• EHRs alone are not enough

    EHRs are one resource needed to improve healthcare integration. On their own, they are seldom enough. An article on complex care in the New England Journal of Medicine sets out a comprehensive investment plan. Its successful, integrated complex care management (CCM) teams at Massachusetts General Hospital has encountered a set of financial and non-financial barriers to expansion. They include:

    Fee-for-service payments Lack of capital for CCM start-up costs, including eHealth Unrealistic expectations for a return on investment in less than 3 years Effective CCM depends on a strong primary care foundation Most primary care is provided by small and medium-sized practices operating in relative isolation Primary care entities don’t have incentives to share key resources such as patient registries, eHealth and analysts. Resistance to change Lack of experience and knowledge of designing and operating CCM eHealth and analytics needed for CCM are underdeveloped Better algorithms could be developed to identify patients who could benefit from CCM Health Information Exchanges (HIE) help to provide real-time data to CCM teams.

    This commentary is an excellent example of how eHealth should fit into healthcare initiatives instead of being an isolated ICT project. It provides eHealth leaders, decision takers, champions and project managers with a clear example of the:

    Enablers and inhibitors that need addressing for success The challenges of organisational change and healthcare transformation that must be overcome.

    African countries have a different set of health and healthcare requirements, so the principles of the article are more relevant than the specific detail. It still applies.

  • Is an EHR market shake-up coming?

    Cerner’s acquisition of Siemens Health IT business for US$1.3 billion raises two questions:

    Will it work? Is it part of a bigger picture for the EHR market?

    Chilmark Research thinks it has some answers. In a blog, it says that Cerner will have more hospital clients than Epic. This alone is a big market shift when Cerner switches Siemens clients to its clinical systems. The acquisition should also fill a financial system hole in Cerner’s products.

    For Africa, perhaps the main implication is that a bigger and broader Cerner will have a bigger and stronger international presence. This could create more procurement options for big-scale strategies and plans, especially for Population Health Management (PHM) initiatives. Cerner sees considerable potential in its HealtheIntent platform.

    Chilmark sees Cerner’s acquisition as the start of a developing market over the next two years. It says it’s “overdue for consolidation.” How will this affect African countries’ EHR plans? Should they wait until the market’s reshaped itself, or carry on as planned? It shows how challenging procurement strategies can be.

  • John Hopkins and Kasier Permanente join forces to improve EHRs

    Kaiser Permanente and Johns Hopkins University are joining forces to share data and look for better ways to put EHRs to work toward better care. The two organisations recently announced that they’ll collaborate to develop best practices to improve population health, and explore other ways to drive improvements in healthcare coordination and cost efficiency.

    The collaboration aims to:

    Bolster the partnership between Kaiser and Suburban Hospital, a member of Johns Hopkins Medicine Work on home health initiatives, leveraging ICT for personalized medicine Advance the partnership between Kaiser Permanente and the Armstrong Institute for Patient Safety and Quality to improve treatment outcomes and reduce costs Pursue new educational programs and research-based best practices.

    “Working more closely with Johns Hopkins Medicine will help us deliver an innovative care experience for our members that will translate into quality care that’s also affordable,” added Kim Horn, president of Kaiser Permanente of the Mid-Atlantic States. “This strategic collaboration will facilitate additional population health research and innovative practices benefiting both individual patients and the larger community.”

    The lessons they learn and the knowledge they gain will be valuable outside of the USA and will help African countries strengthen their eHealth systems. The gains in population health may be especially valuable for Africa.

  • EHRs and HIEs have a few IOp holes

    “Everything in strategy is very simple, but that does not mean that everything is very easy.” That’s how the Prussian military strategist Carl von Clausewitz sees it. Semantic Interoperability (SIOp) might be similar. A strategy for SIOp is unavoidable, but it doesn’t always convert into practice. A very important review by a team of eleven researchers of EHRs’ and HIEs’ SIOp, in the Journal of the American Medical Informatics Association (JAMIA), found eleven holes.

    They’re summarised in a table as:

    Omissions or misuse of Logical Observation Identifiers Names and Codes (LOINC) in results or vital signs Omission or misuse of Systematized Nomenclature of Medicine (SNOMED) in problems Excess precision in timestamps Omission or misuse of Unified Code for Units of Measure (UCUM) in medications, results or vitals in a Consolidated Clinical Document Architecture (C-CDA) for document exchange Omission or misuse of RxNorm, the USA’s catalogue of standard names for clinical drugs and drug delivery devices, in allergies and medications Omission or misuse of dose quantity Omission or misuse of allergic reaction Omission or misuse of allergic severity Omission of dose frequency Omission of results interpretation Omission of results reference range.

    The researchers classify each item as an error, heterogeneity in C-CDA documents or both. These errors limit semantic interoperability. They also provide a schedule of work needed to improve C-CDA document quality and exchange.

    The study shows the challenges of effective accreditation and certification, and the precision needed to achieve SIOp. It’s extremely valuable to all healthcare organisations already dealing with SIOp in their EHRs and HIEs, and for ones about to embark on their SIOp endeavour.

    As African countries develop their eHealth regulations, the study’s findings show a way ahead for some of the content and detail needed for the accreditation of eHealth suppliers. The precision that the study used transfers from accreditation to the detailed assessment of suppliers’ EHRs and HIEs needed for procurements, then onto successful SIOp.

    Clausewitz also thought that “Part of strategic success lies in timely preparation for a tactical success.”The study shows that even certification isn’t enough for a successful SIOp strategy. The study’s findings are part of the solution.

  • Advanced EHRs cut USA hospital costs

    Almost like a Holy Grail, EHRs need to show that they help to cut costs. A new study in the American Journal of Managed Care (AJMC) says that hospitals that use advanced EHRs have lower inpatient costs than hospitals with similar case mixes.

    The study was huge. It included data on 5,047,089 people treated at 550 USA hospitals. Nearly 19%, 104, hospitals had advanced EHRs, 446, about 81%, didn’t. About 30% of patients, 1,509,610, were cared for in hospitals using advanced EHRs.

    The average inpatient cost in hospitals with advanced EHRs was US$10,203, which was US$807, nearly 10%, lower than the US$11,010 for hospitals without advanced EHRs. It also says that the lower costs recover the costly investment in advanced EHRs. After statistical adjustments that standardise for patient and hospital characteristics, the cost difference is about US$731 per inpatient.

    The report says that there is a possibility that hospitals with EHRs can capture information for more charges. Some of tinTree’s economic evaluations of eHealth have found a similar effect with some EHRs.

    Another finding is that advanced EHRs need costly investment that hospitals can recover through savings in patient care. Advanced EHRs have ePrescribing, Health Information Exchange (HIE) with other providers, automated reporting of quality data, electronic recording of patients’ history for demographics, vital signs, medication and diagnosis lists and smoking status, care summary documents, and at least one Clinical Decision Support (CDS) tool. It’s a high cost clutch of eHealth.

    Realising benefits from EHRs also has a large cost in organisational change. A European Commission study put this at an average of 58% of the total cost of EHR initiatives. It found an average of nine years to realise a net socio-economic return.

    The study in AJMC doesn’t say how long it takes to realise the return on advanced EHRs. If all the 10% patient cost gain is due to EHRs, then it sets a solid foundation. It’s also an excellent contribution to the knowledge and library of EHRs impacts.

  • ONC help for procuring EHRs

    eHealth procurement is a tough proposition for the healthcare side. As African countries move further ahead, procurement becomes more sophisticated and complex.

    The USA’s Office of the National Co-ordinator for Health IT (ONC) has published EHR Contracts: Key Contract Terms for Users to Understand, and prepared by Westat, a USA Employee-Owned Research Corporation® in Maryland. It addresses a few procurement issues in a simple way, describes a few key EHR contract terms and suggests how to deal with them. From this position, it may guide people to help to select an appropriate EHR system and protect organizations from business and patient safety risks that may arise when health workers rely on EHRs for critical aspects of their work. It also aims to help to make sure that a selected EHR system does what’s expected of it.

    It’s content includes:

    Negotiating EHR contract terms Ways that EHRs are provided Indemnifications Confidentiality and non-disclosure Warranties and disclaimers Limitation of liability Dispute resolution Termination and wind down Intellectual property issues.

    Unsurprisingly, all the legal themes fit the context of USA law. The principles and concepts are still valuable lessons for other legal codes and domains, and can help to improve healthcare’s ICT procurement. For African eHealth expansion, there’s a gap for an eHealth procurement guide. eHNA looks forward to reporting how it’s being answered, before too long.

    One way or another, it deals with topics that everyone involved in EHR procurement has to succeed with. For those of you who are new to EHR procurement, the guide’ a valuable introduction. If you’re an experienced EHR procurer, it’s a helpful checklist to test and tighten your approach.

  • Google Glass has an EHR app

    Most of us would like our healthcare team to keep an eye on us. It’s becoming easier for them. Google Glass can now provide access to our EHRs. Reuters has a report that says physicians’ growing demand for Google Glass has encouraged Drchrono, a USA EMR supplier, to develop a new app. It claims it’s the world’s first wearable health record.

    Doctors who register for the Drchrono app can use it to record a consultation or surgery. Patients’ have to consent first. It stores patients’ videos, photos and notes in their EHRs held in a Box in the Cloud. Patients can access their data. Security settings need rigorous enforcement.

    Drchrono claims to have 60,000 physicians registered to use its EHR for doctors and patients. More than 300 of them have already opted to use it: not many, but is it the start of a big trend?

    A BBC’s technology correspondent Rory Cellan-Jones didn’t think so, but others love it. Even though glass is experimental, what does its trajectory look like?

    The app is currently free, but Drchrono may charge a fee in the future.

  • Doctors choose how to use their EHRs

    Not only is there more than one way to tie a tie, but a USA study in the Journal of American Medical Informatics Association (JAMIA) says there’s more than one way to use EHRs. It identifies differences in the way that 112 physicians use EHRs and its features for 430,803 visits by 99,649 patients. It found that:

    Users using the same EHR developed their own patterns of using EHR features. Users in the same practice vary substantially in how they use EHRs.

    Differences include;

    Personal EHR metrics to capture how providers accessed and added to patient data, such as problem list updates Using clinical decision support, such as responses to alerts Communication, such as printing summaries after patients’ visits Using panel management options, such as viewing reports.

    Variability was high. The annual average proportion of encounters with updated problem lists ranged from 5% to 60% between uses. Another was where problem list updates were more likely for new patients than established ones. Alert acceptance and alert frequency has a negative correlation.

    Reasons for the differences include:

    Users’ overall familiarity with an EHR system Users’ familiarity with patients’ medical problems Staffing differences at the health centres which affected workflows.

    These differences throw a light on a vital issue for benefits realisation: variations in physicians EHR features and utilisation may be a valuable additional predictor of EHRs’ impact on healthcare quality, efficiency and costs. It also confirms the validity of a core component of tinTree’s eHealth Organisational Change Matrix: organic change. This is where users decide for themselves how to use eHealth for their own and their patients’ benefits. It’s critical in the success or failure of changing some clinical and working practices that are essential for benefits realisations. The study is a reminder of two critical questions about utilisation in eHealth evaluations:

    How much do you use your EHRs How do you use them?

    It’s where economic evaluation bumps up against psychology, and it’s a vital part of continuous engagement. African countries need to know about the phenomenon when introducing large-scale eHealth initiatives. It’s an important finding.

  • Do you like your EHR?

    If you like your EHR, you’re in with a low majority of USA’s top healthcare executives. A survey of 127 healthcare executives by Premier Healthcare Alliance, a USA company aiming to improve healthcare, found that 59% are satisfied with their EHRs. Of the other 41%, about a quarter are indifferent and about three quarters are dissatisfied. For every two happy executives, another one is not happy.

    Alongside this relative lack of enthusiasm, their view of EHR’s impact on healthcare has reduced. In 2012, 41% saw eHealth as having a big impact. Now, 23% do, which is up from 14% in 2013, but still a long way behind earlier aspirations.

    Despite this, almost half the executives say that eHealth is their biggest investment theme over the next year. It’s been top since 2012, but has risen from 45% to 49% now. But, their priority for eHealth resources for supply chain management is dropping. In 2013, 59% said it was a high priority; now, 48% say it is.

    Healthcare IT News, with a headline of “Premier survey shows buyers, remorse,” which might be a bit too strong, quotes PHA Chief Operating Officer Michael Alkire saying, “What we are hearing increasingly from health care leaders is dissatisfaction with their existing EHR systems, often citing cost and difficulty of use.” Alkire goes further to suggest that “providers need a solution that integrates clinical, financial and operational data across their hospitals and health systems; the majority of EHR systems cannot do that.”

    If these findings reflect a similar view in African countries, progress means that eHealth leaders have to work harder to show the benefits of EHRs. This isn’t enough. They also have to match the EHR value they want with what their organisations can afford, make sure that their executives understand this explicit trade-off, procure effective solutions, and realise the benefits on a significant scale to convince top executives that EHRs and eHealth is worth it. It’s a considerable challenge.

  • Costs of EHRs need more attention

    EHR costs are changing, but a report in the Journal of the American Medical Informatics Association (JAMIA) says that Project planners tended to overlook certain costs. It emphasises that hospitals and governments need clarity on major costs and their cost drivers from the first decisions to proceed.

    The researchers evaluated three centrally procured systems in twelve different healthcare organizations as part of England’s £12.7 billion (USD $20 billion) National Programme for IT (NPfIT). As the NHS stopped NPfIT in September 2011, and it was the subject of a critical Parliamentary report in 2013, it is not surprising that the researchers found many problems. For the study, researchers completed 41 interviews with the people involved with NPfIT.

    The findings identified four main cost types: infrastructure, including hardware and software; personnel, such as training team; facilities, such as space; other, such as training materials.

    The European Commission (EC) study on interoperable EHRs study of nine successful EHRs and ePrescribing systems across Europe, found that the average organizational costs slightly exceed ICT costs, The cost of redeployed resources are almost as much as the cost of additional resources.

    Both studies are retrospective, so exclude a significant cost: risk. The tinTree eHealth Evaluation Database (TEED) has these exceeding 200% of some years. Other large-scale adjustments needed when using the research findings for prospective adjustments are optimism bias and sensitivity. The TEED also has additions to these eHealth costs for new priorities and challenges. These are the increased resources and functions for:

    • Effective cyber-security • New eHealth regulations • Appropriate ICT capacity to deal with increasing interoperability.

    The TEED includes socio-economic evaluations of failed eHealth initiatives. These reveal that limiting or failing to plan for the full cost of the resources needed is a major cause of failure. It is not the only one. Others include poor usability, weak or no risk management and feeble benefits realisation. Each of these has several sub-sets.

    Several new eHealth initiatives do not incorporate these lessons. It is vital that African countries, with their very tight budgets and resources do not overlook them.