Physician Satisfaction with EHRs: Finding Balance in a Digital World

Dr. Howard Landa, MD, CMIO Vice Chairman of AMDIS

As Vice Chairman of the Association of Medical Directors of Information Systems (AMDIS), Howard Landa frequently discusses with CMIOs the challenges and opportunities they face in leading informatics and analytics initiatives at their health systems.  We asked Dr. Landa to address physician satisfaction with EHRs and the emerging technologies that may help improve the value of these systems. 

While we have succeeded in providing healthcare systems with a plethora of health information technology pathways designed to improve the efficiency and quality of care, we have also managed to make patient care much more complex. At a recent AMDIS symposium on the evolving role of the CMIO in physician leadership, a discussion regarding the impact of the Electronic Health Record (EHR) on medical practice yielded interesting results.  When polled, many front-line clinicians will tell you that they have a love-hate relationship with the EHR.  They don’t want to give it up completely and return to the ‘old school’ days of paper, but the way it has impacted their workflows has simultaneously improved efficiency and caused a complete shift in the care paradigm.

What are the issues causing the physicians and clinicians to feel this way? One is the transition from Clinician created prose to standardized and structured documentation. EHR templates structure the documentation process by capturing data in drop-down boxes, checked or unchecked boxes and prefilled templates.  The templates provide consistent documentation methods, speed up documentation time and allow rapid analysis of large groups of patients via automatic analytics tools.  Yet they leave little room for interpretation regarding the nuances of the patient’s specific case.  In the analog world, a physician would dictate findings which would later be transcribed and become part of the record.  The dictation process allowed the clinician to share why certain decisions were made, the timing of the care process and “if/then” statements which could guide steps in clinical decision making.  As other care team members provided care to the patient, these aspects of the story were often useful in providing clinical context and understanding.  While the structured data provided by the usage of the EHR is very valuable from a data analytics side, we have lost the physician’s intellectual input into those notes making it difficult to “individualize” the patient.  One patient’s notes-over-time may be almost indistinguishable from each other, raising both cognitive and coding concerns.

So what can we do to swing the pendulum back toward the middle and find a balance between free prose “storytelling” and the high value of structured data?  Natural Language Processing (NLP) is one option. NLP is a practical application which can process free text that is entered or dictated into the record.  NLP enables physicians to extract the data in a more evolutionary and biologic way – i.e., the way a human brain would work as opposed to a computer.  When NLP is combined with nomenclature codification schemas such as SNOMED, structured data can be extracted incorporated into the patient’s record. Leveraging the “OpenNotes” patient engagement/empowerment movement and applying analytics to this data, clinicians will be able to improve the accuracy of the patient story and connect what the patient says with what the physician hears. The patient engagement with the process makes the requirement of clear and individualized information all the more important.

So to find balance and truly deliver the promise of EHRs, NLP and other tools will allow the care team the ability to read the notes and extract data while keeping track of the nuances of patient care due to the specificity of prose.  We will also be able to ask the systems to categorize, store, prioritize, codify, and place structured extracted data where it can be redelivered when needed while still retaining the physician’s intellectual thought processes.  Health systems can then use the findings to improve weaknesses in clinical documentation or care processes, further stratify population health risks and outcomes, provide input into clinical research and more.

Dr. Howard Landa, MD is an accomplished CMIO with a proven record of leveraging innovation, technical expertise and operational knowhow to deliver HIT solutions.  Industry recognition including 20 years as Vice-Chair of the Association of Medical Directors of Information Systems; two years as the chairman of the HIMSS Physician Community, and recipient of  Modern Healthcare’s Top 25 Medical Informaticists Award in 2010, 2011 and 2012.

Beware Best Practices

Almost twenty years ago, in 1996 after publishing “America’s Health in Transition: Protecting and Improving Quality”  the Institute of Medicine launched a long term, ongoing concerted effort on assessing and improving the quality of healthcare.  “To Err is Human” further galvanized the national movement to improve the quality and safety of our healthcare practices by putting the spotlight on how tens of thousands of Americans die each year from medical errors.   The “Quality Chasm” report underscored the importance of a dramatically improved information technology infrastructure to support a 21st century health system.  Building blocks for such a system include an electronic health record system and national standards.  Progress has been made, the federal government has paid out over 30 billion dollars in Meaningful Use incentives as of March 2015 and impressive examples of quality improvements are frequently quoted in the literature.  Yet, most would agree that the results to-date have been underwhelming.

It is important to recognize that most implemented EHRs with a “check-the-box” mentality order to comply with Meaningful Use.   When Meaningful Use was initially launched, our team suggested that we were “enabling the dinosaur”.  And while not prehistoric, the design of today’s healthcare system does have ancient roots.    The Romans constructed buildings called valetudinaria for the care of sick slaves, gladiators, and soldiers around 100 B.C. (Heinz E Müller-Dietz, Historia Hospitalium, 1975).  In the U.S., the number of hospitals reached 4400 in 1910, when they provided 420,000 beds (U.S. Bureau of the Census, Historical Statistics of the United States 1976).  So clinical information technology was about automating existing clinical processes in hospitals (Stead 2005) rather than transforming clinical decision-making and work processes across the care continuum” (Brown, Patrick, Pasupathy 2013). 

 Separately, quality and performance improvement departments focused on deploying best practice – a method or technique that has consistently shown results superior to those achieved with other means, and that is used as a benchmark. (Wikipedia).  While best practices have their place, it is important to recognize the risks associated with emulating others when the practice depends on an antiquated business model such as hospital care. JPGshutterstock_159756653

As health systems transition from 1.0 – Bricks and Mortar Healthcare to 3.0 – Digital, Value Driven Connected Health and Healthcare, we encourage a focus on emerging practice.  A concept born in “systems thinking”, emerging practice assumes:

  • We cannot copy other organizations, use it in our organization and expect it to work given the number of variables at play
  • Intentional design of care management and business models will result in disruption of today’s best practices
  • Collaboration and integration of clinical teams, business leaders, information technology experts and data analyst will create new value
  • Big bang, long term projects are giving way to agile, experimentation where we learn to work in new and different ways
  • Rather than using our intuition or past experience to drive improvement, data driven innovation can often have more remarkable results and new practice will emerge

So, the next time someone mentions “best practice” challenge their thinking.

 

Health Care 2.0 and Beyond

In a recent article in Trustee magazine, Pam Arlotto begins the discussion of how a three stage transformational framework can guide boards as they identify information technology priorities and evolve to value-based care models.

Hospitals and systems now fall into one of three stages:

Health Care 1.0

(EHR implementation, patient portals)

Health Care 2.0

(Interoperable systems; mHealth and telemedicine; business intelligence; cloud-based technologies; cybersecurity; social media

Health Care 3.0

(Care management platforms; biosensors; predictive and prescriptive data mining; precision medicine)

Each health system will have strategic imperatives that drive the digital discussion.  Boards need to know what stage their institution is in and determine how they can prepare to move to the next stage.

Read the full article here.

The Value of Health Information Exchange: Creation of a Health Information Ecosystem

Dr. Jan Lee, CEO, Delaware Health Information Network

The Delaware Health Information Network (DHIN) is the first live, statewide health information network in the nation.  Among its significant accomplishments are financial self-sustainability, near universal participation in core services, connectivity beyond the Delaware state boarders and Stage 7 of 7 on the eHealth Initiative HIE Maturity Model.  In 2011, Maestro conducted “a rigorous evaluation of the value DHIN’s data exchange program to assess the nature and extent to which DHIN had impact on important patient, safety, quality, processes and outcomes within the state”.   Recently, we invited Jan Lee, MD, CEO of DHIN to share the broader Vision, lessons learned and value of health information exchange. 

Over time, I’ve come to define HIE less as a health information exchange and more as a ‘health information eco-system.’  While many in healthcare view the benefit of health information exchange from a cost savings perspective, I view HIEs as a biosphere, where everyone contributes and everyone receives value.  Now it certainly doesn’t happen overnight.  As an early pioneer, there wasn’t a playbook.  We had one chance to get it right, no chance for a do-over.  We were customer focused and tied our business model the needs of our market.

Delaware’s visionary leadership – at the state level and in its health systems started with an environment of collaboration not found in many other states.  Participants focused on finding what is best for patients, even if that means giving away a perceived competitive advantage by sharing data.  Leaders recognized they would have to find other ways to differentiate their organizations.  Sadly, other communities have created their own market barriers by making data sharing difficult.

There was a large list of potential offerings we could provide our stakeholders.  We focused initially on clinical results delivery on behalf of sending organizations and found a return on investment through cost reduction.  We built critical mass, and the momentum grew from there.  Over time the data exchange became the standard for the safe and secure delivery of clinical results (lab and pathology), reports (both radiology and transcribed), and face sheets (hospital admission, discharge, and transfer data, including demographic and billing information).  DHIN has accomplished full participation of all acute care hospitals and skilled nursing facilities in the state.  In addition, the number of providers enrolled as end users of the HIE now exceeds the number of practicing providers in Delaware.  We have a number of practices with affiliations to Delaware hospitals across the Maryland and Pennsylvania borders who have enrolled.  We also have the three Maryland hospitals closes to our borders enrolled as full up data senders, sending us data on both Delaware and Maryland patients.  The value proposition to them comes from our ability to deliver the results to their affiliated practices, which is not a service offered by the Maryland HIE.   Patients have come to expect local and regional organizations to use DHIN’s community health record and because of that, hospitals and other healthcare organizations feel the pressure to participate in the ecosystem or lose business.

We have a number of new initiatives on the drawing board including expanding the ability for ambulatory providers to contribute data, exploring ways to use the data beyond point of care decision making at the population level, developing quality measures and dashboards, and considering options to engage patients in data contribution.  Each new effort is being designed to drive value from the perspective of key customers and stakeholders.  We have learned patience is the key.

Many across the country are acquiring physicians and affiliates, and trying to put all the players on the same EHRs.  The reality is that patients don’t stay in walled gardens, they are mobile and seek care where they choose to seek care.  Even in Delaware, which is a small state, we have over 60 EHR vendors represented.  Often patients cross state lines.  We have found that about 13% of our ADTs come from Pennsylvania and 14% come from Maryland.  Delaware healthcare organizations would be missing out on critical information if they didn’t link to entities outside their own systems.

Why is DHIN so successful?  It’s important to note that DHIN was very deliberative in its development – Return on investment and value did not emerge on day one.  Many, many meetings were held with the stakeholders.  It took over 10 years for DHIN to reach the place where it could begin business and the road to get there was painful.  Organizations approaching HIE today now have best practices available that can shorten the time – but it’s important to recognize that it will take time, there is no magic wand.   Layer on activities, demonstrate their value and then add the next targeted offering.

Jan Lee, MD, currently serves as the Chief Executive Officer of the Delaware Health Information Network (DHIN).  Dr. Lee is a board certified Family Practice physician with a Master of Medical Management degree and a wealth of leadership experience.  Prior to joining DHIN, she was Vice President of Knowledgebase and Content for NextGen Healthcare, a leading vendor of health information technology products and services, where she was responsible for the development of clinical content in 26 medical specialty areas for the NextGen electronic health record.

The Triple Aim and Role of the CHIO

In a recent video, Luke Webster, MD, Chief Medical Information Officer at CHRISTUS Health, is interviewed by Doug Goldstein at the Health Innovation Roundtable — Health 2.0 Innovate Smarter.  Dr. Webster describes the ROI of remote monitoring and the impact on the Triple Aim achieved at CHRISTUS Health.  He also discusses the HIMSS2015 Session, From CMIO to CHIO: Information, Integration and Innovation.  Hear the Interview.

Business Plans for Affiliated Provider Solutions & Services

Despite the healthcare consolidation trend and the health system strategy to build a “System of Care” across the healthcare continuum, affiliated providers continue to be an essential element of the care delivery process in most communities. Even with strong referral management processes and systems, physicians will still refer patients to providers outside the “owned assets” of the IDN, patients will self-refer and primary care providers and specialists will create orders to be delivered outside the integrated delivery network. While most health systems are developing strategies to actively manage referral practices, even the most horizontally integrated health systems will be on a constant search for high-quality and low-cost affiliated providers to compete effectively in a value-based environment.

affiliated

Affiliated provider programs at many health systems have struggled, even with the relaxation of the Stark Laws through the Safe Harbor provisions. Simply offering a donated EHR often fails to address the expanding scope of provider organizations (e.g., practices, skill nursing facilities, home health agencies, etc.) and often ignores the evolving demands of clinical integration and accountable care models which place greater emphasis on services and technologies that complement the EHR. Providers need effective application support services, enabling technologies such as telehealth, and a health system who is continually evaluating new innovations such as wearable technologies, mHealth, analytics, etc. that work with a myriad of EHR environments including donated EHR, web/portal/HIE, call centers, cloud based scheduling, fax and direct.

Developing a Business Plan that includes services and solutions for your affiliated providers doesn’t need to be overwhelming.

Suggested steps include:

  • Step 1 – Recognize that your provider solution and service offering may start with physician practices, but will grow to include other provider settings. This may take time. While most markets share several similarities, there are unique factors that will determine when the business conditions of your market will support expanding the business plan and associated strategies to include additional care settings
  • Step 2 – Develop a standardized services and solutions catalog that your customers need, is easily understood and can be delivered with a high degree of reliability. The services and solutions may be tiered or packaged to appeal to specific groups and level of integration, and specific variations may be designed-in to allow “localization” of based on unique requirements of specific entities, markets and specialties. Yet, the important point is that it is standardized, which by definition will produce a modest set of services and solutions. When a health system allows customizations, the services and solutions catalog expands and operating costs soar
  • Step 3 – Resign yourself to the fact that your organization can’t do it all. Sourcing selected services and solutions from the catalog to value added resellers, Internet Service Providers, hardware providers, etc. will be important. The goal is to create a variable model that reduces risk, creates economies, and ultimately provides exceptional service
  • Step 4 – Determine the business (i.e., operational, organizational, & financial) model that is right for your organization. There are a number of different models that can be used. What is right for your organization will depend on its operating strategy. Key questions include:
    o Do you provide services through existing IT departments or management services organizations?
    o How are the services provided to employed providers and owned entities?
    o Is a separate services organization necessary to provide the services? Do you run the business as a profit center or cost center?
    o Are multiple entities using the services and how do you share oversight and management?
  • Step 5 – Create the go-to-market plan. Communicating the value proposition and earning the trust of customers can be the most challenging component of any business plan. This is particularly true if previous attempt to align with affiliated providers have not been successful at your organization or neighboring health systems. Pre-emptively addressing concerns, demonstrating how services have been tailored to better meet needs, illustrating the executive support, and painting a long-term vision are all required for the program to thrive.

Maestro Strategies uses our collective experience gained assisting health systems with their provider programs as well as our work launching new companies, affiliations and agencies to help explore key strategies and associated operating implications to create a vision, build a business plan and design a road map for affiliated provider services and solutions. Please contact us a insights@maestrostrategies.com to discuss the unique needs of your provider community and how the steps above could be tailored to create a Business Plan for Affiliated Provider Services and Solutions to benefit your health system.

 

Organization Design – Emerging Models for IT, Informatics, Analytics & Quality

“IT in healthcare is no longer a hero’s game” indicates one executive. CIO in healthcare stands for “Chief Infrastructure Officer” and in the future it must stand for “Information, Integration and Innovation” says a CIO who comes from outside the healthcare industry. Our “clinical informatics leaders must think more strategically” indicates a CEO. All quotes from recent interviews of executives from 60 leading health systems conducted by Maestro Strategies CEO Pam Arlotto. CEOs, CMOs, CIOs and CMIOs all indicate new leadership and organizational models are needed as the industry transitions from volume to value. As senior leadership teams tackle consolidation, clinical integration, population health management and a variety of new strategies. Traditional silo based organization structures will not drive value in tomorrow’s health and healthcare enterprise. Emerging themes include:

  • The ability to work across entities, geographies, points in the continuum, service lines, etc
  • Clinical integration is driving new organizations structures and operating models
  • Informatics is being formalized and is pivoting from a focus on technology adoption to information, people, process and change
  • Analytics skills and competencies while not new to healthcare, must evolve to meet the demands of today’s enterprise
  • Convergence of informatics, analytics and quality is needed to manage the health of populations

See a short video (~15 minute) Research Summary of the emerging organization design trends for IT, Informatics, Analytics and Quality. A more in-depth virtual or in person briefing is available for leadership teams.

 

 

The Creative Disruption of the Healthcare Business Model

Smart, connected consumer centric digital platforms offer the healthcare industry the opportunity to rethink strategic choices about value creation and realization.  For most of us, we have easily adapted to the disruption of the banking, airline, book, and music industries and have integrated smart, connected digital products into our daily lives.  Mitch Wasden, EdD, Chief Executive Officer of University of Missouri Health Care in a General Session of the Cerner Health Conference 2014 challenges healthcare to think differently about our use of technology.  Rather than “implementing” information technologies, he describes a technology enabled redesign of the healthcare business model.

In a recent interview with Maestro CEO Pam Arlotto, Mitch explained that he believes traditional healthcare performance improvement has been too incremental.  He said, “In healthcare, we take a process that requires 40 steps and improve it so it only takes 37 steps.”  According to Mitch, “We need more creative disruption.  While technology can impact innovation, we can’t just layer it in – that only adds complexity.  We need a more systemic approach to change – to conceive of more elegant ways to deliver value and then destroy our current system.  Transformation occurs through simplification, engaging patients and clinicians in new and different ways, getting down to the essence of the value.”  

Watch Mitch describe how his organization is working to create a culture of innovation and transformation:  http://www.youtube.com/watch?v=MttasLlDTWI.

ROI and Vendor Sales Strategies

Maestro Strategies has worked with numerous vendors over the years to measure and document return on investment (ROI) to support vendor and service company sales efforts. Our approach has focused on providing an objective, independent and analytical perspective on the value of the solution from the view of the healthcare customer – health system, clinician, financial executive, etc. Typically, we validate hypotheses developed in conjunction with the company, in a number of real-world customer settings and create a model that can be used to project quantitative and qualitative benefits for prospective customers. Much of our work has been focused on expanding the conversation to examine both financial return on investment as well as strategic and process value – tangible and intangible. As one would imagine, over the years we have seen products implemented that were not used by their customers, solutions implemented on top of broken processes, systems whose users resisted mandated components of the applications, and complex modules whose capabilities were only partially configured and deployed – along with products and services that drove significant value for their customers. However, in all cases, potential benefits of the solutions and ROI were not fully realized. The reasons were many – health systems implemented without redesigning processes, executive sponsors didn’t remove barriers, projects weren’t managed well, and oh yes, sometimes the products didn’t deliver promised results.

The transition from volume to value by the healthcare industry will change the rules for both solution companies and their customers. Features, functionality and demonstrations will no longer be enough to drive sales, industry consolidation will reduce the number of customers, and ultimately solutions companies that don’t produce value over the entire life cycle of their product or service (e.g. beyond sales to include implementation and support) will be replaced by those who drive value creation, realization and results. Many solutions companies are developing ROI and value realization measurement tools and methodologies. Maestro’s experience in working tells us that often solution companies and their healthcare provider clients have different goals for the relationship, different perspectives on the value question and different language in explaining benefits.

Presentation1 Different Definitions of Value

 A Joint Value Management Plan that maps out agreed upon initiatives, value targets, milestones and accountabilities is essential to drive successful adoption, use and value creation/realization. Sometimes separate initiatives are occurring in parallel with the implementation and attribution becomes challenging.  Maestro works with both the solutions provider and their client to define common definitions of value and ROI, validate actual realization, understand key levers and accountabilities that will ensure ongoing value.

White Paper — From the Playing Field to the Pressbox: The Strategic Role of the Chief Health Information Officer

Based on dozens of interviews with health systems across the US and additional research, this report looks at where CHIOs and their teams are headed amid tumultuous change in healthcare. Originally seen as the stewards of CPOE and Meaningful Use — and known as the Chief Medical Informatics Officer — the Chief Health Information Officer is now tasked with ambitious information technology initiatives spanning the health continuum, retail health and consumer engagement, and population health management. Historically, limited in its authority and with few resources for support, this emerging role is a key player who must collaborate with Chief Innovation Officers, Chief Transformation Officers, and CIOs to drive clinical integration, care coordination and value realization.

To download your copy of the white paper, click here:  From the Playing Field to the Press Box.