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Health care leaders and policy makers should be commended for making several smart moves in this week’s delivery of the final rule for the meaningful use (MU) criteria, but one of the most critical is the committee’s decision to include the emergency department (ED) as a viable place of service.
For the past several months, several of my colleagues and I have been part of the ongoing effort, working directly with legislators and other industry leaders to ensure that the ED “gets its due” in the MU final rule. One of the most cost and care intensive areas of every health system, but neglected in the initial rounds of MU criteria, the ED is where the flow of patient care most often begins and consistently feeds patients throughout the rest of the hospital – and I’m thrilled that policy makers have now shown that they agree.
Meaningful use was a major focus of many presentations at the recent Picis Exchange User Conference in Miami, but it was the representation from hospitals in Europe (including World Cup finalists Spain and the Netherlands!) and the UK, that sparked some of the most interesting discussions. It made me realize that European hospitals have been working to achieve many of the same “meaningful use” criteria that have become such a huge focus here in the U.S. – but that they have been doing it for much longer than ARRA HITECH has been around. From coordination of care to improving quality measures, Europeans have been in the “meaningful mindset” for a long time.
This blog was created to serve as a forum for the exchange of ideas, and we’ve loved the responses, reactions and dialogue it’s generated over the past several months. Yet for as much as we’ve all come to rely on the blogosphere for the latest and greatest in everything from kayaking to healthcare IT, this week’s Picis Exchange customer user conference in Miami Beach was a great reminder of the power and effectiveness of in-person collaboration and discussion.
Surrounded by health care enthusiasts from nearly 100 hospitals, integrated delivery networks, and government health systems from across six countries and 28 states, I’ve been saturated all week with the most innovative yet real-world ideas from the men and women who serve on the front lines of health care IT every day. Nurses, physicians, IT professionals and administrative staff have spent the past few days sharing stories about how they’re demonstrating meaningful use, moving towards health information exchanges and using evidence-based medicine to improve patient care, by utilizing the data and information they derive from our systems. Not only that, they’re also able to trade war stories and come up with solutions even we might not have thought of.
You may have heard the news yesterday that Allscripts has acquired Eclipsys. I weighed in on this move in an article that ran on HISTalk. You can find the article here, but I also wanted to share my thoughts here on the blog:
There is an increasing trend for general practitioners to be employed by hospitals, but an opposing trend that specialist areas like emergency and anesthesia are outsourcing physician services. So net/net, though on the surface it makes sense to combine the two areas, there is no real market force pushing for an end-to-end hospital-to-physician EHR. To the contrary, the one thing that really is taking off with lightning speed from ARRA is interoperability within and outside the hospital enterprise.
I can cite 10-15 real examples of systems already pushing CCDs among disparate EHRs, for example. Hospitals just aren’t in a position for wholesales swapouts of their IT systems across the board — it’s too disruptive and expensive. The new interoperability mandates will allow more modular approaches to building out EHRs.
Today we welcome guest blogger Geoff Brown, Senior Vice President and Chief Information Officer at Inova Health System, a nonprofit hospital system based in Falls Church, Va. that includes six hospitals and fields approximately 400,000 emergency room visits annually. We tapped Geoff for his thoughts on a common debate in HIS circles: Will hospital-wide HIT oust specialty systems?
Many hospital CIOs are facing a similar question: will house-wide hospital information systems (HIS) reign supreme, or is there still a place for specialty systems? We faced this very question at Inova Health Systems and found that, while a house-wide information system is important to the overall flow of data, a hybrid approach with specialized departmental systems that support the workflow and interoperate with our core HIS met our needs.
At Inova, our busy emergency departments and free-standing emergency care centers were central to our decision to supplement our HIS with specialty systems. Most CIOs would agree that an ED has different IT needs than other departments – from decision-making support to complicated levels of documentation required for reimbursement – and these needs require specific functionality that not all systems provide. Furthermore, EDs are fast-paced and highly stressful environments that represent the front door of a hospital, a gateway for the rest of the building and the hub from which many diagnostic decisions are made and patients are funneled to different departments. One size fits all in some areas, but one built for admissions would not be the best for physicians or patients.
A recent article in the Pittsburgh Tribune–Review speaks to a growing problem for hospitals: not getting paid for the complex medical care they provide. This is happening at an increasing and alarming degree as a result of insurance auditors determining that when a patient is admitted to the hospital from the emergency department (ED), “medical necessity was not met” – meaning the patient should have been treated under “Observation” status rather than “Admission” status. Federal regulations driving these audits speak to the growing need for proper medical necessity documentation at the time of “patient disposition” – when a physician decides whether a patient should go home, be admitted or held in observation. As a result, emergency doctor admissions are now closely scrutinized.
A maddening Medicare rule is responsible for this increasing incidence of post-payment audits and physician scrutiny. This rule, often enforced by Recovery Audit Contractors (RAC), is based in congressional law. The Medicare Modernization Act of 2003 established the RAC program to identify improper Medicare overpayments and underpayments, and RACs are paid on a contingency fee, receiving a percentage of the improper overpayments and underpayments collected from providers. From March 2005 to March 2008, a government demonstration project in several states found $993 million in overpayments. Hospitals were found liable for 94 percent of the total overpayments. Of the inpatient admissions, 40 percent were deemed medically unnecessary and an additional 35 percent were targeted due to incorrect coding. What does this mean for hospitals and physicians? Medical necessity is 100 percent determined by physician documentation.
There’s no arguing that healthcare lags behind other industries when it comes to technology, but contrary to popular belief, physicians are not the ones holding it up. Healthcare IT vendors are as much of the problem as they are the solution.
The truth is that many healthcare software systems are overly complex, provide a clunky physician/EHR interface, and require a significant amount of time and effort to transform them into user-friendly tools that actually make physicians’ lives better. When doctors lack the time to master their department’s IT systems, they often turn to the use of scribes – typically hourly paid resources who step in for time-constrained doctors and input patient, clinical, and charge capture data into EMR systems on their behalf.
In some cases, hospitals use scribes to perform far more valuable duties than just data input – George Washington University created an educational program for pre-med college students and first year med students considering emergency medicine. In this case, scribes serve as “workflow facilitators,” where a small slice of time is spent entering physician documentation into an EMR, while also helping ED efficiency by helping track down labs/x-rays/consultants, prepare discharge paperwork and ease communication between staff and patients/families.
Although still far from achieving mainstream adoption, anesthesia information management systems (AIMS) have made significant strides since the early part of this decade. My research has found adoption of AIMS in the US at about 8-10% and rising, with 15-25% growth expected over the next few years. These systems have been available for more than two decades, but only recently has the notion of implementing an automated anesthesia record become widespread within the practice of anesthesiology.
It’s no surprise that the most successful AIMS solutions are those that allow the electronic anesthesia record to operate seamlessly with the other information systems installed in the hospital – where the interoperability begins in the operating room and extends as far as the outpatient areas. However, the latest anesthesia report issued by KLAS , entitled The Growing Market for Anesthesia Software: Liability, Integration and the Benefits of Adoption, has caused a wave of confusion for hospitals and health networks by using the terms “interfacing” and “integration” inaccurately.
Standing in the Interoperability Showcase at HIMSS10 is frankly amazing. We are participating in the Emergency Department interoperability scenarios, passing clinical documentation to and from other systems, using IHE standards for information exchange. I was standing with a friend and CMIO who is a practicing physician, and when he saw how easy it was to get information regardless of source, his comment was, ”This is how it is supposed to work, how it was always supposed to work.” I agree. And more vendors than ever are participating.
Talking with the HIMSS folks that orchestrated the impressive setup, I come to find that the numbers of folks “interoperating” in this display have more than doubled in the past two years, now demoing nearly 60 use cases and 28 clinical scenarios. Similar to the IHE show in January, the interest in interoperability and move to embrace standards at HIMSS is palpable. And it’s not just on the show floor – I have been talking to vendors all over that are now delivering or planning to deliver shortly to their customers this type of technology.
HIMSS is always a great conference, but I have to admit – on my flight down to Atlanta, I was slightly dreading four days of endless hypotheses around meaningful use. The understandable theme of this year’s show, meaningful use, has quickly escalated from an exciting and game-changing initiative to one that has even the most optimistic healthcare enthusiasts scratching their heads and drowning in buzzwords, overpromising and under-delivering. It was only at last year’s HIMSS that one of the largest HIT vendors claimed they had meaningful use nailed down (only weeks after the announcement of the initiative) but when tested, couldn’t give a straight answer on what it meant or how it would deliver value to patients.
This year, however, I’m already noticing a reality running through HIMSS that I was pleased to find. This year’s sessions have revealed that a lot of attendees are more comfortable admitting the reality of the situation; that they are just now really understanding the challenges that this will bring. I overheard an IT executive from one of the most prestigious and well-regarded health centers in the world claim, “If we’re not sure that we are going to be ready by 2011, I can only imagine what others are facing.”
