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Best Practices For Selecting An EHR

Rebecca Armato doesn't mince words. "Just as the right medical treatment is critical to a patient's survival, the right approach to EHR selection and adoption is critical to the health/survival of a physician's practice," she said.

Via Presinet Healthcare
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EHR and Health IT Consulting
Technical Doctor's insights and information collated from various sources on EHR selection, EHR implementation, EMR relevance for providers and decision makers
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How can we make the EMR note more legible? Here are some ideas.

How can we make the EMR note more legible? Here are some ideas. | EHR and Health IT Consulting |

Despite the well-known rollout problems for hospitals and clinics across the nation, there are many palpable and welcome advantages to using electronic health records.

Chief among these are the ability to access the chart from anywhere, rapidly search for information needed, and reducing the centuries-old problem of illegible doctors’ handwriting.  But with the good comes the bad, and in these still relatively early stages of health care information technology adoption — the current IT solutions remain slow and cumbersome, ultimately taking time away from doctors and their patients.

I’ve written a lot about these problems and will continue to do so until we get this right. However, another less talked about disadvantage is that if they are not optimized carefully, use of IT significantly reduces the quality of physician documentation in the medical records.

Let’s take the example of a history and physical, which is the core document the physician produces when he or she first sees the patient. In the traditional way of doing things, the doctor would dictate (using a transcription service) the medical history, physical exam findings, and then their overall assessment of what’s wrong with their patient and the treatment plan. The final product is a letter-like record that appears in the chart, carefully sub-headed and in flowing paragraphs that look like they have been written by a human being.

Thankfully this remains the process for lots (if not most) doctors. However, it may not be for much longer. In the new health care IT world, where capturing data is paramount and many EMRs make the doctor into type and click bots — the new up-and-coming way to do a history and physical is to go through a checklist and series of tick boxes on the computer. Typing and use of voice-recognition software are encouraged for the other parts. The end result is a ream of information, often incoherent, and a final assessment that is robotic and frequently lacks clarity of thought. Unfortunately from what I’ve seen, medical students and residents are increasingly adopting this new method of doing things, with the result being a vastly inferior product that is displeasing to the eye and whose content lacks downstream thought. A problem of both style and substance.

I would challenge anybody, including the IT gurus who promote its use so much, to look at a history and physical produced by the two methods and honestly assess which one is more coherent: the traditional one or the new computer generated report? Ditto for progress notes and discharge summaries, where the same problem exists.

So what can be done apart from going back to the bad old days of no information technology? Actually, an awful lot, if we optimize the information technology correctly. Remember IT is not the enemy here — it’s the design and implementation. Here are some solutions:

  • Decide what is and isn’t useful information to put in the main physician documentation sections. Should there be a gold-standard definition from a leading authority?
  • Make the final computerized document more eye-friendly and avoid reams of data in favor of intelligent looking descriptions and paragraphs. If tick boxes must be used, make the output a better one.
  • Seek feedback and guidance from other institutions who already do things better with their own electronic medical records.
  • Put tremendous resources into developing better voice recognition software. The particular one I’ve seen used the most (no name mentioned) is painfully slow and I feel a bit sorry when I watch colleagues talking slower than a 5-year old as they dictate their notes, correcting mistakes every few seconds with the keyboard.
  • Create a national task force to address this issue for the future.

A good start would be for hospitals to establish committees involving senior physicians, IT staff, and administrators. Because every hospital has their own electronic medical record, the work to do will be unique to each institution.

The world of health care needs to quickly correct course before this problem gets too far away from us. With information technology, health care will reap what it sows. If it encourages new doctors to become thoughtless type and click bots — just see what that doctor generation will look like in 10 years time.

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Prepare for the tsunami of patient data with integrated, flexible technology

Prepare for the tsunami of patient data with integrated, flexible technology | EHR and Health IT Consulting |

In 2013, 68 percent of U.S. consumers owned a smartphone and 80 percent owned a personal computer with Internet access, according to a February 2014 report by the Nielsen Company. These ownership rates are expected to increase, especially with mobile devices, and are influencing consumers’ behavior.

“Today’s consumer is more connected than ever, with more access to and deeper engagement with content and brands thanks to the proliferation of digital devices and platforms,” according to Nielsen.

Those brands include healthcare brands, although hospitals and physician practices have been slow to adopt online platforms that allow them to connect with patients at home or on their mobile devices. However, in the coming years, patients will increasingly demand online connections with their providers and will also be electronically submitting large amounts of data to their healthcare organizations.

This changing patient communication and engagement dynamic is why organizations need to be prepared with highly flexible, integrated information technology (IT) systems that, regardless of the source, collect, interpret and manage the information to deliver insight that helps providers better manage populations and individual patients. Organizations that have been reluctant to adopt such technology should avoid further procrastination so their providers can become accustomed to this type of patient interaction, but also to take advantage of financial incentives offered by the Meaningful Use of Electronic Heath Records (EHRs) program from the Centers for Medicare and Medicaid Services.

Wearable monitoring devices will become the norm

The approaching “tsunami of data” arriving at healthcare organizations will, in part, be from patients’ wearable health monitoring devices, according to the PwC Health Research Institute (HRI) (PDF). Although now primarily used for exercise and wellness, these monitoring devices offer “useful, shareable information while gathering valuable consumer health data,” HRI reports, adding that “the opportunity is there” to leverage that data to “deliver more personalized care and experiences.”

Although adoption will be gradual, patients wearing durable biometric sensors wirelessly reporting blood glucose levels, blood pressure, heart rate and other metrics to providers will become the norm in the near future. Providers must be able to efficiently collect and integrate this data into their current workflow so they can monitor patients’ management of chronic illnesses and detect when a potential adverse event is imminent.

This capability will become increasingly significant in the near future given the recent inundation of announcements from technology companies that they will be launching tools and apps that gather and transmit this consumer generated data to physicians directly from patients’ smartphones. Without an effective plan in place, this additional source of data could overburden practices.

With EHRs becoming an essential tool in organizations, providers need to deploy patient-facing technology integrated with EHRs and other existing IT systems to ensure that data collected from these devices and manually entered by patients are normalized and assimilated for clinical analysis and reporting. This data exchange and standardization process is still evolving, but new industry-driven collaborative organizations, such as Carequality, are dedicated to accelerating progress in health data exchange among multi-platform networks, healthcare providers, EHR vendors and health information exchange vendors.

Additionally, organizations will need to establish workflows that leverage allied professionals such as case managers, nurse practitioners and physician assistants, who can review the data delivered from these wearable health-monitoring devices. One such workflow has yielded positive outcomes for Kaiser Permanente Colorado, which used at-home blood pressure monitors and web-based reporting tools that connected clinicians and 348 patients with uncontrolled hypertension, aged 18 to 85 years. Kaiser’s six-month study of these patients showed a significantly improved ability to manage high blood pressure to healthy levels for the home-monitoring group, who were also 50 percent more likely to have their blood pressure controlled to healthy levels compared to the usual care group.

Once these industry stakeholders finalize a standards-based interoperability framework that enables information exchange between and among networks, expect the wearable health-device technology market, as well as health-monitoring apps for mobile devices, to rapidly expand.

Capturing and leveraging data efficiently

Before health data exchange with patients intensifies, organizations can set the stage for the data influx by establishing the necessary IT infrastructure and introducing digital communication into staff and provider workflows.

For example, by 2014, most organizations should have implemented a patient portal with functions for secure health information exchange and provider messaging that are required to successfully attest for Stage 2 of the Meaningful Use program. To make this investment truly worthwhile, the portal should also be able to perform routine administrative tasks such as appointment scheduling, reminders and prescription renewal requests.

Once staff and providers have become accustomed to those basic functions, they can start to add more interactive functionality, such as performing online visits and sending text message reminders to patients’ mobile devices that encourage the patients to engage in their care, such as confirming a scheduled appointment or approving a prescription refill.

If an organization has implemented a patient portal only to attest to Meaningful Use, then it should check with its vendor to ensure that the technology contains this more advanced patient-interactive functionality and that it is fully integrated with existing IT systems. This portal must also include integration with an app for mobile devices since patients will increasingly demand that type of access, as well.

Sustained engagement through integration

If consumers can access their healthcare data via a patient portal as easily as they can online shop on their tablets or buy movie tickets on their mobile phones, the organizations implementing the solution will reap the benefits. These benefits are not just financial either. A patient who is more interactive with his or her providers and health information is likely to be more engaged in his or her own care and have better outcomes.

With integrated, easy-to-use patient-facing technology, organizations can ensure that these activated patients who are communicating with and supplying information to their providers will continue to be engaged for years to come.

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Electronic Health Record Vendors Take Patient Data Hostage: What Should We Do?

Electronic Health Record Vendors Take Patient Data Hostage: What Should We Do? | EHR and Health IT Consulting |

In today’s interconnected world it seems intuitively true that instant access to comprehensive medical patient histories will help physicians to provide better care at a lower cost. This simple argument was persuasive enough for the federal government to spend $26 billion to incent medical providers to adopt electronic health records (EHR) systems so that they can electronically share medical records. The initial investment appeared to be large, but it was an economically sound solution to control the rising healthcare expenditure. The resulting HITECH act is one of the few healthcare laws that maintains bipartisan support. To establish a nationwide health information exchange network, officials designed a two-stage plan. First, incent every medical provider to create an electronic archive of their patients’ medical records. Second, connect these electronic archives together so that the providers can share their patients’ records. The $26 billion in federal incentives was a lucrative source of revenue for hundreds of different software vendors to develop and aggressively market their own type of EHR products in a medical market that knew little about information technology. According to the Office of National Coordinator for Health IT, in 2008, less than 10 percent of hospitals had basic EHR systems, and a mere five years after, 94 percent of the hospitals use a certified EHR system.

The next step forward is to connect these electronic silos together so that physicians can share their patients’ records. The billions of dollars in federal spending will only have any tangible benefit if this is done successfully. EHR vendors have taken patient data hostage and are not willing to release it unless they receive a big ransom. They typically claim that technical problems limit the interoperability of their products. This prevents physicians from sharing their patient records with other doctors. This is like T-Mobile claiming that its users cannot make calls to AT&T customers. The claimed interoperability limitation does not end here. The vendors are proposing hefty charges to allow data sharing between their own customers.

As I have discussed in detail before, this a hole that the government has dug for itself. A nationwide health information exchange network sounds great, but it is not possible to achieve this goal without the proper alignment of economic benefits for every player in the healthcare market. In the face of this problem, the government has three choices:

  1. Pay EHR vendors the ransom that they are asking to release their hostage and allow sharing of the patient data among medical providers.
  2. Regulate the industry and force the EHR vendors to allow sharing of patient data among medical providers.
  3. Do nothing.

The government appears to be following the first plan. Officials had not anticipated interoperability challenges and assumed that all of the providers with EHR systems would have the capacity to exchange records. Based on this assumption, the third stage of the EHR incentives program was designed to encourage physicians to actively engage in the exchange of medical records. Today nearly every physician has an EHR system and although many of them also want to exchange information, the EHR vendors do not allow them. The incentives, which were initially planned to encourage physicians, will end up with EHR vendors and help drive future profits. As Rep. Phil Gingrey (R-GA) put it, "we have been subsidizing systems that block information instead of allowing for information transfers, which was never the intent of the [HITECH] statute.”

Regulating the industry seems like the only feasible solution to this problem. Rep. Michael Burgess (R-TX), the leader of the House Energy and Commerce trade subcommittee is drawing up a bill to enforce data sharing. The benefits of regulating the EHR industry, if any, will take a very long time to become tangible. The EHR vendors will furiously push back against any kind of regulation and will insist that technical challenges are a real barrier to interoperability. Congress is poorly situated to adjudicate this claim. Time is a critical factor in the long term success of HITECH plans, which threatens the viability of this strategy.

The best solution for the government is to do nothing. The new pay for performance payment methods in which the medical providers are being paid a fixed amount for treating patients would drive them to become more efficient and increase their profit margin by seeking solutions such as health information exchange to cut costs. Because the market for new EHR products is now saturated, the only revenue source for EHR vendors are charges for data exchange. Currently, they can get away with outlandish charges because they know the incentives from the federal government allow doctors to cover their costs. But if the free money from the government were to stop, then EHR vendors would have to persuade the physicians to pay for the exchange fees. Just like any other service, the highest price that the medical providers would pay is equal to the value of the service for them. If the electronic exchange of information helps medical providers to cut back on their costs and save some money they will be willing to pay a fair price for it. EHR vendors will end up lowering their fees to a reasonable level or will eventually go out of business.

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Survey Shows Many Unprepared for ICD-10 Implementation

Survey Shows Many Unprepared for ICD-10 Implementation | EHR and Health IT Consulting |

Is your physician practice ready for ICD-10 implementation? The latest survey commissioned by Navicure and conducted by Porter Research found that ICD-10 preparedness varies tremendously among US healthcare providers. The survey takers included practice administrators, billing managers, practice executives, coders, and billers.

With the prior delays of the ICD-10 implementation date, it would stand to reason that there may be another postponement. However, 67 percent of respondents trust that the ICD-10 transition will take place on its newly scheduled date of October 1, 2015.

A major challenge of the ICD-10 transition that 41 percent of respondents cited is lack of payer readiness. One of the issues associated with the prior ICD-10 delays is that many providers paused the preparations for the transition until the date was closer. Only 23 percent continued with their efforts after the delay took place.

Some of the top concerns survey respondents commented on include the impact on staff productivity, lack of staff training, and the possibility of the ICD-10 transition deadline being pushed back yet again. However, only 5 percent feel that their technology won’t be ready in time for the implementation.

When it comes to being prepared for ICD-10 integration, only 21 percent of survey takers claimed they were “on track for implementation.” A total of 15 percent have not started preparing for the implementation at all while 11 percent developed a plan.

Those who have not started preparing for the ICD-10 transition cite five major reasons:

(1) Waiting on EHR vendor to provide ICD-10 software updates

(2) Waiting to implement a few months before the October 1 deadline

(3) Lack of staff, time, and training resources

(4) Belief that the ICD-10 transition date will be further delayed

(5) Lack of knowledge on where to begin

Despite some of these issues, out of all polled, 81 percent are at least somewhat confident that they will be ready to implement ICD-10 coding by the October 1, 2015 deadline. While these numbers are high, they have actually dropped from the 87 percent vote of confidence from a survey taken in the fall of 2013. Clearly, with only 21 percent of respondents feeling they are on track, providers may not be completely prepared for the ICD-10 transition as of yet.

“Since 2013, Navicure has been conducting ICD-10 readiness surveys, which have allowed us to gain broad perspective on how we can best help healthcare organizations prepare for the transition,” Jim Denny, founder and CEO of Navicure, said in a public statement.

The majority of respondents expect staff productivity loss of one to 40 percent. Providers may need assistance with improving productivity and efficiency when the ICD-10 integration takes place. Additionally, 49 percent of survey takers are either planning to conduct end-to-end testing or are already in the midst of this process. Unfortunately, this is a decline of 7 percent when compared to the fall 2013 survey.

The report goes on to explain the importance of beginning ICD-10 preparations such as staff training and clinical documentation practices even if waiting on new software updates. End-to-end testing is also vital to incorporate in order to address any risks with payer collaboration before the October 1 deadline.

Additionally, providers should prepare for a dip in staff productivity for the first three to six months after ICD-10 integration. It is important to develop a plan to manage these potential issues. Transitioning to ICD-10 will not be an easy road, but with thoughtful strategies in mind, it will be more manageable over the long-term.

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EHR Vendors Will Lower Data Exchange Prices or Close

EHR Vendors Will Lower Data Exchange Prices or Close | EHR and Health IT Consulting |

In an opinion piece for the Brookings Institution's "TechTank" blog, Niam Yaraghi, a fellow at the Brookings Institution's Center for Technology Innovation, writes that the best way for the federal government to address "outlandish" health data exchange fees charged by vendors is to focus on new pay-for-performance efforts.

According to Yaraghi, the federal government has spent billions of dollars "to incent medical providers to adopt electronic health record systems so that they can electronically share medical records."

However, Yaraghi writes that EHR vendors "have taken patient data hostage and are not willing to release it unless they receive a big ransom." He notes, "They typically claim that technical problems limit the interoperability of their products" and charge significant fees to allow providers to exchange data.

To address the issue, Yaraghi argues that the federal government has three choices:

  1. Pay EHR vendors' prices to release data and allow sharing between medical providers;
  2. Regulate the industry and make EHR vendors allow such data sharing; or
  3. Take no action.

He writes that the "government appears to be following the first plan" noting, "The [EHR] incentives, which were initially planned to encourage physicians, will end up with EHR vendors and help drive future profits."

In regard to the second plan, Yaraghi writes, "The benefits of regulating the EHR industry, if any, will take a very long time to become tangible."

Therefore, he argues that the "best solution for the government is to do nothing." According to Yaraghi, "The new pay-for-performance payment methods in which the medical providers are being paid a fixed amount for treating patients would drive them to become more efficient and increase their profit margin by seeking solutions such as health information exchange to cut costs."

Further, he notes that because of market saturation, EHR vendors' only source of revenue is data exchange charges and that currently they can charge "outlandish" prices "because they know the incentives from the federal government allow doctors to cover their costs." However, Yaraghi writes that "if the free money from the government were to stop, then EHR vendors would have to persuade the physicians to pay for the exchange fees." He concludes, "EHR vendors will end up lowering their fees to a reasonable level or will eventually go out of business".

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Vendor Fees Harm EHR Interoperability, Other Goals

Vendor Fees Harm EHR Interoperability, Other Goals | EHR and Health IT Consulting |

Stakeholders say that fees charged by electronic health record vendors to transmit and receive data between different EHR systems are hindering the progress of the meaningful use program and harming efforts to achieve interoperability, Politico reports.

Under the 2009 economic stimulus package, providers who demonstrate meaningful use of certified EHRs can qualify for Medicaid and Medicare incentive payments.

Details of EHR Vendor Fees

Lawmakers did not anticipate the EHR vendor fees when creating the meaningful use program, Politico reports.

According to more than a dozen sources interviewed by Politico, providers generally pay between $5,000 and $50,000 to transmit information between their organizations and other entities, such as:

  • Blood and pathology laboratories;
  • Health information exchanges; and
  • Government agencies.

In addition, EHR vendors sometimes levy additional fees every time a physician receives or sends data.

Stakeholder Reaction

Former National Coordinator for Health IT Farzad Mostashari said that the vendor fees to share data are "not because of technical standards, but because of business practices," adding, "The vendors don't have the same incentives as the providers do."

According to Politico, EHR vendors have become increasingly reliant on such fees as sales of new software decline. For example, NextGen Healthcare and its parent company had sales revenue decline from $149 million in 2012 to $87 million in 2014. Meanwhile, revenues from interchange fees increased from $49 million in 2012 to $67 million last year.

Some stakeholders contend that such fees are making health data sharing prohibitively costly.

Lance Donkerbrook, COO of Commonwealth Primary Care accountable care organization, said, "The No. 1 factor hindering the exchange of information between health care stakeholders is the exorbitant fees that most EHRs are charging for integration, connectivity and reporting." He said that many of the 250 independent physicians in the ACO are not able to share data with one another because they have a total of 30 EHRs among the doctors, with vendor fees ranging from $7,500 to $40,000.

According to Politico, the problems associated with EHR vendor fees have become particularly acute in the past year as providers have attempted to attest to Stage 2 of the meaningful use program, which requires providers to share data.

Meanwhile, Sarah Corley -- vice chair of the Electronic Health Records Association, which represents the majority of EHR vendors, and CMO of NextGen -- said, "As with other areas of health care, variability increases costs, and all stakeholders in health care need to work together to reduce this variability and the factors that drive it."

Potential for Legislative, ONC Action

National Coordinator for Health IT Karen DeSalvo at a meeting earlier this month described concerns about of EHR vendor fees as a "common refrain" that "Congress has asked us to do something about."

The Office of the National Coordinator for Health IT's certification program requires EHR vendors to demonstrate that their EHR software will allow providers to demonstrate meaningful use of EHRs, including data sharing. However, ONC does not have the power to regulate vendor fees, according to Politico.

Meanwhile, some Republican lawmakers are considering potential legislative solutions. Rep. Michael Burgess (R-Texas), chair of the House Energy and Commerce Trade subcommittee, is drafting a bill to enforce data sharing among providers, Politico reports. He said, "Interoperability is what makes an EHR useful. It's unfair that practitioners have to spend money on connections they thought were part of the EHR when they bought it." Although he acknowledged that vendor fees are an issue that "should be resolved in the marketplace," he noted that "you can't just drop your EHR like a used car and get another one." He said that lawmakers are "very closely" examining what legislation would "look like" if the market does not fix the problem on its own.

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Behavioral Health EHR Adoption Shows Promise in Survey

Behavioral Health EHR Adoption Shows Promise in Survey | EHR and Health IT Consulting |

In today’s healthcare sector, implementing EHR systems has become a way of life. It is nearly impossible for a medical office to avoid EHR adoption, said Jennifer D’Angelo, Chair of the new HIMSS Long Term Care and Behavioral Health Task Force and Vice President of Information Services for Christian Health Care Center.

“From an interoperability standpoint, and from a reimbursement standpoint, it’s being required,” D’Angelo told Behavioral Healthcare. “All levels of care will need to have an EHR for care coordination among all providers.”

A survey of Behavioral Healthcare readers shows that most of the respondents find their EHR systems satisfactory and are using them extensively. Only a small percentage (9.1%) are “very unsatisfied” with their current EHR technology. In fact, 72.5 percent feel neutral or satisfied with their EHR system.

The survey points toward the majority of behavioral health specialists viewing EHRs as technology that enhances patient care. While most have adopted EHR systems, some have yet to make the transfer often due to low funding for this particular expenditure. Some of the common reasons for not adopting an EHR are: financial (41.3%), no need for it (32.5%), haven’t found the right one (13.8%), and staff resistance (5.0%).

Others may continue to shop for better health IT technology, especially if their current systems do not line up with meaningful use requirements. Physicians are more likely to adopt EHR technology with features that achieve meaningful use in order to receive financial incentives from the Centers for Medicare & Medicaid Services (CMS). For example, some vendor’s health IT systems may be capable of meeting Stage 1 Meaningful Use requirements but not Stage 2.

Other potential disadvantages of EHRs that the survey highlighted are:

(1)   time consuming

(2)  causes confusing

(3)  difficulty getting data reports

(4)  costly

D’Angelo recommends that hospitals and clinics have support onsite during the first couple of weeks during EHR implementation in order to resolve any potential end-user issues quickly and efficiently. Despite the potential problems associated with EHR technology, there are significant benefits that physicians are seeing. Survey respondents reported a number of benefits including:

(1) improving patient care

(2) reducing paper-based records

(3) boosting staff efficiency

(4) helping guarantee reimbursement

The best EHRs offer a more streamlined workflow process for a variety of tasks including pulling up patient files, recording new visitor data, and finding key information quickly.

EHR consultant Eileen Casella Rider explains that EHR technology that is developed with the input of healthcare staff members tends to work better in a care setting than those built solely from a technical standpoint. Rider goes on to say that some clinicians may not have superior computer skills, which may lead to confusion and emphasizes the need for extensive training on EHR systems.

A final aspect of the survey finds that, out of all respondents who knew their EHR server choice, 34 percent use the software-as-a-service (SaaS) option. Experts claim that SaaS is the server of the future and will only increase in popularity. This type of feature allows clinicians to run their EHR system through the cloud.

These survey results display the tangible benefits of EHR technology in the medical care setting.

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EHR Integration Assists Lean Production Design

EHR Integration Assists Lean Production Design | EHR and Health IT Consulting |

The healthcare industry has emphasized “Lean Production” – a term coined by MIT researchers meaning the elimination of waste – in recent years, as it continues EHR integration initiatives and the adoption of electronic prescribing along with other health IT technology.

According to a report from the Agency for Healthcare Research and Quality (AHRQ), lean production refers to subtracting waste that eats up resources (funds, staff, time, or room) without increasing value or quality.

The report covers six case studies in which healthcare organizations incorporated lean initiatives such as improving the recording of outpatient data, bed flow, and outpatient EHRs. Lakeview Healthcare adopted these programs among others and interviews were conducted with physicians, nurses, and both clinical and nonclinical staff.

Many of the interviewees reported that Lakeview Healthcare experienced enhanced efficiency, employee satisfaction, and a more organized environment. Additionally, top executives stated the focus on lean production led to a $29 million return on investment over the last 14 years.

The organization also focused on quality improvements and increasing patient satisfaction. EHRs were introduced through group training in outpatient medical offices. Some physicians learned how to effectively use EHR technology in one-on-one training sessions.

EHR systems assisted greatly in improving patient flow in the ambulatory care setting. In order to reduce potential issues during EHR implementation, senior leadership incorporated process improvement work before adopting the health IT systems.

Initially, EHR implementation led to a dip in productivity due to the learning curve of adopting new technology. However, this trend reversed and a management engineer reported that chart filing time decreased by 70 minutes once the implementation was finished. This reduced wait times for patients as well, thereby improving patient satisfaction. The incorporation of technology also ensured patient safety.

“The use of technology meant integrated and improved patient safety processes,” the report stated. “The management engineer reported that, as part of the larger value stream of projects that included the Surgeons’ Preference Cards, patient safety improved as a result of checklists that were built into the computer system that could be used as a communication and debriefing tool.”

The results show enhanced routinization and organizational culture. In fact, the interviewees indicated a rise in teamwork and encouragement to gain better outcomes for patients. The focus on “Lean Production” has led to higher reported employee satisfaction and a low nursing vacancy rate.

Another case study came from Central Hospital where both improvement of emergency cardiac care and management of surgical procedure cards were incorporated into the lean strategy. The top leadership at this organization has used lean initiatives to enhance care and efficiency as well as transform the work culture.

A third case study from the academic medical facility Grand Hospital Center incorporated cardiology follow-up appointment scheduling as part of its lean program. Both EHR and scheduling systems were used to collect the necessary data to track progress of the lean initiatives.

The team at the Grand Hospital Center also aimed to decrease the costs of supplies, implants, and other resources. Some of the benefits the program achieved are the reduction of discharge time by three and a half hours and assigned rehabilitation therapists to specific floors to cut down on travel time.

Essentially, EHR integration could play a significant role in medical facilities’ aims to reduce waste and adopt the “Lean Production” style.

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ICD-10 Acknowledgement Testing Checklist for Providers

ICD-10 Acknowledgement Testing Checklist for Providers | EHR and Health IT Consulting |

While ICD-10 acknowledgment testing is available any day of the year up until October 1, 2015, CMS is taking the first week in March to host another dedicated opportunity for providers.  The testing weeks serve as way to gather data about the way providers send their sample ICD-10 claims to Medicare and allow providers to ensure that their claims can be accepted by the adjudication system without any technical glitches.

Those organizations that have not participated in previous testing weeks are encouraged to join in during the next chance on March 2 through 6, or the final scheduled occasion at the beginning of June.

In order to successfully submit claims for ICD-10 acknowledgement testing, direct-submit healthcare organizations, including providers and clearinghouses, will need to keep the following questions, tips and, requirements in mind.

What is ICD-10 acknowledgement testing?

Acknowledgement testing is the most basic form of assurance that a claim can be accepted by a Medicare Administrative Contractor (MAC) for later adjudication.  It should not be confused with end-to-end testing, in which a claim is processed through all Medicare system edits in order to produce electronic remittance advice (ERA).  Acknowledgement testing simply provides a yes or no answer to the question of whether or not the sample claim can be accepted.

Providers are encouraged to use ICD-10 acknowledgement testing as a basic way to ensure that they are on the right track with their ICD-10 preparation.

How do I participate?

Information about acknowledgement testing will be provided on your local MAC website or by your clearinghouse.  Any provider that submits electronic Medicare fee-for-service claims is eligible for participation.  There is no registration required.  For more information on eligibility, click here.

ICD-10 acknowledgement testing does not test initial connectivity to the MAC system, nor does it ensure that your internal systems are capable of producing, accepting, storing, or transmitting codes.  Internal preparations for the generation and transmission of ICD-10 codes should already be completed before MAC testing.

How do I prepare my sample claims for submission?

Ensure that you have enough claims coded in ICD-10 to represent your typical submissions spectrum.  CMS reminds providers that claims must have the “T” in the ISA15 field to indicate the file is a test file.  Use a valid submitter ID, national provider identifier (NPI), and Provider Transaction Access Numbers (PTAN) combinations.  Claims that contain invalid identifiers will be rejected.

Be sure that the claims do not include future dates of service.  All claims must be dated before March 1, 2015 in order to be processed. Claims must also have an ICD-10 companion qualifier code or they will be rejected.

Providers may engage in “negative testing” by submitting purposely erroneous claims in order to confirm that the MACs will catch defects or incorrect information.

What information will I receive from my MAC?

Test claims will be assigned a 277CA or 999 acknowledgement as confirmation that the claim was accepted or rejected by the system.  The test will not confirm that the claim would be paid under ICD-10, nor will testers receive any remittance advice.  The MACs and the Durable Medical Equipment (DME) MAC Common Electronic Data Interchange (CEDI) will have extra staff available to take calls from providers who have questions about the process or their results.

Providers will need to engage in full end-to-end testing with their payers if they wish to receive information about their coding accuracy or payment rates.  While CMS has scheduled end-to-end testing for April 2015, participating providers have already been selected.  Providers are still encouraged to engage in end-to-end testing with their private payers as soon as possible.

What do I do next?

During prior acknowledgement testing, CMS has released basic data on acceptance rates several weeks after the dedicated testing period.  But providers participating in the opportunity do not need to wait until then to take action based on their own results.  With a mere seven months until October 1, 2015, organizations that experienced unexpected denials from acknowledgement testing should work with their ICD-10 preparation teams or consultants to resolve internal or coding errors quickly.

Healthcare organizations should also make sure that they are coordinating with their major payers to conduct additional, more robust testing of ICD-10 claims.  Providers should continue to utilize clinical documentation improvement programs, revenue cycle contingency planning, and coder training and education during the last few months of preparation in order to combat potential negative impacts from the new codes.

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EHR Switchers Ranks Amazing Charts #2 for Happiness

EHR Switchers Ranks Amazing Charts #2 for Happiness | EHR and Health IT Consulting |

A new survey of physicians that switched Electronic Health Record systems ranks Amazing Charts #2 for customer satisfaction. Published by the American Academy of Family Physicians this month, the EHR Switch Survey: Responses from 305 Family Physicians is one of the first major studies examining the relationship between changing EHR systems and greater practice satisfaction. AAFP lists Amazing Charts as having gained net new switching customers during the survey period.

In response to the statement, “I am happy with our new EHR system,” practices that switched to Amazing Charts responded with the second-highest positive score. The article explains: “On this last point, it seems worthwhile to note that two systems, Praxis and Amazing Charts, had zero negative responses to the statement, ‘I am happy with our new EHR system.'”

Fifty-nine percent of those surveyed agreed or strongly agreed that the new EHRs have useful new functionality; and fifty-seven percent agreed or strongly agreed that their new systems allow them to achieve meaning­ful use.

“The number of practices switching EHRs is growing as more and more physicians and their administrative teams realize their current system was the wrong choice and does not meet their needs,” said John Squire, president and COO of Amazing Charts. “Created by a family physician, Amazing Charts combines a high level of usability in clinical documentation and office workflow with overall affordability, which makes it ideal for physician-owned practices, especially in family medicine.”

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Orion Health, a population health management and healthcare integration company, today announced that Greenway Health has selected Orion Health’s Rhapsody Integration Engine®to unify Greenway’s financial transaction processing solutions on a single, scalable technology platform. Rhapsody will help accommodate Greenway’s tremendous growth in transaction services, and the organization will use Orion Health’s professional services to design and build the core transaction-processing engine. Rhapsody will process eligibility, claims and remittances for millions of daily transactions across Greenway’s growing national customer base.

“Greenway Health is dedicated to using standards-based interoperability to streamline secure data flow and improve our customers’ connectivity, processes and outcomes,” said Shantanu Paul, Executive Vice President of Product Development at Greenway Health. “Likewise, we’re always seeking to do the same within Greenway. The flexible and adaptable Rhapsody Integration Engine and the relationship with Orion Health will help us achieve that as we continue to grow our transaction services capabilities.”

Rhapsody enables the secure electronic sharing of claims data, achieving real-time connectivity from any system to any system, streamlining processes and reducing operational costs for improved financial performance. The integration engine enables health information technology companies and partners to quickly and easily connect complex financial and clinical systems between healthcare trading partners, regardless of technology or standards.

“This new partnership is strategic to both organizations as we continue to enable our customers to automate critical business processes including financial clearinghouses. Orion Health worked closely with Greenway Health to ensure we fully understood their business and technical environment to jointly design and scope the final solution,” said Harish Panchal, Global Vice President of Sales, Intelligent Integration, at Orion Health. “We have long-standing relationships with our clients, and everyone at Orion Health is very excited about working with Greenway Health, a great company and leader in the healthcare industry.”

Rhapsody is used by thousands of organizations in the United States and around the world, including hospitals, IDNs, software companies, public health agencies, health information exchanges (HIE), health plans and now financial clearinghouses. The integration engine provides comprehensive support for an extensive range of communication protocols and message formats, and helps interface analysts and hospital IT administrators reduce their workload while meeting complex technical challenges.

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Study: ICD-10 Costs for Small Practices Less Than Previously Estimated

Study: ICD-10 Costs for Small Practices Less Than Previously Estimated | EHR and Health IT Consulting |

ICD-10 expenditures for small physician practices will not be as high as previously estimated, according to research from the Professional Association of Health Care Office Management, published recently in the Journal of the American Health Information Management Association.

Researchers polled 276 physician practices with fewer than six providers, with results finding that the practices spent an average of $8,167 on ICD-10 implementation, while individual providers spent an average of $3,430. According to the researchers in this study, there are now three studies documenting that ICD-10 implementation costs in small physician practices are dramatically lower than originally reported in the widely publicized American Medical Association (AMA)-funded study, which estimated the cost for a small practice to implement ICD-10 was in the range of $22,560-$105,506.

Survey respondents were asked to specify the number of providers in the practice where a provider was defined as a direct caregiver, such as physicians, physician assistants, and nurse practitioners. Respondents were asked to specify the total expenditures in the practice for all ICD-10-related activities, including costs already incurred and costs remaining to be expended. The instructions associated with the question on expenditures specifically noted that the costs of obtaining ICD-10 manuals and documentation, ICD-10 training costs, the cost of superbill conversion to ICD-10, and software system upgrades and testing should all be included as ICD-10-related expenditures.

As expected, the expenditures associated with ICD-10 increase as the size of the practice increases, but the per-provider expenditures decrease as the size of the practice increases. The per-provider ICD-10 average expenditures ranged from $4,372 for a practice with a single provider to $1,838 for practice with six providers, the study found. What’s more, on average, the combined amount of ICD-10-related hours expended across all personnel types in practices with six or fewer providers was 45.5 hours per provider in the practice. “Based on this survey and the two other recent studies, the financial barriers to ICD-10 are significantly less than originally projected,” the researchers concluded.

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Electronic health records and data abuse: it's about more than medical info

Electronic health records and data abuse: it's about more than medical info | EHR and Health IT Consulting |

On the heels of the recent announcement that medical insurance firm Anthem was breached, we look at the nuance and impact of a medical record breach versus a medical data breach. They are certainly related, but digging through troves of data containing primarily identity information is significantly different to an attack that focuses on specific treatment of a specific patient.

If an attacker can harvest name, social security number, phone, address, email and the like, that haul has a much wider potential audience than, say, whether or not a patient underwent a specific medical procedure. A stolen medical record containing a lot of detail may sell for a lot of money, but that market is more specialized than the broader market for general identity data.

To help folks visualize the different levels of data that thieves might want to swipe from a medical facility, and then abuse, my colleague, Stephen Cobb, created this diagram of a generic electronic health record.

Level one is pretty basic info, things that are fairly easily knowable about you without any hacking, normally sourced through Open Source Intelligence (OSINT) gathering. However, grabbing a big fat collection of such data might still earn a bad guy some black market bucks, say if a spammer needed fresh targets.

The illegal earnings potential goes up a notch if you can grab Level 2 data. Scammers can use that to carry out several kinds of identity theft, creating fake IDs, opening credit card accounts, committing tax fraud (filing fake returns to get a refund) or even use it to answer challenge questions to online accounts, thereby pivoting the attack to new digital beachheads. Even Level 2 data is enough to commit some types of medical ID theft, though the bad guys have no clue how healthy or sick you really are (here’s a pretty scary case of what can be done with just a stolen driver’s license).

Level 3 data just makes all of the above that much easier; plus, it enables new forms of badness. Some crooks prefer taking over an established account to opening a (fake) new one. the number of electronic records or EHRs that actually contain financial or payment data is not clear, but obviously a lot of healthcare entities do handle it at some point, making them a target for digital thieves who turn around and sell it on carder forums.

When you get to Level 4 data, the badness takes on a new dimension. If an attacker has a patient’s full (or partial) history, it’s easy to imagine matching up a willing bidder who has a need for a similar medical procedure with a donor record to (roughly) match, in an attempt to get pinpointed specific services they would otherwise have difficulty receiving.

But the options for selling medical history-style Level 4 records may be much narrower in scope than, say, bulk repackaging and resale on the underworld markets of lower levels, appealing to any buyer who wants to assume an identity, spread a wider net and attack other properties, or engage in fraudulent activity which is then blamed on you (if it’s your record that was compromised).

Of course, the threatscape may well change as the EHR becomes more universal. With the proliferation and sprawl of third party providers who are somehow tapped into a cohesive health ecosystem, there will always be various specialized smaller providers whose business is targeted to a specific subset. That’s not bad, it’s just how the health segment does business; in many cases it leverages strengths of one organization to help another. But it does imply a larger potential attack surface, which has implications for security if the data sprawl is not carefully managed. For example, if an attacker can gain a beachhead in one of the providers in the ecosystem, will they then have an elevated trust relationship with other systems within this ecosystem?

And here’s the rub: having instant digital access to all of a patient’s medical data (or other sensitive information) wherever a doctor happens to physically be is a wonderful tool, but now we have many more endpoints in question with security environments to understand and corral. This implies an ongoing need, not just for really smart endpoint protection, but also strong encryption, and authentication, as well as sane network segmentation, vigilant network monitoring and reliable disaster recovery.

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Secrets to EMR Success

Secrets to EMR Success | EHR and Health IT Consulting |

Aging services providers generally lag behind hospitals and medical practices when it comes to purchasing and using electronic medical records (EMR) systems, in part because government incentives—and penalties—weren’t implemented with them in mind. As the government and other health system sectors increasingly recognize the vital role that entities traditionally serving seniors play in the care continuum, however, the necessity of EMRs in long-term care settings is becoming a reality. One continuing care retirement community recently shared its EMR selection and implementation experience with those attending a Long-Term Living webinar.

The Jewish Association on Aging (JAA) realized that an EMR system could bring benefits to its CCRC, said Deborah Winn-Horvitz, MS, president and CEO. Among the advantages: enhanced coordination of care thanks to a seamless flow of patient/resident information across its service lines; improved availability, accuracy and reliability of data to enable decision-making and reporting; and enhanced efficiencies leading to cost savings—all resulting in improved quality of life for patients/residents and job satisfaction for staff members. The changing healthcare landscape and requirements related to ICD-10, the IMPACT Act, healthcare information exchange, new payment models, an increased focus on length-of-stay rates and rehospitalizations and other factors converged to convince the CCRC that the time had come to select and implement a system, she added. (Click on the “Go Live” image, upper left, to discover the motivations and information sources of webinar participants implementing an EMR.)

Four main challenges

“Funding was a big challenge for us,” Winn-Horvitz said. The Pittsburgh-area CCRC is a nonprofit, faith-based organization that includes a 159-bed skilled nursing facility; an outpatient rehabilitation center; two personal care facilities with a combined 120 units and including independent living; hospice, palliative care, home health and adult day services; and Meals on Wheels and other community resources.

JAA sought grants from local foundations and contributions from individuals to cover some of the cost of system selection, purchase and implementation, Winn-Horvitz said, and operations will cover some of the cost. Support from the organization’s board was critical, however, she added.

“It’s going to be very important from the beginning to have board participation, so when it comes time for you to be in front of your board asking for support for the EMR, they will have a vested interest in this and have an understanding as to why it’s so important,” she told webinar attendees. Because the JAA board was involved in planning from the beginning and had been educated about the project, she added, members permitted funds from its endowment to cover much of its costs.

A second challenge, Winn-Horvitz said, was ensuring sufficient information technology (IT) support. Before implementation, JAA had outsourced its help desk function to one person. “We really needed to put some type of infrastructure in place,” she said.

At the beginning of the project, the CCRC hired a full-time project manager who had an IT background. As implementation loomed, JAA hired an EMR nurse clinician. “One of the looking-back lessons learned is, I would have hired that EMR nurse clinician earlier in the selection process as opposed to waiting until implementation,” Winn-Horvitz said. The Pittsburgh Regional Health Initiative and Pennsylvania REACH West, a federally funded regional extension center (REC), provided assistance as well, she added. (JAA was one of the first long-term care providers to benefit from REC services, Winn-Horvitz said. Find out how a REC can help you by listening to the webinar, “Transform Your Organization with Information Technology: 5 Steps to Success,” available on-demand through Jan. 22, 2016.)

A third challenge related to JAA’s EMR journey, she said, was upgrading the CCRC’s hardware and networks. What JAA had was “bare-bones minimal and clearly not adequate to support the implementation of an EMR,” Winn-Horvitz said. “And so we ultimately rolled that cost up into the entire implementation.”

Actually selecting the system was a fourth challenge. “We knew what our core components were of our IT strategy,” the CEO said. “We had an idea of what we were looking for—there are, of course, a number of systems out there on the marketplace—but we really didn’t know where to begin in terms of the selection process.”

The LeadingAge Center for Aging Services Technologies (CAST) electronic health records system selection tool also was a “tremendous resource” for discovering systems and analyzing their capabilities, she said. JAA also contracted with a consulting company that specializes in EMR selection. “For the spend that was associated with their assistance, it was very, very insignificant compared with the spend for the whole EMR system,” Winn-Horvitz said. “It was a very, very worthwhile investment for us.”

JAA sought a system that was sustainable, high-performing and compliant with the Health Insurance Portability and Accountability Act. The system had to have mobile accessibility, too, since “physicians prefer to access information either on-the-go or from their offices when they’re not here physically rounding in our facilities,” Winn-Horitz said.

The CCRC narrowed its choices to six, then three, then two products, aided by the LeadingAge CAST tool and information gathered by the consultants. “We did very, very detailed site visits for both of those vendors,” visiting providers that were using the systems, Winn-Horvitz said. The scrutiny also included calls to additional facilities geographically less convenient to visit as well as examination of responses to a request for information.

The consultants calculated the five-year total cost of ownership for the two finalists, including software, hardware, incremental staffing and consulting costs for the implementation, the cost of keeping the CCRC’s current system operating during the change, costs for training the project team during the selection process and training all system users during implementation, costs to convert existing patient data into the new system and costs for interfaces to systems not being replaced.

“Some of these are things that we would not have thought of,” Winn-Horvitz said, “so they were able to put together a very, very comprehensive picture for us of what that total cost of ownership would be for the systems that we were considering.”

Ultimately, JAA chose the HealthMEDX EMR. The company “had a really great track record in terms of a rollout that was pretty standardized at this point in their life cycle, and that really made it much easier for us,” Winn-Horvitz said.

Overseeing the project

At the beginning of the project, she said, JAA and its board established guiding principles and goals for the project as well as committees to see it through. The executive steering had oversight at the highest level and included some board members with IT or project management experience as well as the president/CEO, the chief financial officer and the project manager. The system selection committee included heads of all of the lines of business as well as staff members from the front lines.

“We included CNAs, and we included some LPNs and RNs, because we knew that they were going to be critical not only to helping us understand their challenges on a day-to-day basis but also critical in terms of adoption,” Winn-Horvitz said. “If we were to select a system without them and then kind of force it on them, then that clearly would not go over well.”

Remember to include the medical director in the process as well, she advised.

JAA began implementing the EMR in the first quarter of 2014, and the system went live in the skilled nursing, personal care and independent living areas in July. “It was really a very efficient six-month implementation process, and we were able to go live on time,” Winn-Horvitz said. “We’re scheduled to go live with our home- and community-based services by the end of this calendar year.”

The implementation phase has included several forms of oversight: an executive committee of senior managers; the initial oversight committee from the selection process, which included some board members; an implementation team, including representatives from all levels of the organization; an administrative work group that included staff members in business functions such as billing and collections; a project team, led by the project manager, which addressed technical issues; and clinical work groups.

“We formed the clinical work groups at the time of go-live and have continued them in those areas where we’ve gone live,” Winn-Horvitz said. “They meet on a biweekly basis right now to continue to refine workflows, make changes to the system and work with our vendor partner to continue to refine.”

The clinical work groups also identify where retraining is needed. “It’s not enough to train everyone just once,” Winn-Horvitz said. “You have to tell them, and then tell them again and again.”

As the rollout was set to begin, JAA tried to create a sense of excitement and enthusiasm among all staff members, making it “more than just an IT project,” Winn-Horvitz said. “We actually gave a name to the project. We called it J Care, and we were counting down the days to the launch of J Care at the organization. We had signs up. Everyone knew it was coming.”

The organization identified ‘super users’ who could troubleshoot issues and help their co-workers learn the new system, and everyone knew in advance who the super users were. On the go-live date, those super users wore bright green T-shirts so that they were easily identifiable. “We asked them to wear the T-shirts for the first week of go live so that if anyone had a problem anywhere, they knew where they could find a super user,” Winn-Horvitz said. “All shifts, all over the organization.”

The contingency planning the CCRC had completed ended up being useful during implementation, she added. “When you’re going live with an EMR, everyone knows there’s a chance that something could happen, and as fate would have it, we actually ended up having some issues with our power. We had a number of unplanned power outages probably two weeks into our go live.”

But one of the most important lessons JAA learned in the entire EMR selection and implementation process was the importance of communication, Winn-Horvitz said. “You cannot over-communicate,” she said. “It’s so important to include individuals from all levels of the organization. It makes everyone’s job much easier if everyone really knows what’s going on.”

The CCRC already is reaping rewards from its implementation to date: improvements in quality measure scores; access to real-time information; improved workflows in admissions, finance and nursing; and accelerated cash flow due to full electronic claims submission and payment processing.

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Mobile EHRs forge a patient journey platform

Mobile EHRs forge a patient journey platform | EHR and Health IT Consulting |

As last year wound down, Practice Fusion optimized its electronic health record service for Apple and Android tablets — and, in so doing, joined the growing number of vendors making mobile EHRs.

In addition to the obvious benefits of cutting the proverbial cord and arming clinicians with software tuned to specific devices, mobile-optimized EHRs lay a foundation for providers.

On tap for 2015? Patient check-in.

“Very soon the front office staff will no longer have to get out paper forms,” Practice Fusion CEO Ryan Howard says, stressing that this upcoming Practice Fusion feature would finally cover “every step of the patient journey.” 

Indeed, Practice Fusion revealed online check-in earlier this month and explained that patients will be able to submit insurance information, prescription status, and the reason for their upcoming visit before they even set foot in the doctor’s office. 

The company claimed that its new service will eliminate a quarter-billion pieces of paper this year by replacing the average 3-7 page forms patients complete at the doctor’s office.

Beyond check-in, Practice Fusion will also be looking to gear its cloud-based offering toward medical specialists.

“We’re pretty focused on flow sheets this year and really delivering a lot of functionality for subspecialties,” Howard revealed. 

As far as legislation and regulation go, ICD-10 and telemedicine mandates will be huge in 2015 and key at HIMSS15, Howard says. Meaningful Use Stage 3 will also be entering the fold this year, a fact the industry is hard-pressed to heed given the difficulties currently unfurling with Stage 2.

And EHRs optimized for mobile use will be underlying all of the above, Howard explains.

That’s because patients want mobility as much as doctors do.

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RNs are Choosing Where to Work Based on Hospital EHR

RNs are Choosing Where to Work Based on Hospital EHR | EHR and Health IT Consulting |

I came across this tweet and it made me stop and realize how important the selection and more important the implementation of your EHR will be for your organization. In many areas there’s already a nurse shortage, so it would become even more of an issue if your hospital comes to be known as the hospital with the cumbersome EHR.

Here’s some insight into the survey results from the article linked above:

79% of job seeking registered nurses reported that the reputation of the hospital’s EHR system is a top three consideration in their choice of where they will work. Nurses in the 22 largest metropolitan statistical areas are most satisfied with the usability of Cerner, McKesson, NextGen and Epic Systems. Those EHRs receiving the lowest satisfaction scores by nurses include Meditech, Allscripts, eClinicalWorks and HCare.

The article did also quote someone as saying that a well done EHR implementation can be a recruiting benefit. So, like most things it’s a double edge sword. A great EHR can be a benefit to you when recruiting nurses to your organization, but a poorly done, complex EHR could drive nurses away.

I’m pretty sure this side affect wasn’t discussed when evaluating how to implement the EHR and what kind of resources to commit to ensuring a successful and well done EHR implementation. They’re paying the price now.

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Is your medical practice ready for dual coding?

Is your medical practice ready for dual coding? | EHR and Health IT Consulting |

Although medical practices cannot submit medical claims with ICD-10 codes until Oct. 1, there are a few good reasons to start using them sooner.

Those reasons support dual coding — when healthcare organizations assign ICD-10 and ICD-9 codes simultaneously to medical records.

The advantages include:

  • Medical coders can practice their ICD-10 knowledge
  • Clinical documentation deficiencies are exposed
  • Extensive internal and external testing can be done

This won't be cheap. Systems need to be designed for dual coding. And no matter what your vendor promises, dual coding is extra work. That means there will be a productivity loss. Maybe computer assisted coding (CAC) will help. Costs would be associated with:

  • Added time
  • Maintaining data collection
  • Analyzing data

Medical practices likely will need to assign extra coding resources. Extra medical coders can be hired to cover the dual coders. Healthcare providers need to do a cost-benefit analysis to determine if it's better to hire personnel or accept longer reimbursement cycles.

To get dual coding started, the Centers for Medicare and Medicaid Services (CMS) recommends answering the following questions:

  • Can the practice management system (PMS) or electronic health record (EHR) can capture ICD-9 codes and ICD-10 codes in the same patient encounter?
  • How much dual coding will be done?
    • How often?
    • How many encounters will be processed?
    • Are all diagnoses or just the top X percent of diagnoses are represented?
  • Will the ICD-10 codes be captured in the PMS or EHR system or on paper?

Before dual coding can start, a medical practice should:

  • Upgrade systems so they are ICD-10 compliant.
  • Make sure clinical documentation can support ICD-10 coding.
  • Start ICD-10 training and education.
  • Test with healthcare vendors or payers.

Then start practicing ICD-10 coding on real cases in the medical practice. Chances are that all this time and money will be investments that payoff after Oct. 1.

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EHR Usability Challenges for Clinical Decision Support

EHR Usability Challenges for Clinical Decision Support | EHR and Health IT Consulting |

To live up to its potential, clinical decision support tools should be able to assist clinician EHR users to make the most appropriate evidence-based decisions when treating their patients. Current EHR technology, however, still exhibits signs of growing pains in terms of how clinicians receive these support services.

“That companion, support tool is absolutely appropriate, but there are certain instances where it needs to be a little more forceful,” says Harvard Vanguard urgent physician Erin Jospe, MD, who also serves as Associate Chief Medical Officer at PatientKeeper.

“That is why there should be a range of different types of alerts that a physician gets,” she explains. “There are certain things where it is fine for them to be in line; there are other things where you need a hard stop.”

The fine line is between prescriptive medicine and physician autonomy. EHR developers need to be mindful of the various and varying needs of clinicians when determining how clinical decision support tools and services impact their EHR workflows.

“Understanding the different applications of clinical decision support will allow them to shine,” Jospe maintains. “It’s not going to be a one-size-fits-all approach. In certain areas, just offering evidence links is sufficient — not everybody needs to see it and will go with the recommendation being presented. Other times you think your patient might be the exception.”

According to Jospe, that latter notion is more often than not a common one among clinicians and likely a source of their frustration when clinical decision support becomes implemented into their care delivery.

“We all think that our patients are special and we want to value and respect the individual human person in front of us, she continues. “When we then try to plug that into a rules-based engine, there is a dissonance between those two imperatives — there is a rule and my patient is exceptional. Trying to understand that and allowing for both as appropriate is what EHRs should be striving to do.”

Connecting filtering with EHR usability

A patient’s EHR comprises numerous fields of data, notes, and other bits of information, but in order for a clinician EHR user to be most effective in her care delivery she must be able to identify the most relevant pieces of clinical data.

“The ability to dive into the specific area of information you’re looking for is crucial,” says Jospe. ” You have to be able to find just what you’re looking for either based on what you’re seeing with the patient or idea that you had. Being able to navigate quickly and efficiently to the information you think you need but still be to trace your way back to broader pools of information is the key or at least one of the primary tenets of a good EHR.”

Historically, this kind of EHR functionality has not featured in EHR design. As a former primary care physician, Jospe claims it created struggles for her earlier in her career and still does for others today.

“That was one of my struggles with primary care and the EHR system that I had to be in,” she reveals. “I was responsible for all of the information that I was seeing but understood the context for maybe five percent of it. I wasn’t the ordering provider — there were specialists, things done in the past, etc. — so how to make sense of that is a real burden and it keeps a lot of docs up.”

Echoing EHR usability sentiments recently expressed by Micky Tripathi, PhD, MPP, of the Massachusetts eHealth Collaborative (MAeHC), Jospe foresees future EHR design that enables EHR end-users to filter clinical data based on their needs.

“You have to be able to find just what you’re looking for either based on what you’re seeing with the patient or idea that you had,” she maintains. “Being able to navigate quickly and efficiently to the information you think you need but still be to trace your way back to broader pools of information is the key or at least one of the primary tenets of a good EHR.”

In the context of a physician, that’s the ability to parse the notes of particular colleagues separately or together. “That ability to give control over finding and communicating information — that’s the secret sauce,” adds Jospe.

It’s so exciting that there is data that can be used to predict the direction and trajectory of your patient’s health. Having that brought to your attention as things are changing is really important and that deserves to be moved and flowed up to the top instead of presented as an option to go in that direction.

Returning to clinical decision support, the road ahead for EHR developers is to ensure this technology is a useful touchstone for clinicians of varying types. “It’s a hard balance. There is a fine line between forcing a particular thought pattern and offering some guidance,” says Jospe.

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Why Are So Many Big Health IT Companies from Small Cities?

Why Are So Many Big Health IT Companies from Small Cities? | EHR and Health IT Consulting |

I was reading over something on HIStalk the other day that talked about how many major healthcare IT and EHR companies have come out of small cities. In fact, when you think about the EHR world, there are only a handful of EHR companies that have come out of the tech hub of the world, Silicon Valley, and they’ve all been started within the past 10 years.

In the article HIStalk mentioned the town Malvern, Pennsylvania. I hadn’t even heard of the town, but a look at Wikipedia has Siemens Healthcare, Ricoh Americas, and Cerner as among the companies based in Malvern. I think the Cerner mention in the list must be because Cerner just purchases Siemens Healthcare, so they are now claiming them. However, Cerner is definitely a Kansas City based company. Either way though, Kansas City is not a HUGE city either and certainly hasn’t been the hub of technology (although, I know they have some cool tech things happening now, like most cities).

The healthcare IT behemoth, Epic was founded in Madison, Wisconsin and now has headquarters in Verona, Wisconsin. If you aren’t in healthcare IT, my guess is that you’ve probably never even heard of Verona.

Those are just a few examples and I’m sure there are many more. Why is it that so many of the large healthcare IT companies have come from small cities? Will that trend continue or will large cities like San Francisco, Boston, New York, and LA start to dominate?

I’m a bit of a young buck in this regard. So, I don’t have the answer. Hopefully some of my readers do. I look forward to hearing your thoughts. Is there an advantage to being from a small town when going into healthcare? It’s exciting to me that healthcare innovation can come from anywhere. I hope that trend continues.

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Free iOS App from ADP AdvancedMD Allows Any Physician Practice to Assess ICD-10 Preparedness

Free iOS App from ADP AdvancedMD Allows Any Physician Practice to Assess ICD-10 Preparedness | EHR and Health IT Consulting |

South Jordan, Utah – February 24, 2015– ADP® AdvancedMD, a leader in all-in-one, cloud electronic health record (EHR), practice management, medical scheduling, medical billing services as well as a pioneer of big data reporting and business intelligence for smaller medical practices, today announced the release and availability of AdvancedMD ICD-10 Toolkit, a free app that gives private practices a suite of ICD-10 preparation tools. Now anyone with an iPhone or iPad running iOS8 can easily test their readiness and train staff for the October 1deadline, free of charge. Customers of AdvancedMD practice management software can also leverage the app to add ICD-10 codes to their charge slip templates.

“ADP AdvancedMD has been a leader in the ICD-10 transition process and a champion of independent physicians and small practices, with such tools as, a website aimed at helping medical practices prepare for the ICD-10 transition, featuring a timeline and a wealth of tools, training and tips to help practices prepare for the change,” said Raul Villar, president, ADP AdvancedMD. “With less than half of all practices ready for the change, we saw a need for a tool that would aid the entire community of independent physicians in their progress.”

The app was created as part of the ADP AdvancedMD iCommit program, which offers incentives to engineers for independently pursuing innovations in addition to their regular jobs.

“We decided that there should be a tool to help everyone prepare for the change to ICD-10 and give our community the ability to gauge their readiness,” said Barlow Tucker, software engineer, ADP AdvancedMD. “A free app was the clear choice because it’s easy to access and use, plus it allows people to get an ICD-10 ‘checkup’ at any time.”

The AdvancedMD ICD-10 Toolkit allows users to:

– Track preparedness for ICD-10
– Compare ICD-9 codes with the ICD-10 equivalents, including risk of increased specificity
– View potential high-risk areas
– Search for ICD-10 codes and sub codes
– View articles and action plans to guide a specific transition

Download the new AdvancedMD ICD-10 Toolkit app for iPad®, iPhone®, and iPod Touch® available for free on the Apple app store.

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EHRs are not a business strategy

EHRs are not a business strategy | EHR and Health IT Consulting |

Somehow health systems have adopted the notion that electronic health records are central to their competitive strategies – viewing the technology’s capabilities beyond their original design and intent.

EHRs were created to collect information and help practitioners from within the four walls of the health system make better informed decisions; they weren’t built to connect hospitals with their trading partners, nor were they built to solve critical business issues such as dwindling reimbursements and the transition away from fee-for-service to value-based care.

In fact, once all health systems inevitably implement EHRs, they become another toolset within the hospital; they become expected assets of the institutions, not unlike thermometers, stethoscopes or examining rooms. What they don’t do is provide a market advantage. A successful provider network will look to cost-effective cloud-based solutions to complement EHRs, broaden and connect the care community, grow revenue, create workflow efficiencies and, ultimately, provide a truly competitive advantage.

The problem with EHRs

Since their inception, EHRs have been a touchy subject. Operating executives have acknowledged the importance of upgrading outdated analog tools and implementing effective instruments for retrieving patient data, entering orders, receiving results and documenting visits. But they have also admitted their disappointment in the resources – both financial and operational. Physicians have also been vocal in their dislike of EHRs, pointing to the technology’s disruptive nature and time-consuming requirements.

Hospital executives that expected to see returns on their EHR investments have been disillusioned, knowing now that new revenue opportunities originate outside of those walls. Inpatient admissions and surgical procedures are no longer contributing needed revenue growth, as volumes are being reclassified and transitioned to outpatient settings.

As Moody’s Investors Service has reported, nonprofit hospitals’ income declined for the second straight year in 2013. Hospitals must turn their attention to technologies that can connect the broader community of independent providers, uncovering the value in new referral sources and effective care coordination. EHRs were not designed to meet this need.

The cloud-based solution

Regardless of EHRs’ deficiencies, the initial decision to digitize was not wrong – it was necessary to improve efficiency. But that action was a one-time occurrence and should not be viewed as a competitive strategy.

Though arguably useful in the long term, investments into EHR technologies do not improve outpatient revenue and associated contribution margins. And with the shift to value-based care, it is more important than ever that health systems prioritize care coordination across organizational boundaries. EHRs’ limitations in this area can be detrimental to a health system’s business strategy.

Network providers must turn to additional tools that can help fill the holes left by EHRs. Inexpensive cloud-based software can help supply what EHRs lack – the ability to quickly grow outpatient volume, curtail network leakage and lift contribution margins. These tools act as referral management platforms and assist in scheduling and analytics. They are designed to interoperate with EHRs, adding new value to the tool and potentially helping create the investment returns that were originally expected.

Health system executives who want to create a competitive advantage will think beyond EHRs, unlocking value unknown to those who simply implement the same cookie-cutter tools as their competitors. 

David Greene's curator insight, February 24, 8:28 PM

Good article.  Most EHRs are still missing the key concept of creating engagement with patients because that was not in their initial design.  Now systems need to look to other solutions for improving quality and cost containment by better engagement throughout the continuum.  Healthcare should look to other industries to replicate how they create successful interactions with customers, and then devise strategies that will truly engage those who will determine the future pay for performance revenues...

Bharat Employment's curator insight, February 25, 1:58 AM!

Acute Care EMR Purchasing Plans 2015

Acute Care EMR Purchasing Plans 2015 | EHR and Health IT Consulting |

Stiffer competition between key vendors is causing a growing number of providers to be undecided about which EMR to purchase when looking to make a buying decision. In the KLAS acute care EMR purchasing plans report released today, researchers found that even though providers have fewer choices due to market contraction, they are less likely to have made up their minds about which system to buy when evaluating future purchases.

Energy in the market is being driven largely by legacy customers looking to make a purchasing decision. This report shines a light on which companies are under consideration by providers looking to make a decision and what is fueling that consideration.
“The competition between Epic and Cerner is closer than it has been in years past as customers determine their future purchasing plans. This has left twice as many facilities “up for grabs” as there were last year,” said report author Coray Tate. “The lion’s share of the remaining customer mindshare is split between MEDITECH and McKesson, pretty consistently along partisan lines.”

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How EHR Data Exchange Drives Healthcare Reform, Improvement

How EHR Data Exchange Drives Healthcare Reform, Improvement | EHR and Health IT Consulting |

Increased EHR data exchange is beginning to play an important role in reforming the healthcare industry and enhancing the quality of care. Essentially, EHR data exchange is being used to transform the efficiency of care, engage patients, support population health management, and boost healthcare quality.

The Office of the National Coordinator for Health Information Technology (ONC) explains that the benefits of exchanging EHR information include reducing test redundancy and improving efficiency by ensuring all healthcare professionals handling a patient’s care have access to the same data. Additionally, EHR systems provide a more streamlined approach to administrative tasks and in doing so the costs associated with these aspects of care are reduced.

Through patient portals and the curtailing of redundant paperwork due to the growth of health information exchange (HIE), patient engagement is also increased. In fact, the Centers for Medicare & Medicaid Services (CMS) has elevated the importance of patient engagement by incorporating patient-centered conditions into Stage 2 Meaningful Use requirements.

For example, the EHR Incentive Programs calls for patients to be able to access their health information and communicate with their healthcare professionals electronically. Many patients have already received follow-up or preventive care reminders and used a patient portal to access their medical data such lab test results and current medication lists. Privacy and security of these messaging services are also of the utmost importance to the healthcare field, as it is a major part of Stage 2 Meaningful Use requirements.

As part of its Health IT Success Stories series, ONC discussed the patient engagement initiatives at Helping Hands Pediatrics, Inc., a small clinic located in Sharon, Penn. Using this practice’s assessment tools, patients with asthma are able to contemplate how the condition influences their day-to-day life.

“Through the integration of assessment tools, the children in our practice really get a chance to think about their disease and how it affects their daily life. This sense of ownership in their disease management was well worth the effort,” Office Manager Angie Chlpka told ONC representatives.

Along with increasing patient engagement, EHR data exchange improves population health management by allowing physicians to coordinate with public health officials and improve community health initiatives.

EHR systems can improve public health reporting by offering an efficient data collection process with the ability to share information across various healthcare facilities. For example, immunization registries and electronic laboratory reporting provide a streamlined system in which physicians can send population health data to public health officials.

This type of information exchange could play a large role in studying, preventing, and managing disease. For instance, clinicians should be able to receive alerts on major public health concerns in the near future. EHR technology also offers a way to improve communication and collaboration between public health officials and physicians.

One of the most important roles EHR systems play in healthcare reform is in quality improvements. EHR technology is poised to reduce medical errors and drug prescription mistakes. On the whole, this should lead to better patient health outcomes and improved safety.

Accurate and error-free EHR data is tied directly to quality improvements in the healthcare industry. Poor or insufficient data, on the other hand, will reduce patient safety and undermine the effectiveness of HIE, according to the American Health Information Management Association (AHIMA).

Enhanced decision-making and quality care delivery is directly linked to complete and accurate EHR data. In order to ensure data quality is first-rate, AHIMA advises medical organizations to focus on data capture and improving clinical documentation practices. Also, incorporating uniform data models will better establish the reliability of the information stored in EHR systems.

Whether it’s patient engagement and greater healthcare efficiency or better population health management capabilities and quality improvements, the collection and sharing of EHR data plays a large role in the ongoing healthcare reform across the nation.

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CDC Sees Increase in Emergency Care, Ambulatory EHR Adoption

CDC Sees Increase in Emergency Care, Ambulatory EHR Adoption | EHR and Health IT Consulting |

The Centers for Disease Control and Prevention (CDC) recently released a survey that shows an increase in emergency and ambulatory EHR adoption between 2006 to 2011. It was found that, by 2011, 84 percent of hospital emergency departments (EDs) and 76 percent of outpatient departments used an EHR system.

In fact, EHR adoption rose from 19 percent in 2007 to 54 percent in 2011 among EDs. Additionally, more outpatient facilities began focusing on Stage 1 Meaningful Use requirements. The trends show a steady rise in the implementation of any EHR system among emergency care facilities across the five-year timeframe.

The HITECH Act of 2009 is one of the reasons that EHR technology has seen greater implementation as it gave eligible hospitals and professionals monetary incentives to adopt health IT systems.

As such, the number of emergency departments with EHR technology that meets meaningful use guidelines rose significantly from 2007. Since payments for meeting Stage 1 Meaningful Use began in 2011, this increase comes as no surprise. For example, electronic prescribing (e-prescribing or eRx) increased from 38.6 percent in 2007 to 62.6 percent by 2011.

Along with the widespread use of ordering prescriptions electronically, health IT systems increasingly began recording patient history, patient problem lists, and providing warnings of negative drug interactions or allergic reactions. However, less than 20 percent of emergency and outpatient departments reached thresholds for nine Stage 1 Meaningful Use requirements. To receive meaningful use incentive payments, hospitals will need to demonstrate the achievement of 14 core set objectives and 5 of 10 menu set objectives.

As part of its Health IT Success Stories series, the Office of the National Coordinator for Health Information Technology (ONC) shared the experience of one emergency department at a hospital-based clinic in Cincinnati, Ohio. In 2011, the University of Cincinnati (UC) Internal Medicine and Pediatrics practice implemented an EHR system in order to share patient data through the hospital’s Health Information Exchange (HIE).

One major aspect of the HIE included incorporating the Emergency Department/Admission Alert System, which warns the facility when a clinic patient has entered emergency room care or hospital admission. With the help of the alert system, the physicians at the clinic were able to develop care plans for patients to prevent future emergency room visits.

“After our patients are discharged from the hospital or ED, our clinic is able to proactively reach out to them to make sure they understand their discharge plan and set up follow-up appointments as needed,” Dr. Jonathan Tolentino, an internal medicine and pediatrics physician at the clinic, told the ONC.

Along with the follow-up care, the clinic incorporates EHR-based risk stratification to determine which patients need the greatest amount of assistance after emergency department care.

“The risk stratification system, combined with the ED alerts, not only helps us deal more aggressively with high-risk patients, but also helps us increase care coordination,” Dr. Tolentino went on to explain.

Greater adoption of alert systems and EHR technology among emergency departments will likely improve patient safety and health outcomes over the coming years.

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Laying the foundation for an image-enabled EHR / EMR

Laying the foundation for an image-enabled EHR / EMR | EHR and Health IT Consulting |

As more and more types of patient data and images are being created across hospital departments and externally across the continuum of care, healthcare organizations’ data management needs are rapidly evolving. And as industry pressures for improving quality of care and controlling costs continue to mount, it has become paramount that hospitals have the ability to access, share and optimize patient information from the EHR / EMR—all data, regardless of source, location or format—in a fully integrated, patient-centric manner.

Imaging data is no different. It requires long-term enterprise archiving solutions that go beyond simply storing digital imaging data to ones that manage data based on industry standards, ensure its protection, and enable easy search and retrieval of all unstructured content, while laying the foundation for EHR / EMR integration.

But the healthcare industry is at a critical impasse as it moves from an age of time-honored traditional care to an age of redefined ability where we’ll empower more patient-centric care to keep our communities healthier. Despite the investments we’ve made in electronic health records (EHRs), much of the patient information clinicians need access to—mostly unstructured—resides outside the EHR / EMR with little facility for accessing or the ability to share it.

To achieve long-term enterprise data management strategies, meaningful-use initiatives and create longitudinal patient views of the patient record, imaging data and other unstructured content must be integrated into the enterprise in order to achieve EHR / EMR goals. And it will be crucial that we redefine how diagnostic images and related content are managed and accessed to create a single patient-centric view, enterprise-wide as we look to improve patient outcomes while lowering the cost of care.

Building an Enterprise-Centric Solution for Today’s Image & Content Challenges
IDC has defined the patient-centric evolution of the vendor-neutral archive (VNA) as an application-independent clinical archive, or AICA. Many in the industry have contended that this is, in effect, the second generation of the VNA—a ‘super VNA’ of sorts. But, as IDC outlines, the concept of an AICA is differentiated from the VNA. An application-independent clinical archive would move the industry more towards patient centricity by shifting focus to enhancing clinical relevance as opposed storage rationalization.

I’ve been a big supporter of this movement, and IDC is certainly on the forefront of changing how the healthcare industry will achieve long-term enterprise data management strategies and meaningful-use initiatives. And if the recent RSNA conference is any indication, so is the industry itself. But to create longitudinal patient views of the patient record, imaging data and other unstructured content must be integrated into the enterprise in order to achieve EHR / EMR goals.

To this end, I see the next evolution of diagnostic image management as a slightly different acronym—ICM (image and content management). Similar to the concept of an application-independent clinical archive, ICM would include all the functionality of a VNA for diagnostic image storage, but additionally include enhanced capabilities of enterprise content management for comprehensive clinical content management, integration and sharing. As a scalable data management and archiving solution, ICM would be optimized to manage all unstructured content—irrespective of type. And through integration with the EHR / EMR, it would make available to multiple clinicians at the point of care, a longitudinal, patient-centric view of a patient’s medical record.

The ICM concept would allow healthcare organizations to redefine their clinical content management strategy and image-enable their EHR / EMR with a single, integrated system for managing and viewing all types of unstructured data—not just diagnostic images. And it would allow hospital Chief Information Officers (CIOs) and PACS administrators to simplify infrastructure and expand capacity, undisrupted, through both routine maintenance and PACS migrations.

Redefining Image and Content Management
While VNAs are typically implemented as a department-centric solution, the concept of an ICM would be implemented as an enterprise-centric solution. It would afford healthcare organizations the ability to eliminate departmental imaging silos and consolidate medical image resources to create an integrated management and viewing experience of all clinical content from any EHR / EMR. And it would enable a strategic approach to enterprise data management while increasing productivity and simplifying, at a reduced cost, the achievement of Meaningful Use Stage 2 and HIMSS Stage 7, as well as compliance with federal and state regulations.

In a more simplistic view, an ICM would allow healthcare organizations to consolidate medical image storage resources to create an integrated image and content management platform that affords the ability to:

  • Facilitate Sharing: through the use of open standards, enable the sharing of all diagnostic images and unstructured content throughout the enterprise and across the continuum of care while maintaining patient privacy and security.
  • Aggregate Data and Index Metadata: aggregate any data type and index the associated metadata to ensure that all clinical images are stored in a central location, organized by patient, for easy access.
  • Image-Enable the EHR/EMR: from a single data repository to provide a fully integrated, patient-centric view of the complete patient record—further facilitating enterprise-wide consistency and collaboration, and supporting Meaningful Use Stage 2 and accountable care organization (ACO) efforts.
  • Improve Data Availability and Protection: by consolidating growing volumes of imaging data across multiple departmental solutions, and providing instant access to both new images and evaluation of relevant prior diagnostic studies. And ensure regulatory compliance by making data secure, immutable—unable to be deleted or altered—and auditable.
  • Apply Workflow Processes: allow for workflow processes to be applied against the data to enable further improvements to patient care.
  • Improve Interoperability and Virtualize Data: improve the interoperability of information and virtualize data within and between systems to enhance clinical efficiencies, reduce healthcare delivery costs and improve patient-care decisions.
  • Avoid Vendor Lock-In: to more quickly adopt or incorporate new imaging technology, or replace clinical applications, by using standard, non-proprietary data file formats—allowing for the avoidance of compatibility issues, costly integration and data migrations, and potential workflow disruptions.

By leveraging a single repository beyond the imaging department and across multiple departments to manage image and non-image data based on industry standards, healthcare organizations will be better suited to realize their data management strategies under the concept of ICM—and move more readily from imaging silos to content-centric synergies in delivering better patient care across the continuum.

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