In my opinion…not even close. Oh, it can help a little, but no cigar.

Before you say HIT will solve it, you need to be able to answer this question –
What is healthcare? Or; What is good (better or best) healthcare?

As a former healthcare CFO (with prior commercial industry experience) and one who has taught health care finance courses, before you can accurately identify costs you must define the end product. Healthcare is a process, not a product or static outcome.

And, it is a process that never ceases to change. We have been trying to define it for over a century and every time we get even close medical researchers along with the medical industry come up with new protocols, diagnostic tools, and therapies. Until this moving target stops (and I doubt it will) the best you can expect is a rough, very rough, approximation. As far as using outcomes to define it even though we have defined more outcomes today than ten years ago, we are a long way from a complete definition…and they also seem to change (see the recent reports on Pap smear screening, prostate screening, etc.).

And when providers get hit with Pay for Performance (P4P) in the very near future not being able to get at ‘true’ costs will put them at great risk.

Frank Poggio
President
The Kelzon Group

You touched on one key question, the big difference between payment/reimbursement and charges. How’d that happen? Commercial businesses would never do something as crazy as that.

For decades government and insurance companies have rendered payment based on hundreds of pages of elaborate and convoluted calculations. They were the ones that decided way back in 1970 that charges would be used simply as a ‘statistic’ to allocate costs using a formula called RCCAC, that’s the ratio of costs to charges as applied to costs, a key piece of every Medicare Cost report. a real Medicare ditty. They started from the assumption that charges (process) were related to costs (wrong) and would always be related (wrong gain).

As a former CFO I can tell you that it wasn’t hospital CFOs that dreamt up this weird pricing /charge scenario. Since CFOs are charged with legally maximizing reimbursements (not unlike tax accounts legally minimizing taxes) they quickly figured out that if I have an ancillary service like surgery (big money!) with high Medicare utilization that is the first place where I will bump up prices (charges) to increase the cost allocation to Medicare. Meanwhile Blue Cross the biggest commercial payor before 2000 was paying based on UCC – usual and customary charges. It got even worse when DRGs came on the scene.

I find it ironic and unfair to blame the health provider for this insanity. It was the government and payors and still is.

For over forty years the payors have dictated that charges are really nothing more than statistics that are used to approximate costs. When I get questions as you did from friends and relatives I do not try to explain this. I merely advise them that if you do not have insurance, do not have to pay the full charge. CFOs know this and are acutely aware of the unfairness.

My advice is if you get a bill say for $20,000 and have no insurance ask for a meeting with a account manager, or better the CFO, and simply state that you will pay 50% of the bill in thirty days or less, in cash (or credit card) or they can send your account to a collection agency after 90 days. The agency will get 33% of the money (or more). The CFO knows that his charges are a ‘joke’ and will gladly take the 50% rather than fight for a full payment he knows is grossly unfair.

Lastly, I really like your note about costs of operation vs. costs of production. I refer to it as process costing (hospital) versus product costing (commercial). Health providers have no idea about real product costs. Which leads me to note that with the upcoming movement to pay for performance (P4P ) the cost /price insanity can only get worse. I’d explain more but that would be another five screens and Anthony probably thinks I’ve already taken up too many characters.

Nice blog.
Thanks,
Frank Poggio
The Kelzon Group

As a vendor, we do our best to deliver the happy meal. Everything you need: nuggets, fries, apple slices, a container of milk, and, of course, a toy. In the case of a MU vendor, that’s software and services, with shrink-wrapped starter sets of content, and terse guidance on transformation. Clients, even those who have already installed other EHRs and are socially well-networked, plan to consume these meals as you might consume fast food.

This year, the early majority, ready-or-not-here-we-come implementation teams are entering hospitals, clinics and small practices with MU-enabled EHRs, hot from the grills and deep friers.

Fortunately, the metaphor does break down to a degree. The discipline to maintain and communicate problems, allergies and medications reliably and electronically is long overdue. The ONC and the collaborative community process leading to the rules were excellent. Not enough people stop to applaud the content of Stage One, and the process.

To your point, there is a speed-of-change; see the classic book, Managing At the Speed of Change, by Daryl R. Conner (http://www.amazon.com/Managing-Speed-Change-Daryl-Conner/dp/0679406840/ref=sr_1_1?ie=UTF8&qid=1332172785&sr=8-1). It typically requires a minimum of three months per phase for awareness, acceptance and execution-based commitment. By those standards, we’re all running late!

As you point out, one big difference is that those we serve, doctors, nurses, service line managers and so forth, didn’t order that meal. They didn’t order any meal. They weren’t even hungry. And, if they were, many adults wouldn’t select the happy meal. The work of transformation is clear. And, you’re right, it cannot be rushed. Of course, that doesn’t open the door to delaying the transformation work!

I would be very interested in getting an invitation to the Meditech 6.0 group.

Does your facility still use MedHost in the ED and have they been able to get the pharmacy to interface with Meditech 6.0?

Keep dreaming.
Frank Poggio

Let me know once you go live and I will try and get you a invitation to the group. The host will not allow sites that are not yet live to join. Not sure why but I had to wait too. Good luck on your go live.

J

Funny you should state that. We just met this morning as an executive team to review the impact of that decision and how that impacts what we are working on have on our organizational plate. I presented an interesting chart from one of the AMA Journals that showed “overlapping timelines of ICD-10,Meaningful Use, and Health Reform Initiatives”. It was a very visual depiction of a perfect IT storm. If you took the ICD 10 timeline and just moved it a year the big question was will this just mean that we have to move right into IDC -11 (also known as ICD 2015) and what will the financial impacts be overall.

While there will always be the “I told you so crowd”, the ability to utilize these changes as a way to dialog about strategic direction, priorities, and action items is a real benefit. You use it to focus on engagement from a strategic reference and if comfortable in the progress point out that you are ahead of the game and if not use the opportunity to not let up and drive realist dates for defined deliverables. In other words it is what you chose it to be.

Unfortunately for JG, Siemens (SMS) has been saying ‘wait’ for too many years (decades!). As recent market decisions have shown (a la Allegent and others) the client base has just about run out of patience. That’s too bad for Siemens, but those are the facts.

I wish him well but, in my experience, public companies have the least patience of all.
Frank Poggio
The Kelzon Group

Clear & appropriate expectations need to be set up front between the vendor and the client. You can have a flexible configurable solution that will require more involvement on the part of the end users throughout the implementation and after, or they can take the vanilla, out of the box product, implement and use ‘as is”.

Two ways to implement, it depends on how you like your pain:

A) A little pain over a long period: minimally configure the application and clinical content to the practice, then once live maintain a steering committee to evaluate and prioritize customization of the product as they move forward. This gets you up and running fast with minimal decision making, workflow consideration or customization of the product, which you can then gather feedback from your users as to how they want it to work going forward. Users do not really know what they want the application to do until they know what it does and does not do to begin with, therefore by waiting until AFTER Go Live (when the rubber really hits the road) you are saving yourself upfront implementation time & resources, but you will need to maintain ongoing customization resources, development meetings and training.

B) A lot of pain for a short period: Invest time resources and money in your implementation process. Get your project team lined up and fired up, then turn them loose on the software as is. Ask the vendor to demonstrate your most common clinical workflows in the system as is and allow the project team to determine if this is workable or if other workflow processes need to be created. Once the most common are nailed down, repeat the process with your most unusual/complicated clinical processes. Configure the application appropriately and re-test the workflows until acceptable. In the meantime, collect the clinical content required by all providers and insure this is included in your application build. Never forget the 80/20 rule. If 80% of patients/providers need it, it goes in, if 20% it is an exception to the rule. Roll it out, use it, and provide a process for users to submit enhancement requests to the project team for evaluation, prioritization, build & training. This becomes part of how your practice functions going forward.

So I agree, there really is not wrong or right answer, but appropriate, detailed guidance and expectation setting on the part of the vendor, or better yet, your consulting implementation manager, will provide the practice with a robust understanding of what the options are, and the pros and cons to each, thus allowing the practice to choose which path to take based on facts and options, not just a sales pitch or vendor only guidance.

For me, New Years is about stopping and looking at what is working and what isn’t. Your contributions are working for me. Thank you, Anthony.

I am going to make a renewed effort to strengthen my supports. Thank you for reminding me of the importance of family and friends. In our fast paced careers its easy to take them for granted.

Good luck to you in your new role.

You are so on target with the feelings and stress involved in a job search. Your support system can make all the difference. When I chose to not renew a position with an engineering consulting firm I worked for, the economy was good and I figured no big challenge. Unfortunately during the trip for my first interview I got Bell’s Palsey. The whole right side of my face was as good as paralyzed, my speech slurred, and quality of life non-existent, as I even had to wear an eye patch because my right eye would not blink. My spouse at the time was very supportive, though, as were my real friends. I was surprised at how may guy’s that used to just drop by for a beer when I was employed stayed away or ducked calls. Meanwhile, others came by at least once a week and were extremely supportive.

Like your wife, mine said, “Let’s celebrate – your were less than happy and now we can go fishing more often.” It took 9 months for me to get my next gig and, even then, interviews were tough. I got through them, though, and had a good long run with the company that hired me before deciding to take a promotion elsewhere.

In the end, you can’t loose faith and have to enjoy the small wonders that life has to offer.

No software vendor ever wants to use the word ‘sunset’. The second you do, half your client base starts looking at other vendor options, and shortly thereafter half of them will be gone. So, what you do is to buy time –as much as you can – saying we will keep supporting the old system (Horizon), until ‘you’ (really means ‘we’ – see below) are ready to move it to the new one, Paragon. McK will need time, and lots of it. Heck it only took them (and Siemens) some ten or so years to write from scratch a new ERM…and Cerner gave up.

The issue really is not technical scalability. I agree with him, with today’s SQL technology there is no reason why you can’t run a large facility on MS-SQL. Although I would have not have said that six or seven years ago. MS-SQL has come a very long way, enough to give Larry E fits.

The real issue with scalability is in the business logic. Not the screen /user interface, not the communication speed, not the reporting or back office support. To paraphrase a past President – It’s the business logic, Stupid!

As someone who has designed many health care applications over the years, I’ve learned the place where the project bogs down – big time – is in the core business logic. Moving that core to another development tool is a long, tedious and difficult process.

Why? Because over some three decades, thousands of lines of program code have been buried in the system, and I would guess, in many instances, not documented. For example, in an ERM system, the permutations and combinations of how to handle covered and non-covered services can vary from county to county, contract to contract, and on and on. My guess is that as they migrated Horizon from state to state, payor to payor, city to city, etc. a lot of ‘down and dirty’ code was buried deep inside the Horizon executables. Uncovering that is usually a long trial and error process. Many times you do not know it’s there until after you start a Paragon install in a new locale. Uncovering it, figuring it out, finding the documentation, etc…takes ten times longer than anyone expects. (which, by the way, is one good reason to hang on to those old coders, and not re-deploy them).

It’s even more fun in the clinical modules where variations in medical practice change based on what Medical School the docs went to.

So the good news for current Horizon clients: it will be around for many more years. The bad news: don’t expect any new enhancements or quick regulatory updates. And, if it all takes too long, bye-bye clients.

Frank Poggio
The Kelzon Group

However, please don’t be disillusioned that the traditional type of consulting firm no longer exists – ones that do what consultants are engaged to do: identify problems, define and implement solutions using a structured but customized approach that takes unique circumstances into account, collaborate with colleagues and clients, commit to change client organizations in meaningful ways, transfer knowledge, and move on. Although there may only be a handful of these in the industry today, these firms work very hard to vet candidates to qualify their expertise and consulting abilities, and they pride themselves on the results delivered to the client, which requires strong oversight on engagement quality. These firms also invest significantly in professional development for their associates and develop structured methodologies so associates across the organization can apply collective knowledge using consistent, proven approaches.

It’s really up to the client to determine what their need is and partner with a consulting firm with the business model that fits their needs. If an organization needs a person with a specific skillset to fill a hole on its team and is willing to manage and oversee quality of deliverables and work, the staff augmentation model can work well.

If a healthcare organization needs a strategic partner to manage a large-scale project or program, facilitate a vendor selection, deploy a repeatable method for developing and updating standardized clinical content (e.g. order sets), or help set the go-forward IT strategy to support emerging models for ACO-based reimbursement, a more traditional consulting model is the preferred approach.

Right. And I’ll speculate you knew that before you ran your test.

As you noted the challenge is running the app via the iPad but unlike your balanced piece your CTO in his “iPads in Healthcare: Not So Fast” made it appear that the iPad was the problem, not your legacy EMR or the lack of an effective interface.

At the end of the day it comes down to the revenue generators want to use their iPads as an input device having seen or read of successful deployments.

Your data security concerns are quite valid and if Cerner isn’t working on that iPad bridge that recognizes your perspective then it is setting up a potential leak of ‘their/your’ patient data. My bet you aren’t the only CIO to challenge Cerner for an iPad interface and if they aren’t engaged to service their deployed legacy systems then they are failing to see where the market demand will require them to go.

Suggest you just ask them if they remember BetaMax. They may not. Hint.

I find it interesting that the Meditech call is for post go live CIO’s. Maybe I am off base not having had the opportunity to take part in one but I would think those CIO’s in pre-go live status might gain the most from the lesson’s learned.

Thanks for the luck wishes I look forward to joining the calls post 1 JAN.

j

Will I go back to the orchard in question next year? Not if there’s another convenient alternative. If there’s not, I’ll go back, only perhaps I’ll be wearing a disguise

On the flip side I think I see a trend towards customers having higher expectations and maybe not being a “good” customer or as willing to work with company as in the past. I just recently had my car detailed and the company did a really terrible job. In discussing it with them they offered to re-do some of the work but I refused as they had the car for over 8 hours already and was frustrated. In the end I am sure they were as frustrated with me as an unsatisfied customer as I was with them but instead of the dialog being something that resulted in a win – win we ended up in lose -lose situation negatively impacting the relationship moving forward. Perhaps we both just need to put down the frustrations and take 3 steps back so that neither of us cut off our nose to spite our face.

Hope that helps!

Dale

Choose some meetings that your direct reports can attend and represent you, or the department. Get feedback from them as to how things went, and why.

Get direct reports directly involved in the departmental planning, goal/budget setting and evaluation of the results. This works really well when they have a stake in the game and merit and/or bonus pay is on the line.

In your absence and to the extent possible, delegate responsibility to a direct report to act on your behalf.

Support their attendance at training, conferences and participation in user groups.

Utilize feedback mechanisms such as 360 degree programs, where possible.

Above all, have regularly scheduled one on one discussions with direct reports that provide a safe environment for open and frank dialogue.

In contract negotiation, information is real power, too bad it’s overlooked by most buyers.

Frank Poggio
The Kelzon Group

The other strategy we’ve employed is tapping into student talent. Students are eager to pick up projects with a “can-do” attitude, if not simply for the sake of gaining as much experience and exposure as they can. Another benefit of using student talent is that they bring a perspective that’s lost on employees
that have been knee-deep in the industry for as long as they can remember; they can see things from an outsider perspective. That kind of insight is invaluable.

Cheers,
Daisy

Another outstanding, thought provoking and realistic post by Anthony!

Look back at the definition you quoted:
HIE provides the capability to electronically move clinical information among disparate health care information systems while maintaining the meaning of the information being exchanged.

Note “maintaining the meaning of the information being exchanged”. The HIE is not primarily dealing with transportation, it is dealing with TRANSLATION. They translate the data so that it means the same thing to each system.

We have no need for HIEs to do transportation. The internet already solves that. We already can pipe 1′s and 0′s. One EMR can readily communicate with another. The issue right now is translation of data and verification of that data (both the content and source).

And honestly, this issue has been solved in many other realms with standards rather than 3rd parties. The internet has standards to deal with transferring data (like HTML standards) and standards of how to verify sources of data (DNS – which does require oversight by a central agency).

I see the need for a NHIE, but only to uphold proper standards of communication would allow EMRs, PHRs, etc. to exchange information freely without going through a 3rd party “pipe”.

Thanks very much,
-Aaron

Because Halmka is so influential it is important that his advocacy is not only based on a conceptually a good idea, but they also need to be achievable given the other priorities in the healthcare industry.

The topic is also well addressed in this interview:

http://healthsystemcio.com/2011/07/05/john-stanley-svpcio-riverside-health-system-chapter-4/

ONC wants to help. They have announced free software to help track and calculate these quality measures. Under the auspices of the ONC, open source software has been developed that “automates the reporting of Meaningful Use quality measures” for EPs. It is called popHealth. This open source will allow vendors to incorporate the functionality into their systems. See…ONC is from the govt and they are here to help! More info at: http://projectpophealth.org/

Frank Poggio
The Kelzon Group

Regardless of whether physicians are salaried and/or employed by the facility (as opposed to being an independent physician with a private practice), there is still a very real cost to participating in EHR related training and meetings. Just because a physician is employed or salaried doesn’t mean that he/she only works a certain shift and then goes home. Instead, there is always a certain amount of clinical care that has to be delivered at any one time by the physicians as a group.

I am a salaried academic physician, primarily inpatient. If I am in CPOE training, my colleague would have to cover my patients as well as his/hers. Or I have to go back and see all of my patients after the training is over and just return home later that night.

Many employed physicians are on plans that have salary plus incentives based on productivity measures. So time that takes away from patient care also reduces the take home pay of these individuals just as much as it affects the independent clinicians.

Already, facilities are generally more sensitive to the needs of independent clinicians since they can always admit patients elsewhere. The employed physicians don’t have that option and are already feeling more of the brunt of a wide range of institutional demands that the independent physicians will just refuse. Although the institution may think they can keep sticking it to the employed/salaried physicians, they are wrong. You will run the risk of losing your top people and having the rest be disgruntled and burned out. Sooner or later they will revolt either overtly or covertly. Fueling perceived inequities in the ways that salaried and independent physicians’ time is valued will only accentuate problems.

Also, realize that the time spent in CPOE and other EHR training is just the tip of the iceberg. If the facility has an EHR that is poorly designed and has a negative effect on the physicians’ ability to get their work done, complete necessary documentation and provide high quality care, then this will also lead to physician dissatisfaction and resentment. Alternatively, if a CIO shows that the time and skills of the physicians (employed and independent) are valued, that the computer system functions efficiently and effectively, and that training is efficient and not perceived as a waste, then you will promote physician adoption across the board.

Why do so many physicians love iPads? They’re versatile, easily customized to fit the desires and needs of the end user and they make our lives more efficient (and fun). Why do so many physicians resist EHR adoption? Although systems are well-designed, well-implemented, and enthusiastically adopted, many are not. EHRs often don’t have any iPad-like features — they are clunky, hard to customize to meet the needs of our patients, detract from clinical decision making, focus on banal metrics rather than truly improving the quality of care to patients and above all are inefficient to use. Yet they are being rammed down our throats anyway. Simply giving training incentives or adoption incentives isn’t going to change this for employed or independent physicians. It’s the broader picture that needs to be addressed in a thoughtful manner.

Thanks. You can reach me at jgrillo@cphospital.org or 315-261-5200. Let me know how I can help.

j

I really appreciate your insight and taking the time to share your experiences with others. I am a clinical analyst with a small CAH and we are also currently considering a Meditech/ECW solution. I would love to bend your ear regarding your experiences getting those two programs to talk (along with other queries regarding Meditech). Would you mind sharing your email–or if email is not preferred–if I phone you? Thanks again.

Ryan

I have two comments.

As ‘bad’ as many people say meaningful use is, and I for one have taken my share of knocks at it, if it accomplishes one thing and one thing only, that is true interoperability it may be all worth it. Just making big box vendors tow the interop line could solve many problems you mentioned.

As I have written on this blog and others the real job of the CIO is to get the best systems for each clinical area (or suite) and make sure they work together. You seem to be doing that and I commend you. Many other CIOs take the single vendor approach because it is ‘less work for mother’ (Ms CIO). When they do they short change their organizations.

Thanks for a great blog.

Frank Poggio
The Kelzon Group

Your credentials sound strong. It is tough to break into the hospital arena, if you have been away for several years. You may have to look at joining a healthcare IT consulting firm, or even a healthcare IT vendor to get some direct experience in hospitals or health systems. I know several large consulting firms, with outsourcing contracts at hospitals, which have big needs for implementation experts and clinicians in IT. If you want to share your resume, I can give you more specific advice.

Thanks and good luck,
Bonnie

Thanks for your time and feedback…

Dan

http://bit.ly/kuVPUC

1) It is not a new idea, it’s a PHO-physician hospital organization, first tried in the 1970s. Or it’s an HMO (without the insurance piece) first tried in the 1980s and early 90s. So now the government calls it an ACO and says IT can help.
2) Yes, IT can help. But not where it needs the most help. The big barriers to the ACO are not technical, they are political and monetary. Ask yourself, why would a doc (or group of) who is an independent entity work for a hospital?

The irony here is that it was the Feds, AHA and AMA that created the original wall between doctors and hospitals when they set up Medicare Part A and Part B back in 1966. They even put in financial incentives to have them function separately. Now 50 years later the Feds finally figure out it was not a good financial set-up for the government or payers.

Unfortunately not even throwing $100 million at the monster they created is not going to entice the independent doctors to jump on board the institution. If you look at what happened in the 1990s when hospitals were buying up physician practices left and right here’s what you see:
1) Most docs that sold their practices were ready to retire,
2) When a doc went to work as a hospital-based physician, his/her productivity went down by 50% and the hospital lost its shirt!
3) And therefore, hospitals sold or dismembered most of the practices they acquired.

Yet I am a fan of the ACO concept having been a patient not so long ago, and having had relatives suffer thru the incessant lack of care coordination. I just do not think it will get solved without a serious overhaul of the current system, probably requiring some butt-kicking legislation along the way, not at all likely.

Given that, I surely do not think IT people should venture into this fray, let alone suggest it can be ‘solved’ via more IT.

The first is creating semantic and process interoperability for cumulative diagnostic test results by using a standardized reporting format that can display results, not as incomplete, fragmented data, but as complete, clinically integrated information. This is one new way to drive performance and quality up and testing costs down.

The second is ensuring identity integrity for both patients and caregivers by using low-cost, maximally accurate iris scanning technology.

Not only were self developed applications ignored, as in the IHC case, but till the last minute they ignored best of breed and suite solutions. Which leaves us with a certification process that is at best a hodge-podge. As an example look at a major vendor’s certification list of certified criteria for an anesthesia system. The vendors EHR Module was certified to meet a quality measure for ER wait times! Someone please explain how an anesthesia app is able to track ER wait times???

If this process is not slowed down, and in some cases redesigned, in time it will collapse under its own weight. I firmly believe they are building this boat as it floats down river, I just hope they get it done before they get to that big waterfall.
Frank Poggio
The Kelzon Group

Consider this comment (i.e. one month past your original post,) to be a real test of who chooses to use RSS comment feeds!

I think the lumping and splitting over “what AMCs are good for” has gone too far.

I contributed to that, so I’ll apologize here. And offer a better framework for consideration.

Elsewhere, I have written about my daughters care at four AMCs, seeking a diagnosis and therapeutic intervention for one, fixed, congenital issue requiring pediatric orthopedic intervention. The post was titled “Reality and Relativity.”

By the end of the story, the four AMCs delivered not just a second opinion or a third, but a total of four, different opinions and resulting recommendations. Two of the those four were using relevant pre- and post- surgical experience (evidence); those two were the same that had strong financial endowments. The reimbursement system does not pay for gait lab studies that is critical to collect the objective measurements that underlie adequate assessment. The AMCs closest to my home, as a result reimbursement and no endowments for gait labs didn’t offer gait lab services. Those with endowments, more than a dozen centers, each do between 500 and 1,000 patient assessments per year, and they’ve been doing so for more than a decade. The science goes back to the 1940s and computerized measurement was being done since at least 1973. My daughter got a great result, because of three factors: a) a highly dedicated and disciplined pediatric orthopedic surgeon; b) an AMC with unusual vision clarity around patient needs; and c)an adequate endowment to support the mission.

Bottom line: The question, AMC or not AMC is the wrong framework.

What’s the right framework, then? It’s those same three factors above.

In the 2000 HBR article “Will Disruptive Innovations Cure Health Care?” by Clayton M. Christensen, Richard Bohmer, and John Kenagy, an objective that caught my attention was this:

“Create—then embrace—a system where the clinicianʼs skill level is matched to the difficulty of the medical problem.”

I have participated in care delivery in about a half dozen AMCs, often particiing at the highest level of a medical license (to use of currently popular phrase). I have advocated for patients and family members in several more AMCs, as well as several very well tuned non-AMCs. As Christensen, Bohmer, and Kenagy describe, it’s the

1) the matching of clinician skill to the complexity of the problem,

2) the “organization’s organization,” i.e. is it truly patient centered, and

3) the impact of the reimbursement model that make the difference.

AMCs can impact all three; those focused on using adaptive design can and do consistently outperform any delivery system, AMC or not. AMCs that fail to address each of those factors deliver flawed processes and outcomes.

Each of those three is worthy of it’s own blog post to elaborate! Thanks again for drawing us into a useful dialogue, Dale.

-Joe

Yes, I think, in general, I agree. If I suffered from an unusual disease or syndrome– what I call the small n diseases– I would probably seek treatment at an AMC. But, an IDS like Intermountain and Kaiser have fairly impressive outcomes with the small n diseases, too, along with a good track record of chronic disease management with complex co-morbidities. Dollar for dollar, at the macro-economic level, I feel that an IDS provides a better overall return on investment for the healthcare dollar. Johns Hopkins would be at the top of my list if I were desperately searching to treat an unusual small n condition, but I would make sure that I was being treated directly by one of the veteran research staff, and not his/her proxy resident.

I’m ENORMOUSLY grateful for and proud of my past position with an AMC. That said, there is always room for reflection and improvement– it’s time for the AMCs to start borrowing concepts of clinical operation from the integrated delivery systems…or maybe we should simply change our expectations and let AMCs focus exclusively on the small n.

Thank you, Gerry.
Dale

I agree that chronic disease management is not the focus of NIH-funded AMCs. However, I do have to say (I now consult for the NIH and have served as a Section Chief there in the past) if you are funded by the NIH as a physician-scientist, you will know the “bleeding edge” of your discipline better than any other physician. Only 5-7% of grant proposal submissions are funded by the NIH, and this represents the cream of the crop. If I had a deadly form of cancer or degenerate neurological disease, I would go to a large AMC, because my odds of survival would be better. You can look at the data from the Association of American Medical Colleges for confirmation.

Kind regards – Gerry Higgins

As I travel around the healthcare world, I’m still amazed at what Intermountain achieves that most of the industry still struggles to simply embrace, conceptually. Whatever success I’ve enjoyed in my healthcare career, I owe to what I learned from my beginnings at Intermountain, on many different levels.

We actually derive LOTS of data from our EHR and implementing change in our clinical processes occurs via our clinical systems. With the introduction of new tools from our development efforts, the EMR is very important.

With this said, you are correct it requires a lot more than simply an EMR to achieve excellence in clinical care. However, the benefits being achieved by organizations such as Kaiser, Giesinger, Mayo, the Univeristy of Utah, Montefiorre, Sentara, and many, many more with an EMR suggest there is tremendous value in this rapidly improving technology.

There are no magic bullets…but it is exciting to see the increasing use of clinical systems which are making a difference in healthcare delivery.

Intermountain has achieved success through all the points you make PLUS the fact we have advanced (and improving) clinical information systems…not to mention some pretty great knowledge leaders who still work here.

The Advisory Committees are necessarily comprised of both visionaries and realists. Their product ultimately needs to meet both ends. The need to connect assumptive goals (stretch) with a place that can be bridged from today.

I recognize the frustration of the “poor state” commenter, but respectfully point out that rushing into something unproven a la Dixie Baker/Staff Huff’s perspective, creates the possibility –and based on experience with massive implementation of federal mandates – some would assert even a probability of failure.

Who is at risk of that potential failure? The patient! It would be contrary to the Policy and Standards committee’s own principles to recommend something that carries a knowably serious possibility of putting patient safety at risk.

The key to paradox is recognizing it. Failure to do so predictably leads to abuse, whether it’s managing subordinates, children, or translating regulation into prudent policy.

Frank Poggio
The Kelzon Group

I reach the opposite conclusion of the workgroup member who made that comment. If the quote included the word “industry”, so that it read “the industry was in a poor state of affairs”, then it’s simply incorrect. Industry in a good and healthy state knows that a proof-of-concept, while usually essential, does not reliably portend scaling issues. Only some of those are technological. The broad, international success of IHE exemplifies that industry can and has produced true interoperability and meaningful standardization.

Similarly, if the quote was actually saying that “the government regulatory and industry complex was in a poor state of affairs,” that would be incorrect as well. The ONC’s S&I framework has incorporated a staged-approach, concordant with respect for pregnancy-type processes that are irreducible. It has also been carefully kept open and inclusive, like the industry’s IHE process.

Anthony, your account sounded balanced (as usual). It would appear that what we’re seeing is responsible, adult supervision with respect to a regulatory process.

The slur on industry or regulatory process being “a poor state of affairs” is simply and profoundly ignorant. Was that taken out of context?

- Research
- Teaching
- Patient care delivery

If you put these in a vend diagram there is a cross section sweet spot…but rarely is it realized. Typically the research docs wants/needs patients for the data they bring (a la grants), the teaching doc sees patients as teaching fodder for the students & interns, and the true clinician sees the patient as a ‘customer’. A customer orientation for one out of three ain’t good and finding a faculty MD that can keep all these in balance is extremely difficult.

So now the government (which historically has significantly underwritten all three roles) says…become an ACO…get more patient focused…what a challenge for the AMCs. A Medical School Dean I used to work with described the balancing as ‘herding cats’. Good luck to all AMCs.

Very impressive!