Galen Healthcare Solutions: Allscripts Consultants Enterprise EHR

In response to a guest post on EMRandHIPAA, we take a look at the top EHR data integration challenges faced today:

Technology

Proliferation of point-to-point interfaces instead of using a hub-and-spoke type of model (like that which Surescripts utilizes with electronic prescribing). Unfortunately, most organizations which exchange data in and out of the AE-EHR utilize highly-customized point-to-point interfaces for orders, results, documents, etc. The point-to-point model is highly inefficient and does not adhere with a “plug and play” model that so many organizations desire.

We’ve seen Allscripts make an effort to move away from this by introducing capabilities to automatically send immunizations to state registries via the Allscripts Hub by  simply modifying configuration setting (with the caveat that Allscripts has worked with the state to develop the intergration).  We’ve also witnessed companies like Medicity and its Novo Grid technologywhich offers electronic communication between physician practices, hospitals, and other health care providers. Novo embeds agents (small but powerful Java programs) in hospital data centers, physician practices and other locations. The grid component is an object oriented system that can replicate an object to multiple agents and keep it in sync across locations.

 Standards

As outlined in the EMRandHIPAA post, there are no mandated standards for EHR vendors to follow, thus making it difficult to coordinate data sharing between medical devices and other systems. Allscripts does offer the Universal Application Integrator (UAI),  which facilitates extendibility to other applications and devices. However, there is a certification process that needs to be pursued. In terms of the point-to-point interfaces previously mentioned, the Allscripts proprietary (API)  Application Programming Interface(which consists of inbound and outbound stored procedures to their primary clinical DB) does not segment out the data and configuration components of clinical exchange, something touched on in detail in a previous Galen Blog post.  Lastly, most vendors have their own specifications for HL7 message definitions. For instance, Quest may send ordering provider in OBR-16 in an interfaced result ORU message while LabCorp sends this in ORC-12. Another example is communication of “Ask at Order Entry” questions – something Quest expects to receive in repeating OBX segments while LabCorp expects this across Z-segments in an interfaced order ORM message.

Adherence to HL7, proprietary approaches.

Cost

John Halamka bravely predicted that when health IT vendors and providers began adopting new standards, the cost for interoperability would plummet: “We know that we won’t get precisely plug and play—this is a journey,” Halamka told Government Health IT. “But each year, we will get more constrained. We are going from a $20,000 -$30,000 venture hopefully to $5,000-$10,000.” Unfortunately the numbers quoted are accurate – and provide a high barrier to entry for smaller groups looking to electronically exchange data. There is the flip-side to cost and that is the ROI, which could include reduction in direct annual labor costs, elimination of non-billable tests, and elimination of lost charges.

Summary

The benefits of health information exchange are well documented. As outlined in the EMRandHIPAA post, there is a need for a “consistent, secure and reliable way to capture and share patient data among all systems and healthcare providers,” especially given that benefits in improved coordination of care and reduction of medical errors.

Tags: Allscripts, Extensibility, HIE, HL7, Integration, Interfaces, Interoperability, Results Interface, Standards

Last Wednesday I attended the VITL Summit ’10 in Burlington Vermont.  VITL is non-profit “public charity” that operates as a partnership between the public and private sectors; VITL receives funding from the federal and state governments, as well as the Vermont Health IT Fund.

As part of the HITECH Act (Health Information Technology Extension Program) VITL became a Regional Extension Center (REC) and received $6,762,080 in Round 1 funding from the ONC.  RECs provide: training and support services to assist doctors and other providers in adopting EHRs, information and guidance to help with EHR implementation and technical assistance as needed.

The Summit Key Note speaker was Dr. David Blumenthal, the national coordinator for health IT.  Vermont Governor Jim Douglas was also there to emphasize how important the topic is to the state.  Dr. Blumenthal’s speech touched on a variety of topics and as expected, stressed how important the adoption and use of EHRs is to the future of how doctors practice medicine.  An interesting personal note Dr. Blumenthal shared was about his daughter who is currently in Residency.  Her current rotation had her moving from a practice that used an EHR to a practice that did not.  Her immediate response… ‘how could someone possibly be affective without an electronic system in place?’; an opinion father and daughter obviously share.  Along those lines, he suggested that new doctors, fresh out of medical school, would know nothing other than an electronic practice.

Additional notes from Dr. Blumenthal’s remarks;

• Dr. Blumenthal is an self-proclaimed “non-geek”, with a house in South Pomfret, VT.  He believes Vermont serves as a model for how EHR/HIE programs could be designed and thinks VT has a unique, competitive edge because of its collaborative spirit and natural desire to exchange information.
• Some reasons he thinks EHRs develop better doctors;
  • 24/7 Information access – problems, meds, history, etc
  • “See” what’s been done – even if you weren’t around when it happened
  • Knowing/receiving result more quickly
  • Decision support
  • Interaction checking – allergies, meds
• The big benefits of adoption – (most, if not all are oft repeated by those in our industry)
  • Reduce costs – an important point for many of the individuals participating in the conference.  Short term improvements in terms of reducing operational costs of a practice (efficiencies), longer term.. see next bullet.
  • Increase the quality of care – this was a point he expressed a number of times.  He pointed out that perhaps not in phase 1 of MU, but long term (phases 2 and 3), this was the ultimate goal.  I.e. EHRs would improve patient outcomes, remove redundancies and ultimately affect overall patient health.
• 3 Barriers of EHR adoption (+1 more)
  1. Financial
  2. Logistical/technical – especially for smaller practices.. there is a tendency to think it’s too difficult or time consuming
  3. Sharing – Will sharing patient data be accepted?  Will it actually hurt my practice?
  4. Trained workforce – Dr. Blumenthal mentioned that many more colleges and universities are now developing disciplines in Healthcare IT (including some in Vermont!)
• Meaningful Use will be here before you know it…
  • Practices will have 2 years, from Oct 1^st , to pick an EHR and meet MU requirements for reimbursement.  DO NOT wait.  Time will pass quickly and inevitably a bottleneck will develop.

In a separate presentation, VITL’s HIE offering was discussed.  Connection to an Exchange like this one will eventually be a requirement for all those participating in the MU program.  VITL’s exchange is run by GE and like other HIE’s, employs a hub and spoke model to connect practices and make the exchange of patient data possible.  Besides the physical network making the connections and the software platform running the exchange, HIE policy will play a large part in how information is shared.  Whether individual patients choose to participate, what privacy rules are in place and how security is managed will all play a central role in an HIE.

An interesting part of the Summit was the presence of all the big vendors; GE, McKesson, Greenway, NextGen, Athena, Cerner, Medent, eClincalWorks and of course Allscripts.  The interesting part came from being able to go from both to both and see one application after the next.  Seeing and feeling the dramatic differences in how they each work, look and perform.

This year’s event was sold out and overall seemed like a big hit with everyone in attendance.  Great job VITL!

Tags: EHR, EMR, HIE, HITECH, REC, VITL

Currently, exchange of clinical data in and out of the Allscripts Enterprise EHR is facilitated via stored procedures. This  application programming interface (API) approach certainly comes with its downsides. In this article, we propose a re-design of the API to segment out the data and the configuration components of clinical data exchange.

At the outset of an interface project where there has been precedent set (existing Quest or LabCorp <-> AE-EHR order/result data exchange deployments), we almost always get the following questions from the vendor:

• Shouldn’t the interface be the same from client-to-client?
• Why do we need to pay Galen (vendors will often times subsidize the cost of interfaces) to design a known interface deployed across hundreds of clients?
• Why do we need to reinvent the wheel?

Now these are very valid questions. And the response is as follows: Due to the approach utilized with the Allscripts interface API, an interface designer must take care in translating data extracted from outbound stored procedures into a valid, compliant HL7 message the vendor can accept (ORM for orders) and also take care in translating an HL7 message from a vendor (ORU) into a stored procedure call which sets both data elements and configuration options. To help guide the client and vendor through design decisions, Galen provides interface-specific (document, result, immunization) questionnaires.

Back to our proposed re-design: segmentation of the data elements (patient first name, provider ID, order item code) and configuration settings (enable tasking, utilize NPI for provider matching, utilize EntryCode for item matching – setting the traditional form parameters of the inbound stored procedures). With this approach, the vendor is responsible for providing the data elements as they normally do in the HL7 message (ORU for results), and the client sets the configuration settings via a workplace within the TWAdmin context in the AE-EHR – much as they do to set application preferences:

We have covered AE-EHR inbound interfaces quite well, so let’s address proposed re-design for outbound interfaces. Instead of each client requiring a site-to-site VPN and individual interface deployment, what if Allscripts chose some of its top vendor partners (Quest, Labcorp) and offered the capability to exchange out of the box, without the need for one-off interfaces? This approach is somewhat analogous to that of Surescripts acting as the hub and router for electronic prescriptions. In the case of outbound interfaces (orders for our example), there would still be the need to segment data (patient, provider, item) from configuration settings (a setting to enable or disable sending insurance information – IN1 segment of an HL7 ORM order message).

In conclusion the Allscripts clinical data exchange API serves its purpose quite well, but it could do a better job. Much of the functionality is derived from legacy, antiquated methods. Our hunch tells us that in promoting themes of Community Exchange and Connecting, the “new” Allscripts will be addressing this in short order.

Tags: Allscripts Enterprise EHR, ConnectR, Database, Enterprise EHR, Enterprise Order, HIE, HL7, Integration, Interfaces, Interoperability, Meaningful Use, Results Interface, Technical

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

Last Thursday, I attended Governor Deval Patrick’s HIT conference in Boston and present my own musings and takeaways from day 1 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 and look for a recap of day 2 of the conference on the Galen blog this Wednesday.

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.

Tags: EHR Implementation, HIE, HL7, Integration, Interfaces, Interoperability, Meaningful Use, RHIO

I’ve spent the past year working with a health system that is taking advantage of the recent Stark exception and Anti-Kickback statutes and has donated the TouchWorks EHR to private physicians in the community. The health system, made up of two hospitals and a multi-specialty medical group, seized the opportunity to connect the community and help small, independent practices adopt an EHR.

In contrast to a traditional ASP or hosted model, this is a community health record where each provider along the continuum of care works exclusively from a fully shared patient record, updates the same medication list, allergy list and problem list. Instead of mailing a consult note, an independent physician can send a task to the referring provider at the host health system to review details of the visit. Coordinating a surgical procedure, a process that could take over 2 weeks in the pre-connected world, now happens in less than an hour as the primary care physician from the Medical Group and private specialist use tasking to communicate in the context of the patient record.

For more info click here

Tags: EHR, HIE, RHIO, TouchWorks