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Understanding Care Management

Planning for Radiology CDS


The Demise of the Nevada HIE


Volume 31, Number 8

November/December 2014

Healthcare IT Leadership, Vision & Strategy

Imaging Informatics

The End of ‘Big Box’ Image Storage Planning?

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Informatics Healthcare IT Leadership, Vision & Strategy

2014 EDITORIAL BOARD Marion J. Ball, Ed.D. Professor, Johns Hopkins School of Nursing Fellow; IBM Center for Healthcare Management; Business Consulting Services, Baltimore, MD William F. Bria II, M.D. Chairman, Association of Medical Directors of Information Systems (AMDIS) Tina Buop CTO, La Clinica de La Raza, Oakland, CA



DIAGNOSTIC IMAGES MOVE BEYOND ‘BIG BOX’ STORAGE How are the multiple revolutions taking place in healthcare—accountable care, population health, HIE development, policy and reimbursement changes, and data sharing and storage technologies—transforming imaging informatics? BY MARK HAGLAND SIDEBAR


FEATURES 17 PLANNING FOR RADIOLOGY CDS TECHNOLOGY While federal requirements for radiology CDS may still be a few years away, one thing is for sure: they are coming. The time is now for laying the groundwork for implementation and physician buy-in ahead of the mandate BY CYNTHIA E. KEEN

24 GETTING A HANDLE ON CARE MANAGEMENT Care management is a multi-faceted concept that is difficult to define. Experts weigh in to provide a clearer picture of what it means, and to shed light on the technology choices, strategies and partnerships necessary for a successful care management program BY GABRIEL PERNA

28 WHAT CAUSED THE COLLAPSE OF THE NEVADA HIE? Despite hard work from a committed and able team, the Nevada HIE shut down in January 2014—after five years and spending $4.2 million of state funding. Here’s what the major players have to say about the complex set of factors that led to the demise of a once hopeful enterprise BY GABRIEL PERNA SIDEBAR


Bobbie Byrne, M.D. VP for HIT, Edward Hospital, Naperville, IL W. Reece Hirsch Partner, Morgan, Lewis & Bockius LLP, San Francisco, CA Christopher Longhurst, M.D. CMIO, Lucile Packard Children’s Hospital, Clinical Assistant Professor of Pediatrics, Stanford University School of Medicine, Palo Alto, CA G. Daniel Martich, M.D. Chief Medical Information Officer, UPMC Pittsburgh, PA Brian D. Patty, M.D. Vice President and CMIO, HealthEast Care System, St. Paul, MN Chuck Podesta CIO, UC Irvine Medical Center, Irvine, CA Benjamin M.W. Rooks Principal, ST Advisors, Inc., San Francisco, CA Rick Schooler Vice President and CIO, Orlando Health, Orlando, FL Patricia Skarulis Vice President and CIO, Memorial Sloan Kettering Cancer Center, New York Fran Turisco Director, Aspen Advisors, Denver, CO Ferdinand Velasco, M.D. Chief Health Information Officer, Texas Health Resources, Arlington, TX

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Informatics Healthcare IT Leadership, Vision & Strategy






REAL-WORLD DATA ANALYTICS In a wide-ranging discussion, a group of healthcare experts weighing in on policy, provider and vendor perspectives have a consensus: the broader purposes of data analytics must circle back to patients and their communities BY MARK HAGLAND



GETTING SERIOUS ABOUT HEALTHCARE DATA SECURITY Why Mac McMillan, cybersecurity expert and current chair of the Privacy and Security Committee of HIMSS, is issuing a stern warning about the nature of cyberthreats to healthcare, and the preventative measures that need to be taken BY MARK HAGLAND





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How one physician has tapped into a provider-to-provider social media network as a learning tool and a platform to share his ideas with his peers BY GABRIEL PERNA


MANAGING VIRTUAL EMPLOYEES How a host of technologies are enabling far-flung employees to function as a tightly integrated team BY TIM TOLAN

*2015 BUYERS GUIDE* 43

SENIOR ACCOUNT MANAGER, NORTHEAST Steve Menc [email protected] 216-373-1206 DIRECTOR OF SALES, IHT² EVENTS Robert Jaggers [email protected] 732-822-2518 PROJECT MANAGER, DIRECTORIES/ SPECIAL PROJECTS Libby Johnson [email protected] 216-373-1222

East River Medical Imaging has pushed hard on meeting Stage 1 and Stage 2 requirements. In a revealing interview, the leaders of that effort comment on what that it has meant from the perspective of a radiology group BY MARK HAGLAND



DIGITAL SALES DIRECTOR, WESTERN U.S. Michael Madej [email protected] 216-373-1234 SENIOR ACCOUNT MANAGER, SOUTHEAST Sal Silletti [email protected] 212-812-8430


How one health system’s initiative for early conversations about payment has paid off, both for the patients and for the hospital BY JOHN DEGASPARI






EDITOR-IN-CHIEF Mark Hagland [email protected] MANAGING EDITOR John DeGaspari [email protected] SENIOR EDITOR Gabriel Perna [email protected] ASSOCIATE EDITOR Rajiv Leventhal [email protected] ASSOCIATE EDITOR, READER ENGAGEMENT Megan Combs [email protected] SENIOR CONTRIBUTING EDITOR David Raths [email protected]



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Heading Towards $5 Trillion in Annual U.S. Healthcare Spending As healthcare spending hurtles toward unprecedented levels, ACO and population health strategies can help reduce spending on imaging informatics s seems always to be the case in such situations, we as a society are facing a “good news-bad news” scenario around U.S. healthcare spending. Indeed, as I wrote in a blog back in October, the new numbers coming out of the federal Centers for Medicare and Medicaid Services (CMS) in October were—and should be— alarming. The article, “National Health Expenditure Projections, 2013-23: Faster Growth Expected Mark Hagland with Expanded Coverage and Improving Economy,” written by a large group of actuaries in the Office of the Actuary at CMS, headed by Andrea M. Sisko, appeared in the October issue of Health Affairs. Essentially, for a variety of macroeconomic, healthcare-economic, policy, and societal reasons, the actuaries predicted that overall U.S healthcare spending is set to rise faster in the coming years than it has in the past few. With the U.S. economic recession technically over and beginning to fade in reality, and with millions more Americans now accessing health insurance coverage through the Affordable Care Act (ACA), things are set to change soon. As the article’s abstract puts it, “The combined effects of the Affordable Care Act’s coverage expansions, faster economic growth, and population aging are expected to fuel health spending growth this year and thereafter. …Because health spending is projected to grow 1.1 percentage points faster than the average economic growth during 2013-23, the health share of the gross domestic product (GDP) is expected to rise from 17.2 percent in 2012 to 19.3 percent in 2023.” What’s more, the CMS actuaries note, total U.S. spending on healthcare is expected to go from $3.056.6 trillion this year to $3.207.3 trillion in 2015, to $4.042.5 trillion in 2019, and to $5.158.8 trillion in 2023. That’s right: healthcare will cost our country more than five trillion dollars a year—and will consume 19.3 percent of our gross domestic product— within 10 years. Some of us remember how, back in the 1990s, many as/

serted that our entire economy and society would fall apart if U.S. healthcare spending went over the $2 trillion mark or over 15 percent of GDP. Well, obviously, that hasn’t happened; but healthcare has continued to consume an everlarger proportion of our economy’s financial energy. What’s more, the growth in healthcare expenditures as a percentage of GDP from 17.6 percent this year to 19.3 percent by 2023 should alarm any thinking person. That level of growth will compel every single person, from all stakeholder groups (purchaser, payer, provider, and consumer)—in other words, every one of us—to do what is possible to improve outcomes and efficiency and help control costs. In this issue’s cover story beginning on page 8, we discuss how the forward evolution of accountable care organizations and population health strategies is impacting imaging informatics. What’s clear is that significant savings will be possible in reducing or eliminating redundant diagnostic imaging procedures and improving results reporting and reporting-based actions, even as it is becoming clearer by the day that the way forward in terms of imaging informatics will not be through the creation of gigantic repositories of images, studies, and other data, but rather through the creation of mechanisms for direct communications and connectivity between and among providers. What’s more, the articles immediately following the cover story help point to ways in which imaging informatics and other leaders are doing things to improve care delivery and cost containment. Such development work will inevitably provide one element of a broader solution to our exploding healthcare cost crisis. And frankly, as we speed rapidly towards spending over $5 trillion annually on healthcare within the next decade, every single area of solution will be critically important.

Mark Hagland Editor-in-Chief

Purpose-built for healthcare leadership

Used by 50 leading healthcare organizations

Call: +1.877.685.7348 | Email: [email protected]


As ACOs and Population Health Move Forward,

No ‘Big Boxes’ of Diagnostic



Images Needed

Multiple revolutions are taking place simultaneously, with accountable care and population health, HIE development, data-sharing and storage technologies, and policy and reimbursement changes, all impacting imaging informatics now. BY MARK HAGLAND Informatics 9



overlapping ideas. So yes, repositories, but honestly, focus will be most imporI think, leave the images tant.” where they are, get the What’s more, Shrestha, meta-data, get the studies a practicing radiologist, if you need them. There says, “If you look at what are some advantages accountable care means in a centralized reposifor imaging groups, retory model with regard to ferring physician groups, workflow, per the cloud,” hospitals, etc., it means he concedes, “but more different things to differand more, even those are ent people. And just movgoing away. In fact,” he ing everything into censays, “the workflow adPhil Beckett, Ph.D. tral repositories doesn’t vantages of centralized make sense. What we’ve models will go away.” Most already started to do is importantly, he says, into embrace the power creasingly, “you’ll be able of the cloud, of collabto access things remotely orative care, and also of without having to move value-based healthcare images from PACS [picacross the continuum. ture archiving and comFor imaging, the care munications systems] continuum starts at the systems to centralized repoint of a patient searchpositories.” ing for a physician; or of Rasu Shrestha, M.D. aban order being placed for solutely agrees with Becka certain type of imaging ett that accountable care Rasu Shrestha, M.D. procedure. The care conand population health advancement will shift the discussion tinuum goes all the way through the imaround imaging informatics to one of aging procedure, the study report, and availability and agility. “In fact,” says, archiving.” Indeed, Shrestha says, “I call it the value-based imaging continuum—and YOU DON’T NEED ONE GIGANTIC IMAGE REPOSITORY. we need to look at things from an endSOME ARE ARGUING FOR CENTRALIZED to-end perspective. It starts from how you get scheduled and have imaging REPOSITORIES, BUT HONESTLY, I THINK, LEAVE THE procedures ordered; and it goes into IMAGES WHERE THEY ARE, GET THE META-DATA, GET smarter reports that are more meaningful today, managing archives, and radiTHE STUDIES IF YOU NEED THEM. —PHIL BECKETT, Ph.D. ologists facilitating collaboration with the ED physician and the vascular sural in October 2011, encompasses 10 hos- Shrestha, the vice president of medi- geon and the neurologist, making sure pitals in southeast Texas, making it one cal information technology at the vast follow-up happens. Looking at the care of the larger in the U.S. Beckett says it’s 20-plus-hospital University of Pittsburgh continuum is most important and what clear that the direction of HIE is moving Medical Center (UPMC) health system drives my thinking.” away from any notions of trying to repli- in western Pennsylvania, “the approach cate and store countless diagnostic im- should not be one of boiling the ocean, MOVING TOWARDS ‘SEMIages and reports in the cloud. “You don’t but one of focus—especially with regard UNIVERSAL REGISTRIES’ need one gigantic image repository,” he to the concepts of population health Rethinking patient care organizations’ ensays. “Some are arguing for centralized and accountable care, two distinct yet meshment in proprietary systems of imndustry executives and thought leaders agree: the bottom line, when it comes to the intersection of accountable care and population health with imaging informatics and health information exchange (HIE) and datasharing and data-storage technology advances, is this: the future is not about gigantic warehouses of diagnostic images and radiologic reports in the sky. Rather, it’s about intelligently connecting clinicians and other appropriate healthcare professionals in order to share and access diagnostic images and radiology reports at the right moment and in the right way. Perhaps, for some, that concept might seem self-evident; and yet it really isn’t, as the path of health information exchange has been a wandering one over the past decade, with all sorts of concepts and objectives involved. But as health information exchange matures, as the technology and processes around HIE mature, the focus is becoming clearer. Phil Beckett, Ph.D., chief technology officer of Greater Houston Healthconnect, is a good person to talk to in this context. Greater Houston HealthConnect (GHHC), which became operation-


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2013 Speaker Faculty Included:

Bryan Sivak Chief Technology Officer US Department of Health and Human Services I

Keith Perry Associate VP & Deputy CIO UT MD Anderson Cancer Center

Matt Chambers Chief Information Officer Baylor Scott & White Health

Bill Phillips SVP & CIO University Health System

COVER STORY age storage will be an im“most of the VNA [ven- image-communication systems across portant step forward, says dor-neutral archive] ven- diverse IT environments within the Joe Marion, founder and dors are beginning to em- same health systems. “If you go to a principal at the Waukesha, brace the XDS standard VNA strategy with an XDSI protocol, Wis.-based Healthcare Inas a more universal way of you can build a common registry,” he tegration Strategies conbeing able to access im- adds; and that is exactly what he is sulting firm. He cites a reages, documents, all con- helping the UMass folks do. cent consulting experience tent. So my point is that if as really underscoring for they embrace that, there FOCUSING ON IMAGE him one of the challenges are two elements associ- AVAILABILITY to making images availated with the definition. Still, says Micky Tripathi, Ph.D., presiable for population health One is a repository, where dent and CEO of the Massachusetts and accountable care purthe data is physically eHealth Collaborative (MAeHC), “There Joe Marion poses. “I’ve been working stored. The other is the is no single best answer to the question with a group in a western registry, like at a store— [of centralized image storage versus province of Canada,” he it’s a means of identifying point-to-point facilitation], because it reports, “And in the Canathe information. So you depends a lot on imaging utilization dian healthcare system, can have one registry and patterns and what systems are already hospitals are governmentmultiple repositories, and in place.  Jumping towards creating the owned, while physicians that’s where we’re head- facilitation of point-to-point sharing of contract with the governed, towards semi-univer- images and data is a big step, and probment to do imaging prosal registries.” ably the option of last resort.  Storage is cedures in the hospitals. The advantage, Marion cheap, but I would focus in any case on In this case, a government adds, is that “The registry an approach that unifies access to disstudy had recommended knows about every study, tributed imaging information, rather that the healthcare adminand the repositories can than on the consolidation of the images istrators of that provincial Micky Tripathi, Ph.D. study them. The advan- themselves, he says. health authority should tage is that let’s say you Drilling down one more level, Tripaconsolidate and store everything in the have three competing hospitals, and thi emphasizes that there are layers to provincial PACS, for easy accessibility. The the economics of combining their ar- the issue. He cites the following as improblem,” he says, “is that everything has chives is not there; but with an XDS- portant layers to consider: now been stored in a proprietary system, and that there would be costs for the in- THERE IS NO SINGLE BEST ANSWER TO THE QUESTION dependent physicians of sending their studies in to be stored in that system. That [OF CENTRALIZED IMAGE STORAGE VERSUS POINTmakes no sense. It would cost millions of TO-POINT FACILITATION], BECAUSE IT DEPENDS A dollars to do that, at $1.99 per study.” Given the situation, Marion says, LOT ON IMAGING UTILIZATION PATTERNS AND WHAT “What I’ve suggested is that they consid- SYSTEMS ARE ALREADY IN PLACE. er leveraging the XDS [cross-document —MICKY TRIPATHI, Ph.D. sharing] standard as an alternative, and set up an XDS-based archive, because it based registry, and it would connect r *NBHJOH JOGPSNBUJPO BWBJMBCJMJUZ‡ would have much more broader appeal all communications. You’d know that some ability to know that a relevant for imaging across all –ologies, DICOM- Mary Smith had four different studies imaging study has been done and based or not. Also, the way that the XDS in four different places.” He adds that where to go for the results/interpreis structured facilitates the easy sharing he is already working with integrated tation ( followed by a manual proof diagnostic images, documents, faxes, health systems across the country on cess to chase down the results, as any format of information that’s a docu- such efforts—for example, the UMass needed and relevant); ment. There’s an extension called XDSI, Memorial Health System, based in r *NBHJOH JOUFSQSFUBUJPO BDDFTT‡ for imaging. In fact,” Marion notes, Worcester, Mass., to create data- and some ability to gain electronic ac/


In the Cloud, Image Sharing Made Easy

When it comes to medical imaging, the days of CDs are behind us, as the most advanced organizations are implementing technology that will enable them to instantly view, share, and store medical images and associated reports for patient care. Undoubtedly, patients want fast, decisive care decisions, while clinicians need instant access to medical exams and images; and certainly, that need heightens in the face of trauma, as time is of the essence. In Birmingham, Children’s of Alabama hospital serves as the state’s only pediatric trauma center and the only pediatric burn center in the Southeast. As everywhere, receiving medical images on CDs became very problematic at the hospital, and issues would constantly arise with formatting and damaged discs, says Josh Pavlovec, picture archiving and communication system (PACS) administrator, at Children’s. “[Image] viewing had been an ongoing issue for us, as our workflow is complicated even more due to the fact that we don’t have 24/7 attending radiologist coverage,” he says, noting that Children’s would often depend on radiology residents who would sometimes be down the street at the university hospital. “If we had a CD come in to be imported into our PACS for remote viewing, the disc had to be walked down the street to that resident. It caused a lot of heartache and patient care issues,” he says. After investigating different resolutions, Pavlovec and others decided on the Burlington, Mass.-based Nuance’s PowerShare Network, a cloud-based medical imaging network that enables providers and patients to coordinate care and share information across disparate health systems (Nuance recently announced that 3 billion images have been shared on its PowerShare Network). Prior to joining the network, Pavlovec says, providers were not able to easily share images and reports with nonaffiliated organizations, resulting in inconsistent and delayed patient care, and added costs for unnecessary reimaging. Now, he continues, it is extremely rare that Children’s gets images that it cannot import and view remotely. “It has evolved to the point where we will see images someContinued on next page Informatics 13

COVER STORY utilization to a smaller set of lower cost imaging providers, Tripathi adds. Indeed, he says, it may be easier to get providers to refer to a smaller set of imaging sources than it is to figure out sharing across multiple imaging sources. “Finally,” Tripathi says, to the extent that HIE activities/organizations can provide value here, I would suggest that it’s in record location (identifying that a relevant imaging study has been done somewhere), providing access to the reports/interpretations, and lastly, perhaps providing access to distributed PACS systems or to commercial image sharing providers, through SSO enabled by the HIE activity.  I would not go to having the HIE activity handle/store images themselves.” One non-technological, yet very important, factor in all this, says Jim BReay, will be for healthcare leaders to consider the impact on radiologists’ medical practice (and business) generated by the forward progress of HIE development. Specifically, more advanced HIE development will almost certainly continue to reduce the number of redundant diagnostic imaging procedures and studies going forward. With recent federal reimbursement mandates to bring down healthcare utilization, radiologists are beginning to feel unfairly targeted. “The reimbursement trendline is very clear,” says B-Reay, a Minneapolis-based principal at the Pittsburghbased Aspen Advisors consulting firm. “And radiology really is at the tail end of that, but it’s going to hit the radiologists hard over time. They’re going to see, and probably are seeing, a decrease in tests ordered; and it’s like, wait, I did five fewer than last year at this time, right? And it’s because we won’t do that third MR on the knee, right?” Though such personal reactions to the advance of technology having nothing to do with the technology itself, they inevitably will influence physician (and especially radiologist) acceptance of such changes in

Continued from previous page times hours before the patient arrives. We’ll have it imported in PACS before the patient comes through the door,” he says, adding that the ability to view it on the mobile app has even allowed physicians to see images on their phones when they’re at conferences. “Physicians love that they don’t have to deal with a CD anymore. The network takes their mind off of whether or not they can access an image—allowing them to focus on treating patients.” At last count, notes Pavlovec, there are more than 80 facilities that Children’s has connected with that could push images to the hospital immediately, as well as several of its referral facilities and countless physicians that are set up on the network. “Our workflow structure has eight physicians that are part of our facility, and we give them full access to images on our cloud. It’s part of our Health Insurance Portability and Accountability Act [HIPAA] coverage, and can view anything as long as they log in securely,” he explains. Regarding data security, Pavlovec says that any device issued by the hospital to a staff member has built-in encryption or requires a passcode, even for email. “If you install our email on your personal device, it will require a log-in, and that goes for the mobile app too. We trust the vendor and its security measures,” he says, adding that if an outside organization wants access to a patient’s images, once the method of contact—usually email—is secure and signed up, the images can be sent. “We receive a lot more [images] than we send out, but if we have a patient getting a procedure done or getting a second opinion in Salt Lake City, for example, we contact that physician, and we can share those images through this product within five minutes of getting the email address. We police everything, such as if they could view only or view as well as copy, he says. Regarding patients’ ownership of their images, even though Stage 3 of meaningful use will require providers to be able to give a medical portfolio to caregivers and patients—including images—Children’s is not quite there. “Meaningful use was definitely a driver for our patient portal, and while viewing images on the portal is possible right now, the results of the scans are not involved yet,” Pavlovec says. However, he notes that is on the horizon, in addition to moving to a vendor neutral archive (VNA) architecture, citing the desire to not be locked down to just one viewer. That said, since implementation of Nuance’s product, Pavlovec says the volume of CT scans has dropped considerably, and repeat scans—especially for trauma patients—have also been reduced significantly to the point where they are extremely rare. What’s more, previously, if a patient had a contrast material—needed for some CT scans to help highlight the areas of your body being examined—there would have to be a wait to do it again, which could increase the length of stay for the patient. “We’ve had numerous instances when patients didn’t bring images with them, and if the scan couldn’t be repeated at the time of the visit, the patient would have to return for a repeated scan,” says Pavlovec. “We can now pull those images almost immediately and prevent the patient from having to return. It’s a scenario that has happened many times, and it’s saved a lot of time,” he says.


—Rajiv Leventhal


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COVER STORY the coming months and index aspect. That is a years, he says. challenge for everyone; Meanwhile, radioloin HIEs, ACOs, you’ve got gists and referring phyto be able to match a pasicians themselves are tient across facilities, and beginning to see that crethat’s not an easy task. ating big boxes full of imWe’ve all got mistakes ages and reports doesn’t and duplicates internally. really make sense. “I was But now you’ve got to talking to someone in be able to match up the radiology recently at a imaging study with the major medical center,” master-patient index, so B-Reay says. “And essenI can get a list back of evJim B-Reay tially, he was telling me erything that’s been done that creating the imaging part of an to one patient. So you need that metaHIE at that health system was turning data.” out to be a kind of a bust. The value of As UPMC’s Shrestha underscores,




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creating a centralized repository for all images ended up not really being there. It was sufficient to know that a test had been done, and then one needed to do a point-to-point transfer of images. The shared-tank concept of imaging repositories has proven to be kind of a flop.” At the same time, as patient care organizations and HIEs move forward on multiple fronts in the accountable care and population health spheres, experts say it will continue to be very important to get the basic “blocking and tackling” right in terms of image-sharing, and that includes the correct matching of patients and their images, studies, and reports, a set of tasks that remains challenging. “The key piece,” says GHHC’s Beckett—is the whole master-patient

“Population health means having the ability to define patient populations, identify gaps in care, and risk-stratify, especially in the accountable care context. So when you identify gaps in care and risk-stratify, and this is where imaging comes in, you need to manage care and identify gaps intelligently. So it’s not just ordering a study, but understanding why that study is happening for that patient at that time,” he says. “It’s also about care coordination, which implies the right levels of communication between the radiologist and the referring physician. Last but not least, it’s also about measuring outcomes. And having that level of transparency through all of these different steps, is really critical.” ◆


Panasonic .................................... 23 SCC Soft Computer ........................ 3 Time Warner Cable Inc. Business Class ....................................... 15 Verizon Wireless .....................CVR 3

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Planning for Radiology CDS Technology While federal requirements for a radiology CDS are still a few years off, there is a strong case for laying the groundwork for implementation, and physician buy-in, ahead of the mandate BY CYNTHIA E. KEEN s value-based medicine takes hold in the paradigm shift from fee-for-service to accountable care, the role of the hospital radiology department is expected to shift from being a profit center to a pivotal center that drives cost-savings. Imaging’s forté is to provide rapid diagnoses of suspected clinical conditions and to enable caregivers who depend upon radiology exams to function better and more efficiently. But the use of diagnostic imaging has an Achilles’ heel if a physician doesn’t order the most appropriate exam for a desired diagnosis. Regrettably, there has been little incentive to mandate this. While the radiology profession has developed evidence-based guidelines through 20-plus years of continuous work by the American College of Radiology (ACR), it’s not been hospital culture—nor has there been any financial reason—for radiologists and radiology departments to intervene when exam-ordering mistakes are made by well-intentioned doctors. Until recent years, the clinicians and staff of radiology departments had no easy access to appropriateness guidelines, and often patients’ files themselves, to be able to determine this. The use of electronic medical records (EMRs) has eliminated the barrier to review a patient’s file. Computerized physician order entry (CPOE) systems

integrated with EMRs have made the process of ordering imaging exams efficient. Radiology clinical decision support (CDS) systems integrated with both provide a workflow-integrated, point-of-care evaluation of the appropriateness of the exam being ordered for a patient’s clinical indications, along with recommendations of more suitable or alternative exams. Commercial CDS systems and electronic medical record CDS modules deliver an appropriateness score based on the ACR Appropriateness Criteria guidelines or individual preferences of the hospital itself.

Right now, a very small percentage of U.S. hospitals use radiology CDS technology; but this will change dramatically as of Jan. 1, 2017, thanks to the passage of the Protecting Access to Medicare Act of 2014. Any healthcare provider ordering an advanced imaging exam—specifically computerized tomography (CT), magnetic resonance imaging (MRI), nuclear medicine and positron emission tomography (PET) will be required to consult appropriateness criteria approved by the Centers for Medicare and Medicaid Services (CMS). Use of appropriateness criteria will be mandated by law, and based on input to CMS by professional Informatics 17

FEATURE medical organizations (presumably the ACR and potentially other physician organizations). Reimbursement for advanced imaging exams performed for Medicare/Medicaid patients will be made only if appropriateness criteria are consulted and verified. Smart money is betting that private insurance companies and other payers will follow suit. It’s not a moment too soon. An estimated 20 percent or more of CT scans are duplicative or ordered inappropriately each year, according to numerous studies published in peer review journals. Early adopter hospitals of EMRs and CPOEs that have either developed their own proprietary CDS systems or purchased commercial ones have documented impressive results in exam reduction. This intelligent software technology is an effective gatekeeper; but it’s not plug-and-play, and it can be gamed by its users. So what’s a CIO, COO and CMO to do? Those employed by hospitals that are heading toward accountable care would do well to reap the cost-savings benefits that even a partially implemented radiology CDS system can provide. Early adoption would enable physicians to become comfortable with this technology, easing the pressures associated with mandatory usage. Through usage, a CDS system can be modified to fit the exact needs of their specific hospital or hospital enterprise while preparing to meet the federal requirements. Just like any new healthcare IT technology, physicians are not likely to embrace a radiology CDS system with open arms. Similar to speech recognition dictation systems, there may be far more resistance than acceptance. A machine is going to judge the wisdom and recommendations of a physician? Although a soon-to-be-mandatory fact of life when practicing medicine, resistance will need to be overcome through

cultural change starting with top man- staff within the organization, so it is imagement and proof through practice portant to know how frequently a CDS that the system will be of clinical value vendor incorporates these changes and rather than another bureaucratic hin- additions and the manner by which it drance. notifies its customers. This can be esMost commercial radipecially important if a ology CDS systems today customer hospital has have licensed ACR Select significantly customized software from the Nathe rules for a guideline tional Decision Support that would be impacted. Company, Andover, Mass., Beyond this, workflow which itself has entered a integration, ease of use, licensing agreement from speed of delivery, custhe ACR. However, CDS tomization, flexibility, systems—like radiology and analytics capabiliinformation systems (RIS) ties are the key factors to and picture archiving and evaluate. communication systems Integration: A radiolSteve Herman, M.D. (PAC S)—dif ferentiate ogy CDS system must be themselves in features and functionality. integrated with the CPOE system to Should a hospital use the free ACR be efficient. However, the better it can Appropriateness Criteria and de- be integrated with the EMR, the better velop its own radiology CDS system? it will be for users. If pertinent patient Such an initiative was undertaken by data from the EMR can automatically early adopters, most notably Boston’s and seamlessly populate the fields of Brigham & Women’s Hospital in 1998; the radiology CDS, workflow will not be but with today’s selection of commer- impeded by the need to re-enter necescially available products, why even con- sary patient data that a physician has sider this? already entered into the EMR. A savvy CIO would do well to estabSimplicity, ease of use and efficient lish a small multidisciplinary team workflow: In addition to an easy-to-vito evaluate the offerings. A good mix sualize and use graphical user interface, would include several physician tech- the content should be context-specific, nology evangelists from different clini- concise, unambiguous and easy to secal departments, an emergency phy- lect. Complexity of options and dropsician, a radiologist, a radiology IT down menus, numerous scroll bars, manager, and a healthcare IT general- and fields to fill will be detrimental to ist. The team should also be assigned to use. The decision-tree chain should be evaluate the best ways that a radiology designed to minimize mouse-clicks, CDS system could be utilized with the instead providing one-click options highest level of success, the greatest po- that rapidly deliver an appropriateness tential to achieve the greatest positive score. Access to explanatory informaimpacts, all in the context of available tion and published studies should be training and deployment resources. available through links, but not a required part of the process. According to Steve Herman, M.D., a FACTORS TO CONSIDER WHEN thoracic radiologist and chief medical EVALUATING CDS SYSTEMS ACR guidelines are developed and kept officer of MedCurrent (which offers the updated through the work of about 100 OrderRight clinical decision support member specialists and by a dedicated system), the last thing a busy doctor


FEATURE wants would be bombardment with numerous options, check boxes, and extra information. “Ordering physicians must find the system efficient and easy to use. They cannot be presented with

critical importance to user acceptance. Even a few-second delay can give physicians the perception that their workflow is being hampered. Flexibility: The ability to change an or-

ORDERING PHYSICIANS MUST FIND THE SYSTEM EFFICIENT AND EASY TO USE. THEY CANNOT BE PRESENTED WITH SCREENS FULL OF INFORMATION THAT WILL SLOW THEM DOWN. THE LAST THING THAT A CIO WANTS TO CONTEND WITH IS DOCTORS WHO HATE THE SYSTEM, BECAUSE ULTIMATELY THEY ARE GOING TO BE REQUIRED TO USE IT. —STEVE HERMAN, M.D. screens full of information that will slow them down. The last thing that a CIO wants to contend with is doctors who hate the system, because ultimately they are going to be required to use it,” he says. He also advises that in situations when other exams are recommended instead of the one being ordered, a user should be able to immediately switch to ordering a different exam without having to start all over. “A successful CDS system needs to have the ‘intelligence’ to switch gears midstream quickly with-

der for an exam midstream is one example of flexibility. The other is the ability to override a negative recommendation and to continue to order the desired exam. Some hospitals intervene with a requirement that the ordering physician must consult with a radiologist to continue to place the order. This may be very appropriate for certain types of exams and clinical situations. However, such interventions might be best only after the CDS system has been in use for a number of months, after there has been a period of time of analysis of “out-

A SUCCESSFUL CDS SYSTEM NEEDS TO HAVE THE ‘INTELLIGENCE’ TO SWITCH GEARS MIDSTREAM QUICKLY WITHOUT IMPEDING WORKFLOW. IT NEEDS TO BE PERCEIVED AS AN AID TO PROVIDE RELEVANT CLINICAL SUPPORT TO A PHYSICIAN, NOT BE A HINDRANCE. —STEVE HERMAN, M.D. out impeding workflow. It needs to be perceived as an aid to provide relevant clinical support to a physician, not be a hindrance,” he says. Among his recommendations for a successful system are: Speed: The faster the system works the better. System performance is of

lier” orders and the reasons for them. Customization: The ability to easily customize a CDS system, both with respect to authorizing specific exam categories and also to modify the ACR guidelines, is a necessity. Dr. Herman says that virtually every hospital executive he has talked with has said that


while the ACR appropriateness criteria is excellent, it is not 100-percent applicable to their hospital. “The last thing that a CIO in a hospital is going to want to do is be boxed into a set of rules that doesn’t work for them. Hospitals also need the flexibility to make modifications quickly and easily, without needing to ask the vendor to do this; although when selecting a vendor, it’s important to make sure that that sort of support can be immediately offered as well,” Dr. Herman says. As an example, he cites a hypothetical case in which a MRI exam had a score of 8 and an ultrasound exam had a score of 7. If getting a MRI was difficult in the middle of the night, for example, and the clinical situation for the ultrasound would not compromise the patient, it might be more appropriate to tweak the system and give the ultrasound exam a higher score. Analytics: A CDS system should have a strong analytics component, with the ability to be easily customized as well. Constant monitoring not only shows who is using the system and how well they are adhering to appropriateness criteria, but also identifies areas where modifications may be needed and areas where better guidelines should be developed.

PLANNING FOR IMPLEMENTATION OF A RADIOLOGY CDS Like any new technology, thoughtful, comprehensive planning is the key to successful adoption. The main objectives are to get physicians to incorporate decision-support technology into clinical routines and to follow the advice they receive. Gradual implementation of the system may be the easiest route, whether determined by the most frequent exams ordered, by type of specialty, or by geographic entity such as an outpatient clinic, or by a combination thereof. Identifying champions and determining who within a system would be the


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FEATURE best pioneering adopters is important. A pilot group of users needs to receive tangible benefit from use of the system and show positive measurable results. Successful adoption is as much a factor of strong leadership and a culture to “do the right thing” as it is the functionality of the system. Radiology needs to be involved from the outset. First, a senior radiologic technologist or a department manager needs to perform a comprehensive procedure mapping exercise with respect to names of an exam. If the name of a procedure used by a hospital differs from the name in the CDS system, the name in the CDS system needs to be changed to conform. This typically takes a day or two. The implementation of a radiology CDS should be perceived as a way to restore consultations by radiologists with physicians that have predominantly disappeared with the accessibility to PACS. The hospital’s radiologists need to buy into this, and they need to be ready to answer questions by ordering physicians when a call is placed to the department. There are obviously numerous ways to plan this but the process should be defined and in place before the CDS goes live. What should be monitored and the frequency of monitoring should also be determined in advance. Feedback needs to be defined. A standard process and protocol for inquiries about “outlier” orders should also be established and conveyed in advance to users. “Outlier” orders may be indicative of a physician who needs better information and a friendly consultation by a radiologist. Or they may represent the exception to the rule. Outlier orders also may identify gaps in guidelines that need to be addressed. Managers also need to plan how, to whom, and with what frequency reports are ordered. Users need to be kept informed. Doctors by specialty, depart-

ment, and individual should be kept informed with respect to overall performance and comparison with peers. Compliance, after all, is a factor of objective feedback and peer pressure. “Launching a CDS system well in ad-

Every well-established commercial CDS vendor using ACR Appropriateness Criteria evidence-based guidelines as the foundation of their products or who have licensed ACRSelect software plans to comply with the rules that


vance of the federal requirement of 2017 means that there is much less pressure for both ordering physicians and the hospital. With the right analytics and feedback loop in place, the better and more smoothly it will work when it becomes mandatory,” Dr. Herman explains. The other benefits: cost-savings to patients, payers and the U.S. economy by eliminating inappropriate and clinically useless exams. There will be enhanced quality service to patients by minimizing physician misjudgment with respect to the exam they are ordering and also by convincing patients who may demand a specific procedure that expert advise may show they are wrong. There will be enhancement of patient safety, especially if a radiationemitting procedure can be eliminated or substituted with an equally appropriate non-ionizing radiation MRI or ultrasound exam. What is the risk of a hospital implementing a CDS system in advance of federal requirements and facing the risk of needing to replace it if not ultimately approved by CMS?


CMS establishes to vet and approve CDS systems. CMS media spokesman Donald McLeod advises that the agency was still very much in early stages of planning as of October 2014. No office has been formally established yet within CMS to answer inquiries or offer advice. However, it seems highly unlikely that CMS would not adopt the ACR guidelines which cover hundreds of clinical conditions and have been in widespread daily use for over 20 years. The ACR, which works closely with the American College of Cardiology (ACC), the American Society of Radiation Oncology (ASTRO) and other professional organizations that use specialized imaging, has expanded its guidelines-related staff and has been meeting regularly with CMS. So—is it time to act? If vendor feedback is indicative, a lot of CIOs think so. ◆ Cynthia E. Keen is a freelance writer based in Sanibel Island, Fla. She has been writing about radiology clinical decision support technology since it was first commercially introduced, and has spent more than two decades covering healthcare IT.




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The Trouble with Putting Care Management in a Box Health IT leaders are finding it difficult to define care management technology because they’re finding it difficult to define care management BY GABRIEL PERNA


t seems as though no one can clearly define care management technology. Many see care management and the technologies that enable it in direct correlation with population health management. In that sense, care management could be described as the process of analyzing, identifying, monitoring, and improving the care of specific patients within a vulnerable population. Yet as Dave Levin, M.D., CEO of health IT consultancy Tres Rios Group, and other observers note, this overall concept in itself is comprised of many technologies and stakeholders. In other words, care management technology can’t be easily defined because care management is probably too complex to be put in a single box. There are consumer-facing technologies, analytics tools, and physician dashboards that service diverse groups of patients, payers, and providers. Ex-

to enable [care management], whether we’re talking about analytics and data aggregation and dashboards or the connectivity tools. They are out there,” Dr. Levin says. “The challenge in front of


us is to have a better understanding of the full cycle of this kind of care management. It’s not just identification and


stratification; it’s about outreach, intervention and engagement too.” Whatever it is, it seems to be the future of healthcare—at least, according to Markets and Markets, a Dallas-based research firm, which predicted explosive growth for the care management software industry over the next five years, culminating in a value of $7.3 billion in 2018. That would be billion, with a b. Markets and Markets says the value-based legislative reforms of the Affordable Care Act (ACA) and an aging population are the primary drivers of this growth. At the same time, integrated care networks are popping up across the country with payers and providers entering into unlikely alliances to get in on the

FEATURE action. This has led to an investment in care management technologies, whether it is analytics, telehealth, dashboards, or something else. Investments have come from payers and providers, but mainly the former. Levin notes that providers don’t yet have the experience, while a recent survey of payers from Framingham, Mass.-based IDC Health Insights indicates that more than half of payers are investing into care management applications.

WHAT WORKS IN CARE MANAGEMENT? This wave of interest and investment in these technologies, regardless of where it is coming from, has led to a wide range of opinions and feedback on what works and what doesn’t. In Richmond, Va., a physician-hospital organization (PHO) by the name of inHEALTH formed in the mid-1990s, during the previous managed care era, 20 years before risk-based contracts and care management became trendy. The PHO, led by CEO Michael Matthews, has sustained itself by providing health IT and other services related to care management programs. To Matthews and inHEALTH CMO Stephen Cavalieri, M.D., the most important element in a care management program is successful transitions of care. For their group, this has been accomplished through data exchange, encounter alerts, and secure messaging. inHEALTH has a health information exchange subsidiary, MedVirginia, that it uses to accomplish this. From there, inHEALTH utilizes an analytics system ( from the Dallas-based Phytel) that helps determine which patients have the highest risk. “What population health and analytics tools can do is give you the visibility to understand the patient in between [doctor encounters] and healthcare episodes. When you tie in clinical events [through the EMR] with the type of workstation the care manager has, and also can con-

based director of technolnect in claims informaogy and innovation at the tion, which we have access Denver-based Aspen Advito...a lot of it is blending sors puts it, what works in those information sources one place isn’t guaranteed and creating this tapesto work in another. “When try that we can act on in you’ve seen one integrated a complimentary way to care network, you’ve seen what the physician is doone. Every market is differing,” Matthews says. ent,” he says. Or to sum it up, as Many burgeoning proCavalieri says, “The holy grams are using different grail is interoperability.” remote technologies to Levin affirms that potenDave Levin, M.D. enable care management tial data interoperability problems are a “huge boulder sitting in through patient engagement. Carethe way” of any successful care manage- More, a Medicare health payer based in

WHEN YOU’VE SEEN ONE INTEGRATED CARE NETWORK, YOU’VE SEEN ONE. EVERY MARKET IS DIFFERENT. –GREG MCGOVERN ment program. If different sets of data Cerritos, Calif., is centered on a model can’t interact in and out of the provider’s that provides proactive, risk-based care workflow, he says, the program is going management plans to high-risk elderly populations. According to have a high failure rate. to Scott Mancuso, M.D., Indeed, many burgeonsenior medical officer, the ing care management procompany has invested in grams rely on interoperable several remote monitoranalytics software, which is ing technologies as well able to connect payer and as telemedicine to care provider data and spit out for patients at home. actionable information on “We’ve made investhigh-risk patients. It’s the ments in congestive heart reason why integrated care monitoring, hypertennetworks, like the ones sion monitoring, COPD at the Danville, Pa.-based monitoring of oxygen Geisinger Health System Michael Matthews saturations. Those are and the Oakland-based Kaiser Permanente, have been successful things we’ve been doing for years. More recently, we implemented video into the in care management for a long time. Still, as Greg McGovern, a New York- patient’s home. That video goes far be-


FEATURE Snapshot of a Care Management Program

yond the reach of physicians, it goes out to social work case managers and pharmacy workers,” Dr. Mancuso says. Telemedicine is one of the technologies of choice for leaders of a diabetes care management program at the University of Mississippi Medical Center (UMMC). The medical center is teaming with the State of Mississippi, GE-Intel care management software vendor, Care Innovations, and rural hospital North Sunflower Medical Center to improve care for diabetics in Ruleville, Miss. Clinicians at UMMC connect with their rural counterparts and the patients through a telemedicine platform. Furthermore, patients in the program are managed through a cloud-based platform. (See sidebar.)

NON-TECHNICAL DIFFICULTIES The UMMC Telehealth Center, which provides eICU and remote telemetry services. Nurses remotely monitor patients, serving as a second set of eyes to closely track their conditions. Photo: UMMC

The University of Mississippi Medical Center (UMMC) is leading a diabetes-based care management effort among public and private stakeholders to improve health outcomes in a state that’s ranked nationally at the bottom in overall health outcomes and specifically for diabetic care. Here are a couple of details on the program, which has already moved the needle only a few months in. Stakeholders: UMMC, State of Mississippi, Care Innovations, Sunflower Medical Center. Aim: To improve the care and outcomes of diabetics in Ruleville, Miss. and replicate the model for other chronic disease management programs. Technologies: Use of UMMC’s telehealth capabilities connects an eClinic in Ruleville to UMMC; a care management platform which allows providers to monitor a patient’s vital signs and glucose levels, adherence to medications, and provides them with personalized content on diabetes. Results: It’s early, but no patients have had to do to the emergency department and glucose levels are trending down. Quote: “If the telehealth and remote monitoring systems work well, you’ll see an improved efficiency in the entire healthcare system. It has a huge potential.” —Kristi Henderson, M.D., Chief Telehealth & Innovation Officer at UMMC. Read more on the UMMC diabetes telehealth care management program at

While no one would claim that the various care management tools on the market have fully matured, many are looking past the technology itself in their critical analyses of the emerging philosophy. Steve Krupa, managing partner at the New York City-based venture capital firm Psilos Group, says that the biggest hurdles of implementing care management technology isn’t the technology, it’s the lack of a business case for participation in a care management program. “From the health insurance companies’ point-of-view, [implementing care management programs] hasn’t been something they’ve felt they needed to do from a core competency standpoint. And certainly that’s the case for the feefor-service provider side as well,” Krupa says. “The mechanisms of the business haven’t required care management yet.” Mancuso, from CareMore, agrees that there are financial hurdles in implementing the kind of care management technologies his organization has invested in. The return on investment is difficult because the technologies cost a lot up front. It’s one of the reasons why, as Levin and Matthews from in(Continued on page 38)



What Caused the Collapse of the Nevada HIE? Despite hard work by a committed team, a complex set of factors led to the demise of a hopeful enterprise. Here’s the inside story from the major players of a failed HIE BY GABRIEL PERNA


n Jan. 24, 2014, the board of directors at the Nevada Health Information Exchange (NV-HIE), the state-designated entity to foster data exchange, ceased operations by a vote of four to two. Thanks to Nevada Open Meeting Law requirements, the decisioin is immortalized for future generations to ponder. One month after the vote, the NVHIE shut down completely. CEO David LaBarge stayed on until March to close up operations completely. All the parties involved in the NV-HIE have since moved on, and the only thing remaining is the website. It’s easy to say the board killed the Nevada HIE that day in Carson City. However, this isn’t a simple “whodunit.” The NV-HIE wasn’t done in by its board of directors, the maid, or the butler. There are several elements that led the people behind the NV-HIE to cease operations, just as there would be if a local startup restaurant flopped. LaBarge, a health IT veteran currently working as a consultant, whittles the failure of the HIE down to three specific reasons. “The lack of opt-in capabilities; not having the legislator allocate money from the Medicaid population to help fund and sustain the HIE; and not starting early were three components we didn’t have that make most HIEs successful. If you don’t do at least one or two of those three, it’s pretty difficult to

get started and to be sustainable,” LaBarge says. “We were zero for three.”

HIES: STRUGGLING TO BE SUSTAINABLE The genesis of the HIE was the State Health Information Exchange Cooperative Agreement Program, based on the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. HITECH authorized the establishment of the infrastructure that would lead to statewide HIEs. In 2010, the Office of the National Coordinator for Health Information Technology (ONC) doled out grant funding to 56


states and territories through the State HIE Cooperative Agreement Program. The Nevada Department of Health and Human Services (DHHS) was awarded $6,133,426 over the course of a fouryear period. Simple math tells us that those four years have passed. With funding from the Cooperative Agreement Program finished, many HIEs are facing serious sustainability concerns. In 2013,  a survey of HIE entities from the Robert Wood Johnson Foundation determined that three out of four were struggling to develop a business model for their organization. A few HIEs that were de-

FEATURE veloped from the cooperative funding the NV-HIE say that kind of far-back have already ceased operations, like in planning didn’t happen in its case. “[We] had nine months Nevada, and  some have to do a multiyear project,” been forced to make subsays LaBarge, who was stantial shifts in direchired in May 2013. tion. In 2010, the Nevada It hasn’t been all bad. Office of Health InformaOther statewide HIEs tion Technology (OHIT) have seen substantial sucdeveloped the “State Incess. HIEs in Maine and formation Technology Delaware, for example, Strategic and Operational are blossoming examples Plan.” This was finalized of the concept at work. in May of 2011. The same Some have even achieved year, the Nevada Senate sustainability. It’s a mixed David LaBarge passed a bill that required bag, and many observers are wondering how HIEs will take DHHS to establish or contract a governshape. Andrew Pasternak, M.D., a physi- ing entity for the statewide HIE. In late cian with Silver Sage Center for Family 2012, NV-HIE was established as a nonMedicine in Reno and one of the NV- profit organization. A few months later, HIE board members who voted to cease it became the sub-grantee of the DHHS operations, was involved with the HIE State HIE grant. The NV-HIE board of from its earliest days. His directors came on board experience left him with in May of 2012. Pastermore questions than annak was recruited as a swers. physician representative “I think we’re going to because of his history need a lot more clarificawith health information tion of who is paying for technology. Silver Sage HIEs. How are we going to was one of the first offices make them financially viin Nevada to qualify for able and also, how many meaningful use Stage 1. do you need in a state? “When they decided How will this all play to create the Nevada HIE out? That’s what I’ve been Andrew Pasternak, M.D. board, the Nevada State reading nationally. Those Medical Society put my are the two big issues,” Dr. name forth as a physician representaPasternak says. tive,” Pasternak recalls. The board met, in accordance with open meeting laws, STARTING SLOWLY Timing isn’t everything, but it’s close to for the first time in August of that year. it. In many successful HIEs, leaders have LaBarge was hired nine months after gotten the concept off the ground, im- this and a request for proposal (RFP) for plemented a plan, and moved forward the HIE technology vendor was released at rapid pace. Take North Carolina, for two months after that.  According to Amber Joiner, DHHS example, where the plan for the statewide HIE (which covers 800 ambulatory Deputy Director and NV-HIE board sites and 33 hospitals, thus far) was laid member, the NV-HIE was on a timeline back in late 2010, shortly after the funds similar to many other states. Further, were distributed. Many involved with she says they met all of the milestones

according to the federal grant guidelines. “People have different impressions of when implementation starts and what success means, and for us, we were successful in meeting our milestones for that grant,” she says. LaBarge confirms that NV-HIE met the goals that the ONC requested of them. However, he, Pasternak, and others stress that DHHS was late to the game in many ways. Pasternak says that the board of directors should have been created shortly after the grant funding was distributed. This lack of a head start allowed HealtHIE Nevada, a privately run HIE in the state that is still operational, to recruit hospitals and clinics that may have gone with the NV-HIE. One source who observed the NVHIE closely agrees with the idea that they took forever to get up and running, while HealtHIE Nevada (established in 2010) moved ahead from the start. “They didn’t have an executive director for the longest time. All they would do is hold these board meetings,” the source, who chooses to remain anonymous, says. “And they were prohibited from discussing anything related to the HIE outside the board meetings.”

OPEN MEETING PAINS The open meeting laws were a thorn in the side for many involved with the HIE. In a letter to Michael Willden, the director of Nevada DHHS, Pasternak specifically said the open meeting laws had numerous undesired effects. In his interview with Healthcare Informatics, he says that instead of getting things done quickly through email, they had to be accomplished in a public forum. This was a problem because they were on tight timelines to begin with. Erick Maddox, HIT manager of HealtHIE Nevada, says that his HIE had an advantage for this reason. It was able to move quickly and be responsive to the market, whereas NV-HIE couldn’t hold a meeting and make a decision without Informatics 29


IT Coordinator position, which was filled by Lynn O’Mara in 2009. There were also funds to hire Capgemini Government Solutions, starting in 2010, well before the board was ever created. DHHS used $2.4 million of the funds to hire the State HIT Coordinator, her staff, and Capgemini. Pasternak is unsure why this is the case. Meanwhile, Pasternak says that Capgemini was a wasteful hire. In his letter to Secretary Willden, he says it didn’t get enough value out of the investment and should have created the board before hiring a consultant.


going through an agenda creation, putting it on a board, waiting for comment, and having a quorum. “You can’t run a business that way,” Maddox says. As mentioned, one of the major effects of these open meeting requirements was that LaBarge wasn’t hired as the CEO until May of 2013. He says this was because of a funding issue. “They didn’t have the money to hire me until late April 2013,” says LaBarge. “The board was unable to access the funds to hire me.” Whether this was because of DHHS or ONC remains unclear.  LaBarge could

not identify which entity was holding up the funds. Pasternak says ONC wouldn’t release the funds until they had a statement of work, which took a while to develop because of the open meeting laws and minimal staff support. Joiner, at DHHS, sent  Healthcare Informatics an information fact sheet that points the finger at longer-than-anticipated federal approval processes and federal changes as the core reason the implementation of the plan was delayed. However, the same fact sheet details how some of the funds from HITECH were spent on a mandated State Health


Beyond open meeting laws and scrunched timelines, a lack of trust between DHHS and the board of directors also helped doom the HIE.  A number of board members, including original chair, Joan Hall, left after one year. Pasternak says this became another obstacle they had to overcome. It also affected the relationship between DHHS and the NV-HIE board going forward. Reasons of those departures are unclear. One major reason may have had to do with HealtHIE Nevada. Hall is currently on the board of directors of HealtHIE Nevada.  (Hall did not respond to a request for comment). The two entities could never see eye to eye. While cooperative agreements were floated, it never came to fruition and they were seen as competitors. Board members were discouraged from interacting with HealtHIE Nevada. “I never got the sense the state folks wanted us to facilitate a good relationship with HealtHIE Nevada,” says Pasternak, who is currently serving on the security and privacy committee for HealtHIE Nevada. “There was definite distrust [ from the state].” After conversations over possible consolidation efforts, LaBarge says HealtHIE Nevada determined that it was in good enough shape going for-

FEATURE ward that it didn’t need NV-HIE. However, Pasternak says this came after the state rebuffed the private HIE. These kinds of bumps in the road seemed increasingly common by those involved with the NV-HIE. For instance, the University of Nevada School of Medicine decided to interface with HealtHIE Nevada instead of it. Another bump, Pasternak says, was when DHHS signed up just a fraction of the 200 providers required of them for the Direct Secure Messaging system that was launched in mid-2013. A document detailing plans for the launch confirms the goal of 200 users. DHHS ended up signing 30 to 40 providers.“ DHHS had incredibly limited resources. They didn’t have a large staff,” Pasternak says. “They needed people to go to the hospitals and sign up providers for Direct. They sent out emails, worked the State Medical Society and we sent out emails. They had some good knowledge when it came to the macro issues of HIE use, but none had practical experience on how it worked in day-to-day, hospital settings. I think that was another clear problem.” There were other support issues from DHHS, Pasternak says. He mentions that he did more work on that board than any of the others he has served on. Until LaBarge was hired, he says, the board did a lot of the groundwork and received only limited help from DHHS. For example, he posted and paid for the ad that led to LaBarge being hired.

FUNDING TROUBLES Both LaBarge and Joiner say the end of the NV-HIE came about because of ONC funding issues. Like other state HIEs, Nevada requested a no-cost grant extension from the ONC. It asked for another six months for access to the funds that was allocated as part of HITECH. It was denied on Jan. 15, 2014. At the same time, Joiner says ONC moved back the date in which DHHS had to match the grant funding from May to February. By

January, DHHS had matched $300,000 of the $1.3 million needed. “For us, the reason we had to ask for an extension is that we were in the process of getting match, gathering donors and participants. To cut three months off that timeline was problematic. That’s why we asked for the extension; we realized they were cutting it shorter, not even giving us what we had for the match,” Joiner says. While the request for the extension was being made, LaBarge and his team estimated how long it would take for the HIE to reach self-sustainability. He pegged it at six months, four if he was being optimistic. They presented it to ONC.

“What seems contradictory to me is hearing how ONC wants to be able to increase interoperability but they pull the rug on existing programs,” LaBarge says. Other state entities, such as the Pennsylvania eHealth Partnership Authority, were similarly denied an extension for the HIE grant funding.  No reason was given in a letter to the Pennsylvania group and it decided to dole out funds to groups within the state. An ONC spokesperson said that the State HIE Program had a rolling completion date based on when the state programs were originally awarded their grants.  “All grants should have been completed earlier this year,” the source


“We were trying to show them that if we stayed the course, we could be successful,” LaBarge says. “Instead, the rug was pulled from under us.” On top of that, LaBarge says ONC did not allow the Nevada HIE to pay its contracted funds (to Boston-based Orion Health) in advance. “That was a crippling event,” he says. “I could no longer pay the contracts that I had put in place, with the approval of Nevada DHHS and ONC. Orion Health was our HIE vendor. We had a software-as-a-service payment for $300,000 that was due at the end of January. I was not allowed to make that payment.” LaBarge understands that the denial of this decision came from the highest levels. It occurred at the same time Karen DeSalvo, M.D. became National Coordinator for Health IT, and he is unsure if that was a major change in policy on her part.

says. “No cost extensions are not being considered for states with unspent funds.” Since all states have enabled statewide directed exchange or querybased exchange during the grant period, the spokesperson says the additional work that could be completed through no-cost extensions would be very limited.  Nevada ended up spending $4.2 million of the $6.1 million given to them by ONC. Joiner is adamant in saying that the state didn’t have access to the rest of the funds before the timeline ran out. “The timeline dictated how we spent that money,” she says. With the federal grant funding scheduled to end on Feb. 7, 2014, LaBarge says he scrambled to see if he could gather some interim financing. He secured two bank sources but the board didn’t want to be personally liable for the funds gathered from the private sector. He Informatics 31

FEATURE Survey: HIEs Still Struggling With EHR Interfaces In October a federal task force recommended that the Office of the National Coordinator should switch gears with meaningful use to focus solely on interoperability through use of the Fast Healthcare Interoperability Resources (FHIR) standard under development by HL7 and the use of public application programming interfaces (APIs). Serving as a reminder of why a new approach might be necessary was the eHealth Initiative’s 11th annual data exchange survey, released Oct. 8, which found health information exchange organizations still struggling with interoperability issues. The survey of 135 health information organizations found that, as in previous years, challenges to interoperability include financial costs of building interfaces, getting consistent and timely response from EHR vendor interface developers, and technical difficulty of building interfaces. During a webinar panel of HIE executives responding to the survey, Kevin Stambaugh, director of Physician e-Services of Intermountain Healthcare in Utah, talked about the difficulty in working with providers and vendors on exchanging Continuity of Care Documents (CCDs). “The vendors are not mature in this space,” he said. “Only last year were we able to get the first CCD out of an EMR into our data repository, and it took two years. That was their first experience doing it.” “Some EHR vendors have gotten smarter and assigned specific resource to work with us every time. That has made things easier,” Stambaugh said. Other vendors, he added, might have a new person deal with Intermountain each time and “it is like we are starting from scratch every time.” Other vendors have task list queues for integrations that might be five to six months out. “We have no ability to impact their resources, and often the practices don’t feel empowered to pressure them to move quickly,” he said. Three-quarters of 101 respondents incorporate secure messaging into their data exchange models. Eighty-one respondents report their users access data through secure messaging. Seventy-eight respondents offer a Direct address directory. More respondents indicated that they are using Direct for all given use cases this year than last year. During the panel, Christina Galanis, executive director of Southern Tier HealthLink, a regional health information organization in Binghamton, N.Y., expressed concern about the increasing use of Direct. It is the easy button for practices and vendors who don’t want to get creative and figure out how to use the HIE more fully, she said. “It is great for one-to-one referral,” she said, but she senses that providers that would have found a way to do full-blown exchange are just doing Direct instead in order to check off a box for meaningful use. “Then it is harder to get them back to the bigger table of contributing data. Galanis said if HIEs are just the post office passing messages through with no access to the data, how will they make it available in life-saving emergencies or offer sophisticated analytics services? Eighty-five respondents have implemented notification/alerting services to support transitions of care. More than 100 offered care summary exchange as a service, and 74 respondents offer reporting to immunization registries. Sixty-four said they support an ACO, while 52 support a patient-centered medical home. Yet most still have a long way to go to achieve sustainability. Only 41 organizations report that dues or fees are their greatest revenue source. When a webinar attendee asked about the potential of FHIR and public APIs, some panelists expressed concern that introducing something new could further delay interoperability because the industry hasn’t caught up with the requirements around exchanging documents yet. “It might help if the government mandated standards, but they have to be careful because we have seen problems in the past with the government imposing standards that weren’t fully baked,” said David Grinberg, deputy executive director, Pennsylvania eHealth Partnership Authority. —David Raths


doesn’t blame anyone, though, for not wanting to take that on as a volunteer for a board of directors.

THE HYPOTHETICAL LaBarge seems confident that had the ONC either not changed the course on its policy or it had gotten interim financing, the HIE would still be up and running today. He and his team were working nights and weekends to get the HIE off the ground. “It was a tragedy. I feel terrible. We were on the brink of being self-sustainable. We worked so hard,” LaBarge says. “I had a 50-50 chance of making this turn around. We were close.” Yet there were other things, LaBarge says, that were going against Nevada from the get-go. As mentioned, he says those that have been successful with HIE have implemented opt-in capabilities and allocated funding from Medicaid to the HIE. Nevada had neither. There was also, of course, the lack of a head start. Pasternak may not have the same certainty in his voice that LaBarge had when it comes to what might have been, but he too says that more time would have given them a better chance. He says things should have happened sooner. “If we had started the board a year earlier, hired (LaBarge) earlier, I think we would have had a shot,” he says. Even so, there were still potential issues around funding and membership, Pasternak adds. HIEs across the country are struggling with sustainable models, bringing competing regional organizations together, and dealing with multiple networks. Just like starting the local restaurant, hope is not always painted in reality. “You’re not going to make it viable in a year or two. It might take three to five years before you have enough revenue and members to make the whole thing work,” Pasternak says. ◆


Real World Data Analytics D.C. panel consensus: In the end, data analytics comes back to patients, communities BY MARK HAGLAND hile data analytics is having profound and wideranging effects on healthcare delivery, any provider organization employing analytics needs to keep patients and their communities in sharp focus to be effective. That was the main point of agreement of a panel of healthcare industry leaders who met in October to discuss the topic “Digging Deeper in Analytics.” The discussion panel was part of the Health IT Summit in Washington, sponsored by the Institute for Health Technology Transformation, or iHT2. (Since December 2013, iHT2 has been in partnership with Healthcare Informatics, through the Vendome Group LLC, HCI’s parent company.) In a discussion that spanned a broad range of points and perspectives, the panelists agreed that, in the end, the broader purposes of data analytics must circle back to patients and their communities. The panel was moderated by Zachery Jiwa, a former Innovation Fellow at the U.S. Department of Health and Human Services (HHS). His panelists were Arun Natarajan, a health insurance analyst at HHS; Arumani Manisundaram, director of the Center for Connected Health at Adventist HealthCare, a Gaithersburg, Md.-based integrated health system; Samantha Burch, vice president, legislation and health information technology, at the Washington, D.C.based Federation of American Hospitals (the Federation), a nationwide association of investor-owned hospitals and health systems; and Mark Solomon, director of innovation at the Ozark, Mo.-based HealthMEDX, LLC, a solutions provider specializing in long-term care and post-acute IT solutions.

program that doesn’t effectively incorporate those people, you won’t be able to be successful. I’ve seen a lot of different kinds of set-ups,” she added. “But you need those people involved. We’re also seeing a huge evolution in terms of hospitals that deal with technology. You’re seeing a lot more chief medical information officers; you’re seeing a lot more integration around process and technology. It’s not just plug-and-play. And you need translators.” LEVERAGING ANALYTICS IN THE REAL WORLD Adventist Health’s Manisundaram noted that his organizaBy halfway through the wide-ranging discussion, panelists tion has been busy implementing the electronic medical agreed on what was a critical factor in the leveraging of an- record in its hospitals, and has been involved with meaningful use. “A lot of people think that because the majority of dollars are invested in that EMR system, that it will be at the core of what we need to do, but some of those EMR systems —SAMANTHA BURCH lack the capabilities to do real analytics,” he said. He alytics—a focus on real-world usability, on behalf of patients added that “In terms of doing population health and analytics, and communities. The Federation’s Burch put it this way: “The each of our hospitals has its own incentives, and may look at people on the ground, the people in the trenches, those who the data differently or look at a different subset of data. We are part of the care delivery process—if you build an analytics need to look system-wide at what our end goals are in defining


(Continued on page 35) Informatics 33


It’s Time to Get Serious about Healthcare Data Security An expert on healthcare data security issues stern warning about the nature of threats and preventative measures that need to be taken BY MARK HAGLAND


ac McMillan, one of the healthcare industry’s leading lights on data security, offered stern warnings and bold perspectives on Oct. 6,  as the opening keynote speaker at the “Health Information Executive’s Guide to Cyber Security: A CHIME LEAD Forum Event in Collaboration with iHT2.” The event, being held on Oct. 6 at the Westin Arlington Gateway in Arlington, Va., is being cosponsored by the Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME) and the Institute for Health Technology Transformation, or iHT2. (Since December 2013, iHT2 has been in partnership with Healthcare Informatics, through the Vendome Group LLC, HCI’s parent company.) After an introductions by Russell P. Branzell, president and CEO of CHIME, McMillan, the president and CEO of CynergisTek, an Austin, Texas-based consulting firm, and the current chair of the Privacy and Security Committee within the Chicago-based Healthcare Information and Management Systems Society (HIMSS), gave a passionate, sobering presentation on the extent of the current threats to healthcare data security in the U.S., warning his audience of healthcare CIOs and other senior IT executives that things are going to get worse before they get better in healthcare IT security. McMillan underscored in various ways the exploding set of threats facing healthcare organizations in the current operating environment, noting that while the healthcare industry was ranked by some as 15th or 16th in terms of data security risk several years ago because of the lack of electronic data storage,

emailing of 10,000 patient records to 200 patients by a neurologic institute; and a very sobering phishing-based conspiracy that involved the theft of $3 million from six academic medical center-based health systems. In that last case, a group of extremely sophisticated criminals over a period of months infiltrated the human resources data processes of the academic medical center organizations, quietly scraping information from employees’ benefits renewal applications. It then used that information to assume identities within those organizations’ email S systems, and later intercepted any legitimate emails questioning what S —MAC MCMILLAN was going on. Ultimately, they were it is now seen as one of the most threatened U.S. industries, as able to essentially steal identities within those organizations, triggering a series of events. The hackers over time were able up to 99 percent of patient data is now electronic. to divert portions of the electronic paychecks of the employees whose identities they had stolen, diverting those monies SOBERING EXAMPLES OF BREACHES AND THEFTS MacMillan walked his audience through a list of serious cyber- to a mule account, and from there to North Africa and then security incidents in U.S. healthcare that have taken place this to Russia. These thefts took place over a three-month period past year, including one incident involving 4 million medical and netted $3 million, in a shockingly successful theft of milrecords breached on four workstations; the loss by a physician lions of dollars from the payroll systems of major patient care of a laptop carrying psychiatric patient records; the accidental organizations in the U.S.



iHT2:DATA SECURITY PERSPECTIVE McMillan strongly urged his audience to think both broadly and deeply about what their organizations need to do going forward at a time of increasing data insecurity. Among his key points: r%BUBCSFBDIFTBSFJODSFBTJOHTUFBEJMZOPX POUXPGSPOUT PVUTJEFS IBDLFST BOE PUIFS DSJNJOBMT  BOE JOUFSOBM TPVSDFT  who include clinicians and administrative staff in hospitals and medical groups. rîFDPTUPGEBUBTFDVSJUZJTHPJOHVQ BOEQBSUPGUIFDBVTF is the increasing cost of lawsuits against patient care organizaUJPOT XIJDIDBONVMUJQMZUIFJOJUJBMEBUBCSFBDIDPTUT r*UJTBIVHFNJTUBLFUPiDIBTFUIFEFWJDF uXIFOJUDPNFTUP NPCJMJUZ*OTUFBE XIBUTOFFEFEJTBDPNQSFIFOTJWFTUSBUFHZ BSPVOEXIFSFUPBMMPXUIFQMBDFNFOUPGEBUB POFUIBUMFBWFT mobile devices secure. r*OPSEFSUPBDUVBMMZCFTVDDFTTGVMJOUIJTBSFB UIF*5MFBEFST of patient care organizations will need to develop sophisticated behavioral modeling strategies to spot those from within UIFJSPSHBOJ[BUJPOT EPDUPST OVSTFT BENJOJTUSBUJWFTUBò FUD  who are engaging in these criminal activities. Simple audit trail work will no longer suffice. New federal mandates around accounting for disclosure and minimal necessary response will inevitably be forthcom-

JOH CVUNPTUMJLFMZOPUVOUJMBGUFS the 2016 presidential elections. Whichever party of the president XIPJTFMFDUFEJO TPNFUVSOover of top political appointees will UBLF QMBDF JO  BOE  îF most likely timing of new federal mandates around data security XJMMDPNFBGUFSUIBU HJWJOHQSPWJEers a bit of time to get caught up with current mandates and build Mac McMillan stronger security infrastructures. *O UIF NFBOUJNF  .D.JMMBO BTTFSUFEUIBUi0OMZBCPVUQFSDFOUPGIPTQJUBMTBOEIFBMUI TZTUFNTIBWF$*40T BOE PGUIPTF POMZBCPVUQFSDFOUIBWFSFBM$*40Tu‡JOEJWJEVBMT with the capabilities to meet the increasing demands of the emerging operating environment. 4UJMM .D.JMMBOTBJE IFSFNBJOTPQUJNJTUJDPWFSBMM)FTUBUFE that he believes that the healthcare industry is about halfway UISPVHIBZFBSKPVSOFZPGEFWFMPQJOHUIFQFPQMF QSPDFTT  and technological infrastructure needed to support the industry in terms of data security going into the future. ◆

iHT2 DATA ANALYTICS PERSPECTIVE (Continued from page 33)





Radiology Group Pushes Ahead on Meaningful Use East River Medical Imaging in Manhattan moves ahead on Stage 1 and sets its sights on Stage 2 meaningful use BY MARK HAGLAND s the meaningful use process under the Health Information Technology for Economic and Clinical Health (HITECH) Act evolves forward, physicians practicing in different specialties face diverse situations, challenges, and questions. One specialty in which questions have been particularly heightened has been that of radiology. Many radiologists interact primarily with referring physicians, and thus their patient contact is limited compared to the vast majority of specialties; what’s more, radiologists’ workflow is in some ways quite unique, and until recently, most radiologists did not use electronic health records (EHRs) in their fullest sense. All that said, the Office of the National Coordinator for Health Information Technology (ONC) and Centers for Medicare & Medicaid Services (CMS) have made it clear that they expect virtually all physicians in private practice to participate in the meaningful use program—not only that, but also that radiologists are liable for reimbursement penalties under the program’s guidelines, as well as for its funding rewards. One radiology group practice that has been striving forward on meaningful use is East River Medical Imaging, which has been participating in Stage 1 of meaningful use, and is simultaneously planning for Stage 2 participation. Its leaders have been partnering with the Fort Lauderdale-based  IDS, which provides the group with its core EHR solution, a product de-

ATTESTATION TIMELINE: A RADIOLOGIST GROUP’S VIEW Healthcare Informatics: Tell me about your participation in Stages 1 and 2 of meaningful use. Did you attest for all 12 radiologists for Stage 1? Andy Wuertele: That’s correct, yes; all 12 radiologists submitted their attestations in March 2013, and received their incentive payments at the end of March. HCI: And can you share about Stage 2? Wuertele: We’re in the midst of our second year of Stage 1 data-gathering and participation for this OctoberDecember quarter, and are preparing for Stage 2. We are still finalizing our plans and watching very closely what CMS is guiding the field to do, and are awaiting some further clarification on their expectations for 2015. HCI: When are you thinking of attesting to Stage 2? Wuertele: We believe we will need to begin as of January 1, so it will be a 365-day Stage 2 attestation process. We would be quite supportive of the discussion to transition that to a 90-day process. HCI: Will it be a significant burden to do a 365-day period for a medical group your size? Wuertele: Yes, if only because vendor preparedness has

THE INCENTIVES THAT THE GOVERNMENT HAS PUT IN PLACE DON’T RECOGNIZE THAT RADIOLOGY IS A LEADER IN ACCOMPLISHING WHAT THEY’RE INCENTIVIZING, SO WE NEED TO DO MORE THAN WE HAVE ALREADY DONE; WE NEED TO MAKE TECHNOLOGY INVESTMENTS ON TOP OF THOSE MADE OVER THE PRIOR DECADE. —ANDY WUERTELE signed specifically with radiologists and orthopedic surgeons in mind. Andy Wuertele, East River Medical Imaging’s chief administrative officer, and David Vazquez, its systems administrator, spoke recently with HCI Editor-in-Chief Mark Hagland. Below are excerpts from Wuertele’s comments to HCI.


IMAGING UPDATE taken this much time. If we were attesting to Stage 1 for 365 days, that would not be a problem; it’s adding in the new technology right now that is challenging for so many. HCI: You’d have to be doing that right now, correct? Wuertele: Yes, that’s right, and very few vendors have implemented their 2014-approved technology. One requirement is for patient participation. We’re very excited to develop a

at what we think the definition of meaningful use is, relative to driving better results and higher quality with each encounter, we recognize that a patient’s flow through radiology is different. HCI: For one thing, the patient often doesn’t have direct contact with the radiologist. Wuertele: Yes, that’s right; let me give you an example of a patient who comes in for an MRI of the brain and the cervical spine as well as a chest x-ray. That single visit could be a single encounter, or it could be two encounters. That is determined by how many providers, how many radiologists, are involved interpreting the results of those exams. We happen to document the brain MR [magnetic resonance imaging], the cervical spine MR, and the chest x-ray as three separate exams. The neuroradiologist who reads the brain and cervical spine exams may be reading those together, even as separate exams, but because it’s the same radiologist and the same day of service, it will be counted as a single encounter. Then the chest x-ray will probably be counted as a separate encounter. We certainly don’t want the patient to have to answer questions like smoking cessation, three times; so it’s about workflow. We happened to implement a kiosk technology for gathering information from patients, so that the patient doesn’t have to enter smoking information three times, for example. Rather than having an administrative worker go in afterwards to decide whether that was two or three encounters because the neuroradiologist read two and another radiologist read the third, we apply our CPT [current procedural technology] and ICD-9 coding data to populate the database and determine which encounters have been completed and can be closed. HCI: How hard was it to make all of this work out? Wuertele: It was a substantial challenge, but it was one that was accomplished within a five-month development window. We worked very closely and intensively, as did the IDS people, to define what we needed and to put into action. HCI: Was the attestation for meaningful use Stage 1 in any way difficult? Wuertele: The attestation itself was very straightforward. I think because there are so many different rules and guidelines, it was challenging at times to become comfortable that we were fully meeting all the expectations. For example, there has been great debate about whether or not a patient visit that doesn’t include face-to-face contact with the radiologist should count as an encounter. Our determination was that not only was it prudent to include all the encounters, whether a patient saw a radiologist or only technologist under the supervision of a radiologist, but that it was the safest approach, from a regulatory standpoint. We’re unusual in our setting in that the radiologists will spend time with patients more often

THE ATTESTATION ITSELF WAS VERY STRAIGHTFORWARD. I THINK BECAUSE THERE ARE SO MANY DIFFERENT RULES AND GUIDELINES, IT WAS CHALLENGING AT TIMES TO BECOME COMFORTABLE THAT WE WERE FULLY MEETING ALL THE EXPECTATIONS. —ANDY WUERTELE patient portal, but we need for it to be very patient-friendly to support it and meet the high expectations for service that are essential in our practice. To have so many question marks still in the atmosphere about what’s expected and for it to be this late in the game to have the 2014 versions of the EMR systems being approved, we’re still in a bit of a standby mode. HCI: Your core solution is from IDS? Wuertele: Yes, the Abbadox solution from IDS. It’s a cloudbased solution. HCI: Is it particularly good for specialists? Wuertele: It’s supportive of specialists’ workflow. I believe their client base supports radiologists and orthopedic surgeons; they have the capability of adapting it to the needs of other specialties as well.

MU REQUIREMENTS FROM A RADIOLOGIST PERSPECTIVE HCI: What have been the special elements of meaningful use for radiology practices? Wuertele: First and foremost, our conversion to a comprehensive electronic workflow had already happened more than ten years ago, driven by the efficiencies around PACS [picture archiving and communications system] use, and the large amount of data we’ve had to manage and turn into further information. The vendors in radiology have legacy products and systems tailored to those sets of challenges, and their willingness to reinvent their products to add meaningful use capability has been limited. The incentives that the government has put in place don’t recognize that radiology is a leader in accomplishing what they’re incentivizing, so we need to do more than we have already done; we need to make technology investments on top of those made over the prior decade, so it’s a very unique situation. In radiology, therefore, there has been skepticism about the impact of the meaningful use requirements. All that is a historical note; but when you start to look Informatics 37

IMAGING UPDATE than in an academic medical center. Certainly, there are kinds of patients and procedures where they’re not directly working with them; but there are certainly many times where the radiologist will sit down with the patient at the request of the referring physician. We have a very strong hands-on approach, but that in itself creates another challenge. The last thing we want in terms of workflow is for our radiologists to take their eyes off the images in PACS and have them have to type in smoking history data.

LEARNINGS AND ADVICE FOR OTHER RADIOLOGIST GROUPS HCI: So you would advise other radiology groups to facilitate kiosk-based or other information-gathering processes, to help physicians with workflow and to minimize patient frustration? Wuertele: Yes, absolutely. Ironically, the biggest objection patients raise is around giving their weight more than once. Some patients question what we’ll be using their information for. HCI: What have been your biggest learnings overall so far? Wuertele: That’s a great question. One has clearly been to find a responsive and focused technology partner. We searched, starting in 2011, for the right combination of technologies to enable to participate in meaningful use. We started with an

expectation that we would use our RIS [radiology information system], PACS, and practice management combination and would use a modular approach. After about a year, it was clear that our vendor would not be able to stitch all those together, and that we would need a dedicated EHR vendor that would close all the gaps. The expectation was that we’d have to hire a substantial number of data entry clerks, because gathering the data was not an off-the-shelf prospect. We happened to be working with IDS in a couple of other areas; this was our first EHR, in terms of what the federal government would classify as an EHR. Then again, 10-plus years ago, we were already in the electronic medical record realm with PACS. We weren’t able to participate in meaningful use in 2012 because we didn’t have the right technology combination, and it wasn’t until May 2013 that we finally signed off on the proposal to put these final pieces in place. Had we not had the confidence in and relationship with IDS to pull this off, we would have had to forego that participation last year and thereby lose out on the incentives and face penalties, and not have the move forward with expertise internally with meaningful use. I think meaningful use attestation and achievement is an important indicator of our quality as a provider. It gives us credibility with sophisticated hospitals, payers, and employers, in the community we’re working in. ◆

CARE MANAGEMENT (Continued from page 26)

HEALTH say, care management systems have been primarily payer driven. Those that have implemented care management programs, like the inHEALTH duo, further acknowledge that there is a huge learning curve, which goes well beyond any technical difficulties that an organization will incur. There is a huge amount of work that has to go into getting physician and patient buy-in in the Stephen Cavalieri, M.D. first place, Cavalieri says. Once that’s accomplished, experts say it’s imperative that care management includes ancillary providers such as pharmaceutical managers, social workers, and behavioral health specialists. “One of the elements of a well-designed care management program is that it recognizes that many of the drivers are psychosocial and economic in nature, and not just clinical. They connect to partnerships in the community,” Levin says.


In fact, McGovern at Aspen Advisors recommends that implementing technology should come last when payers and providers are developing care management programs. “Slow down, back up, and talk to your business people about what your specific strategies are and then nut that out to specific business workflows and requirements. Once the business has told you what’s required to be successful, Scott Mancuso, M.D. then go shopping for IT,” he says. Levin says that organizations should start by designing their enterprise and clinical strategy before doing anything else. “Figure out who is going to do what, when. Figure out the workflows of the team and what the outreach/engagement strategy will look like. Be transparent with your team so it’s clear where the limitations in technology will be,” he notes. ◆


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Moving Collections Up Front One hospital system’s initiative for early conversations about payment minimizes the chance of ‘sticker shock’ later BY JOHN DEGASPARI


f there is one constant in the ever-changing world of U.S. healthcare, it’s that there is a huge squeeze on profit margins—a fact that affects even not-for-profit hospital systems, which need operating funds to continue their mission of providing care. That’s the observation of Lori Szymonowicz, senior director of patient financial services at Thomas Jefferson University Hospitals (TJUH), a Philadelphia-based academic medical center with 1,020 beds in four primary sites. She notes that her organization recognized that it was not deploying point-of-service collections in many of its departments, including the ED. She says that initiating the collections process early benefits both the hospital and the patient. “We have an obligation to educate our patients and work with them pre-service, so we can address financial matters separate from their clinical experience and improve their experience overall at Jefferson,” she says. The initiative at TJUH reconfigured the collections process so that the patient meets with a representative from the finance department before undergoing a scheduled or emergency treatment. (Szymonowicz notes that the collection process for patients admitted into the ED does not interrupt or impede stabilizing the patient, and adheres to EMTALA, or the Emergency Medical Treatment and Labor Act, legislation that ensures the public’s access to ED services regardless of the patient’s ability to pay.) The hospital’s financial representatives who meet with the patients already have information, and the patients are informed about their insurance liability.  The hospital uses an analytics solution (supplied by Austin, Texas-based Experian Health) that provides the finance department with information about the patient’s ability to pay. The hospital provides demographic and financial information to Experian, which returns information about the patient’s propensity to pay, along with scripting and recommendations, based on that information, for use by the financial representative in conversations with the patient. The purpose of scripting is to build rapport with the patient as well as to educate the patient on the expectation on payment of copays and open balances owed.

ADDRESSING PAYMENT OPTIONS EARLY HELPS TO AVOID UNPLEASANT SURPRISES Being ahead of the curve in introducing the conversation about payment gives the hospital the opportunity to have financial counselors to interact with the patient and, if necessary, provide the best financial solution for a particular circumstance, Szymonowicz says. /

She observes that many patients who are newly insured under the Affordable Care Act (ACA) do not understand their financial responsibilities. In her view, the hospital, as a partner, should help the patient navigate through the payment scenario. That might take the form of referring the patient to a financial counselor or seeing if the patient qualifies for aid under the hospital’s charity program. “We want to assist them so they don’t have a negative experience at their last touch with our organization,” she says. Szymonowicz says the process has involved training of the collections staff, including role-playing that encourages openended discussion with patients. “We have educated and gone through a culture change with that group to enable them to use the technology to engage the appropriate financial conversation with the patient, regardless of the setting,” she says. Results of the initiative so far have been impressive. Pointof-service collections increased by 30 percent for the 2013 fiscal year compared to the previous fiscal year. That resulted in a savings of $1 million during a period when the program was being rolled incrementally, she notes. For the three-month period beginning Jan. 1, 2014, there was a 40-percent increase in collections compared to the previous three months, which equated to $500,000, she says. Also beginning in January, the hospital system introduced accountability measures that are tied to productivity goals. Reporting is done on a monthly basis, which fosters friendly competition among departments, says Szymonowicz. There is also an incentive for meeting goals that is paid out quarterly.  The end result, she says, has been positive. Patients now are much less likely to be blindsided with a bill they didn’t anticipate, which would also be a patient dissatisfier and negatively affect their ability to heal. “If you have a heart attack, you don’t want to have another one when you get your bill in the mail,” she says. ◆


Gaining Access to Expert Advice How one doctor taps into a provider-to-provider social media network as a learning tool and platform to share his ideas with his peers BY GABRIEL PERNA


t would be easy for a guy like Jorge Armando Brenes Salazar, M.D. to rest on his laurels and what he has accomplished so far. Dr. Salazar is from Costa Rica, where unlike in the United States, medical school takes seven years to complete. After getting his degree from Escuela Autonoma de Ciencas Medicas de Centro America, he went north to Minneapolis. There, he did his four years of residency at Hennepin County Medical Center, in the Level 1 trauma center’s challenging training program. For many, that would be enough learning. For Salazar, it was just the beginning. He currently is engaged in a program at the Mayo Clinic (Rochester, Minn.) for cardiovascular specialty training. After he completes that, he plans to dig even deeper and focus on geriatric cardiovascular training.  What’s more, Salazar is among a growing community of doctors who are using web-based tools to engage and learn from other physicians. Whether it’s Doximity (a network that claims 300,000 users), Sermo (claiming 270,000 users), or QuantiaMD (claiming 225,000 users), more than ever, doctors

at presentations found on QuantiaMD while taking breaks on his iPad. He showed it to Salazar, who was drawn to it immediately. “One of the key advantages is that they have a select group of experts who are able to provide key counseling and key information in their field,” Salazar says. “You’re able to interact with them with questions and you even have the opportunity to address them in a private fashion with encrypted messages. I have the luxury of being part of the Mayo Clinic. If I have a question, I can pick up the phone or run into someone down the hall. I have that luxury here. Others don’t have that.”

ONE OF THE KEY ADVANTAGES IS THAT THEY HAVE A SELECT GROUP OF EXPERTS WHO ARE ABLE TO PROVIDE KEY COUNSELING AND KEY INFORMATION IN THEIR FIELD. YOU’RE ABLE TO INTERACT WITH THEM WITH QUESTIONS AND YOU EVEN HAVE THE OPPORTUNITY TO ADDRESS THEM IN A PRIVATE FASHION WITH ENCRYPTED MESSAGES. —JORGE ARMANDO BRENES SALAZAR, M.D. and other healthcare professionals are getting social with each other. Salazar uses the Waltham, Mass.-based QuantiaMD as his network of choice. He was brought into it by one of the residents he supervises. The tech-savvy resident was looking


QuantiaMD, which works with providers from Mayo Clinc, National Institutes of Health, and other prominent healthcare provider organizations, allows doctors and practitioners to learn from others through 15 to 30-minute online presentations and interactive discussions. There are also clinical case examples in the form of presentations and “image challenges,” where doctors interpret an image. The platform allows them to earn continuing medical Informatics 41

SOCIAL MEDIA PERSPECTIVE education (CME) credits as well and focus on interests specific to them. For example, Salazar is alerted on his QuantiaMD homepage when a new case on cardiovascular medicine pops up. Salazar says the interface is “smooth,” and easy to use. “I can tell this is the case because many of the physicians are gray-haired professors and they use the website without any problems,” he says. Jorge Armando Brenes Salazar, M.D. In terms of usefulness, Salazar says that he rarely comes across something that he doesn’t find useful. Most of the conditions covered in presentations aren’t extremely rare but are uncommon enough that he says practitioners probably need better exposure to them.  “There’s a lot of content in the community that you won’t find in structured textbooks and structured journals,” he says. Some of this doesn’t even include clinical information. There are presentations on practical matters of being a doctor, such as learning to interact with difficult colleagues or finding ways to relax in a stressful atmosphere. “If you don’t take

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care of yourself as a healthcare professional you won’t be able to take care of others,” Salazar says. In a time-crunched atmosphere, Salazar also finds it to be very practical. Not only are the presentations mobile-equipped, but the short presentations, lasting three-to-five minutes, are important enough to be eligible for recertification. Interacting with others through commenting, he adds, can be done just as quickly. As more doctors turn to social media, Salazar says he hopes that QuantiaMD and other networks can recruit more international participants. He has worked with international participants before. He looks at the current crisis around the Ebola virus as an opportunity in this regard. Most notably, he mentored an intern in Pakistan on the topic of neurology. “He told me he was a practitioner in Pakistan but he didn’t want to be in the back seat of medicine, he wanted to be the in driver’s seat. There’s a lot of potential everywhere. It’s just about networking,” Salazar says. ◆

HCI’S INNOVATOR AWARDS PROGRAM For the seventh year in a row, we at Healthcare Informatics have chosen to once again open our website to submissions to our Innovator Awards Program. As always, it is a great privilege and pleasure for us to sponsor this program every year. At a time when efforts to improve care quality and patient safety, restrain costs, reduce avoidable readmissions, and apply the concepts of accountable care, bundled payments, value-based purchasing, population health, and the patient-centered medical home, as well as efforts to optimize revenue cycle management and materials purchasing, are all advancing nationwide, the opportunity to publicize team-based achievements is greater than ever. So this is your official note of encouragement: Please consider submitting an entry describing the achievement or set of achievements that a team at your provider organization (hospital, medical group, integrated health system, health information exchange, or public or community health entity) has been able to demonstrate and document. (Please be aware that we will not accept any submissions from representatives of vendor firms; the submissions must come directly from provider organizations.) The form is on the website: Our Innovator Awards Program will showcase the winning teams’ stories in the March/April 2015 issue of the magazine and online, and at our Innovator Awards reception, to be held during the HIMSS Conference next April in Chicago. Good luck from all of us! —Mark Hagland, Editor-in-Chief



nterested in information on a particular product or service? The 2015 Buyers Guide will help you research key vendors quickly and easily. You can also access the Buyers Guide online at http://, where you may contact vendors directly through e-mail and social media, and view additional detailed product information. We hope you will find this to be a valuable resource. BU Y ER S GUID E IND EX ACO/HIE Data Analysis/Predictive Modeling Software.................................... 44

Education/Compliance/Legal ......................... 47

Messaging .................................................... 52

EMR/EHR ...................................................... 48

Outcomes Reporting Systems ....................... 52

Acute ............................................................ 44

Enterprise Content Management ................... 48

Pathology Information System....................... 52

Ambulatory ................................................... 44

Enterprise Imaging........................................ 48

Payroll .......................................................... 52

Business Continuity/Disaster Recovery ......... 44

Enterprise Resource Planning/Business Intelligence/Business Process Management ............................................ 48

Practice Management ................................... 53

Care Management ........................................ 44 Clinical Documentation ................................. 44 Clinical Information System/Hospital Information System .................................. 44

Enterprise Revenue Management ................. 48

Cloud Computing Providers ........................... 45

HIE/RHIOs/NHIN ............................................ 50

Coding .......................................................... 45

HIM............................................................... 50

Computer-Based Provider Order Entry........... 45

Human Resources Management ................... 50

Computer Carts/Mobile Computing ............... 45

ICD-10 Compliance ....................................... 50

Consulting—Meaningful Use Strategy .......... 46

Imaging/PACS ............................................... 51

Consulting—Outsourcing.............................. 46

IS Management and Consulting .................... 51

Consulting—System Implementation ............ 46

Lenders/Financial Institutions........................ 51

Dashboards—Census/Labor/Financials ........ 46

LIS ................................................................ 51

Dashboards—Revenue Cycle Management .. 46

Long-Term Care ............................................ 52

Data Solutions .............................................. 46

Managed Care .............................................. 52

Dictation/Transcription .................................. 47

Master Patient and Provider Index ................. 52

Dietary and Nutritional Management ............. 47

Medication Carts........................................... 52

Disease Management ................................... 47

Medication Management—Bar Coding/ RFID ......................................................... 52

Document Imaging/Management .................. 47

Fraud and Abuse Detection and Analytics ...... 48

Provider Data Management........................... 53 Quality Reporting .......................................... 53 Radiology Information System....................... 53 RCM—Claims Management ......................... 53 RCM—Payer Contract Managemen .............. 53 RCM—Self Pay ............................................. 54 Revenue Cycle Management ......................... 54 Revenue Management .................................. 54 Scheduling—Staff ........................................ 54 Security ........................................................ 54 Software Development.................................. 54 Systems Integration ...................................... 54 Telehealth/Telemedicine................................ 55 Wireless Devices .......................................... 55 Wireless Networking ..................................... 55 Workflow Solutions ....................................... 55 Workforce Solutions ...................................... 55

Healthcare Informatics November/December 2014





InfoMC, Inc. Conshohocken, PA Contact: JJ Farook (484) 567-0601 E-mail: [email protected] Web:

American Health Information Management Association (AHIMA) Summit Healthcare

MedeAnalytics Emeryville, CA Contact: Randy Hamamoto (310) 930-1769 E-mail: [email protected] Web:

Braintree, MA Contact: Jason Behan (866) 925-9375 E-mail: [email protected] Web:


NextGate Pasadena, CA Contact: Richard Garcia (626) 376-4100 E-mail: [email protected] Web:

InfoMC, Inc. Conshohocken, PA Contact: JJ Farook (484) 567-0601 E-mail: [email protected] Web:

Chicago, IL Contact: Jackie D. Palmer (312) 233-1988 E-mail: [email protected] Web: ICD-10 Clinical Documentation Training Supports Time-Pressed Physicians. The leading resource for ICD-10 education and training, AHIMA represents more than 71,000 health information management professionals in all settings. AHIMA’s Clinical Documentation for ICD-10 by Specialty program provides interactive, on-demand, online training on the documentation needed to support ICD-10-CM/ PCS. Written by physicians, CDI specialists, and medical coding experts, this program helps engage and motivate physicians and clinicians by supplying highly relevant, actionable content in an easy-to-learn format. See our ad in this issue



NTT DATA Healthcare Technologies Hauppauge, NY Contact: Larry Kaiser (800) 699-6733, ext. 5329 E-mail: [email protected] Web: www.

AMBULATORY SA Ignite Chicago, IL Contact: Jeff Galowich (312) 759-5001 E-mail: [email protected] Web:


November/December 2014

3M Health Information Systems Murray, UT (800) 367-2447 E-mail: [email protected] Web: 3M Health Information Systems delivers software and consulting services to help organizations improve clinical documentation, quality, and financial performance. We offer expertise in coding, ICD-10, dictation, transcription, speech recognition, medical terminologies, and data exchange to support electronic health records. With more than 25 years of healthcare experience, we work as a trusted and stable business partner to provide reliable implementation, training, and support to our clients.

Health Care Software Inc. (HCS) Wall Township, NJ Contact: Thomas Visotsky (800) 524-1038 E-mail: [email protected] Web: HCS has delivered healthcare information systems since 1969. Interactant™ is an integrated platform of clinical and financial modules supporting the spectrum of care including acute, post-acute, and behavioral health providers.

Healthcare Informatics



Practice Management Information Corporation (PMIC)

NTT DATA Healthcare Technologies Hauppauge, NY Contact: Larry Kaiser (800) 699-6733, ext. 5329 E-mail: [email protected] Web:

Prime Care Technologies Inc. Duluth, GA Contact: Bill Briggs (877) 644-2306 E-mail: [email protected] Web: PCT’s powerful cloud-based IT infrastructure and services help providers save money, increase revenues, and insure compliance through managed hosting; digital dashboard reporting; T&A, HR, and payroll solutions; automated procurement services; claims management automation; and more.

OBIX by Clinical Computer Systems, Inc. Elgin, IL Contact: Elizabeth Hobson (888) 871-0963 E-mail: [email protected] Web: OBIX by Clinical Computer Systems, Inc. named Category Leader for Labor and Delivery in the January 2014 KLAS® report, “2013 Best in KLAS Awards: Software & Service.” OBIX combines enterprise-wide surveillance and alerting with comprehensive, point-of-care patient charting, data archiving, and Internet-based physician access. It is ideally designed for interfacing to other hospital systems. Exclusive E-Tools provide decision support and promote safety. Superior education and service assures user satisfaction and success. Visit for information.

Psyche Systems Corporation Milford, MA Contact: Lisa-Jean Clifford (508) 473-1500 E-mail: [email protected] Web:


Los Angeles, CA Contact: Meta Rias (800) 633-7467 E-mail: [email protected] Web: PMIC, the nation’s leading independent publisher of medical coding and compliance solutions since 1989, offers a variety of comprehensive IT solutions including data files, e-books, and software. Our e-books can be delivered at low cost to thousands of users from your document servers. Our #1-rated Flash Code software can be accessed via the internet by an unlimited number of users. We have ICD-10 ready solutions for your IT staff.


3M Health Information Systems Murray, UT (800) 367-2447 E-mail: [email protected] Web: 3M Health Information Systems delivers software and consulting services to help organizations improve clinical documentation, quality, and financial performance. We offer expertise in coding, ICD-10, dictation, transcription, speech recognition, medical terminologies, and data exchange to support electronic health records. With more than 25 years of healthcare experience, we work as a trusted and stable business partner to provide reliable implementation, training, and support to our clients.

NTT DATA Healthcare Technologies Hauppauge, NY Contact: Larry Kaiser (800) 699-6733, ext. 5329 E-mail: [email protected] Web: www.


ALTUS Walker, MI Contact: Eric Kahkonen (888) 537-1311 E-mail: [email protected] Web: ALTUS designs and manufactures mobile and wall-mounted technology workstations at our state-of-the art facility in Grand Rapids, Michigan. ALTUS Functionology is successfully optimizing EMR/CPOE initiatives and efficiency in thousands of healthcare facilities around the country.

Healthcare Informatics November/December 2013


SPECIAL ADVERTISING SECTION Futura Mobility Fort Washington, PA Contact: Daria Cuda (215) 642-3363 E-mail: [email protected] Web:

CONSULTING—OUTSOURCING Optimizing the business of healthcare

Hayes Management Consulting 3M Health Information Systems

Industrial Computing Waltham, MA Contact: Anna Mae Melchiorre (781) 890-3111 E-mail: [email protected] Web: Industrial Computing’s Medical Grade Computer Tablets are EN60601-1/EN60601-1- 2 compliant, IP54 certified, EMR/EHR software compliant and designed with an anti-microbial housing for utilization in point-of-care areas at patient’s bedside, exam rooms, hospitals, home visits, healthcare centers, emergency rooms, ambulances etc. They have touch screen displays, long battery life, multi-connectivity, dual cameras and many accessories. The Portable Guardian Models are: 7”, 9” and 1.9 lbs, 10” and 2.8 lbs. Medical Stations have 15” to 19” touch screens.

CONSULTING—MEANINGFUL USE STRATEGY SA Ignite Chicago, IL Contact: Jeff Galowich (312) 759-5001 E-mail: [email protected] Web:

Murray, UT (800) 367-2447 E-mail: [email protected] Web: 3M Health Information Systems delivers software and consulting services to help organizations improve clinical documentation, quality, and financial performance. We offer expertise in coding, ICD-10, dictation, transcription, speech recognition, medical terminologies, and data exchange to support electronic health records. With more than 25 years of healthcare experience, we work as a trusted and stable business partner to provide reliable implementation, training, and support to our clients.

Newton Center, MA Contact: Patty Kellicker (617) 559-0404 E-mail: [email protected] Web:

DASHBOARDS—CENSUS/ LABOR/FINANCIALS Prime Care Technologies Inc. Duluth, GA Contact: Bill Briggs (877) 644-2306 E-mail: [email protected] Web:

DASHBOARDS—REVENUE CYCLE MANAGEMENT Sedona Learning Solutions Phoenix, AZ Contact: Linda Hainlen (602) 840-1000 E-mail: [email protected] Web: Sedona Learning Solutions offers EMR educational services. Sedona’s project managers, instructional designers, and instructors work with you to design and deliver customized e-Learning, training, and support for your EMR. Sedona delivers instruction on site or online.

MedeAnalytics Emeryville, CA Contact: Randy Hamamoto (310) 930-1769 E-mail: [email protected] Web:


VCPI Milwaukee, WI Contact: Tim Tarpey (414) 865-2005 E-mail: [email protected] Web:

DEA, Inc.


Wilmington, DE Contact: Gregory Merritt (877) 482-5400 E-mail: [email protected] Web:

Futura Mobility Fort Washington, PA Contact: Daria Cuda (215) 642-3363 E-mail: [email protected] Web:


November/December 2014

Healthcare Informatics



Fujitsu Computer Products of America, Inc.

HealthLine Systems Inc. San Diego, CA (800) 733-8737 E-mail: [email protected] Web: HealthLine Systems, Inc. provides credentialing software, contact center software and quality management software and support to the healthcare industry. With our wide selection of healthcare software solutions, find the tool that meets your organizations needs.

MEALTRACKER Dietary Software Hornell, NY Contact: Cole Racho (800) 755-3284 E-mail: [email protected] Web:

Sunnyvale, CA (888) 425-8228 E-mail: [email protected] Web: See our ad in this issue


Futura Mobility InterSystems Corporation Cambridge, MA Contact: Market Development (800) 753-2571 E-mail: [email protected] Web: InterSystems is a global leader in software for connected care. InterSystems HealthShare® is a health informatics platform enabling interoperability between disparate systems, information sharing, and smart use of aggregated data.


Fort Washington, PA Contact: Daria Cuda (215) 642-3363 E-mail: [email protected] Web:

InfoMC, Inc. Conshohocken, PA Contact: JJ Farook (484) 567-0601 E-mail: [email protected] Web:

Newark, NJ Contact: Patricia Morrison (877) 207-0035 E-mail: documentmanagement@ Web: scanners/healthcare-scanners.asp See our ad in this issue



American Sentinel University

Speech Processing Solutions USA Inc. Atlanta, GA Contact: Michaela Kraft (877) 773-3242 E-mail: [email protected] Web: Philips voice technology solutions are indispensable daily tools for healthcare users. Our digital dictation solutions, including the new SpeechMike Premium and smartphone apps, are equipped with state-of-the-art technology for use in a medical setting.

ChartMaxx by Quest Diagnostics Mason, OH Contact: ChartMaxx Sales and Marketing (800) 444-6235 E-mail: [email protected] Web:

Aurora, CO Contact: Chris Wolfe (800) 922-5694 E-mail: [email protected] Web: American Sentinel University is a 100% online university accredited by the Distance Education and Training Council (DETC), a recognized member of the Council for Higher Education Accreditation. A proud member of the HIMSS Academic Organizational Affiliate Program, American Sentinel’s healthcare focused informatics, management and technology programs are designed to provide busy working professionals with the skills necessary to be instrumental in today’s challenging healthcare environments. We take learning to the next level!

Healthcare Informatics November/December 2013





ChartMaxx by Quest Diagnostics Sedona Learning Solutions Phoenix, AZ Contact: Linda Hainlen (602) 840-1000 E-mail: [email protected] Web: Sedona Learning Solutions offers EMR educational services. Sedona’s project managers, instructional designers, and instructors work with you to design and deliver customized e-Learning, training, and support for your EMR. Sedona delivers instruction on site or online.

Mason, OH Contact: ChartMaxx Sales and Marketing (800) 444-6235 E-mail: [email protected] Web:



Health Care Software Inc. (HCS) Wall Township, NJ Contact: Thomas Visotsky (800) 524-1038 E-mail: [email protected] Web: HCS has delivered healthcare information systems since 1969. Interactant™ is an integrated platform of clinical and financial modules supporting the spectrum of care including acute, post-acute, and behavioral health providers.

Apollo Falls Church, VA (703) 288-1474 E-mail: [email protected] Web:


Henry Schein MicroMD Boardman, OH (800) 624-8832 E-mail: [email protected] Web:

Interaction Information Technology-Pace+ Mesa, AZ Contact: John Hopkins (866) 359-3829 E-mail: [email protected] Web:

ENTERPRISE RESOURCE PLANNING / BUSINESS INTELLIGENCE / BUSINESS PROCESS MANAGEMENT ChartMaxx by Quest Diagnostics Mason, OH Contact: ChartMaxx Sales and Marketing (800) 444-6235 E-mail: [email protected] Web:

Dimensional Insight, Inc.

Experian Health/Passport Franklin, TN (800) 930-9095 E-mail: [email protected] Web: Experian Health and Passport provide the healthcare industry with a single platform that orchestrates every facet of the revenue cycle. Our integrated offering redefines efficiency with an exception-based workflow, Touchless Processing™, and data and analytics to ensure unmatched payment certainty from patients and payers.

Burlington, MA Contact: Ed O’Brien (781) 229-9111 E-mail: [email protected] Web:

NTT DATA Healthcare Technologies Hauppauge, NY Contact: Larry Kaiser (800) 699-6733, ext. 5329 E-mail: [email protected] Web: www.

SA Ignite Chicago, IL Contact: Jeff Galowich (312) 759-5001 E-mail: [email protected] Web:


November/December 2014

Healthcare Informatics


Informatics Healthcare IT Leadership, Vision & Strategy

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Certify Data Systems Inc.

3M Health Information Systems

Campbell, CA Contact: David Caldwell (408) 426-3160 E-mail: [email protected] Web: Certify Data Systems, Inc., a pioneer of inspired technology for life, is redefining value-driven care with a fully-integrated population health platform. The company’s HealthLogix™ platform empowers HCOs, ACOs, care teams and administrators with real-time actionable health intelligence® to ensure every individual can achieve their best health. Certify Data Systems is a wholly owned subsidiary of Humana Inc. (NYSE: HUM) and is located in Campbell and San Diego, California.

Murray, UT (800) 367-2447 E-mail: [email protected] Web: 3M Health Information Systems delivers software and consulting services to help organizations improve clinical documentation, quality, and financial performance. We offer expertise in coding, ICD-10, dictation, transcription, speech recognition, medical terminologies, and data exchange to support electronic health records. With more than 25 years of healthcare experience, we work as a trusted and stable business partner to provide reliable implementation, training, and support to our clients.

Woburn, MA (800) 869-5200 E-mail: [email protected] Web:

SmartLinx Solutions Manalapan, NJ Contact: Janine Tullock (877) 501-1310 E-mail: [email protected] Web:


3M Health Information Systems

InterSystems Corporation Cambridge, MA Contact: Market Development (800) 753-2571 E-mail: [email protected] Web: InterSystems is a global leader in software for connected care. InterSystems HealthShare® is a health informatics platform enabling interoperability between disparate systems, information sharing, and smart use of aggregated data.

American Health Information Management Association (AHIMA) Chicago, IL Contact: Jackie D. Palmer (312) 233-1988 E-mail: [email protected] Web: AHIMA is the premier association of health information management (HIM) professionals. AHIMA’s more than 71,000 members are dedicated to the effective management of personal health information needed to deliver quality healthcare to the public. Founded in 1928 to improve the quality of medical records, AHIMA is committed to advancing the HIM profession in an increasingly electronic and global environment through leadership in advocacy, education, certification, and lifelong learning. See our ad in this issue

Murray, UT (800) 367-2447 E-mail: [email protected] Web: 3M Health Information Systems delivers software and consulting services to help organizations improve clinical documentation, quality, and financial performance. We offer expertise in coding, ICD-10, dictation, transcription, speech recognition, medical terminologies, and data exchange to support electronic health records. With more than 25 years of healthcare experience, we work as a trusted and stable business partner to provide reliable implementation, training, and support to our clients.

Haugen Consulting Group Denver, CO Contact: Mary Beth Haugen (720) 502-7690 E-mail: [email protected] Web:


November/December 2014

Healthcare Informatics

SPECIAL ADVERTISING SECTION MedeAnalytics Emeryville, CA Contact: Randy Hamamoto (310) 930-1769 E-mail: [email protected] Web:


American Health Information Management Association (AHIMA) Chicago, IL Contact: Jackie D. Palmer (312) 233-1988 E-mail: [email protected] Web: AHIMA is the premier association of health information management (HIM) professionals and is committed to advancing the HIM profession in an increasingly electronic and global environment. Leverage AHIMA’s well-established expertise and knowledge in the clinical coding industry, including best practices for adult professional education. Our ICD-10 product suite is designed to provide a full spectrum of rigorous yet flexible learning opportunities for staff development in a variety of roles, and proficiency levels. See our ad in this issue

IMAGING/PACS Winthrop Resources Corporation

Infinitt North America Inc. Phillipsburg, NJ Contact: Diane Sappah (908) 387-6960 E-mail: [email protected] Web: INFINITT  North America has introduced an enterprise data management solution—the INFINITT Healthcare Platform (IHP)—that consists of a centralized, vendor neutral storage architecture; manages all data formats (DICOM, non-DICOM, document management, etc.); and includes Intelligent Life Cycle Management. On the departmental level, INFINITT offers advanced PACS and Reporting tools for Radiology, Cardiology, Mammography, Dental, Ophthalmology, 3D/Advanced Visualization and more.  Greatly simplifies multi-site support. Call INFINITT at (877) 387-6960 or visit our website at www.

NovaRad Corporation American Fork, UT Contact: Paul Shumway (801) 642-1001 E-mail: [email protected] Web:


Flash Code Solutions, LLC Los Angeles, CA Contact: Meta Rias (800) 633-7467 E-mail: [email protected] Web: Flash Code™, the #1-rated medical coding software, is used daily by thousands of physicians, medical groups, hospitals, and third party payers for comprehensive coding and compliance tasks. Flash Code users will find the transition to ICD10 easy with our ICD-10-CM coding module, ICD-9-CM to ICD-10-CM code mapping (GEM), ICD-9-CM to ICD-10-CM Side-by-Side™ display, and our ICD-10-PCS Code Builder™ module.

Ashvins Group Inc. Miami, FL Contact: Lynn Hilt (877) 274-8467 E-mail: [email protected] Web:

Minnetonka, MN Contact: Brad Swenson (952) 656-7689 E-mail: [email protected] Web: Technology changes rapidly, post-warranty maintenance is expensive, and interdepartmental connectivity causes ripple effects through your organization that drive unplanned change. Winthrop provides custom technology leasing solutions to hundreds of leading healthcare organizations.


PathView Systems Anna, TX Contact: Michael Mihalik (800) 798-3540 E-mail: [email protected] Web: From specimen tracking to web/EHR reporting, Progeny by PathView Systems is a comprehensive LIS solution for today’s Anatomic Pathology, Cytology, and Molecular laboratories. Realize LEAN efficiencies and empower your business to compete in a dynamic marketplace.

Psyche Systems Corporation Milford, MA Contact: Lisa-Jean Clifford (508) 473-1500 E-mail: [email protected] Web:

VCPI Milwaukee, WI Contact: Tim Tarpey (414) 865-2005 E-mail: [email protected] Web:

Healthcare Informatics November/December 2013




SCC Soft Computer Clearwater, FL Contact: Ellie Vahman (727) 789-0100 E-mail: [email protected] Web: See our ad in this issue

Conshohocken, PA Contact: JJ Farook (484) 567-0601 E-mail: [email protected] Web:

ClientTell Inc. Valdosta, GA Contact: Chad Greer (877) 244-9178 E-mail: [email protected] Web:


RAM Technologies Inc. Fort Washington, PA Contact: Mark Wullert (215) 654-8810 E-mail: [email protected] Web:

LONG-TERM CARE MASTER PATIENT AND PROVIDER INDEX NextGate American Health Information Management Association (AHIMA) Chicago, IL Contact: Jackie D. Palmer (312) 233-1988 E-mail: [email protected] Web: In this, the only Summit of its kind, AHIMA, the Long-Term and Post-Acute Care (LTPAC) Health IT Collaborative, Strategic Partners, and others team up to address the issues facing the LTPAC care setting. This two-day meeting provides thought-provoking, interactive sessions aimed at advancing HIT Priorities; showcases implementation successes; and puts the spotlight on LTPAC technologies. The 2015 LTPAC Summit will be held June 22-23 in Baltimore, MD. See our ad in this issue

SmartLinx Solutions Manalapan, NJ Contact: Janine Tullock (877) 501-1310 E-mail: [email protected] Web:

VCPI Milwaukee, WI Contact: Tim Tarpey (414) 865-2005 E-mail: [email protected] Web:

Pasadena, CA Contact: Richard Garcia (626) 376-4100 E-mail: [email protected] Web:

MEDICATION CARTS Futura Mobility Fort Washington, PA Contact: Daria Cuda (215) 642-3363 E-mail: [email protected] Web:


Medical Decision Network, LLC Charlottesville, VA Contact: Greg Menke (866) 791-6108 E-mail: [email protected] Web: Medical Decision Network, LLC provides a wide range of solutions dedicated to improving the quality and cost of healthcare. Our FDA cleared GlucoStabilizer automates the calculation and insulin dose for IV infusions and adjusts the dose, timing of next glucose test and target range. Visit ICUTracker helps show the state of your critical care units and provides information and reports that can lead to improved outcomes and quality. Visit

PATHOLOGY INFORMATION SYSTEM Psyche Systems Corporation Milford, MA Contact: Lisa-Jean Clifford (508) 473-1500 E-mail: [email protected] Web:

Fort Washington, PA Contact: Daria Cuda (215) 642-3363 E-mail: [email protected] Web:

PAYROLL SmartLinx Solutions

MESSAGING 1Call, A Division of AMTELCO

Manalapan, NJ Contact: Janine Tullock (877) 501-1310 E-mail: [email protected] Web:

McFarland, WI Contact: Michael Friedel (800) 225-6035 E-mail: [email protected] Web:


November/December 2014

Healthcare Informatics



QUALITY REPORTING MedeAnalytics Emeryville, CA Contact: Randy Hamamoto (310) 930-1769 E-mail: [email protected] Web:

RAM Technologies Inc. Fort Washington, PA Contact: Mark Wullert (215) 654-8810 E-mail: [email protected] Web:

Henry Schein MicroMD Boardman, OH (800) 624-8832 E-mail: [email protected] Web:



American Fork, UT Contact: Paul Shumway (801) 642-1001 E-mail: [email protected] Web:

ZirMed, Inc. Louisville, KY (877) 494-1032 E-mail: [email protected] Web:


RCM—CLAIMS MANAGEMENT SK&A, A Cegedim Company Irvine, CA Contact: Jack Schember (800) 752-5478 E-mail: [email protected] Web: SK&A is your #1 source for healthcare marketing leads and medical marketing resources. Our accurate database of 2.1 million physicians and other professionals is continuously telephoneverified and audited by BPA.

Vistar Technologies Wellington, FL Contact: Jim Gifford (888) 266-4532 E-mail: [email protected] Web: istar Technologies offers powerful Provider Data Management solutions with comprehensive end-to-end functionality for all aspects of provider and network management. The eVIPs™ system offers robust workflow solutions that will streamline recruiting, enrollment, provider relations, contracting, contract fulfillment, credentialing, ongoing monitoring, quality management and communication management to provide a central provider data repository. Vistar’ s solution will serve as a core source system for integration, quality analysis, data access and reporting.

Experian Health/Passport Experian Health/Passport Franklin, TN (800) 930-9095 E-mail: [email protected] Web: Experian Health and Passport provide the healthcare industry with a single platform that orchestrates every facet of the revenue cycle. Our integrated offering redefines efficiency with an exception-based workflow, Touchless Processing™, and data and analytics to ensure unmatched payment certainty from patients and payers.

Franklin, TN (800) 930-9095 E-mail: [email protected] Web: Experian Health and Passport provide the healthcare industry with a single platform that orchestrates every facet of the revenue cycle. Our integrated offering redefines efficiency with an exception-based workflow, Touchless Processing™, and data and analytics to ensure unmatched payment certainty from patients and payers.

InfoMC, Inc. Conshohocken, PA Contact: JJ Farook (484) 567-0601 E-mail: [email protected] Web:

NTT DATA Healthcare Technologies Hauppauge, NY Contact: Larry Kaiser (800) 699-6733, ext. 5329 E-mail: [email protected] Web: www.

NTT DATA Healthcare Technologies Hauppauge, NY Contact: Larry Kaiser (800) 699-6733, ext. 5329 E-mail: [email protected] Web: www.

Healthcare Informatics November/December 2013





Avantas Omaha, NE Contact: Larry Punteney (888) 338-6148 E-mail: [email protected] Web:

ZirMed, Inc. Louisville, KY (877) 494-1032 E-mail: [email protected] Web:


Experian Health/Passport Franklin, TN (800) 930-9095 E-mail: [email protected] Web: Experian Health and Passport provide the healthcare industry with a single platform that orchestrates every facet of the revenue cycle. Our integrated offering redefines efficiency with an exception-based workflow, Touchless Processing™, and data and analytics to ensure unmatched payment certainty from patients and payers.

SmartLinx Solutions Manalapan, NJ Contact: Janine Tullock (877) 501-1310 E-mail: [email protected] Web:


Experian Health/Passport Franklin, TN (800) 930-9095 E-mail: [email protected] Web: Experian Health and Passport provide the healthcare industry with a single platform that orchestrates every facet of the revenue cycle. Our integrated offering redefines efficiency with an exception-based workflow, Touchless Processing™, and data and analytics to ensure unmatched payment certainty from patients and payers.

MedeAnalytics Emeryville, CA Contact: Randy Hamamoto (310) 930-1769 E-mail: [email protected] Web:

MorphoTrak LLC

ZirMed, Inc. Louisville, KY (877) 494-1032 E-mail: [email protected] Web: ZirMed delivers proven end-to-end SaaS business and clinical performance management solutions designed to optimize both fee-for-service and fee-for-value reimbursements while managing population health. ZirMed combines innovative software development with the industry’s most advanced transactional network and predictive analytics platform to improve the business and process of healthcare, give organizations a clearer view of their financial and operational performance, and streamline critical connections between providers, patients, and payers.

Alexandria, VA Contact: Robert Horton (714) 575-2945 E-mail: [email protected] Web:

SOFTWARE DEVELOPMENT Ashvins Group Inc. Miami, FL Contact: Lynn Hilt (877) 274-8467 E-mail: [email protected] Web:

REVENUE MANAGEMENT ZirMed, Inc. Louisville, KY (877) 494-1032 E-mail: [email protected] Web:


MedeAnalytics Emeryville, CA Contact: Randy Hamamoto (310) 930-1769 E-mail: [email protected] Web:

Summit Healthcare Braintree, MA Contact: Jason Behan (866) 925-9375 E-mail: [email protected] Web:


November/December 2014

Healthcare Informatics


TELEHEALTH/TELEMEDICINE Futura Mobility Fort Washington, PA Contact: Daria Cuda (215) 642-3363 E-mail: [email protected] Web:

WIRELESS DEVICES Futura Mobility Fort Washington, PA Contact: Daria Cuda (215) 642-3363 E-mail: [email protected] Web:

Buyers Guide Your online resource for technology products and services.

WIRELESS NETWORKING VCPI Milwaukee, WI Contact: Tim Tarpey (414) 865-2005 E-mail: [email protected] Web:


Apollo Falls Church, VA 703) 288-1474 E-mail: [email protected] Web:



Avantas Omaha, NE Contact: Larry Punteney (888) 338-6148 E-mail: [email protected] Web:



Healthcare Informatics November/December 2013



Managing Virtual Employees Today there are a host of technologies that allow a far-flung workforce act like a tightly integrated team BY TIM TOLAN


ike other market segments, the HIT world is moving to a workforce of virtual employees. As the candidate market gets tighter, I believe this trend will become even more commonplace. The virtual worker train left the station a long time ago. I’ve personally led business development teams for over two decades, and the bulk of my teams have been mostly virtual. With a shortage of Tim Tolan HIT workers, more organizations are becoming creative to find great talent, and many are allowing their employees to work virtually (at least to some extent). This trend is something we need to embrace. It was always hard for me, back in the day, to track productivity and know what my team was working on; and that was nearly impossible with those working remotely—but not anymore. We are all wired 24/7, and the tools that are available today

the office/facility, or that those who live too far away spend one week each month onsite, giving the remote employees a chance to build and maintain important relationships with the rest of the team. Hosting a team luncheon periodically is another way to foster team-building and relationship development for the entire team. r Instant Messaging. IM is an integral part of communications for organizations with or without remote employees. Being able to send an IM message on the spot to a team member or an entire team about an issue an employee is having is great. It’s immediate and the employee has a chance to respond regardless of what he or she is doing at the time. We use Yammer as a tool to communicate with other offices around the country. Great tool. r Text Messaging. Again, it’s a great tool that many of us use in our personal lives and one that is already getting lots of usage in the commercial world we live in. All you need is a cell phone number and you are connected. It’s more commonplace now to use text messaging with our candidates to confirm interviews, travel and other search related items. rHosted Email and Outlook. With so I WOULD ARGUE THAT IT’S MUCH MORE PRODUCTIVE many options on hosted services like TO HAVE REMOTE TEAM MEMBERS AS PART OF YOUR WebMail and Microsoft Office 365, being plugged in is easier than ever. IntegratWORKFORCE. —TIM TOLAN ing email on our mobile devices and smart phones has been around for a long time, but now to track productivity for those working virtually make the almost any application we are using on our desktop is task much easier. Let’s take an inventory of the tools and or portable to other devices, including laptops, tablets and processes that can help us better manage a remote worker: smart phones. With lots of authentication and security r VoIP Telephones. Plug-and-play Voice over Internet tools most of your concerns around the Health Insurance Protocol (VoIP) phones are a great way to keep people Portability and Accountability Act (HIPAA) should be connected to the organizations’ main phone number, and minimal. really help remote employees feel like they are part of the It’s becoming much more difficult to argue that having team. VoIP phones also have great reporting features and the ability to get all of the voice mail messages sent to the remote employees is not efficient. I would argue that it’s much more productive to have remote team members as part of your smart phone. A real plug-and-play tool. r Video Conferencing. This technology has come a long way workforce. Based on our experience, remote employees work over the past few years. With WebEx, Skype and a host of more hours and are much more productive. They don’t have to other video applications, the sky is the limit to what you can deal with the minute-by-minute interruptions of co-workers do. We have video meetings that allow remote employees to or the impromptu meetings they never had on their calendar. visually participate in team meetings—which I believe adds Your remote employees may prove to be your most productive employees in your entire IT organization. Try it! ◆ to their sense of belonging to the team. A real plus. r Integrating Virtual and Office Time. It’s a good idea to integrate some portion of the remote workers to be physically Tim Tolan is senior partner at Sanford Rose Associates-Healthcare IT Practice. in the office and visible to the rest of the team. I recom- He can be reached at [email protected] or (904) 875-4787. His blog mend that remote employees work one day per week in can be found at /

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