Thursday, July 30, 2009

So Happy Together......

It was just announced that the Provinces of British Columbia and Alberta have come to an agreement to coordinate their medical supply purchases. Sort of a "Coastal Costco" for the provinces. To work around the provincialization of healthcare in Canada, they created a third-party entity to negotiate volume discounts for the two provinces.

When might the other provinces join in? And why not have the Federal government sponsor such a thing? The clear follow through is lower prices for everyone, but there would be another upside; consistency and continuity of the care experience.

If most supplies and physical resources are the same across the nation, then their management practices would be the same as well. A nurse who moves from Nova Scotia to Ontario would have a much shorter learning curve in getting acclimated a new facility. And a patient really would know what to expect--wherever they are. This would by itself reduce the costs of both "onboarding time" for staff and "patient orientation."

Would this be a good lead to follow for technology? Well, a little over two years ago, the BC Ministry of Health certainly thought so. The Ministry directed the regional health authorities to work together to figure out a unified EMR approach. Coastal (Central Vancouver) and VIHA (Vancouver Island) began working on a joint agreement to use PARIS, a software system already being used at Coastal. As part of this discussion, the issue of "bulk buying" was raised. In early analysis of existing contracts and the license extensions, huge potential savings were identified in the simple elimination of buying and customizing a new software installation. How much could be saved if The Nation were to buy the same software everywhere?

A single system has been done successfully. The United States Department of Defense uses one system, AHLTA for all of the millions of people they serve. Was it easy to do? Not at all (DISCLAIMER: I worked on the AHLTA deployment a number of years ago, when it was still called CHSII). Delays came from the bottleneck created by using a single, new vendor and from doing what had never been done before. The first two deployment efforts were cut short by the refusal of the end-users to implement software that was still, really, only in Beta. Often, new things can only be learned by trying and failing. Once the software was sufficiently developed to work, user adoption was generally successful.

Now, patient records are available wherever the patient goes, not wherever the patient carries them. Prescriptions, drug allergies, provider notes--all are available and accurate. Patient misidentification is fast becoming a bad memory as electronic orders track to accurate patient identification. Are there savings? Certainly of lives, time, and yes, money. (I leave the question of whether healthcare should be about money to Bill Maher's blog.) A full audit of the savings cannot be done yet, but it is looking awfully good.

What is already known is the new mobility of both staff and patients. The orientation period is vastly reduced, and the very necessary and long-overdue ability of staff to "parachute in" to a new facility is greatly increased.

Single-system, bulk buying--call it what you will, but perhaps these examples from both sides of the border might lead CIHI and HITSP to work together towards one cross-border standard. It might enable competition in that larger market, leading to lower prices and ease of never knows, do one?

Wednesday, July 29, 2009

"Meaningful Use:" Meaningful to Whom?

In the States, ARRA has authorized funds to assist organizations implementing EHRs. ARRA requires "Meaningful use." The healthcare Information technology Standards Panel (HITSP) has just defined seven core types of data exchange; prescriptions, lab results, clinical data summaries, biosurveillance data, immunization registries, public health and quality measurement. [Full article here] Clearly a committee was involved--certainly prescription data, clinical summaries and labs would enable healthcare while reducing potential misidentification issues.

But what do immunization registries do for patients or providers? public health data? And biosurveillance is about accessing multiple data sources to identify trends or potential outbreaks; so that means making the electronic record readable for "phishing," not improving the care of the patient. Is that wrong?

The American Health Information Management Association (AHIMA) commented to The National Committee on Vital and Health Statistics on this (April 2009, AHIMA), and had some very interesting points. Sandra Fuller delivered a very thorough discussion of both the product and the process to arrive at "meaningful use." AHIMA felt that public funding should be used to drive improved care as well as the public interest.

To improve care, they spoke of prescriptions, labs and results and discharge data. These are all considered core elements of care-information communication and patient transfer (provider to technician, provider to pharmacist, provider to provider) and areas of greatest risk of error.

The report looked beyond the patient--to both public-health policy and to patient-care policy. To serve public health interests (and after all, this is being publicly funded), AHIMA recommends investment in development of improved reporting methods and systems with coordination through the HIEs being developed (and funded) with other ARRA resources. But, at the end, AHIMA circled back to the patient;

Be relevant to consumers: Taxpayers are funding these investments as a prerequisite to effective health reform. More broadly, this is an extraordinary opportunity to be transparent and to increase public recognition of the challenge and opportunity of an interconnected health system and the progress that is being made.

All in all, a very interesting and valuable report--check it out

Well, the committee got to it and politics seems to have moved things to the, if you will, "right." Immunization records should certainly be part of the patient record, but is it really a priority element for standardization? Discharge summaries fell out, but biosurveillance got in. Should readability by outside agencies be a "core element" of meaningful use? If an EHR is about communicating patient data (and it is usually thought of as an active process, not a passive one), then is anxiety overwhelming the mission? Or is this use of "surveillance" simply a way to get Homeland Security behind the drive for a national standards for data formatting and encoding? After all, the multiple-vendor system has led to a wide variety of proprietary methods that inhibit data communication and portability. And are we still in the times of driving by fear? Thoughts?