Healthcare information systems

Healthcare IT standards still not clear

Healthcare actually pushed the Iranian elections out of the top news slot this week. Most of the attention has been on the administration’s efforts to establish a government insurance plan of last resort. But in the background, the health information technology (HIT) effort continues to boil along, with a lot of action and not much clarity emerging on standards for electronic health record (EHR) software.

Dr. John Halamka, noted CIO of CareGroup Healthcare System, reported on the second meeting of the HIT Standards Committee, of which he is a member. The committee is currently engaged in a four-dimensional exercise: drilling deep into the information space that healthcare inhabits to understand what data in what format has to be interchangeable, all the while trying to understand how these standards will develop over time. It’s a Herculean task, even at the 50,000-ft. level, and I’ll be very interested to see where they are able to make progress and where they stall. Halamka points out that already people are beginning to see that EHR won’t progress unless complementary initiatives like lab results data standardization also proceed apace.

Meanwhile, the standardization picture is far from clear. Neil Versel is hearing rumors that CCHIT may be replaced or augmented as the certification body for EHR software. The presumptive favorite body to certify may be sidelined or augmented by the Office of the National Coordinator for Health Information Technology, the federal agency overseeing the Recovery Act initiatives in electronic healthcare. One hospital IT director I’ve spoken with says he expects the Joint Commission that accredits hospitals to step into the fray. That might be a culture shock, as the Joint Commission has a reputation for rigor in its clinical inspections that could be a rude awakening for software vendors.

The next few months will hopefully clarify just what IT needs to do to demonstrate meaningful use of healthcare IT. Meanwhile, IT organizations are not standing still. Alex Barrett wrote recently about Boston-based Beth Israel Deaconess Medical Center’s EHR project to get private physicians integrated into their systems. BI-Deaconess is making creative use of server virtualization to build an infrastructure that can grow and adapt as it gains acceptance and use. This is not an insignificant problem for architects who face uncertain usage targets and unknown ramp up times.

Chris Griffin documents an interesting culture shift in healthcare IT, which he describes as a “culture that puts a big emphasis on software applications, rather than on hardware and a holistic view of the computing environment.” That’s probably a dysfunctional approach for IT departments that will face increasing pressure to store more patient data from imaging and other diagnostic procedures as well as for longer and longer times due to regulatory compliance requirements.

IT will be a leader in electronic health records projects

For 20-odd years, the many problems with electronic health records (EHRs) ably highlighted by Karen Guglielmo have stymied the pervasive use of IT in healthcare. But the Feds’ newfound interest in EHR could well change all that. The reason is not so much the $34 billion allocated by the government for electronic health record development – much of that seems destined to help individual doctors or small practices and clinics. For hospitals and other health institutions, the payoff may well be the new air of seriousness surrounding EHR. With the Feds looking for major cost savings to help offset historic deficits, I expect a certain amount of arm twisting to get all the parties to play nice.

We recently surveyed several hundred IT managers in healthcare institutions to see where people are at. Sixty percent have some form of EHR under way, with 36% either planning or in some stage of deployment. IT managers at these healthcare organizations see themselves overwhelmingly as playing a major role in EHR implementation, often leading the project.

The EHR troika is shaping up to be IT, medical records and medical staff. Pencil in the compliance officer and make that a quartet. CIOs I have spoken with are talking up the idea of a chief medical information officer (CMIO), most likely a doctor with an IT bent, as the ultimate application owner. The CMIO is shaping up as the person who can hold software vendors accountable for the two main issues that have plagued EHR to date and that Guglielmo wrote of in her blog entry: unwieldy user interfaces and lack of interoperability.

Within IT, CIOs and security managers will have the biggest involvement in the up-front planning and decision making around which packages to buy, etc. Development staff will, of course, be involved in the inevitable customizations. However, 75% of our respondents will bring in outside professional services for some phase of the project, especially for customization and deployment.

Once established, EHR will become the responsibility of application managers (CMIO or not) and of course, the usual infrastructure directors of servers, storage, database and networks.

Hospitals have often lagged behind corporate IT in their adoption of new technology, with notable exceptions in digital imaging and wireless networking. Still, we are likely facing a wholesale modernization of hospital IT to accomplish the broad goals of electronically managed healthcare. Without high-density commodity servers and server virtualization, for example, it’s hard to see how hospitals can afford to run all this new software. Will they also say goodbye to Unix and rely on Windows and Linux exclusively? Will hospitals be able to afford maintenance of fat clients in every exam room, or will they opt for desktop virtualization of some flavor? Time will tell.

The other thing time will tell is if the government or industry can rationalize the cuckoo economics of EHR. Conventional wisdom is that payers will be the biggest beneficiaries of cost savings, while providers the biggest spenders. Seems like we’re just trading one series of problems in healthcare financing for another unless that’s addressed.

Why don’t connected healthcare information systems work?

In a perfect world, connected healthcare information systems would be easy to use, offer doctors a way to effectively communicate with their patients without any barriers or restrictions and give patients a secured means of keeping track of their electronic medial records (EMR).  Today’s healthcare information system doesn’t do this.  

According to last month’s New England Journal of Medicine, 17% of U.S. physicians use some kind of electronic medical records system and only 9% of U.S. hospitals are adopting EMRs. What’s the holdup?

Some say it’s a case of misalignment of incentives. At this week’s MIT Sloan CIO Symposium, Dr. John Halamka, CIO of Harvard Medical School, talked about how implementing connected healthcare information systems comes at a high price in terms of cost and productivity to doctors and medical facilities, with little return on their investment. Halamka talked about how doctors are presented with this great new technology for electronic health records. But the doctors initially have to put their own money up to fund the technology investment. They then see an immediate loss in productivity due to the setup time and management of the system. Finally – their staff ends up quitting or complaining about all the extra work involved in the new process. What are the incentives to this? Extra hours, lack of productivity and no additional compensation. And how is that supposed to improve my healthcare experience?

Or maybe it’s a workflow issue that’s holding up the progress of connected healthcare information systems. Fellow panelist Gregory Veltri, CIO of Denver Health and Hospital, blamed the lack of progress on workflow. Veltri gave a great example of his CEO telling him, ”Nurses chart today the same way they did 30 years ago. You need to fix that.” This was a wake-up call for Veltri, who realized that doctors and medical facilities have a major workflow issue. They have been using the same systems and workflow processes for years and literally haven’t had the time to make changes.

Could the holdup be blamed on the technology? Does the technology behind connected healthcare information systems do a good enough job in meeting the needs of doctors, patients and insurance carriers? Connected healthcare information systems are very complex and involve doctors constantly codifying data for flows, reminders and alerts. Most doctors don’t think in terms of codes. Moreover, a lack of standards means the system your primary care doctor adopts might not be the same as the one a specialist or hospital has, making your record unusable by anyone but the facility that created it.

The goal of connected healthcare information systems should be “to push the right data to the right provider at the right time,” said Veltri. I’m not sure about you, but I’d rather have my doctor use a system that will allow him to spend more time figuring out my diagnosis, not just the right codes to enter.