Galen Healthcare Solutions: Allscripts Consultants Enterprise EHR

Last Friday, I attended Governor Deval Patrick’s HIT conference in Boston and present my own musings and takeaways from day 2 of the conference. Be sure to check out Dr. John Halamka’s reactions from last Thursday morning’s CEO summit at the Govenor’s HIT Conference.

Keynote from the Surgeon General – Vice Admiral Regina M. Benjamin

• She covered how Hurricane Katrina affected her community in Alabama and the fact that due to the natural disaster, they were reliant on pharmacy chains to provide a record of what medicine the patients were taking.
• She also touched on a story of how members of her clinic were drying out the patients records after Hurricane Katrina and after they had them completely dried; a fire burned the entire clinic down. This brings to light the need for disaster recovery and collocation in some circumstances. Galen Healthcare Solutions proudly offer a downtime solution in its VitalCenter product.
• After the fire, Bentley college students came down to assist and one of those classes contacted the president of e-ClinicalWorks and convinced him to donate the EHR – integrated with both labs & referrals
• She stressed that prevention is the foundation to the National health System and as such we should be incentivizing prevention.
• She also mentioned how the EHR played a major role in prevention of errors

Getting Clarity – Developing Effective Health IT Policies and Standards

• Need to integrate claims and clinical data to provide total model for exchange
• 15 cents of every dollar in healthcare goes to administrative overhead
• Two key issues for data exchange – identity and consent
• Public Health entities currently receive data, however not every public health entity has the infrastructure to receive data
• How do we pull quality measures out of unstructured text?
  • Analogy of querying for alcoholics, but free text match is returned about using alcohol to swab skin before applying needle.
• The tough part of concerning clinical quality measures is the balance of structured and unstructured data
• Healthcare delivery is complex in that there is heavy fragmentation – 80% are solo or two physician practices
• Dr. John Halamka mentioned that we are the stewards of our own data and architecturally that is the design of the system

Jobs, Jobs, Jobs – Health IT, Business Opportunities, and Job Creation

• Healthcare workers do not have not enough IT in their educational curriculum
• Howard Messing, the President of Meditech mentioned that in Massachusetts in particular the cost of living is a barrier – Meditech actually has commuters from Atlanta.
• Girish Kumar Navani, CEO of e-ClinicalWorks indicated that they currently employ greater than 1000.
  • He anticipates hiring 500 new workers over the next 2 years for programming and business analyst positions
  • He also mentioned the analogy of the electrical socket – broadband network need to be as irreplaceable in physician office as the electrical socket.
  • He believes there is a need for a  new type of worker, the knowledge worker, who understands workflow and is able to analyze and make better decisions about population health
• Richard Reese, Executive Charmain of the Board, Iron Mountain, anticipates helping hospitals clean up paper mess.
  • He mentioned non-compliance in healthcare IT to storage and backup standards
  • Lesson in compliance can be drawn from Wall Street years ago and that healthcare organizations must design for workflow, but compliance as well
• Brad Waugh, President & CEO at Navinet, indicated that the network his company providers connects payers and providers, saving $800 million per year.
  • They currently require Microsoft .NET certified engineers and have over 30 openings
  • He indicated that the educational system must produce the folks needed in healthcare IT and currently it is just not doing so domestically
• This discussion brought to light a deeper seeded issue in American society in that as a society we are not pushing computer technology anymore as it is no longer the glamorized industry.
• There is a major need for qualified issues and it is a supply versus demand issue with the roots in education and society.
• One member of the audience mentioned that the goal of healthcare reform is to eliminate costs and the irony is that in a sense we are creating jobs to eliminate jobs
• Another member of the audience commented on the arrival of programs for night healthcare professional courses, much like it was the trendy thing to get a night MBA in the 90s
• Finally the point was made that by the middle of the current decade, we will be facing baby boomers hitting Medicaid and the amount of care they need is incredible. With less dollars, we will need to re-engineer the system and what could come as a result is care rationing

Panel: Successful HIEs – How They Did It and How It Helps

Fallon Clinic HIE

• Emergency care was the highest reason for HIE usage
• Some quotes from physicians on the value the HIE provided
  • “Importing the CCD expedited documentation”
  • “Reduced need to ask patients questions”
  • “Expedited verification of medication and allergy list”
  • “Saved time”
  • They estimate phone calls were avoided for 75% of hospitalist and were extremely beneficial for new patient visits
  • They estimate they spent 3 years and $3 million learning and developing “trust” and $1M in building and implementing in the final 2 years
  • Lesson learned:
    • They pre-registered all of their patients in the community (bulk-load) and this helped with performance as they didn’t have to query the state
    • They felt the key to sustainability was to reduce operating expenses
    • Each organization in the HIE was responsible for server maintenance – ends up being $2000/year/organization which represents rounding error in most healthcare IT budgets
    • Key points – earn trust – utilize real-world workflows – value of low cost

Indiana Health Information Exchange

• Federated data model – 62 hospitals – 3 billion structured results – doubling time of 4 months
• They meet the providers where they are whether it be delivery of data to the EHR or physicians receiving data as PDF or view into a portal
• They view sustainability in the sense of funding via offering services
  • work with public health services for syndrome surveillance and track immunizations
  • Their business model for sustainability is such that scale is needed and again they emphasized avoiding grants for operational costs.

NEHEN

• Their sustainability model is such that their organization provides governance – decide what has value – much as a board of directors would
• Federated model works better than centralized – more accepted in the marketplace
• Lessons learn include integrating processes across the enterprise
• The case of the transfer of information to public health is needed to sustain HIEs as well as the capability to sell other products within the network.

Tags: Adoption, Business Continuity, HIE, HL7, Immunizations, Integration, Interfaces, Interoperability, Meaningful Use

More structure and planning help to head off excuses and voluntary non-compliance.  One of the more common excuses is finding reasons the system is less than perfect, ignoring the fact that the system is replacing a flawed system in many cases.  I couldn’t count the times I have spent  explaining “flaws” in a system that were really the same flaws that existed in the paper world.

There has to be accountability for non-compliance with expectations.  Metrics have to be in place to track compliance and remediation has to be in place to assist with compliance.  This needs the appropriate chain of command authority and support.

Here are some thought to promote compliance.

Competition – Use individuals competitive spirit to drive compliance.  Publish compliance success stories that prove utilization is possible which naturally spark some competitive spirit in some, which also is aided by the “un-biased” peer being the one that made it work and can use their clinical credibility to persuade.  Physician Champions are often well suited for this because they have a better understanding of the big picture.

Buttons – Take the time to take notice of what the pain points and satisfaction buttons are for the varied audiences.   If you know what these are the message can be tailored to accommodate the differences.

Piloting – Use piloting to work out the kinks.  If you aren’t sure how something is going to play out in a specific situation, play it out with a willing participant or champion to refine the process before rolling it out in mass.

Tags: Adoption, EHR, Successful EHR Implementation, TouchWorks

Mandated functionality use with a Live date without a plan to get there are begging for user adoption failure.   There are few organizations that have the ability to staff “Big Bang implementations.”  Whether big bang or some portions of the functionality, I think having just a live date can be very frustrating for users.  There are several factors coming into play on effective EHR adoption of functionality that are not accounted for in a situation where there is only a Live date and not a plan around what “Live” means.  For instance if we “go-live” on e-prescribing, what does this mean?  Some groups never define what this means and get several flavors of compliance or non-compliance.  What does it mean?  Does it mean that every patient from go-live forward will have a complete EHR medications list or all new prescriptions will be ordered from within the EHR or does it mean that the module is now available for use.   Come up with a fair solution that enables compliance without setting an expectation that is not realistic.

There are variables which vary by practice type or specialty affecting what makes sense for the implementation or adoption of functionality.   For instance, if I see 15 patients a day the expectations could be different than someone who sees 40 patients a day.  Some more variables include the first which I will call “Patient Repeat Value” or PRV a ratio that has to do with how often patients will return for a visit defined by number of visits divided by number of unique patients over a given period of time, and second which I will call “Patient Population Cycle Time” or PCT is the amount of time it takes to cycle through your active patients.

Volume is more obvious so let’s look at PRV.   If a clinician sees 40 patients a day but his PRV is high any pain associated with new functionality that is driven by items that are maintained list such as the various items on the paper face sheet like medications, problems and allergies will be more short term than someone who has a lower PRV that sees the same patient load, because they have a larger population and ergo more lists to maintain.  PRV may not be as relevant in items like electronic noting where it comes down more to practicing and repetitions to become efficient.

Let’s look at PCT as it applies to the first go-live of the EHR.  The best way to explain how PCT comes into play is that it makes every patient’s first visit in the EHR almost like a new patient visit.   We know that visits for New Patients typically take longer and their appointment times typically plan for this.  A logical conclusion from this comparison would be that schedules need to be changed to accommodate these “New to the EHR” patients.  If the PCT is 60 days, like it might be in an Obstetrics office or perhaps even lower in a Nursing Home, it could be practical.  However in Family Medicine it isn’t practical if some of my patients might not come in within 18 months but they are still considered active patients.

Since all practices aren’t created equally with regard to these variables it isn’t realistic to expect the same results from different groups.  Required utilization should be mapped out to accommodate the differences.  Come up with a strategy that allows the practice to step through to full utilization.   Sometimes it is simply something like applying the new functionality to every third “New to the EHR” patient for 60 days and then you’ll have a majority of your visits utilization compliant.  In other situations the logic is broken down by seeing different appointment or patient types initially and then working into the other types as you progress.  The main logic is to come up with steps that are easier to swallow than doing everything different than what was done yesterday.

Worth equal consideration, is a realistic timeframe for supporting an in progress EHR.  We have to coach the users through the implementation, to do more than what they think is possible.  Having an approach just as defined above will serve as the roadmap for the end user to get to some where they have never been.  Having never been there they don’t know what to expect.  Users can’t be allowed to always take the easy way out.  This sometimes involves repetitive reference to the gains and benefits that will be available.  If you don’t get the medication lists and problem lists in for the patients, notes can’t automatically cite from these lists etc.

Tags: Adoption, EHR, Successful EHR Implementation