Articles from Life as a Healthcare CIO

1. Accountable Care Organization Measures Explore Life as a Healthcare CIO (Dec 21 2011) Accountable Care Organizations , Quality Improvement , Scoring On December 19, CMS announced the selection of 32 Pioneer ACO organizations, five of which are Boston-based:  Beth Israel Deaconess, Mt. Auburn, Steward, Atrius, and Partners Healthcare.To participate in the shared savings model, we'll need to compute 33 different quality metrics and submit them via survey, claims or the group practice reporting web interface (GPRO).What are these metrics?7 measure the Patient/Caregiver Experience based on survey6 measure Care Coordination/ Patient Safety 6 based on claims or submissions to the GPRO web interface8 measure Preventative Health based on submissions to the GPRO web interface12 measure care to At Risk Population based on submissions to the GPRO web interfaceHere's a comprehensive list of what needs to be computed, how, and when.At Beth Israel Deaconess, we'll use our all-payer claims warehouse and quality data center.   My role as CIO has been to prepare the necessary analytics for panel and population health, as described in this overview As I posted from IHI, our challenge ahead will be navigating the new business model while still maintaining the stability of the old business model during the transition.From a CIO perspective, use this simple equation: ACO = HIE + Analytics  and you'll be ready for whatever tomorrow will bring. (Read Full Article)

   Comment Mentions:   Partners HealthCare   Beth Israel Deaconess

2. The New Metrics for CIO Success Explore Life as a Healthcare CIO (Nov 1 2011) Business Process Improvement , Revenue Cycle When I begin my career as a CIO in 1997, success was function of the basics - email delivery, network connectivity, and application functionality.    I personally wrote code, experimented with new operating systems, and created analytics using web servers, SQL, and ASP pages.In 2011, CIO success is much more complex to measure.  Infrastructure success can be defined as 99.99% uptime of all systems and no loss/corruption/breach of data.   The magical belief in the cloud sets expectations that IT infrastructure should be like heat, power, and light - just there as a utility whenever it is is needed in whatever amount is needed.Application success could be defined as on time, on budget delivery of go lives according to project plans.  Two important forces make this more complex*Consumer software stores set expectations that enterprise software should be easy - we need to fix revenue cycle workflow, isn't there an app for that?*As the economy forces downsizing and efficiency gains, there's an expectation that workflow automation is a pre-requisite to organizational change so there is more pressure on the IT department to deliver application solutions quickly.This all sounds impossible - deliver massive infrastructure with constant change but keep it entirely reliable and secure.   Deliver applications that support business processes in increasingly short timeframes with limited IT and ... (Read Full Article)

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3. What Keeps Me Up at Night, FY12 Edition Explore Life as a Healthcare CIO (Oct 31 2011) Accountable Care Organizations , Business Process Improvement , Meaningful Use , Revenue Cycle Every year I write about the projects and trends which keep me up at night.   Here's my list for FY12:1. Workforce recruitment/retention - $27 billion in stimulus funds from HITECH have increased demand for experienced IT staff to implement and support electronic health records.   In many ways, it's a mini "dot com" boom for healthcare IT experts.    This makes recruiting and retaining qualified staff even harder.  Tomorrow, I'm meeting with a consulting team to formulate an FY12 workforce strategy.2. 5010/ICD10 -  5010 describes a set of X12 standards used for administrative transactions (benefits/authorization. referral authorization, claims).   Payers and providers must support 5010 by January 1, 2012 or risk disruption of the revenue cycle.   BIDMC completed all its 5010 work and is now in final testing with every payer.   Most payer and provider stakeholders will meet the deadline, but significant resources have been pulled from other projects.   ICD-10 implementation is required by October 1, 2013 and I've written about those challenges.  Billions will be spent, many healthcare IT projects will be deferred for the next 2 years, and the end result will be no cost savings (coding costs are likely to increase 50%), no quality improvement, no increased safety, and no efficiency gains.  If we complete the ICD-10 project on time, no one will ... (Read Full Article)

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4. Preparing for a New CEO Explore Life as a Healthcare CIO (Sep 27 2011) Accountable Care Organizations , Meaningful Use , Revenue Cycle On October 17, 2011, Dr. Kevin Tabb MD joins Beth Israel Deaconess as the new CEO.As part of his briefing packet, I needed to summarize all the key IS issues for the next 3 months, 6 months and 1 year.     Here's what I said:IntroductionInformation Systems at BIDMC has a 30 year tradition of industry firsts:First web-based Healthcare Information Exchange, CareWeb - 1997First web-based Enterprise-wide Personal Health Record, Patientsite - 1999First web-based Enterprise-wide Provider Order Entry system - 2001First web-based Enterprise-wide electronic medication reconciliation system - 2007First "Magic button" for health information exchange invented at BIDMC - 2008Pilot hospital to exchange data with Google Health, Healthvault, and CDC - 2008Pilot hospital to exchange data with the Social Security Administration (Megahit) - 2009First hospital to implement clinical iPads - 2010First hospital to achieve federal certification of its EHR systems - 2011First hospital to achieve meaningful use and receive Federal IT stimulus funding - 2011The Information Week 500 Awards ranked BIDMC the #1 healthcare IT organization in the country for 2011.   By the end of 2011, we'll have eliminated handwritten orders and the emergency department will be paperless.We've done this with an operating budget that is less than 2% of BIDMC's operating expenses and a capital budget that has been increasingly constrained.Scope of responsibilitiesInformation Systems at BIDMC is responsible for all clinical, financial, research ... (Read Full Article)

   Comment Mentions:   Google Health   Health and Human Services   Health Data Management

5. The Challenges of ICD10 Implementation Explore Life as a Healthcare CIO (Sep 21 2011) Cost Reduction , Meaningful Use On October 1, 2013, the entire US healthcare system will shift from ICD9 to ICD10.   It will be one of the largest, most expensive and riskiest transitions that healthcare CIOs will experience in their careers, affecting every clinical and financial system.   It's a kind of Y2k for healthcare.Most large provider and payer organizations, have a ICD10 project budget of $50-100 million, which is interesting because the ICD10 final rule estimated the cost as .03% of revenue.  For BIDMC, that would be about $450,000.   Our project budget estimates are about ten times that.CMS and HHS have significant reasons for wanting to move forward with ICD10 including1) easier detection of fraud and abuse given the granularity of ICD10 i.e. having 3 comminuted distal radius fractures of your right arm within 3 weeks would be unlikely2) more detailed quality reporting3) administrative data will contain more clinical detail enabling more refined reimbursementLarge healthcare organizations have already been working hard on ICD10, so they have sunk costs and a fixed run rate for their project management office.   At this point, any extension of the deadline would cost them more.Most small to medium healthcare organizations are desperate. They are consumed with meaningful use, 5010, e-prescribing, healthcare reform, and compliance.   They have no bandwidth or resources to execute a massive ICD10 ... (Read Full Article)

   Comment Mentions:   Health and Human Services   ICD

6. Authority, Responsibility, and Risk Explore Life as a Healthcare CIO (Sep 15 2011) Cost Reduction , Meaningful Use When I became CIO of CareGroup/BIDMC in 1998, I promised to listen to all my staff and collaboratively embrace technologies that would benefit patients while also enabling employee career growth.   The IT team worked together to implement new infrastructure and new applications.   Success led to an upward spiral of success.    Other groups such as Media Services, Knowledge Services, and Health Information Management joined  IS.  We continued to grow in scope and capability.  My sense at the time was that additional authority, budget and span of control were great - more was better.However, in my nearly 15 years as CIO, I've learned that while more authority may bring more opportunities to succeed, it also brings increased responsibility and with it, additional risk.In a world of increasing regulatory pressures and compliance requirements, the likelihood of something bad happening every day in a large organization is high.    The larger your role, the larger your risk.Today in my BIDMC role I oversee83 locations18000 user accounts9000 desktops/laptops/tablets3000 printers600 iPads1600 iPhones450 servers  (200 physical, 250 virtual)1.5 petabytes of storageserving over a million patients.If one employee copies data to a USB drive and loses it, a potential breach needs to be reported. If one workstation is infected with malware that could have transmitted clinical data to a third ... (Read Full Article)

   Comment Mentions:   Health Data Management

7. BIDMC's Accountable Care Organization IT Strategy Explore Life as a Healthcare CIO (Sep 14 2011) Accountable Care Organizations , Meaningful Use , Quality Improvement No one really knows what an Accountable Care Organization is, but many provider organizations want to be one.As a CIO, I've been asked to create the financial and clinical analytics needed to support high value care (low cost, high quality), population health, and care coordination across the community.   I believe that Accountable Care Organizations will be based on healthcare information exchange and analytics.  BIDMC's approach is accelerate our health information exchange work and continue our existing work on financial and clinical data warehouses.Here's how it will work.There are over 1800 clinicians in the Beth Israel Deaconess Physicians Organization (BIDPO).    Some are owned, some are private.   The BIDPO Board of Directors mandated that a certified Electronic Health Record be in use at every BIDPO practice by December 2010 as a condition of participation in payer contracting efforts.   Those payer contracts require "clinical integration" - all clinicians must be knit together by IT.   To accomplish this goal, we implemented a cloud-based EHR which was offered to each practice that did not yet have a certified EHR.   We required all clinicians, owned and private, to send a standardized, structured summary of each visit to a central quality registry.  As each encounter is completed and signed, eClinicalWorks, Altos Solutions, and webOMR, send a very specific Clinical Document Architecture (CDA ... (Read Full Article)

   Comment Mentions:   Pqri   Massachusetts Medical Society

8. Healthcare is Different Explore Life as a Healthcare CIO (Aug 10 2011) Business Process Improvement , Employee Productivity I'm often asked why healthcare has been slow to automate its processes compared to other industries such as the airlines, shipping/logistics, or the financial services industry.Many clinicians say that healthcare is different.I'm going to be a bit controversial in this post and agree that healthcare has unique challenges that make it more difficult to automate than other industries.Here's an inventory of the issues1.  Flow of funds - Hospitals and professionals are seldom paid by their customer.   Payment usually comes from an intermediary such as the government or insurance payer.  Thus, healthcare IT resources are focused on back office systems that facilitate communications between providers and payers rather than innovative retail workflows such as those found at the Apple Store. 2. Hiring and training the workforce - Important members of the workforce, the physicians delivering care, are seldom employed by the hospital.   This is rare if not non-existent in any other industry.  It's as if Toyota built a factory that anyone can use but does not hire or train the workers who build cars.   If someone wanted to create a Toyota with wings and an outboard motor, they would have the freedom to do it.3. Negotiating Price - Reimbursement no longer is based on a price schedule hospitals and professionals can control.   It is based ... (Read Full Article)

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9. The Burden of Compliance Explore Life as a Healthcare CIO (Aug 3 2011) Cost Reduction , Patient Access In a recent email noting the challenges of implementing ICD-10, 5010, eRx, EHR, and HIE simultaneously, Jim Walker (CMIO of Geisinger) referenced a paper in the British Medical Journal by Enrico Coiera ( BMJ 342: d3693, 2011)"Experimental computer modeling has shown that as the number of dependencies increases in a system, the height of the local optimums [of organizational fitness] in a landscape lowers.  In other words, the more dependencies there are in a system, the more likely they will be in conflict (through competing demands), flattening the landscape and diminishing the potential for improving system fitness. Thus the more complex a health system becomes, the more difficult it becomes to find any system design that has a higher fitness."As we draft new regulations that impact healthcare IT organizations, we need to keep in mind that every regulation has a cost in dollars, time, and complexity.  Many people have spoken to me about the burden created by the Accounting of Disclosures NPRM, highlighting three major challenges it creates - an implementation burden that goes beyond the intent of HITECH, an inadequate impact analysis especially on small entities, and administrative overhead that is incompatible with impending budget cuts from the recent debt ceiling compromise plan.Here's a commentary based on a compilation of comments I've received.Challenge 1 – Scope ... (Read Full Article)

   Comment Mentions:   Health and Human Services

10. Preparing for the Future of IT at HMS Explore Life as a Healthcare CIO (Jul 21 2011) Accountable Care Organizations , Business Process Improvement , Meaningful Use Every day I examine my life and think about the roles I serve.   I consider all the unresolved issues in my professional and personal life, then ponder the processes needed to address them. I think about the next week, the next month, and the next year.   Hopefully, I'll be able to skate where the puck will be.As I approach 50, I've become particularly introspective about the challenges in healthcare and medicine that lay ahead.I believe that Accountable Care Organizations, Patient Centered Medical Homes, and the Partnership for Patients/CMS Center for Innovation  will create exponential growth in healthcare IT requirements.  My senior leadership at BIDMC knows that we'll need novel approaches to healthcare information exchange for care coordination and population health management.    They know we'll need new analytics which include cost, quality, and outcomes.   They want new tools to make these analytics available to every stakeholder, both outside and inside the EHR.Furthermore, state infrastructure to support "push" and "pull" data exchanges will need to be built.  The need for Federal standards and policies will accelerate.At the same time, the science of medicine at Harvard Medical School (HMS) is becoming more computationally intensive.  The next generation of whole genome analysis requires tools like BFAST  that  require new approaches to processing and storage infrastructure ... (Read Full Article)

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11. Making Patient Engagement Useful Explore Life as a Healthcare CIO (Jun 20 2011) Meaningful Use Stage 2 of Meaningful Use is likely to include numerous patient engagement features.BIDMC has been offering Personal Health Records since 1999 and we've learned that patient information must be organized appropriately and wrapped in patient education materials so that the data is transformed into knowledge, and is actionable.I recently visited my PCP for an annual physical.  Ok, to be honest it was my first visit in 4 years since as a physician I am uniquely poor at seeking regular preventative/wellness care.   My PCP ordered a Urinalysis, a metabolic panel, lipids, and a CBC from Quest.   Quest has a very cool feature that enables patients to upload their lab results into Microsoft Healthvault and Google Health.Google does a technically elegant but less than useful thing - a list of test names and values in alphabetical order that mixes my urine, chemistry, microbiology, and hematology tests together randomly.    You cannot even tell what is a blood result and what is a urine result.   There are no educational materials.Microsoft organizes the results by panel, which is great.    Although at times, healthcare data should be organized into attribute-value pairs for mining and analysis, presentation to patients requires persistence of the original format of the lab panels as they were ordered.  Microsoft wisely recognizes this.   The only improvement would be ... (Read Full Article)

    Comment Mentions:   Google Health   Microsoft HealthVault

12. Freeing the Data Explore Life as a Healthcare CIO (Mar 2 2011) Business Process Improvement , Meaningful Use I'm keynoting this year's Intersystems Global Conference on the topic of "Freeing the Data" from the transactional systems we use today such as Enterprise Resource Planning (ERP), Customer Relationship Management (CRM),  Electronic Health Records (EHR), etc.  As I've prepared my speech,  I've given a lot of thought to the evolving data needs we have in our enterprises. In healthcare and in many other industries, it's increasingly common for users to ask IT for tools and resources to look beyond the data we enter during the course of our daily work.   For one patient, I know the diagnosis, but what treatments were given to the last 1000 similar patients.  I know the sales today, but how do they vary over the week, the month, and the year?   Can I predict future resource needs before they happen?In the past, such analysis typically relied on structured data, exported from transactional systems into data marts using Extract/Transform/Load (ETL) utilities, followed by analysis with Online Analytical Processing (OLAP) or Business Intelligence (BI) tools.In a world filled with highly scalable web search engines,  increasingly capable natural language processing technologies, and practical examples of artificial intelligence/pattern recognition (think of IBM's Jeopardy-savvy Watson as a sophisticated data mining tool), there are novel approaches to freeing the data ... (Read Full Article)

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13. The Japanese Congress and the Global Health Forum Explore Life as a Healthcare CIO (Feb 28 2011) Editors Choice , Accountable Care Organizations , Meaningful Use This week,  I traveled to Japan as part of a 'US-Japan health care policy dialogue' a partnership between the Center for Strategic and International Studies (CSIS), a Washington-based foreign policy institute, and the Health and Global Policy Institute (HGPI), based in Tokyo.  This collaboration between American and Japanese experts focused on critical areas of innovation and reform in the health sectors of both Japan and the United States - initially payment systems and healthcare IT.  Over the next 6 months, we'll complete an analysis with actionable policy recommendations.As part of the effort, I provided testimony to the Japanese Congress (Diet) and joined an all day Global Health Forum organized by the Health and Global Policy Institute (HGPI), a leading Japanese think tank.The Congressional experience was interesting.  Japan has the longest lifespan of any country in the world, has comprehensive healthcare coverage for all citizens, and has very low healthcare costs - less than half the US expenditure per person per year.   It's challenging to highlight lessons learned from the US which has highly variable quality, high cost, and 40 million uninsured.Luckily, the Japanese agreed that Healthcare IT is to be embraced for quality/safety/efficiency, cost reduction, and job creation.I described the US Healthcare IT program as guided by 5 goals*Improving quality, safety, efficiency, and ... (Read Full Article)

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14. The Direct Project and Patient Engagement Explore Life as a Healthcare CIO (Feb 9 2011) Business Process Improvement , Point-of-Service Collections The proposed Stage 2 Meaningful Use Recommendations include numerous patient engagement features: patient communication preference, electronic self management tools, EHR interfaces to PHRs, patient reporting of care experiences online, and patient generated data incorporation into EHRs.I've long felt that a barrier to patient engagement is the lack of common approach to transfer data between EHRs and PHRs as well as to send reminders/alerts/communications to patients.Patients lack a Health URL or Health Email Address which would enable any EHR or HIE to route data securely among providers and patients.There's a solution in sight, enabled by the Direct project.Last week, Microsoft announced that it will provide a health email addresses (your_name@direct.healthvault.com) to every user of Healthvault. Also, they've provided an innovative way to sign up users who do not yet have a Healthvault account - just send an email to newuser@direct.healthvault.com with a subject line containing the patient's existing email account. The patient will be sent instructions to set up an account and receive their secure health message.All of this uses the Direct S/MIME secure email approach for transport.If Google, Dossia, and other PHR vendors support a similar Direct approach, then all we need to do to support the patient engagement aspects of Meaningful ... (Read Full Article)

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15. A Healthcare Information Services Provider Business Model Explore Life as a Healthcare CIO (Jan 5 2011) I've written previously about Healthcare Information Exchange Sustainability and the need for Healthcare Information Services Providers (HISPs) to serve as gateways connecting individual EHRs.How should HISPs be funded and how can we encourage HISP vendors to connect every little guy in the country?We've started to think about this in Massachusetts.There are numerous vendors promising HISP services -  Medicity (Aenta), Axolotl (Ingenix), Surescripts, Verizon, and Covisint. An HIE needs to include at least one common approach to data transport, a routing directory, and a certificate management process that creates a trust fabric.   Existing HISP vendors have heterogeneous approaches to each of these functions.    In the future,  the Direct Project may provide a single approach, but for now HISP vendors will need to be motivated to adhere to State HIE requirements.An idea that has been embraced by some State HIEs, such as New Hampshire, is to pay HISP vendors a modest fee (under 100K) to support State requirements.   This "connectivity" incentive results in interoperable HISPs, creating a statewide network of networks.Once a standardized HISP approach is supported by multiple vendors, then individual practices need to be connected.   Some practices will be aggregated into hubs by EHR software vendors as has been done in cities such as North Adams (Massachusetts), projects such as the New York City ... (Read Full Article)

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16. Defining Business Requirements Explore Life as a Healthcare CIO (Dec 29 2010) Innovations and Best Practices , Business Process Improvement , Point-of-Service Collections In my recent blog about consultants, I highlighted the work of Robert X. Cringely, who noted that most IT projects fail at the requirements stage.   This is topic worth its own blog post.In my roles at various institutions, I've had the opportunity to work with thousands of highly diverse stakeholders.   Some are IT savvy, some are not.   Some are project management savvy, some are not.  Some understand leading practices for their particular departmental functions, some do not.Here's what I've learned.1.  Automating a dysfunctional manual process will not yield a successful performance improvement outcome.   Before any technology project is launched, the business owners need to understand their own process flows and goals for improving them.2.  If business owners cannot define their future state workflows, software is not going to do it for them.   Sometimes, business owners tell me "I need to buy a wonderful niche software package from XYZ vendor."  When I ask how they will use it, they answer that the software will define their workflow for them.3.  The IT department can impose governance and project management processes to ensure that future state workflows and requirements are defined prior to any procurement processes.  However, the business owners who are least experienced with project management methodology will accuse the IT department of slowing ... (Read Full Article)

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17. The December HIT Standards Committee Explore Life as a Healthcare CIO (Dec 20 2010) Editors Choice , Point-of-Service Collections The December HIT Standards Committee focused on a review of the President's Council of Advisors on Science and Technology (PCAST) report, a review of the Standards and Interoperability Framework Priorities, and a review of NHIN Direct (now called the Direct Project). We began the meeting with an introduction from Dr. Perlin in which he noted that reports by commissions such as PCAST need to be read, not for their details, but for their directionality.  We should ask about the trajectory the experts think we should be on and how/when should it modify our current course.   Dr. Blumenthal also offered an introduction to the PCAST discussion, noting that the White House fully supports and encourages interoperability, suggesting that we should accelerate the priority of healthcare information exchange in the progression from Meaningful Use stage 1 to 3.We discussed the origins and history of the PCAST report.  The President asked PCAST how health IT could improve the quality of healthcare and reduce its cost, and whether existing Federal efforts in health IT are optimized for these goals. In response, PCAST formed a working group consisting of PCAST members and advisors in both healthcare and information technology.The working group held meetings in Washington, D.C., on December 18, 2009, and in Irvine, California, on January 14 15, 2010, as ... (Read Full Article)

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18. What is Our Cloud Strategy? Explore Life as a Healthcare CIO (Dec 15 2010) Innovations and Best Practices In a meeting last week with senior management at Harvard Medical School, one of our leaders asked, "What is our cloud strategy?"My answer to this is simple.   The public cloud (defined as the rapid provisioning and de-provisioning of CPU cycles, software licenses, and storage) is good for many things, such as web hosting or non-critical applications that do not contain patient or confidential information.   At Harvard Medical School and Beth Israel Deaconess Medical Center, we've embraced public cloud technology, but transformed it into something with a guaranteed service level and compliance with Federal/State security regulations  - the private cloud.Here's the approach we're using to create private clouds at HMS and BIDMC:1.  At HMS, we created Orchestra, a 6000 core blade-based supercomputer backed by a petabyte of distributed storage.   Thousands of users run millions of jobs.    It's housed in Harvard controlled space, protected by a multi-layered security strategy, and engineered to be highly available.  We also use grid computing technologies to share CPU among multiple high performance computing facilities nationwide.2.  At BIDMC and its physician organization (BIDPO), we've created a virtualized environment for 150  clinician offices, hosting 20 instances of logically isolated electronic health record applications per physical CPU.   It's backed with half a petabyte of storage in a fault tolerant ... (Read Full Article)

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