Cool toy of the month!!!! Watch your internet shows on your TV

Ok, it has been a while since i was able to watch anything that talks about technology on TV. I used to watch in the past TechTV, but that's long gone and been replaced. I settle now for reading/watching tech podcast during lunch at work, or before I start my day in the morning. The challange I kept finding was that I can never efficiently organize and view that information as entertainment. Ok, let me explain. In the evening instead of learning about Desktop virtulization or the latest micrtosoft developpement tools 2010, I am stuck surfing tv reality shows between commercial breaks from MSNBC and CNN. So, I finally made a decision to bring those useful shows to my TV. And that's when I discovered the D-Link 520/510. These are neat little devices that act as a Top Set where they connect to your wireless network and your tv, and allow you to bring your media library to your TV and control it using a remote control. Just imaging the following:
at 10:00 AM you receive an update from an RSS feed you signed up for, and it talks about the latest microsoft Surface SDK, and different showcases or uses in the medical field.
Now imagine that you are too busy to click on it and view it, because like all of us you have deadlines a boss breathing your neck. So, you are disapointed that you missed that opportunity to learn something new and cool.
Then you go home and realize that you have this little cool toy that actually keeps track of your favorite RSS feeds, and presents them to you directly on your TV. Well that toy or one of them is the D-Link 510/520.
You kick back on your couch or start on your tradmill, then press play and voila. You are now watch and learning about the exciting new Microsoft Surface and trying to think of ways you can get your boss to spend 15k on it to prove how cool it would be to use as part of your next EMR presentation.

PS: i am convinced that this technology one day very soon will be in the radiology departments as well as other specialties!!!

Can you exchange patient healthcare records

While many of us are exposed to the ARRA or stimulus, many healthcare groups are still wondering how this is all going to play out once all the requirements are defined. In a series of blogs I will be posting, I am going to discuss three different subjects with several scenarios of different practice types with different infrastructure and package.

The three subjects I am going to cover will be:

Interoperability
Meaningful use of a "certified EHR"
Certified Package

I will start by discussing the first one, and it is my favorite one. In the last few months, I have been very fortunate to participate with some very smart people. We worked together as part of the Technical & development Committee for NCHICA to create a draft that identifies our recommendations for a state wide/Community base Health Information Exchange Network.

Basically our goal was to identify the architecture of a NC HIE that would be able to participate a the national level and facilitate the exchange of health records amongst stakeholders such as (ER, Hospital providers, Physicians, State entities, SSA, and others..).

During that process I have learned tremendously from the team, and I could not help but try to envision how many of the providers I know would use and benefit from such a system.
So to help explain how a State HIE and its uses would look in the future, I have three practice scenarios to explain the implementation:

Practice 1:Dr. Smith with Practice SoloProv is a small provider practice with a single physician who is using a Basic EMR. This EMR called SoloEMR is a small vendor that is not planning on getting certified, and will not be enabling any interoperability in their software.

Practice 2:Dr. Jones with BusySpecPractice is a mid size busy specialist practice that feels that an EMR might slow them down, and elected to stick to paper charts but would like to participate at a state level HIE.

Practice 3: Dr. Ashton with Busy multiSpec which is a mid size busy multi specialty practice that has implemented recently a well known EMR that does support interoperability and also is planning on using the state HIE.

As for many of the patients of Practice 1 are becoming more aware of the advantages of having access to their PHR (Personal Health Records) they started requesting from Dr. Smith that they would really like to see their records on state HIE as well as receive updates under their (Google Health or Health Vault). This puts a lot of pressure on Dr. Smith as he realizes that he will need to do something before patients start looking at other providers that may have that edge or those capabilities. So, he approach the software vendor but with no luck. Then he decided to take a another approach. He came up with a plan to basically charge a patient a small fee to cover the cost of a staff member entering that data directly into the State HIE web portal. Not only the basic medication list, allergy and vitals, but also scanning sections of the paper chart to be uploaded. While the cost per patient becomes break even with what he is charging, he realizes that this is his only option unless he goes for an EMR package that has that functionality of Interoperability. This model allowed him to still maintain business as usual, but also allowed him to print/receive updates on his patients anytime their records are updated by another health provider. Unfortunately, the down side to this model is that the provider will be missing out on the stimulus money, but also on the advantages that an EHR offers. Anything from Drug interactions, to E&M coding, Rx History, Paperless office and much more.

Practice B, is a busy specialist practice. No time to waste typing on a tablet PC or laptop. They do everything on paper, and very comfortable with that method, and not looking into any change anytime soon. However, they realize that they would like to move the practice toward a EMR model and the next years, and would like to minimize the upfront costs as well as lowering the risk and change. With this group, it was a very simple yet powerful approach. They decided on using an EMR lite package that not only allowed them to access/request patient records from the Community/State HIE, but also perform electronic prescriptions as well as enter the basic clinical information electronically (Vitals, allergy, diagnosis, procedures, basic notes..) which was available for the Community/State HIE, and the rest of the medical record was still transcribed. This group was able to maintain the efficiency, be more informed before making decisions, and still provide the same amount of attention the patient deserves during the visit.
Now in my opinion this model above is a lot better than the first one. You have access to more information of the patient conditions (problem list, medication, allergies, vital and such), also the provide has visibility of the patient "CCD" or summary record provided by the HIE, but still does not provide a way for the practice to "measure quality or improvements". This is the part where the NQF will select our of their existing criteria which one will be utilized and implemented as part of "meaningful use".

With the last practice 3, recently implemented an EHR system across multiple departments. Each has all their patient records stored electronically. From the radiology department to the pediatrics. If you are a patient there, there one comprehensive electronic health record that contains all your data gathered from across the departments. So, you will have all your imaging stored as a standard DICOM, then you have all your lab data in HL7, and your overall summary of record as a CCD. Anytime any outside entity needs your record, the Community/State HIE sends a request and then receives a response with all your medical data from this group. The nice thing about this model, is that the providers did not have to do anything different to enable the interoperability here. Except of course paying for it (some vendors are planning on charging you for that functionality separate!!!!). In addition, this group will have as part of their participation in the Community / State HIE, any new patient or existing patient's PHR or LHR can be downloaded to a special tab in the EHR (Outside Records) to allow care providers to view patient's medical records from previous or other entities. Unfortunately this model is most likely the most costly for a practice, although it has tremendous advantages and will truly be the best case that the ONC and our administration would like to see, it is still the most challanging.

I am a firm believer that technology is going to help improve our healthcare system. The cost of it would be the variant here, but nevertheless, it is something that is needed. My mission while working with providers is to show the value technology can bring. Whether it is using EHR, or efaxing, virtualization or just simply securing their network to better protect patient information, it is important to show the many positive things that technology can bring to the table, it is just a matter of putting the RIGHT one to resolve the RIGHT problem. It does not always have to cost an arm and a leg either. I have seen enough successful open source products out there, that we don't have to continue to use cost as an excuse.

My favorite open source products:
Open Vista (VA EMR)
CONNECT (NHIN that allows for Health Information Exchange)
Mirth (Interface Engine for Labs, Demograhpics, DICOM CCD and many more.)
ClearCanves (My favorite .net PACS solution, and it is open source and as good as the 100k solution).

I will cover more of those open source solutions in another blog.

The health Provisions in the stimulus package and what it means to your practice

While I am trying to juggle between getting all my work done, and packing to prepare for our new office move, I had to find time during my non excising lunch and do a quick blog message.

Earlier this week president Obama signed the stimulus bill, so that meant that everything that is proposed for our healthcare is now law. But after spending two nights trying to read the healthcare section of the 1071-page American Recovery and Reinvestment Act, I still had a lot of questions to ask about what are we really getting, and how do the healthcare groups go about getting it. I even had more questions than the ones I started out with.

So, as I googled all my concerns and questions, I found articles that really put a negative spin on the new stimulus bill. I have read things about how the seniors in the US will face rationing, and how doctors will be influenced by the government. These articles could not be more wrong. It was important to really stay positive and make the best out of the assistance that healthcare has long needed to help the adoption of the technology that it most definitely needs. I found many of my answers in the following site Click Here.

The incentives proposed for the health professionals are payments of 15,000 to 18,000 dollars for the first year, 12,000 dollars for the second payment and on until the fifth and last payment of 2,000 dollars.

Things that will be potentially requested from health professionals in order to be eligible for the incentives:

• Submission of claims with appropriate coding (such as a code indicating that a patient encounter was documented using certified EHR technology) ---This reminds us on how we reported on PQRI.
• The use of Electronic Prescribing (e-Prescription, and this can be achieved with third party vendors, so you don’t have to change your EMR if it does not support it).
• The ability to exchange / forward your patient medical data to “data repository” defined by the Secretary ( RHIOs and hospitals have implemented these types of data warehouse and can store any of the following (which one they will request is the million dollar question):

Electronic Referrals and Consultation

Electronic Lab Orders/Results

Electronic Prescription

Electronic Imaging of patients

Electronic medical history

Radiology reports

Discharge reports

• Treatment plans
• An attestation
• A survey response

Since I am still reading the Healthcare section of the stimulus, I will continue on this blog in the next few weeks and describe some of the ways that small to mid practices can utilize to benefit from this.

Obama’s push for digital health records and what I think its flavors should be

While our new administration is doing the right thing by pushing for the modernization of our healthcare system, it is important to have a plan that will work and motivate everyone in the healthcare industry.
In my view the 5 year timeframe that our government is looking at will be very short to accomplish EHR implementation and standardization, especially in the small to mid size medical groups. In working with some of these types of offices in the last 10 years, I realized that many of them have complex workflows, and many encompass diverse delivery systems while many still suffer from the lack of proper infrastructure (Backups, server hardware requirements, scanners, efaxing,…etc.).
It is important to note that, in order to overcome the daily challenges that these groups are faced with (small IT Budgets, lack of HIT knowledge, and few uncooperative providers, high software costs), the new administration will have to create a road map that will impose some standards and also still be flexible by having different flavors of the modernization plan.
The package that should be offered will offer different options for different models as shown below:

Small Size Practices

• The offering of a complete web based solution (PMS/EMR) that will eliminate having to make large IT hardware/software investment, and still allow the practice to have EHR. Which package is needed would be a another blog subject).
• An option for the practice to use an EMR package that has been certified and approved by a Healthcare body.
• Educate the practices of the advantages of medical data sharing.
• Strong financial incentives in form of tax breaks or grants to offset the costs of time spent in training, and other requirements to get the new system going.
• Appoint at the state level a body that does nothing but consult with the practices and make sure they are seeing the benefits of such a system.

Mid Size Practices

• Work with these groups and allow them to keep using their current systems to maintain their patient medical records. Since these are the groups that have long implemented successfully many of the EMR packages that are offered.
• Provide financial incentives if they choose to migrate to a new EMR package.
• Provide financial / technical assistance to interface these systems to a central data repository. Similar efforts have been seen working with RHIOs where there is a substantial amount of resources needed to accomplish this.

Community health systems and hospitals

• I think we can all agree here that based on many of the recent statistics that still a larger number of hospitals are using electronic health records. So, the need here would be to centralize or allow for data sharing with the central data repository.

The only thing that I would add is that the effort should be shared amongst government and non government entities. Many health groups have successfully implemented some sort of central data repository where information is being exchanged and shared. The government role should be to enforce the standards, and offer reward to those who take the initiative to get on board.

Navigating in the rough waters Part 1: (small practices)

Navigating in the rough waters Part 1: (small practices)

During these difficult times, I find it that the media is more focused on the negative news and the problems that businesses are facing, rather than making recommendations and special reports on how we can become part of the solution. In our group, when we have our weekly brainstorming sessions, we discuss our economy and go around the room asking all individuala to provide feedback in the following format: what can we do to help practices navigate through these rough Waters and be part of the solution not the problem.

This was the mindset that we have been in, even during consulting with clients. As healthcare technologists, when we meet with clients and discuss how we can assist them with their technology needs, we focus on listening to what they are looking to resolve. And more than ever, where are hearing that it is about how we can use technology to “SAVE THEM MONEY, and INCREASE THEIR REVENUE” as well as how is the new administration is going to assist them.

So, in my mind it is two subjects that we need to tackle.

PART 1: Plug the leaks in your practice

When I got married, my wife and I were young and eager to see what it feels like to live on our own house. We chose to rent an older home close to my work for about a year. During that period, we were paying off school loans and such, and trying to save as much money as we could. Things went well during the summer up until the winter time. Living in the Carolinas with 30 degree temperatures had raised our gas bill to over 300 dollars a month. Keeping in mind that we both worked full time and had a relatively small house (1200 sqft), we did not know what to do, and the landlord did not care much. We knew that it was too expensive for us, so we had to do something about it. The only option we had while bound to a lease contract was to find ways to save on our gas bill. So we came up with a good short and effective list of solutions:

Wear thicker clothes and lower the thermostat by an additional 3 degrees.

Request the landlord to put weather stripping in all the cracks and the doors to the outside.

Close the rooms that we don’t go in and close the vents in them.

Perform maintenance on the Heating unit to get it to function efficiently.

While we knew that this was the last time we would live in a home without doing an initial inspection, we were extremely pleased with the results that we saw the next billing cycle. We were able to save over 40% on our gas bill. This was a great solution that had measurable results.

With the similar model, I found that we can apply different solutions to a medical practice that can help cut costs, and especially during this difficult economy. The following are some examples of things that can benefit a practice through the use of technology:

Review the clearinghouse services you are getting and add more functionality

Things to consider:

Patient eligibility: Get your money upfront when a patient does not have valid insurance, and eliminate the need to waste resources in filling an already denied claim, in that this will be saving precious staff time and money.

Automatic Electronic Remits Posting: if you thought about it in the past , and were too afraid to try it, well this is the best time to make the jump. Eliminate the time spent on data entry for the payments by allowing the system to do it automatically for you. This will give your billing staff enough time to allow them to focus on getting the AR where it needs to be.

Claim Submission: There are still practices out there that send claims via paper. This is the time for the switch. You are wasting your dollars if you are paying someone to print, folder and mail a claim. You can save on stamps and staff pays to do it electronically.

Practice trends: Getting the right reports to help you realign your practices goals is critical. Since you are still a business, it is important to see how you are doing and not wait for a phone call from the accountant at the end of the year. Some clearinghouses offer dashboard that give you a snapshot of where you stand, and what are certain services that are more financially beneficial to you than others

Working your collections and statements

Things to consider:

Outsource Statements: It is nice to see how we can have an assembly line when working on statements. One person prints, the other folds and stamps, however having a company that will reduce your costs and errors is far more beneficial in the long ran. You can start to see saving right away with this method, by uploading your electronic statements and letting them print them and mail them for you.

Outsource Collections: While it is nice to get a third party collection agency to call and try to get your money back, it is critical to choose the right company. One that will not make you loses your patients by scaring them off. These services will help you get more of your money, and allow your staff to be more efficient.

Revisit your IT support and maintenance contracts

Things to consider:

SLA contract and flat fee support package: This is the one thing that motivates an IT company to do the best job they can, by preventing problems. Having an SLA (Service Level Agreement) forces the IT Company to try to minimize the time spent on a problem as they want to ensure that they would need to spend less time on fixing things they can prevent to keep the margins up.

Get a good lite Preventative maintenance package “lite managed Services”: While it is a common practice for an IT shop to recommend monitoring the workstations, the servers, and even the temperature in the room, you only need to have monitoring done on critical equipment in your building. The front desk computers, or the ones in the break room are not important devices, you can save yourself money by buying some spare ones and keeping them in the back ready. Your main goal here is to prevent major downtime and loss of revenue by focusing on monitoring Backups, servers, server room temperature, and logs of critical applications such as RIS/HIS/EMR/PMS/Exchange... The provider’s tablets can be skipped as long as there is a good policy and training around saving important files or personal documents to the local computer disck drive, which would jeopardize data.

Get that EMR you have always wanted today

Things to consider:

Gethe best package for the best price: Because of the tough times and some good old competition, we finally have affordable EMR/PMS packages, and plenty of room for negotiations. We are seeing 20 to 30% off some of the top EHR packages out there. This would be a huge savings that might not last for long.

How About Free EMR: If you haven’t heard this yet, well it is true. You can get a free EMR and the only cost is the maintenance and support. OpenVista is the OpenSource (developed by a comunity of developers) EMR product developed and currently used by the V.A. in many hospitals. There is a commercial version of the product that medical offices can use and its Free!

Get Free Money from the government

Things to consider:

Grant money: whether you are a Community Health center or a private practice, the new administration is working on some great packages to offer as part of the healthcare modernization push and Stimulus package. Our president Obama is looking to get Healthcare IT some much needed financial assistance to get us where we should be. So, you have to start looking at the details of the stimulus package and how you can get approved for that assistance.

Free or low cost e-RX: Take advantage of the bonus that Medicare is currently offering. If you are seeing a large volume of patients from Medicare, then you should highly consider implement e-prescribing (e-Rx). This 2% bonus based on your anual reimbursments will last up until 2011 and then it will be reduced to 1% bonus, and by 2013 you will start losing about 0.5% of your total reimbursements from Medicare.

Remove the paper based tasks

Things to consider:

Low end scanning solution: Get with your IT Company or Copier machine guy and see what you can do about those paper EOBs that you have to keep in the back. While most of us think that we can shred them, it is critical to keep them around if you ever get I.R.S. knocking on your door, or one of the payers decides to take back some money and you need to have some supporting documentation for a claim or two. Turing your EOB into electronic documents will save your staff a lot of time as they will not have to spend a lot of time looking in boxes and such for 10 minutes or more for a single EOB.

Hybrid document management system: This is by far the most cost effective EMR and paperless solution. It offers the best of both worlds. Having all the benefits of an EMR while still keeping it simple to use for the clinical staff, and still maintain the same amount of patients and workflow.

eFax: Implement an eFax solution. You only have to spend just few hundred dollars and get a complete eFax solution. Believe it or not, you can get a complete eFax application for free as part of your windows Server 2003. All you need is a modem. This will save your nurses from having to chase paper lab results, and other faxed patient documents. One other advantage is to eliminate the need to spend time scanning, filing them, or the toner when printing them.

Consider refurbished workstations

Things to consider:

Refurbished workstations: As the computer prices have dropped, there is potential saving in buying refurbished workstations. They still hold the same warrantees, and would still run just as good as the new ones.

Free software

Things to consider:

Free office tools: Many practices thing of Microsoft Office suite when you mention word processor. In reality, you spend over 299 on to get those applications. I highly recommend looking at the free OpenOffice.Org OpenSource product. It does everything that word, excel and PowerPoint do. Except it will cost you 0 dollar.

Lower your electric bill

Things to consider:

Turn off the switch: Turn off PC, speakers, calculators and monitors automatically. Many of us underestimate the power consumed by PCs even when we don’t use it. During the night time when a PC is in standby, it is still running up your bill. So, if you want to save 30% or more on your energy consumption then buy a smart power surge for your workstations. A power surge like “Power-Saving Essential Surge Arrest 7 Outlet with TEL 120V” for as little as 20 dollars. This surge protector is smart enough to sense when the computer goes to stand by, and then it shuts off power to the PC, Speakers, calculators, digital picture frame, and last but not least monitor. This is truly a great out of the box idea that will save you tremendously on your electric bill.

EMR ASP vs. Client/Server

Recently, I was asked by one of our clients what were some of the advantages and disadvantages of going with an EMR that is running on ASP (application service provider) model or an EMR on a Client Server setup.

Unfortunately, few online articles have labeled the ASP model as the EMR where you don't own the data, and also the Client Server model where you will suffer from terrible performance if you have multiple locations.
So, I wanted to provide some alternatives to the models listed above. When you look at the ASP model, you will find that it can be divided into two very different modes that have very different advantages and disadvantages.

Please view the following Comparative analysis: Click here

Disaster Recovery and Business Continuity Plan

There was a time in my youth I was told to be proactive in order to maintain my cars to get the most out of them. I believe that was one piece of advise my father gave which I should have listened to. Especially after going through two cars with blown engines during my college years. Today, in technology i have seen similar situations that do not get the proper attention, and assumptions are being made until the day you are faced with a true disaster then realize that you are all alone and no one to blame but yourself. The moral of this little part of my life is: "You should always monitor and perform checks on items that are important enough in your work or life".


In today's Healthcare information technology, many components go unchecked, and when disaster strikes, several organitations suffer from many directions.



So, now looking at all the complex systems that are implemented in today's health care, from a small medical office, to a large IDN the reliance on technology one must wonder, how can we better prepare for any disasters.

Working with small to mid size practices one of the key mistakes that I have seen repeatedly is the lack of awareness of what their backup consists of. There is actually a small list of things they must know but no one tells them about:


Current challenges:

• No one knows where the IT service support stops and when the PMS vendors begin.


• Are all the practices important documents stored on the server with all the other major data, or is it still lingering under the "My Documents" on the office managers desktop.


• Is the data restorable?


• Is the data being backup daily (are the backup logs monitored.) PS: "in some applications, if one file is missing the data may be unusable."


• If the practice is not using Microsoft Exchange or Lotus Notes, are their POP3 emails being backed up?

Solutions:

• Design or request a network and application layout.


• Request documentation or weekly reports on backup logs


• Implement restore drills even on a testing server. (You can actually lease servers to perform tests on.)


• Discuss disaster recovery with your staff, providers, IT support, and all your software vendors. Remember each software can have specifics when it comes to recovering from a technical disaster.


• Identify what applications are business critical and which ones are not.


• Make sure the backup rotation is appropriate. (Weekly is not acceptable, and can cause you financial and legal penalties).


• Discuss your disaster recovery process with your insurance (it can lower your premiums if you have implemented and documented best practices.)


• Invest in the right solutions up front. In many cases it might seem that you should settle for the low cost backup solution with limited storage without accounting for the growth of your storage over the next few years. Think of where your EMR plan might come in the picture, and when you might decide to scan all your paper chart. Your backup storage should be an investment that will have to be done wisely. You should not have to replace your backup solution in a year or so. So, ask if the backup you have in place is upgradable, and scalable.


• Implement server monitoring to allow for your servers to be reviewed for errors that can help in preventing disasters.

Disaster recovery for Hospitals and large organizations...to be continued..Once we move to a hospital /IDN environment, it is a different challenge. It becomes clear that it is not just a question of putting in the storage infrastructure alone, but more of having to manage the following:

• What will be covered (if there are other organizations that might not be in the same geographic area)
• Awareness and preparedness (understanding the risks to the business as well as the challenges that will need to be overcome.)
• Procedures that would need to be implemented in order to guarantee that everyone is on the same page. From an IT prospective all the way to the Disaster Management Team and staff.
• Technology infrastructure. This would include plans to either have a hot site ready with data that is replicated real time, all the way to stand by servers and solid backup or virtual platforms.

From a technology standpoint, there are many challenges that the IS department is faced with is the vast infrastructure that is in place. To point out few of them that we see in Figure 1.1.

Figure 1.1

There few more items tat might be missing from the Figure 1.1, such as the integration engine that keep all the hospital system all integrated and patient information centralized. Ranging from SUN JAVA CAPS all the way to MS BizTalk servers. In addition, there is the task to coordinate with all the different vendors. Any thing from the RAD system to the EMR servers that might be under maintenance contracts through a third party.

Reda Chouffani.. To be continued.....