Squeeze out waste

Understandably, the painstaking scrutiny of healthcare costs has reached a fever pitch. While administration is a relatively small percentage of the overall costs in the system, the pressure is on payers to trim as much waste from their operations as possible.

Administrative costs—or any outlays that are not specifically tied to medical care—are a political hot button. Insurers defend what they spend on tasks such as case management and disease management as well as investments in technology as necessary spending that results in net savings and improved health. Some critics of the insurance industry characterize administrative costs as nothing more than profits and executive compensation and seek legislation to control how premium dollars are spent.

In fact, 15 states have implemented laws dictating minimum medical loss ratios (MLRs), ranging from 50% to 80%. In 2008, California Governor Arnold Schwarzenegger vetoed a bill that would have forced insurers to maintain an MLR of 85%.

According to America’s Health Insurance Plans, in a 2008 study conducted by PricewaterhouseCoopers (PwC), 87 cents of every premium dollar goes to healthcare and medical services, and just 3 cents goes toward profits.

PASSING THE BLAME

Governments are taking some steps that could eventually result in lower healthcare costs, such as smoking bans in public places and removing soda and sugary snacks from school vending machines. On Jan. 1, 2010, California became the first state to ban the use of trans fats in restaurants and bakeries. New York City adopted a similar ban several years ago.

Nonetheless, it was inevitable that scrutiny would intensify on payers and their efforts to reduce costs and minimize wasted resources in the system, and now that it has, they’re possibly receiving more blame than is fair.

“When people look at waste in claims processing, for example, they assume [all of the money is being wasted] by insurers, when a lot of it is wasted by providers,” says Mark Merlis, a health policy consultant who has written several papers on the topic of healthcare waste. “But in fairness to providers, they have to comply with many different insurers’ administrative processes, so we should be doing as much as we can to promote uniform transactions.”

Merlis says the more uniformity that can be achieved among payers, the more money the system overall is going to save. Market complexity makes it difficult to identify who is “committing” the waste. Furthermore, cutting waste from one area might simply shift costs to another. For example, in an attempt to fight losses from fraud, payers could investigate more claims in detail, but that will delay payments to providers, damaging relations and potentially resulting in legal action under prompt payment laws.

TECHNOLOGY TO THE RESCUE

The siloed yet sprawling nature of the U.S. healthcare system—payers, physicians, pharmaceutical companies, hospitals, government agencies and consumers—means that waste elimination isn’t as easy as making an individual organization operate more efficiently.

Some Americans, including some physicians, believe a shift to a single payer system would simplify healthcare administration, but the large majority is firmly opposed to such a change. As Merlis points out in his paper, “Simplifying Administration of Health Insurance” (January 2009), complexity is not just a byproduct of the insurance system—it is what insurers are selling.

“The value-added of the managed care industry consists of the very features that make insurance complicated: different coverage rules and formularies, authorization requirements and careful scrutiny of claims, and so on,” he writes. “The variations are what differentiate one plan from another, and competition and uniformity may be conflicting goals.”

Still, that doesn’t mean plans can’t improve their internal operations and their relationships with other healthcare stakeholders. There are also high hopes that technology can eliminate some waste in the system, and at least one project is proving that to be true.

In 2008, Blue Shield of California (BSC) created its Partnership in Operational Excellence and Transparency (POET) transactions-tracking tool to improve payment accuracy and dispute resolution, speed claims turnaround, and increase operational transparency. The program is available online for 90 of the hospitals Blue Shield of California contracts with across the state.

“POET has been enhancing our working relationships with network hospitals by providing opportunities for data-driven discussions that directly improve operational efficiencies,” says Juan Davila, the plan’s senior vice president for network management. “Using key claims performance indicators and transparent claims data, we work jointly with our facilities to target and prioritize impactful process improvements.”

Davila says the claims-processing related improvements have been impressive, and the benefits of improved relations with network providers are even more so.

“We wanted to show that we were really trying to get at the root of the problem,” he says. “We paid for the system up-front, and we were increasing our transparency to them, as opposed to trying to cover up our errors. We genuinely wanted to develop a more collaborative relationship with our network hospitals, and that’s changed the way we think of each other in a very positive way.”

The hospital association of Southern California recently approached BSC to help the association with another large-scale project.

“I have been in this business for 20 years and have never gotten a phone call like that before,” Davila says.

Within administrative functions, such as those BSC is addressing, it’s hard to know exactly what is waste. A 2008 study by PwC’s Health Research Institute, “The Price of Excess: Identifying Waste in Healthcare Spending,” points out that “inefficiency” and “waste” are not interchangeable terms; the former is merely one component of the latter.

Authors define waste as costs that could have been avoided without a negative impact on quality, which is similar to the definition used by the Institute of Medicine and the authors of another watershed study conducted by Thomson Reuters in October 2009: expenses that don’t add value.

WHERE TO FIND WASTE

The PwC research estimates that slightly more than half of all healthcare spending ($1.2 trillion of the annual $2.2 trillion spent) is wasteful and breaks it into three categories:

• Behavioral waste, which accounts for $303 billion to $493 billion each year;
• Clinical waste, accounting for $312 billion annually; and
• Operational waste, which consumes $126 billion to $315 billion.

The study further breaks the operational waste segment down into four subsets:

• Claims processing, which accounts for $21 billion to $210 billion in waste;
• Inefficient use of technology ($81 billion to $88 billion);
• Staff turnover ($21 billion); and
• Paper prescriptions ($4 billion).

The research by New York-based Thomson Reuters Healthcare Analytics (October 2009) is slightly less pessimistic, estimating that each year, between $600 billion and $850 billion of healthcare spending is wasted.

The study, “Where Can $700 Billion in Waste Be Cut Annually from the U.S. Healthcare System?” identifies six primary culprits:

• Unnecessary care (40% of waste), accounting for $250 billion to $325 billion;
• Fraud (19%), $125 billion to $175 billion;
• Administrative inefficiency (17%), $100 billion to $150 billion;
• Healthcare provider errors (12%), $75 billion to $100 billion;
• Preventable conditions (6%), $25 billion to $50 billion; and
• Lack of care coordination (6%), $25 billion to $50 billion.

Those figures are so staggering that the system can’t expect to “cut” its way out of them, according to Bob Kelley, Thomson Reuters’ vice president of healthcare analytics and author of the report.

“Simple external controls on cost and utilization will not work, and any effort to control costs by eliminating waste must be careful to consider possible unintended impact on access to appropriate and necessary care,” he says. “We should expect that any change to the system of care that improves its performance will require a realignment of the types and levels of professional and facility resources and the relationships among these resources.”

The best solutions will effect positive changes and recognize that the healthcare market dynamic is much different from other product or service markets. Most consumers believe that their access to all potentially useful services is a right.

“We need to shift the public’s perception and expectation [of quality] away from ‘more services is better’ to ‘the care that will most likely result in the outcomes that are best for me,’” he says. “Simultaneously, we must begin to reward physicians for providing this type of care, and recognize and pay for the required time and effort.”

CONSUMER BAD HABITS

Shifting public perception is critical, because for many Americans, “waste in healthcare” brings to mind images of bloated, lethargic mega-plans with outdated technologies and overpaid, fat-cat executives. Although the U.S. Centers for Disease Control and Prevention estimate that fully half of the nation’s deaths each year are the result of bad and avoidable habits, most Americans, rather than look in the mirror, latch onto headlines about excessive health plan profits and executive bonuses.

When consumers learned that former UnitedHealth Group CEO William McGuire received more than $124 million in total compensation in 2005, it’s understandable that many of them reacted with indignation. While the public’s sensitivity to what they perceive as excessive income is at an all-time high, salaries and bonuses paid to health plan executives are a very small number in a very large sum, according to Dan Munro, principal with The DMM Group.

“If you added up all of the executive bonuses and salaries for the entire healthcare industry, it would just be a drop in the bucket compared to the other costs,” he says. “Healthcare is nothing at all like Wall Street, where firms are racing to pay back their Troubled Asset Relief Program funds because they want to go back to handing out those huge bonuses again.”

Merlis agrees, saying executive compensation “might look ugly when you see how much money certain people are being paid, but it’s really not a driver of healthcare expenses.”

It’s clear that politicians are doing what they can to foster greater use of technology in healthcare, particularly with federal funding included in the stimulus package to spur greater adoption of electronic medical records, which are not yet widely adopted.

“The government is trying to encourage the meaningful use of electronic health records,” Munro says. “For the first time, the government is mandating that EHR applications engage the consumer. If you tell most EHR vendors that you’re going to develop a patient-focused system, they’ll laugh at you. They have always been provider-focused, because that’s where the money is.”

An EHR system can cost millions of dollars, so small providers are less likely to adopt them simply because of the cost. The government has realized that use of health IT won’t progress if it doesn’t engage the consumer, Munro says.

THE OPPORTUNITIES ARE REAL

To further explore IT’s opportunities to improve healthcare, Kelley and Thomson Reuters are working on a follow-up whitepaper highlighting specific initiatives that have been successful in eliminating waste, or that show the potential to do so.

“There are certainly high expectations for the contributions of IT to both improved quality and reduced waste,” he says. “Many of these initiatives are either directly related to new or enhanced IT applications or require IT system support to enable new relationships between providers, or between providers and patients.”

Examples of the first type include electronic medical records, health information exchanges, and clinical registries. Examples of the second type include patient-centered medical homes and bundled or episode-based payment systems.

“I think that these opportunities are real, but changes in the systems of care and the relationships among providers and patients will be required if the great potential for these solutions is to be ultimately realized,” he says.

According to Davila, BSC’s POET program is improving efficiencies at the larger system level.

“Historically, when we would show up to renegotiate a contract, the hospital representative would say, ‘My people are telling me that you don’t pay your claims right, you don’t handle appeals well, and you owe us X million dollars. Before we recontract, I need you to fix that.’ The result, inevitably, was a lot of negative energy.”

To solve the problem, BSC worked with a third-party vendor to develop a system that enables participating hospitals to review 24 months of processed claims information and performance metrics on the POET Hospital Dashboard, an online performance analytics portal specifically designed for those hospitals.

Those facilities routinely receive quarterly claim summary reports that provide information on key indicators such as cycle time; submission type; denial volume and reasons for denial; appeal volume, outcomes, and reasons; and claim volume for patients with Bluecard, a national program that allows any Blue member to receive care from another Blue company when traveling or living outside of their usual service area.

“It’s all right there in black and white for everyone to see,” Davila says. “One national hospital system was upset because they thought we weren’t paying as quickly as we should, until POET revealed the problem: We were paying the claim in 12 days, but it was taking them 25 days to get the claim to us. The system showed them exactly where the process was broken so they could fix it.”

PHYSICIANS’ WEIGH THEIR COSTS

The need for such transparency is significant, according to research from the American Medical Assn. Its second annual National Insurer Report Card study attempts to diagnose the strengths and weaknesses of the claims processing systems used by eight of the nation’s largest health insurers. Five of the eight plans showed improvements in the median amount of time necessary to respond to providers’ claims, but the report estimates that providers still divert as much as 14% of their revenue to ensure they are receiving accurate payments.

Physicians reported spending three hours weekly interacting with plans in 2006, according to a Web Exclusive produced by Health Affairs in May 2009. When time is converted to dollars, the cost to practices is estimated at $23 billion to $31 billion annually, or 6.9% of all U.S. expenditures for physician and clinical services. Further, 45.9% of physicians surveyed for the report said the cost of dealing with health plans had “increased a lot.”

The report goes on to note that administrative cost cannot be reduced to zero dollars and that interactions that cost money also can produce benefit, such as prior authorization, which can reduce inappropriate use.

The height of health IT

Even health insurance giant WellPoint—with more than 35 million members and arguably enough reach to change the system with sheer volume alone—is taking few chances on the future of healthcare delivery. Like most plans, it’s testing new programs with cautious optimism, while aiming for large-scale implementation.

Charles Kennedy, MD, WellPoint’s vice president for health information technology, has a vital role in the plan’s innovation because few initiatives these days can be accomplished without the backbone of health IT.

Specifically, WellPoint’s emerging Individual Health Record—a simultaneously patient-facing and physician-facing electronic record—is “almost an air traffic control system to manage disease,” according to Dr. Kennedy. It’s probably one of the most promising efforts to control costs among members with chronic conditions. Pulling claims and clinical data through complex algorithms to arrive at a functional health summary differentiates the Individual Health Record from the typical EMR system.

“If you’re a hospital or institution, you have a variety of clinical data sources that have information on the patients that you see,” he says. “If you haven’t deployed an interface engine or some way of pulling those various clinical data sources together, you’re late to the party, and you need to do that ASAP.”

With more than 20 years of experience comprised of clinical practice and health IT implementation, Dr. Kennedy began his career in internal medicine. When he was a resident at Highland General Hospital in Oakland, Calif., he noticed how the patients’ needs far outstripped the hospital’s resources, and that experience solidified his vision of where medical care and information should meet.

“We tried to treat each patient regardless of who they were or their ability to pay,” he says. “It had the unfortunate side effect that we never thought about cost. We only thought about what was right for a patient. But that created a system where people are actually being hurt because they can’t afford care. I began to realize that the very laudable and applaudable approach of not caring about cost—only the patient—is right, but that doesn’t mean you can become cost unconscious. Cost unconsciousness has its own set of bad outcomes. That’s what’s led me into thinking we need to be more efficient. We need health IT.”

Earlier this year, Dr. Kennedy was named by the Government Accountability Office as a member of the new Health Information Policy Committee, which was established by the American Recovery and Reinvestment Act. Serving a three-year term, he and other committee members are creating policy framework for the development and adoption of a nationwide health IT infrastructure, including standards for the exchange of patient information. The committee will also make recommendations for handing out the $38 billion in health IT funding earmarked in the reinvestment act.

WHAT ARE SOME OF THE HEALTH INFORMATION POLICY COMMITTEE’S GOALS?

A:We’re trying to make sure the Obama health reform strategy becomes real. What people don’t realize is the number of things the industry and the government agree on. For instance, the government invested $1.1 billion in comparative effectiveness research.

The stimulus bill has $38 billion in it for health IT, and we’re trying to help the government develop policies to spend that money wisely. Our function is to say, ‘How do we take this incredible resource that Congress and the President have given us, and how do we turn it into an investment that creates healthcare value for the whole country?’ It’s a massive undertaking.

Our first objective was to ensure that the money from the stimulus package paid out over five years created value. We asked ourselves where we wanted to be five years from now, and then we worked backwards from there.

Deploying computers is not the goal. Having physicians and patients use computers to create better care at a lower cost is the goal. To do that, we have to set the bar high for the care system. Not only must you use the computer, you must use it in a meaningful way for better care. These are the ‘meaningful use’ criteria that we’ve published.

If we distribute a substantial number of computers, and physicians don’t use them, we won’t be successful. We didn’t want to focus on technical measures. We created the meaningful use criteria, and every single one is clinical.

We want physicians to achieve a clinical result, and we want information technology and the money in the stimulus package to be a contributor to that improved clinical result. For instance, one of the criteria is to avoid 1 million heart attacks and strokes by 2015. Another is to make cardiac disease no longer the leading cause of death in the United States. Those are stretch goals. That is not something simple and trivial.

It would have been much easier to say, ‘Our goal is to make sure 90% of physicians have computers.’ But we consciously didn’t do that because we recognize that health IT is a tool and that other changes need to happen.

HOW WILL THE INDUSTRY ACTUALLY ACHIEVE MEANINGFUL USE AND OTHER MILESTONES?

A:The law is actually quite specific in defining what a qualified system is, and we have a subcommittee that’s identifying the actual entity—such as the Certification Commission for Healthcare Information Technology (CCHIT)—that will assess systems as to whether they qualify or not. The bigger challenge is data integration.

Everyone recognizes that healthcare is horribly fragmented, that there are silos of care. We know that there’s massive inefficiencies, and there are significant quality concerns because information is not shared as people move across silos.

The challenge with data integration is that we really haven’t figured out how to do it correctly. If you’re an integrated delivery system and you buy one EMR, that’s fine, and that works. But 70% of physicians practice in a community setting, solo and small group practice. You have this tremendous problem that all of these systems are different. They call things by different names, and they even capture different sets of data.

WELLPOINT HAS CREATED THE INDIVIDUAL HEALTH RECORD SYSTEM THAT USES ALGORITHMS. HOW WILL THAT MAKE A DIFFERENCE?

A:Algorithms, also known as decision support, are going to be the key to getting value out of these systems. Let’s say the federal government funds a comparative-effectiveness study that identifies a new drug is great for certain people. In today’s world, we know it can take up to 17 years for that to be commonly found in a physician’s paper record. With this approach, you can create an algorithm as soon as physicians or specialty societies have decided on certain best practices. Now you’ve created an infrastructure to get that message to every doctor, but only when there’s an appropriate situation for that rule to be applied. That will take that 17 years down to 17 days. That’s a huge advance.

Let’s say we have noticed that there’s a lot of inappropriate use of PET scans. In today’s world, a doctor would have to call us for preauthorization every single time he orders a PET scan. In the future, the algorithms will be running, and they will only alert the doctor if there’s an issue with a PET scan. Today, they call 100% of the time, and we generally approve the scan more than 90% of the time. Algorithms will take hassles, administrative costs and bureaucratic burdens out of the system.

The right kind of health IT allows us to use new knowledge from our outcomes research subsidiary [HealthCore] and any gaps in a member’s care identified by our informatics company [Resolution Health] in much more effective ways. The right kind of health IT allows these advances to be applied real time at the point of care while the doctor is treating the patient or helping the patient at home.

IS WELLPOINT’S INDIVIDUAL HEALTH RECORD WORKING? HOW IS IT ANY BETTER THAN OTHER EMRS OR PHRS?

A:We’ve run a pilot in Dayton, Ohio. The idea was not just to create interoperability—don’t just allow System A to talk to System B. When you connect systems together, what you create is just a data dumpster. It’s like putting a jigsaw puzzle on a physician’s desk.

That information has to be organized to just the summarized information that the doctor needs…You don’t take all of the information out of these various systems, you only take the information necessary for the ongoing management of the patient.

Many EMR implementations have failed to show value. About 30% of the time, physicians will actually turn them off because they are incredibly time-intensive and will reduce a physician’s productivity. That will hit them in the pocketbook. We’ve looked for solutions that wouldn’t be so intensive from a physician’s data-entry perspective and would do more sorting of information and presentation of information.

Physicians are not data generators. They’re data consumers. Their orders create significant amounts of data, but the physicians themselves usually just scribble a relatively brief note. The problem with many EMRs is they will require physicians to become data-entry clerks.

In Dayton, Ohio, we have a very significant market share. We’re Anthem Blue Cross Blue Shield of Ohio, and we also have a strong partnership with Kettering Hospital Network.

Kettering had already installed an application integration solution, so even though they had 120 different clinical sources, many of those clinical sources could be accessed through infrastructure they had already built. That made it easy for us to collect all of the clinical data out of their systems. We built feeds to the application from Anthem’s claims systems. We were able to get this application up and running in a little over three months, which is incredibly rapid. We made it available to the patient in the form of a PHR and to the doctor in the form of a CCHIT-certified EMR with e-prescribing.

When we looked at who was using the tool, we found that patients who had a higher illness burden actually made preferential use of the tool. For many of the tools we’ve deployed, the ‘worried well’ have been the type of people who used it, not the people with the chronic disease that we really need to reach.

We noticed the people who used the tool and had the higher illness burden, their cost increase year over year was actually less than the people who didn’t use the tool, even though those people who didn’t use the tool were healthier.

We built algorithms in the system that exactly correlated with various HEDIS measures and every time the doctor or the patient logged on, they could see their exact compliance. By giving the patients and the doctor the same information in a simple red light, yellow light, green light format with algorithms enabled us to see quality improvement scores of anywhere from 10% to almost 40%.

WHAT’S THE BUSINESS CASE FOR A HEALTH PLAN TO CREATE A SYSTEM LIKE THAT?

A: Our strategy is maximizing healthcare value, and healthcare information technology is really a tool to get you there. But it has to be the right kind of health information technology. It has to influence doctor’s decisions, and you have to present sufficient clinical data—not mountains of data but the key things the doctor needs to know so that you can influence his decision to do something that’s consistent with the evidence base, or to prescribe a drug that will cost the patient less but has the same likelihood of creating a good patient outcome.

If you look at why healthcare spending is out of control, it’s chronic disease, not health plan profits and not health plan administrative costs. We are seeing an explosion of chronic disease in this country, and chronic disease is managed largely by the patient at home. They’re managing their diabetes 99% of the time at their home, not in the physician’s office. If you don’t make your health IT solutions patient-centric and if they don’t address chronic disease, I don’t think that you’re going to get the kind of value that you want.

HOW ARE THE PHYSICIANS EMBRACING THE INDIVIDUAL HEALTH RECORD?

A:We have 300 physicians using the system now. We’re planning for a broader rollout to the greater Dayton area in 2010 to virtually all primary care physicians.

What we’re focusing on is chronic disease management, and there’s not huge debate about many of the things that need to be done to take care of these patients. That’s not the problem. The problem is actually getting it done. The physicians in general have been positive and are beginning to see how their lives could be easier.

We also added all of our pay-for-performance rules. We pay physicians more if they practice medicine consistent with the evidence base, and we took the existing measures and turned them into algorithms in the system. As long as the physician follows all the alerts, he can be sure that he’s going to maximize his pay for performance incentive. That’s convenient for the doctors because what they usually have to do is identify the patients who haven’t had certain interventions and then reach out and call them.

We’re just starting to incorporate our utilization management rules. If we can begin to move those algorithms to the point of care, then physicians might not have to call except for when there’s a real reason to discuss something, which might be 5% of the time.

DETERMINING THE EFFECTIVENESS OF TREATMENTS IN ORDER TO BUILD THE ALGORITHMS IS AN EXPENSIVE PROCESS. HOW CAN IT BE DONE?

A:This is the beauty of health information technology…if you bring it together in a repository that’s reflective of the patient’s clinical condition and how they’re being managed, you can begin to do database-driven studies rather than very expensive prospective clinical trials where you’re enrolling patients and following them over time. You can begin to do database driven studies that are a fraction of the cost. No, they’re not the gold standard, which will always be a randomized perspective-controlled clinical trial, but there’s a lot of information we’re going to be able to glean out of database-driven studies that are more observational and more retrospective.

BE A VISIONARY. WHAT DO YOU SEE AS THE POTENTIAL FOR HEALTH IT?

A: I hope that every time a patient needs information when they’re home or need to take care of their chronic disease or want to stay well, that they have that information at their fingertips, it’s actionable, and they don’t even have to think about it. If we can make it that easy—and there is a path to get there—we could actually fix the healthcare system.

Charles Kennedy, MD, has held strategic health IT positions with a variety of organizations. He also served as the medical director of a California health center in addition to other clinical service. He earned an MBA from Stanford University, an MD from the University of California at Los Angeles, and a bachelor’s degree in genetics from the University of California at Berkeley.
” Physicians are not data generators. They’re data consumers.”

2009: A Year of Surprises and Change for the EHR Technology Market

2009 began with a bang for legacy Electronic Health Record (EHR) vendors, promising strong sales and windfall profits on the heels of stimulus package incentive bonuses initially worth more than $19 billion to doctors and hospitals. But things changed dramatically along the way.

Here are some surprises and notable events that have impacted the EHR market:

Payment for Meaningful Use of EHR technology, not for the software and hardware itself.

The idea that using EHR technologies ought to produce improvements in quality of care, better communication with patients, enhanced safety, and better public health reporting and that these outcomes ought to be monitored and providers held accountable for their achievement was itself a surprising innovation in 2009.  It has to be counted among the best 10 health care ideas to come out of government in the past generation.

For several years many EHR technology vendors had expected federal money to enhance IT adoption flowing straight to them and their investors.  But the interpretation of “meaningful use” by David Blumenthal, MD and his staff and advisors at the Office of the National Coordinator (ONC) proved that they want EHR adoption tightly linked with health reform and capable of supporting accountable care payment schemes, such as bundled payment, pay-for-performance, and accountable care organizations. The burden of proof that EHRs are being used appropriately lies squarely on the physicians and hospitals that purchase them.

It’s become PC to ask tough questions about EHRs, quality, and health care costs

For several years it seemed that any criticism of EHRs, any questioning of the relationship between the use of health IT and the attendant quality of care or its cost, was off limits in policy discussions.  EHRs were all good, all the time. But in 2009 we’ve seen a trickle become a torrent of serious challenges to the conventional wisdom about EHR value. It’s come from diverse sources including distinguished federal science panels, academic studies, testimony before ONC and the National Committee of Vital and Health Statistics (NCVHS), and from a chorus of individual users with personal experiences to relate on list servs and blogs. While generally extolling the virtues of health care computerization, these voices of dissent have drawn attention to the large gaps in performance, ease-of-use, and standardization that plague the current crop of EHR products and services.

Perhaps more importantly, in the process they have unburdened the physicians and hospitals who have sat on the sidelines from being labeled “slow adopters,” anti-technology, cheapskates, and even worse.  As it turns out, these folks may have simply not seen the value in current EHR products that offer mediocre performance at best, and which have, so far, mostly demanded a king’s ransom to purchase, implement, and sustain. We expect to see continued critical examination of the uses of EHR technologies, and new reporting that links health IT with documented enhancements in safety of care, quality improvement, and cost efficiencies.

CCHIT’s loss of invulnerability and the displacement of its monopoly on EHR certification

2009 didn’t go as well as the Certification Commission on Health IT, or CCHIT (pronounced sea-chit) might have liked. The HIT Policy Committee advised ONC to replace the vendor-sponsored methodologies for both selecting certification criteria and then carrying out the “certification.”  Instead, the criteria for “certifiied EHR technologies” would be set through an HHS Certification process, and then an international standards-based process used for certification and for selecting accredited certifying entities on the basis of competitive bid contracting.

This was a stunning reversal for the industry-leading companies involved with CCHIT. Many external to the process had criticized CCHIT as a “foxes guarding the henhouse” scheme, with apparent conflicts of interest that would never be tolerated in other industries. But CCHIT’s real sins were a Byzantine certification process that failed to increase EHR adoption among physicians and hospitals, and the glaring fact that, despite an interoperability certification process, it failed to promote health data exchange among EHR applications.  Among the most dramatic and damning testimonies at the HIT Policy Committee hearings in July was that of the CIO of East Texas Health System, who testified that her organization had jettisoned a multi-million dollar CCHIT certified (for interoperability) HIT system because it couldn’t exchange information with another CCHIT certified system.

Then, recently, CCHIT’s embattled CEO Mark Leavitt, MD announced his resignation from the organization. Although still retaining a primum inter pares status as an EHR-certifying entity due to its contractual ties to ONC, it seems likely that several other testing labs will compete with CCHIT for the contracts to certify EHRs under the ARRA/HITECH program. In fact, one company, Drummond Group, announced on November 2, 2009, that it would submit to become a certifying body upon the release of the requirements, expected in late December. The hope is that competition and oversight will create a more level playing field by keeping certification costs down and reducing the barriers to market entry.

Innovation as a theme and goal going forward, backed by the White House
One of the most unexpected, but also most promising, twists in 2009 was Aneesh Chopra’s arrival into the fray, with support from the new Chief Technical Officer for HHS, Todd Park, the former co-founder of web-based practice management software company AthenaHealth. Aneesh holds the title of first Chief Technical Officer of the United States. A known innovator and proponent of off-the-shelf and open source software, Chopra was previously Virginia’s Secretary of Technology.

Chopra sits on the ONC advisory HIT Standards Committee, where late this year he formed an Implementations Workgroup. That effort breathed much needed fresh air into the smoky backrooms atmosphere of the HIT Standards Committee, which had effectively blocked entry of innovative and start-up firms into the EHR technology market by recommending a set of untested, complex, and large enterprise-centric standards.

Apparently recognizing that these were unimplementable, Chopra’s work group held a day of hearings that solicited advice on what does and doesn’t work with respect to standards from – imagine this! - experts with proven track records outside of the health care industry. We don’t yet know the results of this last minute counterbalance to the incumbent and legacy vendors’ influence on ONC. But even some of the most entrenched people on the HIT Standards Committee are now blogging on their ideas for the “Health Internet,” a term quietly replacing the older National Health Information Network. This is good news.

The Power Shift Away from Legacy HIT Firms

Physicians, particularly those whose practices are owned by hospitals, will continue to purchase legacy EHR systems. But there are now alternatives, supported by a grass roots movement towards modular, web-based, and much less expensive software for managing clinical work and information in medical practices.

We’ve called this emerging and disruptive innovation Clinical Groupware to differentiate it from the previous generation of EHR products. We’re happy to report that there is new trade association on the scene, the Clinical Groupware Collaborative, with a mission to educate, promote, and organize collaboration among its members. It’s existence is simply one indication that Web-based applications and software-as-a-service (SAAS) is finally arriving in health care.

This new health IT paradigm is being aided by the phenomenal success of Apple’s iPhone and apps store (2 billion downloads, more than 100,000 apps) and a chorus of technologists, politicians, and public commenters who are asking why a similar platform + modular apps approach hasn’t gained more acceptance in health care among physicians and hospitals.

Interest in HIT by Big Technology Companies

The convergence of the opportunities in health care and the race toward cloud computing isn’t lost on the largest Web firms. Organizations like Microsoft, Google, Salesforce, Covisint, IBM, Intel, and Amazon not only are marshaling their forces to create new health care products, but have the resource bases and very deep IT infrastructures required to rapidly scale the kind of effort that will be required in a sector as vast and sophisticated as health care.

Their emergence in this space presents a non-traditional challenge to legacy firms, which have typically faced and easily out-gunned smaller, less resource-capable innovators. These new entrants are extremely sophisticated, established businesses with enormous capitalization and, often, more leading edge technologies.

These unexpected turns of events are profoundly important for a simple reason. The changes in health information technologies over the next few years could well be foundational, shaping how health care works globally for the next several decades. Which is why it is imperative that we not allow older paradigms that have outlived their utility to prevail, just because they were there first.  2009 has been a bright spot, in the sense that we’ve seen signs that the old guard could be dislodged. Against a backdrop of a health care reform effort that, as far as we can understand it, will not do much to improve the system, this progress in Health IT is encouraging.

Standardizing Electronic Documentation Using a Perioperative Nursing Language

Our places of work and homes are abuzz with new terms: toxic assets, monetary policy and stimulus packages. While the current state of the economy is to many a relatively new development: cost containment, productivity and revenue struggles are not new to healthcare. Consider the dizzying predicament for healthcare professionals when economic issues are mixed with industry issues such as safety, quality, evidence-based care and pricing transparency. Adding regulations offering incentives for the “meaningful use” of electronic health records (EHR) and the clinical care environment transitions into a tense, high-pressure conflict between actual care, documentation and data collections.

In the midst of this conflict and pressure is the professional nurse. No doubt, nurses affect clinical care and patient outcomes. A report studying the effects of nurse-to-patient ratio validated a strong correlation with reducing patient morbidity and mortality.¹

However, healthcare organizations, especially perioperative areas, have difficulty with data collection, integrity and retrieval that provides the basis for operational and clinical decisions. Poor or inconsistent data restrains the allocation of appropriate resources or tools to develop a scientific foundation for an evidenced-based nursing practice model.

Increasingly, healthcare and the perioperative environment are going digital. With this transformation, there is a need to provide rigorous standards that promote safe patient-centered care. A market survey of over 200 perioperative units in healthcare facilities and ambulatory surgery centers (ASCs) revealed many wanted, or had some version of, the Perioperative Nursing Data Set (PNDS) in their documentation, but did not know how to incorporate it into their plan of care. Additionally, the respondents were unsure if their documentation met standards or regulatory requirements due to the complex regulatory environment and the difficulty of maintaining the frequent updates.²

Clearly, healthcare organizations need to identify the critical factors to be employed when developing an information infrastructure and the tools to quantify efficient, cost-effective quality care. By applying a standardized perioperative language, the clinical environment has a mechanism to aggregate consistent data representing patient-centered care. The American Medical Informatics Association (AMIA) also offers additional guidance for selection and implementation of an information system to promote a national infrastructure for healthcare:

• Establish a local, regional and national health information exchange (HIE) to ensure that health information is available whenever and wherever needed
• Create standards, policies and practices that foster security, confidentiality, transparency and public trust
• Identify health terminologies and classifications allowing health data to be uniform and consistent across information systems
• Link information related to individuals in order to ensure the validity and integrity of health data for care and research
• Develop decision making and other knowledge management tools in order to permit delivery of individualized, evidence-based care
• Develop appropriate and secure linkages between EHRs and the public health surveillance systems.³

The PNDS is foundational to this effort as it meets an essential point of the information infrastructure criteria by providing clear, consistent and precise terminology, and definitions for clinical problems (nursing diagnoses), nursing interventions and patient outcomes, and reflect perioperative nursing practices.⁴ The PNDS is not a standard of care, but a structured vocabulary allowing the aggregation of clinical information across the perioperative continuum of care. In a standardized perioperative framework, the PNDS is associated with practice standards, accreditation criteria and regulatory requirements to facilitate efficient and safe patient care, while staying current with changes in healthcare. Throughout the healthcare system, initiatives to promote patient safety, improve outcomes and report consistently on quality metrics are gaining considerable momentum. Congress has directed the Centers for Medicare and Medicaid Services (CMS) to put into place a reporting system for ASCs to track quality by the end of this year, with financial penalties for those failing to submit the required data.⁵

Responding to this heightened emphasis on quality reporting will not be easy. Compliance with the Joint Commission or other accreditation standards is another concern for ASCs. Automating documentation in the clinical setting can greatly improve the ability to meet these goals. Information systems not only satisfy regulatory demands, it also reduces inefficient manual processes.

Healthcare organizations do not want to re-invest in a new surgical information system but want collected data to be used more efficiently for benchmarking and quality initiatives. A standardized data framework that overlays the existing user information documentation system and standardizes perioperative documentation and nursing workflow will help guide decision making for patient-centered care. Such a framework enables hospital decision makers and nurses to:

Guide safer care by integrating:

• The Association of periOperative Registered Nurses’ (AORN) Perioperative Standards and Recommended Practices
• Regulatory and mandatory reporting requirements
• Accreditation standards
• PNDS
• Consistent, standardized communication.

Guide effective care by:

• Enabling evidenced-based clinical decisions
• Providing information to develop protocols
• Integrating current regulatory requirements, accreditation criteria and national standards
• Promoting nurse-sensitive interventions and plan of care.

Drive efficient care by:

• Returning nurses from the conference room to the operating room
• Reducing nurse documentation time
• Facilitating perioperative staff training by
• Training new orientees
• Orientating temporary staff.

The framework should complement rather than replace any information technology (IT) vendor system, focusing on standardizing the perioperative content of the EHR, nursing documentation and functionality with surgical information systems. There are four general categories of technology that should be considered when purchasing any new IT application:

• Presentation – what is seen on the screen
• Workflow – how information is proceeded and sequenced
• Reference files – tables and files of predetermined values, such as allergy types or patient positions
• Data – where patient-level information is stored

With this framework, healthcare organizations can standardize the perioperative content for workflows and reference files.

Workflows should be standardized across both the perioperative continuum (pre-admit to post operative recovery) and throughout the nursing cycle (assessment, nursing diagnosis, desired outcome, implementation, evaluation and actual outcome)

Reference files should be created by the organization implementing the system. The framework provides a comprehensive and detailed list of standardized reference files scalable to any organization.

So how does all of this represent patient-centered care?

1. It does not require more documentation; it is transparent to the user
2. It integrates national standards, recommended practices and regulatory requirements across all phases of perioperative care
3. It employs PNDS as the universal perioperative language with associated data elements reflecting nursing interventions
4. It reflects nursing workflow in the entire plan of care, assessment, implementation, evaluation and patient outcomes
5. Enables data to be used for benchmarking, both internally and externally
6. It supports national mandatory reporting measures (e.g., Surgical Care Improvement Project measures) by utilizing continued documentation of the assessment findings throughout all phases of perioperative care
7. It supports the submission of required CMS quality data.

References

1. J. Needleman, PI Buerhaus. Nurse Staffing Levels and Quality of Care in Healthcare Organizations. The New Eng J of Med May 30, 2002, No. 22, Vol 346:1715-1722
2. CSC market survey conducted on behalf of AORN from 8-1-2008 thru 9-30-2008.
3. D. Detmer. AMIA recommendations for achieving a national infrastructure for HIT and  informatics to President-Elect Obama. January 7, 2009. http://www.amia.org/files/ObamaLetter_January2009.pdf. Accessed April 3, 2009.
4. C. Peterson, ed. Perioperative Nursing Data Set Revised 2nd ed. Denver: CO: AORN, INC; 2007:9-15.
5. Centers for Medicare & Medicaid Services (CMS). 2008Deficit Reduction Act (DRA) 2005 (c). http://www.cms.hhs.gov/HospitalAcqCond/. Accessed April 3, 2009.

Sharon Giarrizzo-Wilson, RN, BSN/MS, CNOR, is a perioperative nurse specialist, in Clinical Informatics for AORN. Julie Hammersley, RN, is a senior manager in the Perioperative practice at CSC. Louise Kenney, RN, is a senior manager in the Perioperative practice at CSC. Barbara Ripollone, RN, is a partner and the solution leader for the Perioperative/Supply Chain practice at CSC.

GE Offers No-Interest Financing for Health-Care Technology

General Electric Co. said its GE Capital division will make 0% loans to hospitals and health-care providers that purchase GE’s health-care information-technology offerings.

GE said it expects to offer $100 million in interim financing to hospitals and health-care providers for projects that are expected to qualify for funds from the U.S. government’s economic-stimulus package. GE calls its program Stimulus Simplicity and connects it to the company’s Healthymagination marketing initiative.

One early borrower will be Hazard Clinic in eastern Kentucky, which plans to install an electronic medical-records system.

GE said the move offers doctors, community health clinics and hospitals a bridge to qualify for stimulus funds and faster access to electronic medical records. The company said the move also indicates GE will continue certifying its products to government standards.

The federal stimulus package allocates $19 billion to health-care information technology.

Vishal Wanchoo, president and chief executive of GE Healthcare IT, said many hospitals are cash-strapped and unclear on when stimulus funds will start flowing. The program will “take away a lot of the concerns hospitals have,” he said. “We think this will help us increase our market share.”

Healthcare IT makes up only 10% of GE Healthcare’s $17 billion in annual revenue. The company has said it would like to expand its presence in the fragmented health-care IT market.

Tumors After Stem Cell Injections and Other Health News

Boy Develops Tumors After Fetal Stem Cell Injections

An experimental injection of fetal stem cells caused tumors to develop in an Israeli boy’s brain and spinal cord, according to a new report in the journal PLoS Medicine. The child had a rare, deadly brain disease called ataxia telangiectasia, or A-T. The disease can lead to degeneration of a region of the brain; most people with A-T die by their teens or early 20s. The boy had traveled to Russia at age 9, when he was injected with fetal neural stem cells in his brain and spinal cord, the Associated Press reports. He received two additional sets of injections at ages 10 and 12. By age 13, the boy needed a wheelchair for his A-T, and he was experiencing headaches. The tumors in his brain and spinal cord were discovered soon after that. A test of the tissue found that the tumors were caused by the fetal cells.

Treatments involving stem cells, such as a heart attack procedure offered in Thailand, are still viewed as experimental, yet some researchers believe they may help certain medical problems. Consider these3 ways that stem cells may speed new cures for certain diseases. Also, human stem cells now can bemade from adult skin, without using embryos or eggs.

Electronic Medical Records: Will Your Privacy Be Safe?

Electronic medical records have become a national goal, a way to replace the highly fragmented and inefficient paper system used in most medical settings today, Bernadine Healy reports. President Obama has made revamping the medical system a top priority, with the national electronic medical record first up in healthcare reform. Indeed, the economic stimulus package assigns billions of dollars to that effort. In light of public sensitivity, this major jump-start for centralized records comes with provisions to further strengthen privacy laws.

While electronic medical records are being touted as part of the key to an efficient healthcare system in the future, some doctors have been slow to take up the technology.

Stressed Out? Find a Great Deal at a Spa

Discount is not a word that traditionally has been associated with the spa industry. Yet, people looking for relief from the stress brought on by their shrinking portfolios will find that spas nationwide arevying for their business, Lindsay Lyon reports. “I’ve been in the spa industry 30 years, and I have never seen so many deals and so many good deals . . . unprecedented deals,” says Susie Ellis, president of SpaFinder.com, a website that helps people research and book visits at more than 5,000 day, resort, and destination spas worldwide. Many vacation spas, Ellis says, are lowering room rates, tossing extra services or meals into their overnight packages, allowing a free guest, or slashing the package price of midweek stays, for example.

Looking for an escape? Here are 12 deals currently available at spas around the country. If visiting a spa isn’t in your budget, check out these tips for managing your money-related stress.

Stimulus Package Overview (With 18% Relating to Healthcare)

Two day ago, history was in the making with President Barack Obama signing into law one of the most expensive bills in US history, a $787 billion emergency stimulus package geared toward saving America’s troubling economy.

Obama claimed it is “the most sweeping economic package in US history” and after signing this historical bill, stated: “There you go. It is done.”

This $787 billion package is allocated in the following manner:

Description Amount %	Â	Â
Tax cuts	$260 billion	33%
Healthcare (subsidizing health insurance for unemployed)	$141 billion	18%
Infrastructure projects	$89 billion	11%
Funds to states for education	$87 billion	11%
Energy plans	$86 billion	11%
Improved unemployment benefits	$81 billion	10%
Other	$43 billion	6%

The healthcare spending side of this bill further breakdown as follows:

• Accelerating Adoption of Health IT Systems to Modernize the Health Care System, Save Billions of Dollars, Reduce Medical Errors and Improve Quality.
• Protecting Health Care Coverage for Millions of Americans During This Recession.
• Providing Health Care Coverage for 7 Million Americans.
• $1 billion investment in Evidence-Based Prevention for Americans.
• $500 million in Strengthening the Health Workforce
• $10 billion in Investments into the National Institutes of Health
• $1.1 billion investments into Comparative Effectiveness Research.
• $2 billion investments into Community Health Centers
• $500 million to modernize Indian Health Services
• $50 million to the Health and Human Services for IT Security

To learn more about the healthcare aspects of the stimulus package, go to http://www.whitehouse.gov/assets/documents/Recovery_Act_Health_Care_2-17.pdf