Tim J. Edwards

My boss and I were invited to the National Institute for Health (NIH) last week to share our experience in developing physician and patient portals. After spending most of the day meeting with various NIH staff members and their Medical Executive Committee, I came away with a renewed sense of energy and excitement for what we do; using IT to improve hospital operations. Like HIMSS a couple of weeks ago, my time with the NIH has shown there is a growing group of dedicated healthcare professionals who see the way to reform is through the use of HIT. What has also become apparent is the way to reform is not going to be found by looking within healthcare.

All too often you hear these questions: What are other healthcare institutions like us doing in this space? How are the leading healthcare organizations dealing with this problem? Who is best-in-class in this and how can we learn from them? These are all excellent questions, but they need to be applied to those outside of healthcare. Benchmarking each other will produce incremental improvements and not the kind of reform needed today. Healthcare needs to recognize what customers expect in their online experience and step-up.

Do you want to streamline patient appointment scheduling? Look at the airline industry. Through the web, I can search available flights by cost, time, or flight duration, select the flight that best meets my needs, schedule and pay for the flight and even pick my seat (unless you are on Southwest…).  That is best-in-class thinking and it is what the general public is used to for online interactions. Is making a clinic visit really that much more complicated then flying a plane?

You want to improve the laboratory testing process? Take a look at the pizza industry. On the web, I can select the exact pizza I want, size, toppings, crust, follow the creation of the pizza, and know exactly where it is in the creation process. What if you applied that process to the lab? Allow physicians to order the exact test they need, schedule when it is going to happen, and provide transparent access to the entire process so they can know exactly when those results are going to be available.

You want to improve you patient check-in process? Look again at the airline industry. Airlines allow check-in up to 24 hours prior to the flight. This eases congestion at the gate, moves people through the airport with greater efficiency, reduces the staff required to process passengers, and generally improves the entire user experience. What if you took this process and used it in healthcare? Patients could check-in prior to their appointment, electronically review information and sign any required forms, and electronically process any co-pays or required fees. Patients could receive a “boarding pass” that indicates they are ready to go and be allowed to focus on the business of their care versus the logistics of being a patient. Think of the savings in staff hours, space utilization (patients are not spending minutes/hours completing forms in the waiting rooms), and the reduction in no-shows.

The bottom line; there are others out there who are doing the same processes used in healthcare who have found ways to do it better. Find those examples, study them, and adapt processes based on that new learning.

Yes, there are barriers to change and there will always be barriers to change. What we can no longer afford to do is keep our heads in the sand as an industry or only accept what others like us are doing.

The world has changed, the bar has been raised, and it is time for us to jump.

Anyone who has spent time advocating for Healthcare IT has no doubt heard some variation of, “You can’t send medical records over the Internet.” There seems to be a prevalent belief that electronic communications are somehow less secure than other forms of communication and that using tools like the Internet is inherently dangerous. Let’s take a look at the processes used for four types of communication (phone, mail, fax, and web) and compare how they stack-up against the measure of protecting health information (PHI).

US Mail – The old tried and true method of sending PHI has always been the US Mail. You drop that letter in the box with the utter 100% assurance that it will reach the intended recipient each and every time and never be misrouted or intercepted. Really? You take PHI, print it on a piece of paper, stick it in an envelope, seal it with spit, drop it into the hands of the Federal Government and hope it gets to where it’s going.

Here’s what you don’t know. You don’t know who handles the PHI in transit. Did the PHI actually reach the intended address and was the address correct? Can anyone out there say their contact database is completely accurate with only correct addresses? You don’t know who opens the envelope and who handles that piece of paper along the step from envelope to chart. There is no audit trail to ensure authorized individuals only viewed the PHI.

All this trouble yet US Mail seems to remain as the leading form of communication in use today for the exchange of medical information. We can do better.

The Phone – You call the patient/physician directly and share PHI with the individual on the other end of the phone. This method seems a bit more secure, as long as you verify the identity of the individual on the other end of the line, make sure they are not using a speaker phone, and that no unauthorized individuals are within earshot of the call.

Here’s what you don’t know. You don’t know if that call is being intercepted. Is the call placed on a cordless phone? If so, someone with a simple radio receiver could be listening to your conversation. If a cell phone is being used, you may have the same problem. What if the person is not there? Heaven forbid you leave a message on a voicemail box or answering machine for anyone to hear.

While the phone seems to be a better solution for exchange of PHI, it requires both parties be willing and available at the same time in order for the transfer to take place. Ultimately, this proves to be the biggest problem with the phone approach.

FAX – The FAX machine was invented in the mid-80s and quickly dominated the business landscape. The ability to instantly transfer documents to locations around the world has great appeal and it seems like a natural fit for exchanging PHI. Simply place a document on the FAX machine, dial the number, and hit send. Instantly, the information is sent to the hands of the intended recipient and everyone is happy.

Here’s what you don’t know. You don’t know for sure if the number you dialed was the correct number. Yes, you can get a confirmation page, but you have to request and review the confirmation page and if that confirmation comes back with the wrong name, you cannot recall the FAX you just sent. The damage is done. With the explosion of mobile devices, phone numbers are changing constantly and having the correct FAX number is a bigger nightmare every day. Can anyone honestly say their contact phone numbers are 100% accurate?
You also don’t know if anyone is standing at the FAX machine when the document is being sent. Yes, you are supposed to know, but who really takes the time to confirm the correct individual is standing by the correct machine at the correct time?

These are the three standard and accepted forms of communication for PHI and all three of them have serious security concerns for patients and providers. To be more secure, all three require more resources. Mail can be registered. Phone call can be planned and scheduled to ensure security. FAX messages can be scheduled, tested, and confirmed. All of these measures have significant cost increases for healthcare organizations. What else is there and is it better?

Internet Communications – You make PHI available via a secure web site, require users to be authenticated, encrypt the transfer of information, log every instance of PHI access with unique user, date, time, location, IP address, operating system, web browser, etc., and run audits periodically to ensure security is maintained. If done right, this form of communication is far and away the MOST secure and cost effective way to exchange data.

Here’s what you DO know – You know who logged in, when, how long, from where, and exactly what they viewed. You know communication was encrypted and could not be intercepted during the coarse of the transaction. You have the added ability to limit or end access to PHI on a per user basis if a patient decides to stop communications with a given provider.

You have also provided access to information outside of the demands for a scheduled information exchange time. You can send records to individuals on the opposite side of the globe and do it during regular business hours. You are falling in line with other industries who recognize the power of Internet transactions such as banks, retailers, and everyone else doing business in the world.

Are there any risks with Internet access to PHI? Of course there are. My qualifying statement was, “if done right.” There are HIT professionals who can design and build systems that accomplish all the security goals for electronic PHI exchange. Those individuals need to be engaged in the design and deployment of any electronic system. You also need to engage information security professionals.

There is also the issue with forgetting passwords or sharing passwords. Both of those ultimately fall on the end user, but a well-designed system would minimize the “forgots” and eliminate the sharing.

The only true secure way to exchange PHI is in-person face-to-face. After that, using a web-based secure system is the ONLY way to go.

The M. D. Anderson Cancer Center’s physician web portal, myMDAnderson for Physicians, (https://my.mdanderson.org) has been providing improved access to patient information and streamlined communication to non-M. D. Anderson physicians since 2005. While the site has been a major step forward, access to the complete medical records for a patient has been lacking. To complete the continuum of patient care and strengthen the relationship between M. D. Anderson and their community physician partners, M. D. Anderson will soon unveil an improved version of myMDAnderson; providing access to nearly the entire patient medical record.

Physician portals range in scope and effectiveness; form “post card” sites to those who exchange medical information. I’ve seen examples of physician referral request systems that amount to little more than providing the ability for users to suggest when their patients may want an appointment. While this is certainly an improvement from phone-based systems, it still leaves a lot to be desired. myMDAnderson for Physicians has set the standard for physician portals and this new level of access will continue to raise the bar.

If you are a licensed, practicing physician and have patients being treated or want to refer a patient to M. D. Anderson, go to myMDAnderson for Physicians and register today.

Welcome the second full day of HIMSS09. After yesterday’s marathon sessions and opening reception, I was a little slower in getting out of bed this morning, but still made it in time to hear George Halvorson’s keynote address. Of course, it was a two coffee morning.

The keynote started with a video of people on the streets of Chicago discussing their feelings on medical records and the access that is available for their own records. The responses ranged from hilarious to disturbing; here are two of my favorite lines:

• I’m a physician in my 50s and my goal is to make it out of practice before being required to implement an EMR. EMRs cause 4-5 months of financial turmoil and they have not shown any ROI.
• I live in a small town and they know everything about me. My medical records are available behind the desk in my doctor’s office. If I needed my records, I could just go there and grab them.

I guess we still have a long way to go.

Liz Johnson, HIMSS Vice Chair started things off with a couple of administrative tasks and a quick overview of yesterday. She then discussed the financial report for HIMSS that basically closed before the economy went south. Operating revenue increased by 7% over the past fiscal year and HIMSS is financially sound and poised to lead HIT now and in the future. That was good to hear and judging by the attendance this year, next year’s report will likely be similar.

George Halvorson, Chairman and Chief Executive Officer of Kaiser Foundation Health Plan, Inc. and Kaiser Foundation Hospitals, did a great job in setting the stage by outlining some of the most interesting issues facing HIT today. A couple of interesting quotes/facts from his talk:

• The business model of care is based on maximizing the number of things that have fees. We have 18,000 billing codes for procedures and not one billing code for a cure. No billing codes for improved health.
• A Rand study found caregivers got care right only 50% of the time for adults and less than 50% for kids.
• How often doe diabetics get the right care? According to Rand, 8%. If we could move that to 80%, it would cut the number of kidney failures in this country in half.
• He sits on the board of the IOM and their goal is to see 90% of care based on scientific evidence by 2020. In what other industry would we set the bar so low?
• You’ve seen the commercials for new Alzheimer’s drugs and the warning to inform your physician if you are taking various medications before starting on their drug. How pathetically sad it is when we ask Alzheimer’s patients to inform their doctors of the drugs they are taking?

Kaiser seems to be ahead of the curve in their HIT implementation and I would have liked to have another 30 minutes of his talk. I am planning to pick-up his new book, Health Care Will Not Reform Itself. The proceeds from his book are going to a medical charity in Oakland.

Session: The Intersection of Healthcare Reform and Health IT

This session featured Georgia Congressman and physician Phil Gingrey and former Wyoming Governor Jim Geringer. Both men have a history and strong interest in healthcare and after some opening statements, got down to some serious Q&A.

The session opened with discussion of healthcare reform and HIT reform and how the two are required to make any serious change. “If we automate a bad system, all we will have is a really fast, bad system.” Both men seemed to be advocates for wellness and looking beyond episodic care to public health. “Prevention is the key to moving forward; prevention of illness and prevention of bad health.”

One of the most compelling questions came from an individual who outlined how federal regulations (Red Flag Rules, Stark, HIPAA, FDA Regulations, etc.) are putting a squeeze on smaller hospitals and making it harder to keep the doors open. Governor Geringer had the most interesting response, he said, “Your first obligation is to tell somone. The world is run by those who show-up.” While at first I was put off by the answer, the more I thought about it, the more I like it. He encouraged using the Obama Administration’s emphasis on transparency and accountability as a reason to expose just exactly what the federal government is doing to squeeze healthcare providers. Governor Geringer’s quote, “The government’s roll is to recognize when to get out of the way.”

In the end, both men were clearly on the side of fully integrated EMRs which brought another interesting question. Apparently, many supporters of a Michigan RIO have pulled out of the effort to develop their own EMRs and earn their slice of the stimulus package HIT pie. What can be done to address those who were working together and now are off on their own? Neither had a great answer to the question and sited the need for cooperation and interoperability, but missed the general point. Is the ARRA actually being somewhat counter-productive in regard to HIT? We will see.

As for not answering questions, Congressman Gingry had some great comments:

• If I were doing this and it was within my power, I think the adoption of a fully integrated ERM would be goal number 1.
• Patients don ‘t wan t the government standing in the exam room between them and their provider.
• I’m not sure if that answered your question, but I’ve learn politically if you don’t like the question, answer another one.

And that brought me to a big two hour, visit your favorite vendor break. I recognize why HIMSS wants this break, but I don’t particularity like it. The good news is, I had time to write the first half of this post and catch-up on some communication. Suggestion for next year’s HIMSS, more Recharging Stations!

Session: Using an EMR to Find a Needle in the Haystack: The Next Generation of Clinical Decision Support

The session was conducted by Dr. Robin Helm and  their EMR ManagerSandra Olsen who work for St. Joseph Family Medicine Residency in Northeast Wisconsin. They went live with their EMR in 2001 and completed,  feature build-out in 2004, and now are looking into ways to leverage the data that is now available in the system. “The EMR was not important unless we cold improve patient care.”

So, to improve patient care, they started by developing  a quality improvement model

• establish benchmarks
• select champions (utilizing both nursing and physicians is a key)
• set goals based on benchmarks
• write reports
• provide education to provider or patient
• create interactive programs
• apply to other disease populations

They have used this model to improve immunization rates, improve the quality of diabetes care, extend screening for led-related health issues, and many other issues. A side benefit to their system is the availability of quality metrics that can be leveraged on multiple improvement efforts and are used to benchmark physicians against their peers; blinded of course.

My sense of their system is, it is relatively basic, but quite effective. You don’t have to have the most impressive system to improve clinical quality; you just need the data in a structured and meaningful way.

Session: From Kiosks to Web: Self-service Opportunities in Healthcare

The presentation was conducted by Jeff Nieman and Ron Kelley Conifer Revenue Cycle Solutions (an off-shoot of Tenet Healthcare).

This session was one of those moments when your realize that there are people who “get it” out there. Conifer has produced kiosks for online bill payment and patient sign-in that are incredibly successful and producing real cost-savings while improving accuracy. The basic premise is, we want to have self-service and if it’s done right, it will make a big difference.

“Self service is doing exactly what you done before in a self service way.” You don’t need to create a new process for self-service, just do what you do.

In 2008, the first year of the system, they had the following results

• 19,821 patients used the self-service kiosks
• 97.3% of patients successfully signed-in
• 84% of patients did not want a printed paper copy of their forms
• on average, patients took 2.6 minutes to check-in
• 98% of patients were satisfied with the tool
• 48% of users were 55 or older
• 33% corrected their records, improving accuracy of their data

Those are solid numbers and really point to what is going on in the world today. We want automation and self-service. Go to a supermarket, the airport, a Home Depot, they all have kiosks and everyone from kids to seniors are using them. They save time, save paper, and improve accuracy.

Great quote, “If you are not online and paperless, you are missing a huge opportunity for cost savings.” Their ROI model is based on a cost of $.25 per printed page and with the reduction in paper of 80%, they are saving over $5 million annually. That’s a lot of green.

Next up, the HIMSS09 Tweetup. Looking forward to meeting all the tweeps running around here.

HIMSS09 Tweetup

The first annual (I hope) HIMSS Tweetup was a smashing success. I enjoyed meeting as many of the HIT tweeple as I could and hope to stay in touch when we get back to the real world. Kudos to Cesar (@himss) for pulling this together!

This is a very long post and if you didn’t make it to the end, I completely understand. If you did, please share your thoughts on the HIMSS09 conference.