The Build or Buy HIT Decision

Posted on November 9, 2012 by Dr. David Edward Marcinko MBA MEd CMP™

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Best of Both Worlds for Healthcare IT Systems?

By Brent Metfessel MD

An important consideration when looking at the development of new technological functionality is whether to obtain an HIT system from an outside vendor or build the system using primarily internal staff.

Three Parameters

Basically, such a build or buy decision depends on the following aspects:

  • availability of internal resources to hire the highly skilled staff needed to create a new system;
  • availability of vendors with proven expertise in the area of technology relevant to the new project; and
  • flexibility of the vendors to customize their products for hospitals with unique needs.

The temptation to use consultants rather than FTEs to develop and implement the new system needs exploring.

Both Sides and the Consultants

On the positive side, finding consultants that have highly specialized expertise relevant to the project is often less difficult than finding such expertise in people willing to come on board as FTEs.  Such expertise in clinical informatics may be critical to the success of the project.

On the negative side, the cash outlay for multiple consultants can be staggering, especially if multiple consultants come on board with long-term contracts and retainers. Specialized consultants may charge up to $150 to $200 dollars per hour, quickly draining the most robust of IT budgets. Consultants should be used for just that — consulting. They exist on the project for their expertise and transfer of knowledge to the rest of the staff. To use consultants to do the hands-on tasks of actually building the system is generally not an optimal use of the consultant’s time.

Consultants, if used at all, should typically be used on a temporary basis to share their expertise and advice during critical parts of the project.

Buy Off the Shelf

Overall, buying an application off the shelf may be favored for more sophisticated applications. For example, computerized order entry [CPOE] and EMR systems have a number of dedicated vendors that are vying to achieve market share.

For major projects, distributing request for information (RFI) packages to selected vendors enables senior management to critically evaluate the different vendors in parallel, in the end selecting finalists and ultimately the vendor of choice. A critical requirement when evaluating vendors is a strong client reference base. The best predictor of future success is past success, and thus multiple existing satisfied clients are essential for the chosen vendor. Larger academic or tertiary care systems, however, tend to have more access to expertise and more significant customization requirements. Consequently, building a home-grown system rather than outsourcing the work to a vendor may be the best strategy for such institutions.

Vendors

When working with vendors, one should be strategic in price negotiations. One suggestion is to link part of the vendor compensation to the success of the implementation. This puts the vendor partially “at risk” for project success and thus provides additional incentive for vendor cooperation. Additionally, one should not purchase a system or services from the initial bid. It is critical that more than one vendor bids for the project to provide a pricing and negotiation advantage.

There is nothing that states only one vendor can be chosen for a project. Although obtaining everything from one vendor can lead to a more seamless integration and prevent the juggling of multiple vendor relationships, using more than one vendor may in some cases lead to a higher quality end product. This is known as the “best of breed” approach and is a viable option, in particular for complex projects where a single vendor does not adequately meet user needs.

Assessment

For more basic administrative systems, there are also off-the-shelf products from vendors that may be applicable. Where there is less need for customization, a single vendor may work out very well. Where there are significant unique needs that require customization, once again it may be best to develop the system internally or outsource the work to multiple vendors.

There is also the issue of small or rural hospitals that have limited resources. For such institutions, investments in more complex information systems may be difficult. Consequently, many vendors offer “stripped down” versions of their systems at a more affordable price, specifically tailored to the small hospital. The ability to customize the system for unique needs, however, is significantly more limited.

More info: http://www.hitconsultant.net/2012/10/01/healthcare-it-systems-buy-vs-build-or-best-of-both

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“Meaningful Use” for Ambulatory Care Medical Practices

Posted on June 3, 2011 by Dr. David Edward Marcinko MBA MEd CMP™

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EHR Objectives and Measures

By Shahid N. Shah MS  

For ambulatory care practices and physicians there are about 25 objectives and measures that must be met to become a “meaningful user”. Keep in mind that meaningful use is not tied to a certified EHR alone; in fact, unless you use the EHR properly and in all the ways the government wants you to, you will not be a “meaningful user”.

Don’t be fooled by EHR vendors guaranteeing that they will make you a “meaningful user” – no vendor’s software, no matter how nice, can get your staff to use the software in the way the government wants. You, as the CIO of your practice, are the only one that can guarantee that. In fact, you don’t even need an EHR from a vendor to meet the requirements – you can even roll your own, use open source, or find any other means.

Fear and Promises

In general, as long as you can attest and send data to the government that they require you can do it in any way that you want. Be aware that some unscrupulous vendors are scaring practices and making promises that they cannot keep.

Final MU Rules

The final Meaningful Use (MU) Rule was published by HHS on July 13, 2010. It defines 24 objectives for and measures eligible hospitals that could be met to become a meaningful user and qualify for incentive funding. There is a “core set” that must be met by all institutions and a “menu set” of from which organizations must implement at least 5 objectives.

Core Set Objectives

These are the “core set” of 14 objectives that must be met by all institutions and a “menu set” of 10 from which organizations must implement at least 5 objectives (at least 1 public health objective must be chosen from that set).

  1. Use Computer Provider Order Entry (CPOE).
  2. Implement drug-drug, drug-allergy, and drug-formulary checks.
  3. Record demographics.
  4. Implement one clinical decision support rule.
  5. Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT.
  6. Maintain active medication list.
  7. Maintain active medication allergy list.
  8. Record and chart changes in vital signs.
  9. Record smoking status for patients 13 years or older.
  10. Report hospital clinical quality measures to CMS or States.
  11. Provide patients with an electronic copy of their health information, upon request.
  12. Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request.
  13. Capability to exchange key clinical information among providers of care and patient-authorized entities electronically.
  14. Protect electronic health information.

Menu Set Objectives

These are the “menu set” of 10 objectives from which organizations must implement at least 5. At least one public health objective must be chosen from this set as well (numbers 8 or 9). Drug-formulary checks.

  1. Record advanced directives for patients 65 years or older.
  2. Incorporate clinical lab test results as structured data.
  3. Generate lists of patients by specific conditions.
  4. Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate.
  5. Medication reconciliation.
  6. Summary of care record for each transition of care/referrals.
  7. Capability to submit electronic data to immunization registries/systems.
  8. Capability to provide electronic submission of reportable lab results to public health agencies.
  9. Capability to provide electronic syndromic surveillance data to public health agencies.

Government Agencies and Participants Involved in MU

As you can see in the Figure, the Office of the National Coordinator for Healthcare IT (ONCHIT) is a component of the Department of Health and Human Services (HHS). ONCHIT, usually abbreviated just ONC, is the principal policy group of the Federal Government that defines and manages NHIN.

Figure Link: Figure 

* ONC is responsible for coordinating with the Department of Commerce’s National Institute of Standards and Technology (NIST) on the specifications for the NHIN standards.

* The HIT Policy and HIT Standards Committees are the working groups that advise ONC on what to put in the standards.

* NIST is responsible for coming up with the test materials (assertions, procedures, methods, tools, data, and so on) that will be used to certify working systems 

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On Physician Relations Management [PRM] Technology

Posted on May 12, 2011 by Dr. David Edward Marcinko MBA MEd CMP™

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Criteria for Selection

By Dr. Gary L. Bode MSA, CPA, LLC

Both research and experience reveals an often confusing, complicated world of claims, features, and upgrades, a wide array of technical architectures, and an even wider array of pricing structures when it comes to choosing Physician [Customer] Relations Management [PRM] software.

For me – as a medical practice management consultant – critical criteria for selection includes the following features.

Scalability:

In a young medical practice, a scalable marketing program and PRM infrastructure should be flexible enough to accommodate specialty trends effortlessly and seamlessly without crushing your marketing infrastructure or its’ people, patients or processes. A scalable PRM infrastructure should allow a new channel, a new patient segment, a medical product or service-line seamlessly and with minimum incremental effort or cost.

Interoperability:

You may need an authoring tool today to develop your collateral data, and so select a simple MSFT Word® program. Later, you may want to conduct campaigns to re-introduce your practice or gauge satisfaction among current patients through an online survey. The software you build or purchase for individual activities should be able to co-exist and talk to each other. The software you purchase does not have to be monolithic, but it needs to be modular and work together incrementally.

For example, your e-mail campaign software, CPOESs [computerized physician order entry systems] and e-prescribing functions should work with your authoring tools and eMR.

In today’s complex and fast paced evolution of PRM products, newer technologies need to co-exist with older legacy technologies, and futuristic eMR systems; so interoperability is one of the critical criteria for PRM technology selection.

Ease of Use:

As a young medical practice, pulled in different directions, it is important to have a PRM solution that is easy to use and does not necessitate extensive user training.

Cost structure:

Remember, all PRM software comes with obvious costs as well as hidden costs. Ask the right questions and find out the hidden costs for systems implementation, integration and user training.

Assessment

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On Track for Meaningful Use?

Posted on March 7, 2011 by Dr. David Edward Marcinko MBA MEd CMP™

Are we on track to be a huge disappointment to our children’s children – or What?

[By Darrell K. Pruitt DDS]

When our grandchildren get the bill for the Obama administration’s subsidies benefitting primarily the health information technology industry, I bet they’re going to be really, really pissed at us for allowing today’s lawmakers to blow their 28 billion dollars to please HIT advocates who mislead consumers as well as lawmakers about the benefits of EHRs.

The Doctors Speak 

According to physicians who actually do the hard lifting in healthcare, the “meaningful use” requirements that they must prove in order to qualify for stimulus money will arguably increase both the cost and danger of healthcare – all for the benefit of stakeholders rather than principals. For one thing, “meaningful use” is meaningless if it fails to help physicians treat their patients. I think HIT stakeholders’ grandchildren should somehow be held accountable to my grandchildren.

Opposing Opinions  

Just days apart this week, two HIT reporters, Rich Daly from ModernHealthcare.com and Joseph Goedert from HealthDataManagment.com described two opposing letters the Office of the National Coordinator for Health Information Technology (ONC) recently received: One from doctors and one from patients (et al).

On Monday, here is how Daly’s article “AMA to ONC: EHR program doesn’t work for docs” began:

http://www.modernhealthcare.com/article/20110302/NEWS/303029950/1153

“Many physicians—specialists in particular—will not participate in the federal electronic health-record adoption incentive program because it requires them to include patient data that they do not otherwise collect, according to a Feb. 25 letter from 39 medical organizations letter to the Office of the National Coordinator for Health Information Technology”

On Wednesday, Joseph Goedert, writing for HealthDataManagment.com began “Consumer Groups: Hold Strong on MU” with this:

http://www.healthdatamanagement.com/news/meaningful-use-criteria-comments-consumers-42080-1.html

“A coalition of 25 consumer groups and unions is asking federal officials to hold firm on more stringent criteria for Stage 2 of electronic health records meaningful use, and expressing support for going further. For instance, because patients still trust their providers more than other information sources, holding providers accountable for actual usage of a patient Web portal ‘is entirely appropriate and we strongly urge ONC to resist pressure from the provider community to absolve them from responsibility for making these services available and useful to their patients,’ according to a comment letter to the Office of the National Coordinator”

  • AARP
  • Advocacy for Patients with Chronic Illness, Inc.
  • AFL-CIO
  • American Association on Health and Disability
  • American Hospice Foundation
  • Caring from a Distance
  • Center for Democracy & Technology
  • Childbirth Connection
  • Consumers for Affordable Health Care
  • Consumers Union
  • Families USA
  • Family Caregiver Alliance
  • Healthwise
  • Mothers Against Medical Error
  • National Alliance for Caregiving
  • National Coalition for Cancer Survivorship
  • National Consumers League
  • National Family Caregivers Association
  • National Health Law Program
  • National Partnership for Women & Families
  • National Women’s Health Network
  • OWL – The Voice of Midlife and Older Women
  • SEIU
  • The Children’s Partnership

Like the “Record Demographics” MU mandate, this is all for the “common good” I suppose. Consumer Advocasy groups wouldn’t mislead patients, would they?

I doubt many Americans represented by these 25 organizations ever imagined a new federal requirement that doctors record each patient’s demographics. (Notice of Proposed Rulemaking: Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Federal Register / Vol. 75, No. 8 / Wednesday, January 13, 2010 / page 1861; RIN 0938-AP78).

This means that the 25 stakeholder groups are doing their best to help American taxpayers hold physicians accountable to record and share their patients’ demographic information with the US government – private information about me and my family members that I personally don’t trust the government to be given – even if I’m in vulnerable need of health care.

Daly’s Article 

According to Daly’s article, the demands of MU are distractions for increasingly busy doctors and staff whose focus, I believe, should include eye-contact with patients with specific health problems rather than irrelevant data needs of third parties, including consumer advocacy groups.

On the other hand, if consumer advocacy groups have successfully defined for the federal government what clueless patients allegedly need, who will the mandate really benefit? 25 consumer advocacy groups don’t equal one consumer, so their letter isn’t grass roots at all. It’s deception wearing lipstick. Gullible and vulnerable patients are again being misrepresented by HIT stakeholders for a cut of our grandchildren’s 28 billion.

Assessment

Finally, if MU requirements are an arguably expensive and dangerous distraction for physicians, how can the law possibly be any less absurd for dentists? I’ll look at meaningful use as well at the ADA’s apparently flagging commitment to EHRs next. The ADA is abandoning state informatics departments – leaving them exposed to ADA members’ questions they are unable to answer. It looks to me that intra-ADA relationships are deteriorating quickly, but nevertheless, traditional stoicism still hasn’t been broken. “Image is everything” – ADA/IDM slogan.

Dentists

Here’s a teaser, dentists: Chances are, your state ADA organization hasn’t yet shared with you how the MU requirement of CPOE (Computerized physician order entry – page 1858) will change your practice communications. If you are a HIPAA-covered entity with an NPI number and you don’t email instructions to your denture lab rather than include a hand-written note with the relevant patient’s plaster models, you won’t qualify for stimulus money. What can possibly go wrong with that meaningful idea?

Conclusion

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Brief Summary of “Meaningful-Use” for eHRs

Posted on October 21, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Objectives Listed

By Shahid N. Shah MS

www.BusinessofMedicalPractice.com

In 2009, the ARRA HITECH bill coined the term “meaningful use” and was a game-changer in the healthcare IT industry. In a series of regulations, the Recovery Act specifically required the following.

Summary of MU

Here are the substantive Meaningful Use objectives of the new ARRA HITECH bill:

  • Use Computer Provider Order Entry (CPOE).
  • Implement drug-drug, drug-allergy, drug-formulary checks.
  • Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT®.
  • Maintain active medication list.
  • Maintain active medication allergy list.
  • Record demographics.
  • Record and chart changes in vital signs.
  • Record smoking status for patients 13 years and older.
  • Incorporate clinical lab-test results into EHR as structured data.
  • Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, and outreach. This is a common feature in EHRs.
  • Report ambulatory quality measures to CMS or the States.
  • Implement 5 clinical decision support rules relevant to specialty or high clinical priority, including diagnostic test ordering, along with the ability to track compliance with those rules.
  • Check insurance eligibility electronically from public and private payers.
  • Submit claims electronically to public and private payers.
  • Provide patients with an electronic copy of their health information upon request.
  • Capability to electronically exchange key clinical information among providers of care and patient-authorized entities.
  • Perform medication reconciliation at relevant encounters and each transition of care.
  • Provide summary care record for each transition of care and referral.
  • Capability to submit electronic data to immunization registries and actual submission where required and accepted.
  • Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice.
  • Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities
  • Generate and transmit permissible prescriptions electronically.
  • Send reminders to patients per patient preference for preventive/follow-up care.
  • Provide patients with timely electronic access to their health information within 96 hours of information being available to the EP.
  • Provide clinical summaries for patients for each office visit.

Conclusion

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More on the Meaningful Use of eMRs

Posted on September 3, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

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Final Meaningful Use Rules Released by HHS on July 13, 2010.

[By Shahid N. Shah MS]

Link: http://shahid.shah.org

For ambulatory care practices and physicians there are about 25 objectives and measures that must be met to become a “meaningful user”. Keep in mind that meaningful use is not tied to a certified EHR alone; in fact, unless you use the EHR properly and in all the ways the government wants you to, you will not be a “meaningful user”. Don’t be fooled by EHR vendors guaranteeing that they will make you a “meaningful user” – no vendor’s software, no matter how nice, can get your staff to use the software in the way the government wants. You, as the CIO of your practice, are the only one that can guarantee that. In fact, you don’t even need an EHR from a vendor to meet the requirements – you can even roll your own, use open source, or find any other means. But, in general, as long as you can attest and send data to the government that they require you can do it in any way that you want. Be aware that some unscrupulous vendors are scaring practices and making promises that they cannot keep.

Final MU Rules

The final Meaningful Use (MU) Rule was published by HHS on July 13, 2010. It defines 24 objectives for and measures eligible hospitals that could be met to become a meaningful user and qualify for incentive funding. There is a “core set” that must be met by all institutions and a “menu set” of from which organizations must implement at least 5 objectives.

Core Set Objectives

These are the “core set” of 14 objectives that must be met by all institutions and a “menu set” of 10 from which organizations must implement at least 5 objectives (at least 1 public health objective must be chosen from that set).

  1. Use Computer Provider Order Entry (CPOE).
  2. Implement drug-drug, drug-allergy, and drug-formulary checks.
  3. Record demographics.
  4. Implement one clinical decision support rule.
  5. Maintain a problem list of current and active Dxs based on ICD-9-CM or SNOMED CT.
  6. Maintain active medication list.
  7. Maintain active medication allergy list.
  8. Record and chart changes in vital signs.
  9. Record smoking status for patients 13 years or older.
  10. Report hospital clinical quality measures to CMS or States.
  11. Provide patients with an electronic copy of their health information, upon request.
  12. Provide patients an e-copy of discharge instructions at time of discharge, upon request.
  13. Exchange key clinical e-information among providers and patient-authorized entities.
  14. Protect electronic health information.

Menu Set Objectives

These are the “menu set” of 10 objectives from which organizations must implement at least 5. At least one public health objective must be chosen from this set as well (numbers 8, 9, or 10).

  1. Drug-formulary checks.
  2. Record advanced directives for patients 65 years or older.
  3. Incorporate clinical lab test results as structured data.
  4. Generate lists of patients by specific conditions.
  5. Use certified eHR technology to identify patient-specific education resources and provide to patient, if appropriate.
  6. Medication reconciliation.
  7. Summary of care record for each transition of care/referrals.
  8. Capability to submit electronic data to immunization registries/systems.
  9. Capability to provide electronic submission of reportable lab results to public health agencies.
  10. Capability to provide electronic syndromic surveillance data to public health agencies.

Assessment

As can be seen in the link below, the Office of the National Coordinator for Healthcare IT (ONCHIT) is a component of the Department of Health and Human Services (HHS). ONCHIT, usually abbreviated just ONC, is the principal policy group of the Federal Government that defines and manages NHIN.

  • ONC is responsible for coordinating with the Department of Commerce’s National Institute of Standards and Technology (NIST) on the specifications for the NHIN standards.
  • The HIT Policy and HIT Standards Committees are the working groups that advise ONC on what to put in the standards.
  • NIST is responsible for coming up with the test materials (assertions, procedures, methods, tools, data, and so on) that will be used to certify working systems.

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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On Hospital CPOE Systems [Part Two]

Posted on June 13, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

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Computerized Physician Order Entry Systems

By Brent Metfessel; MD, MIS

A significant initial cost outlay for an organization-wide CPOE system is necessary, which for a large hospital may run into the tens of millions of dollars.  Understandably, the majority of the hospitals that have installed a CPOE system are large urban hospitals.  The up-front cost outlay may be prohibitive for smaller or rural hospitals unless there is an increase in outside revenue or third-party subsidies.

However, although it may take a few years before a positive ROI becomes manifest, there can be a significant financial return from such systems.

www.CPOE.org

Potential Benefits

The potential benefits of a CPOE system go beyond quality. Significant decreases in resource utilization can occur. In one study, inpatient costs were 12% lower and average Length of Stay (LOS) was 0.89 day shorter for patients residing on general medicine wards that used a CPOE system with decision support. Rather simple decision support tools can reap cost benefits as well. When a computerized antibiotic advisor was integrated with the ordering process, one institution realized a reduction in costs per patient ($26,325 vs. $35,283) and average LOS (10.0 days vs. 12.9 days), with all differences statistically significant.

Studies have shown that CPOE systems can significantly reduce medication error rates, including rates of serious errors.

For example, one large east coast hospital saw a 55% reduction in serious adverse medication errors after the system was installed. However, on occasion errors can actually be introduced due to the computing process; in particular, errors can be introduced if the provider accidentally selects the wrong medication from the list or drop-down menu.

Accordingly, a CPOE system should not be viewed as a replacement for the pharmacist in terms of checking for medication errors. In addition, proper user interface design such as highlighting every other line on the medication screen for better visibility and having the provider give a final check to the orders before sending are some ways of reducing this kind of error. Overall, error rates from incorrect order entry on the computer are much smaller than other medication errors prior to introduction of the system.

Appropriate use of a CPOE system helps prevent errors and quality of care deficiencies due to problems with the initiation of orders.  However, errors can also occur in the execution of orders, particularly with the administration of medications to patients.  Bar coding of medications, discussed previously, is a simple way to close the loop in medication error prevention as well as further increase the efficiency of workflow.

Despite its advantages, a CPOE system has been implemented on an organization-wide basis in only about 45% of all US hospitals and growth in implementations has been relatively slow, although about 67% plan to add a CPOE system in the next few years.  Implementing a CPOE system is not an easy task, and there is a significant risk of failure.  Most hospitals utilize vendors for implementation rather than attempting to develop the system in-house given the difficulty of hiring full-time IT talent that specializes in CPOE systems.

One critical feature of any CPOE system is to obtain physician buy-in to the technology, since they will be doing most of the ordering.  Actually, unless the system is of the highest sophistication, physicians may claim it takes more time to write orders using a CPOE system than using the paper chart, as there may be a number of drop-down menus to negotiate prior to arriving at the appropriate drug.  Real-time retrieval of information and electronic documentation, provision of on-line alerts, and the ability to use standard order sets (prepackaged sets of orders pertaining to a particular clinical condition or time period in an episode of care), when relevant, can make the net time spent on writing orders similar to using paper charts.

Doctor Acceptance

It is also important, for physician acceptance, to not overwhelm them with on-line alerts.  Clearly, the system needs to point out the more serious errors, but if the physician’s process is frequently interrupted by alerts, they may increasingly resist the system.

For example, medication allergy alerts may warn physicians not only of potential problems with medications that have an exact match to the allergen, but also, as a defensive maneuver (“better safe than sorry”), to other medications that have a related molecular structure,, even though the patient may already be taking such medication and tolerating it well.  Furthermore, allergies to medications that may result in life-threatening anaphylactic shock may not be distinguished from “sensitivities” that consist of side effects that are not true allergies and are usually much less serious.

Thus, the potential exists for frequent alert generation that would interrupt the work flow and require time spent to override the alerts, making the system difficult to use and leading to user resistance.  One suggested solution is to have a hierarchy of importance, with alerts for potentially life-threatening situations being allowed to interrupt the work flow and requiring specific override or acknowledgment, and alerts for less serious problems being “noninterruptive,” allowing easy visibility of the alert without requiring stoppage of the work flow.

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CPOE Pitfalls

Other pitfalls with respect to CPOE systems include the following:

  • crowded menus making it easy to select the wrong patient or wrong drug with the mouse;
  • fragmented information necessitating navigation through numerous screens to find the relevant information;
  • computer downtime (scheduled or unscheduled); and
  • location of terminals in busy places, which can lead to distractions and resulting incomplete or incorrect entries.

Intelligent, well-thought-out system designs can serve to mitigate many of these problems.  It is important that such difficulties appear on the systems designers’ “radar screen” and are explicitly considered in the implementation.

Pharmacists

As for pharmacists, a CPOE system will not take them out of the process. Although a CPOE system has the capability to capture many drug errors and remove the need for manual order entry, there will always be a need for pharmacists to not only give a second look at possible errors, but to take a more active role in patient care, including going on ward rounds for complex cases, defining optimal treatment, and giving consultative advice.

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Assessment

A CPOE system has the potential to give physicians ready access to patient data anywhere in the hospital as well as at home or on the road, especially with Internet-based connections. This is significant given the difficulty in obtaining patient charts for mobile providers.

In today’s environment of high expectations for care quality and pay-for-performance initiatives, enhanced quality of care can translate into financial gain. Although there is a significant up-front allocation of funds for CPOE systems, given present trends the time may arrive where there is no longer a choice but to implement such a system.

Conclusion

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On Hospital CPOE Systems [Part One]

Posted on June 12, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

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Computerized Physician Order Entry Systems

[By Brent Metfessel MD, MIS]

Since the late 1990s, there has been increasing pressure for hospitals to develop processes to ensure quality of care. The Institute of Medicine (IOM) has estimated the number of annual deaths from medical error to be 44,000 to 98,000.  Manual entry of orders, use of non-standard abbreviations, and poor legibility of orders and chart notes contribute to medical errors.  They also concluded that most errors are the result of system failures, not people failures.

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Other studies suggest that between 6.5% and 20% of hospitalized patients will experience an adverse drug event (ADE) during their stay. Both quality and cost of care suffer.  The cost for each ADE is estimated to be about $2,000 to $2,500, mainly resulting from longer lengths of stay. The National Committee on Vital and Health Statistics reported that about 23,000 hospital patients die annually from injuries linked specifically to the use of medications.

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The Joint Commission and the Leapfrog Group

In addition, the Joint Commission and the Leapfrog Group, a consortium of large employers, have pushed patient safety as a high priority and hospitals are following suit. The Leapfrog Group in particular highlighted CPOE systems as one of the changes that would most improve patient safety.  These patient safety initiatives have further advanced CPOE systems, since these systems have the reduction of medical errors as a prime function.  State and federal legislatures have also stepped up activity in this regard.

For example, back in July 2004, the federal government strongly advocated for electronic medical records, including the creation of the Office of the National Coordinator for Health Information Technology to develop a National Health Information Network. Consequently, regional health information organizations have been established in many states, and these are used for the purpose of expediting the sharing and exchange of healthcare data and information, although there still remain issues in terms of providing adequate funding to these programs.

In addition, consideration was given to the allocation of grants and low-interest loans to aid hospitals in implementing healthcare technology solutions.  In 2000, California first enacted legislation (Senate Bill 1875) stating that as a condition of licensure, acute care hospitals, with the exception of small and rural hospitals, submit plans to implement technological solutions (such as CPOE systems) to substantially reduce medication-related errors by January 1, 2002. Hospitals in California had until January 1, 2005, to actually implement their medication error-reduction plans and make them operational. Unfortunately, many are still not in compliance today.

Health plans also entered the patient safety stage. In 2002, one large health plan in the northeast provided a 4% bonus to hospitals implementing a CPOE system and staffing intensive care units (ICUs) with “intensivists.” Today, this goal is almost the norm, but not yet reality for all.

More than Data Retrieval 

Many hospitals have “data retrieval” systems where a provider on the wards can obtain lab results and other information. A CPOE system, however, allows entry of data from the wards and is usually coupled with a “decision support” module that does just that — supports the provider in making decisions that maximize care quality and/or cost effectiveness.

In this application of HIT, physicians and possibly other providers enter hospital orders directly into the computer. Many vendors of such systems make special efforts to create an intuitive and user-friendly interface, with a variable range of customization possibilities. The physicians can enter orders either on a workstation on the ward or in some cases at the bedside.

Features of a True CPOE System

Basic features of CPOE should include the following:

  • Medication analysis system — A medication analysis program usually accompanies the order entry system. In such cases, either after order entry or interactively, the system checks for potential problems such as drug-drug interactions, duplicate orders, drug allergies and hypersensitivities, and dosage miscalculations. More sophisticated systems may also check for drug interactions with co-morbidities (e.g., psychiatric drugs that may increase blood pressure in a depressed patient with hypertension), drug-lab interactions (e.g., labs pointing to renal impairment that may adversely affect drug levels), and suggestions to use drugs with the same therapeutic effect but lower cost. Naturally, physicians have the option to decline the alerts and continue with the order. In fact, if there are alerts that providers are frequently overriding, providers will often provide feedback that can lead to modification of the alert paradigms. Encouraging feedback increases the robustness of the CPOE system and facilitates continuous quality improvement.
  • Order clarity — Reading the handwriting of providers is a legendary problem. Although many providers do perfectly well with legibility, other providers have difficulty due to being rushed, stressed, or due to trait factors. Since the orders are accessible directly on the workstation screen or from the printer, time is saved on callbacks to decipher illegible orders as well as preventing possible errors in order translation. A study in 1986 by Georgetown University Hospital (Washington, D.C.) noted that 16% of all manual medical records are illegible. Clarifying these orders takes professional time, and resources are spent duplicating the data; thus, real cost savings can be realized through the elimination of these processes.
  • Increased work efficiency — Instantaneous electronic transmittal of orders to radiology, laboratory, pharmacy, consulting services, or other departments replaces corresponding manual tasks. This increase in efficiency from a CPOE system has significant returns. In one hospital in the southeast, the time taken between drug order submission and receipt by the pharmacy was shortened from 96 minutes (using paper) to 3 minutes. Such an increase in efficiency can save labor costs and lead to earlier discharge of patients. The same hospital noted a 72% reduction in medication error rates during a three-month period after the system was implemented. Alerting providers to duplicate lab orders further saves costs from more efficient work processes. And, in another instance, the time from writing admission orders to execution of the orders decreased from about six hours to 30 minutes, underscoring CPOE system utility in making work processes more efficient; thus positively affecting the bottom line.

Assessment

In today’s environment of high expectations for care quality and pay-for-performance initiatives, enhanced quality of care can translate into financial gain. Although there is a significant up-front allocation of funds for CPOE systems, given present trends the time may arrive where there is no longer a choice but to implement such a system.

Conclusion

Although a Computerized Physician Order Entry system alone will reap significant benefits if intelligently implemented, in order to realize the greatest benefit a CPOE system should be rolled up into a fully functioning EMR system where feasible.

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Prominent Politician Views on Health Information Technology

Posted on December 20, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

A Guest Thought-Leader Op-Ed Piece

Ann Miller; RN, MHA [Executive-Director]  

By Alberto Borges; MD

In this review, ME-P thought-leader and colleague, Al Borges MD dissects and presents the political views of HIT by several prominent politicians.  WHY?

He believes that only a handful of politicians are questioning whether the cost of HIT will actually improve healthcare as promised, which can end up in wasted taxpayer money, and worse, become a slow-moving HIT blunder which puts patient lives at risk. Even President Obama’s staff quietly admits that these statements are unproven.

Assessment

For example, Dr. Ezekiel Emanuel, the brother of White House Chief of Staff Rahm Emanuel and the current health-policy adviser at the Office of Management and Budget and a member of Federal Council on Comparative Effectiveness Research stated last year that:

“Vague promises of savings from cutting waste, enhancing prevention and wellness, installing electronic medical records and improving quality are merely ‘lipstick’ cost control, more for show and public relations than for true change.”

Link: Politician Views of HIT [updated November 2009]

Conclusion

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Integration of Hospital Automatic Data Collection Technologies

Posted on August 19, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Review of Automatic Data Collection Equipment

By David J. Piasecki, with
Hope Hetico; RN, MHA

While hardware costs of automatic data collection [ADC] equipment continue to come down for hospital and healthcare organizations, the cost of integration will often prove to be the project buster. Software and integration costs will often be several times the cost of the hardware, especially in smaller health system operations where only a few devices will be used. Integration of ADC technologies is also far from standardized.

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Example:

For example, when implementing a system with portable terminals, one integrator may create a program on the terminals that will write directly to the file on the host system, another may create programs on a separate server to do this, another may write or modify a program on your host system and use terminal emulation software, and another may use a screen mapping tool to reformat an existing program to be used on the portable device. So, make sure to speak with several integrators to ensure the best solution. Also, make sure to participate heavily in equipment selection and program/process design (prompts, data input) to ensure a system that provides the highest levels of accuracy and productivity.

Real-Time Locator System 

A real-time locator system (RTLS) uses RFID technology that provides the objects they are attached to the ability to transmit their current location.  The system requires some type of RFID tag to be attached to each object that needs to be tracked, and RF transmitters/receivers located throughout the facility to determine the location and send information to a computerized tracking system. While it sounds like a great way to eliminate “lost” inventory, the systems are still too costly for most inventory-tracking operations and are more likely to be used to track more valuable assets.

Screen Mapping/Screen Scraping

This software provides the functionality to change the arrangement of data fields on a computer screen that accesses a mainframe computer program. Screen mapping is frequently used in combination with terminal-emulation software to “remap” data fields from a standard mainframe program to be used on the smaller screen of a portable hand-held device.

Speech-Based Technology

Speech-based technology, also known as voice technology is really composed of two technologies:  (1) voice directed, which converts computer data into audible commands, and (2) speech recognition, which allows user voice input to be converted into data.  Portable voice systems consist of a headset with a microphone and a wearable computer.

Terminal Emulation

Software used on desktop and portable computers is available that allows the computer to act like a terminal connected to a mainframe system. If you have a networked desktop PC and are accessing mainframe programs (green screen programs) you are using terminal emulation. Terminal emulation is also a common method used to connect portable computers (as in pharmacy bar-code ADC systems) to mainframe software.

Warehouse Management System

Computer software designed specifically for managing the movement and storage of materials throughout the healthcare system warehouse or chain of command generally controls the following three operations:  (1) put-away, (2) replenishment, and (3) picking.  The key to these systems is the logic to direct these operations to specific locations based on user-defined criteria.  Warehouse Management Systems (WMSs) are often set up to integrate with ADC systems. 

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Can you think of any other data integration technologies?  Tell us what you think. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe to the ME-P. It is fast, free and secure.

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