While no two providers are alike in their I.T. footprints, everyone longs for regulatory relief in one form or another (see related story, page 26). Following are the wishes and concerns of a widely disparate group of HIT leaders during the holiday season.
Name: Michael Krouse
Title: Senior Vice President and Chief Information Officer
Organization: Ohio Health, Columbus
Wish List Items: Virtual Desktop, Natural Language Processing
One thing Michael Krouse does not wish for is another hospital to oversee. He's got a full plate now, as Ohio Health spans 17 hospitals, employs some 500 physicians, and maintains affiliate relationships with another 2000. The $2.5 billion health system runs a McKesson EHR at eight of its inpatient facilities with its ambulatory practices running on either GE or athenahealth. Several of the hospitals run under co-management agreements, and maintain their own I.T. infrastructure, Krouse says. The system is moving ahead full bore into the digital era, as several of its facilities are now all-digital operations, with no paper charts present.
Like many CIOs, Krouse cites regulatory certainty as his top wish list item for 2013. Closer to home, the CIO's top need is what he calls "the extension and maturity of the virtual desktop." Ohio Health has taken a step in that direction already, by converting many desktops to a virtual environment in which monitors function much like the dumb terminals of the past. Rather than having software loaded locally, the monitors connect into a central server where core applications are run.
The problem, Krouse says, is that many applications are not designed to run well in such environments. And beyond connecting to standard workstations, Krouse would like to open up his network to whatever devices clinicians feel most comfortable using, be they iPads or smartphones.
"I would like to open up our infrastructure to become more device agnostic," he says. "I don't want to limit devices, but I would like to expose our applications without exposing our security." To that end, Krouse longs for mature access management tools, software that could regulate and monitor network access and grant it based on role.
Software vendors lag when it comes to adapting their applications to run in virtual environments, he says. "Our legacy apps are about 75 percent compatible with a virtual environment, but not in a well-orchestrated way," he says.
"They are compatible in that we can figure out a way to make it work. But we don't want to support PCs and desktops. We want to support apps and connectivity. I just wish that space would mature." Krouse would love to enable physicians to connect to his apps with the device of their choosing. But there's more to that than making use of the EHR easy for physicians, he says. To wit, his second wish list item is a maturity of natural language processing software and technology. That software would enable data mining of dictated and transcribed reports, freeing up physicians to tell the patient story in their own version and not be beholden to discrete data fields. "I would like to mine data in transcribed reports rather than telling physicians you have to document in a certain way and put it in this box. That is time consuming for physicians. There is more pressure on physicians to document more, do more and be paid less. We want to deliver technology that makes the process easier."
Enabling physicians to dictate a progress note would free up their time. And if NLP software were more mature, other staff could use the technology to extract key data for billing or quality reporting purposes, Krouse says. That would support Ohio Health's foray into population health management, which requires deep analytics capability to identify patients with certain disease states.
Krouse's other wish list item is only partly related to technology. "I would like to deepen clinical collaboration among caregivers and collaboration among the workforce," he says. Ohio Health does offer some tools, such as Share Point, to enable that. And better integration of applications would help too. But the wish is deeply rooted in culture, he says. "Caregivers have to open themselves up to unified communication," he says. "Ten years ago, hospitals were hubs. Caregivers and physicians saw each other in the hallway, the dining room or during grand rounds. Physicians don't come as often to the hospital. But they are slow to adopt technology that keeps them well connected. To maintain that culture of being one big family in one digital space would require that they would open up their cell phone numbers or their schedules, or give the broader community ability to share data with them."
Toward the goal of fostering collaboration, Krouse envisions one other piece of technology-social networking platforms. "We are oriented now the targeted message," he says. "If I have a message, I need to know who I am sending it to. It is all about e-mail." Instead, Krouse wishes he had a type of social networking tool which would enable him to broadcast messages pertaining to a wide audience, and let the audience opt in when relevant. The tool might facilitate communications with patients sharing common disease states or even staff. "We need to have the toolsets align with how the next generation of the workforce is accustomed to working," he says.
Name: Tim Terrell
Title: Chief Information Officer
Organization: Cornerstone Health Care, High Point, N.C.
Wish List Items: Interoperability, Cloud Security
Tim Terrell's holiday list is small, but critical to the future of Cornerstone Health Care, a 250-physician group practice. The practice embraced the EHR in 2005, and has been running its Allscripts system since then to good measure, the CIO says. But the practice continues to grow, adding new physicians and merging other groups-about one per month, he says. Increasingly, the practices joining Cornerstone have been on their own EHRs and the list of vendors in play is long, including GE, NextGen, eClinicalWorks and Greenway Medical Technologies. As Terrell points out, importing data from other systems is often very difficult, and in some cases, impossible. "Having better interoperability standards across the industry is my top wish," the CIO says. "Every EHR has its own structure."
The practice's core Allscripts EHR is driven by some standard clinical dictionaries including LOINC for lab values and SNOMED for certain clinical values. But many databases in the industry are not written to these standards, or if they are, they are written to different versions. "The data integration work needed is incredible," he says. "And sometimes there is no way to join elements between two systems." In those cases, the practice saves some data as PDF image files, which suffice to meet data maintenance regulations (seven years or longer, depending on the patient's age). But the PDF files lack discrete data, which will only grow in importance as the practice moves to population health management.
Terrell hopes the federal government will continue to tighten interoperability standards. HIPAA was a start, but did not go far enough. The meaningful use program may push the requirements even harder, he says.
Terrell's other big wish for 2013 is better security when it comes to cloud-based applications. "We're in transition from the old style computing to the cloud," he says. "We like the trend of the cloud. But for health care, it can be intimidating from the standpoint of security." Current security regulations, he says, are designed as if protected health information resides on an organization's server housed locally. But with more and more data being stored on remotely hosted Web sites accessible via the Internet, security is no longer is direct control of the provider, Terrell says. "We are in a dangerous intermediary time. If data is stored in a cloud, you don't have access to where it is stored, who has seen it, how secure it is. If data is on my servers, I can run a query and pull out records of who has accessed protected health information. If someone is outside the company and does that, I would never see in my application audit log."
Cornerstone is building out a data warehouse, using Terra Data. The vendor's warehouse will be cloud-based, which to Terrell offers some big operating advantages. "They will take care of scalability and growth," he says. "Instead of us investing in a capital expense of scaling a data warehouse, they will charge us a monthly fee." The warehouse will include claims, clinical and patient generated data from remote devices. Terrell says Cornerstone is working diligently with the vendor to assure security, but in the long term he would like to see federal certification programs in place for data security.
Name: Subra Sripada
Title: Vice President, Chief Information/ Administrative Officer
Organization: Beaumont Health System, Royal Oak, Mich.
Wish List Items: Mobile Device Security, Vendor-Neutral Archive
Security is foremost on the wish list of Subra Sripada, who oversees the I.T. operations at three-hospital Beaumont, which generates $2.2 billion in annual revenue. The health system has been running an Epic EHR for five years, a system used by 700 employed physicians and some 2,300 affiliated ones. The health system is widely automated and has attained Level 6 on the HIMSS Analytics 7-rung scale of I.T. adoption, a perch occupied by only a small percentage of hospitals nationwide.
Sripada cites security as his top concern. "The fundamental way of delivering information is changing," he says. "We moved to 'bring your own device' two years ago." As physicians and others have clamored for network access privileges through smart phones and other devices, Sripada has faced a growing challenge: how to secure those devices. "We have Epic running on iPhones, and it's easy to lose those devices." He is currently investigating three vendors which offer network device management capability and hopes to have a system in place in 2013.
The considerations are many, however. Sripada has to analyze how well the monitoring software would work with Epic, how easy the system will be for his staff to deploy and manage, and how it would fit in with his operating environment. "We're trying to see what is smoke and mirrors versus what is real," he says. That entails vendor demos and reference checks.
Sripada's other big need is a vendor neutral archive. As Beaumont ascends the EHR ladder, the amount of data it is accumulating grows. The hospital's total data archive has exceeded 2.5 petabytes in aggregate and Sripada says he could spend $2 million annually just to feed the growth of his indigenous systems, where data currently resides. "Our storage costs are spiking," he says. He's looking for a vendor to step in and solve the problem. Beaumont needs a storage archive to house not only radiology images but also EHR and other data. State law requires him to store patient records for 11 years, or longer for children. But not all data needs to be immediately accessible.
He's looking to a vendor who can offer a repository in which access is tiered by immediacy of need, with older records being stored in such a way that is less costly but requiring more time to retrieve them. The archive will set the stage for Sripada's other need: expansion of medical devices integrated with the Epic system. Currently, Beaumont has integrated its ICU and emergency department monitoring devices into its Epic system, sidestepping the need for nurses to re-enter data from the devices to the EHR. The device integration was a hit with the medical staff and nurses, who are now clamoring for more data feeds. "We have a long list of what to do next," Sripada says, adding that the medical staff is prioritizing its requirements. He figures that trapping ventilator and EKG data will be the next move.
Beyond that, Sripada envisions a day when clinicians and administrators can not only retrieve data quickly through the EHR and other systems, but create their own business intelligence reports as well. "In the legacy model, I.T. would create reports," he says. "Now we are moving to giving users access to data." Beaumont has installed software from QlikTech, a self-service data mining vendor, and hopes to expand its use in 2013. "We need data transparency," the CIO says.
Name: Bill McCoy, M.D.
Title: Chief Medical Information Officer
Organization: Metropolitan Health Networks, Boca Raton, Fla.
Wish List Items: Cooperation, Push Technology
Bill McCoy understands that the future of medicine is wrapped in clinical I.T. But his primary need for the future is not technology. "Cooperation with providers" is how the CMIO describes his most pressing requirement for the future. Metropolitan Health Networks runs a provider services network focused on adult primary care. With 80 employed physicians, the publicly traded company is reimbursed through at-risk Medicare contracts. It also contracts with hundreds of other primary care physicians in some 200 practices.
Metropolitan is transitioning its employed base of physicians to an EHR, from eClinicalWorks, using a vendor-hosted version of the ambulatory software. McCoy figures all the offices will be live on the system by the end of 2014. The practice operates under the patient-centered medical home model, which McCoy describes as "primary care quarterbacking." The I.T.-rich model calls on primary care physicians to orchestrate care delivery among specialists and uphold various quality measures along the way.
Technology, McCoy says, is not the hurdle to the model's success-getting various external providers to cooperate and share data is. "Some hospitals don't want to give up their data," he says. "If a patient stops at the emergency department, or gets admitted for something unrelated to what we are treating them for, we are at the mercy of the medical records department to send us a discharge summary," he says. "If a patient has been in the local hospital, we want to see that patient in three to five days. But it takes an act of Congress to get the discharge summary."
McCoy's I.T. arsenal includes some tools to enable better exchange of data. Its eClinicalWorks EHR, for example, includes a secure messaging app built into the system. Hospitals or specialists can participate by signing up through Metropolitan. "It is getting the person on the other end to change their behavior that is difficult," McCoy says. "No one has said they won't do it, but they are dragging their feet. They are used to the fax machine."
There is one piece of technology McCoy would like to have: a vendor-agnostic piece of software that would "push" relevant data back to the practice from contracted physicians. The set-up would resemble a private health information exchange, with data from the contracted offices being delivered to a central repository operated by Metropolitan. McCoy is just beginning to investigate vendors that could deliver such technology, with DB Motion among the candidates. He'd like some text mining capability built into the system, so he could more easily scour text narratives for critical data not captured in a discrete format.
The group is currently trying out one natural language processing vendor to mine data from "long rambling dictations" produced by physicians. "We need to pull out the diagnosis and we need to mine the data to see if the physician is ordering the right tests and noting all the diseases," McCoy says. "It would be like a chart review, which, without technology, requires a person paging through the notes and reading everything. You can't hire enough medical directors to do this."
The text mining tool could even be used in capacity with his own physicians who dictate most of their notes on the eClinicalWorks platform (which also has the capacity to capture structured, discrete data). McCoy says that the potential of EHR is promising, but that the industry needs more mandated cooperation for it to take hold. "We are just scratching the surface about using technology most effectively for patients," he says. "The way I'll get cooperation more quickly is some sort of stick. If the government says to providers, 'under these circumstances, with the right security and business relationships, with the right documents, you must cooperate,' it would happen. Ethically, it's the right thing to do. The ability to coordinate care and keep people out of the emergency room would increase dramatically."
Name: Charlie Santangelo
Title: Vice President and Chief Financial Officer
Organization: Susquehanna Health, Williamsport, Pa.
Wish List Items: CPOE, Registration Scorecard
CFO Charlie Santangelo has one overriding wish when it comes to I.T. "We need information systems to help lower the unit cost of departments throughout the organization," he says. Operating efficiency is tops on his mind. Susquehanna's four hospitals generate some $500 million in total revenue, but Santangelo says the costs associated with earning that revenue can be driven down. His mantra: "perfect billing," an ideal state in which physician work is captured accurately at the get-go and then billed appropriately-without reworking rejected claims.
Toward that ideal, Santangelo would like to see an expansion of the health system's CPOE system, from Siemens, as the first step. Susquehanna is currently using electronic order entry on the inpatient side of the house, with nearly 90 percent of related orders entered electronically by physicians. "We need CPOE on the outpatient side," he says. The health system is in the process of building out the system for its 150 employed physicians, and Santangelo says it will come online in 2013. At the same time, the health system is expanding its Siemens financial system, which offers an integrated billing module.
In the integrated model, physician orders from the clinic or for outpatient services such as lab would draw on data from a master patient index, which includes insurance and demographic information. The system connects to payers, who in turn verify electronically if a given test is covered. "If it appears a test isn't covered, we can show the patient they may be responsible," Santangelo says. An all-electronic transaction would reduce the cost of the department offering the affected service, he adds. Processing orders that originate in paper requires rekeying. Ordering tests electronically "may add a little more cost to the practice but lowers the cost on the back-end and more importantly it reduces the chance of errors," he says. Currently many orders are billed without a preliminary diagnosis, a missing piece of information the integrated order entry/billing system would catch.
The first step is to deploy the orders system in the practices of the employed physicians. After that project, Susquehanna will bring on affiliated physician offices. The system, Santangelo says, will have to be user-friendly for the physicians and their staff. "The connection would be a great patient satisfier," he says. "Every time there is a mismatch between their condition and what the lab test is, it won't be paid. It is a great patient dis-satisfier. Payers tell the patient they have to get the diagnosis changed by their doctor to pay. It happens more than we want it to."
Santangelos's envisioned set-up would preclude problems down the line with payers. "Bills should be going to payers electronically, with electronic payment coming through, no manual touching-that is the way it is supposed to work. When you get a rejection from payers, somebody has to make phone calls and send e-mails. I can't lower the cost of billing if I'm chasing down rejections."
The CFO's other dream item is what he calls a "registration scorecard." The data analytics tool would assess the performance of his registration staff, offering insights into the accuracy of data being input and how much manual intervention is later required as the data feeds into the revenue cycle. Santangelo says a few bolt-on tools exist that might work, but he's unsure how well any of them would perform.
Name: Harry Greenspun, M.D.
Title: Senior Advisor Health Care Transformation and Technology
Organization: Deloitte Center for Health Solutions, Washington, D.C.
Wish List Item: Innovation, Insight
When the topic swings to innovative technology, Harry Greenspun brims with enthusiasm. "This is the most exciting time in health care in 30 years," he says. "There is an alignment of incentives, tremendous innovation and a lot of great thinking brought to the industry."
There's also a missing piece that Greenspun says would spur adoption. "CIOs need a clearer view into the innovation community," he says. "They are asked to provide mobile devices, telemedicine and consumer connectivity. There is a huge world of innovation they could tap into. But it's impossible to track what is available. It's difficult to vet a company [providing needed technology] and understand their viability. Do these companies offer a real product? Keeping tabs on that is very challenging and takes more time than CIOs have to spend."
Greenspun says member associations and other organizations in the industry could do a better job of facilitating vendor introductions and offering a way to assess products.
"The industry needs to ask CIOs: what issue are you trying to solve?"
Common Wish: Regulatory Stability
While CIOs have many particular needs for their operations, they share one overarching concern. They'd like better clarity, if not outright relief, from an ever-growing list of federal regulations governing their operations. A better sense of "regulatory certainty" is tops on the holiday list for Michael Krouse, senior vice president and CIO at Ohio Health, a 17-hospital delivery system based in Columbus. The regulations in play include ICD-10 (postponed to 2014), meaningful use (under fire from certain Republicans), and ACO payment models (reinforced in the federal health reform legislation). "We are working hard and fast and will try to be compliant with all the regulations," Krouse says. "But we would hate to find ourselves in a position after doing all that work that it doesn't matter anymore."
The ICD-10 deadline, which CMS once asserted was set in stone for 2013 deadline (then subsequently shifted to 2014), is a moving target for many CIOs-and some experts contend that the federal government has lost credibility on its pronouncements about the regulation as a result. Many CIOs looked at the most recent postponement of ICD-10 with a mixture of relief and dismay-relief in that a resource-draining project had been delayed, but dismay in trying to regroup yet another effort around compliance.
For Chuck Christian, CIO at Good Samaritan Hospital in Vincennes, Ind., ICD-10 and meaningful use Stage 2 are "on a collision course." Reporting deadlines for meaningful use and ICD-10's go-live converge in October 2014, a timeline which Christian says will be very challenging for smaller hospitals to fulfill. "The timing of the programs is like juggling running chainsaws," the CIO says, adding that Stage 2 ups the ante on quality reporting requirements. "I wish that we had done ICD-10 a long time ago and had it in place before meaningful use came about," he says.
Christian describes an industry in conflict over ICD-10. "There are competing agendas," he points out. "AHIMA [the American Health Information Management Association] says 'let's get it done,' while others say 'slow down, we're not ready.' The question is: who do you listen to?" Christian says that last summer's delay on ICD-10 helped his hospital, and he predicts Good Samaritan will be prepared on schedule. "Payers are the ones that will struggle," Christian says. "They have more customized systems." Thus, some claims may be rejected, or stalled, he says, echoing a common industry concern. "If you can't bill with the appropriate coding, or the coding is wrong, it will negatively impact reimbursement. Just because we can produce the transactions doesn't mean someone else can process and adjudicate them. We will need to be able to monitor and audit that. A lot of things are hanging in the balance."
Other industry observers say the variety of agencies in play with federal regulations create confusion industry-wide. "We need clarity and coordination of regulations," says Harry Greenspun, M.D., senior advisor health care transformation and technology, Deloitte Center for Health Solutions. "Many agencies have responsibilities for overseeing parts of the industry in quality, safety and mobility." Greenspun describes the regulations around mobile devices for consumers as "happening in siloes. You have the FTC regulating the device, the FDA wanting to weigh in, and other parts of HHS pushing consumer engagement through these apps."
To Christian, the regulatory stability so many of his peers seek may be long in coming. "The industry won't ease up anytime soon," he says. "It won't make a difference who gets elected. We are still in a situation where health care costs are unsustainable. Even if the GOP repeals reform, or parts of it, we have to go back and answer the question of how to provide broader coverage without breaking the bank of the United States."