chronic conditions—invited by predicitve analysis or does increase the replicability of this design.” through an application process—who generFernandopulle, who was the first executive ate a bulk of the costs. The Center has grown director of the Harvard Interfaculty Program its patient population to 2,500 and operates for Health Systems Improvement, co-founded with two full-time physicians and one nurse the Boston-based Renaissance Health and practitioner, with specialists on retainer. launched the Special Care Center in July 2007 These professionals are complemented by a as a pilot for 1,200 high-cost chronic patients. mix of nurses, nutritionists, and mental health Renaissance Health partnered with the two professionals who act as health coaches to enlarge self-insured companies in Atlantic City, gage patients on multiple levels. HEREIU Fund, a large trust fund for casino “We spent a lot of time focusing on teamworkers, and AtlantiCare Health System, a based care,” says Fernandopulle. “If you want to Malcolm Baldrige National Quality Award help people, particularly with chronic diseases, winner (the nation’s highest Presidential honor for innovation and excellence), to pro- Rushika Fernandopulle, M.D. engage in their health and improve their diseases, it’s a lot of hard work in what you track vide better health outcomes and lower costs. Fernandopulle, who was profiled last year by surgeon, and what you eat, and instead of depending on doctors to do writer, and public health researcher Atul Gawande in The all that, we hire health coaches, who are from the communiNew Yorker, has since launched the Cambridge, Mass.-based ties, speak their language, and live their life.” This high intensity care has yieled results like high Iora Health to create more of these high engagement primary care practices. “Our goal is to build three or four of these satisfaction rates and reduced admissions, ED visits, and [practices] this year in very different settings to see how the procedure rates. Patient satisfaction HCAHPS scores for model works in different places,” says Fernandopulle. “Four access and timeliness to treatment have improved 30 to different populations, different sponsors, and starting from 40 percent, largely due to the Center’s same day/sick day scratch to do primary care very differently—hire new people, policy and longer than average appointments. 42 October/November 2012 •

CHRONIC CARE PERSPECTIVE REPLICATING THE MODEL ACROSS THE U.S. Culinary Extra Clinic Las Vegas, Nev. Partners: Culinary Health Fund Opened February 2012

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The Center outperforms national indicators on diabetes, chronic obstructive pulmonary disease (COPD), and cardiovascular patients, and Fernandopulle notes that more than 90 percent of diabetics were under control and had an A1C below 9 percent while he was medical director during the first two years. Festa adds that even now all the Center’s 889 diabetics have a current A1C logged. An onsite pharmacy and an electronic reminder system for pharmacy refills contribute to a 98-percent medication fill rate. In turn, the Center’s readmission rate of 3 to 6 percent is much lower than the national average for 30-day readmission rates of 16.1 percent ( for Medicare patients in 2009).

ALIGNED INCENTIVES AND IT INFRASTRUCTURE Instead of employing a fee-for-service model, these primary care practices develop a global budget or a flat rate per member per month. Partnerships are made with selfinsured groups to share costs of operation, and all staff receive bonuses for improved quality. Patients receive waived office visits and prescription copays to join. The Special Care Center started with two payers and has grown its partnerships to nine insurers that now include Horizon Blue Cross Blue Shield of New Jersey and the Medicare Advantage plan. Festa says that due to this model, the average patient’s healthcare spend decreases by 12 percent after the first year of care. The Special Care Center is now looking at other disease states to target that could possibly include a medical home

bundle for cancer care or infectious disease. “It’s about reducing the gaps to seamless transitions,” adds Festa. “We’re stiching up the seams so to speak.” The Special Care Center has always been electronic and uses an electronic health record (EHR) from the Westborough, Mass.-based eClinicalworks. What Fernandopulle and his colleagues recognized early on, though, was that an EHR by itself would not be enough for population health management. Subsequently, a standalone registry (provided by DocSite, now the Detroit-based Covisint) was installed, which AtlantiCare is now mounting in all of their ambulatory practices. Because of the difficulty of tailoring EHRs and registries and “after getting tired of beating our head against the wall,” Fernandopulle and his team decided to build their own homegrown IT system for Iora Health primary care practices. “Building software in 2011 is not as hard as it used to be,” he adds, “and we can build software that really does what we want to do.” Iora Health has since built a native web app in the cloud using agile software development with a development team making iterations every two weeks. “The focus unfortunately on most EHRs is how do I bill a code higher,” says Fernandopulle. “That is the sort of business model of a typical practice. [EHRs] are very fancy cash registers with a bunch of clinical stuff laid on it. At Irora, we don’t need any of that. We don’t do any billing. We wanted a system that would enable us to better manage a population.” ◆ • Healthcare Informatics 43




he Center for Medicare and Medicaid Services (CMS) on Aug. 22 announced a  roster of 500 primary care practices  in seven regions that will participate in its Comprehensive Primary Care Initiative, a public-private partnership to strengthen primary care. The initiative includes participation by CMS, state Medicaid agencies, commercial health plans, self-insured businesses, and primary care providers. Under the initiative, CMS will pay primary care practices a care management fee, initially set at $20 per beneficiary per month, to support enhanced coordinated services on behalf of Medicare fee-for-service beneficiaries. At the same time, participating commercial, state, and other federal insurance plans are also offering enhanced payment to primary care practices to support high-quality care for their practices. The initiative started in the fall of 2011, when CMS solicited a pool of commercial health plans, state Medicaid agencies, and self-insured businesses to work with Medicare to support comprehensive primary care. Public and private health plans in Arkansas, Colorado, New Jersey, Oregon, New York’s Capital District-Hudson Valley region, Ohio, and Kentucky’s Cincinnati-Dayton region, and the Greater Tulsa region of Oklahoma signed letters of intent with CMS to participate in the program. The markets were selected in April of this year, based on the percentage of the total population covered by payers who expressed interest in joining the partnership. Practices were invited to participate and start delivering enhanced healthcare services this fall. The practices were chosen in a competitive selection process, based on their use of health information technology, the ability to demonstrate recognition of advanced primary care delivery by 44 October/November 2012 •

selected clinical societies, service to patients covered by participating payers, participation in practice transformation and improvement activities, and diversity of geography, practice size, and ownership structure. At a conference call announcing the selection, Richard Gilfillan, M.D., director of the Center of Medicare and Medicaid Innovation at CMS, said the focus of the initiative was to provide better primary care, resulting in improved health and lower costs. The primary care practices selected in this latest stage of the initiative represents “over 2,000 doctors, nurse practitioners and other physician extenders, serving 300,000 Medicaid beneficiaries, and hundreds of thousands more people who have private health insurance or coverage through Medicaid or the states’ health insurance program,” he said. “The initiative aligns our resources to one goal: better health, better care and lower costs to improvement,” Gilfillan said. To do that, “we have to look to the front-line doctors and nurses and support them and give them the tools they need to deliver better care,” he added. “With the aligned approach of Medicare, Medicaid, private insurers, and large self-insured employers, we can no longer penalize doctors for spending extra time with patients, but reward them for spending extra time with patients, coordinating with the specialists, managing medication, or taking the time to sit down with a patient to develop a plan to help a patient to lose weight or manage their cholesterol or blood pressure,” he said. “In this partnership, all doctors’ payments, not just Medicare payments, will compensate them for being accessible after hours, for fully coordinating electronic health records into their care coordination efforts, instead of simply doing more procedures and more tests.” He added that for patients, this will


Participating Primary Care Practices

Arkansas: Statewide 66 primary care practices 228 providers 4 payers Estimated 51,000 beneficiaries served

Colorado: Statewide 73 primary care practices 335 providers 9 payers Estimated 41,000 beneficiaries served

Ohio and Kentucky: Cincinnati-Dayton Region 75 primary care practices 261 providers 10 payers Estimated 44,500 beneficiaries served

New Jersey: Statewide 73 primary care practices 252 providers 5 payers Estimated 42,000 beneficiaries served

Oklahoma: Greater Tulsa Region 68 primary care practices 265 providers 3 payers Estimated 45,000 beneficiaries served

New York: Capital DistrictHudson Valley Region 75 primary care practices 286 providers 6 payers Estimated 40,500 beneficiaries served

Oregon: Statewide 70 primary care practices 517 providers 6 payers Estimated 49,000 beneficiaries served

Source: CMS

mean valuable extra time with their doctors to talk with them on how to lead healthy lives and take care of their chronic conditions.

MEASURING SUCCESS Gilfillan said CMS sees great potential [once the initiative gets started in October] to begin testing how the model works and when they see causal results, to be able to spread it broadly across the country. He said success will be determined by a set of quality metrics similar to those used to measure the success of accountable care organizations. Total cost of care of services such as ED visits and hospitalizations will be evaluated, as will be satisfaction surveys by beneficiaries receiving treatment from the primary care practices. According to Gilfillan, the $20 reimbursement figure will gradually decrease to $15. “That provides coverage for a set of services that can deliver the kind of outcomes we are after. Net invest-

ment will be on the order of $300 million over three and a half years, and we think there will be a positive return,” he said. He added: CMS needs to demonstrate that this model improves or maintains care quality and results in decreased expenditures, noting that the significant patient population CMS has identified will serve as a realistic test over the next 18 to 24 months before it expands the program nationally. Participation of public and private insurers in the selected markets was a critical selection criterion. “We looked for effective participation from other insurers, and the distribution of practices,” Gilfillan said. Another selection criterion was practices that had fully implemented electronic health records. “This will be a well-identified community, one of the largest with full electronic health capability, with a lot of interesting analysis to understand what EHRs bring to the effort,” he said. • Healthcare Informatics 45

PHYSICIAN PRACTICE PERSPECTIVE A PRACTICING PHYSICAN WEIGHS IN One physician who is participating in the initiative is Stacy Zimmerman, M.D., an internal medicine and pediatrics physician from Clinton, Ark., who is a practitioner at Ozark Internal Medicine and Pediatrics. Zimmerman has recently converted her practice to a patient-centered medical home (PCMH), following a two-year pilot project. The PCMH concept embodies many of the goals of the CMS initiative. “When I started my practice nine years ago, I was motivated to improve healthcare in an underserved area,” she said. It wasn’t long before she was bogged down in patient charts. While she purchased an electronic health record, she found that even a great computer program could not instantly fix everything or make her patients well.  “It became obvious that the health and welfare of my patients depended on a partnership between the patients, the physician, and the healthcare team.” This was the foundation of the transition of her practice to patient-centered care, she said. She outlined some results of the transformation: • Same-day open access for her patients. If patients are sick, they can get same-day appointment, no exceptions. • The practice’s website offers a secure portal access for the patients to connect with their electronic medical record and access their chart. They can request appointments,

patients can find condition trackers such as blood sugar trackers, can record their home readings, send the results directly to their charts through the portal, along with an alert to the doctor to review those results. Zimmerman said that since implementing these features, the practice has seen “a marked decrease in ED visits and a marked decrease in the hospital readmission rates compared to other clinics in its geographic area.   This model demonstrates how a clinic can decrease healthcare costs.”

A HEALTH PLAN’S EXPERIENCE John Bennett, M.D., is president and CEO of the Capital District Physicians’ Health Plan (CDPHP), a health plan located in upstate New York, which is a participant in the initiative. Five years ago, the CDPHP board of directors came up with a directive to save primary care. “The local medical school was no longer graduating and sending significant numbers of physicians to choose primary care as a career,” he said. CDPHP launched its Enhanced Primary Care Initiative, which uses the PCMH features of patient-centered care and combines it with a global payment model, he explained. “It allows primary care physicians to be rewarded for better health, better care, and lowering costs,” he said. The initial pilot of three practices has been successful. An independent analysis of its Enhanced Primary Care Initiative showed per member per month savings of $8 per member per month, resulting from a 9 percent reduction in emergency room visits and a 15 percent reduction of inpatient admissions, he said. He added that as a regional payer, CDPHP participates in all lines of business, both commercial and New York State funded and federally funded Medicare Advantage plans. “We found this [to be] true of the population as a whole,” he said. As a result of that, the health plan’s Enhanced Primary Care Program is thriving, and it will soon cover close to half of all 400,000 CDPHP members within the next year, he said. An example of its success from a population health level, was an Albany, N.Y. practice whose physicians have achieved a drastic improvement in blood glucose levels in their diabetic patients, as measured by their hemoglobin A1C levels, he said. He said that as a regional plan, CDPHP has engaged the local business community by introducing a Shared Health product portfolio that rewards employers to promote healthy lifestyles and behaviors. “We believe that better health and better care leads to lower costs, and we are seeing it every day,” he said. ◆

WHEN I STARTED MY PRACTICE NINE YEARS AGO, I WAS MOTIVATED TO IMPROVE HEALTHCARE IN AN UNDERSERVED AREA. IT BECAME OBVIOUS THAT THE HEALTH AND WELFARE OF MY PATIENTS DEPENDED ON A PARTNERSHIP BETWEEN THE PATIENTS, THE PHYSICIAN, AND THE HEALTHCARE TEAM. —STACY ZIMMERMAN, M.D. refills, referrals, and email their doctor. The functions also allow messages to be routed to the correct individual, bypassing the receptionist, thereby improving efficiency and response time. • The clinic operates in a real-time system. At the end of the visit, when the doctor signs off on a visit note, a visit summary is triggered and is sent to a patient’s email along with patient information materials; prescriptions are electronically sent to the pharmacy; referrals and orders are sent to the staff, and the chart is sent to the billing module. All of the functions are done when the patient exits the exam room. • The practice uses its Facebook page to reach out to patients with announcements and health tips. It has developed educational modules and tools on its website. There, 46 October/November 2012 •

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ADVERTISER ...........................................PAGES Aetna, Inc.................................................................. 7 AFC Industries ........................................................ 13 Amcom Software ................................................... 19 Anthro Corporation ................................................. 5 athenahealth .................................................... 24, 25 Bright House Networks, LLC ................................. 41 Carstens, Inc. .................................................... CVR 3 Fujitsu Computer Products of America .................11 GCX ............................................................. 31, 33, 35 Ignis Systems ................................................... CVR 4 Infor......................................................................... 29 InterSystems Corporation ....................................... 1 Mountain States Health Alliance .......................... 39 NetApp.................................................................... 15 Sedona Learning Solutions ............................ CVR 2 SSI Group Inc., The .................................................. 3 Suntrust Wealth...................................................... 37 • Healthcare Informatics 47




oing to an interview can be a very stressful and trying exercise for many people. We are all wired differently, and while some of us thrive in an unknown setting—others simply cringe at the thought of crossing the vestibule into unfamilar territory. I like to relate it to how I feel when I arrive at my doctor’s office. I’m fine in the car, but as soon as I enter the waiting Tim Tolan room I start getting stressed, and by the time I’m in the exam room, I’m, well, very stressed. I think it’s called “white coat syndrome.” (Well there’s a bit of personal health information about me I’m happy to share with all of you!) For me, being nervous is all about the unknown, especially when I am subjecting myself to someone who will totally control the visit while I listen and learn. Believe it or not, some candidates react the same way. Try these actions to calm your nerves during an interview so you can put your best foot forward. Meet your interviewer with a strong handshake and smile, and find a way to enjoy the fact that you finally made it to the face-to-face part of the interview process. It’s a step in the right direction. You are definitely on base—so make it count. Make sure you’re prepared for your interview and that you know your audience or the organization by performing your due diligence well in advance of your arrival. I talk about this all the time—preparation is the best way to demonstrate how serious you are about this interview and opportunity. Winging it never works. Never! Breathe. Oxygen is a very important component if you want to be able to relax during an interview. A few deep breaths will help keep the nerves at bay and your mind 48 October/November 2012 •

sharp. Make sure you pause for those necessary deep breaths before you enter the building to help kickstart the calming of your nerves. If the interviewer is not wearing a suit and you are, ask if you can remove your jacket. This will make you more comfortable and will help take down the wall between you and the person you are meeting. It will also allow you to relax a bit more. Have five or six well thought-out, open-ended questions to ask the interviewer once you are given the chance or to fill in any pauses during the interview. Have your attaché case so you can read your questions or notes, and make sure you write down (in shorthand) their answers so you can reflect on them afterwards. Make sure your body language is sending the right message to your audience. Eye contact is very important, as is displaying your emotions with an occasional smile or a chuckle (if the topic warrants that emotion). What they see should offer a glimpse of who they will be working with once you are on-board. Candidates who want to make an excellent first impression in a face-to-face interview need to show their real human side. If you are generally not tense and stressed, find strategies to eliminate those physical dynamics from your audience. Be who you are and not who you think your audience wants you to be. You will be happier not trying to be someone else, and they will get a better sense of how it will be working with you on a full-time basis. Lose the nerves and build your confidence, and you will know you’re going to have an excellent interview. Make a decision to have an excellent interview in advance of walking thought the door. Attitude really matters. Now…Go knock ’em off their feet! ◆ Tim Tolan is a senior partner at Sanford Rose Associates Healthcare IT Practice. He can be reached at [email protected] or at (843) 5793077 ext. 301. His blog can be found at tim_tolan.