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Eyes Wide Shut – Patient Engagement Pitfalls Prior to Meaningful Use Reporting Period

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July 1, 2015 – the start of the Meaningful Use Stage 1 Year 2 reporting period for the hospital facilities within this provider integrated delivery network (IDN). The day the 50% online access measure gets real. The day the inpatient summary CCDA MUST be made available online within 36 hours of discharge. The day we must overcome a steady 65% patient portal decline rate.

A quick recap for those who haven’t followed this series (and refresher for those who have): this IDN has multiple hospital facilities, primary care, and specialty practices, on disparate EMRs, all connecting to an HIE and one enterprise patient portal. There are 8 primary EMRs and more than 20 distinct patient identification (MRN) pools. And many entities within this IDN are attempting to attest to Meaningful Use Stage 2 this year.

For the purposes of this post, I’m ignoring CMS and the ONC’s new proposed rule that would, if adopted, allow entities to attest to Meaningful Use Stage 1 OR 2 measures, using 2011 OR 2014 CEHRT (or some combination thereof). Even if the proposed rule were sensible, it came too late for the hospitals which must start their reporting period in the third calendar quarter of 2014 in order to complete before the start of the fiscal year on October 1. For this IDN, the proposed rule isn’t changing anything.

Believe me, I would have welcomed change.

The purpose of the so-called “patient engagement” core measures is just that: engage patients in their healthcare, and liberate the data so that patients are empowered to have meaningful conversations with their providers, and to make informed health decisions. The intent is a good one. The result of releasing the EMR’s compilation of chart data to recently-discharged patients may not be.

I answered the phone on a Saturday, while standing in the middle of a shopping mall with my 12 year-old daughter, to discover a distraught man and one of my help desk representatives on the line. The man’s wife had been recently released from the hospital; they had been provided patient portal access to receive and review her records, and they were bewildered by the information given. The medications listed on the document were not the same as those his wife regularly takes, the lab section did not have any context provided for why the tests were ordered or what the results mean, there were a number of lab results missing that he knew had been performed, and the problems list did not seem to have any correlation to the diagnoses provided for the encounter.

Just the kind of call an IT geek wants to receive.

How do you explain to an 84 year-old man that his wife’s inpatient summary record contains only a snapshot of the information that was captured during that specific hospital encounter, by resources at each point in the patient experience, with widely-varied roles and educational backgrounds, with varied attention to detail, and only a vague awareness of how that information would then be pulled together and presented by technology that was built to meet the bare minimum standards for perfect-world test scenarios required by government mandates?

How do you tell him that the lab results are only what was available at time of discharge, not the pathology reports that had to be sent out for analysis and would not come back in time to meet the 36-hour deadline?

How do you tell him that the reasons there are so many discrepancies between what he sees on the document and what is available on the full chart are data entry errors, new workflow processes that have not yet been widely adopted by each member of the care team, and technical differences between EMRs in the interpretation of the IHE’s XML standards for how these CCDA documents were to be created?

EMR vendors have responded to that last question with, “If you use our tethered portal, you won’t have that problem. Our portal can present the data from our CCDA just fine.” But this doesn’t take into account the patient experience. As a consumer, I ask you: would you use online banking if you had to sign on to a different website, with a different username and password, for each account within the same bank? Why should it be acceptable for managing health information online to be less convenient than managing financial information?

How do hospital clinical and IT staff navigate this increasingly-frequent scenario that is occurring: explaining the data that patients now see?

I’m working hard to establish a clear delineation between answering technical and clinical questions, because I am not – by any stretch of the imagination – a clinician. I can explain deviations in the records presentation, I can explain the data that is and is not available – and why (which is NOT generally well-received), and I can explain the logical processes for patients to get their clinical questions answered.

Solving the other half of this equation – clinicians who understand the technical nuances which have become patient-facing, and who incorporate that knowledge into regular patient engagement to insure patients understand the limitations of their newly-liberated data – proves more challenging. In order to engage patients in the way the CMS Meaningful Use program mandates, have we effectively created a new hybrid role requirement for our healthcare providers?

And what fresh new hell have we created for some patients who seek wisdom from all this information they’ve been given?

Caveat – if you’re reading this, it’s likely you’re not the kind of patient who needs much explaining. You’re likely to do your own research on the data that’s presented on your CCDA outputs, and you have the context of the entire Meaningful Use initiative to understand why information is presented the way it is. But think – can your grandma read it and understand it on HER own?

June 30, 2014 I Written By

Mandi Bishop is a healthcare IT consultant and a hardcore data geek with a Master's in English and a passion for big data analytics, who fell in love with her PCjr at 9 when she learned to program in BASIC. Individual accountability zealot, patient engagement advocate, innovation lover and ceaseless dreamer. Relentless in pursuit of answers to the question: "How do we GET there from here?" More byte-sized commentary on Twitter: @MandiBPro.

This Geek Girl’s Singing: HIMSS 14 Social Media Finale

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As one of the inaugural crop of HIMSS Social Media Ambassadors, a second-generation native Floridian, and a former Orlando resident, it is my sworn duty to summarize, recap, and perhaps satirize the last group of Blog Carnival posts, to metaphorically sing the HIMSS opera finale. And you folks submitted some doozies! I’m very grateful to the HIMSS (@HIMSS) and SHIFT Communications (@SHIFTComm) team for providing me with links to all entries. Y’all have been BUSY!

A man after my own heart, and a frequent #HITsm participant who weathers harsh criticism with witty aplomb: Dan Haley’s (from athenahealth, @DanHaley5) piece on 3 Takeaways From HIMSS – Policy And Otherwise caught my attention with the line, “Regulators are from Mars…” He stole my favorite blog entry prize with the line: “Orlando is magical when you are a kid. Kids don’t attend HIMSS.”

First-time attendee Jeffrey Ting (from Systems Made Simple) outlined his experiences with some of my favorite topics in his piece, HIMSS Reflections By A First-Time Attendee: HIEs and interoperability. I agree with him: the Interoperability Showcase’s “Health Story” exhibit was one of the best presentations of the whole conference.

Dr. Geeta Nayyar’s perspective as a board member of HIMSS and CMIO for PatientPoint gave her a unique vantage point for her post, HIMSS 14: A Truly Inspiring Event. Take note, HIMSS conference planners – your monumental efforts were recognized, as was the monumental spirit of the closing keynote speaker, Erik Weihenmayer.

HIMSS Twitter recaps permeated the blogosphere, with my favorite being the inimitable Chuck Webster’s (@wareflo) HIMSS14 Turned It Up To 11 On And Off-Line!. Chuck also periodically provided trend analysis results of year-over-year #HIMSS hashtag traffic for each period of the conference, complete with memes for particular shapes: Loch Ness monster humped-back, familiar faces of frequent tweeters.

Health IT guru Brian Ahier’s (@ahier) wrapped up the “Best In Show” of HIMSS Blog Carnival , complete with Slideshare visuals awarding Ed Parks of Athenahealth “Best Presentation” and providing an excellent summation of must-read posts.

Interoperability was one of the most prevalent themes of HIMSS, and a plethora of posts discussing the healthcare industry’s progress on the path to Dr. Doug Fridsma’s (@Fridsma) High Jump Of Interoperability (Semantic-Level) were submitted to the Blog Carnival. Notable standouts included: Shifting to a Culture of Interoperability by Rick Swanson from Deloitte, and Dr. Summarlan Kahlon’s (of Relay Health), Diagnosis: A Productive HIMSS 2014, which posited that, “this year’s conference was the first one which convinced me that real, seamless patient-level interoperability is beginning to happen at scale.”

And who could forget about patient engagement, the belle of the HIMSS ball? Telehealth encounters, mobile health apps and implications, patient portals, and the Connected Patient Gallery dominated the social media conversation. Carolyn Fishman from DICOM Grid called it, HIMSS 2014: The Year of the Patient, and discussed trepidation patients feel about portal technologies infringing on face-time.

Quantified-self wearable-tech offered engagement opportunities, as well. Having won one such gadget herself, Jennifer Dennard (@SmyrnaGirl) gave props to organizations like Patientco and Nuance for their use (and planned use) of wearable tech in support of employee wellness programs, and posited on the applications of such tech in the monitoring and treatment of chronic disease in her piece, Watching for Wearables at HIMSS14.

Finally, if you’re able to read Lisa Reichard’s (from Billians Health Data) @billians) highlights piece,Top 10 Tales and Takeaways, without busting out into Beatles tunes, you probably wouldn’t have had nearly as much fun as she and I did at HISTalkapalooza, dancing to Ross Martin’s smooth parodies. You also probably don’t have your co-workers frantically purchasing noise-canceling headphones.

I did say I’d be singing to bring HIMSS to a virtual close.

Can’t wait to get back to the metaphorical microphone for HIMSS 2015 in Chicago!

March 14, 2014 I Written By

Mandi Bishop is a healthcare IT consultant and a hardcore data geek with a Master's in English and a passion for big data analytics, who fell in love with her PCjr at 9 when she learned to program in BASIC. Individual accountability zealot, patient engagement advocate, innovation lover and ceaseless dreamer. Relentless in pursuit of answers to the question: "How do we GET there from here?" More byte-sized commentary on Twitter: @MandiBPro.

Eyes Wide Shut: Meaningful Use Stage 2 Incentive Program Hardships

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In my January update on Meaningful Use Stage 2 readiness, I painted a dismal picture of a large IDN’s journey towards attestation, and expressed concern for patient safety resulting from the rush to implement and adopt what equates to, at best, beta-release health IT. Given the resounding cries for help from the healthcare provider community, including this February 2014 letter to HHS Secretary Kathleen Sebelius, I know my experience isn’t unique. So, when rumors ran rampant at HIMSS 2014 that CMS and the ONC would make a Meaningful Use announcement, I was hopeful that relief may be in sight.

Like AHA , I was disappointed in CMS Administrator Marilyn Tavenner’s announcement. The new Stage 2 hardship exemptions will now include an explicit criteria for “difficulty implementing 2014-certified EHR technology” – a claim which will be evaluated on a case-by-case basis, and may result in a delay of the penalty phase of the Stage 2 mandate. But it does nothing to extend the incentive phase of Stage 2 – without which, many healthcare providers would not have budgeted for participation in the program, at all, including the IDN profiled in this series. So how does this help providers like mine?

Quick update on my IDN’s progress towards Stage 2 attestation, with $MM in target incentive dollars at stake. We must meet ALL measures; there is no opportunity to defer one. The Transition of Care (both populating it appropriately, and transmitting it via Direct) is the primary point of concern.

The hospital EHR is ready to generate and transmit both Inpatient Summary and Transition of Care C-CDAs. The workflow to populate the ToC required data elements adds more than 4 minutes to the depart process, which will cause operational impacts. None of the ambulatory providers in the IDN have Direct, yet; there is no one available to receive an electronic ToC. Skilled resources to implement Direct with the EHR upgrades are not available until 6-12 weeks after each upgrade is complete.

None of the 3 remaining in-scope ambulatory EHRs have successfully completed their 2014 software upgrades. 2 of the 3 haven’t started their upgrades. 1 has not provided a DATE for the upgrade.

None of the ambulatory EHRs comes with a Clinical Summary C-CDA configured out-of-the-box. 1 creates a provider-facing Transition of Care C-CDA, but does not produce the patient-facing Clinical Summary. (How did this product become CEHRT for 2014 measures?) Once the C-CDA is configured, each EHR requires its own systems integrator to develop the interface to send the clinical document to an external system.

Consultant costs continue to mount, as each new wrinkle arises. And with each wrinkle, the ability to meet the incentive program deadlines, safely, diminishes.

Playing devil’s advocate, I’d say the IDN should have negotiated its vendor contracts to include penalty clauses sufficient to cover the losses of a missed incentive program deadline – or, worst case scenario, to cover the cost of a rip-and-replace should the EHR vendor not acquire certification, or have certification revoked. The terms and conditions should have covered every nuance of the functionality required for Stage 2 measures.

But wait, CMS is still clarifying its Stage 2 measures via FAQs. Can’t expect a vendor to build software to specifications that weren’t explicitly defined, or to sign a contract that requires adherence to unknown criteria.

So, what COULD CMS and the ONC do about it? How about finalizing your requirements BEFORE issuing measures and certification criteria? Since that ship’s already sailed, change the CEHRT certification process.

1. Require vendors to submit heuristics on both initial implementation and upgrades, indicating the typical timeline from kick-off to go-live, number of internal and external resources (i.e., third-party systems integrators), and cost.
2. Require vendors to submit customer-base profile detailing known customers planning to implement and/or upgrade within calendar year. AND require implementation/upgrade planning to incorporate 3 months of QA time post-implementation/upgrade, prior to go-live with real patients.
3. Require vendors to submit human resource strategy, and hiring and training program explicitly defined to support the customer-base profile submitted, with the typical timeframes and project resource/cost profiles submitted.
4. Require vendor products to be self-contained to achieve certification – meaning, no additional third-party purchase (software or professional services) would be necessary in order to implement and/or upgrade to the certified version and have all CMS-required functionality.
5. Require vendor products to prove the CEHRT-baseline functionality is available as configurable OOTB, not only available via customization. SHOW ME THE C-CDA, with all required data elements populated via workflow in the UI, not via some developer on the back-end in a carefully-orchestrated test patient demo script.
6. Require vendor products adhere to an SLA for max number of clicks required to execute the task. It is not Meaningful Use if it’s prohibitively challenging to access and use in a clinical setting.

Finally, CMS could redefine the incentive program parameters to include scenarios like mine. Despite the heroic efforts being made across the enterprise, this IDN is not likely to make it, with the fault squarely on the CEHRT vendors’ inability to deliver fully-functional products in a timely manner with skilled resources available to support the installation, configuration, and deployment. Morale will significantly decline, next year’s budget will be short the $MM that was slated for further health IT improvements, and the likelihood that it will continue with Stage 3 becomes negligible. Vendor lawsuits may ensue, and the incentive dollar targets may be recouped, but the cost incurred by the organization, its clinicians, and its patients is irrecoverable.

Consider applying the hardship exemption deadline extension to the incentive program participants.

March 5, 2014 I Written By

Mandi Bishop is a healthcare IT consultant and a hardcore data geek with a Master's in English and a passion for big data analytics, who fell in love with her PCjr at 9 when she learned to program in BASIC. Individual accountability zealot, patient engagement advocate, innovation lover and ceaseless dreamer. Relentless in pursuit of answers to the question: "How do we GET there from here?" More byte-sized commentary on Twitter: @MandiBPro.

Eyes Wide Shut – January, 2014 Meaningful Use Stage 2 Readiness Reality Check

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Happy New Year?

As I begin the 2014 Meaningful Use measures readiness assessment and vendor cat-herding exercises, I’m reflecting on this portion of CMS’s Director of E-Health Standards and Services, Robert Tagalicod and the ONC’s Acting National Coordinator Jacob Reider’s statement regarding the Meaningful Use timeline modification: “The goal of this change is two-fold: first, to allow CMS and ONC to focus efforts on the successful implementation of the enhanced patient engagement, interoperability and health information exchange requirements in Stage 2.” (Previously published on EMRandHIPAA.com.)

I call BS.

If the “goal” is a “successful implementation”, then CMS failed miserably by not addressing the START of the quarterly attestation period for Stage 2, which is still required in 2014. CMS and the ONC need more time to successfully implement the measures, and they are bureaucratic agencies that don’t directly deal with patient medical care. Why wasn’t the additional time required to truly succeed at this monumental task extended to the healthcare provider organizations? Because the agencies want to save face, and avoid litigation from early adopters who may be already beginning their 2014 attestation period amidst heroic back-breaking efforts?

Here’s a reality check for what a large IDN might be going through in early January, in preparation for the start of the 2014 quarterly attestation period. Assume this particular IDN’s hospitals’ fiscal year runs October-September, so you MUST begin your attestation period on July 1. You have 6 months.

As of December 31, 2013, only 4 of the 8 EMRs in your environment completed their 2014 CEHRT certification.

Each of those 4 EMRs has a different schedule to implement the upgrade to the certified edition, with staggered delivery dates from March to July. The hospital EMR is not scheduled to receive its certified-edition upgrade until April. You pray that THIS implementation is the exception to your extensive experience with EMR vendor target timelines extending 6-8 weeks beyond initial dates.

The EMR upgrades do not include the Direct module configuration, and the vendor’s Direct module resources are not available until 6-9 weeks after the baseline upgrade implementation – if they have knowledgeable resources, at all. Your hospital EMR vendor can’t articulate the technical infrastructure required to implement and support its own Direct module. Several vendors indicate that the Direct module configuration will have to be negotiated with a third-party. Your clinicians don’t know what Direct is. Your IT staff doesn’t know how to register with a HISP. Your EMR vendor doesn’t support a central Direct address directory or a lookup function, so you contemplate typing classes for your HIM and clinical staff.

The number of active patient problems requiring manual SNOMED remediation exceeds 60,000 records in your hospital EMR. You form a clinical committee to address, but they’re estimating it will take 6 months of review to complete. You’re contemplating de-activating all problems older than a certain date, which would whittle down the number and shorten the timeframe to complete – but would eliminate chronic conditions.

There are still nagging questions regarding CMS interpretation of the measures, so you ask for clarification, and you wait. And wait. And wait. The answers impact the business rules required for attestation reporting, and you know you need any help you can get in whittling down the denominator values. Do deceased patients count in the view/download/transmit denominator? If records access is prohibited by state/federal law, does that encounter count in the view/download/transmit denominator?

Consultant costs skyrocket as you struggle to find qualified SME resources to blaze a trail for your internal staff. Their 60-to-90-day assessments inevitably end with recommendations for “proof of concept” and “pilot” approaches to each of the 2014 measures, which don’t take into account the reality of the EMR upgrade timelines and the looming attestation start date. Following their recommendations would delay your attestation start by 9-12 months. So, your internal staff trudges forward without expert leadership, and you throw the latest PowerPoint deck from “Health IT Professionals-R-Us” on the pile.

Who needs testing, when you can go live with unproven technology the day it’s available in order to meet an arbitrary deadline? Healthcare.gov did it – look what a success that turned out to be!

But wait, this is real clinical data, generated by real-world clinical workflows, being used to treat real patients, by real healthcare providers. By refusing to address the start of the 2014 attestation period, CMS and the ONC are effectively using these patients and providers as lab rats.

I did not give permission to be part of this experiment.

January 13, 2014 I Written By

Mandi Bishop is a healthcare IT consultant and a hardcore data geek with a Master's in English and a passion for big data analytics, who fell in love with her PCjr at 9 when she learned to program in BASIC. Individual accountability zealot, patient engagement advocate, innovation lover and ceaseless dreamer. Relentless in pursuit of answers to the question: "How do we GET there from here?" More byte-sized commentary on Twitter: @MandiBPro.

Eyes Wide Shut – Inflicting Agile On The Waterfall World of Healthcare

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In a recent hangout with John Lynn discussing Healthcare Big Data and Meaningful Use Challenges, he asked me why incorporating more agile development practices into healthcare software and business practice is so hard. In my fumbling attempt to articulate a pithy answer, and I bumbled into an insight: health IT mandates are inflicting agile methodology onto the waterfall world of healthcare, and demanding adoption at an unprecedented pace. It’s creating an uncomfortable, and in many ways untenable, situation for the healthcare system as a whole.

For quick reference, here’s a diagram explaining the difference between the traditional waterfall approach to software development, and the newer agile methodology.

waterfall_v_agile

What immediately jumped out at me about this visualization of waterfall versus agile: doesn’t this inverse-triangle comparison look a bit like a diagram of the “flipped clinic”? “Flip the clinic”, as defined by the Robert J. Woods Foundation project, has become a rallying cry to reinvent the patient-provider interaction, empowering patients and providers to increase the value of each encounter through technology-enabled improved engagement opportunities.

flip_clinic

This “flipping” approach is considered a disruptive concept, with great power to accelerate insights and empower patients. However, currently, it is far from mainstream, and likely to take a decade or more to enjoy widespread adoption.

Health IT mandates are, effectively, demanding that healthcare “flip the systems”: move from a conservative, quality-deliverable “plan-driven” model to an aggressive, loosely-defined-deliverable “vale-driven” model – on an ambitiously aggressive schedule, on a massive scale.

As an industry, healthcare follows a very slow progression through the Waterfall development cycle. A commonly-cited statistic states that it takes 17 years for a single clinical discovery to become commonly applied practice. In the beginning, there is an idea with fixed requirements: a specific clinical trial is designed, with narrowly-defined scope to control variables and insure the highest quality results. The results of the trial are analyzed, published, considered for expansion. Patents are pursued. FDA approval is obtained. Over a decade later, the discovery makes its way into accepted treatment protocols, and eventually becomes part of the attending’s lecture to residents on rounds.

Contrast that slow progress through development and adoption with what’s happening under ACA, specifically with Meaningful Use objectives.

cms_mu_timeline

Now, if it takes 17 years for a clinical discovery to make it to mainstream practice, and that specific type of clinical function is what the healthcare industry is designed to DO, does anyone else see anything wrong with the schedule presented here? Notice there are only 11 years on that timeline, from inception of the certification program to the last year to receive an incentive payment? Only 5 years between program inception and penalties for non-conformance?

Another key differentiator between Agile and Waterfall: the criticality of quality. Quality is defined as “conformance to requirements”. Because Waterfall methodology places emphasis on explicitly-defined requirements, it also demands high-quality deliverables; there is traceability between each requirement and the specific feature/function that is designed to meet that need. Agile methodology places emphasis on flexible deliverables, as requirements are not clearly defined prior to starting work; the scope of the feature/functions that will be delivered varies, according to the results of the development effort and the time left to execute.

In one of my first posts on EMRandHIPAA.com, “Yes, Healthcare IT Adoption is Expensive AND Painful”, I ranted:

Haven’t we all heard the adage, “You can only have things done two of three ways: fast, cheap, or well”? Considering that the “thing” we’re trying to do is revolutionize the healthcare industry, the effects of which may be felt in each and every one of our lives at some point, don’t you want to include “well” as the bare minimum of what is required? After all, this is YOUR electronic health record, YOUR data, YOUR treatment plan and effectiveness measurements. So, what’s the other way we want this “thing” done: fast or cheap?

Now that I’ve spent more time working in the trenches with clinicians, detailing the operational challenges they’re facing with the rate of change the health IT mandates are demanding they absorb, I’ve come to the conclusion that I was wrong.

Health IT adoption must ONLY be done well. No other constraint matters.

Quality is of the utmost importance. Arbitrary deadlines are only increasing the cost required to implement half-baked product and process solutions that meet only the bare minimum “letter of the law” stipulations of the mandates.

The current focus on adopting health IT fast is only incenting corner-cutting measures from both IT vendors and healthcare providers. As a patient, I’m not ready to sign off on User Acceptance Testing of the nationwide implementation of Meaningful Use.

October 8, 2013 I Written By

Mandi Bishop is a healthcare IT consultant and a hardcore data geek with a Master's in English and a passion for big data analytics, who fell in love with her PCjr at 9 when she learned to program in BASIC. Individual accountability zealot, patient engagement advocate, innovation lover and ceaseless dreamer. Relentless in pursuit of answers to the question: "How do we GET there from here?" More byte-sized commentary on Twitter: @MandiBPro.

Eyes Wide Shut – Managing Multi-EMR Meaningful Use Stage 2 Is Hard

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Most discussions on Meaningful Use (MU) seem to focus on a single healthcare provider organization (acute or ambulatory), with a single EMR, and a single Medical Record Number (MRN) pool generating unique patient identifiers. Even in that context, the complaints of the difficulties of successfully implementing the technology and obtaining the objectives are deafening. How daunting might those challenges seem, multiplied across a large integrated delivery network (IDN), attempting to make enterprise-wide technology and operational process decisions, in alignment with MU incentive objectives?

Imagine you are an IDN with 9 hospital facilities, sharing a single EMR. You also have 67 ambulatory practices, with 7 additional EMRs. You’ve made the progressive choice to implement a private health information exchange (HIE) to make clinical summary data available throughout the IDN, creating a patient-centric environment conducive to improved care coordination. To properly engage patients across the IDN and give them the best user experience possible, you’ve purchased an enterprise portal product that is not tethered to an EMR, and instead sources from the HIE. And because you’ve factored the MU incentive dollars into the budget which enabled these purchasing decisions, there is no choice but to achieve the core and select menu measures for 2014.

It is now October 2013. The first quarter you’ve chosen to gather Stage 2 attestation data starts on April 1, 2014. All your technology and process changes must be ready by the data capture start date, in order to have the best opportunity to achieve the objectives. Once data capture begins, you have 90 days to “check the box” for each MU measure.

Tech check: are all the EMRs in your IDN considered Certified Electronic Health Records Technology (CEHRT) for the 2014 measures?

Your acute EMR is currently 2 versions behind the newly-released MU 2014-certified version; it is scheduled to complete the upgrade in November 2013. Your highest-volume ambulatory EMR is also 2 versions behind the 2014-certified version, and it cannot be upgraded until March 2014 due to vendor resource constraints. Your cardiology EMR cannot be upgraded until June due to significant workflow differences between versions, impacting those providers still completing Stage 1 attestation. One of your EMRs cannot give you a certification date for its 2014 edition, and cannot provide an implementation date for the certified version. The enterprise portal product has been 2014-certified as a modular EMR, but the upgrade to the certified version is not available until February 2014.

Clearly, your timeline to successfully test and implement the multitude of EMR upgrades required prior to your attestation date is at risk.

Each EMR might be certified, but will it be able to meet the measures out of the box?

Once upgraded to the 2014 version, your acute EMR must generate Summary of Care C-CDA documents and transmit them to an external provider, via the Direct transfer protocol. Your ambulatory EMRs must generate Transition of Care C-CDA documents and use the same Direct protocol to transmit. But did you purchase the Direct module when you signed your EMR contract, or maintenance agreement?

Did you check to see whether the Direct module that has been certified with the EMR is also an accredited member of DirectTrust?

Did you know that some EMRs have Direct modules that can ONLY transmit data to DirectTrust-accredited modules?

You determine your acute EMR will only send to EMRs with DirectTrust-accredited modules, and that you only have a single ambulatory EMR meeting this criteria. That ambulatory EMR is not the primary target for post-acute care referral.

You have no control over the EMRs of providers outside the IDN, who represent more than 20% of your specialist referrals.

Your 10% electronic submission of Summary of Care C-CDA documents via Direct protocol measure is at risk.

Is your organization prepared to manage the changes required to support the 2014 measures?

This is a triple-legged stool consideration: people, process, and technology must all align for change to be effective. To identify the process changes required, and the people needed to support those processes, you must understand the technology that will be driving this change. Of all the EMRs in your organization, only 2 have provided product specifications, release notes, and user guides for their 2014-certified editions.

Requests for documentation about UI, data, or workflow changes in the 2014 versions are met with vague responses, “We will ask product management and get back to you on that.” Without information on the workflow changes, you cannot identify process changes. Without process change recognition, you cannot properly identify people required to execute the processes. You are left completely in the dark until such time as the vendors see fit to release not only the product, but the documentation supporting the product.

Clearly, your enterprise program for Meaningful Use Stage 2 health IT implementation and adoption is at risk.

What is the likelihood that your Meaningful Use Stage 2 attestation will be a successful endeavor for the enterprise?

As a program manager, I would put this effort in flaming red status, due to the multitude of risks and external dependencies over which the IDN organization has zero control. I’d apply that same stoplight scorecard rating to the MU Stage 2 initiative. There is simply too much risk and too many variables outside the provider’s control to execute this plan effectively, without incurring negative impacts to patient care.

The ONC never said Meaningful Use would be easy, but does it have to be this hard?

October 2, 2013 I Written By

Mandi Bishop is a healthcare IT consultant and a hardcore data geek with a Master's in English and a passion for big data analytics, who fell in love with her PCjr at 9 when she learned to program in BASIC. Individual accountability zealot, patient engagement advocate, innovation lover and ceaseless dreamer. Relentless in pursuit of answers to the question: "How do we GET there from here?" More byte-sized commentary on Twitter: @MandiBPro.

Eyes Wide Shut – Teaching to the Meaningful Use Stage 2 Test

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According to Twitter analytics, one of my more engaging tweets recently stated that Meaningful Use is stifling innovation by requiring that health IT vendors and healthcare providers employ very specific tactics to capture and report on clinical data capture and interoperability standards compliance – ostensibly to engage and empower the patient, and improve coordination of care between providers. Of course, I said it much more succinctly than that. In effect, conforming to the Meaningful Use Stage 2 attestation measures is akin to “teaching to the test”:

Here’s a real-world example of what it means to “teach to the test” of Meaningful Use. In order to qualify for CMS incentive dollars, Meaningful Use Stage 2 Year 1 patient engagement measures must be met, with auditable data captured, in a 90-day contiguous period in 2014. An eligible provider (EP) must demonstrate that 50% of all patients with encounters during that time period have online access to their clinical summary within 4 days of the data becoming available to the provider. 5% of those patients must access the clinical information within the 90 days, and 5% of those patients must leverage secure messaging to communicate relevant health information with the provider. Finally, the MU-certified EMR must proffer patient-specific education materials for 10% of the patients seen during that time.

What I believe the ONC had in mind when they crafted these measures: engaged patients who will log in to their portal after each encounter, review the findings and lab results to assess their own progress and outcomes, read or listen to the condition-specific educational materials provided that resonate with them, and ask more meaningful questions of their providers as a result of this new-found, data-enabled empowerment. That is why they categorize these measures as “patient engagement”, right?

Wrong. This is what “patient engagement” looks like, from the EMR implementation, Meaningful Use-consultant, EP business process standpoint.

First, establish the bare minimum thresholds for meeting the measures. If the EP saw 1000 patients during the same 3-month period the previous year, your denominator is 1000; calculate the numerator for each measure based on that. So, we need 500 patients to have access to their clinical data online; 50 patients must access their information; 50 patients must communicate with their provider via secure messaging; 100 patient encounters must prompt specific educational opportunities.

To meet the 500 patients with online access to their clinical data, patient portal software is preloaded with patient demographic accounts, based on the registration data already available in the EMR. An enrollment request is emailed to the patient or authorized representative (assuming an email address is available in their demographic information). The EMR captures the event of sending this email, which contains the information about how to enroll and access the patient’s medical records via the portal. This measure is met, without the patient acknowledging the portal’s existing, and without any direct communication between provider and patient.

The medical records view and secure messaging measures can be met simultaneously, in a matter of days, by planning to add a few extra minutes to each encounter for 50 patients’ worth of appointments. The EMR has already triggered an email with portal enrollment information to each of the patients in the waiting room on a given day. As the medical assistant (MA) is taking vital stats, she asks whether the patient has enrolled in the portal. It’s likely the patient has not; the MA hands the patient a tablet and has him log in to his email, and walks him through the portal enrollment and initial login process. Once logged in, the MA directs the patient to click the link to view his medical record. That click is recorded, and the “view” measure is met; whether a CCD or C-CCD is actually displayed is irrelevant to the attestation data capture.

Having demonstrated how a patient can view his record, the MA then asks the patient to go into the portal’s message center, to send a test communication to the provider. The patient completes the required fields, and the MA prompts him with a generic health-related question to type into the body of the message. Once the patient hits “Send”, the event is recorded, and the “secure messaging” measure is met.

For all patients, whether portal-users or not, a new process begins when the MA finishes, the provider enters the room and begins her evaluation of each of the 100 patients required to meet the education measure. As the patient talks, the provider is clicking through EMR workflow screens, recording the encounter data. The EMR occasionally prompts with a dialogue box indicating educational materials are available for patients with this diagnosis code, or this lab result. Each dialogue box prompt is recorded by the EMR; the “patient-specific education” measure is met, whether the provider acts on the prompt and discusses or distributes the educational information or not.

To put it simply: the patient never has to log in to a portal to meet the 50% online availability requirement, they don’t have to actually view their records to meet the 5% view requirement, they don’t have to have an actual message exchange with their provider to meet the 5% communication requirement, and they don’t have to receive any tailored materials to meet the 10% education requirement. Once those clicks have been recorded, the actions never have to be repeated; meaningful and ongoing patient engagement is not needed to meet the attestation requirements and receive the incentive dollars.

In a previous post, I introduced my interpretation of the difference between the spirit and letter of the Meaningful Use “law”. By teaching to the test, we’re addressing the letter of the law, only, in its narrowest interpretation. When will we incent vendors and providers to go above and beyond and find ways to truly engage patients in meaningful ways, empowering them with accurate, timely data access and tools to analyze it?

September 30, 2013 I Written By

Mandi Bishop is a healthcare IT consultant and a hardcore data geek with a Master's in English and a passion for big data analytics, who fell in love with her PCjr at 9 when she learned to program in BASIC. Individual accountability zealot, patient engagement advocate, innovation lover and ceaseless dreamer. Relentless in pursuit of answers to the question: "How do we GET there from here?" More byte-sized commentary on Twitter: @MandiBPro.

Eyes Wide Shut – Is This Meaningful Use?

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Again and again, I find myself expounding upon the need to differentiate between the “letter of the law” and the “spirit of the law” of Meaningful Use Stage 2. I believe whole-heartedly in the transformative power of health IT, and support the future vision of the Meaningful Use objectives of patient empowerment and nationwide standards for records transmission and interoperability. The spirit of the “law” is a revolutionary movement towards a technology-enabled, patient-centric healthcare system, where clinical data can be shared and consumed instantly, whenever patient desires or requires it.

The letter of the “law” is daunting, and its implementation could be seen as not only counter-revolutionary, but detrimental to the very patient population it is designed to engage and empower.

Consider this acute care scenario:

You’re a hospital healthcare provider, discharging a patient, in compliance with the patient-specific education and Summary of Care measures. You log in to your EMR, complete the discharge instructions in the correlated workflow, print the discharge summary and any condition-specific educational information for the patient, revisit their room to insure that they can review the instructions and ask any questions, and you’re on to assessing the condition of the next patient in need of care. Right?

How many times did you have to close the “patient-specific education” suggestion windows that popped up, alerting you to available materials for download, keyed off diagnosis codes or lab results?

How many minutes did you spend looking for the HISP address of the patient’s cardiologist, so you could transmit the Summary of Care document to them via the Direct module of your EMR? How many clicks did you have to use to FIND the Direct module in your EMR? And how many minutes did you spend cursing the ONC for requiring Direct for Summary of Care transmission for 10% of your discharged patient population when the cardiologist’s address was rejected by the Direct module, giving you a message that the receiver is not DirectTrust-accredited?

How much time did the discharge process take you before your facility decided to attest to Meaningful Use Stage 2? How much time does it take you now?
Consider this ambulatory care scenario:

You’re support staff for a general practitioner, who is deploying a patient portal in support of patient engagement measures. At check-in (or check-out), you provide the patients with the URL for enrollment and access, give them information on the benefits of having their medical records available electronically, encourage them to communicate electronically with their provider with questions or concerns, and you send them on their empowered and engaged way.

How many minutes did you spend validating each portal account owner’s identity once their enrollment request came? How many minutes did you spend validating the relationship of the portal account owner to each of the patients he/she requests to associate with the account? How did you document the due diligence done to insure no medical records are improperly released per HIPAA and other federal guidelines, as in the case of custodial disputes, behavioral health patients, or emancipated minors?

How many minutes did you spend walking patients through the enrollment, login, medical records view, and secure message functions? How much time did you spend answering questions from patients about the portal, rather than the health concerns that prompted the visit?

How much time did the check-out process take before your GP decided to attest to Meaningful Use Stage 2? How much time does it take you now?

In both of these scenarios, did you or the patient see any measurable difference in care as a result of the EMR’s new functionality?

Now, consider the aggregate of these scenarios over an entire day – dozens of encounters, dozens of clicks, dozens of minutes spent engaging the EMR to record requisite “clicks” for attestation numerator reporting, rather than engaging the patient.

Is this meaningful use of a healthcare provider’s time and energy? Is this meaningful use of health IT, meeting very specific targets to obtain finite objectives rather than enabling innovation and deriving best practice long-term solutions?

Is this what the ONC intended?

September 25, 2013 I Written By

Mandi Bishop is a healthcare IT consultant and a hardcore data geek with a Master's in English and a passion for big data analytics, who fell in love with her PCjr at 9 when she learned to program in BASIC. Individual accountability zealot, patient engagement advocate, innovation lover and ceaseless dreamer. Relentless in pursuit of answers to the question: "How do we GET there from here?" More byte-sized commentary on Twitter: @MandiBPro.

Analytics-Driven Compassionate Healthcare at El Camino Hospital

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Given its location in the heart of Silicon Valley, it may not be remarkable that El Camino Hospital was the first hospital in the US to implement EMR. What IS remarkable is that El Camino implemented EMR 51 years ago, leveraging an IBM mainframe system that Lockheed Martin refactored for healthcare from its original intended use for the space program.

Take a moment to process that. El Camino didn’t need PPACA, Meaningful Use, HITECH, or HIPAA to tell them health data is critical. El Camino saw the value in investing in healthcare IT for electronic data capture and communication without federal incentive programs or lobbyists. With that kind of track record of visionary leadership, it’s no wonder they became early analytics program adopters, and recently turned to Health Care DataWorks (HCD) as a trusted partner.

When I sat down with executive leadership from El Camino and HCD to discuss the journey up Tom Davenport‘s analytics maturity scale from rudimentary operational reporting to advanced analytics, I expected a familiar story of cost pressure, clinical informatics, quality measure incentives or alternative payment models as the business drivers for new insights development. Instead, I heard the burgeoning plan for a visionary approach to patient engagement and “analytics-driven compassionate care”.

Greg Walton, CIO of El Camino Hospital, admitted that initial efforts to implement an analytics program had resulted in “textbook errors”: “’Competing on Analytics’ was easier to write than execute,” he said. Their early efforts to adopt and conform to a commercially-available data model were hindered by the complexity of the solution and the philosophy of the vendor. “One of the messages I would give to anybody is: do NOT attempt this at home,” Greg laughed, and El Camino decided to change their approach. They sought a “different type of company…a real-life company with applicable lessons learned in this space.”

“The most important thing to remember in this sector: you’re investing in PEOPLE. This is a PEOPLE business,” Greg said. “And that if there’s any aspect of IT that’s the most people-oriented, it’s analytics. You have to triangulate between how much can the organization absorb, and how fast they can absorb it.” In HCD, El Camino found an analytics organization partner whose leadership and resources understand healthcare challenges first, and technology second.

To address El Camino’s need for aggregated data access across multiple operational systems, HCD is implementing their pioneering KnowledgeEdge Enterprise Data Warehouse solution,including its enterprise data model, analytic dashboards, applications and reports. HCD’s technology, implementation process, and culture is rooted in their deep clinical and provider industry expertise.

“The people (at HCD) have all worked in hospitals, and many still work there occasionally. Laypersons do not have the same understanding; HCD’s exposure to the healthcare provider environment and their level of experience provides a differentiator,” Greg explained. HCD impressed with their willingness to roll up their sleeves and work with the hospital stakeholders to address macro and micro program issues, from driving the evaluation and prioritization of analytics projects to identifying the business rules defining discharge destination. And both the programmers and staff are “thrilled,” Greg says: “My programmers are so happy, they think they’ve died and gone to heaven!”

This collaborative approach to adopting analytics as a catalyst for organizational and cultural change has lit a fire to address the plight of the patient using data as a critical tool. Greg expounded upon his vision to achieve what Aggie Haslup, Vice President of Marketing for HCD, termed “analytics-driven compassionate care”:

We need to change the culture about data without losing, and in fact enhancing, our culture around compassion. People get into healthcare because they’re passionate about compassion. Data can help us be more compassionate. US Healthcare Satisfaction scores have been basically flat over the last 10 years. Lots of organizations have tried to adopt other service industry tools: LEAN,6S; none of those address the plight of the patient. We’ve got to learn that we have to go back to our roots of compassion. We need to get back to the patient, which means “one who suffers in pain.” We want (to use data) to help understand more about person who’s suffering. My (recent) revelation: what do you do w/ guests in your house? Clean the house, put away the pets, get food, do everything you can to make guests comfortable. We want to know more about patients’ ethnicity, cultural heritage, the CONTEXT of their lives because when you’re in pain, what do you fall back on? Cultural values. We want a holistic view of the patient, because we can provide better, compassionate care through knowing more about patients. We want to deploy a contextual longitudinal view of the patient…and detect trends in satisfaction with demographics, clinical, medical data.

What a concept. Imagine the possibilities when a progressive healthcare provider teams with an innovative analytics provider to harness the power of data to better serve the patient population. I will definitely keep my eye on this pairing!

March 25, 2013 I Written By

Mandi Bishop is a healthcare IT consultant and a hardcore data geek with a Master's in English and a passion for big data analytics, who fell in love with her PCjr at 9 when she learned to program in BASIC. Individual accountability zealot, patient engagement advocate, innovation lover and ceaseless dreamer. Relentless in pursuit of answers to the question: "How do we GET there from here?" More byte-sized commentary on Twitter: @MandiBPro.

HIMSS Analytics Clinical & BI Maturity Model

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While the theme of HIMSS 2013 may have been, “How Great Is Interoperability,” the effectiveness of the many facets of interoperability are only as good as the actionable value of the shared data. The clinical insights that should be enabled by Meaningful Use Stage 2+ are expected to drive market trends in myriad areas of the healthcare system: chronic disease management, targeted member interventions, quality measures. In order to assess organizational readiness to capitalize on the promise of Meaningful Use, HIMSS Analytics began measuring the implementation and adoption of EMR and clinical documentation using a maturity model called EMRAM.

EMRAM

But, in analytics terms, EMRAM’s results are simply targeted foundational reporting, answering the question, “WHAT happened with Meaningful Use EMR adoption criteria.” So, you’ve got your clinical data in an EMR. Now what are you able to DO with it?

In 2013, HIMSS Analytics is taking a broader approach with the introduction of a new Clinical Business Intelligence maturity model, creating a framework to benchmark participating providers’ analytics maturity level.

I’ve been fortunate to know James Gaston, Senior Director of HIMSS Analytics Clinical & Business Intelligence, for many years, going back to his days with Arkansas Blue Cross. His appreciation for BI initiatives is matched only by his enthusiasm for the first day of turkey hunting season. When I ran into him at TDWI’s BI World summit in Orlando in November, he acted like a kid on Christmas morning, telling me about the brave new world of clinical data management that he was about to tackle. The excitement continued to build in the months leading up to HIMSS. James was practically glowing when we spoke about the upcoming C&BI Maturity Model release.

“Our customers are interested in not just understanding how to deploy IT applications, but how effectively they’re using those applications to support clinical business intelligence, as well as analytical pursuits,” James said. “So, HIMSS Analytics partnered with IIA to create and present a Clinical & BI Maturity Model that helps healthcare organizations measure that level of effectiveness.”

Sarah Gates, the VP of Research for IIA (the International Institute of Analytics), elaborated. “The HIMSS Analytics C&BI Maturity Model leverages the Competing on Analytics DELTA model, developed by Tom Davenport, which measures not only how well you’re using data and technology, but how well you’re building an analytical organization.” There are 5 core competency measurements in the DELTA model that will inform the HIMSS Analytics C&BI analysis: Data, Enterprise, Leadership, Targets, and Analysts. The methodology is holistic, touching on the cultural aspects of the organization as well as the technical, allowing a longitudinal view of the organization’s analytics program. A yardstick value from 1-5 will be assigned to each respondent based on Davenport’s criteria for each core competency.

Although HIMSS Analytics will eventually offer Level 1-5 certification program for those organizations with observed results for analytics, James and Sarah agreed that it is not appropriate for every provider to reach for the Level 5 gold star. Per Sarah, “Healthcare is an industry just starting to discover analytics. We’re expecting to see lots of practitioners that are emerging in use of analytics, so we believe it (survey results) will be heavy on the lower end of the maturity scale. Data warehouse capabilities and staffing career paths for data analysts will be key differentiators for mature programs.” Not all providers have the resources – financial, human, and/or technical – to attain advanced analytics nirvana, and James wants to insure that these providers don’t feel as if they’ve “failed”; the goal is to baseline against the peer group, identify opportunities for improvement, and focus on what is possible for each individual organization, working within their constraints.

What can we expect to see at next year’s C&BI survey results presentation? James said, “We want to be able to talk about benchmarking the industry as a whole, helping healthcare find its way with clinical business intelligence and begin to understand how important it is, and where opportunities lie Everyone’s talking about clinical and BI – it is the opportunity to realize savings in healthcare, to use information to empower people to make better decisions.”

So, it’s up to you, providers and technology partners. You’ve implemented your EMR, achieved a high adoption rate across your organization’s core clinical processes, attested to Meaningful Use Stage 2, achieved Stage 7 on the HIMSS EMRAM scale, perhaps even participated in multi-HIE CCD medical records sharing with other provider networks. You’ve got the data in-house and availabe. It’s time to see how ready you are to rise to the analytics challenge and maximize your return on those EMR and HIE investments.

Attempt to beat your previous Doug Fridsma long jump.

Note: for the complete HIMSS 2013 Leadership Survey Results, please download PDF here.

March 14, 2013 I Written By

Mandi Bishop is a healthcare IT consultant and a hardcore data geek with a Master's in English and a passion for big data analytics, who fell in love with her PCjr at 9 when she learned to program in BASIC. Individual accountability zealot, patient engagement advocate, innovation lover and ceaseless dreamer. Relentless in pursuit of answers to the question: "How do we GET there from here?" More byte-sized commentary on Twitter: @MandiBPro.