Summer 2012  
The Complete Electronic Health Record: The Necessity of
Interfacing Devices

By Joseph Borzilleri, Senior Consultant
It's an exciting time for our industry right now as health organizations across the country are focused on implementing electronic health records. Thanks to the meaningful use initiative, organizations are motivated to store patient data into a singular and complete record. There is an immense value to the patient and provider relationship that these integrations will provide. One way to achieve this synergy is developing interfaces into and out of the Epic patient record with various external systems. The bulk of these interfaces are for standard ADT, orders, results, transcriptions, and medication, but there are a few more interesting uses of interfacing to consider as the push for meaningful use continues.
The first one is a twist on the standard transcription interface organizations usually implement. Typically in the past transcriptions were recorded via device and then transcribed by a third party into flat text then transmitted into the health record. Although this method was effective in building and storing patient data, it left something to be desired for regarding speed and accuracy.Thanks to leaps being made in the world of technology we now have voice recognition software that is capable of keeping up with the nuances of human speech; one such voice recognition software is "Nuance" by Dragon. You might have seen the commercials for this
software during the nightly news but it's not just for home use. Many health organizations are implementing "Nuance" software in tandem with handheld devices. These new systems can generate HL7 encoded messages that can be directly and instantaneously filed to a patients chart. Utilizing HL7 standards will reduce the work effort associated with development and maintenance of proprietary interface formats.
As innovation continues, operational areas in addition to transcriptions have begun to take advantage of the flexibility and reliability of HL7 interfaces. Another area of improvement is increasing speed and accuracy for patient vitals. A company called iSinora developed bedside devices to monitor vitals but the difference here is that they built HL7 functionality directly into the device. This allows a bedside machine to generate instantaneous discrete data into a patients chart in real time. The data is discrete and therefore available for reporting. Organizations use the reports to depict trends on vast amounts of data relatively quickly; supporting and contributing to the meaningful use directive.
The last type of device integration to consider are those medical devices that produce pictures or PDF file formats. Two different situations where devices were used to output data in this way: one was for Optimology services, and the other was a Cardiac MRI machine. For Optimology services, pictures could be taken of a person's inner eye and a high quality JPEG was produced. The Cardiac MRI machine produced detailed reports with color picture of veins. Both of these devices produced invaluable data in a form that was not conducive to HL7 text like most results. The Epic system manages these results is by allowing them to be stored on an external server and referenced through the chart. A unique aspect to this capability is that Epic builds these links dynamically so that if anything happens to the files on the server the path to them can be changed in one location and the links in the charts will be updated as well. I have even taken this one step further and created a routine to check the links in the HL7 to verify the server remained constant. If it didn't an email was sent to the interface team informing them of the dead links thus ensuring the external pictures were always available with just a click.
These are just a few of the ways that device integration is changing the data stored with the medical record and increasing the completeness of the patient record. The need to integrate data gathered from various devices will increase as the need to establish meaningful use continues.
Presidents Letter for June 2012
News from Rob Culbert, President
As the movement into Meaningful Use Stage 2, the growing presence of ACO's and the inevitable implementation of ICD-10As continues, healthcare regulation continues to impact the decisions of healthcare organizations and how they invest their IT efforts. Responding to the client need, IT vendors continue to respond by prioritizing research and development investment to meet the multiple layers of their client's IT needs. With late summer and early fall the calendar becomes filled with the annual user group meetings of the leading healthcare IT vendors as well as large professional organizations like MGMA. It is time to take inventory and learn how vendors are prioritizing their research and development efforts for the coming two – three years.
The user group meetings are an opportunity to learn how the vendors are balancing the need to development solutions that meet regulation requirements as well as continue to enhance existing software features to meet client requests for new features in response to the ever-changing nature of healthcare. Consider the following questions when attending user group meetings this year, what percentage or focus of R&D dollars are being allocated to address the following areas:
  • ICD-10
  • Increased automation of manual tasks
  • Data mining for clinical and operational data
Here at Culbert we've guided 15 clients through the process of vendor selection in the first part of 2012. In that process we've asked these and other questions to learn how vendors are balancing the investment in feature/function enhancements to meet today's needs with the need to create features to address healthcare regulation. As the vendors respond to such questions, we help the clients align their business needs with the vendor that matches their need – not just for today – but for the years to come.
Physician Compensation: Adjusting to the Evolution of Healthcare
By Brian McCartie, Vice President, Business Development
Does it seem like we are always in a time of change? People never say things seem to be staying exactly the same. Market demand for physicians remains very robust but physicians in general are concerned by their economic outlook. With an aging population and obesity over 30%, job security and a commensurate income should be a given, but the concern lies in the shifting of the physician's business model resulting in dramatic change in the compensation models for physicians.
Traditionally physicians had a symbiotic relationship with hospitals – they provided the care, the hospitals provided the infrastructure and equipment in which to deliver the care. Physicians billed for professional services and hospitals billed for technical and inpatient visits. But this relationship has changed. Physicians began completing tests and procedures in their offices which were previously conducted in the hospital. This made care more convenient for patients and also gave the physicians a new revenue stream. Groups like Orthopedics, Cardiology and Gastroenterology invested heavily in surgical suites which were effectively same-day mini-hospitals. This resulted in lost revenue for hospitals and increased revenue for the physicians. Hospitals remained responsible for dealing with the very ill (typically most expensive and least revenue producing) patients. As a reaction to this shift, hospital systems responded by examining other models that engaged the physician and aligned them more closely with the hospital goals and success.
The late 2000's saw a myriad of arrangements with community physicians that attempted to shift the sharing of the ancillary revenue stream. In recent past, hospitals focused their energies more towards employing physicians as a means of ensuring alignment. So how does this affect physician compensation today and in the future? When physicians worked for themselves, they were typically on a "revenue less expense" based compensation. Bring those docs into an employment model with a more expensive infrastructure, remove the ability to influence revenue via ancillary services and the result is that this model becomes ineffective.
When CMS introduced a RVU (Relative Value Unit) model, the hospitals quickly adopted this numerical value of measurement and many health systems have used RVU compensation plans as a basis for compensating the physician for his or her work effort. This method can be bench marked against national compensation surveys like AMGA or MGMA. Physicians are usually paid at the level they work – i.e. if the work at the 60th percentile of production they get paid at the 60th precentialile. While this compensation model i incentivizes productivity , it is still a per click incentive model i.e., the more patient's seen, the more revenue earned.
The U.S. is challenged to reduce 20% of total healthcare costs as a result of healthcare reform. Physician compensation will be affected by this need. Physicians and hospitals will continue to evolve their relationship, working more closely together and toward a common goal and objective of a healthier population. This change will be gradual, It will be in comparison to changing direction of an ocean liner, but there will be a shift in compensation methodology away from individual productivity toward a set of criteria that includes panel access, meeting quality metrics, patient satisfaction and patient outcomes. Health systems now with a large integrated physician network are going to jointly be at risk with the payors (already seen in Medicare Advantage) to reduce the overall cost of care delivery. The benefit of their efforts will be sharing the savings which in turn can be distributed among the hospitals and physicians.
The World Health Organization (WHO), ranks the U.S. health care system as the highest in cost, first in responsiveness, 37th in overall performance, and 72nd by overall level of health (among 191 member nations included in the study. With that kind of performance, we have to effect change and one result of that change will be seen in the physician compensation models.
The Demand for EHR Justification and Return on Investment
By Amy Jennings, Consultant
Now that your institution has invested in an electronic health record (EHR) system, it's time to show the Board the return on investment (ROI) for the project. A few key questions need to be answered, including how to identify operational improvements that are a direct result of the implementation and how can an ROI be measured? Since an EHR is different from most financial investments, the process to measure the outcome needs to be broken up into two different categories, a hard return on investment and a soft return on investment.
A hard ROI is characterized by direct financial benefits that have resulted from EHR implementation. They include items such as revenue improvements, reductions in resources, and more efficient patient care that leads to staff savings. Financial benefits may be seen through reduction in transcription costs, HIM/Medical Records staff, paper costs, medical records space, and staff in clinical and other operational units, improved charge capture, and increased collection of co-pays. A complete ROI analysis can be challenging since most EHR benefits accumulate through indirect quality enhancements within a healthcare system. In order to show the full spectrum of benefits that the EHR system is responsible for, a hard ROI needs to be supplemented with its counterpart, a soft ROI.
A soft ROI is formed by return on value and benefits that will position the organization for future success. A soft ROI allows for the analysis of cost avoidance, patient safety, operations improvements, communication, and compliance. If no benchmarks were acknowledged prior to implementation, measuring value and quality may seem overwhelming. You will need to take a closer look at what your expectations for the EHR were and your reasons for implementing the system. Common value improvements that can be seen from an EHR include a reduction in the length of stay, improved medication orders and documentation, elimination of duplicate records, decrease in patient charts, reductions in duplicate testing, real time information and access to information, alerts for abnormal results, restriction of access to patient information, and regulatory compliance with HIPAA, JCAHO, and CMS. A soft ROI has the potential to explore possible cost savings and quality efficiencies that were previously unknown to the institution.
Not only will a complete EHR ROI justify resources that were used for the purchasing and implementation of an EHR system, it may also position your institution for recognition from internal and external constituencies. Receiving recognition from an award such as the Davies Program will garner attention for your hospital and prove to surrounding communities that you have made a strong and lasting commitment to providing high quality patient care.
Generally, it is widely agreed that the clinical and operational benefits of an EHR system are necessary for the enhancement of patient care and for institutions to advance within the healthcare industry. Future healthcare reform and reimbursement changes will require health systems to implement an EHR system to keep up with mandated regulations and policies. As paper charts start to become a thing of the past, questions revolving around the justification of EHR costs will continue to become more vocal. Again, measuring results and developing an EHR ROI is not an easy process, but it is possible to justify almost all of your original IT investment if you are familiar with both hard ROI and soft ROI evaluation methods. Now is the time to show your health system how it has improved overall by organizing and demonstrating what has been gained as a result of an implementation process.
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