Monday, November 29, 2010

"The Direct Project " aka how to connect!

A vexing problem looks to be on a path to being solved!  

The vexing problem?  How to take the paper out of the communications process!

"The Direct Project" is developing specifications for a secure, scalable, standards-based way to enable participants to send encrypted health information directly to known, trusted recipients over the Internet.  In my view, this is the direction necessary to eliminate paper as the communications protocol among healthcare participants - namely providers!

For example, a primary care provided needs to refer a patient to a specialist or to a hospital.  Today, these tasks are accomplished primarily through paper, often with fax.  The Direct Project will enable a purely electronic solution!  Here are other "stories" that have been defined.

And, here are some initial test implementations:

Pilot Project Brief - Rhode Island Quality Institute (shared documents)
Pilot Project Brief - Medical Professional Services (MPS)
Pilot Project Brief - MedAllies (Shared Documents)
Pilot Project Brief - CareSpark 
Pilot Project Brief - Redwood MedNet
Pilot Project Brief - VisionShare and Public Health

Tuesday, October 26, 2010

Fuel Cell Evaluation

Ever since 60 Minutes profiled Bloom Energy I've been interested in using fuel cells to generate electricity, particularly in commercial use (versus auto, residential, and industrial).  While the buzz around Bloom Energy is compelling and many in the blogsphere trumpet the future of Bloom, I've remained unconvinced - I've had a number of nagging worries.

I came across this analysis for the Seattle WA region public utility that confirmed many of my concerns - without the substantial CA State and Federal subsidies, Bloom isn't viable and it's not clean enough when compared to other renewable energy sources.

At this time, there is no compelling reason for City Light to pursue any interests in solid oxide fuel cell systems. Bloom Energy has the only commercially available system, the ES-5000 Energy Server, and it is available only to facilities located in California with very specific energy requirements. This narrow market focus parallels the structure of major subsidies from state and federal taxpayers and utility ratepayers. (Seattle City Light 2010 Integrated Resource Plan, Appendix I, pg 4)

Wednesday, August 25, 2010

Generating Personalized Forms / Documents

Have you ever needed to create forms that would be personalized, much as you might with Microsoft Word's mail merge feature, but wanted to do so in an automated fashion?  There's many solutions to that requirement, but here's one I like.

OfficeWriter for Word from SoftArtisans provides that functionality.  OfficeWriter is a Windows server application that starts with your Word Template and then performs variable substitution to create a Word-compliant .doc file (among other formats).  And it does so without installing Office or Word on your Windows server.  Therefor, OfficeWriter can generate 1,000s of Word files precisely to your requirements in a "lights-out" environment.

Here's an example.  Let's say that you need to generate outbound forms that will be filled-in by people who then fax back the documents to you for processing - order forms, registration forms, applications, and the like.  

With OfficeWriter, you can create your template form using Word on your desktop, then give OfficeWriter on your serve the template, configure your datasources and merge criteria, and the let it rip!  OfficeWriter will create individual .doc files  that have been customized with Names, Addresses, Order Quantities, etc. From there, you could hand the .doc files directly to RightFax:

“A new conversion engine converts documents to faxes on the RightFax Server from native applications such as Microsoft Word, PowerPoint, Excel and HTML. The new conversion engine … uses Microsoft .NET APIs to automate Microsoft programs.”

RightFax, in turn, will fax the converted .doc files to the appropriate fax numbers.  After people make their corrections, updates, signatures to the faxed documents, they can then fax them back to the RightFax server.

A pretty slick way to begin automating a paper-based, manual process.  It's a step in the right direction!

Tuesday, July 20, 2010

Automating Faxes - Turn-Around Documents

Recently a prospect presented the following scenario:

High number of facilities
Fax is the current communication method between facilities and the lab
Faxes are handled by humans at both the facilities and at the lab
How can we improve our process?

The techniques described below can be put into practice in low volume situations as well.

While the ideal would be to eliminate faxes entirely with, for example, a web site or an email-technique, or, ideally, direct application integration, these techniques all require a change on the part of the faciltiy; something that is often too hard to accomplish.

So, what can you do with faxes to improve the process through reducing labor effort and reducing errors?

Phase 1 (Fax Server)
Implement a fax server at the lab.  A fax server can send and receive faxes without a human handling the paper.

At the lab, the fax server can be configured to receive fax as electronic files based upon the number that originated the fax.  As an example, Facility A faxes from fax number A.  When the fax is received at the lab by the fax server, the fax server detects that the fax originated at fax number A and therefor places the fax file into a directory accessed by the clerk that works on faxes from facility A.  alternatively, the fax server can be configured to email the fax file to the clerk.   Variations on this theme include uploading the fax file into a workflow system that automates the routing of the fax.

At the lab, the fax server can be configured to send faxes to facilities, such as Facility A.  An easy way to do this is through a "fax printer" accessible from the Windows Print environment at each desktop.  This makes it trivial to "print" the lab results directly from the lab application and have the results, with a header page, fax out to Facility A.

Phase 2 (Workflow)
Implement case processing at the lab.  Case Processing quickly automates manual steps in a process.  As an example, the inbound fax might contain an order for a single patient to perform multiple tests or it might contain multiple patients for the same test or a combination.  Case Processing automates presenting to a human the fax and enabling that person to quickly key the correct test orders.  It then can queue up the individual test into multiple testers queues in an appropriate priority order.  When the tests are completed, the results can be matched to each of the orders, the orders assembled into a single fax, and the fax sent out to the correct facility.

Phase 3 (OCR)
Implement Optical Character Recognition at the lab to reduce the manual data entry from Phase 1 above.  In particular, OCR can detect a facility identifier, the individual patient medical record numbers (MRN), and, if the fax form has been configured effectively, it could detect which tests to perform.  In this way, the bulk of the work performed by a human in Phase 1 can be reduced.  It can't be eliminated, because OCR always has errors that need to validated, but it can significantly reduce the human effort required.

Additional techniques to improve the above include:

1. use "comb" style hand-print constraints:

Open comb fields (i.e. no line on top)
o Cells must have a U shape (otherwise they might be recognized as an "L"
o Tick marks in between characters must be of the same height but use a high mark to separate words or sections (SSN or date are good examples)

2. provide "turn-around" documents whenever possible
Turn-around documents are those that originate at the lab, sent to the facility, are adjusted by the facility, and returned.  Examples might include a "orders approval" form that lists every lab to be performed for every patient.  The key benefit of turn-around documents is that the lab has complete control of the placement of content on the form, as well as the ability to uniquely identify each page - this enables the OCR product to know what the form is exactly and then do the recognition of the text based on known locations for the content.  Besides, the facility people will have to do less work.

Friday, July 2, 2010

ONC's Temporary Certification Program (provider-focus)

Today ONC conducted another teleconference to inform providers that have built their own solutions how they will be affected by the Certification Program.

Carol Bean, Director of Certification
Steve Pozniak, Director of Federal Policy has a listserv to inform us.

Both Carol and Steve said basically the same as yesterday.  See my previous post.

Each ATCB must provide testing for onsite (at the ATCB's facility) and remote for both development and deployment sites.   The deployment site is typically the Providers facility.

Adding functionality to your existing solution that has been certified does not require that you re-certify.

Questions & Answers

  1. What is an EHR Module?
    • It's anything that meets at least 1 certification requirement. For example, a Problem List could be an EHR Module (thought it's unlikely).  another example might be a List module (Problem, Medication, Treatment, etc) that too could be an EHR Module.  
  2. We use both a complete EHR and self-developed software.  Will we need to certify the self-developed software too?
    • If you have a hybrid then you'll have to test and certify the self-developed software.
  3. Does previous CCHIT certification flow-on?  Grandfather clause....
    • No.
  4. What is the process for getting certified?
    • That depends upon the ATCB.
  5. what if you've got 3 certified complete EHRs and you're using parts of each at different facilities.  Is it sufficient that the 3 EHRs have been certified?
    • A clear answer wasn't provided, in my view.
  6. Would self-attestation suffice?
    • You'll have to check with CMS - incentive payment question.
  7. What testing methods are required?
    • Testing methods approved by ONC.
  8. What if you're running previous version of certified EHRs or highly customized solutions, what certifications are required?
    • Get your system certified.
  9. What kind of cost are we looking at?
    • 14 applications were sent out - it would be great if all of them achieved accreditation. 
  10. Assuming the legacy environment and I get it certified, how long does the certification last?
    • Let's say you get tested at Stage 1 (10 measures) and then we set Stage 2 (13 measures), you'll then need to re-certify.

Thursday, July 1, 2010

ONC's Temporary Certification Program

Today, ONC hosted a telephone conference to update Health IT Developers and Vendors of EHR technology on the Temporary Certification Program.  


The speakers were:
Carol Beam, Director of Certification and Testing, ONC
Steve Posnack, Director of Policy, ONC

The rules serve two purposes:

  1. Established the process for the National Coordinator to select ONC's Authorized Testing and Certification Body (ATCB)
  2. Set some of the parameters around the testing itself.

This rule paves the way for vendors to get their products tested and certified.

Some of the parameters around testing include:
Section 170.420 - the Principals of Proper Conduct
ATCBs must support testing of both developed and deployed solutions
170.445 & 450
ATCBs must also support testing of both complete EHRs and EHR modules.

The following were questions posed by the audience.

  1. What is a new version? (ie does a bug release constitute a new version)
    • If an EHR developers defines it as a new release, then they will require a new certificate.
  2. How does a customer claim certification? (ie do they have to provide some sort of proof of sale / license)
    • The Certified Health IT Product list will be managed by ONC and that website will be the source of truth.  For Meaningful Use reporting, a unique identifier will be assigned to each bundle of products that in combination achieve Meaningful Use requirements.
  3. What if a solution is offered both bundled and un-bundled?
    • There will be unique identifiers for each (bundled and un-bundled).  ONC will not be testing whether they are actually being used - that's a function of the audit (CMS).
  4. What bodies will provide oversight of both the ATCB and the developers?
    • in the temporary program, ONC will provide oversight of ATCB (adhere to the Principals of Proper Conduct)
    • in the permanent program, vendors will be subject to a post-market surveillance program
  5. What will the certification cost?
    • CCHIT had presented potential pricing ranges - we generally used those as our estimates.  We're hoping that the competitive environment that we hope we've created will reduce those costs.
  6. Will there be a "seal" of certification?
    • We require that the ATCBs tell the developers to convey to prospective purchasers and customers:  product name, date of certification, certification number, etc.  We don't specify a particular image.
  7. What about Clinical Quality Measures?
    • When a product is ready to be certified, the measures will have to have been published....  Stay tuned.
  8. What about additional software that may be required?
    • The additional software will have to be identified and listed.

Tuesday, June 29, 2010

Linking your ECM solution with your EMR

Recently I worked with Steve Sawyer from the Mayo Health System to produce a webinar in which Steve discusses why Mayo decided to acquire an ECM system and then to link it to their enterprise EMR.  Steve's done some remarkable work and Mayo, though only about a quarter of the way through their enterprise deployment, has begun to achieve good returns.  Most importantly, the docs like the solution!

Register to watch the webinar.

Monday, June 28, 2010

Leadership is hard work

General McChrystal has been fired. I have to admit that I was stunned to read his remarks in Rolling Stone - they reflect very poorly on his leadership; which is a shame, given his remarkable performance in the past.

As a staff officer, I often commiserated with my peers and with my subordinates about our higher-ups - we often used the phrase Echelons Above Reality to refer to our higher-ups, which was a play on the phrase EAC  (Echelons above Corps) .  And we often had much harsher phrases for individuals that were in staff and sometimes command positions above us. I've seen that kind of behavior in commerce, government and the military so I think it's fairly common.

As a commander, however, the situation was much different . Everything you do, everything you say, everything you write, and all the body language you send out is scrutinized, evaluated, assessed, and probed. It's the nature of the job. As a consequence, I was extremely careful about what I said, when I said it, how I said it, to whom I said it, and the body language I presented. And I'm not a 4-star general.

So, was General McChrystal being immature? Was he somehow caught off-guard?

Or, did he do as I did: prepare ahead of time for every encounter and go into every encounter with a plan to achieve a specific outcome?

My thinking is the later - he knew what he was doing and very specifically chose to do what he did.

What I can't figure out is why? What was he planning on achieving?

Friday, June 18, 2010

How to use eSignature with your EMR and your DM system

eSignature is a term that refers to applying some sort of signature to an electronic document.

One illustration of eSignature is when a physcian reviews and approves an electronic document - perhaps a progress note that has been scanned and linked to a patient encounter. 

There are several common requirements:

1. an audit trail must be retained that provides access details regarding changes to the document, including the signature.  Usually this audit trail will provide user and date / time stamps for each action taken with the document.  For example, when a physician affixes his / her signature to the document, the physician's details and date / time are recorded.

2. the original document needs to be altered in both a visual and a physical manner.  Often the signature is a text string, "Approved and digitally signed by John Smith, MD on June 18, 2010 at 1:07 PM ET." and the text is over-layed at a selected location on the document image; thus, visually the document has been altered.  Next, a new document is created that "burns' the signature into the image, permanently changing the image with the signature.

3.  the workflow associated with applying the signature varies but in general follows:  HIM analyst identifies who needs to approve / sign the document and where on the document the signature needs to be placed.  Next, the document is routed to those that need to review & sign.  The people that need to do the reviewing / signing are presented with options (approve / sign, reject) and make their selection.  Those that have been approved for signature are then signed and a new document created with the signature.  Finally, references to the unsigned-document are translated so that only the new, signed document is returned to users.

In terms of integrating the eSignature capability among multiple systems, usually an EMR for the user interface and a DM system for managing the documents, I recommend that you rely on the EMR's workflow to manage user interaction.  The key reason for this approach is that the EMR provides a consistent UI for the most critical user - the doctor.  There are other reasons too (such as the EMR typically implements a role-based security model and it usually has a chart deficiency module to control the workflow), but not having to train the doctors is essential.

Friday, May 14, 2010

Document Management in Healthcare

What is Document Management?

For a variety of definitions from the Web, click here.

I like examples to illustrate definitions so here's mine from heatlhcare.

Most doctor's offices have a room in which they store patient folders, often referred to as charts.  In these folders are stored the paper that describes the care provided to the patient and typically includes

  • physician notes that detail how the patient presented, what was discussed, symptoms that the physician assessed, the diagnosis the physician arrived at, and the treatment / prescriptions ordered to address the symptoms
  • medical laboratory results from tests perfomed due to physician orders
  • prescriptions ordered
  • medical histories, often completed jointly by the patient and a nurse or the physician
  • and similar content.

Usually these folders have tabs that segregate the documents and nearly always the documents are organized so that the most recent document is at the top - this is an illustration of the Last In / First Out principle.

From a volume perspective, in the US, there are approximately 400 patients / doctor overall.  But for primary care physicans, the patients / doctor ratio is in the thousands and likely close to 4,000 patients per doctor.  So, a brand new, single-physican practice after a year will likely have 4,000 charts.  Established single-physican practices have ~10,000 charts and  established multi-physican practices can reach 100,000 charts fairly quickly.

Put another way, doctor's offices have thousands of paper folders stuffed with paper.

If your labor costs are low, then relying on people to manage folders is a good use of money.  On the other hand, as your labor costs rise, the value of automation increases. 

One simple automation is to convert the paper stored in the folders to images and make those images availble to physicians.  We do this by using a piece of hardware known as a scanner - a scanner takes paper and creates electronic pictures of the pages.  Staff then identifies each picture (this is known as indexing) and the picture is added to a software application known as a Document Management system.  In turn, the physician can type the patient's name and all of the scanned documents are listed for the physician to view.  The physician selects a document to view, and it is displayed.

Abstracting this illustration leads one to other paper-intensive markets such as insurance, financial services, government, engineering, and so on.  Abstracting this illustration also leads one to other content-intestive applications, such as law firms, web sites, marketing ,  and so on

While each of the above have unique requirements for which vendors have created specialist applications, they all fall into the broad category of Document Management applications.

Friday, May 7, 2010

Paper Patient Charts in Remote Practices

As hospitals continue their EMR implementations, they often recognize that they need to address the paper that's in their remote clinics and practices:  ie what to do about the paper patient charts in the practices? 

In brief, the following are commonly used:
  • do nothing - leave the paper charts at the practice
  • pack and ship the charts to a central scanning and indexing facility (often at the hospital or nearby and sometimes a third party that specializes in scanning and indexing)
  • use staff at the practice to do the scanning and indexing
  • send a mobile team to the practice to do the scanning

My preference is the mobile scan team and here's why. 

Scanning is Process Manufacturing
While scanning and indexing isn't really hard work, to do it well requires people that like to do it.  Think of scanning as process manufacturing that starts with raw materials (a paper chart) and after processing produces perfectly indexed images inside of an EMR system.  The process includes
  • document preparation - removing paper from the chart, taking out staples and paper clips, repairing paper tears, and taping small pages to 8x11.5 paper.
  • batch preparation - insert document separators to segregate individual documents.  The most common technique is to use barcodes to identify each document type (progress note, lab result, discharge summary etc)
  • scanning - feeding batches of documents through a scanner
  • indexing - adding attributes to each of the documents such as MRN, Date of Service, Provider ID, Facility Code, etc
  • QA - confirming that the image quality is acceptable
  • commital - sending the documents to the ECM system
People that like to do document preparation are essential to creating high quality images in the EMR while people who take pride in their accuracy will prevent misfiles and rework.  Do you have those kinds of people at your remote practices with the time to do chart scanning?

Scanning Requires Specialized Equipment
While the price of scanners has come down, there remains a significant price for performance. Here's how to think about it: if the scanners is running, then paper charts are being converted to images.  If the scanner breaks down, charts are not converted.  My recommendation is to always buy 2 scanners and as operators become proficient whith those scanners, keep the scanners running.  Let the rate at which the scanner scans become the throttle to your process:  add staff to document preparation and indexing / qa to accomodate the throughput of your scanners. 

Additionally, you'll likely want to have tools that make document and batch preparation more efficient such as "spear-type" staple removers, solid scotch tape dispensers, document and batch separators, and so on.