Borders are for Crossing...

Over the past 20 years, The US and Canada have shared an increasing number of patients and an equally growing investment in health information technology, culminating in the parallel creation of Canada Health Infoway and The Office of the National Coordinator for Health Information Technology.

Despite this past decade’s dramatic increase in the health information technology (HIT) industry, borders throughout the world have become less traversable and the sharing of technology more difficult. People are uneasy or even unable to transfer of data across borders because of complicated and often conflicting security measures. Trade regulations are poorly documented and ill-suited to modern technology. Many technologists are afraid to attempt crossing borders because of anti-terrorism measures and ever-changing documentation requirements.

In discussions with vendors and CIOs on both sides of the US-Canadian border, a constant theme is “The Border.” The government policies of the past 8 years have made the border, in the words of one CIO, “sticky and opaque.” Americans are unsure about export regulations being rushed out by the Department of Homeland Security. As many Canadians in technology are of Southeast-Asian descent, they are often afraid to try crossing the US border. Even carrying a laptop in from either country is now seen as a potential risk to the sensitive patient data it might contain.

Organizations involved in cross-border trade are confronted with differences in culture, practices and expectations. Vendors cannot successfully deliver to healthcare providers’ expectations, and organizations have increased management overhead with every cross-border supplier. All of these inefficiencies of culture and commerce drive costs up and productivity down for all parties on all sides of any border.

Very good work is being done by groups like HIMMS and OHITX to facilitate technological sharing issues. But the issues of cultural dissonance, tangled government protocols and the common human factors have been ignored. Now there is an organization to address these human issues of cross-border sharing--The International Health Information Technology Association, IHITA.

IHITA is a trade association of healthcare technology professionals for healthcare technology professionals; developers, providers, administrators and technologists. Members are in government, business, clinical care and academia across the US and Canada.

IHITA is dedicated to;

Business Support: helping the HIT industry successfully deliver products that improve patient care and healthcare delivery systems within and across all borders by offering members and member organizations education, partner/resource introduction and cultural-knowledge services

· Published studies

· Partnership guidance

· Research and development of cultural commerce knowledge resources

Government Relations: improving patient care options and resources by reducing the negative impact of borders on the HIT industry’s ability to deliver by Educating and advocating governments and government personnel for tools and regulations to enable cross-border trade and transfer of HIT products, personnel and data.

· Better documentation of NAFTA visa requirements for transiting personnel

· Treaty enhancement to enable electronic transfers of clinical data across borders

· Clarification of Ex/Im regulations for technology

Philanthropy and Research: building the global HIT knowledge base by developing learning and solutions to pervasive healthcare delivery problems by working concurrently with multiple governments and NGOs in identifying and researching solutions to common, “borderless” problems.

· Studies to deepen insights into strategic trade challenges in the global HIT marketplace

· Joint US-Canadian technology solution for First Nations chronic, at-home care issues

These challenges impact patient care and safety every day. IHITA is looking to clear these hurdles and make The Border simply “invisible.” We’ll keep you posted….

The Seven Myths of Healthcare Technology5. One Size Fits All

August is over, and so is, sadly, vacation. So, we came back to the office this week, to a pile of mail (I see that Canadian Tire had some nice sales in August) and a week of "start-up" appointments. One was a discussion with a partner company in Toronto. They are in marketing and were contacted by a potential client about an EMR/management system for small-office providers. As an SME, I was brought in to provide support. It sounded like a well-thought-out product serving a clear need. However, as we talked, I recognized a flaw in the initial assumptions;

Myth #5 "Solutions Are Shippable."

The potential client, a software vendor, was thinking of establishing a client base in Ontario and then expanding through Canada and the US--a reasonable and not uncommon business-development route for most products. Vendors and buyers of look on both sides of the border for new clients and better deals, respectively. This works with auto parts, fruit juice and so many other things--especially after NAFTA. And one would assume it would work with HIT as well--and be wrong.

Healthcare IT is only a device to enable a service process. It does not actually deliver healthcare. It just helps keep track of the healthcare being delivered. And that process is not the same everywhere. In Canada, the first goal of record keeping is accuracy of health data and surety of care. In the US, the first task is bookkeeping--determining payment liability and authority. In the US, there are HIPPA regulations carefully restricting access to patient information. These regulations are much more stringent and litigious than those in Canada, where a "circle of care" is more readily extended to include those brought into a patient's care process. These things change the nature of how electronic-record software should be not only managed and used, but actually structured.

In the US, software has be made to accommodate the tangled web of insurers and pre-authorizations required. Before care other than emergency stabilization can begin, financial responsibility and authorization have to be obtained from any one of a myriad of people and documented. Following that, HIPPA practices (coupled with litigation-risk management practices) require careful and full documentation of patient information and consent. Security functions (ID/password systems and access logging and monitoring) are required to assure HIPPA adherence by providers and facility staff. Then each service, each supply and each provider interaction has to be documented in a way that can later be billed successfully to whichever insurance company, HMO, employer fund or government plan may apply. This is often a complicated mix of incremental payments from a number. There often is still a significant balance to be charged the patient (or their family) which may require financing (and the related software functionality). Healthcare software must handle all of these requirements as core elements. This directs a large part of initial development to service coding, annotation of coding, coding-decision support and back-office interfaces and resources (billing office dataset displays and telecommunications with insurance company databases, for example). And these are core requirements for providers in the US.

In Canada, financial issues are far less complicated; a patient is either Canadian or not (or, in rare cases, not up to date on their Provincial premiums). This immediately clears authorization and billing for the majority of primary care services (more than 90% of all healthcare). For "non-urgent" care; optical and dental, elective services or "extras" like private rooms; billing is to one of the fewer-than-in-the-US insurance companies or to the patient. But the billing process is not a primary function in the electronic record. The "Circle of Care" allows easier involvement of providers and requires less documentation of patient information and consent. While patient privacy and security are highly valued in the Canadian practice, the limitations on provider liability in Canada reduce the urgency for liability-risk mitigation through documentation and security processes. Similarly, coding of diagnoses, treatments and prescriptions are important in the Canadian system, but for different reasons. While the US providers are working to ensure that they get paid, the Canadian providers are more concerned with helping organizations like CIHI in the development of trending data and national care standards (as examples).

Clerks in the US ask "Who's paying?" In Canada, they ask, "What's wrong?"

Software is a device to enable a process. While the goal may be the same everywhere, the process is not. And the software cannot.

Some Notes and Then Myth #4, EMRs...

In this slow summer, we are working through the Seven Myths of Healthcare Technology. Myth #2 is "Technology Can Do Healthcare." [check it out below] Here's a comment I found out there--The writer certainly seems to have a reason for his anger. But is he completely correct? What do you think?
Community College - No Way

And is this an attempt at something "Swiftian?"

Responsibility-Based Rationing of Healthcare

"Eat the Elderly" kind of stuff? Or do you think he is serious? With all of the alternate-reality based rhetoric being put out there, I am honestly unsure...

And it looks like telehealth is happening without complex, expensive proprietary software systems...

The doctor is in and logged on

And we continue with…

The Seven Myths of Healthcare Technology; #4 EMRs are for the Doctors

As hospitals and medical facilities move to meet the technological mandates and requirements coming their way (from managers, regulatory agencies and insurance companies), they are confronting the issue of stakeholders--who are they and who is most important. Historically, the final word in healthcare has been that of The Doctor. What the MD says goes. As software is implemented in more and more systems, vendors and internal IT staff are having to customize and personalize software for each facility and clinic.

Healthcare software is not “off the shelf,” as some vendors might present it. It is more “out of the crates, custom-tailored, re-measured and stuck with unusual plug-ins and attachments to serve the vicissitudes of legacy systems.” In the process of making these applications work in the particular digital and business environment, sensitivity to end-user experience is considered essential. And doctors are the obvious end-user stakeholders.

Doctors are characterized as (just a little) demanding. Nurses everywhere tell tales (or at least roll eyes). This is no different, and perhaps worse, with software. Doctors are a technically saavy group and not shy about speaking up. But they are the wrong users on which to model EMR use.

Doctors use EMRs to mostly see data. They look at one or two views of data; to review intake information, view images; check results, or, watch for drug allergy alerts--then they look at the patient. They use systems to place orders or prescriptions--sometimes. Often, these orders are completed by PAs or nurses. Doctors do not move through an EMR very much--they tend not to do patient intake or to record new data very much. They are not the primary users of the digital tools---their skills lie elsewhere. There are certainly providers who are more “hands-on” with electronic systems. These are usually providers in record-intensive practices such as psychiatry or in the unique practice structures of the military.

Clerks, Nurses and PAs are the big users. They are the people using the record systems most--from patient intake through scheduling to checking for labs and rads. Very often it is they who bring up the patient record for a doctor and file orders. And it is the desk staff who are using the EMRs to communicate with insurance companies and other referral facilities. It is their workflow that should be modeled--and theirs are very different workflows.

People will say “Nurses really run the hospital.” I won’t get into that debate, but I will say “If they don’t control the hospital, they certainly control the information in it,” and that is the EMR…..