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Wednesday, January 30, 2013

Hats off to Qualis' WIREC

Providers Enrolled with the Washington & Idaho Regional Extension Center Receive Over 25 Million Incentive Dollars
REC-enrolled providers more than twice as likely to receive Medicare Incentive Program payments

Seattle, WA (PRWEB) January 29, 2013

Qualis Health announces that more than $25 million has been paid to healthcare providers enrolled with the Washington & Idaho Regional Extension Center for Health Information Technology (WIREC). The money came through the Centers for Medicare & Medicaid Services (CMS) Electronic Health Record (EHR) Incentive Program.

WIREC provides consulting services to over 3,600 healthcare professionals across Idaho and Washington State. To date, WIREC has more than 3,000 of these providers’ EHRs up and running – and nearly 1,200 have achieved meaningful use. Meaningful use is the set of EHR standards defined by CMS that allows providers to earn incentive payments. WIREC’s on-the-ground health IT coaches deliver customized one-on-one assistance to providers in different stages of EHR implementation and use, offering health IT outreach and education, EHR procurement guidance, workflow redesign, and implementation support. WIREC assists providers in all these areas with the ultimate goal of improving practice efficiency and optimizing patient care...

About the Washington & Idaho Regional Extension Center
Led by Qualis Health, WIREC provides technical assistance, guidance, vendor-neutral EHR adoption services and information to eligible healthcare professionals to help them achieve meaningful use of EHRs and qualify for Centers for Medicare and Medicaid Services incentive payments. Visit WIREC on the web at

About Qualis Health
Qualis Health is a national leader in improving care delivery and patient outcomes, working with clients throughout the public and private sectors to advance the quality, efficiency and value of healthcare for millions of Americans every day. We deliver solutions to ensure that our partners transform the care they provide, with a focus on process improvement, care management and effective use of health information technology. Visit Qualis Health on the web at
Kudos. Our REC is also bi-state (UT and NV), but our EP and EH populations are a good bit smaller. We have enrolled about 1,500 to date. Qualis has always been a stand-out QIO, so the WIREC news comes as no real surprise.


 Government Should Slow Down Race To Implement Electronic Health Records
Zina Moukheiber, Forbes

In an unusual move, vendors of electronic health records (EHRs) are asking the government to delay implementation of their products, and focus instead on making sure requirements already set in motion on EHR use are effective. “The pace is too damn high,” says John Glaser, chief executive officer of Health Services at Siemens Healthcare, a major vendor. “People are just cramming this stuff in.”

Health IT companies pushed hard for the 2009 HITECH Act, which disburses taxpayers’ money to hospitals and doctors to help them purchase EHRs, provided they use them according to rules set by Medicare. Thanks to that law, revenues at companies such as Cerner, Epic, and athenahealth have soared.

But the initial euphoria is slightly waning. Government rules which prescribe a one-size fits all approach for everyone, from recording height (even for, say, an orthopedic surgeon), to implementing five clinical decision support “interventions,” have turned out in some cases to be cumbersome. While the need to digitize patient records is imperative, no one knows whether those rules have measurably improved outcomes, so far. “To keep moving ahead with such an aggressive strategy strikes me as foolish,” says Stephanie Reel, vice provost for information technology and chief information officer at Johns Hopkins University. “We don’t know what’s working, and what’s not working.”...
Hard to disagree with Ms. Reel's assertion.

She continues:
...The biggest casualty might be innovation. For vendors, their electronic health record becomes generic, as they follow government prescriptions to the letter. At Johns Hopkins, the IT department worked daily with a team of 50 doctors to come up with creative ways to improve patient outcome; now IT is too busy meeting government rules. “We’re sacrificing innovation because of requirements to be compliant. The trade off is stark,” says Reel.


Ran across this via LinkedIn, specifically a thread within the HIMSS Group:

Has HIE become “an unmitigated disaster”?
Author Name Kyle Murphy, PhD   |   Date January 14, 2013

The current work being done to facilitate health information exchange among healthcare organizations and providers is an “unmitigated disaster” falling short of supporting healthcare reform, according the President of the Health Record Banking Alliance (HRBA). “The current approach to HIEs does not and will not work. If we want to succeed, we must try something else,” writes HRBA President William Yasnoff, MD, PhD, in a recent contribution to NHINWatch.

In presenting his case against the current approach to HIE, Yasnoff identifies neither funding nor capability but more simply the approach taken by HIEs as the source of the problem. “The problem is that we’re on the wrong path,” he writes. “We’re trying to build institution-centric systems that leave patient information where it’s created and retrieve and integrate it in real time only when it’s needed.”...
Well, I read through the brief HRBA "White Papers" ("briefs"?) and came away just a tad underwhelmed. Long on undeniably laudable cherry pie and ice cream abstractions and concomitantly way short on proposed technical ops detail (including proposed industry consensus or government "standards" -- though, of course, why would you want to play that card at this point?).

Moreover, having worked in risk management in a bank, I reflexively wince at "bank" and "health record" implicit in the same acronym. The mind reels.

My response on this LinkedIn thread:
There are as of today (29-Jan) 1,780 ONC Certified "complete" EHR systems (1,502 ambulatory, 278 inpatient). While I can't "look under the respective proprietary hoods," I rather doubt that any of them have the same underlying RDBMS data dictionaries / schema -- not even close. Comprehensive 'hub" interfaces do not exist, much less individual peer-to-peer interoperable interfaces.

Imagine "Meaningful Use" Certified" wall outlets, each faithfully delivering 120AC at 15-50 amps ("meaningful" std output), but via 1,780 different sizes and shapes of outlets and plugs.

Permit me another fun analogy. Go to Google translate. Enter some random sentence, say, from English to French, then from French to German, then from German to Spanish, then from Spanish to Farsi, Farsi to Japanese, etc, etc, all the way back to English. Try myriad permutations.

Yeah, the HIT interoperability challenge is not that fraught, but it is to a degree.

Remember, opacity correlates with margin. Particularly absent some core required plug & play standard.
I'll have more thoughts on this topic shortly. In sum for now I think the "unmitigated disaster" loaded question (where you lob a charge 'concealed' in a question) is nothing more than attention-seeking hype.


Never ever seen this before:

Delay Stage 3 Meaningful Use Regs, Physicians Say
Medscape Medical News, Robert Lowes

Organized medicine is urging the Obama administration to postpone drafting its stage 3 requirements for earning a bonus in its incentive program for electronic health record (EHR) systems until it studies how the stage 1 criteria have worked — or not worked — in physician offices.

"The stage 1 criteria were theory-based," said Jason Mitchell, MD, director of the Center for Health Information Technology at the American Academy of Family Physicians (AAFP). "Stage 3 needs to be evidence-based."...

"It makes no sense to add stages and requirements to a program when even savvy EHR users and specialists are having difficulty meeting the Stage 1 measures," wrote AMA Executive Vice President James Madara, MD. "An external, independent evaluation is necessary to improve and inform the future of the program."

The AAFP's Dr. Mitchell told Medscape Medical News that HHS needs to examine some of the assumptions that went into the stage 1 criteria.

"Is computerized order entry of drugs, labs, and tests improving safety or efficiency?" he said. "Is it making a difference in terms of outcomes? Are we decreasing the duplication of tests?"

On top of that, no one knows how the stage 2 requirements will affect physician practices, say the medical societies. Regulators should not develop stage 3 until they first assess how stage 2 plays out, wrote William Zoghbi, MD, the president of the American College of Cardiology. Otherwise, physicians will face new regulations that "seek to change behavior rapidly without respect for the potential consequences," Dr. Zoghbi said...
There is a loud chorus of critics out there who have long bemoaned what they view as a lack of demonstration of  HIT efficacy (going well beyond any Meaningful Use Stages).


...AHRQ will study how EHR implementation alters clinical work processes and workflow, including:
1. Map the physician practices to detect changes made to the physical layout as a result of implementing PCMH and health IT.

2. Observe staff. Physicians, nurse practitioners, physician assistants, nurses, medical assistants, pharmacists, case managers and non-clinical office personnel will be observed to outline overall characteristics of clinical workflow before, during, and after health IT implementation. Particular attention will be paid to interruptions and exceptions.

3. Produce before and after time and motion study to quantify staff time observed spent on different clinical activities and the sequence of executing the task.

4. Extract clinical data in logs and audit trails that have been time-stamped from the EHR to reconstruct clinical workflow related to the health IT system. This information validates and supplements the data recorded by human observers.

5. Conduct semi-structured interviews of end users, including staff, non-clinical personnel and management post-health IT implementation to obtain attitudes and perceptions regarding how health IT has changed their workflow, particularly behavioral and organizational factors.

6. Form focus groups made up of the clinical staff, non-clinical personnel, and management team to assure that the research findings, as well as the interpretation of the findings, accurately reflect their experiences using health IT
I added a comment.
"4. Extract clinical data in logs and audit trails that have been time-stamped from the EHR to reconstruct clinical workflow related to the health IT system. This information validates and supplements the data recorded by human observers."
Better late than never, one supposes. I've been arguing this for years. An EHR audit log is essentially an information workflow record that should be mined to analyze routine tasks times-to-completion and variability. Analysis can also reveal the "pain points," i.e., iterative, recurrent "flow" barriers. You then couple these data with data taken regarding concomitant physical tasks to flesh out a more useful picture for systematic improvement activities
The very word 'workflow' has become a cliche. Rolls readily off the tongue with little thought given to what it entails. A more apt analogy might be a traffic copter shot of the jerky stop-&-go freeway traffic of rush hour. In most clinics, it's nearly ALWAYS rush hour.I joked in one jpeg I did for my blog that this was my Primary's office at 8:03 a.m.
See also (freely distributable)
A decade ago I was working in credit risk and portfolio management at a relatively small privately-held issuer of VISA/MC subprime credit cards (roughly a million active accounts). I had free run of most of the internal network. I got to looking at our in-house developed collections call center system (~1,000 collectors assiduously working the phones every day), and knew the source language and data tables architecture, so I started importing the data into SAS and mining them (it was basically a Collections "audit log," though I was the first to audit it, on my own initiative)
I was able to rather quickly show management that their staffing deployment and call volumes were egregiously misaligned. We were typically spending $1,000 to collect $50 (or less), hounding delinquent customers with sometimes up to 140 calls per month, at all hours of the day and night (the classic, hated subprime M.O.).
It was a lava flow of waste. I issued a snarky monthly report on these activities, dubbed "The Don Quixote Report."
On the basis of my rather simple call log analytics we were able to save the bank about $5 million a year in Collections Ops cost, dragging the VP of Collections kicking and screaming all the way (his annual bonus was tied in part to his budget, which was the largest in the company -- he did not become My Friend).
"Workflow" tactics deployed in healthcare remain stuck about 10-15 years behind the times, as they don't drill down into time consumed and error rates. Mining the EHR audit logs might be of great utility here -- though the datetime() stamps are gonna need to be more granular than just down to the second. SQL now supports time capture down to the microsecond, though tenths or hundreds might suffice.
Another barrier here in general might be "once you've seen one audit log data dictionary, you've seen one audit log data dictionary." Recall that we have at this point nearly 1,800 "complete Certified EHR systems." How many differing audit log architectures we have is probably unknown outside of ONC CHPL -- if they even bother to look.
Let's hope this AHRQ study will move us usefully ahead.

More to come...

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