The Seven Myths of Healthcare Technology2. Technology Can Do Healthcare

"All involved in the healthcare industry will have to understand the entire healthcare system much more deeply than at present."
Dr. Steven F. Collier, CEO White River Rural Health, Arkansas, US

At the HIMSS GHIT conference this week, Doctor Steven F. Collier presented an overview of his work at White River Rural Health in Arkansas. As CEO, he has overseen the development and implementation of an EMR solution over the past 7 years. With a population spread across 10 counties living in towns (usually) of which the largest is less than 50,000, White River clinics are often the sole providers of healthcare to one of the poorest and most poorly served communities in the US. White River has been lauded as a model of best practices in implementation of EMRs to serve diverse, rural, under-resourced populations. The staff of White River has more than 6 years' experience in driving their technologists to develop and deliver solutions that would serve White River's understanding of their own business; so, when the doctor speaks of "understanding the entire healthcare system," he speaks from great experience and not a little pain.

As discussed in "Myth #1: Healthcare Does Technology," the very dialectics of healthcare are the opposite of those of technology. Healthcare is urgent, responsive and independent where technology development is planned, scalar, and collegial. Healthcare personnel neither understand nor welcome technologists in their environments--and the requirements of technologists do not track to the common expectations of healthcare organizations. Doctor Collier made clear that he is a healthcare provider. He spoke of results in clinical terms, of motivating problems as patient needs, and of success metrics in terms of patient wellness.

Technologists do not share this worldview. They speak of results in processing terms (operations/sec), of motivating problems as "needs for new calculus," and of success metrics in terms of technical performance. And while internal IT personnel may want to deliver solutions that serve the organizations' needs and timelines, external technologists are even less likely to succeed at healthcare. In addition to the cultural gap between technology and healthcare, they have the additional gap of being outsiders to the organization. And they are not just technologists--they are vendors.

Vendors have their own priorities, many of which are counter to both the organizational and the cultural interests of their healthcare clients. "Close-out" delivery of a completed solution is a goal of healthcare. Vendors in HIT have a number of self-serving goals that require more time and less closure. Often, technology solutions involve hastily or imperfectly written pieces of software which require more customization or "shake-down" time than a vendor might care to admit. As the HIT industry is growing so rapidly and as many of the vendor companies are so new, solutions are sold before they are fully developed. This leads vendors to use clients as "beta sites" to extend their development time while garnering revenue. Healthcare organizations are so eager for solutions and are often so averse to technology that they will buy "total solutions" with "full support and maintenance." This puts the IT infrastructure of an organization in the control of the vendor being paid to deliver it--where is the motivation for close-out in that? And vendors are businesses. They sell things; software, services, support, training. While interfacing with clients to deliver one product, they are motivated, even driven to upsell more products. which just pushes out the horizon to "solving the problem," when all healthcare wants is to solve the problem.

In a recent KLAS survey, of all organizations who reported a vendor promising tremendous ROI on an investment, not one was able to report actually realizing it within the original purchase. Not one.

So, if technologist can't do healthcare and if healthcare organizations can't do technology for themselves, what is the solution? Is there a third option?

Myths Will Wait--What's a PHR?

Today's column was supposed to be "The Seven Myths of Healthcare Technology; 2. Technology Can Do Healthcare." However, this evening was the opening reception for the Government Health Information Technology (GHIT) Conference in Washington, DC (June 4, 5 at the Ronald Reagan Center). It was hosted at the Canadian Embassy and there were senior representatives of some of the leading organizations in GHIT. It was a good time; There was talk--and rumour. And news.
The word was that there is an urgent push on the Hill to modify the HIT legislation to include Personal Health Record (PHR) with the Electronic Health Record. This led to an impromptu roundtable of core people from HIMSS and the GHIT conference to consider the question;

"Why a PHR? What Would It Be? How Would It Work?

There were different ideas of "Why." A regulatory thinker felt a PHR to be nothing more than a comfort to paranoid citizens who want to "control" their personal information, but that it could never be used as a trustworthy resource by a provider. A sociological view saw the PHR as an opportunity to gather massive amounts of statistical data to drive cultural, epidemiological and other study data--all identity-scrubbed, of course. Others saw it as a traveler's safety, providing accurate information for use in a critical-care situation.
The group came to see it as having value in each of these ways, but requiring two types of data; Mandatory information written and managed by authorized providers (drug interaction/allergies, for example) and optional data which the patient could modify or erase as they wish (treatment for a wart).
This dichotomy would have specific requirements. Among the many discussed, were;
Data requirements to qualify as a PHA (what information MUST be in the record to qualify as a PHA)
Standards of encoding
Clearly defined, documented and controlled workflows for access, addition, modification and deletion of data.
Security and privacy considerations
Most importantly, a standard storage, transportation and access method
This storage method must have access control; For instance, a method to "sign" for "consent to view" by the patient.
A physically secure method to "sign" for "access to write" by providers.

One method posited for serving these requirements was a smartcard. Specifically, a smart-Social Security-card. As a number is issued at birth (or immigration), data collection can begin shorty after the card is issued, ensuring that even children have a PHA to carry into adulthood.This would, however, have to be a very smart card. It would require two physical sections; one secured against patient access and the other enabled for patient access. These securities would have to be "countersigned" biometrically, perhaps in combination with passcode. There were some high-level workflows discussed as well.
A patient enters a new facility and meets a new provider. They present their smartSScard and swipe a fingerprint reader to authorize read-only access to their data.
Following on treatment, the provider wants to add data to the record. Some may be defined as "mandatory." For example, a new drug allergy is discovered. The provider must also identify biometrically, with crosscheck at a centralized, government record. This data would then be written to the "secured" side of the smartchip.
Some of the data may not be mandatory; Perhaps, notes of elective plastic surgery. These would be written to the "optional" side of the smartchip. All of the data would still be entered into and maintained in the regular medical record.
This is only one workflow. There are still questions; How would a PHR be used when traveling? Would an international standard be developed? How could providers from outside the system add data? If the data is pertinent to critical care, how to access the data when the patient is unresponsive? How could data be added without the specialized equipment needed to access the card, contact external databases and read biometric data? What, if any liabilities could arise from use of PHR data? How would PHR data be validated with the EHR?

Lots of questions. Lots of ideas. The PHR/EHR discussions are picking up, and at GHIT there should be quite a few as they come into play with the panel discussion of remote and rural communities......

Let us know what you think....

The Seven Myths of Healthcare Technology: 1. Healthcare Can Do Technology

80% of healthcare organizations want vendor-neutral advice on technology purchasing decisions, according to the newest survey by the eHealth Initiative www.ehealthinitiative.org, and 92% want guidance for workflow modification related to technology implementation. More than 320 organizations of the 425 surveyed say that they cannot do it for themselves and overwhelmingly want funds from the health IT provisions of the American Recovery and Reinvestment Act directed to these issues. (the entire survey is available from their website hereHow is this? Hospitals and healthcare organizations are big, complicated systems managing services as varied as nutrition and transportation. At first glance, it would seem logical that information technology would be just one more service area in the portfolio. But then, healthcare teaches us that first glances are usually wrong.

Healthcare is urgent. It is about reacting to a problem and driving as quickly as possible to the diagnosis. Escalation is to specialists of ever-more granular views. Healthcare priorities are patient care, diagnosis and treatment--speed in all things.

Technology development and implementation is none of these things. IT requires long-term, broad-vision strategy and planning. To be successful, it must be both proactive and patient--and while technologists are known to carry every detail in their heads, specialization is antithetical to valuable solutions. Where healthcare providers are trained to "make the call," technologists are collegial. Technologists seek the input of others and work in "teams."

Healthcare organizations are driven to seek technology solutions. The needs to reduce costs, to improve patient safety and to increase patient service rates have been joined by Federal mandates in both the US and Canada. Two approaches have been used to get manage technology in healthcare environments. Neither of these is truly successful, as both are bound for failure from the start.

Many organizations try integration of a technology group. This is never easy and rarely a complete success--by any metric. In the revenue-centric organizations of the US, internal IT resources are viewed as cost centers without billable services and ever-expanding maintenance expenses. Technical personnel are only welcome on the floor if they are there for an immediate problem--to fix or replace something. Even in the non-revenue driven facilities (in Canada, for example), the balance of investment is tilts in favor of direct patient-care costs over long-term technology investment. In all organizations, the longer, planned cycles of research and development are not seen as contributing to patient care, and the time required for interaction with providers is largely seen as a distraction from patient care. The cultural difference between providers--reactive and urgent--and technologists--proactive and considered--is a source of conflict and an extra impediment to successful development and deployment of new technologies.

Other organizations trust management of new technology endeavors to the outside vendors from whom they purchase their technology. However, this approach almost invariably costs a great deal more than expected and there is little control of ongoing maintenance costs. As documented in today's KLAS study,

Building the case for and helping a client achieve an ROI is something that every vendor reports they do well, yet not a single provider said that their vendor had truly met their expectations. Providers continually expressed their willingness to have a vendor come in and optimize their systems and processes to help get more out of their investment, but few vendors are willing to deliver on that invitation without significant cash from the provider...No major IT vendor in healthcare is leading out with creative, helpful solutions to reduce ongoing financial concerns. Chief among these concerns are the routine maintenance fees inherent to major IT service contracts.

Executive Reaction to the Stimulus Package, May 2009
KLAS Confidential Information.
© 2009 KLAS Enterprises, LLC. All rights reserved.

Most hospitals try to use some combination of these two approaches. This results in multiple layers of management; internal vendor managing IT staff, internal support management, external vendor management, external client-relations management and clinical management. And this model doesn't serve the priorities of the facility successfully.

So, how to succeed? How to develop valuable technology solutions that a healthcare organization can use, manage, maintain and integrate into the healthcare culture? Perhaps the more than 300 organizations that responded to the eHealth Initiative survey have it right and do not even realize it--an external resource to support dissemination of best practices, to provide technical assistance, to aid with workflow modification and most importantly, vendor-neutral advice.

For more on this, see tomorrow's The Seven Myths of Healthcare Technology: 2. Technology Can Do Healthcare

As always, let us know your thoughts and experiences. We will bring them into the discussion.

Real Time Healthcare?

Warehousing. Storage. Overstocking. These are some of the biggest costs in product-delivery businesses today. BMW and Amazon are just two companies that have each spent millions on technologies to achieve the goal of "Real Time Delivery" (RTD). And in many healthcare models--particularly the revenue-driven US system--patient wait times, materials storage and pharmaceutical overstocking are viewed as "cost-centers" and "productivity negatives." They are leading drivers of some of the largest cascade costs; construction, patient transport, bed allocation and purchasing among them.

There are already solutions being applied to services of healthcare; supply and transport. After all, Real Time Delivery is most obviously about "delivery." Velocity Express, a pharmaceuticals delivery company in Connecticut has customized their services to reduce the management impact on hospital staff and to refine the ability of pharmacies to schedule their deliveries later at night within a 15 minute window. An even more explicit delivery solution is Inform's (of Aachen, DE) SyncroTESS system, software for resource management of ambulances and patient transport resources. But these are solutions developed by vendors for themselves--vendors using their knowledge of their own industries and technologies to streamline their own processes. They then market themselves as working to "take the strain off...care nursing sectors" thus "allowing them to focus on patient care."
In these cases, just as in the cases of outsourced pharmacy management, healthcare is not yet using RTD, but is only paying vendors for the benefits of their own RTD solutions.

So what would RTD of healthcare really be? And can hospitals do it for themselves?

BMW is a leader in RTD, and bumpers at BMW do not mind waiting on the factory shelf. healthcare is different--patients do mind waiting. Wait time reduction is a priority for patients. A 2006 survey found that more Canadians ranked a "patient wait times guarantee" as the Number One priority for the government (42%)--more than twice as many wanting lower taxes (19%) and three times those worried about crime (14%). In response, the government of Canada is now spending millions to reduce wait times in all areas of care ($5 Million at Radiation Oncology in New Brunswick and $38 million to reduce wait times in Ontario regional service clinics are just two examples).
Technology is being applied to this; improved scheduling tools, time-motion studies of "bed-turns," and aggressive support for EMRs. King's Daughters Medical Center in Kentucky US instituted and EMR system in the ED and reduced patient wait times almost by half, from 220 minutes to 118. The EMR, in combination with increased staff to manage workflow, reduced the time spent by staff on paperwork and charting, allowing more time for patient interaction. The goal of RTD is a wait time of zero, and the reduction at King's Daughters is impressive, and ED staff are known as the fastest, most efficient providers in a hospital, so why is there still an average wait time of nearly 2 hours?
A reason that is heard in hospitals everywhere is not about the the ED--it is about the rest of the hospital. The disconnect between inpatient resource management and ED outpatient completion. RTD in the ED needs to address not the real-time delivery of patients TO the ED but the real-time delivery of patients FROM the ED to inpatient systems.
EDs have unique issues and are not as controllable as scheduled outpatient clinics. Yet, average wait times in dialysis clinics and family-care clinics are notoriously long. the average patient wait time in some regional dialysis clinics in Ontario can run to 4 hours. There are no sudden strains on resources as in the ED. But, even with careful time-motion studies and more accurate time-per-treatment metrics, patients are still scheduled for a block of time "Wednesday morning" and required to wait their turn within that period. This drives unnecessary costs in clerical staff time spent managing the on-site patients and accompanying support givers, the costs of these support givers, the need for building and maintaining larger waiting facilities to host both patients waiting for treatment as well as patients waiting for transport after treatment. These wait times could certainly be reduced by automating patient intake with an EMR, as was done in the ED in Kentucky.

But these things requires more than just an EMR. RTD is about an entire system from beginning to end, and a REAL real-time solution requires a systemic approach--an organic, interactive connection of bed management to staff notification to diagnostic scheduling to pharmacy right through to nutrition.
A hospital could choose a solution of a single unified system (like the great promise of EPIC's million miles of modules). Or a facility could opt for a customized automated messaging system (like Commtech of Perth, Australia) in combination with specially trained clerical staff. Either way, the facility is still paying a vendor for a solution. Why? Hospitals do all sorts of things, don't they--from birth to death and everything in between, right? So why can't they do this for themselves?
Well, that's for tomorrow; "The 7 Myths of Healthcare Technology: Healthcare People Can Do Technology......"

BMW and Amazon have each spent millions on technologies to reduce the costs or warehousing, stock and delivery to achieve the goal of "Real Time Delivery" (RTD). At BMW's Spartanburg plant, the goal is to have each batch of new bumpers delivered to the line just as the last one is pulled off the shelf. Amazon is working to order more copies of "Blogging for Dummies" at exactly the right moment to ensure that the new stock arrives at the back of the warehouse just before the last one gets loaded into the Fedex truck out front. Millions have been spent to save billions in storage, excess capacity, shipping and control.
As healthcare has become a business like any other, how to manage the same bottom-line demands? And how to map commercial production solutions to healthcare practices?
There are already solutions being applied to services of healthcare; supply and transport. After all, Real Time Delivery is most obviously about "delivery." Velocity Express, a pharmaceuticals delivery company in Connecticut has customized their services to reduce the management impact on hospital staff and to refine the ability of pharmacies to schedule their deliveries later at night within a 15 minute window. An even more explicit delivery solution is Inform's (of Aachen, DE) SyncroTESS system, software for resource management of ambulances and patient transport resources. But these are solutions developed by vendors for themselves--vendors using their knowledge of their own industries and technologies to streamline their own processes. They then market themselves as working to "take the strain off...care nursing sectors" thus "allowing them to focus on patient care." In these cases, just as in the cases of outsourced pharmacy management, healthcare is not yet using RTD, but is only paying vendors for the benefits of their own RTD solutions.

So what would RTD of healthcare really be? And can hospitals do it for themselves?

BMW is a leader in RTD, and bumpers at BMW do not mind waiting on the factory shelf. Healthcare is different--patients do mind waiting. Wait time reduction is a priority for patients. A 2006 survey found that more Canadians ranked a "patient wait times guarantee" as the Number One priority for the government (42%)--more than twice as many wanting lower taxes (19%) and three times those worried about crime (14%). In response, the government of Canada is now spending millions to reduce wait times in all areas of care ($5 Million at Radiation Oncology in New Brunswick and $38 million to reduce wait times in Ontario regional service clinics are just two examples).
Technology is being applied to this; improved scheduling tools, time-motion studies of "bed-turns," and aggressive support for EMRs. King's Daughters Medical Center in Kentucky instituted an EMR system in the ED and reduced patient wait times almost by half, from 220 minutes to 118. The EMR, in combination with increased staff to manage traffic, reduced the time spent by staff on paperwork and charting, allowing more time for patient interaction. The goal of RTD is a wait time of zero. The reduction at King's Daughters is impressive, and ED staff are known as the fastest, most efficient providers in a hospital, so why is there still an average wait time of nearly 2 hours?
A reason that is heard in hospitals everywhere is not about the the ED--it is about the rest of the hospital. The disconnect between inpatient resource management and ED outpatient completion. RTD in the ED needs to address not the real-time delivery of patients TO the ED but the real-time delivery of patients FROM the ED to inpatient systems.
EDs have unique issues and are not as controllable as scheduled outpatient clinics. Yet, average wait times in dialysis clinics and family-care clinics are notoriously long. the average patient wait time in some regional dialysis clinics in Ontario can run to 4 hours. There are no sudden strains on resources as in the ED. But, even with careful time-motion studies and more accurate time-per-treatment metrics, patients are still scheduled for a block of time "Wednesday morning" and required to wait their turn within that period. This drives unnecessary costs in clerical staff time spent managing the on-site patients and accompanying support givers, the costs of these support givers, the need for building and maintaining larger waiting facilities to host both patients waiting for treatment as well as patients waiting for transport after treatment. These wait times could certainly be reduced by automating patient intake with an EMR, as was done in the ED in Kentucky.
But these things requires more than just an EMR. RTD is about an entire system from beginning to end, and a REAL real-time solution requires a systemic approach--an organic, interactive connection of bed management to staff notification to diagnostic scheduling to pharmacy right through to nutrition.
A hospital could choose a solution of a single unified system (like the great promise of EPIC's million miles of modules). Or a facility could opt for a customized automated messaging system (like Commtech of Perth, Australia) in combination with specially trained clerical staff. Either way, the facility is still paying a vendor for a solution. Why? Hospitals do all sorts of things, don't they--from birth to death and everything in between, right? So why can't they do this for themselves?
Well, that's for tomorrow; "The 7 Myths of Healthcare Technology: Healthcare People Can Do Technology......"