I was recently interviewed for this article on the role imaging informatics plays in an integrated, consolidated health system. Have a read.
Change Management
Why should you work here? No EMR!
This article has some great observations and sound bites, including the mention of a hospital promoting the lack of an EMR in their employee recruiting ad as a reason to work there.
Health IT is often touted by IT professionals (myself included) as necessary for the digitization, consolidation, aggregation, integration, access, and exchange of a patient’s information.
The article describes how the introduction of an anti-social third party—a computer with an EMR on it—affects the physician-patient relationship.
It also talks about the current state-of-the-art for user experience design within EMR systems.
In an example of a near fatal medical error involving an EMR, it mentions a phenomena often known as “alert fatigue”, whereby a system provides so many alerts, they become ignored (or disabled). IT professionals may have experienced this in poorly configured system monitoring solutions.
See this article for an more in depth explanation of the problem that caused the medical error.
In talking with organizations that are in the throws of EMR adoption, they are focused on data migration, interface development, pre-canned training, roll outs, organization redesign, and cost management. There is little time for reflection on user satisfaction or efficiency. Vendors trying to sell their solutions into one of these organizations often find it difficult, as resources are scarce and the motivation to add yet another system to manage/interface is low. Budget holders are reluctant to spend money on solutions if their pending EMR promises to have similar capabilities (even if this claim is yet unproven).
When I encounter an organization that is well past their EMR implementation, they are typically looking for ways to optimize their use of the EMR. This may involve configuration changes to the EMR or changes to their workflow, but often involves the use of add-on solutions to fill gaps, or “hacks” to provide alternatives to the user interfaces provided by the EMR to their users.
The above observation on how organizations differ based on where they are in their EMR adoption, makes me think about this excerpt from the article…
“In the 1990s, Erik Brynjolfsson, a management professor at M.I.T., described “the productivity paradox” of information technology, the lag between the adoption of technology and the realization of productivity gains. Unleashing the power of computerization depends on two keys, like a safe-deposit box: the technology itself, but also changes in the work force and culture.”
I think that where Brynjolfsson is recommending that both “keys” are considered and used in parallel—at least where EMRs are concerned—we are more often than not using them serially. First, get the EMR in as quickly as possible (to save costs and hopefully to reap the rewards promised sooner), and only after we better understand what we actually bought and have, start to figure out how to do it right.
There may be no better way, given that healthcare institutions can’t just stop and “reboot” themselves with a system and staff that is optimized. But, one can imagine that living and working in that period following an EMR implementation, and before the age of enlightened optimization, can be painful and frustrating (and even dangerous, as the article shows).
So, maybe promoting the lack of an EMR may attract those people tired or afraid of the post-EMR, pre-optimization period, as there they can be happy. For a while.
Meaningful Use Stage 3 Rule and Imaging
At 3 pm ET on March 20, 2015, CMS released the Meaningful Use Stage 3 proposed rule to “specify the meaningful use criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to qualify for Medicare and Medicaid electronic health record (EHR) incentive payments and avoid downward payment adjustments under Medicare for Stage 3 of the EHR Incentive Programs.”
Here is a useful overview of MU Stage 3 (not just about imaging). And here is another MU Stage 3 overview. And here is an infographic.
A quick search for any mention of “imaging” (there are no instances of the word “images” in the 301 page PDF document; I checked), and here are the main excerpts.
Page 78
In alignment with the HHS National Quality Strategy goals, providers are encouraged to implement CDS related to quality measurement and improvement goals on the following areas:
…
Appropriateness of diagnostic orders or procedures such as labs, diagnostic imaging, genetic testing, pharmacogenetic and pharmacogenomic test result support or other diagnostic testing.
Page 81
Objective 4: Computerized Provider Order Entry
…
Proposed Objective: Use computerized provider order entry (CPOE) for medication, laboratory, and diagnostic imaging orders directly entered by any licensed healthcare professional, credentialed medical assistant, or a medical staff member credentialed to and performing the equivalent duties of a credentialed medical assistant; who can enter orders into the medical record per state, local, and professional guidelines.
Page 82
We propose to continue our policy from the Stage 2 final rule that the orders to be included in this objective are medication, laboratory, and radiology orders as such orders are commonly included in CPOE implementation and offer opportunity to maximize efficiencies for providers. However, for Stage 3, we are proposing to expand the objective to include diagnostic imaging, which is a broader category including other imaging tests such as ultrasound, magnetic resonance, and computed tomography in addition to traditional radiology. This change addresses the needs of specialists and allows for a wider variety of clinical orders relevant to particular specialists to be included for purposes of measurement.
Page 85
We also propose to maintain for Stage 3 the Stage 2 description of “radiologic services” as any imaging service that uses electronic product radiation (77 FR 53986). Even though we are proposing to expand the CPOE objective from radiology orders to all diagnostic imaging orders, this description would still apply for radiology services within the expanded objective.
…
Proposed Measures: An EP, eligible hospital or CAH must meet all three measures.
Proposed Measure 1: More than 80 percent of medication orders created by the EP or authorized providers of the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry;
Proposed Measure 2: More than 60 percent of laboratory orders created by the EP or authorized providers of the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry; and
Proposed Measure 3: More than 60 percent of diagnostic imaging orders created by the EP or authorized providers of the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry.
Page 86
Based on our review of attestation data from Stages 1 and 2 demonstrating provider performance on the CPOE measures, we propose to increase the threshold for medication orders to 80 percent and to increase the threshold for diagnostic imaging orders and laboratory orders to 60 percent. Median performance for Stage 1 on medication orders is 95 percent for EPs and 93 percent for eligible hospitals and CAHs. Stage 2 median performance on laboratory and radiology orders is 80 percent and 83 percent for eligible hospitals and CAHs and 100 percent for EPs for both measures. We believe it is reasonable to expect the actual use of CPOE for medication orders to increase from 60 percent in Stage 2 to 80 percent in Stage 3 and the actual use of CPOE for diagnostic imaging and laboratory orders to increase from 30 percent in Stage 2 to 60 percent in Stage 3. We note that despite the expansion of the category for radiology orders to diagnostic imaging orders, we do not anticipate a negative impact on the ability of providers to meet the higher threshold as the adoption of the expanded functionality does not require additional workflow implementation and allows for inclusion of a wider range of orders already being captured by many providers. Therefore, for medication orders we propose the threshold at 80 percent and for diagnostic imaging and laboratory orders we propose the threshold at 60 percent for Stage 3.
Page 88
Proposed Measure 3
To calculate the percentage, CMS and ONC have worked together to define the following for this measure :
Denominator: Number of diagnostic imaging orders created by the EP or authorized providers in the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
Numerator: The number of orders in the denominator recorded using CPOE.
Threshold: The resulting percentage must be more than 60 percent in order for an EP, eligible hospital, or CAH to meet this measure.
Exclusion: Any EP who writes fewer than 100 diagnostic imaging orders during the EHR reporting period.
Page 221
A table lists the estimated time burden to attest for the CPOE rule (Measure 3 for Imaging), as 10 minutes for an EP and also 10 minutes for a hospital.
The Healthcare Revenue Revolution Continues
I continue to study how healthcare payment reform will affect services like diagnostic imaging. I blogged about it here, and here.
If you are really keen on learning about this topic, I recommend that you follow some of the links provided. Lots of info to absorb.
Now, HHS—in what is being called an ‘historic’ announcement—is making major changes towards value-based reimbursement.
Also, the trends in Revenue Cycle Management (RCM) provide insights to how the financial management leaders see things changing. This article from Healthcare IT News, titled Revenue cycle headed for a ‘new world’, reinforces the trend towards provider consolidation and predicts that RCM will be increasingly outsourced. Worth a read.
One thought I have been musing…
Will value-based reimbursement accelerate the adoption of so called Enterprise Imaging capture and integration within the EMR (using a common platform for image management and viewing)?
Up until now, the ROI on enterprise imaging has been elusive, mostly because it is compared to fee-for-service imaging, like Radiology. However, once the reimbursement model changes, and the improved correlation of images and findings across diagnostic and clinical imaging proves to contribute positively to outcomes (as I expect that it will), the capture and integration of enterprise images within the patient record may be rapidly adopted.
Article – Insurers will have to change to survive
I have been very interested in the changes to how Radiology revenues will be affected during the shift from volume to value based reimbursement, along with changes to healthcare business models in general. I blogged about it here.
I have also been interested in how Radiology will have to change their behaviors in this new environment of transparency and empowered consumers. I blogged about that here.
In this article, a healthcare investment firm details how insurers will have to change in order to compete for mind share among consumers (with choice).
Another very interesting point they make is about wearables. I agree that they are only used by so called Innovators (from the Innovation Adoption Lifecycle model) today.
But what if insurance companies start offering incentives in the form of reduced policy premiums for people that use them (and share the data with the insurer perhaps). This is much like having a security system on your home lowers the cost of your theft insurance, or smoke detectors lowers your fire insurance premiums. This would create a boom in the mHealth sector, and would likely improve outcomes through early detection and correcting unhealthy behaviors.
I wonder: Will providers and insurers compete for who knows the patient best?
Providers have the EMR data (for encounters with their facility), and perhaps from an HIE (if they are part of one). Insurers have info from payment transactions spanning hospitals, clinics, pharmacies and others.
Where will the data from wearables go? If the insurers are buying (by lowering premiums), I will bet that they get it more often that the provider.
Will wearables and mHealth device vendors be savvy enough to provide it to both? Will consumer-controlled PHR vendors (or information aggregation and brokering tools) have an optimized method for getting data from all a patient’s devices and apps into EMR systems? Will the provider’s EMR or HIE be open enough to receive and store the wearable’s data without manual data entry (or copy-paste)?
Will patient’s be willing to share this personal info with providers and insurers? I will bet: yes.
If I thought the data would help my outcome, and I trusted my provider, I would share it.
If it was certain to lower my premiums, I would share the info with my insurer. If the insurer reserved the right to increase premiums based on info that my wearable provided (i.e. if I sit on the couch too long, my payment goes up), I might reconsider.
Will providers supply no cost (or subsidized) wearable and mHealth devices (or apps) to patients? Will insurers and providers share this cost?
So, how can wearables help in Radiology? Other than sending out reminders on where and when to show up for the exam, and what to do (e.g. eating, etc.) prior to the procedure.
Enterprise Imaging – New HIMSS-SIIM Workgroup
The discussion of so called Enterprise Imaging is a hot topic. So I was very excited to read about the newly announced joint workgroup between HIMSS and SIIM. I believe it holds a lot of promise.
In my experience, there is no lack of technical solutions for capturing, managing, discovering, accessing and viewing enterprise images and related information. The challenge is discovering and sharing the knowledge on best practices of how to put it all together and how to operate the systems that manage this information.
Like diagnostic imaging exams, enterprise images are part of the patient’s medical record, so understanding how they should best be incorporated into the EMR is very important. And this is not just a technical discussion, there are lots of issues around policies and governance of the data that organizations—not their vendors—have to get a handle on.
This is why this workgroup is so important. HIMSS knows all about EMR solutions, and SIIM knows imaging informatics. A perfect marriage.
Creating Practical Value in Practice (of Radiology)
There is a lot written these days about the shift from volume-based to value-based in Radiology (and other medical specialties).
The thing is: volume is real easy to measure. And what gets measured, gets managed.
So, how do we measure value?
One can measure the time it takes to complete the report, sign it, and make it available to physicians and other members of the care team. Radiology practitioners call this Turnaround Time (or TAT). This is pretty easy to do.
We could try to measure whether the report is correct. In other words, is what the Radiologist concludes actually what is wrong (or not wrong) with the patient? This can be harder to measure, as it may take a lot of work to correlate many different data points, or a lengthy period of time for proof to be found.
There are a couple of activities that Radiologists, and other people working in the department, can do to improve the perceived value of Radiology.
In this article, a number of suggestions are made as to how to increase the visibility of Radiologists, as well as improve relationships and trust among other physicians and even patients.
And this WSJ article focuses on simply improving the clarity of the report by improving the language and writing skills of Radiologist. Seems obvious as to the value this would provide, when you read it, but how many Radiologists routinely attend training on how to communicate better?
While improving how Radiologists interact with the outside world—whether through better interactions or better writing—will help the Radiologist’s career, one would hope that it would also improve care. Better communication certainly couldn’t hurt.
My First Year as a Consultant – What I have Learned
It has now been over a year since I became a consultant. I have learned many, many things and met some amazing people. I thought I would share some of the things that I have learned.
What was the hardest part of becoming a Consultant?
In past roles, I had direct reports and responsibilities of deliverables and operations. I had authority to make decisions, within my defined scope of control. So, I would make decisions, and instruct people to act. As a consultant, you provide recommendations. You use words like “I have observed…” and “According to my evaluation…” and “It is my recommendation…”. It was not really all that hard to make the shift, but changing any habit takes work.
To be honest, becoming a consultant was never a dream of mine. What attracted me to it was the variety of interactions and the opportunity to work on interesting projects. And getting to choose who I worked with. I have been really lucky to work with some great people at my clients, so I am enjoying it quite a bit.
Why Hire a Consultant?
I have found three main reasons people engage a consultant.
Capability
They lack some important skill set in their organization for some short term project. An example is preparing and managing an effective RFP process.
Capacity
Staff is too busy with the day-to-day operations to take on the work of an additional project.
Neutrality
There is a perception of bias among some stakeholders and they need an independent analysis and recommendation.
My Advice
Clients come to me with a wide variety of problems, but my overarching advice is usually the same. You need 3 things: To know (honestly and accurately) where you are; To know where you want/need to be, and; The right amount of talent to get there.
The first item can often be the hardest as our perceptions can skew our reality. The second requires some vision and input and collaboration from lots of viewpoints. The last sounds hard, but it is actually the easiest of the three. You just need the will to seek the talent and to commit the resources to getting it. If the first two steps are done right, the necessity of investing the resources is usually pretty obvious.
The first step to change is admitting that you can’t stay where you are.
Imaging Informatics Knowledge
I have found that there are a number of people that are skilled in HL7 integration (though still not enough to complete all the interfaces needed fast enough), but the level of knowledge in DICOM and IHE is less than I expected. A lot of problems can be solved if one understands the purpose of the information models and transactions that DICOM and IHE have built. The importance of ongoing learning in this area, such as by being a SIIM member and getting involved in that community, is more important than ever.
What is the best PACS (or VNA, or Enterprise Viewer, or other product)?
I get asked this all the time. The answer is always “it depends”. And, I am not trying to use consultant-speak, but it really depends on what you are try to achieve. If there was a one “best” vehicle for everyone, we would all be driving (or flying) it. Different products have their strengths and weaknesses. If you know your business goals, you can define requirements, and then assess the product (and vendor) as to the fit to your needs. Coming up with methods to verify vendor claims, and validate that the value claimed will be realized in your environment, is another important step in the process. The key is designing the right level of “test” (which will have a cost) for the level of risk that the capability represents.
In Closing
I actually learned a lot more than what I listed here, and am happy to share everything I ever learn …with my clients. 🙂 I will post a similar summary after Year Two and see what wisdom another year brings.
Article – CDC on EHR errors: Enough’s enough
In this article, the CDC has issued a warning on the issues of user interface design when presenting patient information in EHRs.
As the examples in the article illustrate, having information in digital form is not enough. It needs to be presented in an effective way to ensure comprehension. After the current wave of information digitization and consolidation (moving information from disparate, departmental clinical information systems into a single large enterprise system), the next wave of effort needs to be on privacy/security, accessibility/reliability, and usability, or the incredibly high potential gains will not be realized.
Users need to trust the system, it needs to be there when they need it (wherever that is), and they have to want to use it.
P.S. Here is an infographic on EHR adoption.
Report – Second Annual Practice Profitability Index: 2014 Edition
This report is well-written (in plain language) and is worth a read. While it does not specifically refer to medical imaging practices, the trends are consistent.
My clients are certainly facing similar challenges, especially declining (or changing) reimbursement, changes to adopt ICD-10, and “ripping and replacing” systems. The shift from independent private radiology practices is also shifting to very large groups (consolidation) or hospital employment.
Don K Dennison 