From EHR to HIE and Back

According to the latest count, there are 255 Health Information Exchange (HIE) organizations across the country, which amounts to an average of 5 in each State. If you are a practicing physician and have an EHR, chances are someone already knocked on your door offering to connect your practice to the local HIE for a small fee. If you don’t have an EHR, you may have had offers to access an HIE web portal, or maybe an HIE supplied EHR Lite, allowing you to at the very least view clinical data from other sources. Perhaps for free. If you are the proud owner of one of the full-featured EHRs, you may wonder what an HIE can do for you that your EHR is not already doing, and whether that service is worth your hard earned money.

In theory, a top-shelf EHR should be able to connect your practice to multiple facilities and allow you to exchange information to the best of all participants’ abilities. Granted most EHRs are still working on some of the connections, particularly to local facilities, but all in all, an EHR should be able to eventually provide for all your connectivity needs as shown in Figure 1. Note that for some types of connections, your EHR vendor can use a clearinghouse or portal approach to simplify and reduce costs of connectivity. For example, you don’t need a separate interface for each pharmacy – you use Surescripts as the clearinghouse and let them worry about it. You also don’t need an individual connection to each patient’s home – you communicate with all of them through one portal. With the exception of Surescripts pharmacy connectivity and a small number of reference labs, each connection, or interface, is costing you a pretty penny, and the more local the connection, the longer it takes to build.

Enter the local HIE. The value proposition of a regional exchange is in connecting you to local hospitals, imaging centers, State agencies and community resources. Figure 2 shows a typical HIE arrangement. If you compare this to Figure 1, it becomes apparent that your EHR vendor has a much easier job now. Instead of building an interface to each hospital, the vendor needs just one interface to the HIE and presto, you are connected to all hospitals. Yes, this is an outlandish oversimplification of affairs, since most players have no ability to connect to HIEs and since each message type requires its own separate interface (or special code to sort messages out). If your EHR vendor has a critical mass of customers in your area, all needing to connect to the same regional facilities, a connection to the HIE should create significant savings for the EHR vendor, and hopefully some of those savings will be passed down to you. The HIE will in turn try to get a portion of that money from you to cover their costs of building and maintaining interfaces. If there is more than one HIE in your referral region, your EHR vendor may need to repeat the effort for each HIE. This will increase the complexity and costs for all involved.

Some HIEs are trying to do more. Although EHR vendors are increasingly integrating abilities to exchange information between physicians through the Direct Project protocol, HIEs are attempting to do the same thing. Depending on your EHR vendor, the HIE may be a few steps ahead and will offer you that functionality. Of course, it will not be integrated in your EHR workflow, but it may still be worthwhile. Since most HIEs retain data exchanged through them (or have the ability to retrieve it from the source), they are also considering offering patients access to their data. If your EHR vendor does not offer a Patient Portal or charges a lot for one, this may be a very tempting proposition. Figure 3 illustrates this more comprehensive setup, which also includes connectivity to reference labs, as this is a simple thing to do and several HIEs are doing just that. The HIE menu of services in Figure 3 will cost you substantial subscription fees, and rarely some transactional fees, on top of what you are paying for your EHR.

If you don’t have an EHR, some HIEs will offer you a one stop shop, which can include a lighter version of an EHR (geared to Meaningful Use), which includes electronic prescribing. This may be a cumbersome solution if you still need to maintain a paper chart, and perhaps this is why the top HIE vendors offer EHRs that are fully functional and which only need to be connected to your Practice Management System (PMS), as shown in Figure 4. In this scenario, you would have to pay the HIE a hefty price, but you won’t have to pay extra for another EHR. Finally, there is at least one HIE out there, and I am certain more will follow, which can accommodate your billing needs as well.

Having come full circle, Figure 5 illustrates the complete transformation of the HIE into a complete EHR and PMS. The difference between Figure 1 and Figure 5 is not just terminology. The system in Figure 1 stores data either in individual physician databases or in a national database of all EHR customers for an Internet based EHR. In Figure 5, you are accessing an EHR that contains the data of other physicians, hospitals and care agencies in your area. This is a much more powerful configuration and better suited to care coordination and care management. This is pretty much how large health care systems are set up and in most cases the HIE is run by their enterprise EHR vendor. In fact, just like HIE vendors are building EHRs, most large EHR vendors either have, or are quickly assembling, formal HIE capabilities (master patient index, good interface engine, robust database structures).

So here is a wild prediction: it may take a while, but eventually small EHR vendors will be replaced by strong HIEs, and weak, failing or nonexistent HIEs will be displaced by large EHR vendors who had the ability and wisdom to become HIEs, and there will be no distinction between the two types of software vendors. Right now the 255 HIE organizations across the country are struggling to find a way to become sustainable businesses, and most EHR vendors, while posting record profits, are struggling to provide much needed interoperability. A marriage of necessity is inevitable. What should we name the baby?

OIIT Conducts Successful Laptop Exchange in June

During the month of June, OIIT was able to successfully exchange approximately 3400 laptops and give BPS teachers brand new Macbook computers to kick off the second version of the Laptops for Learning Program. Laptops for Learning provides a state-of-the art dual platform Macbook to classroom teachers. By exchanging the laptops in June, teachers were able to take the new computers home over the summer to use while they attend professional development and prepare for the upcoming school year. Teachers were also given an introductory overview of the new Student Information System that will be implemented throughout the district during the 2011-2012 school year.

The June rollout was truly a team effort as all employees of the Office of Instructional and Information Technology took part in the laptop exchange sessions along with interns from TechBoston.

If you are newly eligible for a laptop or you missed the June exchange, sessions will be scheduled at the end of August. Please go to MyLearning Plan to sign up for sessions after they are posted. If you have any questions about eligibility or laptop sessions, please call the OIIT Service Desk at 635-9200.

Bending the Curve with EHRs

The post you are about to read may not be suitable for wonks. Its claims are not fact checked. Its author is not a researcher. And its opinions are not fully thought through. Reader discretion is advised.*

EHR adoption rates are picking up significantly, exceeding the most optimistic expectations. Instead of an EHR for every American by 2014, as the President commanded, we will have dozens of EHRs for each American long before that. And in health care, more is always better, not to mention the freedom of choice that comes with having a different EHR in each care setting. Not surprisingly, we are seeing a decrease in health care expenditures taking place in parallel with the uptick in EHR adoption. Following best practices in health care economics research, when two phenomena develop in parallel, the learned assumption is that there is a causality connection between the two. Deciding which phenomenon is the cause and which is the effect is discretionary and commonly based on undisclosed agendas.

It is therefore postulated here that health care expenditures are inversely proportional to EHR usage rates. The following is a rigorous analysis of the mechanisms by which EHRs are reducing health care costs, intended to inform policy makers as customary in most health care related studies, which cannot be completed, or published, without a salient recommendation of interest to policy makers.

Productivity Optimization – Numerous carefully estimated anecdotal studies consistently show that introduction of an EHR in ambulatory practice can reduce provider productivity by 50% or more. This directly translates into 50% (or more) savings in health care expenditures for office visits. Unfortunately, the same studies also show that in most cases this reduction in office visits is transient, with most providers regaining ability to charge for as much as 80% of their pre-EHR visit volume within six months to a year. Still, 20% long term savings is significant and could probably be optimized further by introducing more speed tempering features into certified EHRs. Equally rigorous studies show preliminary evidence that the savings realized from introducing fully functioning EHRs in Emergency Departments far exceed those in the ambulatory sector. Unlike other Socialist countries that were compelled to nationalize the entire health care system just so they can reduce productivity and discourage utilization by creating long waiting lines, Yankee ingenuity is producing better results at lower costs.

Banishment of THE Pen – The Physician Pen has been long known for being the most financially devastating instrument ever invented. In spite of pharmaceutical reps efforts to the contrary, EHRs are successfully removing all pens from medical practice, including but not limited to, the Physician Pen. Where physicians used to carry several handsome pens in that little pocket right under their embroidered name and title, they now carry an EHR contained in a device that may or may not fit in a less accessible pocket and either way requires both hands, ample light and an adequate supply of battery power to order the simplest thing. The better EHRs also provide various speed bumps on the road to ordering by popping up multiple warnings and good financial advice equidistantly placed at 10 to 15 milliseconds intervals. Data from the very similar retail industry shows that impulse buying is greatly increased by simplifying the process, such as the one-click checkout at Amazon. The reverse logic must also be true, so increasing complexity should reduce impulse ordering in medicine. Judging by Amazon’s successful strategy, the savings in health care are expected to be spectacular.

Customer Intimidation – As EHRs become better at measuring the abysmal state of our health care non-system, and expose the horrors and frequency of medical errors by either careless omission or profit-driven commission, it is estimated that health conscious consumers will increasingly avoid dangerous encounters with the medical complex, thus further reducing utilization and cutting costs. Strategic publicity campaigns advertising security and privacy breaches in other computerized industries, and in health care if any are found, should eliminate another segment of customers. However, the largest cost savings are projected to come from customers refraining from seeking care for, or even mentioning, potentially embarrassing health problems for fear of public exposure through interconnected EHRs.

Accelerated Attrition – EHRs are very powerful tools. So powerful that the prospect of having to purchase and use an EHR is more than enough to prompt older physicians, particularly those in private practice, to consider retirement or transition to other occupations. The evidence shows that there is direct anecdotal correlation between negative reaction to introduction of EHRs and acceptance of cost-saving team approaches to provision of medical care. The semi-natural attrition of experienced and highly compensated physicians who insist on treating, and charging for, every sore throat and every knee scrape, in spite of mounting evidence that lower paid resources can refer those to appropriate specialists with equal outcomes, should in the course of time increase the amount of savings directly attributable to the prevalence of EHRs.

Free Labor Procurement – EHRs are particularly adept at encouraging and showcasing the historical selflessness and ethical conduct of medical doctors, by providing multiple means for doctors to contribute to the wellbeing of their patients practically free of charge, at all hours of day and night. From the ubiquitous email to the occasional webcam session to the continuous evaluation of uploaded self-quantification vital data from patients empowered to have their health expertly monitored, physicians using EHRs can provide this simple courtesy service to their customers from the office, the home, the yacht or the golf course. These proactive preventative measures should result in extensive reductions in disease burden. Constantly connected physicians, armed with the latest monitoring tools, could detect strokes, heart attacks and maybe even cancer years before actual manifestation of symptoms. And at no cost to society.

The implications for policy makers are pretty straightforward. EHR adoption should continue to be encouraged at all costs. EHRs must evolve to seamlessly and continuously connect to all consumer monitoring devices, which implies a preference for cloud based technologies, and a security breach here and there is not necessarily an impediment to success. EHRs should continue to increase the levels of automated decision support, improve analytics and increase frequency and scope of various alerts. Basically, keep up the good work. We’re right on target.

*Disclaimer partialy plagiarized from the UK version of The Daily Show

Voices of Primary Care: What is a Medical Home?

Guest post by ANONYMOUS, MD

I have heard of the "Nursing Home" and I am not sure most of us aspire to getting there…

We all carry an image of our own HOMES: it is often idealized in phrases such as “Home-sweet-home” or “There is no place like home” or "Home is where the hearth is”. We even talk about being “HomeSick”.

Do any of these even remotely resonate with “THE Medical Home”?

Now granted, a “homey” doctor’s office may be a worthy goal. Making our patients feel “at home” with proper hospitality and kindness, a relaxing environment, maybe even the smell of baking are all likely to be improvements over our current obsession with best business practices, efficiency and evidence. To the extent that these characteristics become the defining feature of “The Medical Home” we might be on to something.

But "The Medical Home" instead seems to suggest that the doctor’s office is the place where health resides.

Isn’t the intention of the medical home movement really an effort to reassert the importance of solid, comprehensive primary care built on the ongoing relationship between the patient and his or her primary care physician? If so, why not say so?  What would we call that? How about good Primary Care?

The New York Times Foray into EHR Usability

So the New York Times is throwing its hat into the Electronic Health Records (EHR) usability debate, mixing up terminology to reach a predetermined conclusion, as is customary in modern media coverage. The story starts with a blazing inferno in 1904 Baltimore and ends with a categorical statement from a highly credentialed source naming usability the “single greatest impediment to physician acceptance”. In between this skillful framing of the subject, there are the obligatory dissenting arguments from two EHR vendors and a bewildering array of expert arguments confusing usability with safety and interoperability standards, complete with the usual comparison of health care to aviation. 

The 1904 Baltimore fire, for example, where fire trucks from other cities were prevented from assisting the locals because their hoses could not connect to Baltimore’s water hydrants, makes an excellent argument for the need of interoperability standards in electronic medical records. It contributes nothing to support usability standards, since the problem was not traced to the color and softness, or ease of operation, of the non-Baltimore fire hoses. Nevertheless, most readers have no desire to perish in a blazing inferno induced by EHRs, so a receptive mindset is established upfront, whether it has anything to do with what follows, or not. The little jab at the vendors of fire hoses opposing standardization because they “did not want competition”, and so they “undermined the usefulness of, and investment in, the technology of the day”, is also helpful in framing the desired perception of what’s to follow.

The next nugget designed to create fear, uncertainty and doubt (FUD) is a statement from a computer scientist which obviously deserved its own two line paragraph: “This is an issue that potentially affects the health and safety of every American”. Yes, “changing the size, color and placement of graphic icons on a screen”, cited as an example of the deterministic and measurable science of usability, will definitely do wonders for the health and safety of every American. It will also contribute to gainful employment of many newly minted usability professionals, which is a good thing in these difficult economic times, and it shouldn’t raise the cost of producing EHRs by more than rich doctors can bear. And if government hires its own experts and then dictates where all the little icons should be placed, and what color they should be, maybe EHR vendors can actually cut costs by firing their own experts. After all, there is usually only one way to do things right, and when Bill Joy said that “innovation happens elsewhere”, he probably meant that it happens in federal government agencies and their contractors.

Let’s not forget that according to quoted “specialists”, usability standards worked well for “jet plane cockpits, air traffic control towers and nuclear power plant controls”, ergo “[s]ome of that expertise, …. , can surely be applied to doctors’ offices and hospitals”. Surely. Most Americans have little understanding of those complex industries and are both in awe of their potential disasters, and grateful for not being burned to a crisp by nuclear explosions and great balls of jet fuel fires on a daily basis. If all it takes is placing colorful little icons in certain spots on a computer screen, then by all means, let’s do it. Never mind the advances in avionics, composite materials, computer aided design and testing, and nuclear technology, the improved safety records must be all due to the novel placement of little icons. This is supported by a similar development in health care where marble floors and the presence of at least one atrium has significantly improved the quality of medical care as evidenced by a recent study that shows that critical access hospitals, that lack marble and atriums, provide inferior care. Probably because stepping on smooth Italian marble shaded by exotic banana trees, is much more satisfying for users, than walking on discolored linoleum with peeling edges flanked by cheap plastic ferns.

As to the categorical closing statement naming usability of EHRs as the “single greatest impediment to physician acceptance”, whatever acceptance means, I would suggest a quick literature review of physician surveys that constantly place the price of EHRs and the lack of calculable return on investment as the #1 impediment to technology adoption. Perhaps the experts interviewed or quoted in the New York Times are confusing usability with usefulness.

The government has a clear role in defining interoperability standards for EHRs and the FDA has a duty to ensure reasonable safety of software and devices used in medical care, but the placement and color of little icons has nothing to do with either and with all due respect to user experience experts, clinical safety should be left to those expert in that field. Forcing all EHR vendors to hire interior designers and to order Italian marble and live banana trees, because they seem reassuring, satisfying or just plain cool, will not increase the usefulness of EHRs. It will however drastically increase EHR prices, which are already on the rise as an unintended consequence of Meaningful Use. Once EHRs become truly useful to physicians, there will be no need to be concerned with the dubious “acceptance” factor.

Invitation for Practicing Primary Care Physicians

Health care is currently experiencing tremendous turbulence. The old ways of doing things are about to give way to new ideas and new models, or perhaps just refurbished old models, and at the heart of it all is primary care. The old hope of care management has been rebranded to advocacy for care coordination, because the term coordination sounds more benign and better aligned with the increasingly vocal patient engagement movement.  After all, empowered patients do not wish to be managed, but they do expect that someone will coordinate their informed decisions and preferred courses of treatment. Unlike management, which implies a paternalistic approach to patient care, coordination implies efficiency with no loss of freedom of choice. From a public relations perspective, this is a brilliant change of messaging content.

Care coordination is also the main ingredient in patient-centered care, by far the most overused buzz word of health care transformation. Other than individualized coordination, patient-centered care should be delivered by care teams, guided by population based medical evidence and measured by aggregated, process and outcome, population based statistics. The main vehicle to facilitate such change is the Patient Centered Medical Home construct as defined by the numerous NCQA accreditation requirements. Since Medical Homes require care teams of various capabilities, engaging in the coordinated sport of health care delivery, it is recommended that primary care physicians operate in large systems and facilities, where qualified team members are readily available, and a steady paycheck is guaranteed for the team doctor.

Medical Homes require state of the art computer technology to facilitate coordination, evidence based protocol enforcement and statistically meaningful measurement of compliance and outcomes. Health care computer technology adoption is being encouraged by the federal government through the well-publicized Meaningful Use series of incentives and penalties. The equally well-publicized complexity and prohibitive costs of health care computerization imply that large system are much better suited for widespread deployment, thus freeing their physicians, who have already been relieved of financial uncertainty, to better concentrate on the labor of managing the provision of health care. The quintessential problem of physicians being too busy seeing patients and having no time to deal with administrative, financial and technology demands, is thus resolved.

If you are reading this, and are experiencing an uncontrollable urge to through the computer against the wall right about now, you obviously are able to find a few minutes in your busy schedule to surf the web, read blogs, forums and maybe browse the news pages. Perhaps once in a while you even post a short comment here and there, most likely anonymous. Perhaps you are a social media maven, tending to your own blog or facebook/twitter presence. Most likely this is not the case because maintaining a web presence is pretty hard work. One thing is certain though; you most definitely have at least one opinion regarding the turmoil of our health care system and the particular circumstances surrounding your chosen profession.

So if you feel the need to express your thoughts, once a day, once a month, once a year, once in a blue moon, or when it can be contained no more, I would like to offer you a safe and easy way to do just that. Although this page’s title implies technology, you can see that much of the content is actually geared to the plight of primary care in small, private settings, which has been my personal passion for many years. This little blog has been my home for well over a year now, and I would like to invite you to make it your home too.

Anytime you feel the need to write, on any health care related subject, just type it up (or use your dictation tool) and email it to me. It could be a long essay or a short note, and it does not have to be Shakespearean prose either. All materials will be promptly posted, unedited, uncut, with no judgment and no commentary, anonymously if you so desire. You will not reach millions of readers, but you will reach quite a few influential folks active in the health care field, and I will do my best to spread the word. This is an open invitation, with no strings attached, no expiration date, no exclusions, no rules, no guidelines, no protocols, and with a simple goal of providing an outlet for the voice of practicing primary care physicians who have been largely silent and “too busy seeing patients” for way too long. I view it as a service.

Feel free to forward and share with others. The first such post from an anonymous MD, who was the inspiration for this service, will appear here on Monday, July 18.

Boston Celtics Donate Mobile Lab to the Edison School

The Boston Celtics continued to demonstrate their commitment to supporting the students and families of the Boston Public Schools by donating a brand-new set of 25 Macbook computers and a mobile cart to the Edison K-8 School in Brighton. To further illustrate the importance of community service, Managing Partner Steve Pagliuca and General Manager Danny Ainge also introduced their top two draft picks at the school when they unveiled the mobile computer lab. JaJuan Johnson and E'Twaun Moore were introduced as the newest Boston Celtics and then immediately put to work with 23 students of the Edison School on a scavenger hunt activity using the new computers. The students answered questions about the history of the Boston Celtics, including a question about Celtics general manager Danny Ainge, who also worked with the students.

This is the fifth computer lab donated this year by either the Boston Celtic's Shamrock Foundation or Ray Allen's Ray of Hope Foundation. The other new computer labs are located at the Dearborn School, the Hernandez School, the Tobin School and the Sarah Greenwood School.

Check out video from the event below!