HIT and its Impact on Workforce Development

A Web site titled NetAssets has published the first of a five part series on HIT and its impact on workforce development titled: Part I, HIT Overview

This evening I am in a writing mood and just couldn’t resist commenting on their post. One of the things a blog does is allow me to post my thoughts where friends and colleagues will see them rather than scattering them on fence posts, at the base of trees, and fireplugs around the neighborhood. Comments that would have been scattered at the end of other peoples’ posts just a year ago now go here on my blog.

The three authors of part one, Katz, Saran, and Wool have done a nice job of capturing the current uncertainty surrounding EMRs and the much broader topic of healthcare information technology. Today’s market is badly fractured and still poorly defined. Having said that, I thought it would be fun to take a stand today and look back next week or two years from now and just see how much progress we have made and the direction we have taken.

For what it is worth, my best estimate is that connectivity will be via the Internet with significantly more security at all levels. The primary new employment market will probably be security because is it so critical and the threats will shift as the defenses improve. Block the bad guys here and they will move over there and we have to develop new blocking mechanisms. Then they move again. Security is always more of a process than a project.

Data will be stored using existing technology, both software such as SQL and evolving storage media including virtualized systems and clouds. More people will be needed but the skills will be extension of current skills. At lot of today’s designers, programmers, data base administrators, etc., will use the skills they have to move up. There will probably be a big market back-filling jobs in other industries were incumbents have left to go into healthcare. These will be real jobs, just not in healthcare and they may not qualify for government assistance.

Data acquisition – how the data is captured – will be the place where we see the greatest change. The work-load impact of capturing the information is one of the biggest complaints about most EMRs. There will be new technologies and significant improvement in existing data acquisition technologies. And perhaps equally important, larger markets for these new and improved technologies will bring down costs. Almost all of this will happen in industries outside of healthcare. Healthcare will be buyers, not participants.

There appear to be huge training needs to help almost everyone involved in healthcare learn to use the new tools. Fortunately there a lot of people who are already familiar with computers, office applications, and the Internet. We are not starting from square one. Flip side, most of them know very little about security, the place where I began these comments.

Bill Crounse, MD,  Microsoft’s worldwide health senior director addressed this broader training need in a blog post dated October 7, 2009. “Dr. David Blumenthal (National Coordinator for Health Information Technology) has announced a ‘workforce training initiative’ to educate more health information management professionals with expertise in electronic health records and related technologies.  He says at least 50,000 new jobs are needed in the field.  I would add, based on what I’ve experienced, that we will also need training for perhaps ten or twenty times that number of people; i.e. most of the physicians, nurses and other clinicians who are currently practicing in offices, clinics and hospitals all over America.

“It’s not that these folks have their heads in the sand. Most of them are working so hard day to day in patient care, trying to stay afloat and keep their practices from going under, that they literally don’t have time to come up for air.  So what happens when we expect them to use all of this technology and also give 45 million more people access to their services?  That is going to call for one hell of a training program!

Building an Integrated EMR One Piece at a Time

Today Allscripts made three major announcements:

An agreement with Intuit Inc. to become the first to offer Quicken Health(SM) Bill Pay. The online service integrates with Allscripts’ practice management and revenue cycle management solutions, used by 110,000 physicians, to help patients understand their medical bills and pay them online while helping physicians get paid faster.

An agreement with mPay Gateway allows Allscripts Patient Payment Assurance to provide point-of-care collection of credit card and debit card payments, which all but eliminates the need for patient billing. The solution enables providers to calculate how much the patient owes, based on their own rates and the patient’s insurance, and obtain payment authorization before the patient leaves the office. The patient’s payment card is charged only after the clinic settles the claim with the insurance company. Clinics that are utilizing the solution have realized 50 percent decreases in patient receivables.

A new partnership between Iowa Health System and Allscripts, called ePrescribe Iowa, will offer a free Web-based e-prescribing solution to physicians throughout Iowa. ePrescribe Iowa automates the process of writing prescriptions and transmitting them to pharmacies while alerting physicians to potentially dangerous drug-to-drug interactions, drug allergies, dosage errors and other problems that can occur when writing prescriptions on paper.

This blog post is not intended to be promotion for Allscripts but rather an illustration of how fully functional EMRs may be assembled one piece at a time. Easier for the doctors and a clever marketing strategy that begins with a simple relationship that has  potential for evolutionary growth.

By the way, I picked up this story on that high-tech Web site called Facebook.

Healthcare is dis-integrating its information

Significant parts of American business are integrating information through industry wide interfaces and Enterprise Resource Planning systems (ERP). What is healthcare doing? In too many cases, healthcare is moving in the opposite direction and dis-integrating its information.

Electronic Medical Records (EMR) systems are being designed using proprietary solutions with a facility or group focus that limits the ability to share information outside the facility or beyond a limited group. This is providing better and better data that is aligned to the needs of a limited set of providers with little or no regard for the total healthcare needs of their patients. If a patient needs the services provided by our limited group,we can help. If patients need a service that is not provided by our group, the best we can offer are the services that have been available for years – services from the time before computers.

Clinical systems are being developed using proprietary solutions and are silo focused which makes data and processing incompatible even within organizations.

A Google search for “erp systems for healthcare” lead to a list of links. The top ten included nothing newer than two from 2007, two from 2006, one from 2004, two from 2001, three undated and a vendor job board.

One of the links dated 2007 was Healthcare ERP and SCM (Supply Chain Management)  Information Systems: Strategies and Solutions by HIMSS. The summary of findings included:

Healthcare is far different in its expectations for enterprise-wide systems and solutions due to the nature of the business. The concern that errors in the processes and technology can lead to severe and undesired outcomes has far greater impact than any other industry with ERP and SCM needs. That is why it is alarming that while clinical systems and medical devices continue to evolve, thus contributing to greater and more positive outcomes, the current ERP and SCM solutions are built on 20- to 40-year-old technologies, programming languages, and architectures.

Every technology department has experienced integrating their ERP and SCM information systems with proprietary and cumbersome clinical systems, which are defined in specialties and single purpose roles. In addition, the information remains separated requiring several databases and stores, which are incompatible and not designed to work together. The crisis in healthcare has moved from the operating room to the server room with a need for greater response from the ERP and SCM IS vendors. The healthcare environment and the systems that support it have become too difficult for users to fully utilize all the system capabilities. With constrained budgets and limited resources, the entire system to support the hospital’s business administrative needs becomes a conglomeration of excel, post-it notes, e-mails, and bytes. [emphasis added]

Healthcare reform and cost control will require multiple solutions that include more effective capture, integration and application of patient, clinical and operation data. Integration, not continuing dis-integration.

More than half of all health spending wasted

Some late night Web surfing led to a blog about one of my favorite topics: reducing health care costs. In April 2008, PricewaterhouseCoopers hosted the 180° Health Forum in Washington D.C. The results of that conference are published as: The price of excess: Identifying waste in healthcare spending,

As part of its preparation for the 180° Health Forum, PricewaterhouseCoopers’ Health Research Institute (HRI) interviewed more than 20 participants, reviewed more than 35 studies about waste and inefficiency in healthcare and surveyed 1,000 consumers to understand the public’s perception of waste and inefficiency in the system. From that research came The price of excess: Identifying waste in healthcare spending. …

Key Findings
Our research found that wasteful spending in the health system has been calculated at up to $1.2 trillion of the $2.2 trillion spent in the United States, more than half of all health spending. Defensive medicine, such as redundant, inappropriate or unnecessary tests and procedures, was identified as the biggest area of excess, followed by inefficient healthcare administration and the cost of care necessitated by conditions such as obesity, which can be considered preventable by lifestyle changes. PricewaterhouseCoopers’ paper classified health system inefficiencies into three “wastebaskets” that are driving up costs:

Behavioral where individual behaviors are shown to lead to health problems, and have potential opportunities for earlier, non-medical interventions.
Clinical where medical care itself is considered inappropriate, entailing overuse, misuse or under-use of particular interventions, missed opportunities for earlier interventions, and overt errors leading to quality problems for the patient, plus cost and rework.
Operational where administrative or other business processes appear to add costs without creating value. [My added emphasis.]

Some of these are easier to attack than others. Number 1 on my list would be administrative and business process costs.

See also: The Innovator’s Prescription, The Innovator’s Prescription #1, Reducing Costs, Reducing the Risks of Complexity [and costs]

Time to Kill the PHR Term

Language can be magic carpet that takes thoughts to new and interested places; it can also be a trap. This blog has been about electronic medical records—EMRs—generated by healthcare providers. A corollary to that has been a personal version of EMRs from multiple providers that make up a personal health record—PHR for an individual. There is a trap in dealing with the personal version as a collection of information from other records. The PHR is reduced to a record or data rather than becoming a tool that supports the individual’s efforts to improve and maintain good health.

Microsoft Health Vault, Google Health, and similar programs use the Internet and linked tools including iPhones and “smart” medical devices to create the needed tool or “platform” for more than just records. John Moore of Chilmark Research argues that it is time to move from PH-Record to PH-Platform and I agree

Quoting from John’s post:

… where we really get concerned with the PHR term is that in the meaningful use recommendations that were accepted in July.   Under meaningful use guidelines, those obtaining Stimulus (ARRA) funding for adoption of a certified EHR must provide a PHR to their patients by 2013.  Trouble here is how will HHS define what that PHR is?  Last year, HHS [had] the PHR term defined (see below).  This term, we have been told, is what will be used within the context of meaningful use rule making.  If this is indeed true, adoption of PHRs will continue to be lackluster.

PHR, Personal Health Record: “An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual.”

To move beyond the limitations of this definition (and the baggage that goes with it) Chilmark proposes a new term, Personal Health Platforms (PHPs) with the hope that others will pick up the banner moving us beyond where we are today and hopefully get HHS to look beyond the narrow confines of the PHR definition that they have before them.

What is a Personal Health Platform?

Our proposed definition is as follows:

A Personal Health Platform (PHP) is an Internet-based platform that securely stores and manages a citizen’s personal health data, data that may be derived from multiple sources including among others clinical systems, payer systems, self-enter data, and biometric.  The PHP also provides the framework and capabilities to support applications, services and/or tools that a citizen may invoke to leverage their personal health data enabling the citizen to make better, more well-informed decisions regarding their health or the health of a loved one.

The second sentence of that definition is the key differentiator. A PHP does more than simply store the data, it makes that data actionable.

In a nut shell, we keep the records and the communication links and interfaces that create the personal records and we add capabilities that support additional information and make all of the information actionable. That is a result that is worth the effort.

See also: Including patients in EMRs and
What if? What if we expand the definition of EMR?

Proposal to Microsoft & Google

A core element of healthcare reform in its broadest context is cost. The first step in controlling cost is to gain visibility about what healthcare actually costs at a level where action can be taken. Microsoft Health Vault and Google Health are platforms that can provide that visibility for consumers. That information can then be de-personalized and used to provide visibility from multiple points of view including hospitals, private practices, regions of the country, type of procedure, etc.

The problem

If I receive healthcare services that involve more than a single provider I will be billed for services from the primary provider and a host of other providers and services including labs and pharmacies. These will show up as line items on a statement I receive from the provider if I am a direct pay or on a statement from my insurance company. Some will be prompt; some will show up months later. All of them will be printed on paper.

Any effort on my part to analyze this data will require hours to transcribe it to an electronic form and then to assign it to specific illnesses or injuries and then classify it in meaningful sub-categories for analysis. If I find a potential issue it is difficult to challenge it in a timely manner.

Proposed solution

You could provide an interface to providers to capture the data in its electronic form and post it on my personal health record (PHR) as a standard spreadsheet, e.g., Excel. That format would:

• Identify the service provider with a link to a database for more information, e.g., what services does XYZ Medical provide and how I can contact them – an Internet link would probably take care of most providers.
• Provide a generic classification of the services, e.g., hospital, lab, ambulance, etc.
• The date of service
• Some description of the service which could be a billing code* and a standard translation
• Amount billed, allowed, payer paid, I pay

It should include charges that are covered by insurance plus non-covered charges such as non-prescription pharmacy at drugstores and other providers that are subscribers to Health Vault or Google Health. It should allow me to add in costs related to trips for treatment, special clothing or devices not covered by insurance, etc.

It should provide the means for me to assign each line item or set of line items to a particular illness or injury or some general classification of my choosing, e.g., seasonal allergy.

Benefits

• I could accumulate charges related to an incident to get a better understanding of what it cost
• I could explore options for less costly solutions, e.g., clinic vs. emergency room
• I would have more confidence in the accuracy of my charges if I could see them sorted in ways that make sense to me, e.g., see that two charges for the same service or item on the same day were for something that could reasonable occur more than once on the same day
• I would be able to challenge any apparent issues in a timely manner and with a minimum of effort using the data and information in the report
• I would be able to get a sense of the charges that have been invoiced and those that have not
• I would see the value or limitations of my insurance to negotiate for more cost effective insurance in the future.
• I would be better informed about the cost of healthcare and therefore better able to participate in discussions of options and solutions.

Costs

Participation in this service could be part of a provider or payer’s package of services. A translation from their standard formats to yours would have to be developed but we should be dealing with relatively standard data elements as specified by HIPAA and the current work on electronic medical records. The cost per provider or payer should be relatively small.

I leave the cost and benefits of de-personalizing data for broader analysis to you but I suspect that it is relatively small once the data exists in a standard format.

* Related discussion on problems with billing codes initiated by e-Patient Dave on Twitter

Reducing Costs

Just finished reading a blog post that includes the comment:

The cost of medical care can be calculated by adding up the cost of each unit of care, multiplied by the cost per unit. If an appendectomy costs $8,000 and you need to perform 100 appendectomies a year, the total cost would be $800,000. To add up the total costs of all care you have to calculate this for each procedure, office visit, X-ray, drug, etc., and add them together. Once you understand this concept, it’s easy to figure out how to cut the total cost. You reduce the payment for each service, or you reduce the number of (unnecessary) services used in a given year, or both.*

If you assume that the cost of a unit of service is constant then of course the total cost is simply cost per delivered service times the number of services. Part of health care reform is to change the unit of cost per required service. There are a number of articles that document changes in healthcare processes that can produce significant savings by reducing the cost to deliver a unit of service (and hence to cost to the patient) or the number of required units (and hence the total cost.)

One examples of reducing costs that will reduce the average cost per procedure is described in Reducing the Risks of Complexity Some procedural changes that are simple in concept but not-so-simple in implementation:

In December, 2006, the results were published in The New England Journal of Medicine. Within the first three months of the project, the infection rate in Michigan’s ICUs decreased by sixty-six per cent. The typical ICU cut its quarterly infection rate to zero. Michigan’s infection rates fell so low that its average ICU outperformed ninety per cent of ICUs nationwide. In the first eighteen months, the hospitals saved an estimated hundred and seventy-five million dollars in costs and more than fifteen hundred lives. The successes have been sustained for almost four years.

Another: “For many patients, but not all, RCs [retail clinics] are cheaper (on the order of 30% cheaper), faster even without an appointment, and more convenient (up to 18/7).” A thirty percent savings on some procedures for some patients using lower cost solutions reduces the average cost per unit of service. When doctors substituted office visits in lieu of house calls they simply implemented a lower cost way of providing services that allowed them to deliver more units of service per day and thereby reduce the cost per unit and retain or improve their take home income.

Reducing the average cost (price paid) per unit of service for existing providers is not the only way to reduce health care costs. Better processes and new ways of delivering services can reduce the cost to the doctor of providing services which allows for a lower cost to the patient/payer without reducing the doctor’s take home income.

It won’t be easy but there is growing evidence that today’s health care delivery is not as efficient as it can be. We need to find opportunities to reduce the cost of providing services while maintaining or improving outcomes. Those savings can be passed on to patients.

*For every complex problem, there is a solution that is simple, neat, and wrong. H.L. Mencken

Building a Healthcare IT Team

I am a management consultant with experience in a number of industries including HIPAA in healthcare. Electronic medical records (EMR) appears to be an area where I can make a contribution and a living. But, the opportunity is more apparent than real.

Several things I have noticed:

• Widespread concern in the press about the availability of the people who will be needed to implement near-universal EMR.
• Almost all of the open positions I have seen have a strong requirement for hospital or other healthcare provider IT experience.
• Almost all of the positions are for programmers and other “technical” staff; almost no analysts or others skilled in exploring what is really needed and how current technology and advances on the horizon can be put to good use.
• There is no clear definition within the industry of the scope for electronic medical records.

Of course an IT team should include a lot of direct experience in the specific industry. But strong teams are made up of people with diverse and complementary skills and experience. Effective healthcare IT requires a wide range of skills and experience. The quickest way to develop that range is to incorporate experienced people from other industries who have relevant IT experience. As part of a team they will learn the fundamentals and most of the nuances of healthcare quickly. With fresh eyes, they will make unexpected contributions. They will stimulate the discussions about options and solutions. And, they will bring new points of view about IT and the world with which healthcare must interface, e.g., patients who are growing more computer savvy, healthcare related products and services beyond the normal bounds of healthcare such as retail drugstore clinics, online medical advice, and evolving electronic medical devices.

A friend of mine writes business cases for companies seeking early stage investment. A recent client was a group of doctors who wanted to develop and market a computer application related to their specialty for use in hospitals. They asked hospital IT managers they knew for recommendations for system development support. The recommended “experts” in hospital systems development agreed to take the assignment and offered to assess the competition. For openers, they said there was no significant competition. My friend quickly found there was a significant competitor. Failure to know and disclose that to investors could have led to a lawsuit. Well into the development project, my friend asked me to review what was being developed. Even with my limited healthcare background, it was obvious that the requirements analysis process had missed several key elements. They had started coding before they thoroughly understood how the system should deliver value. In addition, substantial parts of what they were building and charging for are readily available in the market and could have been licensed at a small fraction of the cost of development and would have been available much quicker. The “experts” do know hospital procedures and are good coders but they simply do not have the breadth of experience to identify specialized system requirements, assess the competitive market, or the state of the art of assembling existing elements to support the truly innovative parts of a new application.

If you want a stronger species or IT team, deepen and expand the gene pool.

__________________________
Inspired by a Twit from HealthcareITJob || How To Build Your Team Now So You Can Play (Not Pay) Later Posted on: 8.20.2009 6:53:57 PM http://tinyurl.com/mzmyxk

Including patients in EMRs

I recently responded to a question on Linkedin related to electronic medical records: Health 2.0 Group http://cli.gs/tmBWjr In the response I included: “… unless patients are included either directly or via interconnects such as Microsoft’s Health Vault or Health Google, the value of the records are very limited.”

The next response by a Linkedin members was: “This is a very naive statement. A very close statement would be to make the same claim about bank records, which for the most part, the value in interconnecting them does nothing for the financial benefit if the account holder…”

I would argue that including customers in bank records provides significant value:

1. I can go online or to an ATM and get my balance and my statement at my convenience because I am now able to connect to my bank records
2. I can go online and mange my credit cards which are issued by banks even if they have an airline or gas station logo on them
3. I am able to use home banking to receive and pay bills which can be very convenient.
4. I am able to use home banking for financial record keeping including historic records for several years
5. I am able to move money between my bank and brokerage accounts relatively quickly at no cost
6. My bank records are linked to credit rating agencies and I can link to that information which facilitates finding and resolving errors that affect my ability to get a loan; the problem of errors was big enough that congress acted to provide this added protection and I suspect we will find the same issues with electronic medical records.

Some analogies between bank and medical records would include:

1. When did I or a family member last have a checkup for X? When should I schedule my next one?
2. My EMR should provide medical record keeping similar to the financial record keeping with my bank
3. I will be able to use CVS clinic type facilities for minor medical issues for convenience and cost reduction and assure that that visit and the treatment are known to my regular physician so she is fully informed
4. I will be able to review my medical records and take appropriate action – yet to be determined – to at least comment on errors and perhaps get them corrected. Potentially good for my health and my insurability.

Some other benefits of including patients were discussed in my last post: What if? What if we expand the definition of EMR?

What if? What if we expand the definition of EMR?

What if I were to make a note of those occasional strange things going on in my body? You know, those annoying aches and pains that are hardly worthy of notice at the time. On the other hand, what if just a few are precursors of something going wrong? What if a few small symptoms could signal the need for attention to prevent a heart attack, stroke or some other potentially deadly disease? Or just identify something, the progress of which can be slowed by early medication? What if thousands of people made occasional notes in their PHR and these notes were examined after they had significant medical events? Most posts would probably be insignificant, but what if some proved to be useful? We have little or no access to that kind of data today, but we could.

What if a large number of yoga places were to log attendance electronically (mine does now) and then periodically post when attendees took what level and type of class to their PHR? (With their permission, of course.) Again, a large amount of data that might correlate to risks or significant benefits. There are at least two useful ways of looking at that type of data. Does yoga create a risk or benefit? And, does an unrelated change in medication or lifestyle have more or less impact on people who practice yoga than people who have no record of similar activity.

What if I could use an iPhone application to keep track of when and how long I bicycle, my top speed and average and how many feet I climb? What if I could add the results from my heart monitor? And what if I did that for several years? Risks? Benefits? Correlations with medical events?

What if I went to an acupuncturist and he included notes about what we did and why and I made notes before and after about what was happening to me?

All of this, and certainly more, is possible. Indivio, HealthVault and Google Health and their expanding network of participants such as CVS and Walgreen are moving us in that direction.

Note that all of the data collection discussed here is outside the normal scope of electronic medical records and that the value of almost all of it arises out of the ability to correlate it after a medical event with data that is within the scope EMRs.

Narrow-scoped EMRs will be able tell public health authorities how many people go to the hospital for a spreading virus like H1N1 and how long they are there. EMRs will also report how many people go to see their doctor and whether they go multiple times. PHRs could add data about how many people self-diagnose themselves with the flu. They could tell public health how many of these self-diagnosed and how many doctor-diagnosed victims stay home and for how long or go to work despite their symptoms.  Also, which family member brought it home and how did it progress through the family? There has to be a pony or two in there somewhere.

Expanding the scope doesn’t mean that the amount of effort or cost to system owners will increase. Proprietary systems will have to develop interfaces to other proprietary systems, add one more to access Indivio based systems won’t have much impact. Expanding the scope may even decrease costs a bit by moving some application development and maintenance from proprietary systems to PHRs. At a high level the cost benefit is potentially very attractive. It would be a shame to miss this opportunity because of a lack of creativity and overly narrow focus.