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Physician Centered Design of Electronic Health Record Systems

Development of healthcare software and implementing enterprise healthcare IT systems and software has a major hurdle. Often the people designing the system have little experience in using the tool they’re creating. It is rare that a healthcare program used by a physician was designed and created by a physician. Good design should make things easy to see and do, but the tendency in clinical healthcare IT is to show every piece of information regardless of how meaningful it might be; bogging the physician down with noise. This is further compounded by the fact that clinical healthcare is incredibly complicated on its own. The good news is that much of the complexity of healthcare software can be mitigated with good design practices around the physician experience.

Problems in Current Healthcare IT Design

The major issues facing clinical healthcare software design are:

It is difficult for a physician to find the meaningful information necessary to make decisions.
Physicians are required to do extra clerical documentation necessary for non-clinical purposes.
Common workflows are not minimized for work-time by the physician.
Operational requirements within the organization do not support rapid clinical documentation.
Personalization of the system by physicians is insufficient for their needs.
Too many alerts hide important automated clinical decision-making tools

Because of these problems, The Annals of Family Medicine in Oct 2017 found that physicians spend 6 hours of their work day during and after office hours interacting with the EHR. A 2017 time motion study of the physician day by the Society of Teachers of Family Medicine Journal found that 43% of a physician’s visit accounted for EHR interaction.

These factors led to the Mayo Clinic’s 2016 finding that clerical tasks in the EHR was one of the leading contributors to physician burnout.

Fixing the Design

All changes to physician centered design are in three categories.

Improving user interface (UI) that increases the efficiency of operations.
Simplifying the interface to make the right choices easier, presenting all and only the information necessary to complete the task.
Doing everything that the computer can do on behalf of the physician.

Improving the efficiency of your UI is more of an art than a science. Common strategies include leveled functionality, identified and optimized workflows, and layered details.

Leveling your functionality, or gating, is a process to selectively show more powerful and complicated tools to super users, while showing an easier functionality to general users. Individuals learning functionality might start with a bare bones selection of tools, and slowly graduate to higher levels of use. In this way, we avoid overwhelming physicians with choice while providing maximum complexity to the users who can appreciate it.

Optimizing workflows translated directly from paper systems, or the previous antiquated EHR, can be a complicated process. There is no substitute for shadowing a physician and watching, measuring, and documenting every step they take both in and out of the system. Use that shadowing time to determine what the most common workflows for your users are; and then pull out any step that unnecessarily slows the process down. A click to a different page that needs to load, another manual login, or even picking the patient off a list; every step removed adds significant value to a physician’s week. Each change is multiplied by the number of patients accessed by the physician. In high volume practices, this can be up to 80 patient charts per day!

Layering details, or selectively showing commonly used information and hiding or abstracting the less used components in an accessible way is another technique that is used to improve efficiency. This technique also assists in simplifying your UI to be more easily used. Mechanisms include; collapsible details, tooltips to allow the user to hover to see more details and using decision trees to determine which components to show. Note: it is important to show in some fashion that there are more details to be seen – otherwise it is easy for a user to miss this functionality.

Looking at the Mayo Clinic study, one large area of physician burnout is caused by physicians having to do documentation that was once the province of data entry specialists and front desk staff. These are the clerical tasks of managing an electronic medical record. Many of these tasks are not due to computer use, but rather the compliance office, state, and federal requirements such as Meaningful Use. While some of these guidelines can’t be avoided, such as marking that a physician has reviewed allergies each clinic visit, many of these actions can be abstracted or combined. For example, instead of one click each for allergies, medications, and history, a designer of software can combine these actions. Instead of manually signing their verbally given orders, these actions can be signed along with the open chart and notes. Clinician notes themselves can be further streamlined using templates and automated links to various pieces entered by interfaces to other systems, nurses, MAs, and front desk staff.

In the spirit of letting computers do the computer work, many elements of medical care are protocol driven. Some examples of protocol driven care are: determining appropriate tests that can be administered, refilling prescriptions, delivering chemotherapy to treat cancer, or many treatments in orthopedics. Using decision trees, and physician designed protocols, many of these treatments can easily be handled by the computer without day-to-day physician interaction. Where decisions need to be made – creating a set of nursing review protocols can create care that is delivered in a less costly way that removes the burden from physicians.

In situations where protocol can drive care, but patients need to be given information or a clinical design needs to be made; the patient chart can be used to alert a physician. For example, “Your patient hasn’t had an Hg A1C recently for their diabetes chronic disease management” while adding a button that orders the lab with a single click. Many of these alerts can even be handled by nursing staff by protocol to ease the burden on the physician. With a verbal message that is automatically signed with the chart, a physician is alerted with the minimal amount of interaction.

While letting computers do the computer work, it should be possible then to provide all patient information necessary to do a single workflow on one screen. Avoid bouncing between different tools that each has its own loading time. These One-Stop Shops allow physicians to focus on one task a time and helps a clinician to make informed choices without having to hunt down elements to the task.

The Role of Artificial Intelligence in Healthcare Software

In the spirit of having computers do the computer work, in today’s world we can also have the computers do some of the physician work as well. While this subject is deep and involved, we can graze the surface here.

There are many types of artificial intelligence that can play in the healthcare arena. AIs we are most familiar with are voice recognition in transcription (Dragon, M-Modal Dictation, etc.) and many forms of text searches through a patient chart.

Popular AI in the news today is in the use of neural networks to do supervised or unsupervised learning on healthcare data sets can speed the physician workflow. For example, by learning the most commonly used sets orders by a physician, we can recommend these orders and prepopulate many of the order fields on their behalf.

Neural networks can also be used to conduct raw research by finding relationships between unexpected elements of data. It could then be used to form the framework of the research paper, leading to a faster communication of findings and peer review.

Within the population health management model, neural networks can help determine who is managing their chronic diseases well and learn to leverage the information to suggest changes in care. This model would learn which treatments are more effective given a set of comorbidities, more narrow lab result values, or other collections of drugs. Then, these findings can be turned into another research paper to share what it has learned with other healthcare institutions.

Artificial intelligence and decision trees could be also combined to replace many individuals in health triage – helping patients achieve faster results at a lower cost to the health network while involving the physician only when necessary. Given the popularity of Siri, Google Assistant, and Alexa – these in-home AIs could bet trained to conduct the nurse triage without physician involvement. Given access to the patient charts through a portal, this system could also create appointments on behalf of the patient given the triage results.

The hardest part of building an AI for healthcare is getting access to the data necessary for training. This information is generally walled off due to privacy and HIPAA concerns.

Benefits of Physician Centered Design

Employing these design principles both in the production and setup of your electronic medical record, or clinical focused IT systems could save 10 minutes of the typical 45 minutes spent on a typical primary care appointment.

This time could be used in two ways:

Make the physician’s day shorter – improving physician happiness.
Improve patient throughput by up to 30%.

Focusing the clinician’s time on patient care and less on clerical activities allows the physician to do what they love, patient care, which also helps with reducing the rate of physician burnout.

Also, making the physician’s job easier; rapidly and easily providing them with information needed to make decisions, and assisting with the decision-making process will also help improve overall outcomes for the patient.

Employing these principles at your organization while creating or implementing healthcare software will speed the delivery of care, improve physician and patient satisfaction, and improve outcomes for patients.

For details and methodology on how to implement these principles or artificial intelligence at your organization, contact me through email or my LinkedIn page.

By Stephan | April 11, 2018 | Uncategorized | 0 Comments | Like

Leveraging your EHR to Support Clinical Research

In December of 2016, the Cures Act was signed into law. It provides an additional $5.8 billion in funding slated specifically for clinical research. Its areas of focus are substance abuse, mental health, brain disorders, and pushing for cancer cures like targeted therapies and immunotherapy. One of the biggest tools at the disposal of large academic research centers is the installed Electronic Health Record (EHR). Leveraging this system for clinical research can have a significant impact on both grants received from this fund, but will also enable your organization to use those dollars more efficiently.

The tasks a EHR can do to improve your research related tasks are:

Automated Billing to Research Studies
Identification of Study Candidates
Conducting New Research

DNA Research using EHR

Automated Billing to Research Studies

For Healthcare Research studies; treatment that is standard of care should be billed to the payer directly while treatments that are specific to the study should be paid for by the study’s funds directly. This is the most obvious application of the EHR and the first objective large academic medical research centers reach to overcome. Overall costs are lowered because staff is no longer required to manage work queues – these billing professionals can then be tasked to other needs. Additionally, revenue cycle is improved by having the EHR sort billing requirements.

To redirect these charges automatically, the system needs to understand what research studies exist, what kinds of charges should be sorted between payer and study, and which patients are on studies. This usually takes 0.25 to 1 Full Time Employee (FTE) to maintain – and is usually easy enough to manage that research coordinators could be trained to manage it themselves. Depending on your system build and vendor choices, this information may be automatically updated from your CTMS using an interface.

A Clinical Trials Management System (CTMS) can store information necessary to update your EHR. The best one on the market is Forte’s Oncore, and we highly recommend to use Oncore for your CTMS. This system manages research studies, patient management, investigator management, and regulatory compliance. Your health record system is not designed to be used as a CTMS – however it does manage patients well and holds study information for billing purposes. Using standard HL7 interfaces, these systems can talk to each other well enough that very little manual intervention is necessary. Using an interface can reduce duplicate data entry, removes the need to maintain paper copies of studies, improves research coordinator efficiency, and increases the reliability of the underlying study data.

Identification of Study Candidates

Finding candidates for studies can be difficult – often the specific combination of conditions reduces your cohort to a scant few individuals out of the entire population. Using a medical record system to identify new patients that can be candidates for research studies can speed up the process from weeks to hours. This is best demonstrated through an example.

Let’s say your organization wanted to take advantage of the funding available in President Obama’s Cures Act. Specifically, the $1.8 billion in funding slated for cancer research.

In this example, your organization is researching Trametinib and Dabrafenib; recently FDA approved drugs to fight cancers associated with a mutated B-Raf gene that causes uncontrolled cell growth. If your study was to test the efficacy of these medications then the research coordinators need to find all patients who have the V600E or V600K mutations as detected by the Melanoma, BRAF V600E and V600K Mutation Analysis, THxID test. The coordinators of the study could send out information to all physicians to find these patients which would take weeks of searching for patients and would produce a low response rate. Leveraging the EHR instead would produce larger results in a shorter amount of time.

Research coordinators can proactively find patients through the EHR by:

Create a report to find all patients all patients who are diagnosed with the specific Melanoma that could be caused by the BRAF V600E/V600K genes.
They could send out a bulk communication to their oncologists to run the test.
These patients could also be sent a bulk communication through the patient portal to work with the clinic to take the test.
Interested patients from this list could have this test ordered by protocol – reducing the impact to the physician workday.
Create another report that shows all patients recently testing positive for this test.
Reach out to patients identified in this second report to see if they want to join the study.

Extending this logic – an organization would add clinical decision support tools to alert physicians that their patient is a candidate for a study based on the logic above. This alert would inform the physician to steps to sign the patient up for the study, inform the research coordinator that a new patient is a potential candidate, and set up an appointment with the principal investigator if necessary.

Using these mechanisms, trials can be filled out rapidly with a larger patient base to support study conclusions. Building decision support tools requires 1 FTE that works together with principal investigators for analysis, validation, and testing. Using these tools will enable investigators to find more patients while those patients are in the clinic and already working with their physician.

Conducting New Research

Research on anonymized patient populations could occur directly by your research physicians just by using reporting tools built into, or extended from, your EHR. Much of the data is already categorized into reportable numbers. For example, if your firm implements a new fall prevention policy. Did it work? Being able to plot out the number of fall events that happen prior to the policy, and following the policy is an easy reporting task if this information is captured in discrete fields as it is with many medical record systems today. Kaiser Permentente has been tracking information in this fashion for a decade now and has used this information in both published research studies and in their advertising materials.

Let’s say your information is stored primarily in free-text notes instead of in reliable discrete fields. How can this be used to support research? There are tools which can digest notes using various AI, natural language processing, and data mining techniques. Many of these tools, like Nuance’s Natural Language Processing suite, already interface directly into popular EHRs. Properly setup, these tools can work together to read physician notes and categorize data into reliable and actionable clinical study information. Implementing this properly requires an interface expert as well as someone who can transform the newly created discrete information into actionable reports, outreach campaigns, and clinical decision support tools.

Following the Process

Properly leveraging your electronic health record to support clinical research is challenging – and the process is different for each organization and study. While the barriers lay primarily around interfacing your EHR to other tools, building robust reports surrounding clinical data, and creating the direct clinical support tools within your system; knowing which areas to focus on first can be overwhelming.

How can Serra Health help you tackle these operational challenges?

Work with executives to identify the enterprise research goals and existing strategy
Health System EHR & CTMS Evaluation to identify gaps between current state and best practice
Report Out which includes:
- Identified gaps – with priority & significance
- Solutions associated with gaps
- Implementation costs & long-term support costs associated with each solution
- Expected ROI with each solution – including details behind numbers
- Project plan proposal
- Post-Implementation validation strategy (Evidence of achieved goals)
Agree on project parameters, goals, and timelines
Execute project plan
Validate project success using strategy outlined in the report out

Additionally, Serra Health will produce a Case Study documenting the Health System’s path to success for presentation at trade conferences that the health system participates in.

Following this process will ensure a successful project to improve your ability to leverage your electronic health record system for research studies. To start this evaluation process, you can contact me through LinkedIn or my website.

By Stephan | January 8, 2017 | EHR Optimization, Oncology, Research, Whitepaper | 0 Comments | Like

Population Health Management: Methodology

Population health is a growing topic in health care, especially with the increasing pressure to reduce the overall cost of care among the population. Managing your patient populations is critical to improving the total costs of care as studies have shown. In 2013, a study has shown that wellness care reduced the cost of health care by $60.65 per participant, and chronic disease management saved $214.66 per participant. Additionally, CMS will allow reimbursement $42.60 per qualified patient per month using CPT code 99490.

Many healthcare organizations are launching their own population health management programs to take advantage of these savings. I recently wrote an article on a personal experience that shows why managing chronic illness is important. Now I’m going to show you how to take advantage of these healthcare cost savings for your organization. This article is a systematic guide for implementing a population health program using diabetes as a specific project example.

Steps to Success:

Information Gathering
Design, Validation, Build, & Results
Project Planning

Information Gathering

What defines your population?

“All patients that receive care at our facility” might be a good definition for a wellness plan. However, sticking only to this population group, your organization might miss some of the more powerful features of implementing a comprehensive population health program.

While all care is individual, patients can be lumped together into equivalence classes known as disease cohorts. Some examples of this could be “all patients with severe allergies”, or “patients who have an active cancer and are being treated using cytarabine in a home health setting”. More granularly, your team could target all biopsies done by a dermatology clinic – the registry being active per-biopsy instead of per-patient.

Patients in a disease cohort have similar needs and can be compared to each other more easily. In our example, we’ll pick “All patients given a diagnosis of diabetes that is linked to the SNOMED concept diabetes mellitus”. This will allow us to capture all patients within our health system regardless of who did the diagnosis, or what the specific ICD-10 code was.

Having defined your population, it is necessary to include subject matter experts (SMEs) in the design and validation of your project. Usually this is a physician specialist who actively treats the disease experienced by the patient. In the case of diabetes, we’ll have an endocrinologist as the subject matter expert. Ideally this endocrinologist is comfortable with technology and excited to manage their patient populations.

Design, Validation, Build, & Results

A comprehensive population management program for a single chronic disease includes several parts:

Measures to gauge if a patient is managing their chronic disease well
Registry of the entire target population
Defined charts to visualize the status of the population
Quality improvement goals based on the metrics
Designs of tools necessary to move the status above the goal line

The key role of your SME is to define the metrics that defines if a patient is managing their chronic disease well. In the case of diabetes; intermediate outcomes for A1C, BP, and LDL are strongly linked to health outcomes for the population. These measures, along with other general health indicators like “Last Flu Vaccine Date”, are pulled into a complete registry report.

Your team can now build a registry of all patients fitting the criteria using the definition of the population and the measures identified by your SME. This registry of patients is a finite list that can be managed to provide individualized care. The report can be prioritized to address patients who are in a more critical condition. This includes all patient outreach activities, bulk orders, etc.

The second use of this registry is as the data source for visualizing the current departmental quality. To determine how well your organization is managing the chronic diseases of its patient population, further steps need to be taken. Your EHR is not equipped to view entire populations by itself. Using a Business Intelligence (BI) tool, like Crystal Reports, is critical to determining the current departmental quality and seeing how workflow and tools changes modify the population over time. Without a BI tool, Excel and Access could work.

Following this step in our diabetes example: we could pick average number of patients who are managing their disease well as one of our metrics. Our definition would be “percent of patients who have a current (<30 days old) A1C lab result of <7%”. Each month we’d plot what percent of patients have reached this goal in our BI tool, and then watch it trend over time. This represents one of the measures – and we can weight and combine these measures to create an overall quality status for the department. Note, part of this report definition is also nominating a point person, like the department manager or department head who is responsible for monitoring these reports and meeting goals.

Everything is in place to create departmental quality goals with the reports defined and the registries identified. Philosophy of goals; how aggressive they are, and accountability will vary from one organization to another. Regardless of how your organization approaches goals, these goals should be SMART goals.

One goal for diabetes quality management could be: “97% of our patients will have an A1C lab result within three months if their most recent result was A1C >8% by October 2017.” As the quality of a department improves, these goals will change.

With the goals in mind we can now develop tools for moving the quality bar. This is where the real creativity comes in. Even within disease cohorts these tools will be different from one organization to another. Each of these programs use a combination of operational, workflow, behavioral, and health record system changes. A key benefit of having the BI charts in place is that when we introduce a new change, we can monitor its effect over time. Changes without effect should be reversed or discontinued while modifications with large improvements can be reproduced with other disease cohorts. Some examples at a high level are:

Bulk Ordering based on measures
Patient Outreach & Engagement
Clinical Decision Support
Communication through patient portals

Project Planning

Using Scrum project methodology, my population health projects at client sites run in 4 week cycles for each disease managed. These projects are staggered and run concurrently.

Week 1 and 2 focus on design and validation.
Week 3 is build, validation, and testing.
Week 4 launches our program

It takes an additional month or two of up-front work to identify the high value disease targets. Completed by the project lead; this involves interviewing physician department leads, executives, and other stakeholders to define the order and budget to complete the project.

A project team would include:

Project lead / Project Manager– someone to coordinate activities of the team, line up clinical experts, and direct project work. This person is also responsible for overall project success, timelines, and progress.
Build team:
1. Report writer (including registry reports and business intelligence dashboards)
2. Clinical content builder (the tools to modify behavior within the clinics and in patients)
Subject Matter Experts – These are your clinicians who focus on treating the disease

Conclusion

Following these steps, your organization can implement a Population Health Management program. Every organization is different. Your designs will vary based on organizational structure, capabilities, budget, and your population’s specific health needs.

Once your organization has successfully implemented population health and chronic disease management, your organization should move onto continuous improvement projects following these measures or benchmark your progress against other healthcare organizations (in your area, and nationally). Additionally, share your successes with your patients and peers. Part of our mission in healthcare is to help people – and sharing your organization’s path to success with other healthcare providers can help the population of our nation and shape the conversation in the future.

If you have any questions on how your organization can complete these projects, feel free to reach out to me directly through my personal email.

By Stephan | January 5, 2017 | Chronic Disease Management, EHR Optimization, Technology, Whitepaper | 1 Comment | Like

Importance of Clinical Protocols

Clinical protocols are a collection of procedures and medications that have been pre-approved by physicians for patient care. They come in many forms and are created by healthcare organizations under the guide of physicians so that nurses can perform patient care without further physician intervention. I’ve seen protocols most effectively used to allow nurses to triage patients in telephone encounters, prescription refill requests, and treating patients in oncology though these tools are used in many other settings. Clinical protocols are an important tool for managing overall patient care while reducing workload for physicians and variance in care provided.

I’ve broken protocol ordering into two groups:

If/Then Protocols
Predefined treatment regimens which can be further Individualized for patient care

If/Then protocols are to treat patients without direct physician intervention. Typically these instructions are written for conditions that can be diagnosed with a few simple questions asked by a nurse and easily answered by a patient. Alternatively they can be utilized to rapidly refill prescriptions without physician intervention. In both cases, the burden on physicians responding to patient messages.

For example: A diabetic patient sends a patient portal message requesting a refill of insulin. The computer can look to see that the patient has had a recent visit with their PCP, updated HgA1C labs, and that their diabetes is being managed well. The computer can go ahead and refill the prescription for the patient without physician or nurse intervention.

To help nurses order patient care from telephone encounters, the best system I’ve seen on the market is Schmitt-Thompson. These protocols have been in use by many of my clients and are vetted by many physicians and through use in patient care throughout the US. The best refill protocol tool I’ve seen used is HealthFinch’s Swoop, which is a software tool that interfaces directly into your Electronic Health Record (EHR). While many of the features of this product are available through EHR systems, the designed protocols are invaluable for a quick and safe implementation.

Predefined treatment regimens are used heavily in Oncology. The concept is pretty similar to the If/Then protocols. An oncologist compares cancer type and stage of cancer against which protocol would best suit the patient. Then the protocol is applied to the patient, and individualized into a treatment plan. Once the treatment plan is setup, the physician then signs the orders. These orders wait signed until the appropriate treatment date. The patient then receives updated labs which are then compared against instructions to the nurse. As long as the lab values check out, the patient can receive chemotherapy and adjuvant care without further intervention by the physician.

In both cases physicians design the protocols in advance for the proper care and treatment for patients. This work saves considerable time for both the provider and the patient receiving care. Refill protocols can save physicians up to 30 minutes a day which allows the physician to be used elsewhere. For oncology, protocols and treatment plan creation is the only reasonable method of managing patient care. By installing a refill protocol system, Kaiser Permanente Northwest directly saved $1.2M per year in staff costs alone, and earned an additional half million through increased prescriptions.

Creating protocols from literature is difficult. It takes several dedicated physicians & pharmacists to produce safe protocols, and even then it takes several rounds of review and needs to be updated annually. For my clients, I recommend purchasing predesigned protocols whenever possible. For Nurse Triage and Refill protocols, this content is readily used in conjunction with your existing EHR. Unfortunately this content does not exist in a readily usable format when implementing oncology protocols.

In the next post I will detail the various methods of structuring chemotherapy protocols with your EHR with pros and cons listed for each. Additionally I will include notes on how to integrate standard of care chemotherapy protocols with your interfaced radiology systems, and tie both of these systems to your clinical research modules.

Tour of Oncology EHR Topics

One of my focuses has been around Epic’s Oncology module. I spent several years designing and developing this tool, and helping clients make good choices around it.

In this series I’ll cover some of the major pitfalls, risks, and choices that an organization can make with their system. These topics include:

Protocol Design: Piecemeal vs. Consolidated
Protocol Governance Strategy
Research Protocol – Clinical Focus & Billing Focus
Pharmacist Support & Mixtures
Oral Chemotherapy
Pre-visit Planning
Ancillary Services & Labs
Care Access & Patient Flow
Infusion Clinic & Workflow Design
Dual Signed Orders for Safety & Training
Dual Signed Administration for Safety
Inpatient vs. HOD vs. Outpatient Clinic Design
Blood and Marrow Transplant (BMT) Tools
Pediatric Specific Risks & Conditions
Interfaces with Radiation Treatment Plans
Future of Oncology: Immunotherapy & Targeted Therapies

Post in the comments if you’d like to see a topic featured. I’ll be starting with how to design your protocols. Specifically, what protocols mean for overall care access and physician happiness. Note that clinical protocols are used in many more specialties than oncology – but oncology is a perfect place to showcase this patient care strategy.

Chronic Disease Management: Keeping Lucy Healthy

Chronic disease management – tracking and quality improvement – is the one promise an EHR makes that rarely delivers. To be fair, almost all of the EHRs on the market offer functionality that can be leveraged to accomplish this goal, but the content must be originally created by each healthcare organization. Enabling chronic disease management is an important mission. Probably one of the most important missions an EHR can have. I will share why creating chronic disease management tools is important, the reasons why it is often overlooked, and what you can do to fix the situation.

Why is this important?

Once upon a time, I visited a children’s hospital to review their orthopedics specialty tools. Our goal was purely to learn and understand what happens to children in orthopedics hospitals. I had the privilege to witness the surgery of a 13 year old girl named Lucy, and then looked deeper at the process. This was Lucy’s sixth surgery and is now pretty routine for her. As a father, this hit me incredibly hard.

Imagine your child has Scoliosis. From a non-clinical person I’ll summarize. Lucy’s spine was twisted severely during growth. For older children who have little growth left, the spine will be fused. Nine months later they return to hard physical activity with only minor long-term impairments. For a 10 year old diagnosed with severe scoliosis, things happen differently. Adjustable Harrington rods are attached to the spine of the patient. See, the child is still growing and fusing the spine will freeze this growth. If the spine is fused at this age there will not be room in her chest cavity in adulthood for her organs resulting in severe complications.

These adjustable rods should be adjusted every 4-6 months to adjust her growth. Each surgery has a host of things to prepare for to allow the surgery to have on time. If a patient misses or is late for the appointment, they’ll lose out on the growth for the rest of her life.

To track these appointments, the healthcare organization kept the patient records in a binder kept by one of four nurses. Each nurse was responsible for a cohort of patients and were heavily involved in the lives of the family. Above the desk of each nurse was a filing system labeled by month. Each month held the records of the patients that the nurses needed to reach out to in order to schedule the patient’s next appointments. As the patient received a new surgery, the book was moved to the next month of contact.

Now imagine what happens if the nurse wasn’t able to come to work for a large period of time. What would happen if the nurse made a mistake and missed the contact by a month or two. What happens if the record was misplaced, or someone accidentally removed the record? Imagine a fire. This patient does not receive the care they require and therefore are affected for the rest of their lives.

Chronic disease management can address this risk, and raise the bar. I could tell you similar stories about diabetes, heart disease, dermatology biopsies, asthma, kidney disease, HIV, Parkinson’s disease, and others. These can all be managed to great effect using the chronic disease management tools within your EHR.

Why is this overlooked?

Chronic disease management is hard on the surface. A lot of technology, organizational stamina, determination, and culture needs to come together to make it happen.

A well-crafted EHR with robust reporting capabilities needs to be installed. Most mid-sized organizations in the US only recently installed their EHR once the HITECH act was signed into law in 2009. For them, the technology to even undertake this mission was only recently available.

Most healthcare vendors I’ve been a part of are wary of offering this content out of the box due to liability. Therefore all content must be created originally by each organization. Since they’re recreating the wheel, they need to think of all of the lessons learned themselves. All of this takes physician involvement – a group is usually focusing on treating patients in real time.

What can you do to fix the situation?

Launch chronic disease management registries, quality metrics, and associated quality improvement tools!

Find a consulting firm that has setup disease registries, patient cohort management, quality improvement, care access, and best practice alerts before in the EHR you have installed. This firm will help you avoid some of the common pitfalls other healthcare organizations have hit.
Enlist a physician champion from each specialty to design the quality tracking metrics and reasonable organizational goals for their largest disease cohorts.
Design reporting registries that list all patients from the disease cohort along with these quality tracking metrics.
Build reports displaying trends over time matched against the organization goals.
Create operational plans involving tracking and responding to these goals, patient outreach, and physician compliance.
Build out decision support tools like best practice alerts to encourage physicians to take additional appropriate actions to support the disease management.

What are the benefits of tackling chronic disease management?

You will save a lot of lives.
You will improve the quality of life for many patients suffering from chronic diseases.
You will reduce the total cost of care as patients manage their treatment better.
You will improve your organization quality metrics which may attract new patients.
HMOs and ACOs will reduce their total expense – saving money.
CMS will allow reimbursement $42.60 per qualified patient per month using CPT code 99490.

Creating a solid operational plan around chronic disease registries will empower your organization to help patients more reliably, reducing expenses for patients, and earning the CMS chronic disease management reimbursements. Adding quality tracking metrics to this report will also allow your group to track its progress in population management.

To read more articles like this follow my blog at www.healthtechhero.com.

If you’d like to have a conversation about how your healthcare organization benefit from chronic disease management tools, you can contact me directly through email or my LinkedIn page.

By Stephan | February 19, 2016 | Chronic Disease Management, EHR Optimization, Personal Experiences | 0 Comments | 3

18 Projects to Recover the Expense of Installing an EHR

Partners Healthcare, has recently reported they “expect a $200 million hit to profits over three years from expenses tied to implementing the new electronic health record (EHR) system.” The EHR in question is Epic. While I cannot speak to this implementation specifically, I have seen this same problem at the other eighty or so organizations I’ve investigated. These organizations were able to mitigate most of these financial losses, rapidly turning them gains following an Epic installation. Take advantage of the features of your new EHR to recover the expense of its implementation.

Some losses are expected following a large enterprise EHR roll-out. The newly installed EHR is unfamiliar to end users. For large scale Epic implementations a reduced patient schedule is absolutely necessary to maintain patient satisfaction and physician sanity. This is the strategy that Epic endorses and Partners employed for their implementation.

There are a number of actions any organization can take when faced with the challenges of year-over-year losses related to the implementation of an EHR like Epic. I’ve broken up the challenges into a priority based on opportunity cost. Your mileage may vary.

Minimize schedule reductions prior to Go-Live by:

Train physicians to use EHR with specialty focused content.
Train physicians in basics before go-live and in efficiency tools several weeks after go-live. Advanced features come much later.
Minimize system distractions by only having content physicians need to see on the screen.

Following Go-Live make sure you:

Produce robust financial reports – this is your guide book to future changes.
Reduce claim denials – through proper E/M coding, documentation, and diagnosis setting.
Capture all charges – through a charge capture activity or automatically in your native ordering system.
Make it easy to close encounters in a timely fashion, and encourage your physicians to do so.

After your organization’s EHR is stable, ensure you:

Keep your referrals in house through a guided referrals system.
Eliminate excess readmissions as defined by the ACA (For example: Partners Healthcare is estimated to pay out $1.2M in penalties for 2016 based on government reporting!).
Reduce hospital acquired conditions penalty leveraging your shiny new EHR.
Improve patient portal and enable e-visits to improve access to care.
Address care access metrics and reduce patient wait times.
Optimize your EHR for each specialty.
Reduce variation in care.

Advanced organizations then:

Build chronic disease registries and an outreach program around these disease metrics.
Improve chronic disease metrics with specific quality improvement projects.
Setup physician approved protocols for nurse triage and prescription refills.
Structure your IT team around departments and not applications.

While many of these projects have challenges and take time to complete, addressing each of these will enable your organization to avoid or mitigate many of the losses related to the installation of a new EHR.

I’ve helped organizations in each stage of development achieve these goals and have seen the results of their labor. I’ll be detailing each problem, solutions, and benefits on my blog. Let me know which challenges you are facing today and we will start there together.

By Stephan | February 17, 2016 | EHR Optimization, Healthcare Organizations, Partners Healthcare | 0 Comments | 1

Welcome to Health Tech Hero!

Working to make this blog the place to go for ideas on optimizing your Electronic Health Record (EHR). There are a number of topics to write on, and I’m excited to get going! Initial focus will be on clinical usability and IT maintenance cost reduction. After thoughts on those topics are established we’ll move on to care access, revenue cycle, patient portal systems, and health plans.

A bit of my background: I’ve spent five years designing and developing EHR technology. In my time at this well known software company I’ve analyzed the setups and interviewed the clinical staff of over eighty of the largest healthcare organizations in the world. Many of these organizations have similar pain points in their system setups, and those common themes will be explored here.

Feel free to contact us for comments, advice, inquiries, system assessment, or any other topic. Find me in ‘Contact Us’ page.

By Stephan | February 14, 2016 | Plan | 1 Comment | 2