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%.

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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.

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.

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 – Configuration and Deployment of Imagelink: Overview of Imagelink configuration within the AE-EHR and implementation of corresponding result interface dependencies.

• Wednesday, May 19th, 2010 at 2:00pm EST

300 Series – Advanced Troubleshooting: Error analysis and resolution as well as custom techniques for error remediation

• Wednesday, June 23rd, 2010 at 2:00pm EST

500 Series – Advanced Design: Interface filtering techniques and interface-driven tasking

• Wednesday, July 21st, 2010 at 2:00pm EST

To attend, please contact Justin Campbell, justin.campbell@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.

As with any data conversion, one must be cautious in terms of negative implications. For instance, administrative data has its limitations, and an example or where the process can go wrong is the highly-publicized case of e-Patient Dave.  Ultimately, problem conversions can be useful, but the data needs to be reviewed, and almost treated as suspect.  The value in the conversion is saving the entry of the problems that are accurate – say 80-90%.  Any that are incorrect, will be reviewed with the patient and can easily be marked EIE.

Statistics:

• 1,007,238 problems were loaded to the EHR for 205,831 patients via the interface engine, taking about 11 hours to process totally.
• PM Extract file statistics:
  • Total matchups of ICD9s to patients: 5,405,874
  • Total Unique ICD9s: 8346
  • ICD9s that only match up with 1 patient:1295
  • ICD9s that match up with 100 or more patients: 2027

Approach and Components:

• Master approved “ICD9” list provided by client
• Extract of ICD9 data from PM system provided by PM vendor
• Automated macro that attempts to match ICD9 to Medcin. Potential matches include the following:
  • 1 to 1
  • One to many (20 or less)
  • One to many (20 plus)
  • One to none
  • Each of the different flavors of matches were marked with an annotation (highlighted via an asterisk) to identify to clinicians the logic that was used in importing the problems:

• Once the translation was finalized, it was loaded into the interface engine and mapping logic loaded problems into the patient chart in the EHR via the API (existing stored procedure).

Known Issues Mitigated:

• Due to incorrect logic, some ICD9s were linked to patient profiles improperly. To mitigate this, a script was run to mark these problems as “entered in error”
• Problems were loaded to the “Past Medical History” section of the patient chart with a status of active. However, given this status, it didn’t facilitate providers to easily change the problem to be an active problem linked to a note.

Lessons Learned:

• Execute a proof-of-concept and as with any technical project, get clinician feedback. The client had a pilot group of 5 clinicians to vet out issues and bless the data before the live conversion was run.
• Do NOT use spreadsheets to track the cross-walk between administrative ICD9 diagnoses and clinical Medcin problems. Rather utilize a staging DB to serve as a single repository in developing ICD9 to Medcin translations. Also, the data from flat-file export from PM can be loaded into a staging environment via SSIS such that it can be analyzed and summarized while facilitating persistence.
• Make sure to tie the problem conversion load to a specific provider, that way if side effects or issues are identified after the fact, there is a clear way to identify which problems were loaded in the conversion via the provider they are tied to. The interface log should also have a record of this, but most organizations set the retention time to 90 days.
• Workflow validation – ensure that the workflow to move problems from PMH to Active will not be a barrier to use.

If your organization is looking for assistance in data conversion, please contact sales@galenhealthcare.com and visit our website for more information regarding our technical service offerings.

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.

• This estimated effort is based on 50 physician multi-specialty organization.
• It is intended to give a ballpark of effort involved and the numbers serve as estimates only.
• It does not necessarily scale linearly with number of providers or specialties.
• The effort only addresses four categories of effort – implementation, technical, interface and training.
• Categories of effort not addressed include project management, systems configuration and deployment, networking configuration and deployment, hardware (including desktop) deployment, and helpdesk and on-going support.

The meaningful use matrix with effort broken-out can be found on the Galen Healthcare Solutions Wiki.

Now that we have presented the effort involved, let’s delve into how EHR deployments – specifically  AE-EHR deployements – are typically phased:

Phase I: Base, Document, Scan and Dictate

Description: Provide a baseline level of EHR functionality to all users. Real-time access to physician schedules, transcribed and scanned documents, facilitation of dictation.  Data conversions, Scanned charts and documents, Base Deployment. This approach typically appeals to all providers regardless of technical aptitude and would not require significant workflow changes

Advantages: Clinical information access internal and external to the clinic, reduced level of change for physicians through the use of dictate, realized benefits of decreased errors and re-work.

Interfaces:

• Registration & Scheduling
  • Real-time inbound registration and scheduling feed from practice management system.
  • Initial bulk-load of existing active patients and appointments
• Transcription
  • Real-time inbound transcription interface from transcription system.

*Phase II: Rx+, Note, Forms, Results

Description: Add medication management, structured note and results

Advantages: Ability to collect structured information facilitating use of panel queries. Additionally, formulary compliance, and prescription faxing/e-prescribing to pharmacies and ability to capture results as discrete data elements

Interfaces:

• Results
  • Real-time inbound results interface from lab system.

*Phase III: Order, Charge

Description: Facilitates charge capture and order transmission.

Advantages: Completes the access to centralized patient data and further enhances the quality of care and service to patients.

Interfaces:

• Orders
  • Real-time outbound order interface to lab system
• Charge
  • Real-time outbound charge interface to the practice management system.

*Phase II and III can be combined based upon the organization requirements

In conclusion, one of the biggest questions that lingers for me is how the data is to be relayed to the government such that organizations can be evaluated as to whether or not they meet the thresholds to receive the incentives. Custom reporting comes to mind as precedent has been set here, specifically with PQRI and Medicare HCC. Galen Healthcare Solutions certainly can provide custom reporting specific to organizations needs in order to communicate meaningful use. Another solution is Allscripts Clinical Quality Solution powered by TeamPraxis. In the meantime, we wait for the rule to be finalized and anticipate announcement of how the meaningful use data is to be relayed.

If your organization is looking for assistance in exhibiting meaningful use, please contact sales@galenhealthcare.com and visit our website for more information regarding our technical and professional service offerings.

A Healthcare IT professional’s tools of the trade (must-haves):

• SQL Profiler
• Diff software (Notepad++)
• HTTP analyzer (Fiddler2)
• Screen capture software  (Printkey2000)
• Paint.net
• Windows Process Monitor
• RedGate tools (SQL Toolbelt, Reflector)
• HL7 Editor

In addition to the technical component of the job, an equally-important component is communication. I’ve found that utilizing the proper communication channels can drastically reduce problem-solving time and effort. As Dr. Halamka alludes to in his blog yesterday, a good rule is if more than 3 rounds of emails go back and forth about an issue, it’s time to pick up the phone or have a meeting.

The first step in investigating an issue starts with having the proper background information provided by the client. Utilization of an issue submission form is invaluable to document all items surrounding the issue. With incomplete background information, the Healthcare IT professional is forced to solicit more information from the client – forcing unnecessary additional communication and driving up the time-to-resolution.

Once background information has been assimilated and an email thread has been opened, if the issue cannot be resolved in more than 3 rounds of emails as alluded to above, a conference call should be scheduled. The components and outcomes for a successful healthcare IT technical troubleshooting conference call are as follows:

• Well formulated problem statement and documentation provided to all parties on the call
• Issue submittal form to include short description, full description, screen shots, steps to reproduce, onset, frequency, users/devices affected, etc.
• Skeleton Agenda
• Ensure that the right representatives are on the phone (RIS analyst, Lab HL7 interface analyst, etc)
• Vet issues related to the different “layers”
  • Application Analysts
  • PC/Desktop Techs
  • Network Analysts
  • Server Techs
  • Server Architects
  • Storage Architects
  • OS Architects
  • DB Architects
  • Application Architects
• Action items for representatives if the problem is not resolved
• Eliminate misinterpretation via oral communication
  • Representative 1: “This is what we are expecting”
  • Representative 2: “Really? Wow, we never expected that.”
  • Representative 3: “We never would have interpreted the spec to mean that”

And finally, for a great article addressing troubleshooting complex IT problems, please see Dr. Halamka’s blog article posted in December of last year.

Please contact sales@galenhealthcare.com and visit our website for more information regarding our technical service offerings.

• Patient identifiers – these can be different between driving system (Radiology Information System (RIS), Laboratory Information System (LIS), and EHR. Consistency with the Master Patient Index (MPI) across all interfaces is the desired outcome.
• Filtering – mental health document types, “celebrity patients,” preliminary documents, unverified results – the list goes on and on. Knowing the gamut of different options of configurability is helpful in deciding which filtering should take place.

These interfaces were built in the ConnectR interface engine utilizing the existing Application Programming Interface (API) to the Allscripts Enterprise EHR (AE-EHR) – inbound and outbound stored procedures. It should be noted that the ConnectR interface engine is used as the standard interface engine by Allscripts to facilitate the communication between healthcare systems, however there are alternatives.

This approach is not entirely desirable in that it requires customization of the interfaces to the particular vendor/client based upon their underlying data exchange implementation architecture. In an ideal sense, the data exchange would facilitate a “seamless” plug-in to existing AE-EHR users and HIEs. This is certainly what the industry is driving towards.

As Dr. Halamka alluded to in his blog posting yesterday, the ideal scenario is one in which CDA/CCD documents are used to exchange data between the EHR and the HIE as they offer a complete set of the patient record. HITSP (Health Information Technology Standards Panel) standards describe these transactions  as there are thirteen original Interoperability Specifications (IS) into an EHR-centric view to facilitate alignment with Health Information Technology provisions of the American Recovery and Reinvestment Act of 2009 (ARRA). For more information regarding Health Information Exchanges (HIEs) and “real-world” implementations and their utilization of HITSP products see the following HIMSS webinar. In the interim, for those Allscripts clients looking to get ahead of the game with meaningful use, we are left to develop interfaces within the framework of the existing API to/from the AE-EHR.

In closing, be very aware of the possibilities as the HIE landscape is changing. For example, Navinet now offers subsidization of HIE implementation costs. However, the challenge remains in determining the best business model to fund the exchange going forward.

For additional information regarding Galen Healthcare Solutions’ data exchange / interface services please contact justin.campbell@galenhealthcare.com or visit www.galenhealthcare.com/interface-service