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ePrescribing: Lost in Transmission?

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March 2012

Volume 29, Number 3


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This month’s Top Ten Tech Trends cover story package provides a comprehensive look at the most important developments now taking place in healthcare that have been set in motion by healthcare reform and meaningful use mandates—and which will help reshape healthcare over the next several years.
























GETTING ANALYTICAL How a South Florida medical specialty group found success managing revenue and reimbursements around complex legal issues BY MARK HAGLAND



THE DIABETES DASHBOARD Researchers at the University of Missouri have developed a tool that can help physicians fully assess diabetes patients with a few simple clicks BY GABRIEL PERNA SURGICAL IT PERSPECTIVE


PERIOPERATIVE SUITE RIPE FOR IT INVESTMENT Many healthcare C-suite executives reveal that a majority plan to reduce costs and make enhancements to their perioperative area in the next year, according to a recent survey BY MARK HAGLAND IMAGING UPDATE


PACS IN THE CLOUD, PLUS RADIOLOGY How one Nevada community hospital used a cloud-based PACS and radiology solution to meet the needs of its physicians while saving costs BY MARK HAGLAND ePRESCRIBING UPDATE


ePRESCRIBING: LOST IN TRANSMISSION Despite benefits, ePrescribing still faces hurdles around physician practices and pharmacies, according to a recent study BY GABRIEL PERNA CAREER PATHS


BUILDING A SUCCESSFUL (REMOTE) TEAM Advice for keeping your far-flung employees as integral members of your IT team BY TIM TOLAN

✪ SPECIAL REPORT: 2011 BEST IN KLAS ✪ A TIME OF CHANGE Concerns over federal mandates is a key issue for CIOs as they ponder choices for clinical, financial and administrative IT investments

Healthcare Informatics (ISSN 1050-9135) is published monthly by Vendome Group, LLC, 6 East 32nd Street, 8th Floor, New York, NY 10016. Periodicals postage paid at New York, NY and additional mailing offices. POSTMASTER: send address changes to HEALTHCARE INFORMATICS, P.O Box 2178, Skokie, IL 600767878. Subscriptions: For questions or correspondence about a subscription, phone 847-763-9291 or write to HEALTHCARE INFORMATICS, PO Box 2178, Skokie, IL 600767878. If you are changing your address, please enclose entire mailing label and allow 6 to 8 weeks for change. Subscription rate per year (U.S. Funds): U.S. $58.00; Canada/ Mexico $82.00; all other countries $109.95 (includes air delivery). Single copy rate (U.S. Funds) except September and January: U.S. $8.00; Canada/Mexico $12.00; all other countries $15.00. September 100 and January Resource Guide: $50.00 (U.S. Funds) includes shipping/handling to all countries. Add state and local taxes as applicable. 2 March 2012 •

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Top Ten Tech Trends


his issue’s Ten Top Tech Trends cover story package, which begins on page 8, comes at a time of great excitement as hospital CIOs and other top executives respond to a range of healthcare reform and meaningful use mandates that are reshaping the face of healthcare. What will that future look like? To find out, HCI’s editorial team interviewed top healthcare experts, who provide commentary on the most important developments: Performance Imperatives—Editor-in-Chief Mark Hagland looks at why healthcare leaders are recognizing the need to use formal methodologies to systematize change; Population Health Management and Readmissions—Assistant Editor Gabriel Perna describes how pioneering provider organizations are strategizing to help prevent readmissions; Turning Healthcare’s Business Model Inside Out—Associate Editor Jennifer Prestigiacomo examines how ACOs are creating new business and infrastructure models; Bridging the Care Transition Gap—Managing Editor John DeGaspari looks at how healthcare reform is driving change in this key area; Second Generation Clinical Decision Support—Hagland tells how healthcare IT leaders are rethinking clinical decision support; Year of the CISO—Senior Contributing Editor David Raths on how the regulatory spotlight is raising the profile of chief information security officers; Private HIEs on the Upswing—Prestigiacomo examines the growth of private and payer-fueled health information exchanges; Imaging Informatics and the Enterprise—Perna tells why the proliferation of digital images is resulting in the need for enterprise-wide solutions; The BYOD Revolution—Raths looks at how the “bring your own device” trend has IT departments scrambling to develop mobile tech policies; The Game Changer—Raths examines how the convergence of genetic medicine and EHRs will bring genetic medicine to the point of care. MORE ONLINE: Podcasts of interviews with the top four Healthcare Informatics’ Innovator Award Winners. Also: top three recommendations for Stage 2 meaningful use; evidence-based quality improvement at Ascension Health; a peek at the ACO crystal ball; leveraging the EMR for clinical research; improving stroke care outcomes, and managing imaging informatics in a multispecialty group practice setting. Visit us at for more.

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

4 March 2012 •

Christopher Longhurst, M.D. CMIO, Lucile Packard Children’s Hospital, Clinical Assistant Professor of Pediatrics, Stanford University School of Medicine, Palo Alto, CA Chuck Podesta SVP and CIO, Fletcher Allen Health Care, Burlington, VT Stephanie Reel Vice President and CIO, Johns Hopkins Health System, Baltimore Wes Rishel VP and Research Area Director, Gartner Healthcare, Industry Research and Advisory Services, Alameda, CA Benjamin M.W. Rooks Principal, ST Advisors, LLC, Evanston, IL Rick Schooler Vice President and CIO, Orlando Health, Orlando, FL Patricia Skarulis Vice President and CIO, Memorial Sloan Kettering Cancer Center, NY Lynn Witherspoon, M.D. System Vice President and CMIO, Ochsner Health System, New Orleans

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] ASSOCIATE EDITOR Jennifer Prestigiacomo [email protected] ASSISTANT EDITOR Gabriel Perna [email protected] SENIOR CONTRIBUTING EDITOR David Raths [email protected]

SALES GROUP PUBLISHER MIDWEST & WEST COAST ACCOUNTS Nicole Casement [email protected] 212-812-8416 REGIONAL ACCOUNT MANAGER, EAST COAST SALES Michael A. Moran [email protected] 212-812-8417 PROJECT MANAGER, DIRECTORIES/SPECIAL PROJECTS Libby Johnson [email protected] 216-373-1222


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CORPORATE CHIEF EXECUTIVE OFFICER Jane Butler EXECUTIVE VICE PRESIDENT Mark Fried CHIEF FINANCIAL OFFICER Mike Muller 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.

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’ve found it fascinating reading Googled: The End of the World as We Know It, a 2009 book by Ken Auletta, an author and journalist perhaps best-known for penning the “Annals of Communications” column for The New Yorker since 1992. What Auletta does so well in reporting on the rise of Google is to avoid the usual tack of simply telling a corporate narrative, and instead, not only tells truly interMark Hagland esting anecdotes and behind-thescenes stories, but also supplies the intelligent questions and analysis that make the book a very worthwhile read. Most of all, he puts the story of Google’s development into a very understandable context, without the usual hype. Particularly illuminating is the first chapter, “Messing with the Magic,” in which Auletta relates the story of a visit in June 2003 by Mel Karmazin, the CEO of Viacom, to the Google headquarters in Mountain View, Calif. Like virtually everyone else in the media and communications world, Karmazin was well aware of the already-rocketing success of Google at that point; and he had asked for an exploratory meeting with Google uber-leaders Sergey Brin, Larry Page, and Eric Schmidt. The bottom-line question: did an “old media” corporation like Viacom and a new media whiz-kid company like Google have something of value to offer to each other? As it turns out, Karmazin found it nearly impossible to get his head around the reality of Google’s business model, particularly the way in which it used a combination of information technology and metrics-based viewership accounting to automate new ways to determine advertising rates, something essentially nonexistent in the old media world. Indeed, Auletta notes that, “[U]nlike traditional analog media companies, which can’t measure the effectiveness of their advertising, Google offered each advertiser a free tool: Google Analytics, which allowed the advertiser to track day 6 March 2012 •

by day, hour by hour, the number of clicks and sales, the traffic produced by the keywords chosen, the conversion rate from click to sale—in sum, the overall effectiveness of an ad,” along with “a tantalizing trove of data” that has been giving advertisers levels and types of data never before available in any systematic fashion. Not surprisingly, all this has made Google what Auletta calls a true “disrupter” company, one that has changed paradigms of concepts and activity. Yet as always, early on, it takes people a while to understand that fundamental change has occurred when a disruptive force comes into any field. It’s not difficult to see parallels between the rise of Google and some of the paradigm shifts taking place in healthcare these days. In fact, paradigm shifts are taking place all across healthcare right now. There’s the shift away from a sole focus on one physician and one patient and towards a broader, population health management, perspective; from “one-off ” attempts at tackling specific patient safety and care quality problems, to systematic approaches that apply formal performance improvement methodologies to organization-wide performance; from departmental image and data storage solutions to enterprise-wide, vendor-neutral repository solutions; and so on. You can read in detail about these paradigm shifts in this issue’s “Top Ten Tech Trends” cover story package. Our editorial team has interviewed industry thought-leaders and pioneering healthcare leaders to learn their perspectives on the paradigm shifts sweeping us all into the future. Given all that has happened in the last several years, it’s both exciting and bracing to ponder what could take place in the next several. Keep your hats on, readers! It won’t be “the end of the world,” but it will certainly be a doorway to an emerging new one.

Mark Hagland Editor-in-Chief

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8 March 2012 •


A Time of Exhilaration and Anxiety T

hose who have had the opportunity to learn how to ski will vividly recall the first few times they took the ski lift to the top of the hill, got off the lift, and prepared to hurtle down the hill on two long pieces of fiberglass-and-aluminum hooked to their ski boots. There is that unmistakable sensation of both great exhilaration and anxiety, as one pushes off and begins the true schuss down the slope. Something akin to that push-off sensation is being felt in patient care organizations across the country, as their leaders move forward these days to respond to a plethora of healthcare reform- and meaningful use-related mandates, and the seemingly limitless welter of choices that healthcare leaders face as they navigate this emerging world. Open- or closed-health information exchange? Vendor-supplied or self-developed order sets? Allow physicians to bring in their own devices, or provide devices to them? What kind of enterprise-wide image sharing and storage? How to architect one’s information systems to achieve true case management, care management, and population health management? Which performance improvement methodologies to use in order to speed change? And of course, all of these decisions must be made in an operating environment that is more demanding, and changing more rapidly, than ever before. It is in that context that we offer our readers Healthcare Informatics’ Top Ten Tech Trends. In the following pages, you will find 10 articles looking at some of the most important trends now emerging in healthcare. From the rise of the chief information security officer to the development of analytics tools to systematize population health and work on readmissions, pioneering patient care organizations are moving forward across a range of areas, and industry experts are peering years into the future to give us a sense of what’s ahead. No single anthology of articles can fully capture the immense complexity of this moment in the evolution of the healthcare system, but we sincerely hope that this cover story package will give you, our readers, an overview of some of the most pressing—and exciting—issues and areas facing us as an industry in the next several years, as you and your colleagues work to master the “slopes” of organizational and health system change going forward. Happy reading! —The Editors ∙ May 6-8, 2012 ∙ Orlando, Fla. • Healthcare Informatics 9


Trend: Performance Measurement



s the leaders of patient care organizations nationwide move forward on a host of pressing mandates, driven by healthcare reform and the meaningful use process, as well as a gradually awakening healthcare consumer world, more and more of them are coming upon a very basic truth: change initiatives must be strongly organized to get healthcare where it needs to go. Indeed, the

sors, say the time has absolutely arrived to leverage performance improvement methodologies for change. “We’ve been able to get by with a lot of ad hoc problem-solving, and using talented individuals who are charismatic and have a knack for problem-solving, in a non-reproducible way; but I think those days are gone,” says the Sewell, N.J.-based Van Kooy, who worked most recently as the de facto CMIO at the Marlton, N.J.THERE’S A LOT OF TALK NOW ABOUT MEANINGFUL USE STAGE based, four-hospital Virtua Health, before 2, AND ABOUT HOW, IF ORGANIZATIONS HAVEN’T MADE joining Aspen in July CHANGES FOR MEANINGFUL USE STAGE 1 IN A SYSTEMATIC 2011. “There’s a lot of WAY, THEY’RE REALLY GOING TO STRUGGLE GOING INTO talk now about meaningful use Stage 2, and STAGE 2. —MARK VAN KOOY, M.D. about how, if organizaleaders of pioneering U.S. patient care organizations began tions haven’t made changes for meaningful use Stage 1 in a more than a decade ago to learn and adopt formal perfor- systematic way, they’re really going to struggle going into mance improvement methodologies—including Lean Man- Stage 2,” he insists. agement, Six Sigma, the Toyota Production System (TPS), and others—either individually, TAKING CUES FROM OTHER or more often, in combination—in order to INDUSTRIES turbo-charge change. “It’s only been recently that people in healthAnd, even as the healthcare industry has care have realized that the non-healthcare lagged far behind manufacturing (the industry world actually has some good ideas,” agrees in which all the main performance improveHarry Greenspun, M.D., senior adviser, healthment methodologies were created and first care transformation and technology, at the nurtured), transportation, retailing, financial Washington, D.C.-based Deloitte Center for services, and even the health insurance indusHealth Solutions. Patient care organizations, try, in adopting such methodologies, things Greenspun says, need to recognize the “culare changing very quickly these days. More tural shift” required to begin to effectively use and more patient care organization leaders performance improvement methodologies. Harry Greenspun, M.D. now recognize that deep process change will “It’s not just using them,” he says, “it’s, can we be required to prepare their organizations for take the delivery of healthcare and figure out such healthcare reform-related mandates as value-based how to systematize it? Can we break things down into repurchasing, readmissions reduction, and healthcare-ac- peatable chunks?” That may mean, he says, beginning in quired conditions reduction, as well as to prepare for the individual units such as the cardiac cath lab, pharmacy, or voluntary accountable care organization and bundled pay- home health program, and expanding outward following ment programs, and the mandatory meaningful use pro- initial successes. Most importantly, he says, “What makes cess. these things work is having them be data-driven and getIndustry experts like Mark Van Kooy, M.D., director of ting feedback” from real-time data analysis. “Until recently, clinical informatics at the Pittsburgh-based Aspen Advi- you didn’t have that.” 10 March 2012 •



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And though some hospital-based organizations, such as the Virginia Mason Medical Center in Seattle, the first U.S. hospital organization to formally adopt TPS as a guiding methodology for change management, have already become famous for helping to lead the industry forward using formal methodologies, many other patient care organizations nationwide are beginning to catch up now. For example, at the two-hospital, 226-bed Susquehanna

that the organization also has several full-time management engineers leading the various projects. One area she and her colleagues have been particularly focused on is the perioperative area, one in which Armstrong says the overlap between meaningful use work and systematic performance improvement is especially strong. “I think anybody striving towards meaningful use or making headway in any of these areas is going to be looking to install a perioperative system,” she offers. “But what’s hard is not the installation itself; everyone knows WHAT MAKES THESE THINGS WORK IS HAVING THEM BE to install an IS. It’s educating DATA-DRIVEN AND GETTING FEEDBACK FROM REAL-TIME how people in advance, and getting DATA ANALYSIS. UNTIL RECENTLY, YOU DIDN’T HAVE THAT. their buy-in.” And that inevitably means through pre-implementa—HARRY GREENSPUN, M.D. tion process improvement using Health, based on Williamsport, Pa., Karen Armstrong, R.N., se- formal methodologies prior to go-live. nior vice president and CIO, has been working with colleagues What does this mean for CIOs and CMIOs? Aspen Advito lead a variety of Lean Management projects. To date, she sors’ Van Kooy (who strongly advocates the mixing of differsays, “We’ve educated about 80 of our management staff in ent methodologies for optimum effect) says the bottom line Lean principles,” and have been working forward in numer- is simple: “Learn process improvement methodologies, and ous areas, including optimizing operations in the health sys- become fluent in the subject.” And that, he says, means that, tem’s clinical lab, physician waiting room operations, and so as never before, healthcare IT leaders need to understand care on. Armstrong says she’s been fortunate in particular that her delivery processes at a deep level so that they can be the best assistant CIO is a management engineer by background, and partners possible in leveraging IT for process change. ◆

Trend: Population Health Management



ncreasingly, the leading patient care organizations in healthcare are making an important connection, and the primary edge now among trendsetters is a growing link between population health management and readmissions reduction work. There is a reason why healthcare providers are focusing on preventable readmissions more than ever, and are more and more using population health management analyt12 March 2012 •

ics in order to focus on the issue. Even as the leaders of pioneering patient care organizations are addressing the issue as one of care quality and continuity of care, the cost of preventable readmissions has pushed the issue along as a performance target for payers, providers, and government agencies alike, most urgently for providers, through a new healthcare reform-related mandate on readmissions

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reductions, notes Jane Metzger, principal researcher at the includes specifics on particular patients that, for instance, have Waltham, Mass.-based Global Institute for Emerging Health- been frequent visitors to the emergency department (ED). care Practices at the Falls Church, Va.-based CSC. “If a patient comes into a hospital and comes in at 11 o’clock, Indeed, Metzger says, reducing avoidable readmissions by 1 o’clock that same day, we’re able to tell the caregivers that has become one of the most pressing issues this patient has been in the ED multiple times for hospitals as they look to become accountover the past year,” she says. “That’s incredibly imable care organizations (ACOs). Hospitals, she portant, because as a care team looking at how to notes, have been working on discharge rates for best support the patient inside the organization a long time, but the combination of improving and on the outside, they can better support the quality metrics, and the publicly listed rates of patient with social work care-managers with that readmissions, as well as, for the first time, high information.” financial stakes, has brought population health Allina is not the only healthcare organizamanagement into industry-wide focus. Population employing population health management tion health management strategies can be apanalytics to reduce readmissions. James L. Holly, plied to a broad range of issues, but Metzger says M.D., CEO of the Beaumont-based Southeast Texpreventable readmissions are at the “front and as Medical Associates (SETMA), says his organiJane Metzger center” of such work. zation has been on the road to population health That importance is evident through various management for quite a while. He and his fellow government mandates. The Centers for MedicSETMA physicians use various data sets and staaid and Medicare Services (CMS) and the Obama tistical analyses to audit their entire patient popuadministration have targeted preventable relation and achieve continuity of care. admissions as a way to reduce Medicare costs “Everyone counts or no one counts. That should through the mandatory readmissions reduction be the mantra of healthcare in America, and really program. There are other programs with readthat is the foundation behind population health missions requirements as well. “Readmissions management. Everyone—that’s population manpops up everywhere in the payment reforms for agement; no one—that’s individuals,” Dr. Holly Medicare,” says Metzger, adding the emphasis says. “Either everyone deserves healthcare or no has even gone beyond the federal level. “It’s not one deserves it.” Thanks to SETMA’s work in popujust federal payers paying attention to this,” she lation health management, and its written plan says. “State Medicaid programs are paying attentreatment for when a patient is discharged, the Mary Jo Morrison tion to readmissions, as are private payers.” organization’s preventable readmission rate has improved 22 percent. Holly expects that number to improve even more in the coming year. POPULATION HEALTH

MANAGEMENT IN PRACTICE Industry-leading organizations like the MinneMOVING AHEAD apolis-based Allina Health System are certainly The future of this movement and the next plateau, paying attention. The 11-hospital, multipleMetzger says, will rely on the implementation of medical-clinic organization has implemented health information exchanges (HIEs) to help close population health management and aimed to what she calls the “preventable readmissions reduce readmissions, as well as improve overall loop.” This means determining whether or not a clinical outcomes through internally developed patient, for instance, has received the prescribed metrics. Mary Jo Morrison, Allina’s vice presimedication at the time of discharge. Unsurprisdent of performance resources, says Allina gathingly, she says hospitals with successful populaered 400 disparate clinical measures, thanks in tion health management programs will have to James L. Holly, M.D. great part to its relationship with EMR vendor create a tight communicative bond with the local Epic Systems Corporation (Verona, Wis.) which community of physicians. Of course, growth will come not just from an internal comcould cause readmissions and developed a predictive statistimitment, but from government support as well. Morrison cal model based on that. “By virtue of having this clinical data, which includes things says Allina has gotten support from federal, state, and local like blood pressure and creatinine test results, we’ve used the government agencies, and cites both external and internal predictions to provide to caregivers [information on] those pa- motivations as critical drivers. However, in terms of the most tients that may have a likelihood of being readmitted again,” important aspect to a successful implementation, she stresses Morrison says. She adds the predictive modeling is augmented organizations must take a multi-dimensional approach to anawith the second part of its population health management: in- lytics, have both retrospective and prospective analysis, and formation on the patient experience. This kind of real-time data build a strong collaboration between stakeholders. ◆ 14 March 2012 •


Trend: ACOs and Care Coordination Tools



uch of the industry is still hesitant to dip its toes shared savings model for their first agreement period, but this still may not be enough to encourage broad parin the murky waters of accountable care, according to industry observticipation. ers and recent studies. Centers for Medicare & Industry experts cite several key technology fundamentals that organizations will need to Medicaid (CMS) anticipates anywhere from 50 begin building ACOs. Jim Adams, managing to 270 accountable care organizations (ACOs) to sign up for the Shared Savings Program in the director, research and insights, at the Washnext three years, says Richard Gilfillan, M.D., ington, D.C.-based Advisory Board Company, director, CMS Innovation Center. Undoubtedly, explains that there are three phases in what all eyes will be on the Pioneer ACO organizahe calls the IT maturity model for accountable tions to see if they can pave the way to develop care. The first phase has 12 foundational eleworkable business and IT infrastructure modments that include establishing ambulatory els. Many admit a big part of building ACOs will EHRs, health information exchange, a disease be extending the patient-physician interaction registry, physician engagement, patient enRichard Gilfillan, M.D. beyond the office visit using telemedicine tools, gagement, and a number of other components as well as using health information exchange focused on quality improvement. The second (HIE) to aggregate data from multiple sources. Population phase involves creating performance risk and bundled payments models for end-toI WOULD BE PURSUING TWO TRACKS. NUMBER ONE, TO BE- end acute care episodes surgeries) and for GIN DISCUSSIONS WITH THE NCQA ON WHAT STEPS NEED TO (i.e. ambulatory episodes (i.e. BE TAKEN TO FORM AN ACO, AND THE SECOND IS TO HAVE chronic diseases). The third phase involves acDISCUSSIONS WITH THE INSURANCE COMPANIES AND THE cepting utilization risk for SELF-INSURED EMPLOYERS THAT ARE RESPONSIBLE FOR A a population of patients, SIGNIFICANT PORTION OF YOUR TYPICAL PATIENT MIX, AND and thereby reducing MAKING SURE THEY ARE ON THE SAME PAGE. —DAN COATES utilization by employing preventative medicine. health analytic solutions will be a key foundational element “I would be pursuing two tracks,” says Dan Coates, principal for these accountable care collaborations, but these care in the Pittsburgh-based Aspen Advisors. “Number one, to begin coordination tools can only be implemented after incen- discussions with the NCQA [National Committee for Quality tives are aligned between payers and providers. Assurance] on what steps need to be taken to form an ACO, and Indeed, says Gilfillan, many of the rigorous parts of the pro- the second is to have discussions with the insurance companies posed rule were amended in the final rule that was released and the self-insured employers that are responsible for a signifion Oct. 20, 2011, like reducing the number of reportable qual- cant portion of your typical patient mix, and making sure they ity measures and allowing ACOs to participate in a one-sided are on the same page,” says the Denver-based Coates. 16 March 2012 •


POPULATION HEALTH ANALYTICS Population health analytic tools will be essential to mine clinical information to make informed, cost-effective care decisions. Anthony D’Eredita, EVP, Southwind, a division of The Advisory Board Company, is seeing gravitation in the market toward a product that supports a full continuum of data aggregation across in- and outpatient settings that also ties into disease registries and adds insight into referrals. John Cuddeback, M.D., Ph.D., chief medical informatics officer for Anceta, the collaborative data warehouse owned by the Alexandria, Va.-based American Medical Group Association (AMGA), says that until recently the focus has been on the care of the individual, but with ACOs it will be about extending clinical decision support (CDS) to cover a population through comparative effectiveness research. He says that medical groups are using patient data, fed daily from organizations’ EHRs, within Anceta to develop predictive modeling to effectively target when interventions are necessary to prevent hospital admissions. “It’s the distinction of making the system as efficient as possible for the bulk of patients and providing individualized attention for the outliers, and the hard part is figuring out who is whom,” he says.

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program. Gilfillan says that CMS will be sponsoring extensive shared learning activities designed to help Pioneer ACOs collaborate with one another on successful strategies. CMS will also help to document the organizational advances as they develop, which will feed into a continuing evaluation of the program. There are many challenges that come with coordinating care among patient populations. The main barrier is as Adams puts “turning the healthcare business model inside out.” For starters, organizations will find it difficult managing in a mixed reimbursement environment, and then getting payers on the same page. “Providers need the collaboration of payers to make outcomes-based arrangements a reality,” says Gilfillan, “and some payers may not be ready to take that step.” Another challenge Coates says, will be purely technological, harnessing discreet data across the continuum of care, coming from various care settings and various IT systems, to really understand the health of the population. Coates also adds another challenge will be managing relations between physicians, hospitals, and other caregivers, and making sure to instill a culture of collaboration to align incentives among all ACO members. Despite the complexities inherent with the marriage of different institutions with different IT systems, many will be awaiting the learnings of CMS Pioneers and independent delivery networks that are now blazing trails toward care coordination. ◆


Trend: Care Management Transitions



setting to setting, Greenspun says. IT collaboration tools can help coordinate teams, make clear where responsibilities lie, and help make sure that things don’t get dropped and are not duplicated, WE WILL GET BETTER COMPLIANCE ON WHAT PATIENTS NEED he says. He has observed inTO DO TO CARE FOR THEMSELVES IF WE DO A BETTER JOB OF creasing appreciation CONVEYING INFORMATION IN A SIMPLE, CLEAR WAY. among provider organizations that transitions —PAT RUTHERFORD, R.N. are actually a dangerous done to remedy this persistent—and multi-faceted—prob- time for patients, which is being reflected in the changlem. ing nature of discharge summaries. “In the past, discharge A conference hosted by Kaiser Permanente in Washing- summaries were focused on what happened, as opposed to ton, D.C., last October demonstrated the complexity of the here are the goals, here is what needs to be done and this is care transitions problem. The meeting identified key ar- what has been done so far, and what information needs to eas of focus, including the discharge process, be handed off to make the transition successmedication reconciliation, information flow, ful,” he says. and patient and caregiver interaction. At the Greenspun notes that there is no single soconference, Farzad Mostashari, M.D., national lution to optimizing care transitions. The abilcoordinator for health IT, urged the particiity to pull information together from different pants to embrace technology as a facilitator sources and make sense of it is important. One for improving care transitions, and he made problem in the industry has been that there are a business case, as fee-for-service payment a lot of technology solutions directed at a narmodels are replaced by new models of payrow piece of the puzzle, but they haven’t been ment. incorporated well into what Greenspun calls the “people-process-technology triad. You can solve one problem” he says, “like a great care MULTI-FACETED PROBLEM coordination application. But if the data isn’t Harry Greenspun, M.D., senior adviser for Erica Drazen there, or people can’t access it, or it’s not easy healthcare transformation and technology for the clinician to use it as part of their daily at the Deloitte Center for Health Solutions in Washington, D.C., notes that care management transitions routine, it’s not a real advance.” Erica Drazen, managing director at the Global Institute are an area in which “the application of IT can improve quality, improve safety, and as a result can likely reduce for Emerging Healthcare Practices at Falls Church, Va.based CSC, notes that most provider organizations did not costs.” Good patient care requires an enormous amount of in- choose care transitions as part of their Stage 1 meaningformation to be conveyed, both within care teams and from ful use attestation. She says care management transitions ill 2012 be the year of better care transitions? Many of the pieces are in place to make that happen, although there is still much work to be

18 March 2012 •


Hospitals are in a position to assess a patient’s comprehensive needs, but handoffs of patient information need to be designed to be useful for the end users, and not necessarily written from the hospital’s perspective, she says. Some of the information that skilled nursing facilities, home healthcare agencies, and primary physician offices maintain may be the same, but othTHE MOST COSTLY PATIENTS, FROM A HOSPITAL’S PERSPECTIVE, er information may be different, she says. ARE MORE LIKELY TO NEED COORDINATED CARE, SINCE THEY “We will get better TEND TO GO BACK INTO THE HOSPITAL. —ERICA DRAZEN compliance on what back into the hospital,” she says. Medication lists also rank patients need to do to care for themselves if we do a bethigh: “If you have a medication list, at least you know what ter job of conveying information in a simple, clear way,” she a patient’s likely problem looks like,” she says, adding that says. She describes the hospital’s role as a “pay it forward” medication lists are a small, but a key, part of the continuity dynamic of providing the information that the next providof care document. er of care needs, and what it can do to make that transfer of information successful. For that to happen, each caregiver needs information that is A TIME FOR TEAMWORK Pat Rutherford, R.N., vice president of the Institute for tailored to his or needs to make the best decision, Rutherford Healthcare Improvement, Cambridge, Mass., says there is a says. What’s needed by each caregiver is a one-page summary new awareness of the importance of care transitions com- of information that is relevant to their caregiving role. Rutherford believes that changes taking place under pared to just five years ago, although there is still plenty of healthcare reform can improve care transitions by providwork to do in filling the patient engagement gap. She sees a need for better partnerships between IT so- ing care that is customized to the patients’ needs and preflution vendors and quality improvement experts, to create erences in every site of care, and then build connections to system-wide solutions in an infrastructure that is often the whole continuum of care. “We need to be more patientfragmented. Vendors need to sit down with clinicians who centered, and we need to think about care experiences over time,” she says. ◆ actually use the products, she says. will become a front-burner issue with the emergence of accountable care and incentives to reduce readmissions. Where should hospitals initially focus their attention? Drazen says the smart money would focus on diagnoses. “The most costly patients, from a hospital’s perspective, are more likely to need coordinated care, since they tend to go

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Trend: Decision Support



erry Osheroff, M.D., principal at TMIT Consulting in truly optimize the workflow of physicians and other clinicians. Cherry Hill, N.J., the lead author of Improving Medica- So, what’s next? tion Use and Outcomes with Clinical Decision Support: “The fundamental learning” coming out of that collabA Step-by-Step Guide and the chair of the HIMSS Clinical orative, Osheroff says, “is that there are a lot of care delivery Decision Support Workgroup and Task Force organizations and others who are drawn very strongly to this notion of measurably improving (sponsored by the Chicago-based Health Inhigh-priority outcomes” through the use of secformation and Management Systems Society), ond-generation clinical decision support. “Major has spent years collaborating with physicians learning number two,” he says, “is that there is and others to move forward important clinical a relatively small handful of relatively high tardecision support (CDS) concepts and embed gets [ for broad performance improvement] of them into clinical information systems in orinterest to care organizations. That’s why folks der to improve patient care. have locked onto issues such as optimizing VTE But Osheroff is clear on one thing: he abso[venous thromboembolism] prophylaxis and lutely hates the term “advanced clinical decision hemoglobin A1C management; and the next big support.” In fact, he says, “I’m very nervous about target will be readmissions.” In other words, he using the term ‘advanced’ for clinical decision support, because that conceptualization implies Ferdinand Velasco, M.D. argues, success in CDS implementation going forward will require creating consensus around that there are a whole bunch of other things you have to do first before you get to the ‘advanced’ stuff; and it concrete performance improvement targets the physicians implies that there’s a whole bunch of technologically sophis- can embrace. ticated stuff; and that’s not really what it’s about.” Instead, he says, “I think we should just call it better clinical decision sup- MAKING HARD CHOICES port.” ABOUT PRIORITIES Osheroff, who lately has been helping to lead the CDS For And that issue goes to the heart of the problem, as so many Performance Improvement Imperatives Collaborative, a na- hospitals, medical groups, and integrated health systems, first tionwide volunteer initiative encompassing more than 130 under pressure to implement their EHRs in a timely way, and individuals representing dozens of hospital organizations now under pressure to meet meaningful use requirements, and numerous electronic health record (EHR) vendors, all of continue to try to very quickly embed basic CDS systems into whom are sharing their knowledge and learnings about clini- their EHRs, before achieving full clinician buy-in, with the cal decision support, has a point. Nonetheless, what has be- result being open physician revolt in many cases. Given the come clear in the past few years is that the first generation of intense timetable for fulfilling meaningful use requirements, CDS tools, as embedded in commercial healthcare IT vendors’ what’s the solution? Indeed, says Ferdinand Velasco, M.D., vice president and core EHR systems, has not lived up to expectations; and indeed, has required continuous customization work on the CMIO of the 13-hospital Texas Health Resources, based in part of healthcare IT leaders seeking to avert alert fatigue and the Dallas suburb of Arlington, Texas, “The challenge will be, 20 March 2012 •


which tools do you apply, and in what order? Because now everybody wants advanced clinical decision support for every initiative. And the reality is that we lack the bandwidth or capacity to completely automate and hardwire every single aspect of clinical practice through advanced CDS.” Bottom line? “We’ve had to decide what our top five or 10 performance improvement opportunities are, whether patient safety-related,

there’s a lot of disillusionment now. I think there was an inadequate understanding at first of the sophistication needed to do this right, on the provider side. And on the vendor side, there was a focus on making money.” As a result, Kilbridge says, a very large number of patient care organizations, particularly hospital organizations, implemented their first-generation CDS systems both too rapidly and rather haphazardly. “So there’s EVERYBODY WANTS ADVANCED CLINICAL DECISION been this kind of this take-the-money-and-run feeling, and the whole SUPPORT FOR EVERY INITIATIVE. AND THE REALITY thing has been slammed in, and you IS THAT WE LACK THE BANDWIDTH OR CAPACITY TO end up spending six months just tryCOMPLETELY AUTOMATE AND HARDWIRE EVERY SIN- ing to fix things that are broken, let alone moving forward on optimizaGLE ASPECT OF CLINICAL PRACTICE THROUGH ADtion. So as a result of this approach, VANCED CDS. —FERDINAND VELASCO, M.D. there’s been this rush to results, and or around reducing variations in care, for example,” and have unfortunately, real optimization rarely happens.” had to focus on those areas. In other words, leaders at many patient care organizaBeyond the fact of limited resources and bandwidth, there tions will first have to make peace with their physicians is also, industry-wide, an even deeper problem, notes Peter over poorly implemented first-generation clinical decision Kilbridge, M.D., who spent years as a CMIO at large health support systems before they can get them to buy into the systems, before becoming a full-time consultant. The New second-generation efforts. Only then will healthcare IT York-based Kilbridge, who is now senior director, research leaders be able to get their physicians and other clinicians and insights, for The Advisory Board Company, Washington, to embrace the second-generation CDS tools that healthD.C., says that over the past decade, “We’ve learned a lot about care leaders nationwide agree will ultimately transform what’s necessary” in clinical decision support. “Unfortunately, care delivery. ◆


Trend: Privacy and Security



OCR contractors will conduct up to 150 audits between arren Lacey describes his role of chief information security officer (CISO) at Johns Hopkins University May and the end of the year, at covered entities ranging in Baltimore as being like that of a circus master. At from small practices to multistate health organizations. any one time, he has a list of up to 60 different technologies, “OCR is looking for a culture of compliance, with a focus on having risk analyses conducted and trainranging from firewalls and e-mail encryption to ing and incident response plans in place,” he iPad pilot projects, to work on. But much of his says. Because organizations are struggling to job hinges on building relationships. “You have respond to ICD-10 and meaningful use, CISOs to have a good relationship with your CIO, and must convince other C-level executives to beef you’re only as good as the trust-building you do,” up their staffing with more security personnel he says. “People have to know that you aren’t goor to outsource some of the responsibility to ing to light your hair on fire over small things.” consultants. Like other CISOs, Lacey recognizes that 2012 The Healthcare Information and Managewill be a challenging year. Final Health Informent Systems Society (HIMSS) conducts a mation Technology for Economic and Clinical wide-ranging survey of health security offiHealth (HITECH) Act modifications to Health cials each year. With the 2011 survey released Insurance Portability and Accountability Act Lisa Gallagher last November, Lisa Gallagher, senior director (HIPAA) privacy and security regulations will of privacy and security for HIMSS, is seeing be released. “The HITECH Act doesn’t really change what we are working on, but it does raise the stakes,” gradual progress on some fronts and some stubborn gaps in security controls persisting. “There has been a little bit of he says. CISOs have a higher profile now, but the changes in the progress in the profile of CISOs, especially in larger organirole and in security programs in general are evolutionary, not zations and independent delivery networks,” she says. The revolutionary, says Kate Borten, president of the Marblehead percentage of organizations that report doing risk assessGroup, a Marblehead, Mass. consulting firm, and former ments is relatively flat at 75 percent. “That still leaves 25 percent not doing them,” she notes. “It is tied to the budget CISO of Beth Israel Deaconess Medical Center in Boston. “As we see more data breaches and recognize the cost issue. They often don’t have the resources or knowledge of of regulations—and there will be new regulations in how to do them.” Almost 60 percent of survey respondents 2012—there is a gradual recognition by C-level executives indicated that their IT budget dedicated to information sethat they need a high-profile person in this role and that curity has increased in the past year, but at an average of 3 percent of IT spending, it remains below other industries they must give CISOs the authority to lead this program.” But at some organizations, the CIO is still doing double- that are in the range of 5 to 10 percent, she says. The survey also identified several technologies CISOs plan duty, Borten adds. They don’t usually have the skills or the time to do a good job of security, and it is a built-in conflict to work on in 2012, including e-mail encryption, data loss of interest. “We often see network administrators handed prevention, and single-sign-on, which Gallagher says should these responsibilities, but this is a big leap in scope and vi- make adding security controls more palatable to users. Many CISOs will be addressing the issue of unsecured sion for most of them,” she stresses. This will be a challenging year for CISOs, because the pro- mobile devices in 2012. In a 2011 survey by the Ponemon vider community has recognized that they are way behind Institute LLC, more than 80 percent of respondents said on improving their security controls as HHS’ Office for Civil their organizations use mobile devices that may collect, Rights ramps up its audit program, notes Chris Apgar, CEO store, and/or transmit protected health information, yet 49 and president of Apgar & Associates, a Portland, Ore.-based percent said they don’t do anything to protect these mobile devices. But although the top cause cited for data breaches consultancy. 22 March 2012 •


remains lost or stolen computing devices, Lacey says academic medical centers such as Johns Hopkins also have to increase their intrusion detection and data leak control capabilities. “The percent of breaches due to hacking and malware is small at around 10 percent,” he says, “but the risk at academic medical centers is higher than that. We all have to raise our games in terms of preventive controls.”

Borten’s prediction for headlines for 2012: We will see more breaches reported and more state attorneys general prosecute them. “It is unfortunate, but well-publicized legal cases and fines get senior management’s attention,” she says. Also, new regulations are expected to make business associates’ subcontractors that touch PHI directly responsible for being HIPAAcompliant themselves. “That is enormously important,” Borten adds, “because it is a huge vulnerability today.” ◆

Trend: Private vs. Public HIEs



fter a period of wait-and-see in the health information exchange (HIE) market when the American Reinvestment and Recovery/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act initially passed in 2009, meaningful use has since been pushing providers to adopt the EHR technology necessary to move forward to launch HIEs. Hospitals and health systems, as well as payers, are fueling HIE growth, building information backbones necessary to support care coordination and accountable care organization (ACO) development. With the multitude of health IT responsibilities on providers’ plates now, it’s a tough decision as to whether an organization should build their own private HIE or link to a nearby public exchange, says Mark Allphin, senior research director, KLAS Research (Orem, Utah). Allphin reports that in a recent survey his consulting firm conducted, providers were in a 50/50 split on the choice, and the deciding factors were the amount of organizational resources the organization had and the maturity of the region’s public HIE. Carladenise Edwards, Ph.D., president and CEO, The BAE Company (Miami, Fla.), says that some primary considerations for assessing the value of a public HIE are access to greater legal protections for data breaches and access to data points and public health reporting inaccessible otherwise. This year, public exchanges will be pushing out a thin layer of services including query and retrieval of patient information across their regions to connect competing organizations, while the private sector will be developing deeper services to virtually aggregate ambulatory providers for ACOs and advanced payment programs to effectively manage patient populations, says Kevin Carr, M.D., senior executive, Connected Health, Accenture 24 March 2012 •

(New York). “There’s a business model on the backend that says, ‘if I do this effectively, then I have a platform to help support my accountable care organization effectively, and I am going at risk on certain contracts so I need that technology platform to help run that business,’” says Carr. Some private exchanges will also be building public health gateways to share immunization information and enable public reporting.

RISE OF THE PRIVATE HIE From 2010 to 2011, the number of live public HIEs rose from 37 to 67, while the number of live private HIEs more than tripled from 52 to 161 during that same time period, according to a July 2011 report from KLAS. Allphin sees the big growth in HIEs to stem from hospitals and independent delivery networks (IDNs). He says there is a great motivation to build networks between a hospital’s employed and non-employed physicians to strengthen care coordination. Afterwards, a private HIE has the option of connecting to a public HIE. Allphin attributes the slow growth in the public sector to the time it takes to balance the strategic goals of all organizations involved, and the challenge of politics and user adoption. There’s also a sense in the industry, he says, that there’s some cause for concern that public HIEs won’t be able to find successful sustainability models and garner the participation of competing entities. Provider feedback from KLAS’ recent report said that some organizations wanted to connect with their public HIEs, but moved forward with their own HIE because public efforts had stalled. Edwards recommends that taxpayers hold the federal government and states accountable for these public-funded HIEs

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to make sure they are indeed forming and improving the public health infrastructure, be it by building disease surveillance mechanisms or immunization registries. She also believes that HIE vendors need to be held accountable by the industry and the regional extension centers (RECs) to create systems that interoperate at reasonable costs.

PAYER-DRIVEN EXCHANGES, INTERFACES Edwards sees a major trend this year for health plans and managed care entities to provide solutions to their providers and patients to help coordinate care. Carr says that payers are looking to add value beyond just paying claims, and to drive quality by starting clinically data enriched HIEs and care management programs, so more time can be spent on interventions, rather than collecting information from the patient. Carr notes that the Pittsburgh-based Highmark, a Blue Cross

Blue Shield company, is implementing an HIE to network community providers to help reduce costs “and also to help drive a platform to help make those providers in the community more successful in pay-for-value programs—so helping to mobilize that data so the healthcare system is operating as a fully-integrated system, as opposed to silos.” Last year’s acquisitions of Axolotl (San Jose) and Medicity (Salt Lake City), by United Health Group’s Ingenix Division (Eden Prairie, Minn.) and Aetna (Hartford, Conn.), respectively, were certainly a bellwether in the industry for this trend. To this end, besides an enhanced clinical capabilities program and a private label health plan, Aetna’s population-specific collaboration for Medicare Advantage patients utilizes case management staff and programs, as well as actionable clinical data, analytics, and patient population reporting through provided technology run on the Medicity platform. ◆

Trend: Imaging



o understand where the imaging informatics industry is ments for various reasons. For one, “their workflow is different headed, it’s important to recognize the evolution of im- than radiology,” says Dreyer. According to Joe Marion, founder and principal of Healthcare age-archiving systems. As Keith Dreyer, M.D., vice chairman of radiology at Massachusetts General Hospital in Boston, Integration Strategies, a Waukesha, Wis.-based consulting firm, Mass. and assistant professor of radiology at Harvard Medical there are additional issues that make PACS systems unsuitable for other departments. For instance, he notes that School, puts it, those solutions first emerged as there are unique identifiers in radiology imaging “monolithic” systems for the radiology department. systems that classify demographic information. In the next phase of their evolution, they were used Marion says these identifiers may not crossover to and adapted for cardiology departments. For a pethe other “-ologies.” He also says there is complexity riod of time, the imaging needs in hospitals didn’t in the context of image viewing and a lack of visualoften go beyond those two departments. ization standards. Today, there are numerous “ologies,” such as “If a physician has to contend with more than dermatology, pathology and gastroenterology, as three or four viewing applications, they will never well as other hospital departments, that all have use the system, because they just don’t have the emerging imaging IT requirements. The traditional time to remember all that,” Marion says. “So the image-archiving systems, also known as picture arsimplicity of this means one has to get down to a chiving and communication systems (PACS), howKeith Dreyer, M.D. universal application that can support multiple forever, aren’t fully suited to non-radiology depart26 March 2012 •


Study online mats. You either shove everything into a DICOM [Digital Imaging and Communications in Medicine] format or you have to have the technology to manage and view multiple image formats.” Dreyer notes standards do exist, however, industry and government leaders have yet to mandate them. Rasu Shrestha, M.D., vice president of medical information technology at the University of Pittsburgh Medical Center (UPMC), says the essential issue in imaging informatics in the near future is that most CIOs and other healthcare technology leaders are attempting to figure out an enterprise strategy for imaging informatics across the board.


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DON’T SAY ‘VNA’ Despite numerous differences in other areas, the imaging storage requirements for the various hospital departments are the same, Dreyer says. Thus with the emerging imaging requirements across multiple hospital departments, coupled with the consolidation of the imaging archiving systems vendor market, vendors have begun to sell a product called the vendor-neutral archive (VNA). These products are supposed to represent an all-encompassing service for image storage. Yet many in the industry have panned the term. Why is there such distaste for the term “VNA”? Marion explains that “It’s too limiting. It doesn’t identify the true purpose of the device. What does ‘vendor-neutral’ mean?” he asks. “Does it mean if I have Siemens in one place, and GE in another, that I have to pick a third party so I’m vendor-neutral? If all I’m worried about is archiving the images, then I’m missing the whole point.” The point, he notes, is managing and accessing the images across the enterprise. UPMC’s Shrestha similarly agrees that the term VNA has become an overused buzzword by vendors and the issues in the imaging industry go beyond simply just storing the image agnostically. Like Marion, he says solutions must address the workflow and management issues that typically do not match up across departments. Dreyer stresses VNA solutions ignore the need for a standards-based visualization tools that can be applied to an archive. While many have wondered if an enterprise-wide image solution lies in the cloud, a number of industry leaders aren’t convinced yet. Dreyer says the cloud is suitable for a “second store,” but he hasn’t seen anything today that would make him feel comfortable on not having anything on site. He does see advantages to the cloud, such as enabling easier access to physicians who work outside the walls of a particular hospital. Both Dreyer and Marion say disaster-image recovery is a good option for a cloud solution. Pioneering organizations, like Shrestha’s UPMC, have stayed ahead of the industry by creating their own type of image-archiving platform. UPMC’s Singleview solution federates multiple imaging archives (UPMC has 12 PACS systems in radiology alone) into a more “patient-centric” view, where all of their images are pulled together in one place. Even with certain things that need to be addressed, like integrating imaging from various other departments, Shrestha says SingleView has become a broad platform ∙ May 6-8, 2012 ∙ Orlando, Fla.

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that UPMC can use to “enterprise enable its imaging strategy.” Over the next few years, as healthcare organizations strategize forward on diagnostic image sharing and storage, Marion says success will depend on organizations determining their own specific needs. His advice going forward for CIOs and healthcare IT leaders is before they sit down and accept

a vendor-based solution, is to hammer out basics such as finding a repository that can interact with their EMR, as well as, figuring out how many service areas they have, the objects they are dealing with, and the requirements they have. “Then you can start to zero in on specifics with service areas and vendors,” he says. ◆

Trend: Mobile Health



obile is the cornerstone of true meaningful leaders, who now have to make some tough choices as they formulate policies, says Edna Boone, senior director of mouse.” That is according to Kevin Larsen, M.D., bile initiatives for HIMSS. CIOs are tackling security, remote chief medical information officer and associate medical di- data access, and use of personal devices. “If they allow clinirector of 420-bed Hennepin County Medical Center in Min- cians to use many types of devices, then it might become a support headache,” Boone says. “But they also neapolis, Minn. Speaking at a mobile health must weigh the benefits of standardization verconference last year, Larsen described how sus the risk they might slow adoption.” A HIMSS Hennepin has pushed its Epic (Verona, Wisc.) task force has developed a mobile privacy and EHR implementation out to physicians’ mobile security toolkit and guidance about mobile dedevices, to provider teams in the field, and to vice management software, she adds. HIMSS is patients through a smartphone patient portal also closely following the U.S. Food and Drug application. “The future of healthcare is conveAdministration plans to regulate a subset of monience, integration, and connection with best bile medical apps, generally those that have senevidence,” Larsen says. “To deliver financial valsors that attach to the patient or that serve as an ue and efficiency, we need to get information adjunct viewer for an already-regulated system. and tools to where they are needed.” Some healthcare leaders are confused about But a recent survey by the Health InformaEdna Boone how to proceed, and the clinicians are beating tion and Management Society (HIMSS) hints the IT people to the punch. CIOs have to deat some of the challenges CIOs are facing becide if they are going to support BYOD or not, fore realizing the potential of mobile devices. says Fran Turisco, a director with PittsburghWhile approximately 75 percent of those surbased consulting firm Aspen Advisors. They veyed said their organization allows clinicians need to decide which operating systems and to access clinical data via a mobile device, only devices they will support, and what encryption 38 percent have a policy in place that regulates or middleware they have to put on the devices, the use of mobile devices and outlines a mobile she adds. Decisions also need to be made about strategy. Just less than half of the respondents internal application development and perhaps indicated their organization supports personal a catalog of commercial apps that the IT group devices owned by the end-user, and which are will support. enabled by the organization to support daily “But they need to put these policies in place work activities. quickly. They can’t tell physicians they will get back The rapid adoption of consumer-oriented Fran Turisco to them with a policy and governance structure in devices by clinicians has blindsided many IT 28 March 2012 •

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six months. You have to do it in two months or less, I’d be shot.’” I would say, or else you lose their attention.” Some CIOs are ultraconservative, while othBut IT teams that already have full plates may ers put up kiosks in their hospitals to recruit struggle to develop mobile policies quickly, says physicians to bring their own mobile devices Dan Garrett, principal and health information because that enhances the perception that they technology practice leader at New York-based are cutting edge and supportive. The ones who PwC Consulting. Every provider IT shop is goare slower know they will have to adapt sooner ing through meaningful use and ICD-10 impleor later, Kleinberg adds. mentations. “They are very busy and distracted,” Despite all the activity in the mobile sector, Garrett says. “Plus, there aren’t a lot of common Kleinberg says there is still an underestimation infrastructure tools that are good, clean oneof its impact on healthcare quality and busistop shops to deal with encryption and device ness process improvement. “The value of deDan Garrett management and other issues, so this is not an vices being always on and connected vs. having easy fix.” to wait in a hallway to log on or fire up a laptop Kenneth Kleinberg, senior healthcare director will be significant.” for health consulting and research firm the WashPwC’s Garrett agrees that it is important to ington, D.C.-based The Advisory Board Company, keep the focus on business process improvesees BYOD as the No. 1 issue in terms of mobility. ment. “Sometimes we get lost in the technol“IT teams that had expertise in managing deskogy and the shiny new toys and forget about tops and laptops for 20 years are all of a sudden why we are doing this,” he says. “But as much facing a whole new challenge with the profusion as they contribute to convenience and simplicof mobile devices and the choices they have to ity and make work easier, mobile devices will make in terms of supporting all the apps becomcontinue to have an impact. And on the coning available,” he says. “CIOs have to figure out sumer side, mobile tools that contribute to which to support and how they co-mingle with convenience and make it easier for providers, enterprise apps, and what mobile carrier to use.” consumers, and payers to communicate are alKenneth Kleinberg There is no single common industry-wide ready being successful and commanding more approach because every hospital is coming at market share.” it from a different starting point, and that may depend on Turisco notes that, at some point, the distinctions about whether the physicians are employees or merely affiliated, mobile devices will erode and the policies will become one Kleinberg says. “One CIO at a recent meeting told me, ‘If I and the same. “We tend to treat it as separate now because it told physicians they couldn’t bring their own mobile devices, is still relatively new.” ◆

Trend: Personalized Medicine



he other nine technology trends featured in this issue involve topics that most CIOs are wrestling with in 2012. But the Healthcare Informatics editorial team thought it was important to highlight one trend with a slightly longer timeline: the convergence of emerging genetic medicine and electronic health records. The pioneering clinicians and healthcare informaticists we spoke to stress that CIOs 30 March 2012 •

should start paying attention now. “Many of us believe that genomic information will inevitably transform healthcare beyond recognition,” says Christopher Chute, M.D., a Mayo Clinic bioinformatics researcher focusing on clinical and genomic data sources, management, standardization, and interpretation. “It will be a bigger breakthrough than antibiotics—not immediately, but in the next

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decade or two.” others will adopt.” Yet if the commonplace use of a patient’s The H. Lee Moffitt Cancer Center in Tampa, personalized genetic risk information to make Fla., is one of 18 hospitals taking part in the Toclinical care decisions is still a decade away, tal Cancer Care research study that follows canpilot projects and research studies are not. Dr. cer patients longitudinally and includes genetic Chute is principal investigator on a study called data. “As we look at additional diagnostic and the Electronic Medical Records and Genomics treatment therapies, researchers are starting to (eMERGE) Network, which brings together reunderstand the nuances of different molecular searchers from leading medical research instituprofiles and they can target that for diagnosis tions across the country. One focus is whether and treatment,” explains Mark Hulse, Moffitt’s EHRs can serve as resources for complex genomic CIO. analysis of disease susceptibility and therapeutic Moffitt’s Cerner-based oncology-specific EHR Mark Hulse outcomes. The next generation of EHRs, Chute called PowerChart Oncology does not yet have says, will require at least three things: a facility a way to alert the clinician that genetic data is to access genomic data about patients; access to available. “That is one of the next steps: to get a curated nationwide or international database the clinician information based on genetic data that assigns genomic-clinical implications; and about whether a patient would benefit from clinical decision support tools with a dynamic front-line treatment or perhaps should go dicapacity to make use of that information. rectly into a specific clinical trial,” Hulse says. “Let’s say a physician is about to order an anti“We need to develop clinical pathways to guide depressant. A simple red, yellow, green indicator them to information about how their patient would strongly discourage that drug because the may benefit depending on how genes are expatient would metabolize it poorly or not optipressed. Today this is primarily at the research mally,” Chute explains. The doctor could then phase, but clinical deployment is coming fast.” avoid it or switch drugs. “Mayo has already done Randall Lambrecht, Ph.D., vice president of this on a sample cohort of patients,” he says. research and academic relations at 15-hospital Scott Megill Elsewhere, the Coriell Institute for Medical Aurora Health Care in Wisconsin, says that for Research, Camden, N.J., and the Ohio State UniCIOs, personalized medicine will necessitate inversity (OSU) Medical Center in Columbus are collaborating creased networking across health systems. on a study involving OSU cardiologists and primary care phy“It wouldn’t make sense for most to create their own bioresicians and 1,800 of their patients who have been diagnosed positories or genetic data repositories because they don’t with congestive heart failure or hypertension. The patients’ have the volume of patients,” he says. “It makes more sense genomic information is being attached to their EHRs. The to join networks.” study seeks to understand how likely doctors are to use the Aurora, which has three million patients, has created a information when it is made available to them. large biorepository with 100,000 samples. It uses bar codes to The project has run up against some constraints with the tie the samples to patients’ EHR data in a de-identified way. current generation of EHRs, says Scott Megill, Coriell’s CIO. So far, the biorepository is being used strictly for research and is not used for treatment. “We want to work with universities and MANY OF US BELIEVE THAT GENOMIC INFORMATION academic medical centers on WILL INEVITABLY TRANSFORM HEALTHCARE BEYOND other sharing this data,” Lambrecht says. RECOGNITION. IT WILL BE A BIGGER BREAKTHROUGH “Researchers could view our cardiac population, for instance, and study THAN ANTIBIOTICS—NOT IMMEDIATELY, BUT IN THE how they might respond to different NEXT DECADE OR TWO. —CHRISTOPHER CHUTE, M.D. drugs.” “They currently have no fields ready to be populated by genetMoffett’s Hulse’s advice to other CIOs? Begin to educate ic data, which isn’t surprising,” he says. Coriell and OSU put yourself. “Personalized medicine is coming pretty quickly,” the genetic risk reports in PDF files attached to the patients’ he says. For instance, there may be a dozen tests today about records, much like imaging files are attached. whether a certain drug for breast cancer would work based Designing common ways for EHRs to access genetic data is on a woman’s genetic profile. “But that number is going to a huge challenge, Megill says. It’s more complicated than just scale massively as researchers recognize more and more adding a few blanks fields to a screen. “There are many differ- subtle genetic variations,” he adds. “As leaders in the health ent types of pharmocogenomic results and ways that cardiac IT space, we can influence vendors on how systems are derisks could be impacted by genetics,” he adds. “I think stan- veloped to accommodate this huge change in diagnosis and dards bodies have to get together and create standards that treatment.” ◆ 32 March 2012 •


Getting Analytical A SOUTH FLORIDA MEDICAL SPECIALTY GROUP FINDS SUCCESS WITH REVENUE CYCLE MANAGEMENT BY MARK HAGLAND EXECUTIVE SUMMARY: How one physician group manages revenue and reimbursements around highly complex legal issues.


s physician organizations move forward to implement and optimize revenue cycle management (RCM) programs, they are doing so in an environment of increasingly challenging reimbursement and growing stresses on their doctors. Yet, as many challenges as there are in this operating environment, new, IT-facilitated opportunities continue to open up for intrepid medical group executives willing to plunge in and take on the issues, as complicated as they can prove to be. One organization making progress in this area has been Palm Beach Orthopaedic Institute (PBOI), a 14-physician medical group with four locations within a 15-mile radius in the communities of North Palm Beach (where PBOI is headquartered), West Palm Beach, Jupiter, and Wellington, in South Florida. The practice, established in 1995, encompasses 14 physicians—12 orthopedic surgeons, one podiatrist, and one physiatrist; and a total staff of 85. In terms of PBOI’s patient population, its reimbursement mix is 43 percent Medicare, 23 percent Blue Cross Blue Shield, 10 percent in each of the major HMOs and PPOs in the community, and 4 percent deriving from legal or auto insurance cases.

A THICKET OF ISSUES Of particular interest with regard to its patient population in South Florida, says Brian Bizub, PBOI’s CEO, is the fact that, though the organization’s overall percentage of revenues coming from legal and

auto liability cases is relatively small, the complexities of managing the revenue cycle around such cases have proven highly challenging in the past. “In the state of Florida, auto is quite challenging,” Bizub notes, “and for some reason, we end up handling treatment to patients in the context of a fairly large number of legal cases—slip-and-fall cases, auto cases that become legal cases; and workers’ compensation cases that turn out to be legal cases. Legal cases are quite challenging,” he adds, “because they may start in 1995 and not resolve for five years or more. So you’re carrying cases on AR [accounts receivable] for years—most cases resolve in three years, but some well exceed five years.” What’s more, Bizub explains, his organization in some cases inevitably becomes entangled in complicated sets of processes around legal representation. The bottom line is that, often after a very ∙ May 6-8, 2012 ∙ Orlando, Fla.

considerable period of time has passed, a payment situation that began in one context shifts, with a patient who has been an unsuccessful legal plaintiff becoming a self-pay patient long after medical treatment has been provided. Needless to say, optimizing revenue cycle management has been on Bizub’s mind and on the minds of his colleagues at Palm Beach Orthopaedic for some time. As a result, Bizub and his colleagues, who had already been live with the core electronic health record (EHR) solution from the Horsham, Pa.-based NextGen Healthcare, chose to implement NextGen Practice Solutions, the company’s RCM solution, in order to address their RCM issues.

KEEPING THE RECORD STRAIGHT Given the high volume of patient care claims that PBOI submits annually—the group sees between 40,000 and 60,000 • Healthcare Informatics 33

Most importantly with regard to process, Bizub says, the most important element in RCM success is “really knowing how many claims are out there that are outstanding; how many times we’ve touched those claims; and the reasons why we’ve touched them, because from an educational standpoint, some of the

that indeed is what I do with our physicians.” When it comes to advice he might offer to his peers in other medical group organizations around the issue of vendor selection, Bizub says that it’s important to consider “systems that look at all claims and not just highdollar claims; that provide metrics and analytics to actually provide back to the customer what they’ve accomplished in a given period of time; and systems that have the ability to trend by payer, because we may see something with Medicare that we weren’t seeing with Blue Cross Blue Shield.” What’s more, he says, a good RCM system will proactively prompt analysis. Finally, he says, building a strong relationship with one’s vendor will be essential for long-term success in this vital area going forward. ◆

BETWEEN DECEMBER 2010 AND DECEMBER 2011, OUR CHARGE VOLUME PROBABLY STAYED RELATIVELY CONSISTENT IN THE PAST YEAR; BUT OUR CASH FLOW INCREASED A GOOD 3 PERCENT. THREE PERCENT ON OUR REVENUE OF $20 MILLION IS AN AWFUL LOT OF MONEY—IT AMOUNTS TO SOMETHING LIKE $600,000. —BRIAN BIZUB implemented their EHR in 2006. Then in 2010, they went fully live with the RCM solution. “Between December 2010 and December 2011, our charge volume probably stayed relatively consistent in the past year; but our cash flow increased a good 3 percent,” says Bizub, adding that “3 percent on our revenue of $20 million is an awful lot of money—it amounts to something like $600,000.”

denials can be fixed on the front end or immediately upon the denial. We were struggling with being able to identify the denials trends,” he says, but the solution his organization has chosen encompasses an analytics capability that helps to explain denials, thus improving the process of analyzing RCM issues and trends. With the system they’ve implemented, Bizub notes, “We can sit down with the individual physicians and go over revenues; and

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patients every year—Bizub says the need to select an RCM vendor integrated with the organization’s EHR was vital; this was particularly so since most of PBOI’s billing operations are outsourced. The folks at PBOI went live with an enterprise performance management (EPM) system shortly after having


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n healthcare, the phrase “time is money” isn’t just a saying, but it's reality. Thus, any tool that can help doctors review high volumes of data at a faster rate so they can move onto actual clinical work is typically appreciated. With this in mind, researchers at The University of Missouri, Columbia, have developed a tool that can help doctors fully assess diabetes patients with a few simple clicks. The Diabetes Dashboard is an intuitive tool that is designed as an add-on to an electronic medical record (EMR). It summarizes a patient’s health problems, vital signs and lab results, which are all specifically geared to diabetes quality measures such as blood pressure control and sugar intake. It also prompts the doctor to consider whether or not the 36 March 2012 •

patient is within a satisfactory range with regard to the measures and makes recommendations.

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Richelle Koopman, M.D., associate professor of family and community medicine at University of Missouri School of Medicine, was part of the team that created the dashboard. Koopman says use of the technology to track certain measures of diabetes care can, if successful, eventually reduce the risk of cardiovascular disease. “It’s pretty high stakes stuff for the patient,” Koopman says. “If you can get better care with them or better blood sugar control, you can save life and limb. That’s pretty important. If we can make it easier for patients and physicians to do that, then that’s a win.”

reduced the amount of clicks needed by physicians to find the data from 60 to three.


Unlike the old flow-sheets, the diabetes dashboard is less likely to make an error, according to Koopman. In the same study, physicians reported that the data found from the dashboard was accurate 100 percent of the time compared to 94 percent of the time within the traditional EMR. There’s also an implied cost-savings derived from the dashboard, says Koopman. Even without a cost-study analysis, according to the researchers’ calculations, if a physician who THEN AND NOW makes $180,000 annually in salary and benefits, More than anything else, the dashboard is a confour minutes saved is equal to $6.59 per patient. venient tool to figure out critical diabetes inforOver time, she says, that adds up. In addition, mation, according to Koopman. The dashboard, there is cost-savings by having patients avoid which was created by a team of physicians and the taking duplicate tests, which come about beschool’s EMR vendor Cerner Corp. (Kansas City, cause of unclear information. Mo.), is a huge time-saver, she says. Koopman says that Cerner has provided this With paper records, physicians had to flip technology for their other clients across the through sheets of paper to get all of the related Richelle Koopman, M.D. country. In addition, she says the dashboard diabetes information. Flow-sheets that included diabetes specific information were created, but still hand- shouldn’t be vendor specific, adding that she would like to see entered and thus at risk of human error. Even with an EMR, other vendors adopt it as well. For the actual dashboard, Koopman says improvements will physicians still must click through various screens to get what continue to be made. Already, researchers have made it interacthey need. tive. For instance, if a patient needs cholesterol levels checked, a test to do just that can be set up directly on the dashboard. The next step, according to Koopman, is to incorporate all of the conditions a patient might have. Currently, “Collecting all of the data [relevant to diabetes care] to see the dashboard can only track single conditions. “So if your what needs to be done takes a long time,” Koopman says. “Phy- patient has diabetes, high cholesterol, high blood-pressure, sicians typically have patients scheduled every 15 minutes and and asthma, then you wouldn’t have to navigate to those four it takes five minutes to find this data in a traditional EMR. dashboards because then you’re just navigating again,” KoopYou either have to do it beforehand or during your patient’s man says. “Instead, if the EMR or computer screen says this visit. If you do it during their visit, you are cutting into other patient has high cholesterol, high blood-pressure, and asthma, things like treatment adjustments and talking about diet and here’s everything you need to know about those conditions. What we don’t have yet is a single screen summary that covers exercise.” The dashboard is similar to the flow-sheets, except it’s on all the medical conditions a patient has and the relevant median EMR, encompassing all the necessary information for dia- cal information.” Koopman doesn’t think taking this next step would be that betes care on a single screen. In a study done by the University of Missouri, physicians found the Diabetes Dashboard saved hard. Incorporating recommendations to a multiple condition them four minutes of paging through the various data. It also dataset, she says, would save the most lives. ◆


38 March 2012 •




he Atlanta-based Surgical Information Systems (SIS) recently released a survey of C-suite-level healthcare executives that queried them on their current plans and perspectives in the perioperative operations area, including the operating room (OR). A number of key findings emerged, including the following: • 87 percent are planning to make some kind of enhancement to their perioperative area in the next year; • 78 percent plan to reduce perioperative costs in the next year (with that figure representing a 34-percent increase in perioperative cost reduction projects since 2010); • 31 percent see overall financial performance as their top work concern, while 28 percent cite quality of patient care, and 16 percent say meeting meaningful use requirements; • Asked to name what they saw as the most important approaches to financial improvements in the perioperative area, survey respondents cited “implementing cost control strategies” (24 percent); increasing volumes (23 percent); and decreasing costs of supplies, implants, and materials (15 percent) as most important; • 59 percent see the perioperative area as being a high or extremely high priority area within the hospital for investing in IT improvements (and among those who see it as such, 67 percent cite meeting meaningful use requirements as a driver). Among the 82 hospital executives responding to the survey, representing 70 hospitals, the majority (78 percent) were CEOs, COOs, CFOs, CIOs, CNOs, and chiefs of anesthesiology, while 22 percent held other hospital titles. Karen Armstrong, R.N., senior vice president and CIO at the Williamsport, Pa.-based Susquehanna Health, a three-community-hospital system, and a customer of SIS, spoke recently with HCI Editor-in-Chief Mark Hagland regarding the results of the survey, and her perspectives on its findings. Below are excerpts from that interview. Healthcare Informatics: Are you at all surprised by the 78 percent ∙ May 6-8, 2012 ∙ Orlando, Fla.

finding, regarding C-suite executives’ push for cost reductions in the perioperative area? Karen Armstrong, R.N.: Not at all. Generally, I think everybody would be looking to do that in today’s healthcare environment, not only in the perioperative area, but everywhere throughout the hospital.

CLINICIAN BUY-IN HCI: How difficult will it be to make these changes in the perioperative area, given how clinician-controlled that area remains? Armstrong: Well, people need to understand the operating • Healthcare Informatics 39


environment right now, and hospital executives have the obligation to explain what’s going on to the clinicians, particularly physicians. Having come up through the ranks as a nurse and then an administrator, I do see a shift in physicians’ awareness of things recently. They’re realizing that the hospital won’t survive without them; and they won’t survive without the hospital. I see physicians kind of getting into it and really getting it. And it’s been fun watching them learn the new EHR [electronic health record]. HCI: When did you implement your perioperative system and your EHR? Armstrong: We went live with our perioperative solution this September; in terms of our EHR, we’ve been live on Siemens Soarian since 2004. HCI: Until recently, the usable data and analytics have not been there in the perioperative area, correct? Armstrong: Absolutely; it was a manual effort, if you could get to it at all. And surgeons and other physicians are scientists;

the buy-in and cooperation from all levels in the OR—from the anesthesiologists, the surgeons, the nurses, the support staff. And these are very expensive systems, and you have one chance, and it has to work. HCI: What makes it so complex an undertaking? Armstrong: There are numerous modules, and in addition, it has to integrate with the hospital information system, and the documentation pieces have to flow back and forth so that everybody knows what went on in the OR, and so on; so it’s important that we capture all the metrics that ensure quality. You have to know about the complications—surgical complications are one core measure to report under meaningful use. Another piece of it that sometimes people don’t talk about is retention and recruitment of your staff and surgeons, as well as anesthesia. If I were trying to be recruited somewhere, I’d say, well, gee whiz, if they’re not automated, how are they doing anything else right? So perioperative information systems will be a key tool for recruitment, particularly if specialists trained at a hospital already had one of these. The last piece of this is that with a perioperative system, you have to think about your patients, and about their families as well. If you’re able to track your loved one, that provides great piece of mind; and that all contributes to the whole patient experience, if the family’s comfortable, and so on. HCI: Did any of the survey results surprise you? Armstrong: Not at all; I was happy to see that quality of patient care was so high on the list of work concerns. HCI: How fast will hospital organizations be able to leverage these perioperative systems to make change, in terms of quality, cost reduction, and so on? Armstrong: Well, I think anybody striving towards meaningful use or making headway in any of these areas is going to be looking to install a perioperative system. But what’s hard is not the installation itself; everyone knows how to install an IS. It’s educating people in advance, getting their buy-in, explaining why you’re doing this. HCI: In other words, it’s getting everyone on the same page and marching under the same banner? Armstrong: Absolutely. And the expectations have to be absolutely clear. We were fortunate to have a wonderful perioperative services director, and she absolutely got everyone aligned. And as CIO, I absolutely latched onto her and said, we have to do this together. And plus, my clinical background helped. But we were cosponsors of this right from the start. ◆

HAVING COME UP THROUGH THE RANKS AS A NURSE AND THEN AN ADMINISTRATOR, I DO SEE A SHIFT IN PHYSICIANS’ AWARENESS OF THINGS RECENTLY. THEY’RE REALIZING THAT THE HOSPITAL WON’T SURVIVE WITHOUT THEM; AND THEY WON’T SURVIVE WITHOUT THE HOSPITAL. —KAREN ARMSTRONG, R.N. you have to present to them accurate, credible data, or they’ll question it. HCI: Are you and your colleagues in a similar place with other respondents, with regard to the question around the most important approaches to take to improve financial performance in the perioperative area? Armstrong: Yes, we are, though I would add quality improvement there. In the future, it will all be about value-based purchasing, and our financial reimbursement will be all about quality. HCI: Especially in surgery. Armstrong: Exactly; and the reason you implement a perioperative information system with metrics is so that you know how you’re doing on quality. HCI: Will the OR be a major focus for your efforts? Armstrong: Oh, absolutely.

A COMPLEX CHALLENGE HCI: What will the biggest challenges be for you in leveraging IT in this area? Armstrong: I think the biggest challenge is that it’s an extremely complex type of system to install—and you have to have 40 March 2012 •




he 380-bed St. Mary’s Regional Medical Center in Reno, Nev., a member of the 40-plus-hospital, San Francisco-based Catholic Healthcare West system, is typical in its situation in the imaging informatics area. As at other community hospitals of its size and type, St. Mary’s leaders have been facing the challenge of updating the hospital’s picture archiving and communications system (PACS) with limited funding and intensifying physician end-user demands. Among a growing number of hospitals, St. Mary’s leaders have chosen to replace their outdated first-generation PACS system with a cloud-based solution; in their case, they went live in July 2010 with the combination solution from the Minneapolis-based Virtual 42 March 2012 •

Radiologic (vRad) that provides both cloud-based PACS and teleradiology (external reads) services. Recently, Dan Ferguson, M.D., St. Mary’s chief medical officer, who also fulfills the organization’s CMIO responsibilities, spoke with HCI’s Editor-in-Chief Mark Hagland regarding his organization’s path in the PACS area. Below are excerpts from that interview. Healthcare Informatics: What is the background behind your organization’s choice of a cloud-based PACS solution? Dan Ferguson, M.D.: I took this position in February 2009. One of the first issues I was faced with was a failing, end-oflife, PACS system. It was a big issue for our surgeons, especially neurosurgeons and others, who could no longer obtain remote

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access. It was a 10-year-old system no longer supported by hadn’t thought of, and vRad was very helpful in helping us to the vendor. The issue was that we were faced with a capital make changes to the system. The other major change was the shift to voice recognition. expense that we really could not bear at the time. We simply We had employed six full-time transcriptionists who had did not have the capital to replace the PACS system. My boss, the CEO, came here from the Sacramento service transcribed in the traditional way. It took my radiologists area. And he had known vRad as a teleradiology provider, and some effort to get there; but now, 100 percent of our reports had had a very positive relationship with vRad in that capacity. are generated by voice recognition, and the report is signed in real time, so the turnaround times can now be We reached out to them because of that past relameasured in minutes. And that’s a huge techtionship, and explored the possibilities. They said, nology change for my radiologists. And we’ve gosh, we think we can help you. By the summer eliminated those transcriptionist positions. of 2009, we had an agreement in principle that HCI: The physician edits his or her own report they would provide teleradiology services, and and then signs it real-time, correct? that we would adopt their technology solution for Ferguson: Yes, that’s correct; and this is a a PACS solution and for a radiology workstation huge step forward, and I’m very proud of our solution. Our radiologists actually work on the radiologists, whose group’s name is Radiology same platform that the radiologists nationwide Consultants Limited (RCL). They worked very who use vRad use. Our radiologists work on idenhard with the vRad people on all this. tical hardware and software, as well as the voice HCI: What are your lessons learned from all recognition piece. this? We have six radiologists in our group, and they Dan Ferguson, M.D. Ferguson: The big lesson learned is to make all have a specialized workstation at home, and sure that the solution truly supports the workthere are four workstations here on campus. So 24/7, they have access. The benefit is, if need be, though it rarely flow of the clinicians. We really did stumble in the initial gohappens—from 7 a.m. to 11 p.m., my radiologists read. From live; there were a number of things we hadn’t thought of. But 11 p.m. to 7 a.m., the vRad radiologists read; so if my guys are though we had fully engaged the radiology department staff, really backed up, we can actually send studies to vRad. They do we hadn’t, in my view, engaged the radiologists fully enough in the design and implementation phases. The other learning all of our reading from 11 at night to 7 a.m. That rarely happens. Now, you heard about the air race di- was that we did experience some downtimes and experienced saster this summer [the Sept. 16 airplane crash at the National some loss of productivity. And we’ve lost Internet connectivity Championship Air Races in Reno, which killed 11 people and for brief periods of time, by every way you could lose it, and injured many more]? We got 28 patients from that disaster through every failure point of WANs possible. So we put a here. And those 28 patients underwent a total of 96 different server here in this building, to maintain Internet connectivity. HCI: Based on your experience, what would your advice be imaging studies—head CT, pelvic CT, etc.—done in five hours. Dr. Kim was our radiologist on that evening, and he read about to CIOs and CMIOs? Ferguson: I just think they should be willing to consider novel two-thirds of those studies; but Dr. O’Connell was at home and was asked to help out, and he read about one-third of them. approaches to providing a platform for their physicians to The technology gives us tremendous flexibility. If Dr. O’Connell work on. In our case, having a teleradiology solution like vRad for some reason had not been available, Dr. Kim could have that also provides the viewing capabilities, and doesn’t require any additional capital costs; and in addition, it really lowers gotten backup from vRad at that time. My neurosurgeons, my orthopedic surgeons, all my refer- our operational costs. In fact, our vRad costs are actually lower ring physicians, have access. Prior to going live in July 2010, we than the yearly maintenance fees we used to pay to our old had begun in the fall of 2009 to design the program; this was vendor. We don’t pay that to vRad; we pay them a per-study an innovation for all of us. We started working with the vRad fixed maintenance fee. We also don’t have to go through repeople and our staff, and it took us until the summer of 2010 to peated upgrades here. This approach is something that people architect it all. You can imagine that the workflow of a telera- should consider. Some people might have control issues—the diologist working out of his or her home is very different from idea that you don’t completely control the environment that the workflow of a hospital-based radiologist. We conceptually you’re working in, that you’re dependent on another entity for understood that in the abstract, and thought we understood our radiology solutions; maybe that’s a scary idea for some all aspects of it; but after go-live, we had additional issues we people. But it has worked well for us. ◆ 44 March 2012 •


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he use of ePrescribing still faces operational barriers, despite its growth thanks to federal incentive programs, according to a recent study funded by the U.S. Department of Health and Human Services’ (HHS) Agency for Healthcare Research and Quality (AHRQ). Conducted by the Washington, D.C.-based Center for Studying Health System Change (HSC), the study focuses primarily on transmission in ePrescribing, the electronic exchange of prescription data between physician practices and pharmacies. According to lead researcher Joy Grossman, Ph.D there are multiple benefits from the use of ePrescribing to fulfill and renew prescription orders. Among them are added efficiencies, a reduced risk of medication errors caused by poor handwriting, and ultimately, fewer safety risks. Although the HSC researchers recognized all of the above benefits, for the purpose of the study they focused solely on ePrescribing’s communication aspect, interviewing 114 pharmacies and physician practices. The results were mixed, and spoke to why ePrescribing has yet to take off in greater numbers, despite increasing federal incentives. Both physician practices and pharmacies noted there are problems with the renewals process and connectivity between physician practices and mail-order pharmacies, as well as a need to manually enter some of the medication information on the pharmacy side.

RENEWALS In general, both physician practices and pharmacies said they were satisfied with the electronic transmission of new orders. There are issues with timeliness, but those mainly have to do with either the pharmacy staff ’s lack of training or the physician staff ’s delay in sending orders. Other than that, the problems with new orders were few and far between. The renewals side told a different tale. According to Grossman, nearly one-quarter of the respondents didn’t fill renewals electronically, which was mainly due to a lack of capability or a desire to avoid transaction fees from ePrescribing network vendor SureScripts (Arlington, Va.). For those who had done renewals 46 March 2012 •

electronically, there was a breakdown in communication. On one side, physicians said they often get multiple requests from pharmacies using other means of communication such as faxes and phone calls. These come even after they have processed the request electronically, physicians said. On the other side, pharmacies said this is necessary if they hadn’t received a response from the physician within 24 hours. Making the process even more convoluted, there is the phenomenon of some physicians approving an order by phone or fax rather than doing so electronically. This complication, Grossman says, is caused by a lack of underlying technical standards for ePrescribing systems. There’s limited communication functionality between the two parties, causing pharmacy and physician practice to have their own methods of response.

MAIL-ORDER AND OTHER ISSUES Issues with renewals are only one aspect of connectivity problems between physician practices and pharmacies. Approximately 75 percent of physician practices said they have experienced difficulties with mail-order pharmacies. According to Grossman, most practices aren’t sure which mail-order pharmacies accepted ePrescriptions, and don’t rely on the ePrescribing process even if the pharmacies did accept them. Few vendors that are certified through SureScripts to ePrescribe with community pharmacies are also certified to do the same with mail-order pharmacies, Grossman notes. Thus even if they try to send the order to a mail-order pharmacy electronically, it often comes in as a fax anyway. The study also found there is an issue with some pharmacies having to manually enter parts of the prescription after transmission of the information. Grossman notes that most ePrescribing systems lack an up-todate unique identifier from the Food and Drug Administration’s National Drug Code (NDC). The NDC is used as a standard of medication identification across systems. Without a unique identifier, the pharmacist has to manually select the medication from their own database if the NDC in the ePrescription system and the pharmacy system don’t match. ◆


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Vocera Communications, Inc. .........................29 ∙ May 6-8, 2012 ∙ Orlando, Fla. • Healthcare Informatics 47




anaging a team of IT professionals is both rewarding and challenging—especially if they’re remote employees. I’ve learned over the years that it takes a unique kind of person to successfully function away from the heartbeat of that traditional office environment most workers take for granted. It’s equally challenging to recruit remote employees—to convince the Tim Tolan new hire that you actually have a plan to integrate them with the team. The remote employee needs to have multiple ongoing touch points to keep them engaged and feeling like they’re truly part of the team. If not, you run a very high risk of losing this talent to organizations with a better thought-out plan. The goal? To keep remote employees on track while ensuring that working (remotely) for your organization is both stimulating and fun! The best way to hire and retain remote employees is to de-

ees. This reinforces your belief in them as valued employees and sends the strong message that they matter. By including virtual employees in the interview process, you’re also showing new recruits that you have a comprehensive virtual employee model that works! Regular Team Outings: Plan dinner meetings with your team every five-to-six weeks. It doesn’t have to be at a fivestar restaurant, either. Having all of your team members together for dinner meetings may add to the overall T&E budget, but the team loyalty you’ll build will give you the return on both the time and monetary investment you’ve spent by having happier employees. Video: When you’re holding your weekly staff meetings, allow remote employees to attend via video. While it’s not the same as being there in person, it does allow remote employees to see the faces and smiles of their co-workers. Services like WedEx and ooVoo offer video options where multiple people ( frames) can join the call and visually participate. Conferences: Schedule meetings and team dinners at conferences to allow more face time for your remote employees. Since you already have the conferences built into your budget, you might consider flying or driving in one night and having dinner with your team. The extra effort of having you there will go a long way in letting your team know that it matters enough for you to be there. Building a successful team of remote employees isn’t just smart—it should also provide a preview of upcoming attractions in both hiring and retention, as virtual work environments are here to stay. Without a well thought-out remote employee hiring and retention strategy, some of them will probably figure it out and decide not to stay! The choice is yours. ◆

THE BEST WAY TO HIRE AND RETAIN REMOTE EMPLOYEES IS TO DESIGN A WORKFORCE ENVIRONMENT THAT ALLOWS THOSE WORKING AWAY FROM THE OFFICE TO MEET WITH THE REST OF THE TEAM ON A REGULAR BASIS. —TIM TOLAN sign a workforce environment that allows those working away from the office to meet with the rest of the team on a regular basis. I’m not suggesting that you hold quarterly meetings— that sort of minimum expectation model is fraught with increased risks to your overall team tenure. It also makes hiring much more difficult. I’m talking about using technology and actual face time with you and team members to include remote employees on a more regular basis. Here are a few ways to help build a successful remote team: Hiring: Think about allowing remote team members to participate in the hiring and training of new remote employ48 March 2012 •

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

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or the past 20 years, Healthcare Informatics has been ranking the 100 vendors with the highest revenues derived from healthcare IT products and services earned in the U.S. based on revenue information from the previous year. The Healthcare Informatics 100 list provides readers with a unique information resource and financial overview of vendors active in the healthcare IT market. Healthcare Informatics relies on companies to provide self-reported revenues, but in some instances estimates are listed.

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