As many of you know the ACE 2010 event just took place last week. As I was pouring through some of the handouts I couldn’t help but be drawn into the “Handy Trail Guide” which Allscripts has touted as “The Path to Meaningful Use” This is a great high level guide to reaching Stage 1 of Meaningful Use – Capture and Share Data.

The more I read through this the more I thought of how clients will be looking at this with an eye to the shortest path to receiving their stimulus check, and rightfully so – every group should be looking to take advantage of this, from the largest hospital to the smallest single-doc practice. However, I wanted to make sure we don’t lose sight of the forest from the trees here and bring this trail guide back to the true reason for the stimulus – improving patient care! Hence the genesis of this article, The Path to Meaningless Use.

There are a couple of main points I’d like to highlight before dissecting the step by step approach.

1. Sell benefits of the EHR – I feel like this process is woefully underappreciated. In order for your rollout to be a success you absolutely need buy-in from all end-users, including physicians, nurses, data-entry folks and really any person that will touch the EHR on any level. How is this product going to improve their productivity? Make their job easier? Make their work experience more enjoyable?
2. Change is a good thing – Change is the process by which innovation and improvement are instilled. I know that people are comfortable with the status-quo and yes, change for change sake is useless, but there’s a reason for change here, I promise! Challenge your co-workers to look at everything objectively and really question if the products and processes currently in place really make sense or if there could be a better way.
3. Make concessions, don’t over-customize – The product is designed to work best when used in an out of the box capacity, sans customizations. The reality is that you probably aren’t going to be able to sell the idea of changing every workflow to fit the product, but that doesn’t mean you shouldn’t try. Ultimately in the long term the stability of the system is most closely tied to how close you stay to it’s intended use, therefore fight for those process changes to model the system, there’s a reason the EHR was designed the way it was! This point goes back to selling the benefits, be able to show how using the new workflows will actually improve the end-user experience!

With those main points made here are a few comments on the step in the Path to Meaningless Use, enjoy!

1. Understand Stimulus – Don’t just aim for the stage 1 level of capturing and sharing data, yes this can improve productivity but don’t lose sight of the true end goal, improving patient care.
2. Assess Gaps – Be honest with yourself. Are the tools you are using as efficient as they could be? Don’t keep old processes and tools in use just because people are “comfortable” with them, if there is a better tool out there, use it! Sometimes taking people out of their comfort zone is exactly what is needed to promote healthy growth.
3. Design New Workflows – Don’t be unwilling to change workflows simply because that’s the way it’s always been done. Be prepared to pitch workflow re-design to physicians with benefits for them in mind.
4. Upgrade EHR & Stimulus Set – Don’t rush this upgrade. There are many factors that go into an upgrade (depending on how many versions you are jumping) and simply upgrading for the sake of getting the stimulus approved version may end up biting you if you haven’t correctly re-worked process flows to use the EHR in a meaningful way.
5. Rollout – During training stress benefits to end users, a 3 day crash course on the new EHR system is great but if you can’t prove to your end users why the new product and workflows make sense you aren’t going to receive full buy in and consequently won’t get the most out of the product.
6. Begin 90-day Meaningful Use – Metrics should be kept on an ongoing basis, not just for 90 days. It’s great to hit the 90 day plateau to receive the stimulus check but the true purpose of the EHR is to improve patient treatment, and you can’t improve what you don’t measure.
7. Report & Claim Stimulus – Nothing meaningless about this step, claim the money and move on to the next stage!

Even before our inception nearly 5 years ago, our people have demonstrated an understanding that to achieve our individual goals, we must recognize the value in sharing our expertise and experiences with organizations across our industry that has similar objectives.  We know that to be successful, we must be willing to lend assistance, because we most assuredly will need the support of others from time to time.

It is because of this belief system that we make our combined knowledge freely available to whoever needs access to it through our Galen Wiki and Galen Blog.  We encourage every member of the community, user or vendor, to participate in this free exchange of information with the mindset that we are all in this struggle together.

Further, we are thrilled to introduce a new program in this newsletter where we give our readers an opportunity to increase and direct the body of knowledge that we publish on our wiki by “Asking an expert.”    Users can submit questions to our website and our team of experts will review the questions and use them to direct future content for the wiki.

Additionally, and with the concept of advancing the global effort in mind, we believe strongly in supporting the various regional and niche user groups currently active across the country.  We are witness to the power of these groups nearly every day.  We see email conversations involving dozens of organizations spanning several states sharing concepts with the intention of helping each other move past their obstacles.  We see thousands of users joining to form a single voice demanding resolution to persistent issues.  And we see the times when these groups gather physically, in a single location, to share their experiences, frustrations, and success stories all in an effort to support one another and move forward

We are, of course, in the midst of yet another injection of uncertainty in the form of “Meaningful Use”.  As a result, it appears that ACE 2010 couldn’t come at a better time.  Certainly, ACE is a great opportunity to see old friends and make new ones, but more importantly, it is a chance for the community to convene, give voice to its anxieties, and discuss steps to overcome them.  We relish the chance to participate in that process.

We hope that each of you attending ACE 2010 will stop by our booth, have a little fun (Spin to Win an iPad!), and share your thoughts, voice a concern, or just ask a question.  We know that the success of our organization depends on the success of the community overall.  We, collectively, can achieve that success through a commitment to promoting the greater objectives, freely sharing our knowledge, and continually moving the community concept forward.

Enjoy your summer and I hope to see you at ACE.

Steve McQueen

Keynote Address: The State and National Vision for Health IT and HIE

Dr. David Blumenthal, National Coordinator for Health Information Technology – U.S. Dept. of HHS,  presented his own anecdotal experiences with the EHR, namely a story of how he was going to prescribe a patient a drug containing sulfa, yet the clinical decision support software in the EHR flagged him for a drug-to-drug interaction. If CDS tools within the EHR not available, would the pharmacist have caught this? Could the patient potentially been adversely affected?

Dr. Blumenthal then elaborated on two key components to which he felt would impact behavior via policy: writing regulations and spending money.

Regulations

• There have been 2000 comments received on the Interim Final Rule, with the publication of the final regulation anticipated by the end of the spring
• No comments questioned the conceptual framework nor the direction of Meaningful Use.
• The framework of Meaningful Use consists of 5 domains – quality, efficiency, patients & family, coordination of care, protection and security
• In speaking of the Interim Final Rule, Dr. Blumenthal utilized the analogy of an escalator – allow providers ease of introduction and steps for clear path of usage while lowering barriers to entry.
• Information Exchange – infrastructure is poorly developed for information to follow the patient and thus policy needed to address this. Certification will be the key to interoperability and with tighter standards, HIX should be more interoperable.
• CLIA (Clinical Laboratory Improvement Amendments): Currently, legacy regulations are being addressed such that the barriers to LDX (Laboratory Data Exchange) can be removed.
• Privacy & security: Providing authorities with the means of penalizing individuals and organizations for violations to ensure controls, access, protection

Spending money

• Regional Extension Centers (RECs) are currently modeled after US agriculture, which was intended to disperse new info to the family farm. The goal is to ensure that HIT is reaching the family physician and providing advice in terms of selection and implementation.
• Focused on <10 provider practices such that the full benefits of HIT can be reaped by the practice. Facilitation of re-design of work flows and mobilization of information for quality and efficiency improvements
• 50 states have been funded to promote RECs.
• Different localities will have different solutions for health information exchange (HIX)
• 70 community colleges were funded for workforce training and it is anticipated this will facilitate staffing of RECs

Next Year: Direction

• Implementation
• Finalize requirements for Meaningful Use
• Beacon Community Program – Fund 15 communities around the country directly through a grant program with the intent to offer a source of lessons and inspiration. There have been over 130 applicants to the program thus far.

F/U Questions/Concerns

• Physicians are worried that HIT happens to them, not with them and that users not intimately involved with the design

Panel – Consumer-Centric: The Role of the Patient in Health IT and HIE

• John Moore from Chilmark Research introduced term the term “citizen” as the term patient can often be paternal. He mentioned a John Halamka quote – “automating bad processes will not lead to improvement”.
• David Szabo, a partner, Edward Angell Palmer & Dodge brought up the point of how do we go about engaging citizens and brought up some serious concerns over privacy, especially in regards to patient portals. The topic of behavioral advertising in PHRs was brought up and it was mentioned that  FTC may provide governance to this regard.
• A question was posed about those surveyed and focused on in regards to Healthcare IT in that they are predominately affluent and white. John Moore responded with mobile health technologies being the enabler to reach all demographics and minorities.
• A comment was made concerning the power of secondary data to pre-populate EMRs. Barbra Rabson, Executive Director, Mass Health Quality Partners, provided a response and brought up a cautionary tale in the highly publicized case of e-patient Dave as published in the Boston Globe.
• To touch on concerns about patient security and privacy in regards to the Personal Healthcare Record (PHR), John Moore also brought up a really cool Massachusetts company called “Patients Like Me”  and highlighted the fact that through this vehicle,  “citizens” currently share their healthcare stories and experiences.

Regional Collaboration Meetings (CT, ME, MA, NH, RI, VT)

Later in the afternoon a breakout session allowed public officials to meet with neighboring states to discuss current plans, areas of concern, regional interoperability and opportunities for collaboration.

• NESCO (New England States Consortium Systems Organization) represents a business model built around collaboration and their Deputy Director, Nancy Peterson, acted as the facilitator.
• The idea of health delivery system reform was immediately brought up in that the system incentivizes and currently pays for sickness instead of for health via preventative and behavioral care.
• The model of the state of ME was addressed. Currently they have an operational provider-only HIE available to facilitate treatment improvement and representative of six of the largest healthcare systems in the state. The HIE, established in 2004 and live as of the summer of 2009, covers 50% of the hospitals 46% of ambulatory care.
• Some of the questions and comments posed by the audience included the following
  • How do we bridge between standards?
  • The business case needs to be established as this will drive investment. We need to clarify a vision and clearly express the financial incentive model.
  • Challenges with the business case in that savings on one side put costs on another.
  • We need to attack some of the low-hanging fruit first by implementing a common consent framework.
  • Ownership of the data: Who owns the data? The patient?
  • HIEs need to be consumer-driven.
  • Are we focusing too much on the standards with meaningful use, whereas we should be focused on the transport and the “network”?
  • Where are the interconnections in healthcare delivery that have the highest yields in terms of clinical data?
  • We face the underlying competing entities in clinical standards versus claims standards. Integration of the two needs to be addressed.
  • We are up against perverse incentives as there are many other resistive forces towards HIE, namely disincentives, in the health system.

This is a long overdue ruling, and much necessary. It is crazy to think that a paper process was safer (and offered more security) than e-prescribing could. A link to the article is offered below.

http://www.healthdatamanagement.com/news/controlled_substances_e-prescribing_rule_dea-39995-1.html

Some of our clients have recently expressed the desire for a limited, read-only view in to the AE-EHR to extend access to audit entities. For instance, the requirements of one organization included a limited patient-access read-only environment to be in compliance with FDA Research Part 11 restrictions for clinical trials. Another organization needed it for insurance audit purposes. And still again, others desired to provide an extended environment to allow hospitalists, ED physicians, and critical care physicians access to selective patient charts.

Approach

One of the more popular approaches has been to segment out a separate read-only organization in the Allscripts Enterprise Electronic Health Record (AE-EHR). The AE-EHR handles organizations quite nicely and facilitates an approach of segmenting out entities – the following Galen Wiki article covers a scripted means of deploying a new organization in v10 AE-EHR.

Once the organization has been created, patients can then be “bulk-loaded” to the organization via SQL scripts. New AE-EHR users can then be created and associated to this organization. Finally, to setup the read-only portion, security gates can be implemented.

Extendability

An additional requirement of one of our clients included an approach that offered the capability to dynamically add/remove patients to the “Audit” organization real-time. We facilitated this via creation of a file-based interface from ConnectR to the AE-EHR. The interface accepted its input from a well defined flat-file (comma-delimited, including MRN, Action – Add or Remove, and OrganizationID) and utilized that data to add/remove patients to the org via a custom stored procedures – the de facto application programming interface (API) to the AE-EHR clinical database.

And still further, another client requested that the audit/read-only entities (users of the system) be granted the ability to create tasks . For example, the client desired a specific, high priority task, identifiable as originating from the audit/read-only entity – in this case hospitalists which could be assigned to the patient’s PCP. In this case, the clients’ hospitalists could communicate high priority continuity of care tasks, which require prompt reaction, to the PCP at discharge. However, the PCPs should not be able to task back to the hospitalists, and this can be achieved by setting the EnableOrgFilterFlag preference in the AE-EHR.

If your organization needs assistance in setting up a audit environment to provide limited, read-only access to the AE-EHR, please contact sales@galenhealthcare.com and visit our website for more information regarding our technical and professional service offerings.

These will be structured in a similar format to university courses – the initial three classes will be at 100, 300 and 500 levels.  The list of the webcasts and their times may be found below.

100 Series – Introduction to the Allscripts EHR Database: Overview of the database, patient demographics and dictionary linking.

• Wednesday, December 2nd, 2009 at 2:00pm EST

300 Series – v11 Order and Results: querying configuration and patient data.

• Wednesday, January 13th, 2010 at 2:00pm EST

500 Series – Advanced ConnectR Architecture and Querying

• Wednesday, February 3rd, 2010 at 2:00pm EST

To attend, please contact Mike Dow, mike.dow@galenhealthcare.com.  You must be an existing Allscripts Enterprise EHR client to attend.

We also offer training courses and reporting services for the Allscripts Enterprise EHR database, ETL database, Analytics and the ConnectR  database.  Please contact sales@galenhealthcare.com for more information regarding these courses and our reporting services.

Once the pilot group is live (the two providers starting next week), the rest of the group will go-live starting sometime after the first of the year. Since most of the sites (clinics) range from one to three providers, the general idea is a roll a new clinic out every two weeks. The variables at this point are how efficiently we get charts scanned and how effective our training strategy is.

This group has been successful in keeping the pilot group excited about moving towards an EHR which keeps the whole team positive. Next week will be an exciting time.

It is important to remember to not overwhelm the users, but give them enough of the application to make them more efficient in their roles, (finding that balance can be a challenge). Try to avoid having users perform double workflows (working off a paper chart while also documenting in the EHR) and to make sure they are sufficiently supported during the roll-out. Make them (the users) aware that converting to an EHR is a work in progress (manage their expectations!). While they should have high expectations of the conversion and functionality keep in mind also that the roll-out is a process, not just an action. We are excited to go into the roll-out phase as all the analyzing, design and build work begins to pay off.

Establishing the provider’s expectations is extremely important. Communicate clearly with your pilot provider(s) what exactly a pilot, or simulation means. Providers will have all kinds of different theories of what it means to be converting to an EHR, or upgrading their current version. Let them know there is learning curve and it may not be exactly what they expect right off the bat. The EHR is always a work in progress as efficiencies are added. Hopefully the provider realizes that the purpose of piloting the application and constructive feedback is very important to their role in the pilot. They may not instantly love every aspect of using the application and changes can still be made to add efficiencies if feedback is communicated. Most times, settings and preferences in the application need to be adjusted, or the client devices and workflow need to be configured. To summarize, try to keep the provider(s) excited about piloting the application, while keeping reasonable expectation.

Define the operational/management expectations as well. Piloting is a chance for the build and operations of the organization to make sure they have everything set the way they expected it but the providers may not like all the operational decisions that were made. Which modules are utilized and in what workflow works best in the clinic will come to light very quickly in pilot. Are users expected to be using all aspects of the application in pilot? Do they need to send prescriptions, review tasks, scan chart items, etc. all while piloting? Do the client devices (laptops, tablets, exam room PC’s, etc.) all work efficiently? Just make sure what is being piloted defined. Handing off the application without being sure of what you want back will make it hard to know exactly when you have had a successful pilot and you can look towards your go-live. Your pilot may bring to the surface inefficiencies or weaknesses in the workflow that were overlooked in the build process. Expect that changes may need to be made so that your organization is not disappointed when they realize that the EHR is always a work in progress.

Away from the actual EHR build, the pilot can be very beneficial too. From the IT perspective, if you are using wireless devices it gives you a chance to test the connections for the devices. How are users logging on to the devices and are they secure? Is the application performing to expectations or do bottlenecks in bandwidth need to be looked at?

Piloting the application is an essential part of the implantation process and should be given appropriate attention from all the groups that are involved in the build and deployment. This may be the first time the providers are using the application and how vocal they are after using the application can lay a positive or negative foundation for the rest of the rollout depending on how the expectations are set and how much they feel supported in using the application.

In most situations it makes sense to build them at the same time, but many groups (at least prior to v11) would deploy Result in the first phase or wave and Order later on the down the road. Depending on many variables, there is no right or wrong way to deploy these, keeping in mind it does not make much sense to just go up on Order without Result. One of the reasons to deploy result first is it is one of the most useful modules. Receiving results through the application, rather than on paper can add flexibility and efficiency to the providers time as they can review labs and send instructions to the MA anytime they have a few moments and they do not have to wait to be handed a piece of paper. That being said, understanding and building the process around results is important. The Enterprise (TouchWorks) certified workflows should be followed, or used as a base to design the workflows for reviewing lab results.

Result

When building your Results interface there will be many design meetings and discussions with your lab vendor. Some important items to bring into the discussion are:

· Whose results are included? Are there outside physicians that could be included (IPA for example)? Which providers will be electronic from the group right away and which will not?

· How are HIV results, or other sensitive results, sent back to the provider? This can be filtered by the lab or the interface as an organization will want to be sensitive to how the results for such sensitive tests will be brought into the system and if typical workflow or protocol is appropriate for such tests.

· How are abnormal or urgent results sent? Typically labs will follow standard procedure for this but it should be brought up. If previous to an electronic interface they would phone for urgent results, then that process will likely be kept.

· The reference ranges (normal results) usually come from the lab vendor, however many groups are able to create their own depending on their relationship with the lab.

Order

An order interface in my experience is a little more complicated because it involves sending the lab the orders, and instructions and making sure it all gets to the right place, in the right time for the patient can be tough. Who can send orders, or what orders they can send is an important internal discussion. A few Items to bring up with your lab vendor when building your Order interface are:

· Can future orders be created?

· Can standing orders be created?

· Which instructions (fasting for example) go with which orderable items?

· Can stat and urgent orders be sent over the interface or should those be phoned/faxed over?

· How will cancellations be processed (the orders interface or often one way, so cancellation messages typically are not sent back)?

Those are just a few items to remember when considering your Order/Result interface. Your PM or technical resource may have a similar list or other items to bring up.