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One CIO's Random Thoughts on Healthcare (Part 3 of 3)

November 4, 2009
by Neal Ganguly
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In the first part of this series (over a month ago), I examined the environment driving stimulus and some of the timing challenges that I saw in the various initiatives underway. The second part covered some of the misalignment that exists between the players and the challenges that lack of alignment poses to hospital CIOs.

In this installment I’ll discuss my thoughts on the alignment challenges. To do this, I’m expanding on the challenges covered in Part 2 with the qualifier that this list is still far from complete.

1. Hospital – Physician Alignment

a. Clear agreed upon clinical documentation standards

The latest meaningful use matrix specifies that an up-to-date problem list of current and active diagnoses be maintained using ICD-9 or SNOMED. In the absence of such direction several years ago, we opted to follow nursing standards and build our system on NIC, NOC, and NANDA. Now my team must review the work effort of mapping these nursing standards to SNOMED.

b. HIE / EMR Interoperability

Physicians are clamoring for advice on how to qualify for their piece of the stimulus pie. Our approach has evolved over time. The initial thought was to align with one or two EMR vendors and tight integrate them with our inpatient systems. This approach has several shortcomings, the most serious being the lack of flexibility for the physicians. The current thought involved implementing a local HIE using a commercial application (such as Medicity, MobileMD, Axolotl, etc.) to connect a wide range of EMRs to the hospital’s impatient system. This approach still includes negotiating with a small set of preferred vendors for discounted pricing, but doesn’t close the ‘integration door’ to providers that choose (or require) a different CCHIT compliant system.

c. CPOE

There are so many industry drivers leading us down this path, from Leapfrog all the way through Meaningful Use. This is one is a procrastinator’s dream and has been on the radar for years, but somehow always got deferred for other more pressing matters. Pressing matters defined as something people were more likely to use. The incredible amount of work that CPOE requires – in both build, and (more importantly) culture change, made it daunting. Meaningful use and the deadlines it imposes are forcing this initiative back to the top of the pile. The debate about standardized vs. customized order sets rages on…

d. Quality Measures

Regardless of what we do, and how we do it, it WILL need to be measured. Numerous regulatory bodies want to judge our performance and advertise it to the (often uninformed) public. However, these measures should not be viewed as onerous, rather they should be seen as an opportunity to finally track and improve operations. Key to effective measurement is the electronic capture of necessary data elements. This has a direct impact on how online documentation should be built. A carefully thought out documentation build can reduce the amount of manual work done for reporting dramatically. I am not minimizing the challenges involved in getting a nursing staff to agree to document additional information; it is an uphill climb (barefoot and in the snow). Once the data is captured, make sure it’s being used. Proper analysis and interpretation of this data should give health systems the edge they need to react to changing patient needs, and care delivery models.

e. The Dream

Alignment of the requirements for supporting hospital and physician billing, that would require the physician to document properly for their own reimbursement. No more chasing them to properly document the ejection fraction on a possible CHF case, or specify the lab finding in support of complex pneumonia. For those CIOs who have oversight of HIM, you know my pain.

2. Provider – Patient Alignment

a. Personal Health Record

The PHR is another meaningful use requirement that feels a little ahead of its time. Hospital IT departments will be scrambling to implement or modify applications to ensure that the infrastructure can support the meaningful use of data between the physician and the hospital. That will be daunting enough, without adding the complexities of dealing with the general public right out of the gate.

b. Touchpoints

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Comments

Neal, nice job laying out the challenges and opportunity with alignment. I espeically enjoyed the complexities of the hospital / physician alignment. Shaun

Although I am a healthcare supply chain specialist, I have about as much expertise regarding electronic health records as a member of the uninformed public.

I did, however, asked my personal physician, who has been using electronic medical records for several years, about interoperability. I asked if my records would be accessible if I were admitted to a facility on the other side of the state in which I reside or in a different state. She tells me that my records can only be accessed by facilities within the healthcare system in my county of residence or two adjacent counties.

This certainly appears to be a less than optimal value considering the cost and effort to implement these systems. It seems that the benefits of gathering information to correlate treatment protocols with outcomes to produce evidence based treatment protocols on a national or international basis will not be realized. Are the current incentives that have resulted in the scramble to implement these systems incorrect?

Supply chain examples are also interesting since they produce reductions in operating costs delivered directly to the bottom line with no increase in revenues.

Although materials management systems and perioperative systems generally don't have information connectivity, the potential value of automating the supply replenishment process through interfaces between these systems is real since the necessary supplies for procedures are maintained in perioperative system preference cards. As supply consumption is documented in the perioperative system during a procedure, the transactions can be passed to the materials system as a demand on inventory to activate automatic replenishment. Usually though the perioperative system preference cards are not sufficiently accurate to facilitate the process and the materials management system reorder points have not been determined by employing an algorithm to efficiently balance carrying costs against demand and validated by collaborating with perioperative service line leaders. Both reorder points and preference cards can be corrected but failure to do so usually precludes implementing this advantageous interaction.

This type of cooperation requires a supply chain strategy at the executive level and an alignment of physicians, perioperative and materials management staff to realize the greater advantage to the facility instead of the department managers only looking at their individual departmental performance. Process improvements only result from improving processes regardless of the systems implemented.

Neal, your blog is helping to put into perspective the complexities of managing and leading in the current healthcare technology environment. There are seemingly more questions than answers. However, we have to let the goals drive the direction and realize there are almost no perfect solutions and often the work of today will need to be redone in the future. Keep fighting the good fight and being a thought leader. I am really enjoying following your posts. You end this at Part 3 but it would be great to keep the format going with periodic updates.

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Neal Ganguly

CIO, CentraState Healthcare System, Freehold, New Jersey

Neal Ganguly explores the challenges facing community hospitals as they struggle to remain...