Galen Healthcare Solutions: Allscripts Consultants Enterprise EHR

Organizations exploring Computerized Physician Order Entry (CPOE) might first pursue low-hanging fruit and implement an electronic workflow for results and keep a paper workflow for orders. Often times, electronic order entry can be cumbersome for end users and cause longer workflows.  As alluded to in a previous blog article, the benefits of implementing a solicited result interface are compelling – reducing paper and scanning, and offers the capability for automated result tasking.

In the Allscripts Enterprise EHR (AE-EHR), results can tie back to existing orders, facilitating completion of the order. This functionality is enabled and configured within the results interface deployed at a particular group and can be achieved in one of two ways:

• Order Number: the Order Number EXT generated from Allscripts is sent back with the results. The Order Number is tied directly to a specific order – a specific CBC order in a patient’s chart.
• Requisition Number: the Req Number EXT generated from Allscripts is sent back with the results. The Requisition Number is tied one or more orders – all orders on a single requisition. A requisition is defined by the Patient, Encounter, Performing Location and Ordering Provider.

For some organizations, a paper order work flow may be utilized, in which a paper requisition is presented to the lab instead of an electronic order. However, the Laboratory Information System (LIS) may not allow for discrete capture of the Allscripts-generated order number or requisition number. For that matter, the LIS also may not have the capability to send back this number in the result interface (typically a HL7 ORU result message).

Additionally, most organizations encounter a percentage of solicited results that do not complete the order. In the latter scenario, a lab may manually enter the order introducing the possibility for human error and can cause issue with not only reconciliation of the order, but potentially patient or provider matching.

Furthermore, if a lab has to change an order for any reason (for instance, changing the orderable item), the corresponding result will likely not reconcile the order (with the AE-EHR, the correct protocol would be to cancel the order and place a new order with the desired changes).

This situation can cause nightmares for organizations that are trying to gain semblance as to where lab vendors stand in terms of order fulfillment.  Additionally, order reconciliation reporting will likely be inaccurate.

This is especially pronounced in v11 AE-EHR, in which solicited results that are unable to reconcile to the original order create a “reported order.’ The original order is left unreconciled and a “duplicate” order renders in the patient chart:

We have resources available on our wiki to guide an organization through interfaced result-driven order reconciliation and can assist those organizations looking to gain control of order fulfillment and reconciliation. Please contact sales@galenhealthcare.com for more information.

Tags: Allscripts Enterprise EHR, CPOE, Crystal Reports, Custom Reports, Integration, Interfaces, Interoperability, Meaningful Use, Order Interface, Reconciliation, Reporting, Requisition, Results Interface

As physicians migrate to the Electronic Health Record, there are many new systems and processes they have to learn and adapt to.  One of these systems is voice recognition software, such as Dragon Medical 10.  I have worked with some physicians recently who were implementing a new EHR in their office, as well as transitioning from a transcription service to Dragon voice recognition.  This introduced some new challenges which I hope to shed some light on in this article.

Dragon Medical has the ability to ‘Type as you Talk’, which allows the user to dictate blocks of text and see this appear in their note in the EHR.  This has a huge benefit to the provider by allowing them to review and finalize their documentation for the visit immediately, rather than waiting a few days to receive the note back from a transcription service.  We discovered that there are some steps that you can take to improve the performance and/or accuracy of Dragon.  Here are a few to note:

1. Spend the time training Dragon to recognize your voice.  During this process, the application will learn how you speak, and adapt to your voice patterns.  This will prove to be very beneficial in the long run.
2. Follow the recommendations for the settings for your EHR vendor.  The Dragon representative will have recommendations on how settings should be configured based on the EHR you are using.
3. When words are not typed correctly, correct them using the built in features of Dragon to Train it on how you speak those words.  This will save you time and energy as you become a more advanced user of the speech recognition software.
4. Have reasonable expectations.  Dragon is a tool that improves over time.  When you first begin using speech recognition software, it only has a basic understanding of your vocabulary and how you speak.  It will take time for the application to improve, which will occur naturally as you train it when words are not recognized correctly.

These are a few items that will hopefully help you be more successful when using speech recognition software, such as Dragon Medical.  I have also found that it is beneficial to have a follow-up training session with Dragon after the user has been using it for a few weeks/months.  At this point, the user understands some basic functionality, and is usually interested in how to do more complex functions such as Macros.

Tags: Allscripts, Allscripts Enterprise EHR, Dragon, EHR Implementation, Enterprise EHR, Integration, Successful EHR Implementation

Tags: Allscripts Consultants, Allscripts Demo, Allscripts Enterprise EHR, Data Conversion, EHR Implementation, Enterprise EHR, Extensibility, Integration, Meaningful Use, ScanMD

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

Issue:

A recent issue came up with one of our clients in that interfaced patient appointments from their Practice Management system were not making it in a timely manner to the EHR. The client witnessed that appointment messages built up in the interface queue and there was a delay in processing the messages. The client desired a resolution that would assist in speed up of the processing of the messages such that appointments booked in PM would render in the EHR quickly without a disruption to workflow.

Investigation:

Enter the ConnectR Toolbelt “Transaction Processing Time” report:

This report extracts transaction count, minimum, average, and maximum ConnectR processing time per hour. Using the report, the following analysis was conducted.

Findings:

Based on the aforementioned analysis, it was determined that in the clients Live Reg/Sched system target, blocked messages were being logged. Having blocked messages logged can be invaluable when first designing and developing interfaces. However, as evidenced in the analysis, it can lead to performance degradation as the system requires much less processing time when messages are not logged.

Outcome:

Logging of blocked messages in the Live Reg/Sched target was disabled on 6/30/2010 and as witnessed in the analysis spreadsheet the number of transactions decreased by roughly 70% and peak transaction processing time decreased by roughly 90%.

Tags: Allscripts Enterprise EHR, Business Intelligence, ConnectR, ConnectR Toolbelt, Integration, Interfaces, Meaningful Use, SQL Server Reporting Services

Galen Healthcare Solutions is proud to announce that we will be continuing our popular series of free webcasts this fall related to Allscripts Enterprise EHR.   These Webcasts will cover topics including Analytics, Allscripts Enterprise EHR Note, Interfaces, Reports, Allscripts Enterprise EHR Orders, Tech System maintenance.

Learn more »

Tags: Allscripts, Enterprise Order, Galen Webcast Series, Integration, Interfaces, Meaningful Use, Technical

Last night, my colleagues and I attended a New England HIMSS event in Wellesley, MA covering Mobile Health. After battling through brutal traffic commuting from Boston to Wellesley during rush hour, we arrived and were all equally impressed with the night’s speaker -  Robert Havasy, Business Analyst at the Center for Connected Health in Massachusetts. I particularly liked the presentation technology used for his pitch – Prezi - a web-based presentation application and storytelling tool that uses a single canvas instead of traditional slides.

Some key takeaways from the presentation:

• Will the FDA regulate smart phones or mobile devices and treat them as medical devices?
• Patients are unencumbered by the regulatory process
• Two focus areas for mobile health technology
  • Capturing Data – vitals, blood sugar, etc
  • Coaching – guiding patients to make better choices
• Sunscreen adherence using mobile technology
  • Electronic monitor used to accurately measure usage of sunscreen
  • Reminder texts sent to mobile phone
  • After six weeks adherence rates for the reminder group were almost double that of the control group who did not receive reminder texts: 56 versus 30 percent.
• Utilizing text messaging to influence patient behavior -Center for Connected Health – project in Lynn, MA.
  • Two areas of focus: Opiate addiction and Teenage pregnancy
  • Localization is important – mention people by places and name
  • Who the message was from (especially doctor) meant more to patients that if it were personally addressed to them
  • Barrier to participation – cost – patients were afraid they would have to pay for the additional text messages
  • Unleash the nurses – nurse evangelist sells benefits to non-physician staff
  • Offset workflow changes in offices – take administration off of practice
  • Sustainable reimbursement structure – engage carriers – CMS – insurers – alternative quality contracts
• Northeastern University, working in collaboration with industry players, announced an incubator program for mobile health technologies. Contact Dan Feinberg, Director, Graduate Health Informatics Program at Northeastern University, President at New England Chapter of HIMSS, for more information

Tags: ehealth initiative, Extensibility, Integration, Interoperability, Meaningful Use, mHealth

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

We here at Galen have seen a greater influx of requests to be able to integrate client’s EHR environments with 3rd party applications and/or internet websites.

I’ve created a few examples that I’ve added to our Wiki page.

1. http://wiki.galenhealthcare.com/Patient_Portal_Integration

With this case study Galen had a client who has implemented a patient portal application whereby patients are able to send messages to their doctors regarding tests, results and general questions. The client was looking for a way to have the provider be able to integrate this application directly into the EHR. With RelayHealth’s help we have succesfully built a prototype whereby a provider can seamlessly communicate with a patient in the most efficient manner possible!

2. http://wiki.galenhealthcare.com/images/5/57/Add_new_Web_framework_documents_to_the_EHR.pdf

In this example a client was looking for a new link on their vertical toolbar which would allow them to display any website in their current workspace (the main viewing pane of the EHR). This one example integrates the website directly into the EHR window without having to navigate through a new tab or window, showing a FRAX calculator. The other tab actually has the ability to take in patient context (height, weight, blood pressure, etc.) and pass it into a form automatically populating fields to save physicians valuable time. This article goes through the steps involved in setting up new vertical toolbars, horizontal toolbars, and workspaces to set up these outside websites in the EHR. The actual code to populate patient context is fairly complex but definitely something Galen would love to help out with!

Tags: Allscripts, EHR, EHR Implementation, HL7, Integration, Successful EHR Implementation, Technical

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