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Lou Agosta

Greetings and welcome to my blog focusing on reengineering healthcare using information technology. The commitment is to provide an engaging mixture of brainstorming, blue sky speculation and business intelligence vision with real world experiences – including those reported by you, the reader-participant – about what works and what doesn't in using healthcare information technology (HIT) to optimize consumer, provider and payer processes in healthcare. Keeping in mind that sometimes a scalpel, not a hammer, is the tool of choice, the approach is to be a stand for new possibilities in the face of entrenched mediocrity, to do so without tilting windmills and to follow the line of least resistance to getting the job done – a healthcare system that works for us all. So let me invite you to HIT me with your best shot at LAgosta@acm.org.

About the author >

Lou Agosta is an independent industry analyst, specializing in data warehousing, data mining and data quality. A former industry analyst at Giga Information Group, Agosta has published extensively on industry trends in data warehousing, business and information technology. He is currently focusing on the challenge of transforming America’s healthcare system using information technology (HIT). He can be reached at LAgosta@acm.org.

Editor's Note: More articles, resources, and events are available in Lou's BeyeNETWORK Expert Channel. Be sure to visit today!

August 2009 Archives

Security is a growth industry, and, given human nature, can be expected to remain that way. So the title of this article is a kind of stalking horse. Yet one with a point. From the point of the view of the consumer of healthcare one of the most fearful things is to come down with a dread disease and have no insurance coverage. That means confidentiality. That means keeping secrets - from one's insurance company. Granted that is a practical impossibility, it does not matter when it comes to worry and high angst. Still, insurance companies are operated by and for human beings and have all the strengths and weaknesses of human beings. They will do what they are incented to do. In a market that requires underwriting, insurance companies will perform underwriting - or be at the effect of adverse selection, attracting the sickest patients while the competition "cherry picks." However, if legislation were enacted to require community rating and that the preexisting conditions be insured (covered), then there would be a much smaller penalty if your dreaded disease of choice became know to the insurance company. The patient would still have insurance - case closed. Of course, without community rating, one's premiums would go up by an order of magnitude, which is about the same thing as denial of coverage. So the two requirements go hand in hand. That is not to say that the data should be posted on the Internet; yet in the bigger picture, if one can still get insurance, who really cares? Naturally, it might make less employable because of too many sick days; yet the employer would not be incented to throw the person "over the side" because of the cost of insurance premiums.

Of course, people will care about security because people value their privacy - being able to sit down to dinner without the phone ringing off the hook with marketing calls; being secure in their personal, financial, and medical identities. Yet not because they fear loss of insurance coverage! The point? Regarding data and information security, constant diligence is the order of the day. Yes, technologies such as encryption, passwords, and authentication are critical path. Two factor security solutions are increasingly in demand by both users and regulators. A two factor system requires both a password as well as a device such as a smart card, appliance (phone), or thumb print (biometric id). If one is lost or stolen, it is useless without the other factor. But also be aware of social engineering - someone calls up pretending to be the system administrator who has forgotten her or his password. Don't laugh. It has been used - and has worked. Identify and implement related best practices such as never, ever, ever leaving a laptop computer unattended, leaving a laptop visible in a locked car, attaching a post-it with a password to a computer screen, or allowing sensitive data to go off site.

Posted August 31, 2009 8:48 AM
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On August 5, 2009 PracticeFusion.com and Salesforce.com announced a strategic investment in developing a personal health record (PHR) by Practice Fusion in the health market vertical building on the salesforce.com platform. Please pardon the provocative title of this posting, but . . . It makes perfect sense. The role of salesforce.com is as an information coordination and e-commerce platform. Practice Fusion has the domain expertise, offering an innovative approach - and revenue model - delivering an electronic medical record (EMR) system - and soon a personal medical record (PMR) - over the web. Expect to see and hear about more such initiatives.  


This is significant for three reasons.


First, some 80% of physicians practice in groups smaller than nine doctors. Large (and expensive) electronic medical record systems are too costly and too complex for such practices. Many Quicken-class software applications are still too feature poor to qualify for meaningful use and reimbursement under the regulatory incentives. What is a small practice to do? Software as a service "in the cloud" and over the web is an option. The cloud represents an important and emerging part of healthcare information technology (HIT) market.


Second, the entry of salesforce.com is a signal that - regardless of what happens in the US Congress with healthcare and insurance reform - the billions of transactions between consumers and providers and payers require facilitation and the Internet will be a significant part of the solution. We can expect to see a proliferation of proposals, experiments, and innovations in HIT of which this is one example. Practice Fusion did not invent the option of SaaS for EMR - most large practice management and hospital information system (HIS) are gearing up to offer their products over the web or are already doing so - but Practice Fusion has an attention getting revenue model. Read on ...


Third, the service is free to physicians. Physicians get to look at banner advertising (reportedly inconspicuously placed at the bottom) from Big Pharma, public health organizations, and professional societies. Given the audience, the advertising metrics and conversion rates are compelling. The doctor is ordering a drug, test, or procedure - she or he is a ready listening for the latest study. But that is not all. Even more significantly, the revenue model also includes pennies on the dollar as transaction are generated by e-perscribing and the ordering of tests through the Practice Fusion network.


However, having touted the approach, a few words of caution are useful. Whatever you do, do not run out and sign up (or buy anything) without knowing your requirements. What is the problem to be solved? Clinical decision support? Scheduling? Billing? All of the above? Ask the tough, impertinent questions. These include: suppose your (Practice Fusion, salesforce.com, etc.) data center is destroyed by a flood or tornado, what happens to my data? How often is an off-site back up taken, and can I get this guarantee in writing as part of a 7x24 service level agreement? Suppose my practice flourishes and eventually I want to install and operate my own IT department using proprietary software - how complicated is it to get a disk with all our practice data on it? How much lead time? And, by the way, what is the transactional component? How does the system perform e-prescribing, clinical labs, physician order entry, charting, reimbursements from payers, reporting, pay-for-performance, benchmarking? What are the security certifications and protocols? How is authentication managed? Suppose one doctor on Practice Fusion wants to share a patient chart with another provider not on Practice Fusion - interoperability is one key point of EMRs - how is authentication managed? What happens?


Note these are questions and issues whatever your EMR system happens to be and whether the system is hosted as software as a service or is installed in a closet in your office. Heck, these are questions even if you are totally paper-based, granted that the answer is then "snail mail." For further details on the overall market see - "The Healthcare Information Technology Market is Posed for Growth" http://www.b-eye-network.com/channels/1568/view/11085/


Whether signing up for Practice Fusion or one of its competitors (whose services are generally fee-based) - including PayerPath, AthenaHealth, Emdeon, eClinicalWorks - let me know what are your experiences, thoughts, and comments.

Posted August 18, 2009 11:54 AM
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One of the challenges facing physicians and healthcare professionals is automating their small one to five doctor practices using appropriate information technology. As Dr. Peter Polack points out in his health information technology (HIT) advice on www.eMedikon.com, doctors end up wearing two hats - doing his or her day job of treating patients as well as keeping the printers and photocopiers running to manage charts, treatment plans, and bill/collect payments for services rendered. The approaching requirement to upgrade to an electronic medical record (system) raises the bar for everyone, but especially for the already stressed small practice.


What to do about it?


The community college system is well positioned to offer an associate degree in healthcare information technology. What I am suggesting is that beyond a shortage of funds - which is what I heard when I called a local community college - a closely related issue is a shortage of imagination. Therefore, I am here proposing a model curriculum for an associates degree with a concentration in HIT. I am also hereby applying for the role of the Dean of Imagination. Since such a position does not yet exist, a new possibility will have to be imagined. Note this is a work in progress and - given this is a blog - I am inviting the contribution of other educators, IT professionals, and medical practice professionals and managers to what is really required. What is needed to provide implementation services and support for small to medium-sized medical practice management software? Here is a modest proposal...


Choose two out of three courses:

in operating system: Linux, Windows, Unix;

in database management systems: IBM DB2, MS SQL Server, Oracle,  MySQL, Postgres

in scripting languages: MS Visual Basic; Perl; Java Script


Take one of each:

System and application design

Web concepts and design


Take two out of three:

Introductory Physical science

Biological science

Discrete mathematics (i.e., logic and basic set theory)


The graduates of these programs jump into the HIT gap, help out, bill at a reasonable rate in their new Geek-Squad-Class job roles - note key term "jobs" -  and give the hard-pressed physician some relief, so he doesn't need his own services.


I am also inviting software companies such as Microsoft, Oracle, IBM, HP, SAP, Red Hat, etc., and others to step in and offer complementary software to be installed in the computing labs of the local community colleges. Companies such as Cerner, Eclipsys, Epic, GE Healthcare, Meditech, MedSphere, Siemens SMSAllscripts/Misys, offer larger, more complex systems; but there has got to be a way for them to contribute a downsized version too. This is just good business sense. Everyone knows that most IT professionals recommend and promote the software with which they are most familiar (assuming it is not a real dog), since that is what is they know and can use to benefit the end-user client. This will drive demand for the software in question once the students get into the real world and start making recommendations.


One thing not on the list - but critical path - is how to get the printers running and keep them running. In spite of the new digital economy, broken and malfunctioning printers are everyone's Waterloo. If anyone has best practices on printer maintenance, then the world will beat a path to your door.


The point is that many of these classes are already available in some form at the local community college. The catalyst for this post is already in the news - see "Community Colleges Should be Tapped for IT Experts," Patty Enrado, Healthcare IT News, July 15, 2009 (http://www.healthcareitnews.com/news/community-colleges-should-be-tapped-hit-experts). The Dean of Imagination is proposing to group these course in a cross departmental, interdisciplinary manner. Of course, many innovative and hard working Community College Presidents and Deans and Instructors are probably working on this already - and if they weren't, then they are now! The probability is that it will increase enrollment across the board so it is win-win all-they-way. 

Posted August 14, 2009 9:28 AM
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The catalyst for this post is that on Thursday July 16, 2009 The Office of the National Coordinator for Health Information Technology (ONC) health IT policy committee met to vote on long-awaited recommendations from its workgroups on how providers can qualify to receive incentives through the new stimulus package. These recommendations will have to be approved by ONC chief David Blumenthal, so stand by for update on what will actually be reported out of the committee. However, it is timely to provide background on "meaningful use."


Investment in healthcare information technology is supposed to be a major driver in transforming the US healthcare system, according to the US Congress. The federal government stimulus package contains something for healthcare IT. To be precise, American Recovery and Reinvestment Act of 2009 (ARRA), which became law on Feb. 17, 2009, allocates about $20 billion to digitize the healthcare system by the adoption of electronic health record (EMR) software systems and technology.   


While the rules of the system are still evolving, this much is relatively clear. Hospitals and eligible professionals will qualify for incentive payments beginning in 2011. To receive the maximum incentive payments over a four-year period, professional practices must qualify by 2012 and hospitals by 2013. These payments are estimated at $4 million per hospital and $44,000 per eligible professional. The amount of the incentive declines if they do not qualify by 2013. While the "carrot" associated with qualifying for incentives is attractive, the "stick" begins to be used in 2015, and hospitals and eligible professionals are penalized with lower Medicare reimbursements if they are not yet meaningful users of a certified EHR system. We believe that most healthcare organizations will pursue these powerful incentives. This virtually guarantees that the basic U.S. healthcare system will be largely digitized by 2014-2016. Issues about standards, interoperability, and realizing the promised cost savings should not be taken for granted and are front and center.  


To get over the bar and receive the reimbursement the implementations must satisfy the criterion of meaningful use. This is the part that is still evolving, though fortunately it is by no means a complete mystery. Since it is the end-user enterprise - the hospital or physician practice - that must meet the requirement of meaningful use, the governance gets a tad complicated. Presumably the software must support meaningful so and the implement by the end user must provide for such a use.


Though the Secretary of the Department of Health and Human Services (HHS) is allowed to further define meaningful use of an EHR, it has initially been defined to include such features and functions as the


  • reporting of clinical quality measures
  • use of EHR technology to improve quality of care through care coordination.
  • capacity to capture demographic information about the patient, record a medical history,
  • provide clinical decision support,
  • allow for computerized physician order entry,
  • facilitate quality reporting and be interoperable.


Notice that some of these features are a function of the system and some of them are a function of its use. For example, demographic information is fairly basic; whereas interoperability sets a much higher bar (and may end up being gutted since few systems are interoperable, invalidating the whole process). In between is physician order entry which implies a data model that implements patient details, patient history, and instructions from the doctor to nurses, support staff, as well as the patient - take two aspirin and call me in the morning. If the doctor does not hear from the patient tomorrow, then he receives an alert from the system and someone calls the patient to make sure he is okay. Clinical quality measures suggest the aggregation of data across multiple EHRs. For example, experience show that six out of ten patients with penicillin resistant strep respond favorably to antibiotic XYZ within three days whereas only four out of ten do so with antibiotic ABC.


The standard are still a work in progress and updates (7/14/2009) have included - Other revisions to the 2011 criteria include:

* Implement one clinical decision support rule relevant to a specialty or a high clinical priority;
* Submit claims electronically to payers;
* Check insurance eligibility electronically when possible;
* Provide patients with timely electronic access to their health information;
* Provide patients, upon request, with an electronic copy of their discharge instructions and procedures at the time of discharge; and
* Require the capability to exchange health information where possible in 2011, with participation in a national health information exchange by 2015.


What are your thoughts and recommendations and concerns about "meaningful use"? Is this the equivalent of a "meaningful relationship" from the days of flower power in the 1960s? Let me know your take on this as a healthcare provider, payers, or policy-maker.


Meaningful use matrix -


Posted August 10, 2009 6:30 AM
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"VistA" is the Veterans Information System Technology Architecture, an open source, run-your-hospital software platform that, defying all expectations, has been a runaway success in bringing order out of chaos, reducing costs, and promoting best practices in the Veterans Administration Healthcare System (which serves some six million former service men and women). VistA was - and still is - a strong candidate as a model to be scaled up and out on a nation-wide basis.


This is surprising for at least three reasons. First, healthcare is a risk averse industry - rather like the airlines in having no room for operational error - yet this is a open source software success story. Second, MUMPS as a file system and data store is not exactly the most innovative approach. It has a reputation for being blazingly fast in handling data, but very challenging in terms of data access. The fast process is traded off at the back end in difficult data access and delivery. How about a standard relational database with in memory caching? Or a column-oriented data store for analytics? In short, the latter are emerging possibilities and Oracle and Cache? are apparently coming on stream as options. Third, VistA offers over 130 clinical modules. It is in production at 150 medical centers, 850 clinics, and supports 15,000 physicians. Some 85% of all physicians in practice are exposed to VistA. From a governance and system development point of view, it is hard to know what to do. Suppose you require a laboratory system - what are you going to do? Propose that the developers start coding and the rest will be spontaneously evolved as a rule of variation and natural selection of the code itself in the course of what? Twelve months? Eighteen months? In a business where large software implementations have a history of being routinely over-budget and behind schedule, you just might want to take a flier on such an open software approach. Yet imagine try explaining it to management or to a Congressional committee tasked with making sure veterans are well served. Here's the rock and her's the hard place. Which will it be today?


Like Linux and Apache, Vista has benefited from the evolutionary approach of open software development. According to hackavist - that rhymes with "activist" - Fred Trotter, Vista was developed by programming pairs - not two coders, but one coder and one clinician. The coder automated the clinical expertise articulated by the local hospital provider. Each local VA hospital developed an alternative solution and the best one was distributed through the system in a process of Darwinian variation and natural section where the most robust solution survived and prospered. The whole process is more complicated than can be documented in any blog post, but is exceptional in not being centralized, top down, or orderly in the standard water fall model of software development.


As noted, this has presented a challenge as executives and managers - including multi-star generals in the US Armed Forces who are the equivalent of CxOs for the VA -  reach out to perform their fiduciary oversight to the process. It is also a challenge to those who see Vista as a model scalable across the entire civilian healthcare system - or at least a significant subset of it. In short, governance issues now loom large. Efforts are underway at the VA by management to centralized Vista development, thus marginalizing the innovative energies of the local VA participants. In a parallel and generally positive universe, some key developers have left the VA and formed Medsphere which is a private corporation committing investment dollars to evolving and selling Vista to commercial hospitals and private healthcare providers. However, the momentum seems to have gone out of the Vista innovations at the VA, which reportedly has lost its groove.


In November 2007 - so this is old news - Cerner was awarded a nine (9) years contract to deploy and use Cerner Millennium PathNet laboratory information system in some 150 hospitals and 800 clinics in the Veterans Health Administration system. This creates a challenging mixture of the so-called proprietary and open systems models that has open source advocates sputtering metaphors about amputating living limbs and replacing them with wooden prostheses. I don't think so. Still, it did get my attention when my own personal physician, a practitioner at a large teaching hospital, spontaneously praised VistA and decried its loss of momentum. He had no knowledge of my interest in the matter - none - or that I was writing an article on it. Of course, this is just anecdotal evidence, but, in any case, VistA has a certain buzz about it. And even if a given software module is not the optimal solution for a given set of requirements, the power of open source to drive down costs while improving software quality is demonstrated time-and-again. Granted, software is often initially purchased due to the diversity of features and functions, in which standard proprietary software solutions often excel. However, software is upgraded, maintained, and renewed due to the usability of a few key features that end-users cherish and cannot live without. In the latter area, open source is as strong a contender as any others in the field.


Regardless of the dynamics, open source offers a compelling value proposition. When the code is made the target of a methodological support process with 7x24 support - all richly compensated with an appropriate fee structure - the operational risks are no greater (or less) than any other code, whether proprietary or open. So what are you supposed to do about it? Call your Congressman? I would not rule it out. Send him the URL to this posting - and let me know what you think.

Posted August 6, 2009 6:30 AM
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