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.
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.