Reform is Technology Dependent

Information technology is scattered widely throughout the health reform bill that was passed in the US. In order to accomplish many of the goals stated in the bill, information technology will be increasingly investigated as one component that might offer a degree of savings or capability to the system. Whether we are talking about checking for a patient’s insurance eligibility, medical homes or improving patient access to information, technology is at the heart of the solution. And it isn’t really just technology that will be responsible for this change: what we’re really talking about is information management, using technology as a modernized means of collecting, storing and moving information throughout the system. » Continue reading “Reform is Technology Dependent”

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It All Comes Down to Leadership

Today I spoke at the South Carolina Hospital Association’s Executive Leadership Summit in Charleston, SC. The Association put on a great meeting, and it appeared there were about 100 CEOs and COOs in the room. In what must have been a scheduling “challenge,” SCHA managed to get both gubernatorial candidates to show up to speak. Both Nikki Haley (R) and Vincent Sheheen (D) spoke about employment and healthcare issues in the state which, like several others today, faces serious budget issues. Both took several questions from the audience. Earlier in the day I presented a high level overview of the role of technology and the responsibility leaders have in ensuring it’s successful implementation.

Some key points I tried to make:

Successful health reform is “technology dependent”
Pretty much everything found in the healthcare reform bill will require significant amounts of information, managed in new ways, to accomplish new things. The HITECH act requires that information technology be present, as an underlying component of a more modern healthcare system. In the near-term, the move to increasingly paperless clinical processes will have everyone’s attention (at least in the US), because of the associated incentives for success and penalties for non-compliance. But the longer-term outlook shows an increasing reliance on information technology to support the myriad changes coming in the healthcare system. Slowly, we’ve been moving in the right direction, but even without health reform mandates, hospitals and physicians increasingly expect that technology will play a vital role in the evolution of healthcare business models. And no matter what we want to accomplish in a reformed system, from improved safety to a more cost-efficient supply chain, information technology plays a significant role.

Successful technology implementation is “culture and process dependent”
You can install the latest, most dependable computer systems and the implementation will be deemed an utter failure if no one uses it or, worse yet, the technology impedes or conflicts with the ideal workflow of your business. From a technical standpoint, the implementation was a success. But from a business standpoint, it’s a strategic blunder that could cost millions, damage the reputation of your organization and, in the healthcare environment, put patients at risk. The other dimension to this issue is more about people than processes, and it can be summed up quite simply: People are more inclined to change when they have something to gain from it. Every component of healthcare delivery at your organization should be examined for ways to improve, and your staff, from the management team on down, is best equipped to identify opportunities. Many of these opportunities lend themselves to the thoughtful application of information technology. When people stand to gain something, they are more likely to cooperate, and support change despite differing reasons for wanting that change. In short, re-designed culture and processes logically precede the application of technology, which should be in an enabling role.

Successful cultural and process change is “leadership dependent”
An organization’s culture and business processes don’t change by themselves, certainly not if there is a specific direction or outcome desired. They can drift over time, but generally the changes that occur in this way either reinforce the status quo or are shadow processes that are designed to circumvent the “official” workflow. If systemic change is cast as something “the IT department wants,” you will fail. Only the board and the CEO can endorse systemic changes within an organization in a way that opens everyone’s eyes to a rich assortment of inventive possibilities. Encourage everyone in your organization to think paperless. Then ask how technology can make that happen.

Successful reform then, depends then upon how well executive leadership prepares its organization to embrace technology as a resource, not as the solution.

-Rod Piechowski

Copyright © 2010, Rod Piechowski, Inc., Consulting

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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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