AMDIS Speakers Tackle Tough IT Challenges

Presentations, roundtables and discussions at the 24th AMDIS Physician-Computer Connection Symposium in Ojai, Calif., dove deep into the health IT topics that present the biggest challenges for today’s CMIOs: Meaningful Use and ICD-10.

The annual meeting offers an opportunity for health IT professionals to explore their field and their biggest hurdles. This year, those topics included specific Meaningful Use (MU) objectives, including transitions of care and problem lists, as well as care coordination and struggles with meeting the timeline. Here is a sampling of what will interest you!

The role of CMIO

So what is the state and status of the CMIO? Rresults of the 10th Annual AMDIS-Gartner survey, presented by Vi Shaffer, research vice president, healthcare, for Gartner, found that CMIOs are making more money than a year ago, and though satisfied with their roles, are slightly less so than in the past.

Shaffer reported average annual compensation of $326,000—up from the average of $318,000 reported in 2013. Salaries ranged anywhere from $206,000 to $550,000, with most CMIOs clustered in the $250,000 to $400,000 range.

While salaries have increased, CMIO satisfaction with their roles declined slightly this year. “You are still satisfied, but 43 percent of you are somewhat satisfied,” said Shaffer. “In the early years of the study more than 50 percent of you were very satisfied. This is a change and a challenge.”

Shaffer also reported an impressive level of interest in the new clinical informatics specialty among CMIOs, with 25 percent having already received certification and another 25 percent pursuing it. “For a first-year subspecialty, that is a pretty amazing track record,” she observed.

Tackling transitions of care

Also on tap were presentations devoted to managing the more challenging requirements of MU. Harris Stutman, MD, executive director of clinical informatics at MemorialCare Health System in Orange County, Calif., addressed transitions of care. In fact, it’s the area in which MemorialCare has focused most of its efforts when it comes to MU, he said.

The complexity of the transitions of care objective is demonstrated by the workbook his organization  put together containing the definitions of all the MU objectives. While they average two pages, the one for transitions of care is 15 pages, he said.

The way the transitions of care measure is defined, Stutman’s organization can only count transitions of care to external providers—those who don’t have “native” access to its EHR. MemorialCare had to find all the people to whom patients are referred but still exclude those with native access to its EHR.

The system identified all of those external resources, and all the ways it has been referring patients at hospital discharge or when patients are leaving emergency departments, or being referred by its 500 or so ambulatory providers. They added their information to MemorialCare’s provider directories so they can send documents electronically. They also implemented a Direct messaging portal for posting documents.

Stutman also shared the challenges involved in assembling documents, identifying the routing schema so that the information is routed appropriately, transmitting this through a health information service provider, deciding on the workflows for the error pool when the messages fail, and all the work on the codesets so recipients can reconcile the documents with their own EHRs.

MemorialCare works with a variety of new vendors and signed new contracts with existing vendors, he said. “We were probably spending half a million dollars just on those augmented modules and capabilities to meet this requirement, without considering all of the work we’ve had to do with multiple teams—an inpatient team, an ED team, an infrastructure team, an ambulatory team and an integration team that are all working on this one measure.”

Problems with problem lists

Another difficult MU objective is the need to maintain accurate problem lists in the EMR. William Galanter, MS, MD, PhD, associate chief health information officer at the University of Illinois Hospital and Health Sciences System, talked about his institution’s efforts to automate problem list placement as a means to improve documentation, while “making life a little easier” at the same time.

His institution automated the problem list by using CPOE and computerized decision support to link new medication orders to corresponding diagnoses in the list. If the patient’s medical record already contained a diagnosis that was an indication for the medication, the system wouldn’t respond with an alert. However, if there wasn’t a corresponding diagnosis, an alert would appear asking the physician if he or she would like to add a problem, and a list of problems would appear associated with the drug from which the physician could pick.

A study of how well the system performed found that 96 percent of alerts were appropriate, and 76 percent of the time doctors placed the problem on the problem list with 95 percent accuracy. The system, however, wasn’t quite as accurate with more problematic medications—those that may have had many off-label uses or multiple indications.

Still, not only did the automated system promote problem list placement, said Galanter, it also provided “an added bonus in that it intercepted wrong medication and wrong patient errors.”

John Lee, MD, medical director, clinical informatics, Edward Hospital and Health Services in Naperville, Ill., observed that EHRs have solved the problem of “sparsely populated” problem lists in the past but have had inadvertent consequences.

For example, Lee said, the ease with which doctors can put information into problem lists can leave them long and confusing. “You have all of this information and data, and you have try to collate all this stuff and distill it down so that the end user can use it,” he said, adding that it may be easier than reading through a bunch of notes, like doctors used to do in the pre-EHR days, “but not much easier, and not particularly useful.”

While it’s easy to get the information into the list, it’s difficult to get it out. Plus, physicians add problems to the list but rarely pull out inactive problems. Lee said he’d like to see a problem list that is “dynamic, intelligent, able to automate and make things active and inactive.”

The ongoing ICD-10 debate

A major focus this year for all healthcare providers has been ICD-10. While the Centers for Medicare & Medicaid Services instituted another one-year delay, AMDIS speakers debated the codeset and the challenges it presents.

Stutman cited the benefits reaped when Canada converted to ICD-10. There were staff productivity losses due to the fact that coders were looking for more information in the patient record, but the data provided in converting to ICD-10 increased the level of specificity for clinical, care cost and decision support reporting and provided more relevant data for epidemiological uses, research and other uses of data for population health management, he said. It also allowed for more opportunities to compare clinical data to advance service delivery and system efficiencies and effectiveness.

“The benefits exceed the costs of moving ahead with ICD-10.”

Jonathan Handler, MD, CMIO of M*Modal, meanwhile, called ICD-10 “ridiculously complex” and said it requires much in the way of wasteful work duplication.

Regarding the question of coding and laterality, Handler observed, “I’m sorry—how many times is laterality documented in the record already?” While maybe not specific in the chief complaint, laterality “surely is in the nursing notes, and absolutely is documented twice in the H&P,” as well as in the CPOE, RIS, PACS and radiology report.

“And after all that work that we’ve already piled on to document the laterality, I can’t get paid for it unless I re-summarize that entire medical record into a mini-ICD-10 code,” he said.

Handler also argued that the expense involved in transitioning to ICD-10 has been greatly underestimated, with costs to practices running three to four times more than anticipated. With the costs involved, as well the time expended on ICD-10, Handler suggested there are better ways to spend healthcare collars and use physician time.

Facing the future

While our healthcare delivery system hasn’t evolved as much as has been hoped, the changes experienced in the U.S. over the last decade “will pale [compared] to what is going to happen in the next decade,” said William F. Bria, MD, CMIO at the HCI Group in Jacksonville, Fla., and AMDIS president.

Health IT, of course, will play a crucial role in this continuing transformation and provide the healthcare community with “an incredible opportunity to leap ahead to a strategy of saying what really works.”

Physicians can now easily see what happens in a particular disease state and what specifically works and what doesn’t.

From the perspective of a practitioner, Bria said, “do I fight for more technical tools, or do I need to really get innovative? [Data] must be usable at the point of care, appropriate to what’s going on . . . and must be packaged in a new, creative way that really does apply at that moment to the discussion, rather than retrospectively sometime in the future.”

We need the data, but we need the data at the point of care, “before it’s too late,” Bria said. “The solutions of America’s ills require the best from all of us, and I think we all know where to go,” he concluded. “We now need to insist on going there.”