The Data Life Cycle

This year and most of next will likely be spent figuring out how to get EHR systems installed in hospitals and physician offices. Most of the organizations making this transition will be doing so as a reaction to the federal government’s incentives and penalties for not doing so. But there is a much bigger, long-range picture that should provide a framework useful to healthcare leaders. The meaningful use rules require providers to report quality measures to various agencies for analysis. Some of this will be used to determine whether or not the system is being used at all in order to manage incentive payments, especially in the beginning. Other data, some not even conceived of yet, can be used to help improve what we know about medicine and to develop best prevention and treatment practices. This diagram shows one way to look at the process (click to enlarge).

From "data" to "knowledge"

Today, at least in the US, we’re in the first quadrant in the lower left corner. Here, we are just entering the first round of data collection on a national level. In the next quadrant, data will be aggregated and studied for various purposes. Early on, the type of data collected will help determine compliance with meaningful use, and other quality reporting initiatives. In quadrants 1 and 2, it’s still data, or at best “information,” while quadrants 3 and 4 represent the process of learning from that information and then finding ways to transfer that knowledge into support systems that can improve point of care quality and value to both the patient and the healthcare system.

The interesting questions that must be addressed in order to accomplish this are at the heart of “The Art of Medicine and Technology,” and what we want to explore on this site. Some questions arise at each point along the cycle:

Quadrant 1:

  • What kind of data must we collect at this point in order to add value in Quadrant 4?
  • Are we collecting it now?
  • Will it require re-engineering systems?

Quadrant 2:

  • Who does this work?
  • Who has access to the data?
  • How do we ensure that the analysis is unbiased and adds to the art of medicine?
  • Are there any ethical issues involved in doing mass aggregation and analysis of health data?

Quadrant 3:

  • What do we want to learn?
  • Can technology help us uncover unanticipated discoveries?

Quadrant 4:

  • How will this knowledge translate to support systems?
  • Can we trust what we do?
  • Is it ethical to transfer knowledge “in progress” to computerized systems?
  • How many cycles are required before physicians move from trust to reliance on technology?

As always, your comments are welcomed!

-Rod Piechowski

Copyright © 2010, Rod Piechowski, Inc., Consulting

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Advance Directives and EHRs

The recently unveiled final rules for meaningful use of electronic health records in the United States include as one of the objectives: “Record whether a patient 65 years old or older has an advanced directive as structured data.” It is included as one of the optional “menu set” of objectives and therefore not required as are the objectives found in the “core set.” Advance directives had been in the original, recommended set of objectives from the policy committee, which was created as part of the American Recovery and Reinvestment Act (ARRA) to advise the Centers for Medicare and Medicaid Services (CMS) on how to go about the business of determining whether or not a physician or hospital had become a “meaningful user” of technology. When the proposed rule came out earlier this year, the policy committee’s recommended objective had been eliminated. Now with the final rules, it’s back in, which is a good sign.

What’s interesting is some of the thinking behind this particular objective and how it reflects the way we approach the application of technology to our stated goals. In its discussion of the rules objectives, CMS says:

… a restriction to a more at risk population is appropriate for this measure. By restricting the population to those 65 years old and older, we believe we focus this objective appropriately on a population likely to most benefit from compliance with this objective and its measure.

Okay, let’s accept the assumption that people over 65 are statistically more likely to encounter the type of health issue that would require referencing an advance directive. Knowing that the patient has an advance directive, and noting it in the EHR,  helps the doctors and the institution make better decisions, but only up to a point. The rule does not require that systems store the content of the advance directive, so in an emergent situation, vital facts are missing. CMS says it did not require the content of the advance directive to be held in the EHR because there may be conflicting state regulations about such things. Fair enough.

But by limiting this measure to patients over 65, the rule implies that there is less benefit to younger patients. If Terri Schiavo had had an advance directive, the seven year ordeal over whether or not she should have feeding tubes removed would have been avoided. Resolving her case was costly in both monetary and emotional respects, to her family, the community, and the country. What then, is the real “risk” CMS notes in the rules? It is more complex than the risk of contracting an illness if you are over 65. When talking about advance directives, there are three dimensions to risk:

  1. Risk to the patient. Yes, older patients are more at risk to have a life threatening health issue. But by not having an advance directive, the patient risks loss of personal dignity and control over how these sensitive decisions are handled;
  2. Risk to the institution. This can be summed up as: Lawsuits, Cost, Reputation;
  3. Risk to the community. Whether it is a small town or the entire country, end-of-life care is a difficult discussion with a huge emotional component. Issues of faith, agenda and politics are brought into full view. An advance directive can keep a personal decision from becoming a public debate.

Right now the advance directive objective will only apply to hospitals and critical access hospitals (CAH). The rule will not apply to physicians because, as CMS notes:

…we believe many EPs [eligible professionals] would not record this information under current standards of practice. Dentists, pediatricians, optometrists, chiropractors, dermatologists and radiologists are just a few examples of EPs who would only require information about a patient’s advance directive in rare circumstances.

That makes sense, but by excluding eligible professionals as a class, primary care physicians are also excluded from playing a role in meeting a broader objective of having more Americans make thoughtful decisions about end-of-life care. And primary care encounters are the most logical place for these discussions and for entry into the electronic record. Instead of excluding all EPs, primary care should be included, while specialties should be excluded. Part of the problem here is that the HITECH act attempts to lump providers into broad categories of hospitals and physicians. Technology is simply “certified EHR” technology, with little allowance for the many variants already out there.

Finally, if we want pervasive changes in the system, specific to advance directives, the standard of practice must change. Physicians, especially those offering primary care, could drive this change by asking the question of all patients: “Do you have an advance directive?” Either way, the answer is recorded in the EHR, and the meaningful use requirement is fulfilled. In the short term, this benefits the institution, since it may qualify for incentives. In the long-term, it raises awareness among the general public that this is something to think about now, hopefully long before reaching the age of 65. Smart EHR vendors will include this in their systems now whether they are designed for ambulatory or inpatient care. “Meaningful use” has broader implications beyond qualifying for incentives, and this is one of them.

-Rod Piechowski

Copyright © 2010, Rod Piechowski, Inc., Consulting

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Strategic Square Pegs

Now that we have the final rules for incentive payments and meaningful use, we reach a fork in the road. Healthcare leaders who take the time to look up from the day’s checklist of things to accomplish may realize that there are two ways to approach the required implementation of technology.

First is the path of compliance. This strategic approach asks:

  • What is the minimum we must do to get the incentive money and avoid penalties?
  • What hardware and software will get us there?
  • Can our IT department handle it or do we need more people?
  • How can we pay for it?
  • What is the deadline? Can we wait or should we do it now?
  • Etc.

Second is the path of control. This strategic approach asks:

  • What would the ultimate healthcare delivery system look like?
  • How would patients, physicians, nurses, operations, the organization and the community benefit?
  • How long would it take to get there?
  • What kind of information is required to get there?
  • How can we leverage the best qualities of technology to help us get there?
  • Etc.

Many will take the path of compliance, and realize later that despite a technically competent implementation, the organization did not adapt to the technology, and that the expected performance has fallen short. An organization should not adapt to the technology for one simple reason: its limits of performance and innovation are dictated by the technology.

So this is the time to engage the imaginations of everyone from the board to the support staff. Ask: “How could we improve everything?” Through this process each stakeholder will be expressing the value that could be had with the thoughtful implementation of information technology. If you design systems that provide that value, everyone will have something to gain.

The point here is that implementing health information technology is not purely a “technology” initiative. It is an initiative that starts with a vision of where your organization is headed. Yes, this is a big deal, but it is also a huge opportunity to see beyond the requirements of “meaningful use” and mere compliance with the evolving regulatory landscape. Look at meaningful use as a minimum of what you could accomplish with technology, and realize that the HITECH provisions of ARRA are not designed to get you much further than the minimum. By choosing the path of control, you design the process, and then build technology to support it. If your ideal process features round holes, design your technology as a round peg. Otherwise, all the pounding will result in more headaches down the road. Mostly for you.

-Rod Piechowski

Copyright © 2010, Rod Piechowski, Inc., Consulting

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Final “Meaningful Use” Rules Seen

The Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator (ONC) announced the final rules for meaningful use , incentives, standards and certification today. The requirements to qualify as a meaningful user of EHR technology, and therefore receive incentive payments as defined in the HITECH portion of the American Recovery and Reinvestment Act (ARRA), had been the subject of hot debate over the past year as providers wondered whether they could actually meet the terms set forth in the proposed rules seen earlier this year. The final rules do scale back the number of objectives that must be met somewhat, and provide more flexibility for providers to continue along individualized paths to meaningful use. Hospital systems that share a CMS Certification Number (CCN) will be disappointed to learn that the payments will still be made based on the single number, not as individual hospitals. This could mean millions to some systems, which are no doubt investigating how to separate their operations under multiple CCNs. The hospital-based physician definition was clarified to exclude physicians performing all work in an inpatient hospital setting or emergency room.

ONC is still the process of identifying organizations that will be certified testing and certifying bodies, but it projects that certified software will be available for purchase by this fall. Registration for the incentives begins in January, 2011, and be managed online by CMS. Attestations from providers seeking incentives will be made starting in April, 2011, with payments starting in May, 2011. Medicaid payments will occur on schedules dependent upon individual states and the status of their plan and progress made.

The final rules on meaningful use and the incentive program will be published in the US Federal Register July 28.

-Rod Piechowski

Copyright © 2010, Rod Piechowski, Inc., Consulting

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