Beyond the EHR: Finding Real Innovations That Will Heal Healthcare

	From the left: Gabrielle Pinzon, MD, physician informaticist, Centrastate Medical Center, Freehold, N.J., and Program Chair Jonathan Leviss, MD, listen as Jitendra Barmecha, MD, MPH, FACP, CMIO of St. Barnabas Hospital, Bronx, N.Y., makes a point during the roundtable discussion. Photo courtesy of Dan Caparco

BOSTON—Health leaders from across the U.S. gathered together at the CMIO Summit Clinical IT Leadership Forum on June 10 to hear and converse with colleagues who have navigated the straits of meaningful use, wrestled health information exchange (HIE) and clinical information systems—and lived to tell the tale of success.

CCHIT: ‘Buyer-beware market’ for EHRs

In the current regulatory environment, certification means an EHR has minimum level of testable criteria and interoperability, said Karen Bell, MD, MMS, chair of the Commission for Certification of Health IT (CCHIT), during her presentation, “Overcoming EHR Certification Hurdles & Gaps.”

In addition, the Office of the National Coordinator for Health IT’s (ONC) new program has provided two new reasons for certification: proof that an EHR can perform the functions that the government requires, and to enable eligible providers and hospitals to get EHR incentive money.

The certification program is considered a major success because more than 700 certified health IT products are now on the ONC website. “The idea was to get a lot of new products started,” she said.

However, just because CCHIT or another ONC-Authorized Testing and Certification Body (ONC-ATCB) doesn’t test and certify for a particular ability, that doesn’t mean the EHRs don’t have it. “It’s up to [the provider] to make sure the vendors have it,” said Bell.

“You can buy an EHR right now where the e-prescribing does not integrate with the CDS [clinical decision support] module,” she warned. “If you don’t have integration, you won’t get good workflow support.”

CCHIT has criteria that assess and guarantee a focus on workflow, “but on the ONC side of the house, you’re not going to see an emphasis on workflow, but instead on other functionalities.”  Backup is another feature that’s not part of the ONC certification processes, she added.

Because patient safety issues are tied to usability, Bell recommended that providers work with an EHR vendor that has a commitment to usability, and ensure the vendor has a department dedicated to usability issues.

“There may be a lot of new products on the [Certified Health IT Products List], but they’re not checked for real-world usage and verification. A lot of them are vaporware right now. It’s a buyer-beware market out there,” she concluded.

Busting HIE myths

“Building an HIE and integrating to an HIE is very different from an EHR implementation,” said Ben Stein, MD, president and CEO of the Long Island Patient Information eXchange (LIPIX) during a presentation, “Health Information Exchange: How to Play, What to Gain.”

LIPIX, established as an independent nonprofit in 2007, houses clinical information on 2.5 million patient records in Long Island and downstate New York, including patients in Manhattan, Nassau, Queens and Staten Island from 77 provider entities and has more than 2,081 clinicians enrolled.

Using a traditional distributed HIE model, clinical data flows from systems into a regional health information organization (RHIO) hub which transmits clinical patient data to those who have access to the data.

Begun with funding from the state’s HEAL (Healthcare Efficiency Affordability Law) grant program—LIPIX is looking to expand its HIE service to parts of Florida to accommodate patients who often vacation there. “We see Florida as another borough,” Stein quipped.

Currently, hospitals pay $90 per inpatient bed per year as a baseline that covers the majority of the LIPIX membership fee. “Ongoing sustainability will come from membership fees,” Stein said. In addition to a provider clinical portal, core services from LIPIX include a practitioner directory, edge repository for demographic and clinical data, user interface integration, patient consent management and duplicate medical record number reconciliation.

“We focused on a modular approach that integrates to the system, which allows us to support the RHIO and provide services on top of the infrastructure,” Stein said.

LIPIX also is looking to expand services and beginning to build a patient gateway service. While there’s “no evidence of connecting the patients themselves [to the exchange is beneficial], there is increasing interest from providers to do so.”
Stein took aim at seven HIE myths:

1. Get broad-based stakeholder involvement and buy-in before beginning down the HIE path. “You can’t get all stakeholders involved and engaged with all their needs,” said Stein, who advocated for a ‘If you build it, they will come’ approach.
2. Start with clearly defined requirements based on detailed analysis of current and future workflows. “You can’t define the requirements because things are too new in HIE,” according to Stein.
3. Engage consultant “experts” to facilitate the project. According to Stein, it doesn’t make sense to pay the high consultancy price in a rapidly evolving space.
4. Utilize standards to enable low-cost, high-quality integration. “The standards are emerging, so they are not the Holy Grail at this point,” he said.
5. Let the government lead the way. “While New York has been good and we’ve been fortunate,” said Stein, it may not be good to rely upon the government.
6. Find a killer app. “It’s not out there yet,” Stein said. HIEs should instead follow a suite of apps, leverage data, infrastructure, staff and policies from many different services.
7. Remember that competitors will never cooperate. Stein has found friends among those who would normally be bitter rivals.  

MU: Take the money and run?

There are several approaches to meaningful use, said Reid W. Coleman, MD, medical director of information at Lifespan, a multi-hospital organization in Rhode Island. “You can duck and cover; you can do one and done; or you can take the money and run.” None of these options is necessarily the right approach, he added, during his presentation, “Meaningful Use: The Right Way and Breaking Through the Confusion.”

CDS Best Practices

During his presentation, “Clinical Decision Support: Where to Start?,” Donald L. Levick, MD, MBA, medical director of clinical informatics at Lehigh Valley Health Network (LVHN) in Allentown, Pa., shared some best practices for ensuring a successful clinical decision support (CDS) program: The value of the CDS program to the organization must be consistently and continually communicated at all levels; Successful CDS programs implement interventions with the stakeholders, and not to the stakeholders; Think about the impact on workflow and screen response time; Close monitoring of all CDS must occur regularly to ensure validity; and Be prepared to deal with resistors and detractors, including the ability to answer to negative articles in the literature. As a successful example at LVHN, thanks to CPOE soft alerts and comprehensive communication, brain natriuretic peptide (BNP) test ordering fell from about 1,400 ordered in January 2009 to approximately 500 in November 2009. “We couldn’t have achieved these accomplishments five years ago. There’s an evolution of the medical staff users as they acclimate to the system and as the world changes and people are more accepting of evidence-based medicine and clinical standards,” noted Levick.

A better title might be “A CMIO Looks at Meaningful Use: The View From Under the Bus,” Coleman quipped. Before meaningful use requirements, CMIOs were “responsible for all clinical errors. Now you’re responsible for the financial survival of your hospital as well.”

Nevertheless, Lifespan is ready to submit data for attestation for Stage 1 Medicare EMR incentive payments, he said, and “we think we’re OK for Stage 2, based on what we think the requirements will be.”

The one-and-done approach—in which an organization addresses one requirement and gets the money—applies to Stage 1, but “short-term solutions don’t get you where you want to go if what you’re interested in is improving quality and improving safety,” explained Coleman, who added that it is unlikely that the federal funding will have to be given back if it is later discovered that a facility is not achieving the proper standards.  

“Given the political uncertainty of 2012 and beyond, it’s certainly tempting to take the money and run,” he said. “In 2012, there may be a big political swing, leaving HITECH unfunded and healthcare reform getting repealed.” Although that’s far from definite now, “I am advocating that we get certified as fast as we can and get the money. However, this should be the goal either because the ultimate focus has to be on quality and safety.”

Finally, Coleman advised those who are just starting to embark on meaningful use: “Break it up and do the things that you would want to do to make your IT systems work better regardless of government involvement: Standards, documentation, a data warehouse, quality reporting—these are all things we should do whether or not meaningful use is out there.”

Beyond change management 101

When it comes to system implementations, there’s the hard part and the really hard part, according to Justin V. Graham, MD, CMIO at NorthBay Health System in Fairfield, Calif., in his presentation, “Change Management; Strategies to Drive Clinician IT Adoption.”

NorthBay is attempting to achieve the benefits of its fairly mature clinical information systems implementation, meaning a shift away from the concept that a project has an end date of go-live to the idea that “this is our lives and our operations,” said Graham.

Health IT must be embedded in a system’s organizational strategy: “It has to be inter-digitated with everything that your organization is doing,” he said.

Health IT systems should be structurally embedded in the organization’s strategic plan because resistance to change is natural, as Graham stated: “Culture eats strategy for breakfast. Therefore, you may have to fight these battles and lead the change management enterprise for many years to come.”

Part of managing change over the long haul is evolving governance, Graham said. His organization developed a governance model for projects, but once projects are live, it’s not a good idea to stick with that governance model. For example, with the CPOE implementation at NorthBay, “we were in operations mode [and] we needed to undergo governance retooling [on an enterprise level]. In a provider setting, IT has become too important to be left to just the IT department.”

Graham urged his audience to be realistic because project failure is more likely than project success. “We’re stuck with some legacy architectural decisions from our EHR providers, as well as the needs of the organization, culture of medicine and physicians who don’t want to adopt. We’re trying to get informatics to be more democratized, more federalized, as we don’t want it to be the exclusive domain of the CMIO or the IT department.”

Expect an avalanche of requests and demands following a go-live, Graham explained, because in most facilities, IT has “never considered itself a conduit for PDSA [Plan-Do-Study-Act] cycles.”

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