Telehealth Technologies Addressing the Global Impending Nursing Shortage

Telehealth Technologies Addressing the Global Impending Nursing Shortage... In addition to providing better care for patients at a distance, telehealth technology applications can provide a real means for the nursing profession to alleviate the impending nursing shortage. According to a report of the Health Resources and Services Administration (HRSA), there will be an unmet need for more than Bobhttp://www.blogger.com/profile/16014609332742259093noreply@blogger.com
Read more [Informaticopia]

Our blog shortlisted for Computer Weekly IT Blog Awards!

in
Public Sector IT


This is a really amazing development.
Thanks to the CW team for the recognition!
It's great to see that Rod Ward is listed too informaticopia
Nursing - Community Informatics - let's spread the care!
Read more [Hodges' Model: Welcome to the Quad]

New? Really?

Friday's AHIP Solutions SmartBrief had this item:

New AHRQ campaign focuses on patient empowerment
The U.S. Agency for Healthcare Research and Quality is rolling out a new campaign called "Questions Are the Answer," designed to help patients be more involved in their care to avoid preventable harm. The program offers a Web site that includes video, checklists and advice for patients and providers on asking and answering questions. The Boston Globe (6/26)

The Boston Globe story from Thursday didn't make mention of this being a new campaign; only the Spanish component is new. And that's accurate. Readers of this blog would know that "Questions Are the Answer" is not new. I wrote about it on April 23, 2007.

On another subject, last week's Health Wonk Review was one of the best I've seen to date—and not just because health IT got top billing. Kudos to Jaan Sidorov of the Disease Management Care Blog for his excellent and detailed commentary.

The link to the "Ultimate Guide to Google Health" was particularly useful. It's nice to have time to put together such a comprehensive list. Or so I'm told.

Keeping Young Patients Safe

A nurse at a children's hospital devises a computerized system to alert clinicians about safety risks.
Read more [Health Data Management Magazine Articles]

Fixin' chronic care

An outfit called NewTalk is hosting a 3-day on-line roundtable (today was day 2) on the following question: Chronic care: Do we need an entirely new model of delivery?  The all-star panel includes:

Troy Brennan, Aetna Inc.
Lawrence Casalino, University of Chicago
Susan Dentzer, Health Affairs
Philip Howard, Common Good
Brent James, Intermountain Healthcare
Nancy Johnson, Baker Donelson
Timothy S. Jost, Washington and Lee University School of Law
David B. Kendall, Progressive Policy Institute
Mark McClellan Engelberg, Center for Health Care Reform
Peggy O Kane, National Committee for Quality Assurance
Carol Raphael, Visiting Nurse Service of New York
Arnold Relman, Harvard Medical School
John Rother, AARP
Bruce Vladeck, Ernst & Young's Health Sciences Advisory Services
John E. Wennberg, The Dartmouth Institute for Health Policy and Clinical Practice

The key issues under discussion include both delivery models and payment models.  Seems to me there also needs to be more of a focus on population health and on primary care and prevention, since so much of the disease (and cost) burden is due to preventable conditions.

I heard the following description of an alternative payment system at a recent New England School of Acupuncture function:  In a traditional Chinese village, the local acupuncturist is paid a monthly fee by each of his patents -- unless they are sick.  Some version of a system incentivizing providers to keep patients healthy would be a vital component of any reform in this realm.

-- David Harlow

Panasonic U1 Ultra Mini Computer

Panasonic today unveiled its new computer in the venerable Toughbook line of PC's designed to perform in an environment somewhat more rugged than your lap. We had the ER in mind as a place where the new U1 can be tested. The U1 UMPC (Ultra-Mini PC) is a full featured computer running Windows XP or Vista on the new Intel Atom processor, fully compatible with any PC application. Coupled with Toughbook's standard safety components, like withstanding a 3 foot drop onto concrete, the device may prove to be a winner among doctors and nurses working in hospital wards. What makes the U1 especially suited for healthcare is a combination of the design considerations put into it. Because of the cooler, more efficient Intel Atom processor, the U1 doesn't have ventilation ports through which liquids can enter. The device is effectively sealed, and Panasonic claims that it can take a good splash (of urine or C. diff., we assume) and keep on ticking. (Just don't take it SCUBA diving with you. Its not fully water proof.) Nursing staff and the IT department will also be happy to know that the U1 sports two separate battery slots, which lets the user hot-swap batteries without having to turn off the unit. A hospital can even buy multi-battery chargers to hang on the wall at the nurse's stations for round the clock operation. Somehow this feature seems like it was specifically designed with nurses in mind, who already have enough to think about without having to deal with complicated battery changes during busy hours. The screen is 5.6 inches and is fully touch sensitive, which means it can be controlled with your finger, not just the stylus like so many tablets out there require. (The advantage becomes obvious once the stylus is accidentally left back at the desk.) Optionally it can come with a bar code scanner, which can be utilized for device or medication tracking, and a built-in webcam, which we envision can be employed in a futuristic communication system between clinicians in a hospital ward. We're really impressed by the U1, and would like to see more portable computers come out suitable for use in hospitals. Not to say that this is a good general replacement for a real laptop, as it has only 1GB RAM and tops out at 32 GB for a solid state disk drive. But its nice... Michael
Read more [Medgadget]

Green Houses: A Model of Future Care?

Today’s WSJ had a very good front page article on the concept Green Houses.  Green Houses are a concept championed by a certain Dr. Thomas, a doctor who worked in geriatrics at traditional nursing homes and figured there must be a better way of caring for the elderly.  He made his pitch to the Robert [...]
Read more [Healthcare IT: Analyst's Views]

Ins and Outs

New AMA President Backs Insurers' Doctor Ratings ... [WSJ] In Massachusetts, No Pay for Medical Errors ... [WSJ] Nurse Staffing Mandates Are No Quality Panacea ... [WSJ] Do Hospitalists Improve Hospital Stays or Increase Risk? [WSJ] Eating a big breakfast may be a good way to lose weight... [BBC] United States and China Outline Progress on Agreement on Food and Feed Safety ... [FDA] Auscultation and portable echocardiography detects high rates of asymptomatic rheumatic heart disease in schoolchildren... [Nature Clinical Practice Cardiovascular Medicine] Scientists Isolate a Toxic Key to Alzheimer's Disease in Human Brains... [NIH] Study Shows That Small Protein Can Broaden Immune Response in Humans... [NIH] Mutant Mouse Mimics Human Osteosarcoma Cancer... [HHMI] Chickens 'unlock allergy secrets'... [BBC] Cats 'spark eczema in vulnerable' ... [BBC] For the Wealthy, Private Health Care Consultants ... [WSJ]... Michael
Read more [Medgadget]

UWE pioneers health training using new NHS records software

University partners with Cerner to train nurses and health staff to use electronic patient records Bristol. 23rd June 2008 - To continue its healthcare education leadership, the University of the West of England (UWE) today announces that it will implement the Cerner Academic Education Solution (AES) to train nursing and other health staff on how to use the new electronic patient record system Rodhttp://www.blogger.com/profile/12607263970096550308noreply@blogger.com
Read more [Informaticopia]

Industrial process modeling and analytics tools improve care quality and efficiency in a busy hospital emergency center

I'm back from my travels in Norway.  While I was gone, we published a compelling case study that illustrates how software can be used to improve patient care in busy clinical settings. 

At Microsoft, we published dozens of health industry case studies every year.  But it's not every day that we get quotes like this one.  "In three days’ time, Microsoft and Orlando Software Group were able to provide us with more business intelligence and insight than we were able to achieve in two years of study."  Those are the words of Dr. Christopher DeFlitch, Director and Vice Chair of the Department of Emergency Medicine at Penn State Milton S. Hershey Medical Center in Hershey, Pennsylvania.  Dr. DeFlitch is a strong advocate for process modeling and analytics tools in managing core process redesign initiatives in healthcare delivery systems.  Recently, DeFlitch and his associates learned about ProcessView, a design and analysis tool and add-in to Office Visio Professional 2007, from Microsoft Certified Partner Orlando Software Group.  They used the software to simulate and analyze complex and time-critical processes involved in properly diagnosing and caring for acute coronary syndrome patients arriving at the ED.“In about three hours, we were able to create a top-level process flow diagram for the overall process,” says Frank Kapper, Vice President and principal partner of Orlando Software Group. “We found there were 88 unique workflow paths, and within that, 15 workflows occurred 90 percent of the time.” With this information, the department was able to focus on the highest-occurrence workflows and make sure it had the proper staffing, equipment, supplies, and other resources.

There is a whole lot more to this story than I am able to cover on my Blog.  You can read the full case study here.  Any physician, nurse, or administrator charged with improving clinical workflow and quality of care outcomes will benefit from reading the report.  It's just one more example of how software can be applied to solve some of healthcare's most pressing issues in caring for our patients.

Bill Crounse, MD   Senior Director, Worldwide Health   Microsoft Corporation 

CMS to launch 5 star rating system on Nursing Home Compare Website

The Centers for Medicare & Medicaid Services is preparing to launch a ranking system of America's nursing homes on its Nursing Home Compare Website.
Read more [Healthcare IT News]

Agfa HealthCare Announces Launch of its Leading Nursing Solution ORBIS(TM) Care in Belgium

Agfa HealthCare, a leading provider of IT-enabled clinical workflow and diagnostic imaging solutions, and the Imelda Hospital in Bonheiden (Belgium) announced today that more than 15,000 nursing documentation forms have been registered electronically in ORBIS(TM), after the initial go-live in November, 2007.
Read more [eHealth News EU]

Children's Web site takes mystery, fear out of hospital stay

Lucile Packard Children's Hospital in Palo Alto, Calif., uses an interactive Web site to help pediatric patients prepare for their hospital stay, treatments and surgery. A team of nurses created the site to take the fear and mystery out of going to the hospital. http://include.nurse.com/apps/pbcs.dll/article?AID=/20080616/CA02/106160050Bobhttp://www.blogger.com/profile/16014609332742259093noreply@blogger.com
Read more [Informaticopia]

CfH Conference - The Information Revolution

Today I attended the annual Connecting for Health Conference for Nurses, Midwives & Healthcare Practitioners entitled "Culture Change in Professional Practice - The Information Revolution". This years event was held at Central Hall, Westminster and was less busy and exciting than the first event I attended a couple of years ago, with less than 200 booking for the event & quite a few of them Rodhttp://www.blogger.com/profile/12607263970096550308noreply@blogger.com
Read more [Informaticopia]

Web Site Targets Family Caregivers

The National Family Caregivers Association and Intel Corp. have launched an online community for family members, nurses, social workers and others who care for the aged and chronically ill.
Read more [Health Data management Online Current News]

The Goals of an LIS Compared to Goals of a Hospital EMR

Rob Bush of Orchard Software submitted a comment about a recent post (see: Cultural Barriers to Medical Innovation). His points were so interesting that I am promoting his comment to the level of a blog note, copying it below in its entirety (boldface emphasis mine):

Commenting on the success of the LIS vs the EMR:
The common objective of the laboratory is to provide accurate results in a timely and cost effective way. Everyone working in the lab can agree upon the goals, and behave as a part of the overall solution. The EMR’s goal is not that well defined. Although it is often stated to be improving healthcare for the patient, I believe the working goal is to make each healthcare professional using the system more efficient at doing their job. Naturally, if the goal is to make you personally more efficient, there is a different goal for each person using the EMR. The mentality of the people involved is very different. In the lab the people ask “What can I do to help with the process?” With the EMR, people ask “What can the software do to make me more efficient?”

I have some minor quibbles with Rob's comment but his overall logic is correct in my opinion. The overarching role of the LIS, and the clinical labs that it supports, is to provide accurate results to clinicians in a timely and cost effective way. Similarly, the role of the hospital EMR, and the physicians and nurses working in an inpatient unit, is to provide efficient and effective healthcare to patients admitted to that unit.

Both lab professionals and hospital nurses tend to operate as teams and emphasize teamwork. Both the LIS and EMR are tools to enhance the work of these teams. The role of physicians in hospitals is somewhat different and more attention needs to be paid to their individual responsibility and productivity. As proof of this statement, you need only recall the common conversations of hospitalized patients, who will often refer to "my surgeon" or "my anesthesiologist." The pathologist plays a critical role in the care of a patient in the diagnosis of disease but their role is largely anonymous. Few patients will will make reference to "my pathologist."

So what can we make of all of this? Only that the EMR must serve to increase the productivity of all of the various teams in a hospital, including lab professionals, but also the individual productivity of physicians working in the same environment. Failure to do so will result in opposition from the physicians and I will defend their right to take such a position.

Hospital Switches from Carts to C5s

Anacortes, Wash.-based Island Hospital is no longer using computers mounted on mobile carts. Instead, nurses are carrying C5 Mobile Clinical Assistant devices from Motion Computing Inc., Austin, Texas. The mobile hardware resembles a tablet computer but is equipped with a handle.
Read more [Health Data management Online Current News]

Intel Launches Online Community to Connect Family Carers and Nurses in the UK

With a goal to assist carers in the United Kingdom, Intel Corporation today unveiled ConnectingForCare.co.uk, the first online community of its kind for family carers, community and district nurses, healthcare assistants, social care workers and others to share information and provide emotional support to one another, filling a void in today's healthcare system.
Read more [eHealth News EU]

Bright Lights Help Dementia Sufferers

A group of Dutch researchers clinically tested the effect that long exposure to bright light and melatonin have on the functioning of dementia patients. They say that the light produces positive effects similar to common drugs taken by such patients. From Bloomberg: "On the whole, light treatment could have clinically beneficial effects,'' the authors said in the paper. "The long- term application of whole-day bright light did not have adverse effects, on the contrary, and could be considered for use in care facilities for elderly individuals with dementia.'' The ceiling-mounted lights, more than three times brighter than those the study used for comparison, also reduced depression 19 percent. Moreover, the researchers found that melatonin, a hormone, improved sleep and that the lights reduced melatonin's side effects. From the article abstract in JAMA: Light attenuated cognitive deterioration by a mean of 0.9 points (95% confidence interval [CI], 0.04-1.71) on the Mini-Mental State Examination or a relative 5%. Light also ameliorated depressive symptoms by 1.5 points (95% CI, 0.24-2.70) on the Cornell Scale for Depression in Dementia or a relative 19%, and attenuated the increase in functional limitations over time by 1.8 points per year (95% CI, 0.61-2.92) on the nurse-informant activities of daily living scale or a relative 53% difference. More from Bloomberg... Abstract: Effect of Bright Light and Melatonin on Cognitive and Noncognitive Function in Elderly Residents of Group Care Facilities JAMA. 2008;299(22):2642-2655. Image by eeland.... Michael
Read more [Medgadget]

Improving care quality and collaboration with Microsoft Office Groove

High quality healthcare today can only be delivered by multidisciplinary teams consisting of doctors, nurses, pharmacists, therapists, social workers and others.  This often includes caregivers who work out in the community and in patients' homes.  But such "teamwork" can lead to fragmented information and work processes that put quality at risk with duplication of patient records, unnecessary tests, and prolonged hospital stays.  Effective caregiver collaboration requires an integrated information environment. Clinicians need access to patient information from a variety of locations. The information must always be up to date, and the exchange of information from one caregiver to another must be done securely. In addition, the tools that enable such exchanges and collaboration must be familiar, affordable, and easy to use.

In the latest edition of my House Calls for Healthcare Professionals audio-cast series we examine how contemporary information technology is being used to solve this problem at Eastern and Coastal Kent Primary Care Trust in England. We reveal how healthcare workers in the field can communicate and collaborate with each other and with their hospital or clinic based colleagues more efficiently, no matter where they might be? We make the case that this kind of facilitated collaboration contributes to improved patient safety and caregiver satisfaction. 

This special program examines how one division of what is perhaps the world’s largest healthcare delivery system, has solved their need to improve collaboration across multidisciplinary care teams.  My guest is Julie Ansell, a clinical specialist in intermediate care at the UK National Health Service’s Eastern & Coastal Kent Primary Care Trust.  Also joining me on the program is Ray Jordan, solutions director with Microsoft partner D2i Solutions Ltd.

To listen to the audio-cast click HERE.

Also available for MP3 download

Bill Crounse, MD   Senior Director, Worldwide Health   Microsoft Corporation

Sedation Web Site... For Endoscopy

An internet baby has been born out of one of the biggest Gastroenterology conferences of the year, the Digestive Disorders Workshop (DDW). www.sedationfacts.org is an online resource on endoscopic sedation meant for gastroenterologists and GI nurses. Here's more about the website from the press release: The collaborative effort provides an easy-to-access online body of knowledge about the science, pharmacology, practice management and regulatory environment of endoscopic sedation. This Web site aims to improve the understanding of endoscopic sedation among GI medical professionals and trainees, giving them the information they need to improve their knowledge and to ensure patient safety. Always be sure to keep up with the latest sedation news. Read the press release here...... jhbarad
Read more [Medgadget]

Two Groups Join E-Rx Effort

The American Academy of Nurse Practitioners and the American Academy of Physician Assistants have joined the Get Connected program to encourage adoption of electronic prescribing technology.
Read more [Health Data management Online Current News]

Should the Hospital CIO Report to the CFO

Mr. HIStalk recently commented on the topic of whether a hospital experiences better financial performance if the CIO reports to the CFO rather than to the CEO. Below is his note in its entirety (boldface emphasis mine):

A study says that hospitals in which IT reports to the CFO have better financial performance. Actually, I’m reading between the lines since reading the actual lines themselves would set me back $7.95 and I don’t really buy the premise (and therefore the article). I recognize some Florida State University names among the authors, I think. I would think it’s hard to prove that IT reporting influences the hospital bottom line vs. happens to correlate to it in some way. There’s also the question of value and quality, of course.

Here's the "money" quote from the summary of the report that he makes reference to:

Reporting to the chief financial officer brings positive outcomes; reporting to the chief executive officer has a mixed financial result; and reporting to the chief operating officer was not associated with discernible financial impact.

Duh! News flash. Hospital financials are better when the CFO is in charge of IT. Believe me, I have operated in such an environment and you don't want to go there. I started managing an LIS when the hospital "mainframe manager" (pre-CIO days), an IBM retread, reported to the CFO. As one would expect in such a setting, the efforts of the central IT group were largely allocated to business applications. Projecting such a reporting relationship into today's environment, how could be results be any different?

One small anecdote from these "good old" days around 1985. The mainframe manager was bragging to a hospital IT committee that the computer "up time" was hovering around 98%. Everyone in the room cheered. This was at a time when the mainframe computer had a scheduled "down" of four hours every night for system backup and maintenance. I asked politely how we could achieve a 98% performance given our extended nightly maintenance period. She responded that the "up time" for the hospital computer was calculated using the number of planned available hours per 24-hour period in the denominator. Just my two cents. Hospitals are already too driven by bottom line financial issues. No need to exacerbate this problem even more.

Nurse practitioners, PAs join provider-led e-prescribing initiative

The American Academy of Nurse Practitioners and the American Academy of Physician Assistants are participating in a new program designed to help more of the nation's prescribers begin sending prescriptions to pharmacies electronically.
Read more [Healthcare IT News]

Medical School Comes to Second Life

Several months ago I posted a review about the book Swords & Circuitry: A Designer's Guide to Computer Roleplaying Games and my motivation for reading in. I believed then, and believe now, that the underpinnings of computer roleplaying games have a direct application to Health2.0, and that one day EMRs and the like will create compelling new ways for people to understand and become engaged in maintaining their own health and wellbeing.

I also suspected (but only hinted at) the possibility that the technology that has brought games like Grand Theft Auto and Halo 2 to life would also enable virtual representations of patients with real-world conditions to be diagnosed and treated online. In game-speak, one day computer roleplaying game technology and techniques will transfer Health2.0 from a first-person shooter to a MMPORPG.

What never occurred to me was that this sort of application was well underway, until I came across this article at JuniorDr.com:
One of the earliest projects is the Ann Myers Medical Center - a virtual medical school - where medical education gets a unique opportunity to find new ways of training medical students. It was created to test the possibilities of virtual training for real world medical and nursing students. There are dozens of physicians, medical students and animators behind this unique project who pledge their sparetime and money to this idea. AMMC currently has a voluntary staff consisting of consultant specialists, medical students and several nurses. The founder, Doctor Ann Buchanan (Second Life name), a US physician, envisions a hospital where medical students and nurses could be trained. Currently participants focus on patient history, physical examination and telemetry. A virtual mentor gives the students a disease process with which to familiarise themselves and they have to present it to the physician.

Source: "Virtual Doctors: Medical Training in Second Life"
If you think that this is all pie-in-the-sky B.S., think again. Advanced computer graphics are enabling the creation of 3-D models of DNA, internal organs, the human nervous system, and so forth that - while note quite photo-realistic - are for more "real" than two-dimensional cut-away drawings or text descriptions. The collaborative nature of Second Life also makes for a more dynamic and compelling learning experience than is possible even in real-world classrooms; where else can doctors and medical students from six continents diagnose the same patient?

It would seem to me that the next logical step would be to find a way to translate an EMR into a "character sheet" for patients, so that healthcare in Second Life can make the jump from theoretical and didactic to practical and applied. As anyone who has ever played RPGs generally knows, there are a number of models for doing this already - some better-suited to real-world application than others.

From CAD prototyping to accounting the translation of real-world science into mathematical abstractions that have real-world applications is already well underway; it seems to me that as Second Life-like online experiences become more and more common, it is just a matter of time before the line between online gaming and online healthcare disappears altogether.

Related Post: This is as Close as I Get to Being a Hardcore Gamer
Read more [Healthcare Informations Systems Blog]

Information Technology Supporting Clinical Excellence

Corexcel invites you to the 2008 Siemens Nursing Thought Leadership Web Cast Series - 'Information Technology Supporting Clinical Excellence' sponsored by Siemens. Featured Speaker: Kathy Guyette, RN, MSN, Vice President and Associate Chief Nursing Officer, University of North Carolina Healthcare System The transition to automated clinical documentation requires a new look at things, most oftenVariegatedhttp://www.blogger.com/profile/17164235694530628920noreply@blogger.com
Read more [Informaticopia]

Cultural Barriers to Medical Innovation

The Healthcare IT Guy has just posted a note based on a recommendation from a reader about a presentation on the web by Zen Chu, a  venture capitalist and medical device entrepreneur. It's entitled High-Impact and High-Value Medical Innovation. He makes the point in slide #5 of the set that innovations by physicians are critical for healthcare with "99/100 of the top Medtronic products" invented by them. I found the entire presentation to be original and was particularly impressed by slide #11 that is captioned Cultural Barriers to Medical Innovation. I copy the content of this slide below that lists these barriers:

• Interdisciplinary collaboration takes effort
• Culture of academic and clinical research
  • Grants and publishing mentality
  • Leads to secrecy and slow progress
  • Defining conflicts of interest too broadly
• Fear of failure
  • Better to fail quickly and learn faster
• Experimental model bias
  • Human data of efficacy paramount
  • Only use predictive models that FDA accepts
• Physician's acceptance of current standards of care
• Overvaluing initial intellectual property

Each of these barriers to innovation in medicine is worthy of greater discussion and thought, particularly in relationship to healthcare IT. For various reasons, products in this area seems to suffer from a lack of innovative spirit and efficacy, particularly electronic medical records (EMRs). Office EMRs are particularly bad as measured by adoption rates by physicians. This void has always puzzled me because innovation infuses most other aspects of healthcare and also because most LISs, in contrast, are generally cost-effective and useful products.

I was very interested in Zen Chu's first requirement for medical innovation, the need for interdisciplinary collaboration. Over the years, I have been struck by the fact that EMR deployments seem to evoke a competition among various hospital professional groups including physicians, nurses, and central IT personnel about who will be best served by the system and who will exercise the most control over it. This often results in an over-engineered and customized EMR that proves to be too complicated to manage and serves none of the individual groups adequately. Perhaps because of greater professional cohesion in the clinical labs or because LISs are less complex, such tensions tend to be less apparent in LIS deployments. As a result, failed deployments are extremely rare these days.

St. Vincent's Adopts Scheduling App

St. Vincent's HealthCare in Jacksonville, Fla. has implemented software to enable nurses and other employees in its two hospitals to apply to work open shifts.
Read more [Health Data management Online Current News]

Nursing Home Online Reports Expanded

Read more [Health Data Management Magazine Articles]

SPOTLIGHT: Nursing group urges better IT education for nurses

Despite the increasing need to use IT in day-to-day nursing jobs, nursing schools aren't doing enough to prepare nurses for this eventuality, according to the National League for Nursing. The group Read more...
Read more [Fierce Health IT News]

IBM Helps to Share Health Care Information

Artefact Informatique, a Canadian division of IBM, will be part of a new initiative to share health information with patients and doctors around the globe. This has begun with the creation of the Centre of Excellence in Quebec City, which acts as a repository and registry for healthcare information. It is through the Centre that authorized personnel can search and retrieve important documents, thus improving the efficiency of many patients' medical care.

The Centre of Excellence contains lab reports, digital images, drug profiles and other critical medical documents. This repository was created with IBM WebSphere and DB2 software and was designed to be easily compatible with commonly used Electronic Health Record (EHR) systems. Health facilities that are now using EHR technology should be able to communicate with IBM's new software.

IBM has instituted this new technology as a part of the Integrating the Healthcare Enterprise (IHE) initiative, which aims to improve the way information technology is used within the health community. Primarily, it is making the world safer for patients by keeping better medical records for easier transfer.

Says Jose Mussi, the executive director of IHE Canada:

The new software took three years to develop and was created by researchers and software engineers from Haifa, Israel; Rochester, Minnesota; and San Jose, California. IBM is now promoting the system for more widespread use.

Heather Johnson is a regular commentator on the subject of CNA Certification. She welcomes your feedback and potential job inquiries at heatherjohnson2323 at gmail dot com.

Healthcare IT Adoption by Clinicians: It's a two-way street

On a recent post titled "Improving Preventive Care Compliance" I nudged my clinical colleagues to be more proactive in reminding patients about needed preventive services.  I made comparisons to service notifications that are typical in other industries and the relative paucity of this practice in clinical medicine.  I also provided an example of how technology is being applied to help doctors do a better job.

One of the great things about blogging is its worldwide reach, and the great feedback that I receive on what I write.  A young physician named Jessica read my post and provided what I think is an important perspective on the topic of IT and barriers to wider adoption by physicians.  If you are an IT professional or a developer of health IT solutions, this is definitely worth a read.  I'm sure Jessica speaks for all clinicians on why IT adoption is a two-way street. 

**********************************************************

Dr. Crounse:

As a doctor myself, I am pleased to see this comparison. It is all logical and certainly a great solution for automating routine documentation. There are certainly challenges, however, and the statement you made below, Bill, urged me to comment (although a bit off topic of the article.)

You commented "so doctor, no more excuses!"

I recently attended an eHealth conference in Gothenburg, Sweden (www.mie2008.org) which was a great gathering for the scientific eHealth community, as well as a chance to meet with the vendors of Scandinavia that are well represented in this area of development, whether in the hospitals, primary care setting or even in the community. My bottom-line observation was, eHealth is gaining speed!

Anyhow, I was particularly impressed with a lengthy chat I had with one of your IT savvy partners from Microsoft Sweden. He was the "how and why" guy. So basically, he was talking to me about "How can hospitals, healthcare professionals use what they have more effectively?" and "Why are we so inefficient with what we have and what we use today and is there anything hospital IT departments can do to effectively adapt to end users needs without implementing a whole new operating system? Is the change that is needed based on workflow patterns and training to effectively use what we have? Simply synching outlook for appointment challenges between the ward and the out-patient clinic, bed-managing through an interactive network, etc.

And this is where I got interested...and where I need to reiterate that it is not just about "So doctor, no more excuses"...but also about "So IT technician of the hospital, WHERE ARE YOU?

To give everyone an example,

As a junior doctor for the NHS (in the UK) we received an induction, where  apart from standard information about hospital policy is given, the IT specialists of the hospital give a training session, which was superb...but not enough.

I started my first shift as a junior doctor on a night shift. I was fully supported by my senior doctor staff, nursing staff to be effective and prepared for all encounters. But when I needed to sign-in for the first time onto the computer system to check lab results of an ill patient...I reached a dead-end, no IT tech was available to authorize my newly created account...

My battle didn't end there and I was one of the few doctors (who bothered) to approach the IT department of my hospital pertaining to my disruptive work-flow experiences.

First of all, it was a challenge to get a computer engineer/technician on the phone. After so many attempts I began to wonder WHY? So I once brought it up with my colleagues during lunch, who one of which had a mobile number to one of the IT techs that was kind enough to help out the junior staff. It, furthermore, generated a heated debate with all doctors at lunch that day wondering, "What do the IT technicians do day in and day out in a busy hospital?" Surely I would list supporting end-users with the services they are implementing a key task within their work list.

Second of all, it would be of great benefit to see the health care environment working together on this enormous 'change-of-paradigm-within-the-healthcare-system' sort-of project.

Doctors are often considered as the ones not wanting the technology. Being brief, this is not true. However, I can sympathize and even agree with my senior colleagues and non-IT approving ones that without support and incentives, this will never win the approval of key end-users.

I conclude with my statement for hopes of a diplomatic discussion with the IT health techs out there reading Bill's Healthblog..."Where are you guys?"

I can imagine you have lots to do with supportive, technical aspects of the job but I would encourage you to provide better service to end-users...whether through brief workshops during lunch or through a user info-line hospital staff can reach!

Kind Regards,

Jessica Gabin

***********************************************************

Thanks for keeping folks on "both sides of the isle" on their toes, Jessica.  Your comments are very much appreciated.

Bill Crounse, MD  Senior Director, Worldwide Health   Microsoft Corporation

Growth of Walk-In Clincs Slows Down

I have posted as number of previous notes about walk-in clinics. I had latched onto the idea that such clinics would serve as a new model for healthcare delivery, offering reasonable prices and convenient locations. It now appears that there was probably too much hype associated with this new form of service and there has been a noticeable decline in the opening of new facilities. A recent Wall Street Journal article provides the details (see: Health Clinics Inside Store Likely to Slow Their Growth). Below is an excerpt from the article with boldface emphasis mine:

The boom in walk-in health clinics located inside pharmacies, supermarkets and big-box retailers is showing signs of slowing.[See the chart at the left illustrating the largest walk-in clinic operators in the U.S. as of May 1, 2008.] Hailed as an inexpensive option for treating minor health ailments like sore throats and rashes, the retail clinics have grown in number to 963 as of May 1 from just 125 three years ago. The clinics typically feature nurse practitioners who can prescribe basic drugs, and the price for a visit ranges from $50 to $75. But in recent months, retail health-clinic operators based in New York, Nevada, Indiana and Alabama have closed their doors, shuttering 69 clinics in 15 states...Now, the biggest retail-clinic operator, CVS Caremark Corp., says it is scaling back expansion plans for its MinuteClinic brand...Research shows that patients are enthusiastic about the clinics' convenience and quality of care, but acceptance has been slow...Some operators are finding that the clinics are complex to manage. Earlier this year, CheckUps, a clinic operator based in New York, abruptly closed 23 clinics that it operated inside Wal-Marts in Florida, Mississippi, Alabama and Louisiana....Not everyone is trimming sails. Walgreen Co. says it still plans to more than double the number of its Take Care health clinics this year by adding about 240 locations between now and the end of the year, bringing it closer to the number operated by rival CVS.

My sense is that this apparent slowdown in walk-in clinics is due to the fact that some of the operators did not really understand the business. In other words, part of the bubble has burst. Some of the existing clinics are pursuing new business models such as establishing relationships with local healthcare systems in order to ensure a better referral network. However, I hope that such relationships do not result in a distortion of the basic walk-in clinic business model such that they begin to more closely resemble physician office practices with all of their inefficiencies and opaque pricing policies.

EMR Vendor Site Visit

This entire week my EMR vendor had someone in our clinic going over our EMR implementation. Yes, that’s nearly 4 entire days of our health and counseling staff meeting with our EMR vendor. You can imagine after the first few meetings it’s pretty hard to keep things straight. However, this type of EMR vendor site visit is so beneficial.

The biggest benefit is that it almost forces doctors, nurses, front desk staff, lab, pharmacy, etc to sit down and think about our EMR, how it could be made better and which parts of the EMR are just causing them pains, problems, frustrations, or other discomfort. We tried to make sure that each EMR meeting went over: our current EMR challenges, features of the EMR that we aren’t using and finally discuss ideas for enhancements to the EMR software.

We’re lucky that we selected a smaller EMR vendor that’s completely focused on the college health EMR market. That means that we have a strong relationship with the EMR company. In our final meeting the EMR “trainer” said that they really are our “partner” in not just the EMR, but they’re willing to support us beyond just software. The nice thing is that our EMR vendor really does try to do this. They don’t always succeed at it, but they certainly are sincere in their effort.

Another major benefit of having someone from the EMR vendor do a site visit is that they are looking at your clinic with fresh eyes. They can see things about the way your process works that you may not see. Plus, they have usually been to hundreds of other EMR installs and so they are aware of how other clinics are using the EMR software.

Of course, you can’t expect someone from your EMR vendor to come and work miracles. In fact, many of the ideas they have just may not work for the way you practice medicine. It takes a solid filter to be able to see the benefits, problems, and workarounds that will work best for your standards of care, legal regulations, and clinical organization. The biggest problems that an EMR vendor faces is that it’s really hard to build a one size fits all EMR. Different practices act differently. However, there’s something really valuable about discussing the various options of an EMR.

I highly recommend this type of collaborative approach to working with your EMR vendor. I believe it’s paid amazing dividends for our clinic. In the end, your EMR company better be a good partner or you’ll pay the price later.

How People Learn - Dr Betsy Weiner Presenting

Went to Dr. Weiner's presentation at Vanderbilt Nursing School today and it was WONDERFUL! Remarkable use of Second Life as a Web 2.0 teaching tool! It focused on Disaster Preparedness training, but was a subset of talking about various methods of how people learn (what domains). Besides the How People Learn Powerpoint, there are two demonstrations I will do today in class: www.incmce.org (Variegatedhttp://www.blogger.com/profile/17164235694530628920noreply@blogger.com
Read more [Informaticopia]

Telemedicine Demonstrating Value

Here is an interview (see below) of Dr McConnochie on a Rochester based Pediatric Telemedicine program "Healthy Access". There have placed telemedicine equipment at childcare programs so a child can have a tele-consult with a physician without leaving the child care center in case of illness. This has proved to be a real convenience for families, but has also shown to reduce ED visits. See this press release:Telemedicine a Cost-Effective Alternative to ER Visits
The bottom line from their study: A 24% reduction in ED visits in the group of children using telemedicine and a savings of $14/child per year for the insurers. Also see David William's Healthcare Business Blog for his thoughts on this program.


Complete Dr. McConnochie interview from the 11-21-07 Newscast

Rand: For many busy adults, balancing busy careers and parenting is tough. When a child gets sick at day care or school, figuring out how to get them to the doctor’s office can be a challenge. But a project designed at the University of Rochester Medical Center used technology to bring the doctor’s office to child care centers and schools. The project is called Healthy Access and began in 2001 in five inner-city child care programs in Rochester, New York. Today the telemedicine network has grown to 22 sites, including suburban elementary schools and child care programs and 10 primary care practices. We’re joined`now by Dr. Kenneth McConnonchie, the principal investigator for the project. Dr. McConnonchie welcome, would you please tell us how Healthy Access works?

Dr. McConnonchie: Well, let’s say we have two-year old Sally, and she wakes from nap time with a fever or holding her ear. As with any child care program, the parent is contacted, but instead of the dreaded call to come pick up your child and don’t come back without a doctor’s note, child care staff, in this case, offers telemedicine as an option. Almost always, the parent chooses telemedicine. The trained child care staff person, known as the telehealth assistant, also uses this contact to obtain any history about the illness episode not already known. Then, at the child care site, the telehealth assistant collects additional information, including images, video clips and audio files, about the child’s condition and medical history. We use a digital camera with special attachments to take detailed, high resolution eye, ear drum, mouth, and skin images. We also capture lung sounds using an electronic stethoscope.

Rand: Is all this technology a bit scary for small children?

Dr. McConnonchie: Some may wonder whether the child might be frightened by the whole process, given the fact that usually a parent is not present at the telemedicine visit. Experience, however, shows that quite the opposite is true. Consider the fact that child care and school are like a home- away-from-home for children that they serve. Staff there care for these children almost every day. In child care, many children spend more waking hours with their teacher than with their parents. In contrast, young children know the doctor’s office only as a place they go for shots, and that’s a scary place. Another advantage of the child setting, child care setting at school, is the children love to see themselves on TV, so to speak, and that’s their experience with telemedicine.

Rand: So then what happens with all the information that’s collected?

Dr. McConnonchie: Having acquired all the information, the information is then sent by the telehealth assistant to the child’s primary care practice, where a clinician can use the information to diagnose or treat the patient. If necessary, the clinician conducts a live video conference with the patient, staff, and sometimes parents, to help diagnose the child. If a prescription is appropriate, after diagnosis, the physician can instantly fax it to the pharmacy for delivery to the child care center or school. Once the visit is complete, parents get a personalized letter about the visit and any useful information that the doctor wants them to have, such as a standard handout on ear infections. With an evolving illness, the clinician generally discusses findings and recommendations directly with the parents by phone. For children with a primary care doctor who is not participating, or who have no PCP [primary care physician], the visit is done by the default clinician. This responsibility is usually filled by our primary care pediatric practice at the University of Rochester Medical Center. All local insurance organizations, including Medicaid, Managed Care and SCHIP plans are reimbursing for telemed visits. The default clinician would also see children with no insurance in case there was a participating PCP who’s group refused, so that’s an overview of how it works.

Rand: Dr. McConnochie how effective has your network been?

Dr. McConnonchie: Well, to date, we’ve conducted more than 5,500 visits between child sites and the ten physician offices using telemedicine. Since the program began, we’ve been able to show a 63% reduction in absences from child care due to illness. As we like to put it, it’s health care when and where you need it by people you know and trust.

Rand: What’s been the reaction of parents react to this technology?

Dr. McConnonchie: Well, some parents were initially skeptical, understandably so and appropriately so, about using telehealth to treat their children, but as the program moved along, parents have gained confidence in telemedicine. Parents tell us that without telemedicine in place, illness in their children result in much more – would result in much more time lost from work, more in-person doctor visits, and more emergency department visits, and our data supports their claims.

Rand: So, what’s the next step for this program? Where do you see it going?

Dr. McConnonchie: We think the technology could be used in many additional settings. Obvious examples are group homes for developmentally disabled, assisted living facilities, summer camps. The burden of morbidity for children or adults in each of these settings is high, yet access to care in these settings is often problematic. For example, in-person access for a developmentally delayed child or an elderly individual in an assisted living center often requires a wheel chair van and multiple attendants. Retail-based medical clinics are rapidly developing in many communities around the United States. While extremely appealing to the consumer because of their convenience, retail- based clinics disrupt continuity of care with the medical home. People are seen in retail-based clinics by a nurse practitioner in the store, not by their doctor’s office. Retail-based telemedicine access points, in contrast, would provide the same level of convenience as retail-based clinics while maintaining continuity of care. People would go to the store for access, but with telemedicine, they could be readily seen by a clinician from their own doctor’s practice.

Rand: Regarding the training involved in this program, what does it take to become a telehealth assistant?

Dr. McConnonchie: Well, that’s a very important question and for long-term sustainability, that’s an important issue. The telehealth assistants, as we call them – actually we call them CTAs for Certified Telehealth Assistant. We train them and we certify them. The certification reflects the fact that they’ve gone through the training program and then demonstrated, over a couple of months, visit by visit evaluation, including sample visits or trial visits – that they can perform at a high level. So then we issue – having gone through this – then we issue the certification, and if someone doesn’t do enough visits to maintain their certification, they’re de-certified. But the basic training, the initial training, just takes a couple of weeks and I think one of the strengths of this whole system is that we, you know, we can take a child care staff person without – who never had – most of whom have not had prior health care training. Some have been trained by – been trained as nursing assistants, CNAs, Certified Nursing Assistants, who work in assisted-living facilities, for example – and with relatively brief training, get them up to speed.

Rand: Who funds the staff and training?

Dr. McConnonchie: Well, at the child care site, or the child-end or patient-end of the process, the telehealth assistant is, in most settings, is someone who’s employed/hired by the child site itself. Now, in many day care centers, particularly large ones, there is a health person. This expands the health person’s role and gives them a lot more tools. I would say it makes them a lot more useful, so given that child sites have – child care sites have found that they’re now attracting families that they haven’t attracted before, simply because they’ve got child care. They have found that it’s worth their while from a program development perspective. For sites and many child – certainly many of the city child care sites are also a part of family advocacy programs. Those sites take the perspective of, you know, they want to do everything they can to support families, get families back on their feet, to keep parents on the job, and the like. So they go out and raise their own funding to support this health person or the telehealth assistant. City schools are a little different. Their mission is different. Their budgets are much bigger and they’re much less, you know, personally oriented. Charter schools and actually the parochial schools, in our experience, have functioned more like the, like the child care centers that are very family oriented. So, the – at this point, that’s where the funding comes from. Our very first programs, we provided the funding for the telehealth assistant, so it came from our federal funding. Actually, back then, it was the U.S. Department of Commerce Technology Opportunities Program, the very first programs.

Rand: Dr. McConnochie, let’s talk technology for a minute. If someone is thinking about starting this up, what equipment do they need?

Dr. McConnonchie: Well, we have – we started off with commercially available pieces and we put them together into a functioning model, but certainly not a very efficient model, and certainly not one that was reliable enough or user-friendly enough that a busy pediatrician in their office practice would tolerate it. Faced with, you know, the implied problems, a commercial venture has grown out of our efforts. It’s called TeleAtrics. The initial role, from my perspective, as the Director of Healthy Access – the initial job of TeleAtrics was to develop, you know, the kind of platform that was needed, that – and basically the platform is a web based platform. There’s a central server where records of all the visits reside. At the – you know, at the child site, it’s a very secure system. It’s a lock-down system accessible only through a bio-metric log on by the telehealth assistant. The bio-metric log on is a fingerprint reader. People can’t be surfing the web at that end. And it’s basically a computer dedicated – it’s basically a plain vanilla PC with a couple of peripheral devices, the main – there’s a Logitech video conferencing camera, pretty simple straight forward. Anybody can set that up. There’s – what’s called a Camscope and that’s kind of the all-purpose camera which has different attachments that, kind of, optimize it for looking at ear drums and looking at throats or skin or eyes that actually – the Camscope can also be used to focus across the room. It can be used as a video conferencing camera. It’s a very, very flexible and useful tool. In addition, there’s the electronic stethoscope and that’s basically it. As I said, it all attaches to a plain vanilla PC which is locked down. The software that resides on the server guides the telehealth assistant through the process. We have a training manual that guides them through the process and makes it very clear under what circumstances you definitely need to get ear images and under what circumstances you definitely need to get lung sounds. You don’t need to get lung sounds on every child, certainly not a child whose chief complaint is a skin rash, particularly if the child is acting well. But, so the software guides and teaches, if you will, for the telehealth assistant.

Rand: What about on the clinician’s end?

Dr. McConnonchie: The software at the other end, at the clinician end, first of all, it captures and displays, in an efficient way, the information that – both the text information, as well as the images, and video clips and lung sounds that are – have been captured by the telehealth assistant, what the – actually at the clinician end – what the clinician sees. On the left hand side of his monitor is a waiting room, where children waiting to be seen by telemedicine are listed, and then there’s a media column – if he clicks on one of those visits, a media column and the rest of the visit opens up. The media column is right there and he, basically, has thumbnails of all the images and audio clips and video clips, and then right next to that is the text that’s summarized from the telehealth assistant, and then you scroll down, open and expand boxes for recording through the standard physician’s history, past medical history is available.

Rand: This is Health Care 411, if you just joined us we’re talking with Dr. Kenneth McConnochie, the principal investigator of the Healthy Access telemedicine project at the University of Rochester Medical Center. Dr. McConnochie how are you evaluating the impact of this technology on health care quality?

Dr. McConnonchie: A couple other simple, but, I think, very important measures are continuity of care with visits and also ability to complete visits. In terms of continuity of care, for children who have a participating PCP, the question is, what proportion of those visits do the – does the PCP squeeze in to his busy office practice? And basically, we’re asking them to squeeze those visits in as they come up. The answer is that it varies - some – but the average is about 83%. It varies from about 60% to about 95%. I think the 83% average is pretty darn good considering, especially, that so many of these visits would have ended up in the emergency department. Our – sort of prior to getting this going – we conducted some interviews at some inner city and suburban child care sites, and talking to the inner city families, we asked them – if you were to call your child’s practice in the afternoon about – your child’s sick and you really would like him seen today – 75% of parents said that they would be told to go to the emergency department. So, the point here is, obviously, the additional cost of the emergency department visit, but also, that’s not continuity of care, obviously. So there’s one important effect. The other effect, in terms of completing visits – by that, I mean, a visit seen by telemedicine – what, in what proportion of the time did the clinician feel comfortable/confident with both their diagnosis decisions and their treatment, and being able to, not just make treatment decisions, but actually implement the treatment, and that’s about 96% of the time. So, 96% of visits are completed. Obviously, this is not – you know, these are visits that arise in child care and school settings, that the child wasn’t sick, most of the time, when they went off to child care in the morning. So these are not terribly serious problems, but from a medical perspective, but they are quite serious from a social perspective if moms can get called and told to pick up the child.

Rand: Have you gotten any feedback from people who are in the actual doctor’s office, whose visits were interrupted by one of these calls?

Dr. McConnonchie: Well, yeah, not directly, cause they’re – and I wouldn’t expect to, cause no single visit is going to be interrupted. A doctor’s not going to get up in the middle of the visit and say, “Sorry, I’ve got to go take a telemedicine call.” The visits are completed. Now I am active as a clinician myself and our fairly busy primary care practice – what often happens is – the tele – not every telemedicine visit needs a – the real time video conference component. Many do not. So, I can do many other things that I’m doing – while I’m supervising residents, say, and then pick up the phone or look at the telemedicine visit and make my decision very quickly, and pick up the phone, call the parent or call the telehealth assistant, and just squeeze that in. So, basically, often the decision making part, it’s all so well presented and the images are so crystal clear, when things go well, as they usually do, my decision making just takes a matter of seconds. The communicating and the documentation takes a little more time, but it’s not something that I can’t do, you know, fitting it in between patients or between other things I’m doing in a clinical setting. So these visits are very efficient.

Rand: Have any of the parents expressed concern about sick kids being allowed to stay in the classroom?

Dr. McConnonchie: I don’t think so. It’s a question that comes up. You know, first of all, the issue of – does the child stay or go home – in the – that basically boils down to a decision between the parent and the child. I’m sorry – between the parent and the child care site. If the child care site says that your child cannot participate, is feeling so droopy that, you know, we have to spend – our staff has to spend so much time with your child that, you know, we can’t attend to other children, we can’t care for other children, we can’t teach other children – then, you know, the child needs to be picked up. It’s not an arguable point. The question of communicability – you know, there are, from a strictly medical perspective, you know, most of the times, the viruses that you’re dealing with are just ubiquitous. Children with a common cold, who could be coughing and sneezing and spewing those viruses all over the place – you know, the guidelines say that that child can stay. Um, the child with conjunctivitis, which is pink eye, which is a little more visible, from a specifically contagious disease perspective – that child is no more and probably less contagious than that child with a cold. You know, again, to me, that’s – from a medical perspective, I can put my two cents in and say what I just said, but the final decision is up to the child care site and the parent. – If the child care site – if their guidelines say the child needs to go home, the child needs to go home. That’s it.The American Academy of Pediatrics and their, sort of, school health handbook very much emphasizes the fact that most children with minor illnesses are safe for them to stay and that the decision to leave should be based, primarily, and in most instances, on the ability of the child to learn and participate.

Rand: It seems there are obvious advantages to parents and children – in terms of this being less disruptive to both of their everyday routines. Have you noted any other benefits?

Dr. McConnonchie: We have evaluated – we have published some preliminary analysis which has convinced the local – I should say preliminary analysis of cost effectiveness, which has convinced the local Medicaid, Managed Care, and commercial insurers in the Rochester area to continue reimbursement beyond the end of the current demonstration project for children who are at currently participating sites. We’re right now in the middle of a much more elaborate cost effectiveness analysis, including a few thousand children followed over various periods of time. We expect that this is going to show consistent with the preliminary analysis – that the Healthy Access telemedicine model is highly cost effective. Why? Well, many emergency department visits by children could have been handled via telemedicine. In our community, many problems that would have led to ED visits have now been managed by the telemedicine model instead. Our studies indicate that payers reimburse ED visits at least five to- seven-fold greater than for office visits or telemedicine visits for the same problems. So we anticipate substantial reduction in net health care costs for managing childhood illness, even after paying for telemedicine infrastructure, such as the telehealth assistants and the equipment. Considering the impact of telemedicine on absence from child care or school, and on parent absence from work, we expect that from a societal perspective – in other words, going beyond just the health care perspective – that cost effectiveness will be even greater. So, we’re optimistic based on our final analysis that insurers will expand telemedicine reimbursement for all children locally and, eventually, nationally.

Rand: Dr. McConnochie thank you so much for joining us today.

Dr. McConnochie: Well, thank you very much, it’s been a pleasure.

Rand: Dr. Kenneth McConnochie is the principal investigator of the Healthy Access telemedicine project at the University of Rochester Medical Center.

Once Again Mr. HIStalk Clears the Air

Mr. HIStalk has responded to my blog note of yesterday (Alphabet Soup and the HIMSS Leadership). I had cited one of his recent notes pertaining to the HIMSS execs and challenged the readers of Lab Soft News to decode the alphabet soup following their names on the HIMSS web site. Here is his comment in its entirety (boldface emphasis mine):

I'm sorry to say that I know all of them except two first hand:

CAE: Certified Association Executive
SPHR: Senior Professional in Human Resources
CISM: Certified Information Security Manager
FHIMSS: Fellow (HIMSS)
CPHIMS: Certified Professional in Healthcare Information and Management Systems
PMP: Project Management Professional
MALA - guessing it's either a master's in legal administration or some kind of medical librarian
RN-BC - registered nurse board certified (passed an ANCC exam, I think)
MPA - master of public administration

It's the dirty secret of member organizations - making up some credential means you can charge for the test, renewals, and the prep courses, PLUS make it nearly impossible to renew without attending that same organization's conferences or meetings. It carries a mixed incentive: make it easy enough to sell enough of them so that the market recognizes the credential, but just hard enough not to be a complete joke that doesn't even require study or experience.

Only two of the alphabet soup components you listed are approved degrees; the rest are private industry certifications. There is at least one for-profit organization selling EHR [electronic health record] certifications (and the related prep materials, training sessions, etc.) without any real oversight except their own. I don't know if it has real-world value, but if somebody thinks employers will like it, they'll pay.

For the record, I have no problem with professional organizations providing (selling?) certificates of achievement or mastery of some topic. I just think that the initials representing such certifications don't belong in the same company as formal advanced degrees awarded by accredited colleges and universities and requiring years of study. I really have no knowledge or appreciation of the real-world market value of such certificates, a topic raised by Mr. HIStalk. However, if HIMSS is selling them, then their execs will certainly be buying and using them. In other words, eating their own dogfood.

Using an EMR for Business Intelligence (BI)

I just completed my very last class of my educational career (I’ll graduate with my Masters in IS on Saturday. Yeah Me!). My last class was a Business Intelligence class. While I wasn’t necessarily fond of this class or the teacher, I am definitely interested in business intelligence.

Business Intelligence to me is really just about being able to look at large amounts of data in really cool ways. EMR is basically synonymous with the concept of large amounts of data. Each and every day thousands of really interesting pieces of information are being entered into an EMR. Many times this data is organized in such a way that in can be easily accessed and reported on.

For my class, we’ve been using SQL Server 2005’s business intelligence components. While Microsoft may have its downfalls, they really have put some thought and effort into SQL Server 2005’s BI components. For my final project, I decided to extract some appointment data from my EMR (yes, I guess it’s really my PMS, except for things like the room for the appointment) and run some BI analysis on the EMR data.

I actually had to anonymize all the EMR data before using it, because I was working in a group where they weren’t allowed access to all the HIPAA related information. However, it wasn’t too big of a deal in the end. Although, it does lose some of the reporting ability when you do that.

Since we ended up only pulling out simple appointment data from the EMR database, we could only really run reports about appointments. Don’t get me wrong. There is some really cool stuff you can report on appointments. We reported on appointments by date (this includes day, month, quarter, year, etc), provider, gender, birthdate, ethnicity, etc. We also uploaded the room number that an appointment used so that we could measure the utilization of our exam rooms. Luckily our EMR stored all the information about exam rooms. We also pulled in the data that described when a patient arrived at the clinic, when the nurse started the intake and when the provider finally saw them. We haven’t actually built any reports on that time study data, but it would be really interesting.

That’s really just the beginning of what we were able to do with the EMR data, but I think you get the point. The real question at this point is what other EMR data could benefit from some quality BI analysis? Here’s a few of my thoughts:

-Blood pressure - Depending on how this is stored will determine how easy it is to report. However, it would be really interesting to see trends in blood pressure across our entire population. Add in a few filters for certain medications and you could see some amazing results
-Average Charge per Patient - Could be interesting to look at this and identify which patients are the most profitable. Wait, doctors aren’t about profit are they?
-Average Number of Visits per Patient - Would be interesting to see this grouped too.

Those are just a few off the top of my head. I’m sure there are a hundred more that could be done with diagnosis, prescriptions, charges, procedures, referrals, etc etc etc. Which reports would you find interesting from the data in your EMR?

The best part of this all is that in the next couple weeks I have planned to upgrade my EMR from SQL Server 2000 to SQL Server 2005. That means that I could really easily use all th SQL Server BI tools to create the various BI reports with all the data in my EMR.

Has anyone else done this type of EMR reporting before?

Where the heck am I (and where are you on Hodges' model)?

A combination of nursing experience and informatics knowledge and skills have meant that for a long time I have been able to sit on the fence and listen appreciatively to two sides of an ongoing saga. I am sure the ending will be a happy one, if not for the reason that there is no such thing as a 'finished' (nursing) information system. There is however a need for targets, deadlines, plans for a series of software releases and all the activities that accompany 'IT' projects. In short - project management. There is then a constant need for people to sit on the fence.

While the ability to sit on the fence may be something of an advantageous position, there are times when it becomes a source of anxiety and dissonance. Off the fence as a nurse without an informatics role (without i-portfolio), you feel left out of things. Literally chomping at the bit to contribute to the developments taking place - elsewhere.

Also off the fence, but alternately wearing the informatics shoes you have a sense that those soft, fuzzy caring, psychobabble skills are slowly yet inexorably melting away. How credible can you be if you have not 'nursed', that is - seen a client, managed your case load for 1, 2 or 3 years? Whatever your field, you can lose your touch.

Reading Michel Serres and his use of Harlequin as a trope really caught my imagination and breath (as lots of things do). Here's some background to Harlequin (and Hermes):
Two figures, then, inform Serres's oeuvre: Hermes and the Harlequin. Hermes the traveller and the medium allows for the movement in and between diverse regions of social life. The Harlequin is a multicolored clown standing in the place of the chaos of life. Two regions of particular interest to the voyager in knowledge are those of the natural sciences and the humanities. Should science really be opened up to poetry and art, or is this simply an idiosyncrasy on Serres's part? Is this his gimmick? The answer is that Serres firmly believes that the very viability and vitality of science depends on the degree to which it is open to its poetical other. Science only moves on if it receives an infusion of something out of the blue, something unpredictable and miraculous. The poetic impulse is the life-blood of natural science, not its nemesis. Poetry is the way of the voyager open to the unexpected and always prepared to make unexpected links between places and things. The form that these links take is of course influenced by technological developments; information technology transforms the senses, for example. Source: Dr.Vicente Forés LópezThis short quote hopefully illustrates the attraction of Serres to me as I study Hodges' model and informatics. Discovering Serres really creased me up. I say creased because that is where I am, trapped between two worlds. Stuck in that line between HUMANISTIC and MECHANISTIC realms. If I run the gauntlet there, the only other avenue open to me is that afforded by the INDIVIDUAL and GROUP axis.

Now I'm clearly not the only one able to sit on the fence and take in the views and perspectives of two frequently disparate worlds. On informatics secondment and at events such as HC2008 (HC2009) as a nurse - informatician you have to see lost opportunities looking at the speaker line-up and number of nurses present and able to take the messages home.

As a fact of life change will happen.

How much better though is change borne of
dialogue and engagement?

Like Harlequin those of us with clinical AND informatics insights must mix things up. There is a need to constantly enquire, challenge, influence and direct at times. A need also to pass the baton and let others experience the dual perspectives from the fence (and the splinters too).

Image source: http://commons.wikimedia.org/wiki/User:Malene
http://www.qosmiq.com/cdiadrone/ghis/pfolio/characters/index.htm

Read more [Hodges' Model: Welcome to the Quad]

Blawg Review: the whistleblower edition

Forget Bogey and Bacall.  Head straight over to the Whistleblower Law Blog for the latest edition of Blawg Review, livened up this week with some nursery rhymes.

-- David Harlow

Contagious Media

My purpose in writing this is to promote I believe could be an arm of Nurse Informatics expertise in the near future: social and contagious media. Up front I'd like to ask those in the positions of leadership to consider a conference part, or in whole, dedicated to exploring this. I was very pleased to see that many others promoted "The Wisdom of Patients: Health Care Meets Online Social Media" Variegatedhttp://www.blogger.com/profile/17164235694530628920noreply@blogger.com
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Reading: Social Information Technology - Connecting Society and Cultural Issues

Last Thursday I received a parcel. Thinking it was a duplicate copy of a hardback purchased recently, I was thrilled to find it was a copy of the Social Information Technology title. When I originally enquired about submitting a paper, a complimentary copy of the book was not promised. So this was a real bonus on two counts, having checked chapter 7 and looked through the final product I'm really delighted to be a contributor. Putting my effort to one side - one of several from the UK - there are some really informative papers here. This morning I read through one -

Chapter 19 Technology and Continuing Professional Education: The Reality beyond the Hype
Maggie McPherson, School of Education, University of Leeds, UK
Miguel Baptista Nunes, Department of Information Studies, University of Sheffield, UK
John Sandars, School of Medicine, University of Leeds, UK
Christine Kell, Department of Information Studies, University of Sheffield, UK

Section V: Implications of Social Information Technology in Education

Some points of note for me -

• Learning must be situated in the domain of the use and the learning activities must match the complexity of the domain.
• Learning must contain both direct experience of the world and the reflection on that experience that will produce the intended way of representing it.
• Learning must be provided with the opportunity to explore multiple perspectives on an issue, that is, one activity is not enough to acquire a comprehensive view of a particular concept. p.303.
  

The good, the bad, and the different: accessing health care services on vacation overseas

While on vacation in Israel last month, I had occasion to sample the local health care system.  My teenage son needed an antibiotic, to nip in the bud a recurring respiratory issue.  Fortunately, I had noticed a neighborhood health clinic a couple of blocks from the apartment we were renting in Ramat Gan, a Tel Aviv suburb.  My wife took him into the clinic in the late morning (he sleeps like a teenager, regardless of time zone).  After a little intake dance (and discussing Blue Cross Blue Shield coverage in a country with national health insurance), a nurse determined that he probably needed an antibiotic, but that he would have to be seen by one of the physicians before a prescription could be written.  (What, no NPs? No PAs?)  It was 12:05.  Unfortunately, she came back a few minutes later to report that the docs had all left the building at noon, so -- no chance of getting a prescription.

The options: go to a clinic in another nearby suburb (the nurse called ahead and determined that it was unclear whether, or for how long, a doctor would be there) or head to a nearby emergency room.  The nurse recommended the emergency room: "All the tourists go there."

I drove the ten or fifteen minutes to Tel Hashomer Hospital.  It is a giant university medical center, with about 20% of the signage one might expect.  It took me a while to find the pediatric emergency department (after a brief, but heated, argument about parking).

Once in the pedi ED, service was quick, and -- take note, ED administrators everywhere -- nobody asked about source of payment prior to service.  (That may have canceled out the delay in care due to lack of signage.)  The triage nurse seemed to be the sort of person every physician asks to run interference with other nurses and other hospital departments, so it took her a while to get through the history.  My son was seen almost immediately by a physician who ordered a chest x-ray (done down the hall, image transmitted via PACS back to her workstation), a nebulizer treatment (in a room designed to accomodate multiple patients at once, including one whose mother found it a convenient spot for breastfeeding).  The doc sent us off with a prescription (to be filled at the "Super-Pharm" in the next hospital building).

Oh, and on the way out, the unit clerk validated my parking ticket and said she'd mail out a form for me to have signed and returned by my PCP.  Then she remembered I was a foreigner.  I waved my BCBS card -- again -- but she cheerfully informed me that the hospital did not deal with overseas insurance.  She printed a bill and I paid by credit card:  it was about $250 for an ED visit, including physician services, an x-ray and a nebulizer treatment.  (Not bad, eh?  The only excessive cost for the visit was the airfare . . . .)

It was after 4:00.  I picked up the antibiotic, and we headed back to the apartment to pick up the rest of the family and head south, five hours later than planned . . . .

When we returned to the States, I called BCBS.  The visit is covered; they're sending me a form to fill out and return with the hospital bill (it's in Hebrew, but they say they'll have it translated in Virginia). 

The hospital visit delayed our arrival at Shakespeare's Falafel Stand in Beersheba (yes, really), but it was an interesting peek into another country's health care system.  Still, I don't think I can deduct the trip as a business expense.         

-- David Harlow

Big Pharma Reacts to Its Drug Pipeline Problems

I have posted previous notes about the challenges facing Big Pharma in terms of the lack of potential blockbuster drugs in the development pipeline (see: Number of Global Drug Projects by Phase). David Williams has a posted a very interesting note in his Health Business Blog about how the pharmaceutical industry is reacting, or might react, to this problem (see: How big pharma might use manufacturing as a strategic marketing tool). Below is an excerpt from his note with boldface emphasis mine:

As pipelines dried up and the generic industry became more sophisticated and aggressive, big pharma adjusted its tactics. In product development it’s turned to in-licensing, creating new formulations (especially extended release products), and combination products. Big pharma has combated generics in the courtroom, introduced “authorized generics” that cut into the profits of the initial generic supplier, and attempted to bundle multiple products into its contracts with payers....It’s unlikely that big pharma will succeed in reviving its pipelines anytime soon, but there are things the industry could try. For example, if branded pharmaceutical companies can demonstrate better clinical results through medication adherence programs, they may be able to make the argument that they are selling a “solution” rather than a product.

The suggestion that pharmaceutical companies might launch a medication adherence program as a means to sell a solution rather than a product is very interesting. I know that patient non-compliance with their prescribed drugs is a major, and certainly muiltifactorial, problem. I am sure that some of the underlying reasons include the cost of the medication, avoidance of unpleasant side effects, forgetfulness, mental confusion, and even pure contrariness on the part of patients. I am also sure that inexpensive programs to counter drug non-compliance such as "reminder" web sites would be of little value in counteracting most of these problems. One such site is SmartMinder,  a refill reminder program utilizing phone, pager, cell phone, mail, or email notifications. The service is provide by Echo Pharmacies, a small set of independent pharmacies in the Long Island area.

I believe that visiting nurse or a pharmacy care program (see: Effect of a Pharmacy Care Program on Medication Adherence and Persistence, Blood Pressure, and Low-Density Lipoprotein Cholesterol) as a means to ameliorate drug non-compliance problems would be more effective than web reminder sites but certainly much more costly. However and given the price of many drugs these days, I suspect that many pharmaceutical companies would gladly eat these costs in order to preserve some portion of their market share in the face of stiff competition from generics.

Barcoding and Patient Context

One of the most important areas of connectivity, and one that frequently does not receive the attention it deserves, is establishing and maintaining patient context. Historically, connected devices identified data by location - tagging data with a bed or even port number - rather than the actual patient name or ID. Because patients are frequently moved during an episode of care - not to mention ambulatory - data that is only tagged with a location presents risks of misidentification. In an effort to improve positive patient identification, data is increasingly tagged with a patient identifier.

Besides patient safety, patient context also greatly impacts medical device workflow. (Medical device connectivity is workflow automation through the integration of medical devices and information systems.) How a vendor implements patient context can have a big impact on usability and customer acceptance.

Patient context requirements can vary, based on the type of medical device in question. What is not variable is the requirement to reliably establish and maintain context. Mobile applications (like smart pumps or patient monitoring) where the device may go in and out of network coverage while constantly in use present special challenges. This compares to a fixed or portable medical device, like a dialysis machine or diagnostic ultrasound, with an episodic use case during which neither the device or patient is moved. Another variable is whether the application is life-critical. Continuous patient monitoring and many alarms (e.g., smart pumps and ventilators) are life-critical applications with a higher threshold of requirements. This contrasts with connectivity for documentation like with point of care testing or spot vital signs capture. In all cases though, patient context must be safe and reliable. The above issues just help define how many hoops you have to jump through to be safe and reliable.

In the past few years, medical device vendors have seemingly chosen barcoding as the consensus method for implementing patient context.  This approach has two advantages for vendors, it has been implemented by other vendors and represents a no-brainer default solution, and is relatively quick and easy to design (especially compared to alternatives). The problem is that users don’t like most barcoding solutions.

Barcoding solutions can have the following problems:

1. The resulting workflow is really bad and customers don’t want to use it,
2. Customers don’t want to buy more than one barcode system, and
3. Barcode technology is finicky - you have to have the right barcode, printers, ink and labels for a certain application if you want a reasonably reliable read rate.

To be fair, the workflow around barcoding is not inherently bad. Besides challenges reading barcodes, there is the question of how barcodes are generated, an issue that gets too little attention. System-generated barcodes from a database are a great way to generate barcodes for automated data capture. Barcodes generated from data keyed in by a user is subject to typos, transpositions, and “right data, wrong entry” errors than render the resulting barcode little better than any other manually entered data. Of course, accurately reading bad data doesn’t improve patient safety.

A relatively recent connectivity and patient context application is smart pumps. These systems can illustrate some of the problems, both inherent to barcodes and design short comings, around patient context and workflow.

The word “smart” in the term smart pump is relative; as the market matures, expectations for intelligence increase. Infusion pumps with site specific formularies and software that returns an alert when the user possibly mis-configures the pump is really barely sentient. A pump that also captures patient and user context resulting in a much more meaningful CQI (continuous quality improvement) database is more intelligent. But the summa cum laude of smart pumps is one that integrates with an EMAR (electronic meds administration record) and pharmacy departmental system to provide closed-loop meds administration for the highest risk drug category in the hospital - those that are infused.

This state of connectivity bliss is a ways off for the vast majority of hospitals (who just aren’t ready yet) and many pump vendors (who are still struggling with lower forms of smartness), but smart pump installations continue to grow. According to Pharmacy Purchasing & Products, 43% of facilities in the U.S. have adopted smart pumps. Smart pumps linked to bar coded meds administration systems represent a mere 11.5% of installed IV pumps. Of the smart pumps installed, only 26.9% include wireless connectivity.

Not surprisingly, user satisfaction with systems that are not wireless (I’m assuming no network connectivity at all) is low - only 14.3% rate data collection as excellent or good, 26.2% rate it as satisfactory, and a dismal 59.5% of users rate data collection as less than satisfactory or poor. In contrast wireless data collection is rated excellent to good by 75% of users, and satisfactory was chosen by another 18.8% leaving 6.2% of users dissatisfied. But wireless connectivity is only half the story.

A key challenge with workflow and barcoding is that there are many factors that impact usability. Assuming you get barcodes that are reliably scanned the first time, you need a device that’s easy to use and can be positioned properly. If a barcode reader is mounted to the infusion pump or a cart, the entire assembly must be easily moved into position for scanning.Refer to the latest Spyglass Consulting report on Point of Care Computing for Nursing for examples of barcoding gone wrong - tape on the floor showing where to stand, wrist labels cut off patients and taped to folders at the nursing unit, duplicate drug barcodes printed and taped to folders at the nursing unit, and others. Besides poor wireless network converage, the accessibility of barcodes on patients and drugs is a very common problem. Obviously, poor system configuration and implementation can torpedo even an excellent barcode workflow.

In the fall of 2006, Cardinal Health acquired CareFusion to use as their own meds administration and barcoding system. I recall Cardinal’s CareFusion dem