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On Clinical Groupware, Interoperability and the HITECH Bill

Was it not Aristotle who once remarked “Nature abhors a front end that is not connected to its backend?”

In his recent, insightful blog here on Clinical Groupware as an alternative “meaningful use” of IT under the Health Information Technology and Economic and Clinical Health Act (HITECH),  contained in the American Recovery and Reinvestment Act of 2009, David Kibbe commented that the primary purpose for using these IT systems is to “improve clinical care through communications and coordination involving a team of people, the patient included…in a manner that fosters accountability in terms of quality and cost.”

Yet it takes a “connected” health care ecosystem to make this kind of communication possible, and thus HITECH is replete with references to “interoperability” and “data exchange.”  Indeed, the concepts of “meaningful use” and “interoperability” are inextricably linked in HITECH.  For example, Section 4102 states that hospital incentive payments are dependent on demonstrating, “that during such period such EHR technology is connected in a manner that provides, in accordance with standards applicable to the exchange of information, for the electronic exchange of information to improve the quality of health care, such as promoting coordination of care.”

HITECH sets the bar high for hospital incentives in two substantive ways:

Firstly, hospitals and providers will need to do more than simply show that an EHR is “enabled” for interoperability.

Secondly, while many hospitals today may be able to demonstrate data exchange within the four walls of the hospital, traditional hospital integration environments will have a much harder time demonstrating that they can scale to connect to hundreds of community-based physician organizations with different systems and workflows spread across wide geographic areas.

Many health systems have had disappointing experiences with RHIO’s and take the view that a more incremental, even viral, approach to national health information exchange may be first to  connect one’s own health system, including the owned and affiliated medical practices to the hospital, and then to connect one connected health system to another.

Once connected, we believe that health systems will identify many new ways to exploit a Clinical Groupware “frontend” along with interoperability services on the “backend,” in order to extend services beyond the four walls of the hospital to provide real value to patients and providers.  These include: 
A large physician organization that has wisely given up on trying to get all of its physicians to embrace one standard EMR and must deal with several to (a) create a unified view of the patient across all members of the physician organization and (b) to create a common demographic file so that a patient does not need to re-register every time he/she visits a member physician for the first time.  This unified view would include problem lists, labs, Meds, and allergies.

A large health system that would like to pull a similar data abstract from the ambulatory medical records of hundreds of affiliated physician practices, aggregate this information in a repository and make it available to emergency room docs when a patient presents in the emergency room

Managed care plans and providers who want to mine data from both ambulatory and inpatient systems to identify suspects for chronic care management, which can, in turn, would produce better outcomes and higher reimbursements.

The front end to which Aristotle may so presciently have referred is represented by a group of innovative companies that integrate web applications and present data to clinicians and patients to achieve these goals.  David Kibbe mentioned RMDNetworks and SharedHealth as examples of Clinical Groupware, but there are many other companies.  I would cite two more: dbMotion and Ascender.  The latter, in particular, offers a superb suite of web-based tools for P4P analytics and HCC score maximization by managed care plans and providers.

Whether the objective is data analytics and reporting or patient education and coaching, what is exciting about Clinical Groupware bolted to interoperability platforms that handle the backend, like the platform offered by my company, Accenx Technologies, is the clarity and substance they bring to the vision of “cloud” computing in health care.  Professionals and consumers will enjoy the freedom to pick among off-the-shelf component applications that are low cost, easy to implement and can be assembled to fit the specific needs of many types of end users.

For these leading edge organizations to achieve their full potential to improve quality of care, the very same improvements that are envisaged by HITECH, data needs to flow easily from a multiplicity of backend sources to these frontend applications.  National policy setting should anticipate and facilitate this requirement, and we would encourage the HIT Policy Committee to establish an interoperability work group that would, in turn, create a roadmap that is realistic in providing incremental, practical, and financially scalable options for interoperability at the ground level in what will remain heterogeneous communities of applications, consumers and providers.

Charlie Birmingham is Executive Vice President and COO of Accenx Technologies and a former executive in managed care, chronic care management and physician practice management organizations.  Before joining Accenx, he directed the low income Medicare special needs plans for Secure Horizons, then a division of PacifiCare Health Systems.Accenx Technologies has provided hospital integration services for well over a decade and, today, offers a software as a service (SaaS) approach to interoperability and integration for the exchange of actionable clinical data across hospital and ambulatory boundaries.  These “Private Health Information Exchanges,”  empower large health care systems to compete more effectively for the hearts and minds of community-based physicians who are central to delivering the improvements in quality of care valued by these health systems.

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Jay AndrewsMark Schafer, MDRoger WilliamsCharlie BirminghamMD as HELL Recent comment authors
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Jay Andrews
Guest

The dream of the paperless work environment is a definite benefit of having an electronic medical records system.A benefit of electronic medical records is data accuracy

Mark Schafer, MD
Guest
Mark Schafer, MD

Mr. Birmingham makes a great point here. In this digital era, even with an EMR, we are missing critical medical information on our patients. Until we are able to connect our PCP’s with specialists in the community, hospitals, and health plan data, we will still be delivering medical care in a vacuum. Services that can connect our networks together, like Accenx, will be a critical part of our future and will help us to achieve HITECH’s “meaningful use” of EMR data.
Mark Schafer,MD
Medical Director
Bristol Park Medical Group

Roger Williams
Guest

I am a tech guy and my specialty is collaboration, but…
I have seen numerous instances where the “dream” of interoperability and collaboration were “foiled” by simple human nature motivations like those described by “MD as HELL”.
There are many soft challenges to these hard technologies that must be addressed or they will never succeed. They will be deployed if we push hard enough, but success is not deployment, success is realization of the stated benefits.
For most people, security is the first one. But there are many others and for most people they are very real.

Charlie Birmingham
Guest

MD as HELL:
If I take your point correctly, in the midst of the mad dash to the HITECH trough, the value proposition for the Consumer or, should we say, myriad and diverse groups consumers, has been assumed rather than validated. Perhaps, there are meaningful uses of technology that are best deployed when targeted to specific segments of consumers, who would see the value in sharing their data for that purpose.
Charlie Birmingham
Accenx Technologies

MD as HELL
Guest
MD as HELL

As soon as patients realize that all of there records are spread to the four winds, they will cease to share the sensitive personal information required to really take care of them. The value of the EHR will be minimal and its content suspect. If you limit it to just facts, i.e images and results of tests, that might help some. But a patient who is motivated to participate in his/her care will be motivated to keep his cards close to the vest, unless he wants to dance to someone else’s tune. A patient with an embarassing complaint will not… Read more »

David C. Kibbe, MD MBA
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David C. Kibbe, MD MBA

Charlie: I think the key phrase in your post is “what will remain heterogeneous communities of applications, consumers, and providers.” The image you conjure up reminds me of Indiana Jones peering into the crypt and seeing a writhing mass of different colored snakes. “Snakes,” he says. “I hate snakes.” Making the connections between all sorts of different types of data coming from many different legacy sources, and organizing these into a coherent and more standards-based set of flows, such that various EHR and PHR technologies (clinical groupware) can make use of the information, appears a daunting task, but one that… Read more »