Galen Healthcare Solutions: Allscripts Consultants Enterprise EHR

Are we in an EHR bubble? Evan Steele, CEO of SRSsoft, predicts that much like the dot-com era, the EHR market is in the midst of a bubble which is soon to burst. He foresees a shakeout in which consolidation of the current 472 EHR vendors takes place. Steele envisions causes of the popped bubble to be attributable to missed growth projections, government money drying up and physician dissatisfaction with existing vendors, ultimately resulting in a survival-of-the fittest among the EHR vendors.

Several industry leading bloggers have made bold predictions to this same point. John Moore from Chilmark Research offered the following:

Bloom is Off the Rose, EHR Market Plateaus
Going out on a limb, we see 2012 as the year when we start talking of the post EHR-era. Yes, there will be plenty more EHR sales in the year to come but over 2012 we will also see EHR sales growth begin to plateau and level off by end of Q4’12. You heard it here first folks, it is time to collect your EHR winnings and seek new places to invest.

iHealthbeat had its own 2012 predictions for the outpatient EHR market:

• The use of cloud computing;
• The use of mobile devices; and
• Vendor consolidation.

Over the past several months, Galen has seen quite a bit of consolidation in the industry specifically with conversions in support of acquisitions. We have converted groups to the Allscripts Enterprise EHR from a number of legacy vendors – among them AmazingCharts, eClinicalWorks, Greenway, GE Centricity, SRSSoft, SAGE, MedManager – in support of these groups absorption by larger organizations and Integrated Delivery Networks (IDNs).

We continue to see an increasing amount of conversions on the horizon, supporting the claim made by Mr. Steele regarding consolidation in the industry. Organizations are certainly in acquisition and consolidation mode – will the same hold true for vendors? Will we see more mergers and acquisitions in the outpatient EHR space in 2012? I think it is a safe bet to expect activity from those vendors that own most of the market share. The following is a recent ambulatory market share analysis as offered by American EHR:

Tags: EHR Acquisition, EHR Market Analysis, EHR Merger, EHR Predictions, EHR Vendor Consolidation, Healthcare IT, Meaningful Use

CMS released a couple of updates last month regarding Meaningful Use and the EHR incentive program. I wanted to pass this information along to our readers.

In their December 7 update, CMS indicated that “HHS announced its intention to delay the start of Stage 2 meaningful use  for the Medicare and Medicaid EHR Incentive Programs for a period of one year for those first attesting to meaningful use in 2011”.  The reason as such, according to them, is that the current schedule for compliance to Stage 2 could be a challenge for those that attested in 2011. The decision also was in consideration for vendors and practices.

 The CMS update identified some benefits from the proposal:

• The delay could provide vendors more time to develop their certified technologies for Stage 2
• The delay could also provide providers more time to implement the new software to meet Stage 2 requirements
• Expectations remain current so that providers attesting in either 2011 or 2012 begin Stage 2 in 2014
• And while 2011 has passed, CMS believed this idea would provide added incentive for providers to attest in 2011.

While I am sure there is a group of people out there that is ambitious enough to keep pace for this process, I am certain that we all can stand to benefit from the proposed delay.  The benefits from the added amount of time for both the vendors and practices/providers seem more appealing, in my opinion.

Back on December 1, CMS also announced a new tool to help Eligible Professionals (EPs) through the phases of Meaningful Use.  This tool is an eighty-five (85) page PDF file, dubbed as a “Beginner’s Guide”. This file provides a thorough, interactive walkthrough of Meaningful Use.

Among the items of information provided are:

• EHR Incentive Program basics
• How to participate (determining eligibility and registration)
• Meaningful use and choosing measures
• Attestation
• Helpful resources on the Medicare and Medicaid EHR Incentive Programs

Lastly, they also provided a link to their Educational Materials page for the EHR Incentive Program. This link offers an extensive array of files and tools regarding the EHR Incentive Program.  This is definitely a link to bookmark, as well as the guide previously mentioned.

If you haven’t already done so, visit the CMS EHR Incentive Programs webpage and register to receive their email notifications. 

Contact Galen Healthcare Solutions for any additional questions regarding Meaningful Use and Allscripts Enterprise^TM EHR.

Tags: Allscripts, Allscripts Enterprise EHR, EHR Certification, Enterprise EHR, Meaningful Use

This past Tuesday, I attended the NEHMISS Monthly Event and Social hosted at the Papa Razzi in Wellesley, MA with one of my colleagues, Patrick Zummo. It provided an invaluable opportunity to network with other healthcare IT professionals as the event had one of its best turnouts in the past two and a half years that we have attended (I would estimate about 65 attendees!) It was great catching up with folks and seeing new faces. The networking opportunity can’t be underscored enough!

The event featured a presentation on “An Approach to Meaningful Use” by Laura Leinin, Sr. Project Specialist, Clinical Information Systems at Partners Healthcare, and Jennings Aske, J.D., CISSP, CIPP, Chief Information Security Office at Partners Healthcare.

Laura started things off with an overview of the MU legislation to date:

• Original goal of MU legislation was to target full EHR adoption by 2014
• The three phase of EHR: Adoption – MU – Outcomes
• Compuer Sciences Corporation (CSC) estimated that for a hospital with 276 beds, the potential MU payout would be $4.2 million
• The major certifying entities for EHR software is Certified Commmunication for Health Information Technology (CCHIT) and the Drummond Group. The model utilized is a conformance tool where submission of data is required.
• Attestation if currently a manual process – submission of the numerator and denominator.

Jennings followed by addressing security compliance & MU:

• The main components of security compliance include access control, emergency access (“break-glass” capability), auto log-off, and audit log.
• Jennings noted that with the audit report, requirements included capture of userid, patientid, user activity and the ability to sort by time.
• An example of compliance presented was since Partners had a home-grown EHR system (longitudinal medical record – LMR), in order to comply with CCHIT & Drummond certification, the system needed to possess the capability to handle encrypted file import.
• Jennings expressed that Partners needed to exhibit compliance as described above, but in some scenarios (like the encrypted file import described above) they don’t actually intend on using the functionality. This led me to wonder what the percentage of cases were where the EHR needed to comply with security standards, but would never actually use or implement the feature in operational practice.

For the remainder of the presentation, Laura offered some statistics and updates with regard to Partners MU initiative:

• As of Thursday, September 30^th, 114,644 EPs & EHs have registered for attestation.
• As previously noted, attestation for stage 1 is currently a manual process and Laura warned of the high chance that organizations are likely to be audited post-attestation and as such they should have the records and data to back it up.
• She noted that Academic Medical Centers (AMCs) need to be self-certified in that they often have home-grown systems in the inpatient setting and noted that community hospitals often have commercial off the shelf (COTS) systems provided by the leading EMR vendors.
• She provides a project status dashboard each month to stakeholders and executives with more than 125 data points to track each month!
• Laura also mentioned the challenges of qualifying for MU in the presence of the healthcare information system mosaic at Partners that we’ve previously touched on in our blog in that of the different organizations that are affiliated with Partners (Brigham and Women’s Hospital, Massachusetts General Hospital), there are different vendor systems for ED (Electronic Discharge) systems, PM (Practice Management) systems, etc.
• In some cases, to qualify for meaningful use, workflows had to be adapted. One example was the handout of clinical summaries to patients.

Several great questions were posed by the audience including the following

• Q: Is standardization of vocabularies at Partners being handled by IT or the clinical staff? A: IT staff
• Q: What’s the headcount needed at Partners for the MU initiative? A: About 50 people across hospitals and LMR teams
• Q: How is Partners handling the case where smoking status is not captured discretely, but rather exists in a note? A: The homegrown LMR at Partners currently captures smoking status discretely. However, there are NLP (Natural Language Processing) solutions (Autonomy, Nuance come to mind) to post-process the non-discrete data for those applications which do not store it discretely. We have touched on data-mining non-discrete data in a previous blog post.
• Q: What happens if an organization decides to switch an EHR going forward? How is certification and MU qualification handled? A: No presenter or audience member had experience in switching organizations, but as we’ve witnessed with EHR vendor consolidation and an explosion of acquisitions requiring data conversions, this is likely to be a hot topic going forward.

Tags: Allscripts, Allscripts Data Mining, CCHIT Certification, Custom Reports, Drummond Group Certification, HIMSS Meaningful Use, Longitudinal Medical Record, Meaningful Use, Meaningful Use Security Compliance, NEHIMSS, New England HIMSS, Partners Healthcare Meaninful Use

This webcast will review at a high-level the Menu and Clinical Quality Measures and considerations when selecting you’re the options for your organization. In addition, we’ll review the basic of Clinical Quality Measure configuration.

Visit http://www.galenhealthcare.com/webcasts for more upcoming webcasts.

Tags: Allscripts Enterprise EHR, Clinical Quality Measures, Meaningful Use

The system is upgraded to Allscripts Enterprise EHR^TM (AE-EHR) version 11.2.x- now what to do? Evaluation of current workflows and deciding on the Meaningful Use measures the organization will be using are the next steps. This article will cover some basic key concepts of Meaningful Use as it related to the application and processes as well as examples to provide the foundation to move forward and build. Ideally, obtaining a baseline of the workflows currently used today in each site/clinic prior to the upgrade itself is the recommended approach. This article will highlight at the end the recommended timeline and priority items to provide the best success of not only the upgrade but more importantly capturing meaningful use.

Step 1- Evaluate current state workflows of each site and the role of the end user population

Even if the site recently went Live or had training- end users continuously find new ways to use the application. AE-EHR version 11 in general provides multiple ways to enter information and despite the best training and/or trainer, an end user may change their behavior over time.  Not only will a potential different workflow result in inaccurate testing of what is believed in the workflow; it may potentially allow for an area of missed training when moving to version 11.2. Here’s a great example, suppose clinical staff were not trained to enter problems, however over time the providers and office managers of a site have asked clinical staff to enter the problems for physicians. This would have an impact on training for meaningful use. Or, perhaps the staff is trained to enter smoking status on the social history but behavior has recently changed by the end users and they started capturing it in the comments field in vitals because the end user thought it would be quicker.

The best approach is to go to each site and evaluate each role on what they currently do in the application, as well as how they document in the application. This will allow the testing team to accurately test the role based workflows as well as train as appropriate on workflows. Once the current workflow is established then the foundation for configuration and re-training can begin.

Step 2- Decide which of the Meaningful Use Measures will be used by the organization.

The 15 Core measures will be required by all eligible providers, however only 5 of the 10 menu sets are required.   Additionally, of the 44 Clinical Quality Measures, three of the Core or Alternate Core will need to be used and three of the remaining Clinical Measures will need to be decided upon in order to have a total of six Clinical Quality Measures.

This step can be quite a task depending on your organization. Here are some sample questions to ask:

• Who will be the lead decision maker?
• What teams need to be informed of the Meaningful Use objectives- Business Admin, Executive, Physician Core team?
• Are there multiple teams that will make decisions on different aspects (clinical versus business versus administrative)?
• Do those key decision makers know about Meaningful Use and if so at what level – high-level or detailed?
• Will basic ARRA- Meaningful Use training be required?
• How will government incentives be paid out (to the organization, to the physician, to the site)? This will be asked at meetings and better to be prepared when instituting workflow change.
• What providers are eligible in the organization?
• Will the eligible providers report for Medicare or Medicaid?
• Who is responsible to enroll each provider with CMS?
• Does an analysis of potential eligible providers need to be assessed to make the decision of MU reporting?
• Does an analysis need to be done, and what patient population and/or diagnoses are seen by eligible providers to select the appropriate Clinical Quality Measures?
• Will eligible providers have a choice on whether to participate in MU reporting or will it be decided by the organization?
• Will each site, specialty, or provider select the measures (MENU and Clinical Quality Measures selections) or will it be directed from the organization?
• Will there be a team dedicated for Meaningful Use?
• Who will track the user’s behavior to ensure the necessary information is obtained?

These basic questions will allow the core Upgrade/Meaningful Use team to be prepared for configuration, workflow re-design, testing, and end user training. Each item can have a direct affect on one of the aspects of the upgrade/MU project. For example, if all eligible providers will be allowed to decide which measures they will select for reporting then the configuration team will need to configure to all CORE, MENU, and all 44 Clinical Quality Measures. In addition, if each provider selects their own measures ideally the training would be tailored around the measures for that eligible provider. Training all providers on all 44 Clinical Quality Measures or all 10 MENU items that may not pertain to that provider will not increase retention of the information and workflow change and likely decrease the MU reporting success.  Another example, from the above proposed questions is Medicaid provides a greater financial return if the measures are met however what if no one meets the necessary 30% of patients? Does it make sense as an organization to increase an eligible provider’s percentage of Medicaid patients to capture the higher value and if so who makes this decision and how does the front office staff know to direct more new patients of a certain insurance to a certain provider?

Step 3- Workflow Redesign for Meaningful Use

Once the system is configured and reviewed by the implementation consultant during the upgrade process, the workflows will need to be re-designed to meet the Meaningful Use Measures to guarantee success! A workflow is not just the use of the application but also the process in place for monitoring the Meaningful Use within the organization. At this point, the system has been configured by the organization configuration team (system analyst) based on Steps 1 and 2.  However, unless the users actually change behavior Meaningful Use will not count. Here are some examples below that will need to be considered based primarily on the CORE, MENU and Clinical Quality Measures.

• CORE EXAMPLE:  Suppose that currently the organization doesn’t allow clinical staff to enter and/or update problems or medications on patients, however the providers have not been keeping these lists up to date. Will the organization allow the clinical staff to begin to perform these tasks? Does configuration need to change to allow for retrospective/prospective authorization? Does enable verification of problems need to be added? Do clinical staff need to be trained how to do this item?

Remember there are many new alerts for Meaningful Use however everything doesn’t have an alert and likewise an end user can ignore an alert.

• MENU EXAMPLE:  Providing a Summary of Care Record to the patient and Patient Education. First, who will be responsible for providing the Summary of Care Record- clinical staff or providers? Will the Clinical Summary provided by Allscripts be used or will it print out from the v10 or v11 note? If the patient is a portal patient and you don’t want to provide a Clinical Summary or a non-portal patient how will the provider state if no Clinical Summary is to be provided? What/Who/How is the workflow to be defined, tested, and trained? Regarding Patient Education, will there be a standard developed if not already implemented such as every new medication prescribed by the provider the patient will receive the Drug Ed for that medication? How will the patient instructions be populated and printed?
• Clinical Quality Measure EXAMPLE:  Adult Weight Screening and Follow Up- many sites may already obtain the patient weight today and this may appear as an easy Clinical Quality Measure to capture. However, there are a couple of items to consider, by adding a free text box for comments to document if a patient denied obtaining their weight and if used would count for Meaningful Use. Is this configured already and/or do end users know to enter this information to count for Meaningful Use? In addition, to meet this measure the BMI of the patient needs to be evaluated and based on the patient’s age and BMI an additional workflow must be completed. Part of that measure states if the BMI is greater than 25kg/m2 a follow up plan must be in place. What will that plan be if not already used by an organization/site/provider? Will there be a dietary consultation or a BMI Management Follow Up Order? Will the end user be able to select from any of the potential recordable actions: Dietary consult with the appropriate SNOMED or the BMI Management Follow Up order with the appropriate CPT code? Will the clinical staff perform this action at the time the vital is taken or will the provider be responsible for adding this item on the patient.

These are some examples of Meaningful Use and all the decisions, configurations, and workflow changes that could be affected. This article is not all inclusive, rather, it is intended to begin the process for the team to meet the Meaningful Use objectives.  Please feel free to contact Cary Bresloff, Cary.Bresloff@GalenHealthcare.com, for further questions, guidance, or consultation on Meaningful Use and the impact to an organization.

Tags: Allscripts Enterprise EHR, Enterprise EHR, Meaningful Use, v11

The configuration and workflows relating to the Core Meaningful Use objective Record Smoking Status can get confusing; and recent information was released indicating a change in some of the setup for this measure.  Record Smoking Status requires that providers report that more than 50% of all unique patients 13 years-old or older seen by the eligible professional (EP) have “smoking status” recorded as structured data.  CMS has altered its reporting requirements for this measure so that now reports should only include the CDC smoking statuses.  Those smoking statuses include:

• Current Every Day Smoker
• Current Some Day Smoker
• Former Smoker
• Never Smoker
• Smoker, Current Status Unknown
• Unknown if Ever Smoked

You may be asking yourself, what do I do because providers at my practices have been entering terms other than the ones above as the patient’s smoking status?  Allscripts has developed a script that links previous smoking terms to the terms required to meet the measure in order for the provider to get credit on all smoking terms documented.  One thing to keep in mind when running the script is that it does not always match the terms on the patient’s chart to the most accurate CDC term.  For instance, a denial of smoking documented on the patients chart could fall under two separate CDC terms, “Former Smoker” and “Never Smoker”, but since the script can only link to one term, it chooses “Unknown if Ever Smoked”.  “Unknown if Ever Smoked” is not the most accurate, but the provider does get credit for the Meaningful Use measure. 

Because the script does not give the most accurate information for reporting, it is recommended that providers discontinue using the “denied” option when documenting smoking statuses and add the CDC smoking diagnoses to their quick list for easy reference for physicians.  Providers should attempt to use the CDC smoking terms to identify a patient’s smoking status as often as possible.

The CDC smoking diagnoses can be added to provider’s quick lists using SSMT.  The Content Categories of Favorites: Patient Hx – Active Problem or Favorites: Patient Hx – Social History can be utilized to identify the quick list items.  The steps are as follows:

1. Manually add all of the CDC smoking diagnoses to a user’s social or active problems list. (depending in which problem section the providers will be documenting the smoking status)
2. Extract for that user the Favorites: Patient Hx – Active Problem or Favorites: Patient Hx – Social History content categories from SSMT.
3. Open an Excel spreadsheet.
4. Highlight the whole spreadsheet, right click, and choose Format Cells.
5. Choose the Category of Text and click OK.
6. In SSMT, use CTRL+A to highlight all the text and CTRL+C to copy the text.
7. Paste the text in the Excel spreadsheet.
8. Copy columns B through J and paste on a new Excel spreadsheet. With the same formatted cell settings.
9. In column A, type the username of the provider you want to add the favorites to.
10. Make sure a Y is in the column labeled TopFavoriteFlag and in the column labeled Create.
11. Repeat steps 8 through 10for all providers that need the smoking statuses added to their Quicklist.
12. Copy all fields and paste them into SSMT.
13. Click the Import button.
14. Confirm the import worked for a few users.
15. Repeat these steps if setting the quick list in both Active and Social History problems.

It is important to note that the CDC smoking terms were delivered in Q3 and Q4 2010 Medcin releases.  It is required that these releases be installed in Enterprise EHR in order to meet the Record Smoking Status Meaningful Use objective.  In Allscripts Enterprise EHR^TM version 11.2 HF 9, the Record Smoking MU Alert will be linked to the CDC smoking terms and the provider will be able to reconcile this alert by selecting the appropriate term from the list of smoking terms.

An additional recommendation for configuration includes setting the TWAdmin preference Smoking Status for Patients 13 and Older is Not Documented to “Show in My Alerts”.

The configuration and workflows for the Core Clinical Quality Measure Preventative Care and Screening Measure Pair: Tobacco Use Assessment and Tobacco Cessation Intervention is often confused with the configuration and workflows for the Meaningful Use measure Record Smoking Status.  Although the terms used for recording the smoking status are applicable for recording tobacco use, additional workflow is required to meet the Quality Measure.  The Quality Measures can be reviewed in more detail in the Quality Measures PDF on the Allscripts Client Connect website.

Tags: Allscripts Enterprise EHR, Meaningful Use

Client – UMass Memorial Health Care

Project:  UMassMemorial V11.2 Upgrade

Project Timeframe:  February 7, 2011 – June 13, 2011

Client Contact: Emily Lazaros, Allscripts Application Manager

“I would like to take this opportunity to tell you of our experience with our Galen upgrade team.   Troy Forcier and Kristie Gilbert are, in a word, fantastic.  They are professional and knowledgeable, and have been with us on this upgrade every step of the way.  Kristie’s project management skills and proficiency with the application are exceptional and Troy is about as calm a person as I have ever come across.  This gives us, the client, a real sense of comfort.  And as the IT Ambulatory EHR lead for this upgrade, in an organization of this size, that is invaluable.

….

Last, but not least, we have had lots of laughs and fun together through this process.  Thanks to them and Galen for helping to make our 11.2 upgrade a success.”   –Emily Lazaros, Allscripts Application Manger at UMass Memorial Health Care

 UMass Memorial Health Care is the largest health care system in Central and Western Massachusetts, and the clinical partner of the University of Massachusetts Medical School. The Medical Center has a total of 12,350 employees with approximately 1,700 physicians and 3000 registered nurses representing clinical expertise in Cardiology, Orthopedics, Oncology, Emergency Medicine, Surgery, Women’s Health and Children’s Medical Services.   UMass, on the cutting edge of technology, utilizes Allscripts Enterprise Electronic Health Record^TM (AE-EHR) as a means to help with continued excellence in clinical care and patient service.  Over the last several months UMass has worked, very successfully, with Allscripts and Galen Healthcare Solutions to upgrade their AE-EHR product to version 11.2.

The underlying motivation for this version upgrade was of course, Meaningful Use.  While there are incentives for moving to the new version, the idea of having to implement new functionality with potential workflow impact is regarded with dread.  There are dozens of models for how to complete an upgrade, most of which are painful.  The vendor and we, as your consultants, must take ownership over finding the best model for your practice to reduce the pain of upgrading.  Since Meaningful Use is the ‘next big change’ in healthcare, this change needs to happen for all medical practices across the US.  So the question remains, how do you increase your chances of success? Your Galen consultants will help lead the way.

The duration of this particular upgrade project was a brief 19 weeks, leaving us little time to configure the new AE-EHR version 11.2 functionality and guide UMass towards decisions that would qualify them for all Meaningful Use criteria.  In addition to a rapid project timeline we encountered other challenges: the release of process documentation simultaneously to the stages defined in our plan and shifting resource allocation as priorities changed.  Throughout the entire process, though, we were able filter the information, analyze the functionality, provide appropriate guidance, and enjoy the camaraderie of a great group of UMass team members!  We can now take great pride in knowing we were helping thousands of people use their version 11.2 AE-EHR product in a Meaningful Way.

A week after UMass has transitioned to end users, the real challenge of analyzing their data and incorporating their new configuration into their daily lives will prove to be a reality once the Galen team returns to assist with the Stimulus Set.  I know we are all up for the challenge!  Our willingness to help our clients, to test our knowledge of the latest cloud technologies and data reporting and to pass it along will be a very rewarding journey.  If the final product can be as great as the first steps in helping UMass upgrade their base AE-EHR version 11.2, then sign us up…Galen is ready to go! 

UMass was a fantastic group to work with and we look forward to helping them implement the Stimulus Set.  Congratulations to the staff at UMass for a successful upgrade!  We also appreciate the positive feedback from UMass and plan to make the same impact with other clients.

Tags: Allscripts Enterprise EHR, Enterprise EHR, Enterprise EHR version 11 Upgrade, Meaningful Use, Successful EHR Implementation

This morning, Shahid Shah over at the The Healthcare IT Guy blog, published an article outlining why medical device data is the best way to fill meaningful use EHRs and conduct comparative effectiveness research (CER). What was of particular interest to me is the way in which Shahid elegantly broke down how unstructured and structured data is “sourced” today (scroll down in the blog article for the graphic).

As is evident by the table above, many of the existing MU incentives in Phase 1 (patient reported and healthcare professional entered especially) promote the wrong kinds of collection: unreliable, slow, and error prone. Accurate, real-time, data is only available from connected medical devices and labs / diagnostics equipment.

Given that meaningful Use and CER advocates are promoting (structured) data collection for reduction of medical errors, analysis of treatments and procedures, and research for new methods it’s important to see that we’re not going to get real gains until the medical device vendors are fully connected and providing data directly into EHRs or clinical data warehouses.

Shahid’s article brings to light a larger issue within the industry – a lot of meaningful data is captured in an unstructured fashion. Dr. John Halamka brought this to light in a blog article earlier in the year which addressed “Freeing the data.” In this article, Dr. Halamka suggests that businesses will always have a combination of structured and unstructured data and that businesses must find ways to leverage this unstructured data:

In healthcare, the HITECH Act/Meaningful Use requires that clinicians document the smoking status of 50% of their patients.   In the past, many EHRs did not have structured data elements to support this activity.    Today’s certified EHRs provided structured vocabularies and specific pulldowns/checkboxes for data entry, but what do we do about past data?   Ideally, we’d use natural language processing, probability, and search to examine unstructured text in the patient record and figure out smoking status including the context of the word smoking such as “former”, “active”, “heavy”, “never” etc.

The value of unstructured patient narratives was addressed in detail in one of last year’s Health Management Technology articles – specifically the section which addressed Mining unstructured data:

As EHRs become increasingly widespread due to the billions of dollars in federal stimulus incentives, harnessing unstructured clinicians’ notes gives us the power to yield valuable patient data. With each year of data, more information will be gathered that could be used to find predictors for diseases or adverse effects of treatment that would otherwise have gone unnoticed by most traditional research studies. Though challenging, capturing and delving into this data will be worth the effort, and could potentially help healthcare institutions meet requirements for CMS reporting and for meaningful use, access funding and, most importantly, improve the health of entire populations.

At Galen, we have developed a solution that addresses current limitations with regards to extraction of structured note data within built-in Allscripts Enterprise EHR functionality. Galen’s NoteXML solution is designed to facilitate the querying of data contained within Allscripts Enterprise EHR v11 Structured Notes. These notes are not stored inside the EEHR as discrete data, but rather as XML documents that aren’t easily query-able. The solution has helped our clients extract pertinent MU reportable data that otherwise would not be discretely available.

Again, the aforementioned solution does not facilitate data mining of unstructured note data. However, companies such as Nuance are engaged in “‘unlocking’ unstructured clinical documentation, sometimes referred to as the ‘narrative blob’” Nuance’s NLP solutions assist in collecting and reporting on various diagnostic, quality and safety measures. I have yet to see this integrate directly to the Allscripts product line, but anticipate this possibility in the future months.

I’m curious as to how other groups and organizations are addressing the gap between unstructured data capture and discrete data extraction for MU and quality reporting? Are organizations relying on third-party solutions such as that offered by Nuance?

Tags: Data Mining, EHR, EHR Unstructured Data Mining, Extensibility, Meaningful Use, MU, Natural Language Processing, NLP, Reporting, UNstructure EHR Data

Ever wonder who designs and develops Health Level 7 (HL7)?  Well HL7 international is based out of Ann Arbor, Michigan and they hold various workshops around the country.  I recently had the chance to attend the HL7 Education Summit at the Hilton Suites Chicago Magnificent Mile over March 15^th and 16^th, 2011.  (All images and information were taken from HL7 Educational Summit presentations).

The Clinical Document Architecture (CDA) second release (R2) workshop was a very informational, hands-on experience.  Not only did it allow me to obtain a deeper understanding of CDA but gave me the opportunity to meet other members of the EHR/HL7 world.  In addition, the workshop gave me the opportunity to meet some of the key contributors to HL7 standard, including Calvin Beebe of Mayo Clinic, Diego Kaminker of Kern IT, and Keith Boone of GE Healthcare.  I can personally say that they are a bunch of very bright individuals and I am glad they are developing such an important standard.

CDAs don’t replace v2.x HL7 field delimited messages, and instead compliment them.

CDAs are very informational and pack a lot of information.  However, they were not developed to replace the v2.x HL7 field delimited message.  The main advantage of a CDA is that it is human readable and does not require an accompanying style sheet or specification to interpret as opposed to the v2.x HL7 field delimited messages which require a specification.  So you may be asking yourself, why do we still use v2.x HL7 messages?  Well for one, they are much less bulky than a CDA.  And provide an easy, streamlined way of entering data into EHRs.  I have provided an example of each below to show you the main differences.  As you can see, it is much easier for humans to understand CDAs and how it may be easier to enter data using v2.x HL7 field delimited messages:

CDA                                                                                   v2.x HL7 field delimited message

CDA Resources

CDA’s can be used not only as a CCD (Continuity of Care document), but to send lab results, immunizations, allergies, and much more! CDA is the basic template and the number of schema (set of rules, A.K.A. schematrons) determines the constraints.  A CCD can be used to send a plethora of information.

• A great tool to build CDAs is MiniCDA, you may be able to find it online.  It was developed by Diego Kaminker, one of the HL7 presenters.
• A great XML editor is Oxygen, it allows you to associate schematrons, i.e. constraints to your CDA.
• If you would prefer to validate your CDA using an internet-based program, the CDA validation site is a good resource.
• A great resource for general information about CDAs is CDA tools
• Once you have created a CDA, a great place to locate various LOINCs to validate the CDA is Regenstrief LOINC Mapping Assistant (RELMA),
• And finally, Integrating the Healthcare Enterprise (IHE), is a great healthcare integration resource.

Tags: CCD, CDA, Clinical Document Architecture, Continuity of Care Document, HL7 Educational Summit, Integration, Interfaces, Interoperability, LOINC, Meaningful Use, RELMA

Were you aware that the moment the IS staff plugs a USB connector into a medical device to send data from it to another device, the organization could become the manufacturer of a completely new medical device and subject to recently announced Medical Device Data System regulations from the FDA? Were you aware that devices that collect and store data from a blood pressure cuff for future use or that transfer thermometer readings to be displayed at a nursing station for future use are considered an MDDS product and thus governed by the FDA?  Well if you didn’t know, you are not the only one as neither did I until attending the latest New England HIMSS (NEHIMSS) Monthly Event and Social Tuesday evening at the Papa Razzi in Wellesley, MA.  Rick Hampton did a phenomenal job of running through the rules and regulations surrounding “Integration of HIT & Medical Devices.”  Rick is a Clinical Engineer who has helped write several international standards, including the latest on risk management of integrated HIT and medical networks.  He works for Partners HealthCare as their Wireless Communications Manager.

Rick outlined the trend in increasing attention being paid to HIT integration efforts over the past few years.  The latest are new FDA rules from February 15, 2011, which specified “Medical Device Data Systems are off-the-shelf or custom hardware or software products used alone or in combination that display unaltered medical device data, or transfer, store or convert medical device data for future use, in accordance with a preset specification.”  He then discussed how the new standard, IEC 80001-1, was written to help hospitals perform proactive risk management when creating these integrated systems.

Currently, Electronic Health Records (EHRs) are granted an exception from being considered a medical device, however one might anticipate the day when they are considered as such and are regulated the same as a Laboratory Information System (LIS) or Radiology Information System (RIS). For an interface analyst such as myself, the implications are that there will be liability in the exchange of unsolicited results (for instance) between the LIS and the EHR. For those Allscripts users, this also brings into question the applicability of the regulations on the Allscripts Universal Application Integrator (UAI), which provides Allscripts Enterprise EHR the ability to interface with third party applications. An example would be a Welch Alynn Vital device.

A great question was posed from a HIT project manager in the audience who inquired about where this all fits in the scheme of all of the potentially competing projects in the enterprise (HIPAA 5010 EDI, ICD10 and MU come to mind), and also, where does it come into play in terms of the project to get the necessary departments together to discuss compliance? Often times the clinicians, end-users or decision-makers have already procured the software/solution/system and simply hand-off to IT to implement, and unfortunately it is too late by that point to perform the necessary risk assessment and ensure compliance.

Additionally, Rick provided a great link for organization’s to participate in the AAMI/ACCE/HIMSS Risk Analysis Survey to ensure compliance. This survey is intended to obtain baseline information from healthcare delivery organizations about the application of risk management during the healthcare technology life-cycle (eg. acquisition, deployment, use, modification and retirement).

On a side note, this was my first NEHIMSS meeting which I attended as a member. The group has historically been very gracious in allowing non-members to attend free of charge, but to me it made sense to invest $30 for a chapter membership (essentially a drop in the bucket). Not only do I get great exposure to topics and presentations I normally wouldn’t have access to, but I also get the opportunity to network and form contacts with fellow members of the HIT industry.  To me, that is a $30 well spent (by Galen of course .

Lastly, for those project managers out there, be sure to register for the 5^th Annual New England HIMSS/PMI-NH Project Management Symposium, hosted at the Sheraton Portsmouth Harborside Hotel in Portsmouth, NH. There are some great speakers presenting who will surely offer valuable insight into their experiences with initiatives that directly impact the healthcare organization today (Patient Portal, PM’s role in an EMR implementation, Project Managing a 5010 and ICD-10 upgrade, and HIE implementation to name a few). CPHIMS Credits will be offered for this event as well!

Tags: Allscripts UAI, EHR, FDA, IEC 80001, Integration, Interfaces, Interoperability, LIS, MDDS, Meaningful Use, Medical Device, NEHIMSS, New England HIMSS, Partners, RIS, Universal Application Integrator