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.

Yesterday, the Congressional Budget Office released its report on the Obama health plan:

Claiming back some of the rewards given to doctors for improving productivity could save the government Medicare program up to $201 billion over the next 10 years, a congressional analysis showed on Thursday.

The move, which could pressure healthcare providers to find new ways to improve productivity, would produce greater savings than adopting medical information technology, as advocated by President-elect Barack Obama, or capping medical lawsuit awards, as favored by some Republicans, the study showed.

The productivity option was one of 115 examined by the nonpartisan Congressional Budget Office in its 235-page “Budget Options, Volume 1: Health Care,” released on Thursday. The CBO does not offer recommendations.

Better record keeping and a move to pay-for-performance could result in increased savings. Improved productivity seems like the obvious choice, but at least we are talking about it. Could this finally be the beginning of a true Health IT push? What is interesting here from a social media perspective is what you can find on the CBO Director’s Blog:

Serious concerns exist about the efficiency of the health care system, but no simple solutions are available to reduce the level or control the growth of health care costs. Steps to restructure the insurance market and to encourage people to purchase less extensive coverage could reduce the use of treatments that provide minimal benefits, but enrollees would face higher cost sharing or tighter management of their care.

Other approaches—such as the wider adoption of health information technology or greater use of preventive medical care—could improve people’s health but would probably generate either modest reductions in the overall costs of health care or increases in such spending within a 10-year budgetary window.

That sounds like good news for HIT and for patient safety. The “serious concerns” statement should make us all sit-up and take notice. I beileve it is time for our indusitry to recognize the need for change on a broad scale and start to work on solutions from within the industry. While I’m optimistic about Federal reform, I’m just not 100% confident that more governement intervention is really in the best intrest of our industry in the long run.

Today, I attended the webcast called “Healthcare 2015: The Impact of the Obama Presidency” presented by IBM. The presenters included:

• Dr. Peter Budetti, MD, JD Chair, Department of Health Administration and Policy, University of Oklahoma Health Sciences Center
• Dr. Paul Grundy, MD, Director of Healthcare Transformation, IBM Healthcare and Life Sciences
• Mr. Len Nichols, Director, Health Policy Program, The New America Foundation

Dr. Budetti began the presentation pointing out the differences in the 1993 healthcare efforts and the present situation. For example, in 2009 the White House will have staff with more experience working with congress and there is a stronger commitment on both sides to work together. This time the major medical groups are supporting universal coverage where it was fought in 1993. Another key difference is the engagement of the end users of health reform, creating the site change.gov to solicit input on change.

Here is another example of the role of social media and online communications. The tools that help get Obama elected are not being turned to resolve issues in healthcare. Once again, healthcare institutions and providers who are not involved in the social media space are completely missing the boat.

The key message I heard from Dr. Budetti was, the government is asking for involvement from a better-educated consumer who is more engaged and prepared for change then in 1993. The result, new business opportunities are on the horizon for those who are paying attention.

Len Nicholas agreed with the general sense of Dr. Budetti’s presentation, but had more reserve in his talk. He stressed the need to focus on infrastructure for health. He also believes President-Elect Obama has recognized the importance of speaking with one voice on healthcare reform and the voice will be Tom Daschle.

Nicholas stated health information technology grants and loans will be part of the new stimulus package and the focus may be on outcomes. He indicated the most exciting news of what is happening on the Hill is a ground swell of effort to talk about medical effectiveness and spread the sharing of best practices in medicine, the expansion of the medical home, and a move away from fee for services and toward a fee for outcomes or pay for performance.

Personally, I think this type of change may be a ways in the future, but it is definitely needed. The first step has to be creating of common containers and protocols that will allow for outcomes study and measure to be established. One cannot argue the need for these types of systems when you consider the number of patients who are injured or die from bad medical information.

What did the presenters think of the prospect for economic recovery and its impact? Our economy is in uncharted water, there is a reasonable expectation of recovery by mid-2009 early-2010, but there are no guarantees. If the downturn continues, all could be out the window.

The economic recovery a component of health reform, but Nichols stated that bipartisan support and involvement might be the key to long-term change. He indicated that a lot of the Obama’s campaign rhetoric was based on cost savings that are not realistic and the realization of that fact will have an impact on the healthcare debate. As of now, he believes the Republican strategy is still unclear and evolving and will key on the activities of individuals like Senators Grassley and Gregg.

The two issues affecting bipartisan support are:

1. Building a public insurance plan to compete against private insurance. The plan could be something like Medicare which would not be supported by Republicans or more like state employee plans which would garner more bipartisan support.
2. The role of the employer in the insurer model will also elicit strong reactions from both sides of the isle.

At the end of the day, unlike 1993, there is a feeling of strong bipartisan support for health reform and the presenters believe the legislative committees will be authoring the bills. That should mean greater support from Congress.

Why will Daschle be more effective this time? He was part of the Clinton healthcare team in the 90s and profoundly impacted by the failure of that effort. Daschle saw that the failure to cooperate was the cause of the downfall and the reform effort was completely lead by one-party.

During the Q&A section of the talk came the million dollar question: Should I wait to implement an EMR until the stimulus package is announced and will there be money for me if I don’t have an EMR? This question is the core of the Obama campaign in my opinion. The question of what can government do for you? Right or wrong, what sensible business owner (a.k.a. practicing physician) would not take federal money to build or grow their practice?

The presenters responded by saying it is hard to see exactly what will happen with the stimulus package, but the package will contain very large funding amounts. Further, they indicated that government programs don’t typically award funds to existing systems preferring to help with more ground-up implementations. However, in the world of increasing competition for dollars, being able to show a successful implementation and making a case for rapid deployment and expansion may be an effective strategy. Bottom line, check-out systems that are certified and offer the best interoperability and data integration to plan for any future transitions to new systems. While you are doing your research, keep an eye on Washington for stimulus language to come out after the first of the year.

From where I sit, we live in some very interesting times in healthcare and today’s conventional wisdom could be tomorrow’s unemployment line. It’s time to start thinking differently in healthcare; start thinking about embracing technology.

Yesterday, I attended the first day of the HIMSS Virtual Conference & Expo. HIMSS is the Healthcare Information Management & Systems Society and they describe themselves this way:

The Healthcare Information and Management Systems Society (HIMSS) is the healthcare industry’s membership organization exclusively focused on providing leadership for the optimal use of healthcare information technology (IT) and management systems for the betterment of healthcare.

I’ve been a member of HIMSS for the past couple of years, attended the HIMSS conference in 2006, and received my CPHIMS (Certified Professional in Healthcare Information and Management Systems) certification in May of 2007. Suffice it to say, I believe in this organization and the role they play in healthcare IT.

My background includes spending time in many industries; always in an IT capacity. However, my current position is my first experience in healthcare and HIMSS has played a key role in my education and understanding of the challenges and opportunities within the healthcare industry. As we all know, finding the time for professional development and the budget for travel is becoming an increasing challenge. So, how does a professional find the time and the money to attend training? We attend virtually.

HIMSS offers a virtual conference to their members. The interface is slick and prompted my 17-year-old to say, “Cool” when he first saw it.

Of course, once you get past the glitz of the interface, it all boils down to the presentations which are delivered via WebEx. Let’s face it; a conference is only as good as the presenters and their materials. Fortunately, there were many quality presentations on Day 1, but the highlight was: “Smart Citizens, Smarter Patients: A Primer on Social Media and the Wisdom of Patients” by Jane Sarasohn-Kahn (www.healthpopuli.com). This presentation provided a wealth of information and gave me renewed hope that Web 2.0 and patient-focused care will ultimately improve both the care of patients and promote healthy living.

Now, I’m off to attend Day 2 and perhaps drop-by the vendor area. I’ll post a more complete update later today. If you attend the conference, let me know what sessions you found most useful and I’ll be sure to checkout any good presentations I missed.

News out of Washington today on another Obama cabinet choice:

Former Senate Majority Leader Tom Daschle has accepted President-elect Barack Obama’s offer to be Secretary of Health and Human Services, Democratic officials said Wednesday.

The appointment has not been announced, but these officials said the job is Daschle’s barring an unforeseen problem as Obama’s team reviews the background of the South Dakota Democrat. One area of review will include the lobbying connections of his wife, Linda Hall Daschle, who has done representation mostly on behalf of airline-related companies over the years. They spoke on condition of anonymity because they weren’t authorize to discuss the matter publicly.

What does the choice of Daschle indicate about the Obama Administration?

As Health and Human Services chief, Daschle will be responsible for helping set health care policy. He supports a government-funded insurance program for the nation’s uninsured.

Daschle has also been the head of the health care working group in the Obama transition team. Democratic officials shied away from a term some are throwing around — “health care czar” — but say Daschle “is likely to play a leading role in the passage of health care reform and the strategy to implement it.”

Other sources lay out substantial work being done by the incoming administration to enable health care reform, all of which indicates Obama does intend to move on this issue in spite of the monumental difficulties, including financial obstacles.

Get ready for some serious change in the health care industry. Goodness knows, we need it.