Inside Healthcare magazine is pleased to present the points of view of many different industry stakeholders. If you would like to contribute your own guest blog to our site, please contact the editor at jamie.morgan@phoenixmediacorp.com

By Charles L. Fred

The Centers for Medicare and Medicaid Services (CMS) have helped define a “good marriage” in terms of successfully adopting an EMR. Care providers now must demonstrate “meaningful use” of an EMR by meeting specific thresholds for a number of objectives. CMS have established the objectives for meaningful use that eligible professionals and hospitals must meet to receive incentive payments.

This process of meaningful use is highly dependent on healthcare professionals becoming proficient in the new technology quickly. Let’s begin by looking at adoption as a reinforcing process that occurs as a learner accumulates experience with the new application. Let’s also attempt to move beyond an event-based learning approach that creates this tension in healthcare.

Consider the value of teaching caregivers to use EMRs through role-based simulators. Simulation provides an opportunity to practice in a real-life environment without real-life risks and consequences. Caregivers learn inside their actual EMR application, which is critical for learning workflow and gaining new knowledge about the system. They only learn tasks that are applicable to their role. For example, physicians learn to enter orders and write prescriptions, but don’t have to sit through training on functionality they will never use. It shortens the learning curve by ensuring caregivers are proficient in the use of the system, ultimately feeling confident enough with the technology to adopt and use it to provide care.

Simulation has been used in other industries for decades. We should capitalize on design rigor that has been established in aeronautic simulation. In the 1980’s Boeing was manufacturing airplanes faster than they could teach pilots to fly them. We face a similar challenge in healthcare as the pace of technology development demands more time of clinicians. It is possible to dramatically decrease the time and stress of technology adoption. We can better serve clinicians through the rigorous design of their learning experience. The following are six guidelines for creating that exceptional learning experience:

Short. Providers have less time today as a result of few resources, healthcare reform, and even the implementation of EMRs. The simulations must be easy to access and take less than 15 minutes to complete. Consider that each provider, depending on specialty, may take several of these 15-minute simulations, but will do so as time permits and urgency to learn the new application trumps other priorities.

Relevant. If the workflows in the simulations are not the actual ones that will be used by the provider – game over. This is the greatest impediment obstructing software suppliers from creating generic simulations. When simulations accurately represent the actual workflow of the provider, then the learning can begin.

Role-specific. Simulations must target the actual role and its relationship to the application. Job one in good simulation design is to map the role differences across specialties, locations, and shifts. This step enables a targeted delivery of the learning and sets up a more accurate process for measurements and continuing education credits.
Task centric. Feature and function simulations have little value. Instead, connect the role to those tasks within the application that drive proficiency. The 80/20 rule is a near perfect gauge for the identification of which part of the application to simulate. Less is more in this case, as 20 percent of the tasks within an EMR drive 80 percent of daily use for nearly all roles. Drive toward simulating the 20 percent and support the other tasks with online reference materials and other creative delivery mechanisms, including short videos and podcasts.

Disposable. Strongly consider an update and sustainment strategy that renders out-of-date simulations disposable. Another advantage to short simulations is that they are easily reproduced. An expensive and poor alternative is to spend considerable time with a content management system that manages content that never will be used again.

Mobile. Simulations that will work in healthcare should be installed on the device used by the end user. For many providers, this is a mobile device. In short order, the static devices in healthcare will be obsolete, so begin planning today for a mobile learning environment.

The Medical Group Management Association recently published research on the correlation between EMR adoption, decreased operating costs, and increased physician productivity. The marriage, not the wedding, ensures increased quality of care. Improving the way in which healthcare professionals adopt new technologies must be a high priority. We are committed to help them spend less time learning technology and more time treating patients. This is meaningful work.

Charles L. Fred is managing director of The Breakaway Group, A Xerox Company

Please check the Nov. 26 post for part I of this series.

Inside Healthcare magazine is pleased to present the points of view of many different industry stakeholders. If you would like to contribute your own guest blog to our site, please contact the editor at jamie.morgan@phoenixmediacorp.com

By Charles L. Fred

The initial wedding was remarkable. The eventual marriage, however, had Kardashian consequences.

We often hear the stories of healthcare providers preparing for the go-live event of their electronic medical record (EMR) without a long-term plan to ensure that the technology will support improvements in clinical care. The wedding analogy as it is applied to healthcare stems from a myopic focus on the installation and implementation of software. Instead, we need to apply our attention and diligence toward adoption and use of the technology: the marriage.

Like a typical wedding, an EMR “go-live” is expensive, labor-intensive, and beyond stressful. The most important similarity between a wedding and a go-live is the fact that they are single points in time – an event – that is poorly correlated with long-term outcomes.

A successful go-live should be celebrated, but must be viewed an important one step along the journey to technology adoption and, ultimately, to improved outcomes. Rather than creating false expectations, we enter this journey with our eyes wide open to the work and commitment required to achieve the clinical and financial outcomes that improve healthcare.

In 2009, The Breakaway Group began a series of research studies to examine the barriers and facilitators of technology adoption in healthcare. We discovered four critical areas that affect an organization’s success: engagement of leaders, proficiency of end users, measurements of outcomes, and a process for sustainment and optimization.

The learning strategy was central and critical. The wedding analogy was again insightful. Healthcare is a 24/7 business, and emergencies are a common occurrence. Training events are missed, clinicians don’t attend, and new employees are out of luck. If you miss the wedding, you miss the entire experience. When learners miss the event, they miss the opportunity to become proficient in the technology. Imagine the value of ensuring the learning process was repeatable, measureable, and adaptable to the healthcare environment.

The Breakaway Group first recognized the differences in outcomes between organizations that focus on implementation and those that focus on adoption as a result of our research. We learned that the gap between perceived adoption and actual use of the application is more common than expected, and is often overlooked as the organization struggles to understand the often mediocre outcomes from its implementation. In many healthcare organizations, there continues to be an emphasis on implementation rather than on adoption – many have installed critical functionality in the EMR, but have not yet adopted it. Adoption of an EMR requires a sustained effort to achieve the outcomes promised by computerized order entry, decision support, and more accurate clinical documentation. In the area of clinical decision support (CDS), we found 84 percent of the organizations surveyed had installed CDS, but only 41 percent had fully adopted the functionality. Finally, in the area of computerized provider order entry, we found 73 percent had installed it and only 64 percent had fully adopted it. Good success rate on the weddings; plenty of work to do on the marriages.

Charles L. Fred is managing director of The Breakaway Group, A Xerox Company

Please check back tomorrow, Nov. 27, for part II of this series.

Inside Healthcare magazine is pleased to present the points of view of many different industry stakeholders. If you would like to contribute your own guest blog to our site, please contact the editor at jamie.morgan@phoenixmediacorp.com

By Heather Haugen, PhD

After the successful implementation of a new technology, our tendency is to move on to the next project. We are busy juggling multiple projects and we actually feel some relief in moving it off our list of highest priorities. What we need is a plan to sustain the changes required long-term. A sustainment plan addresses two important areas. First, it establishes how the organization will support the ongoing needs of the end users for the life of the application. This includes communication, education and maintenance of materials and resources. Second, it establishes how and when metrics will be collected to assess end-user adoption and performance. Lack of planning and execution in these two areas will lead to a slow and steady deterioration in end-user adoption over time.

Effective sustainability plans require resources, time and money. Keep in mind that adoption is never static; it is either improving or degrading in the organization. A series of upgrades can quickly lead to decreased proficiency among end users – over time this can completely erode the value of the application. Leadership must plan for the investment and fund it if their ultimate goal is improved performance. Most organizations only achieve modest adoption after a go-live event, and it takes relentless focus to achieve the levels of adoption needed to improve quality of care, patient safety and financial outcomes. Sustainability plans are most successful when they are part of the initial budgeting and planning stages for EMR.

Sustainment is more than simply maintaining the status quo. If sustainment becomes a passive process of maintenance, it is a waste of resources. Metrics are the differentiating factor between a highly effective sustainment plan and one that is just mediocre. End user knowledge and confidence metrics serve as a barometer for their level of proficiency, providing the earliest indication of adoption or use of the application according to the organization’s best practices. Ultimately, performance metrics are powerful indicators of whether end users are improving, maintaining or regressing in their adoption of the system. If we get an early warning that proficiency is slipping, we can react quickly to address the problem. These metrics ensure the organization is progressing toward high levels of adoption, overcoming barriers and gaining the efficiencies promised by EMR adoption. Metrics act just as the scale does in long-term weight management; they are the first indicator that we are falling back into old behaviors that are not consistent with sustainable adoption.

Metrics also keep us on track when performance metrics do not meet expectations. Let’s consider two different scenarios to illustrate this idea. In both scenarios, the go-live event was successful, but specific performance metrics do not meet expectations in most cases, the performance metrics are not achieved because the system is not being utilized effectively. This may be due to inadequate training and therefore lower proficiency, or a problem with the actual performance by end users in the system. Measuring end-user proficiency allows us to identify “pockets” of low proficiency among certain users or departments and make sure they receive the education needed. Once users are proficient, we can refocus our attention on the performance metrics. The second scenario is less common, but also more difficult to diagnose. Sometimes users are proficient, but specific performance metrics are still not meeting our expectations. In this case, we need to analyze the specific metric. Are we asking the right question? Are we collecting the right data? Are we examining a very small change in a rare occurrence? There may also be a delay in achieving certain metrics, especially if the measurements are examining small changes. A normal delay can wreak havoc if we start throwing quick fixes at the problem. In this situation, staying the course and having confidence in the metrics will bring desired results.

EMR adoption is hard work, but the outcomes are worth the effort!

Heather A. Haugen, PhD., is the corporate vice president of research at The Breakaway Group, A Xerox Company. She can be reached at hhaugen@thebreakawaygroup.com.

Please check the Oct. 25 post for part I of this series.

Inside Healthcare magazine is pleased to present the points of view of many different industry stakeholders. If you would like to contribute your own guest blog to our site, please contact the editor at jamie.morgan@phoenixmediacorp.com

By Heather Haugen, PhD

Several years ago, a reputable IT vendor offered us free use of their software. The software provided monitoring of equipment that would be valuable to us. Initially, we were excited. The functionality aligned with our needs exactly, and the application was robust enough to grow with us. We had a need and the software fulfilled the need. The system served IT directly, so our director of IT led the implementation and kept our senior management team updated on the progress. We couldn’t wait to have access to the dashboard of data promised by the vendor. Months after the implementation, we were still waiting.

Although the “free” price tag was alluring, we quickly recognized that the actual maintenance costs and labor required to make the application truly valuable to our organization were lacking. This story drives home a concept that we all understand, but often overlook. Underestimating the “care and feeding” required to maintain a valuable investment puts the entire project at risk. It sounds simple, but we all need to remember the importance of sustainability even when initially getting excited about the value of an investment. It is common to under-appreciate the effort it will take to maintain the value of something, even something that initially costs nothing.

Let’s consider the shift in thinking required to move from implementing an electronic medical record (EMR) to maintaining high levels of adoption over the life of the application. This is analogous to the shift required to sustain long-term weight maintenance after successful weight loss. The percentage of overweight adults in the United States is staggering and continues to rise. Today, more than 66 percent of adults in the United States are overweight and 59 percent of Americans are actively trying to lose weight. But the problem isn’t weight loss! Many of us have successfully lost weight, but can’t keep the weight off. As a matter of fact, we regain all the weight (and often more) within three to five years. This isn’t a complex concept: dieting doesn’t incent long-term lifestyle change, thus the weight re-gain. To be successful long-term, people need to practice weight management behaviors actively – for years, not months.

In the world of EMR adoption, we have taken the “dieting” approach to implementing new software solutions in our healthcare settings for too long. We prepared for a go-live event. After go-live, we fall back into our comfortable old habits – resulting in work-arounds, regression to ineffective workflows, insufficient training for new users, poor communication and errors. The process of adoption requires a radically different discipline, and the real work begins at go-live.

Heather A. Haugen, PhD., is the corporate vice president of research at The Breakaway Group, A Xerox Company. She can be reached at hhaugen@thebreakawaygroup.com.

Please check back tomorrow, Oct. 26, for part II of this series.

Inside Healthcare magazine is pleased to present the points of view of many different industry stakeholders. If you would like to contribute your own guest blog to our site, please contact the editor at jamie.morgan@phoenixmediacorp.com

By David Finn

Today’s healthcare providers must continue to diligently require business associate contracts from their financial institution partners when there is access, use or disclosure of personal health information (PHI). This happens in cash management with lockbox arrangements, with EDI operations and in other areas. Here’s an example: when a bank’s lockbox is used to gather, collect and streamline payments and it includes processing the Explanation of Benefits (EOBs), this will result in the application HIPAA. That is because much of the information in the EOB is individually identifiable health information.

The biggest banks may have a clue about what is coming but I’m not sure all the financial institutions or smaller banks understand what HIPAA/HITECH is all about or the difference between Covered Entity and Business Associate let alone the difference between “the use or disclosure of protected health information on behalf of, or provides services” and “incidental disclosure”. And certainly not in terms of their operations and obligations:

• Smaller banks may not be ready when their healthcare clients – health plans and healthcare providers – ask them to sign a HIPAA business associate contract; and

• Under HITECH, the penalties for non-compliance have been expanded into the business associate category, so the risk level for payment processing in healthcare has increased – - for the financial institution

Most banks already have the security and privacy precautions called for under the federal regulations related to banking but these don’t align perfectly with HIPAA/HITECH. In any case, a gap assessment should be done and calls for “proof” are not uncommon from the provider side and may be written into the BAA. Financial institutions need to be prepared to provide proof.

Here are some of the things that will be impacted: rules for the eligibility and claim status transactions have a compliance date of Jan. 1, 2013. Other rules will cover electronic funds transfers and electronic remittance advice (2014); and claims/encounters, coordination of benefits, enrollment/disenrollment, premium payments, attachments, and referral certification and authorization (2016).

So, here are a couple good things about all this healthcare reform and financial institutions: 1) The use of Electronic Health Care Payments should drastically increase; and 2) financial institutions can help health plans and providers become more efficient (as in reduce costs) by using electronic payments instead of checks.

I’m guessing most of you have seen “ACH” on a bank statement. ACH is the Automated Clearing House and that is how all that money your employer provides you winds up in your bank account (unless you still get a check – - I can’t remember the last time I actually saw a paycheck). NACHA is the private, rule making body that administers the ACH network and after 2014 most of those healthcare payments will have to be in HIPAA standard form.

I won’t try to explain how Electronic Funds Transfer works today except to say there are currently two standards CCD+ (which carries no PHI) and CTX and that the CTX carries the EFT (payment instructions) and the ERA payment information together over the ACH network and either format can be specified in the 835 payment instructions. The good news is that transmission of ACH payments is secure – - these payments are already subject to strict data security controls – - separate and apart from HIPAA and financial institutions have to attest to compliance with these rules. The ACH network is closely audited and Federal regulatory agencies and while the laws are not healthcare specific the protections are applied broadly.

Like HIPPA, the rules require that reasonable safeguards be implemented but doesn’t dictate specific security solutions. Financial institutions must document and implement a security program that includes administrative, technical and physical safeguards (sound familiar?) appropriate to the size and complexity of the organization and the scope and nature of its activities. And again, just like HIPAA, the safeguards must be driven by a Risk Assessment (what a novel idea!).

Most financial institutions don’t provide Business Associate type services to Covered Entities and don’t routinely access PHI to perform the services they do provide. They do banking stuff so they won’t likely be a BA. And lest we forget, lenders may not use, under law, medical information to make credit decisions.

All that said the transition will not be without some effort (and cost, for any CFOs that might be reading). Patient Accounting systems will have to comply with many of the banking standards. Payer EOBs are (still) not standardized. If a BA is required, there will be a lot of “banker education” around HIPAA and then there is the testing. Having looked at BAAs from both sides now, I’m certain the Bank’s BA won’t look anything like the Covered Entity’s – - whose data is at risk here. And given that HITECH expands the risks for Business Associates (as in “the bank”), well, this could take a while.

PPACA, which as of today is still the law of the land, added accountability for financial institutions that provide medical lockboxes and other special services to healthcare providers and payers. HITECH modified and amplified the HIPAA provisions that affect financial institutions. Financial institutions will need to be knowledgeable about HITECH and assess whether these provisions impact current or future services. While the regulations specific to their industry give them a good start, they will need to do assessments/gap analysis and review internal policies, practices and procedures to help ensure compliance. It is not too soon to start.

David Finn, CISA, CISM, CRISC is the health information technology officer for Symantec. Prior to this role he was the chief information officer and vice president of information services for Texas Children’s Hospital. david_finn@symantec.com.