Perficient Healtchare Solutions Blog


Mike Jenkins

Mike Jenkins has over 25 years of experience architecting, developing, and implementing solutions for organizations in the US, Canada, Europe, and Asia. Mike is experienced in healthcare, finance, defense, manufacturing, training, and retail industries. Some of Mike’s healthcare projects include: developing a core measures proactive monitoring system; developing an eHealth strategy for a growing community hospital; implementing transparent pricing and outcomes measurement solutions; automating clinical and administrative tasks through forms automation; connecting multiple healthcare systems through a common patient portal; and developing an electronic medical record application. He designed the Physician’s Portal and Secure Messaging Product for one of the top-five vendors in clinical information systems. His application development experience includes Amalga, CPOE, Clinical Portals, Patient Portals, Secure Messaging, HIM, Interoperability, and NEDSS for State level health departments. He is a Project Management Professional (PMP), a Certified Rational Consultant (RMUC), a LEAN Black Belt, and a Microsoft Certified Technology Specialist (MCTS). He is fluent in most methodologies and teaches the PMP Certification course in Atlanta.

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Pushing the Blue Button for Meaningful Use

It has been shown that active patient engagement results in fewer hospital readmissions, decreased medical errors, and less consequences resulting from poor communications.  Engaging patients improves healthcare, saves money, and reduces errors.  Meaningful Use has a program goal to deploy technology to raise patient engagement.  The timing is ideal, since more patients are connected every day using smartphones, tablets, and other mobile computing devices.

Improving healthcare is a training problem, which I discussed in an earlier blog.  Along with changes to our general education about healthcare, we can adopt new technology to enable this education.  Many organizations are providing online content, encouraging patients to manage their own health, and more technology solutions are appearing every day.  For example, the HealthIT.Gov group has released details of their Blue Button + campaign.

mj blogThe Blue Button + program is intended to engage consumers (patients) in three distinct ways:

  • First, by easily providing access to patient’s health information.
  • Second, by allowing patients to take action on this information.
  • Finally, to shift the patients attitudes about their role in their own healthcare.

The technology behind Blue Button + is designed to ensure everyone can access their health information easily and quickly.  The success of this has been proven.  In 2010, the Department of Veteran Affairs started the Blue Button initiative.  Since then, over 88 million Americans have been given access to download their health record from portals offered by CMS, Department of Defense, Aetna, and United Healthcare.  Over one million Americans have downloaded their health records.

This is a challenging issue because healthcare data most often lacks structure, is inconsistent, has no secure transport, and is not seamless.  The Blue Button + program has been released to address these issues.  It does so by offering a structure and transport mechanism for the data, pre-defined anchor bundles, and triggers to automate the transmission.

Structure is accomplished using a Consolidated CDA (C-CDA) template.  This same XML template is described in the Meaningful Use Stage 2 requirements.  It uses a standard message format to move data between systems.  Most modern Health IT solutions support CDA and will support C-CDA soon.

Transport leverages the DIRECT protocol using SMIME/SMTP transport to move data between systems.  This uses the same infrastructure used by email to transmit health information between systems.  DIRECT adds security to this process by pre-defining trust relationships between the sending and receiving systems.

All of the requirements listed so far are Meaningful Use Stage 2 regulations.  Blue Button + adds some extra considerations to provide a better experience.  This includes the Blue Button Anchor Bundles to pre-define collections of trust relationships, transmit context to help label messages based on their source and time of transmission, and finally enable the ability to automate the message push function via triggers.  Triggers enable automatic updates to receiving systems when patient data changes on the source system. These let patients, when they register, determine how often data is refreshed between these systems.  Once this trigger has been defined, the patient has nothing else to do, yet still receives updated data each time the data is updated at the source.

Have you had experience with Blue Button + or downloading your health information by other means?

EHRs: Change is coming in 2013

Sean Brooks, in his article 5 EHR predictions, very astutely anticipates several upcoming changes related to Electronic Health Records:

  1. 2013 will be the year of the replacement EHRs
  2. Many EHR vendors will disappear
  3. The cloud is here to stay

I believe Sean is spot on and I would like to expand on this based on my research and opinions.

Many physicians jumped on the EHR bandwagon to secure Meaningful Use funding for Stage 1.  In fact, some only had to show proof of intentions to collect a check.  Others jumped off the deep end and installed EHR systems only to spend a long time learning the system.  After investing a lot of time in the setup and learning the new system, they realized it doesn’t support their practice.  I’ve spoken to a lot of physicians who feel betrayed and are angry with their EHR vendor.

2013 will be the year these systems with shortcomings get replaced.   Physicians are realizing there are better options on the market and the cost of upgrading is far lower than the cost of continuing to use systems that restrain their business.  There are EHR systems that are designed to adapt to the physician practice instead of forcing the physicians and their staff to change.  Then, there is Meaningful Use Stage 2.  A lot of systems who enabled Stage 1 will not be upgraded to enable Stage 2.  Physicians will be forced to replace their EHR system if they wish to attest for Meaningful Use Stage 2.

EHR vendors will disappear.   The 2014 requirements to certify a system to attest for Meaningful Use Stage 2 are far tougher than the requirements to certify an EHR system in 2011.  Certifying under the 2011 rules was primarily done by sending data that passed a specific set of tests.  In some cases, this was hardcoded for the test and in a production system no longer worked.  The 2014 requirements ensure the EHR vendor’s systems pass legitimate data.  It is no longer possible to pre-pass these tests.  Because of this, I too believe many EHR vendors will leave the business.  Smaller shops that do not have the reach and resources to certify for 2014 will sell out or quit.  Large, inflexible companies will take too long and choose to sunset their EHR products.  Physicians looking for EHR systems this year must be better informed.  They need to exercise care and scrutinize their vendor before jumping into another solution that doesn’t work. Everyone must use a 2014-certified EHR to attest for Stage 2.  One consideration is that those purchasing 2014-certified EHRs can also use them to attest for Stage 1.

Finally, I agree that cloud-based systems are a very smart idea for smaller practices.  It takes a lot of money, staff, and time to build and manage an internal network to host EHR systems.  Independent physician practices should seek out cloud-based EHR offerings so they can focus on what they do best and let the EHR vendors manage the network.   It is smarter to host your EHR in the cloud for several reasons:

  1. Cloud systems are designed for high availability. Independent physicians cannot afford the infrastructure and Information Technology resources to do this themselves.
  2. Cloud systems are expandable.  As data and bandwidth volume grows, cloud-based system can quickly grow (or shrink) to accommodate this.  On-premise solutions are not this nimble.
  3. Cloud is cheaper.  You are sharing systems with other users and can leverage economies of scale.
  4. Cloud is secure.  Although this is a shared service, all competent EHR vendors designed their systems to support the security needed in a shared environment.  This model is also the model supported at most in-house hospitals and larger data centers.
  5. Cloud is interoperable.  As the fog lifts for Meaningful Use stage 3, we can expect more requirements for interoperability.  Hiring an EHR in the cloud is a strong first step.

2013 is a year for some very good and reasonable changes.  What are you waiting for?

EMR Selection: Caveat Emptor

Based on the most recent meaningful use statistics published by CMS, the majority of Eligible Physicians submitting MU claims for Medicare have not been paid.  Medicaid is only marginally better.


Providers who are shopping for EMR systems must pay attention to the track record of the vendor and investigate claims these systems are MU compliant.  Vendors have to conduct an in-depth certification process.  Shoppers should expect to see the resulting confirmation from ONC proving EMR systems they are considering have passed this certification.  They also should be clear all along what is expected from them to qualify for MU stage 2 reimbursements.Collecting Meaningful Use dollars is difficult but not impossible.  It will require the Provider to study and understand the nuances of these requirements and start developing habits that ensure payment well in advance.  Providers must shop wisely.  The statistics above indicate many systems claim to support Meaningful Use during stage 1 apparently fall short in some way or another.   Meaningful Use stage 2 will be much more onerous for both the EMR vendor and the Provider to qualify. This implies the majority of EPs are not demonstrating MU as per the CMS guidelines.  In my last blog, I talked about software forcing providers to change the way they practice medicine to qualify for Meaningful Use.  Today, I’m sharing some numbers that illustrate the difficulty of getting paid even after all this change.In order to be included in this report, Providers must successfully demonstrate Meaningful Use, and meet the allowable-charges threshold as well as all program requirements to be included in this report.


Angry Docs: A Mission to Conquer Meaningful Use Requirements

Who would have imagined ten years ago that many of us would spend hours using a slingshot to fling hacked off birds on a single mission to destroy arrogant pigs?  We do this using computers smaller than our dinner plates while sitting on airplanes, park benches, the family room sofa, and sometimes at work.  For those of you who have not heard of the game “Angry Birds,” you should make this a goal over the holidays.

The premise of the game is simple.  The pigs have stolen the bird’s eggs and they want revenge.  Each bird has their own specialty and the gamer has to use these specialties to destroy all the pigs in each scene.  If they fail, the pigs laugh at you.  If they win, the birds celebrate.  Each scene gets a little harder to complete creating the addiction.

Last week, I was part of a conversation describing physicians in much the same way.  They are angry because they spent a lot of money to purchase an EMR solution that qualifies for Meaningful Use only to find the system forces them to change the way they practice, doesn’t meet all their needs, or isn’t going to be upgraded to meet Meaningful Use stage 2 requirements.  We concluded many independent physicians are ready to find something better but they are afraid of losing their current investment of having to spend a lot of time and money migrating to a new system.


Passionate for healthcare technology

In my last blog, I talked about technology being disruptive for the healthcare industry.  Since then, I found another article that takes it a bit further.

Valve, an online gaming company, has pushed disruption in the software industry to new levels.  They are disruptive.  Valve helped change the gaming industry from distributing boxed items to digital downloadable format.  This dropped the price of every game by removing most of the logistics costs.  It accelerated time to market, and provides nearly immediate updates.  I explained in my last blog how Healthcare too grows through disruption. .

Valve has passion.  Passion is quickly getting sucked out of the healthcare by increasing costs, lawyers, regulations, and restrictions.  In spite of this, most physicians still love what they do.  They would keep going if someone can help them find a little respite from the bureaucracy.  Healthcare Software vendors need to tap into this passion to help grow and innovate the industry.

Valve knows their customers.   This is a big problem in healthcare.  Patients should be the customers but most of the time they have very little say in how the physician gets paid.  The real customers are the payors, and they have to constantly change their business to meet the ever changing demands of this industry.  Moving toward a more patient-centric model will take time, effort, and some breakthroughs in technology to get us there.  We are already seeing tools evolve that enable immediate interactions with patients, specialists, and the care teams.  More of this will be good for the healthcare industry.

Valve encourages community.  This is the epitome of healthcare innovation.  Everyone learns from everyone else and the industry progresses faster when more get involved.  One challenge today is information overload.  Anyone with a computer can find more information related to disease, treatment, and payment in 30 seconds than was known 50 years ago.  Unfortunately, not all this information is accurate and too much of this is misleading.

Valve is sustainable.  This could be a problem in healthcare.  More regulations, lower payments, and the diminishing passion are all conspiring to hurt the healthcare industry.  Unlike gaming, healthcare has much smaller room for error.  Yet, the Healthcare industry could learn from the gaming model.  With some minor changes in payments and procedures, it is realistic to offer better follow-up, better care management, and overall savings.  It simply starts by thinking outside the box.

In the end, it will be passion that determines the outcome.  Passion will continue to drive innovation and help providers embrace new technologies.  Lack of passion will push some out of the business.  More passion will bring others in.

Are you so passionate about healthcare that you are willing to disrupt the present model? What will it take?

Windows 8 and Surface are poised to disrupt healthcare

Microsoft just announced Rounds, a Windows 8 application that simplifies workflow for doctors and nurses within a hospital.  This is innovation is disruptive and thoughtful.  It epitomizes healthcare.  Let me explain.

Advances in medicine usually come about through the scientific method.  When something works, it gets published and the rest of the industry benefits from the publication.

In my opinion, Rounds is one of these concepts that will provide enough thoughtful presentation to encourage innovation.  The application is not yet connected to the back-end systems to make it practical, but that’s not the intent.  The intent is to get the industry to think about different ways to do their jobs.  In that light, I think Rounds is spot on.

Some hurdles that must be overcome to get widespread use of products like Rounds are high, but not impossible.  Someone will need to connect this to a back-end system that provides patient information.  There are many EMR systems on the market and some will be easier to interface with than others.  Someone will have to find a way to enable Lync to create legitimate orders and to track the creation and execution of these orders via the patient record.  Someone will have to find a way to capture Lync-based consultations and tie them to the patient records and, more important, find a way to get paid when using this kind of technology.

All of this is technically possible today.  The obstacles are legal and procedural.  For a system like this to function, it will take a leap of faith to get the compliance groups on board.  It will take a lot of explanation and safeguards to convince those who would benefit most to embrace this change.  It will take some pretty creative thinking for seamlessly connecting the back and front-end systems to enable this.

This kind of change is very disruptive.  Yet, disruption is how major advances in healthcare begin.

Meaningful Use doesn’t have to be painful

In my last blog, I talked about the changes forced upon healthcare providers and some software developers who were striving to minimize the impact of these changes.  I received comments stating their position that the providers must adapt and it seemed pointless to build systems that mimic an existing process.

I believe this approach is why technology adoption by physicians has been so low.  Physicians are getting squeezed in every direction.  Patients are more knowledgeable and want more of the physician’s time.  Payments are shrinking forcing doctors to see more patients for the same revenue.  All other costs are rising faster every year.  Finally, new software designed by software engineers is causing the physicians to spend hours every day updating the systems.  This time is not reimbursed. (more…)

EMR adoption doesn’t have to hurt a bit

I have blogged about change a few times already.  This is a pretty important topic as it relates to healthcare reform and technology adoption.  It can be summed up in a single sentence: Change is coming.

Physicians don’t have time for change.  Nurses don’t have time for change.  Administrators don’t have time.  Everyone in the industry has more demands on their time every minute and technology isn’t making it any better.  Or is it?

A physician friend of mine told me he spends an extra two to four hours a day updating his new EMR system.  This is time he used to spend visiting patients and growing his practice.  Now he is forcing himself to do this in order to comply with Meaningful Use requirements.   This is typical and there is a lot of angst in the healthcare community as a result.

Many technology vendors focus on the technology and ignore the change.  They build systems that are optimized to collect and present data.  Most of these systems fall short as it relates to the user experience.   Designers and developers assume the users think like they do and are comfortable entering information based on how computers work.


Healthcare is a Social Media Feast

In an article about patient portals, the writer comments, “To be honest, I’m not a big fan of calling people and talking on the phone.”  I think this sentence defines the future of healthcare technology and practice.

Healthcare is a highly interactive process.  Social media, the internet, and the on-demand society have redefined most of this interaction.  The statistics and implications regarding social media are staggering.  Kindergarteners are learning on iPads.  Colleges have stopped giving out email addresses.  Generations X and Y consider phone and email passé. Parents have friended their children on Facebook.  Refusing to incorporate these changes into your business is euthanasia for your company.  What does it mean in healthcare?

Thankfully we are already rethinking healthcare.  At least some of it.  Patient portals that facilitate basic appointment scheduling, reminders, prescription renewal, and sometimes access to the patient PHR are a good start.  Giving me the ability to view my immunization records, discharge instructions, and care team information is ideal.  Future features will link my test results to an online encyclopedia written in my language that helps me understand my health and, more importantly, what I need to do to proactively improve.

Creating this vision is not easy.  Much of the information needed is still on paper.  I talked about this in a past blog.  Once we get the majority of healthcare providers digital, the adoption will increase exponentially.

Today, I can manage email, photos, jokes, politics, calendars, contacts, and even directions from my smartphone.  The technology that lets me manage my health is here.   What’s missing is training and motivation.   For decades, the healthcare system taught us to let the doctor own it.  Now, my healthcare needs to become a partnership.  There are many people on my care team who should be using online tools that work my way to get me healthier.

I cannot wait.

MU stage 1 is the cornerstone of a much larger change

In their WSJ article, Stephen Soumerai and Ross Koppel point out that physicians and hospitals have spent billions of dollars on costly healthcare information technologies and have not realized benefits of these expenses.  While everything they are saying is mostly accurate, I believe they are missing the bigger picture.  Meaningful Use stage one is not about direct savings.  Instead, this is building the stage for real reform down the road.

When I was in college, my bank installed an Automated Teller Machine (ATM).  I walked to the front door of my bank, inserted a card, entered a PIN, and retrieved my own cash.  I had access to a single machine that was physically attached to a single branch of my bank.  At that time, this was remarkable technology.  Today, I can withdraw money out of any machine all over the world.  This is an elegant solution with relatively simple data and it took us nearly 30 years to get there.

When it comes to sharing patient information, The US healthcare system is where the banking industry was thirty years ago.  Many of those creating patient chart data do this on paper or electronically within the confines of their local office.  Hopefully we will see this information available anywhere, anytime to people who have the PIN in far less than thirty years.  Let’s explore the evolution.

Earlier in my career, I designed electronic medical record software for one of the largest EHR vendors.  We believed our database was a great competitive advantage.  This was for several reasons.  First the schema was optimized for patient records and ours was better than all others on the market.  Second, our customers would have to spend a lot of time and money to migrate all this data from our solution to a competing solution, so we had created a mini-monopoly with each account based on the difficulty of moving all this data.  All our competition thought the same way.  Because of the competition, the problem has little chance of correction without outside intervention.

The HITECH Act and Meaningful Use stage one are about moving a lot of physicians from paper to online.  The goal here isn’t to realize an immediate improvement in outcomes, but to lay the foundation for these improvements.  Stage two is released and, guest what, it builds the walls.  Meaningful Use stage two is about moving this data out of the physicians’ offices and hospitals and making it available electronically to patients who can then transport it to other physicians and hospitals in a format that can be readily consumed.  Stage three is over the horizon, but I guess it will expand on making patient data ubiquitous.

Everything the authors of the article say is accurate, but I am convinced there is a much bigger picture they are not showing.  In short, the industry will find ways to share highly complex data in far less than thirty years.  Only then will we see the costs savings, health improvements and benefits.  This is a drastic change over the current process.  Drastic change has a lot of speed bumps. Drastic change takes time.  Drastic change often hurts.

Readmission Rates – No Pain, No Gain

The readmission rate refers to patients who are discharged, then readmitted to the same facility for the same medical condition within a specific time period.  For example, if I am discharged with Heart Failure and I return to the same hospital with Heart Failure conditions within 15 or 30 days, that is considered a readmission.

The rate is calculated by dividing the number of readmissions for the time period by the total number of patients admitted during that same period.  The formula for Readmission Rate = Patients Readmitted / Total Patients Admitted.  This is a Key Performance Indicator.

Hospitals are facing penalties from Medicare reimbursements if their 30 day readmissions rate is not reduced.  This is creating challenges for hospitals since many factors contribute to readmission.


BI Usage is Growing in Healthcare

In his article, Healthcare’s Radar Picks up Increased Business Intelligence Activity, Eric Wicklund makes some good points and ponders the best way to use business intelligence to improve healthcare.

Some background:  75% of payers and 44% providers find value in analytics, yet only 26% have BI programs in use.  This shows a tremendous market for BI vendors and enormous potential for the payers and providers who are still on the fence.  The big challenges are threefold.  First, too many in healthcare do not yet understand the concepts of BI.  Second, collecting good data requires more work in an industry that is already stretched thin.  Third, once the data is collected and actionable, healthcare people need to use this data all the time to improve their process.  In past blogs, I’ve talked about the BI Maturity Level and how to get better data.  Today I want to talk about making data more social.