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Game Changers Pushing EHRs Forward (Wave mention!)
Greg Gillespie
Health Data Management Magazine, 01/01/2011

http://www.healthdatamanagement.com/issues/19_1/game-changers-pushing-ehrs-forward-41625-1.html?zkPrintable=true

(See bolded section below)

Health Data Management launched the EHR Game Changers Awards program to identify and honor individuals who have been true game changers in the design, advocacy, deployment and development of electronic health records technology.

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Nominations came in from the across the spectrum of the health care information technology industry: vendors, hospitals, group practices, payers, not-for-profit associations, and federal and state governments. HDM's editorial staff-Greg Gillespie, Joseph Goedert and Gary Baldwin-teamed with two industry veterans to judge the awards: Vince Ciotti, principal and co-founder of H.I.S. Professionals Inc., a Santa Fe, N.M.-based consulting firm; and Becky Quammen, CEO of Quammen Health Care Consultants, Shelbyville, Tenn.

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Following are profiles of the six award recipients:



Restless Innovation

Vivek Reddy, M.D., medical director of hospital information technology at the University of Pittsburgh Medical Center

In 2002 when he was an internist just starting his career at University of Pittsburgh Medical Center, Vivek Reddy recalls that he complained loudly about a cumbersome system he was forced to use. That, of course, set him on course for a career in informatics. "I had an interest in computers as just a hobby. But when I got recruited into the technology development here, I realized that each and every decision made was going to have a huge impact on clinical care, and that really got me going," he says. "When we first embarked on this project, electronic records were used in the pejorative-physicians perceived that all the technology was doing was taking away time from their physician/patient relationship. It's been exciting to see how that attitude has changed over the years, to the point where physicians are asking for the technology now."

Reddy has spent his time at UPMC neck-deep in the eRecords project, and particularly in the ongoing rollout of computerized physician order entry technology across the health system's sprawling enterprise.

Reddy feels that he's spent the past nine years walking that sometimes sliver-thin line between ease of use and patient safety. The mantra at UPMC has been to never create an extra step in an I.T.-driven process unless it adds clinical value and therefore increases patient safety.

The trick, he says, is to ensure that the electronic processes make doing the right process-the safest and most cost-effective and clinically-sound process-the easiest to do.

"We have standard protocols, and when they want to deviate from those, they can do so, but it will take extra work and we have to ask you additional questions to ensure there's a justification for it."

Reddy doesn't sleep much, maybe four hours a night. Instead of passing those hours reading books, watching TV or working on his Facebook page, he's combing his thoughts for I.T. inspiration or popping up at emergency departments, checking out how the software infrastructure that's become his passion is supporting patient care. "I spend a lot of time thinking about how we can improve."



Singing a New Song

John Mattison, M.D., chief medical information officer at Kaiser Permanente

Mattison, in his own words, is an "accidental informaticist" who was very happy being a fourth-generation California doctor. But after implementing an electronic record at his family practice, he was drafted into the effort to create an enterprise electronic medical record at Kaiser Permanente. "In 1992 I took a two-year sabbatical from my practice to join the effort, and I assumed that by 1994 we would have everything implemented and I could go back to practicing medicine. After 18 years on the project, I still don't recall making a conscious decision to stay in informatics, but here I am."

In the early days of Kaiser's HealthConnect project, scalability was the issue. "I was naïve in thinking we could build an EHR and simply scale it up ... nothing on the market could do it. So we decided to co-develop a scalable EHR with Epic Systems, but it wasn't even technologically possible to scale our system up until about 10 years ago."

But technology was not the only scalability issue, Mattison says. Kaiser also had to take teamwork to new levels by involving more than 2,000 people in the design of HealthConnect for KP's Southern California Region, which encompasses 5,000 physicians at 13 hospitals and 140 clinics.

One innovation was borne from Mattison and his team's love for music. In the early days of the project, he and some team members would write lyrics about what they were doing and do a show in front of the entire HealthConnect team. When faced with the prospect of training 55,000 users on hundreds of EHR modules, and not enough training space in the region, they hit on a training innovation. "We were familiar with packing up our instruments in big boxes, so we hit on the idea of using those boxes to pack up dozens of PCs and a server and making them training rooms in a box that we could use wherever we needed them. We estimated we saved $20 million during the deployment by using conference rooms in instead of renting training facilities."

Mattison's mission now is to create the next generation of clinical documentation architecture. He made a serendipitous discovery in the early 1990s after reading about Charles Goldfarb, the developer of SGML, or Standard Generalized Markup Language, on which both XML and HTML are based. "I realized that the genius of what he had done was to create a structure where all information has a context, which is exactly how everything on health care exists. The value of representing clinical information in context became very apparent to me."

His and his team's efforts have borne the Convergent Medical Terminology, which includes more than 75,000 concepts. It is incorporated in the underlying architecture of Kaiser's health I.T. systems to support data flow between health care providers. It provides uniform concept definitions so that systems used for labs, vaccines, observations, and other medical data can communicate with each other in a common language, making data transferable between Kaiser Permanente systems and among care teams.

Kaiser has donated the terminology to the International Healthcare Terminology Standards Development Organization in Copenhagen, which owns SNOMED and will distribute CMT across the United States through the Department of Health and Human Services. "I never feel we're finished: seemingly every day the opportunities to use I.T. to improve care seem to expand as the technology does."



Speaking a New Language

Doug Fridsma, M.D., acting director, Office of Interoperability and Standards in the Office of the National Coordinator for Health Information Technology

Fridsma is one of the architects of the ongoing, massive overhaul of the U.S. health care system, but to him his mission at ONC is straightforward: "We are trying to modernize the ways physicians communicate."

But he is the first to admit the execution of that mission is anywhere close to being easy. As the point person on the federal government's Nationwide Health Information Network, and its latest effort, the Direct Project, he understands there is still a long road to travel. "Our goal is to solve real problems by providing real solutions in the form of a platform that enables focused collaboration, and gives the industry tools and resources and direction so the market can come up with solutions. We want to let innovation occur and let 'a thousand flowers bloom' as the saying goes."

Fridsma's and ONC's goal is nothing less than creating the language-comprising standards, services and policies-to enable every care facility in the U.S. to "speak" to their colleagues. Until January 2010, Fridsma continued to practice at Mayo Clinic Scottsdale (Ariz.) and served in the Department of Biomedical Informatics at Arizona State University. But the commute between Arizona and Washington D.C. became too much, so he took a leave to devote himself full-time to ONC's efforts.

His greatest satisfaction, he says, is when he witnesses the "Aha!" moments of physicians using the NHIN framework in the field and understanding the benefits of communicating in a common framework.

"In the first phase of meaningful use we adopted a series of standards that enables people to create a clinical summary that not only can the patient read, but it's in a machine-readable format that conveys that information as well and enables it to be used for decision support and other methods that benefit the patient. The HITECH Act didn't focus much on technology, but on the outcomes. And our goal is not technology for technology's sake, but technology to better the lives of patients. It's a big challenge that we're tackling one piece at a time and getting our hands and heads around each step.

"At ONC, our job is to make sure that value exists in everything we do, that what we're asking physicians to do provides higher quality care and fits in to a logical workflow. If we haven't done that, then we're not doing our job. "



Selling Connections

Glen Tullman, CEO at Allscripts Inc.

When Glen Tullman signed on to be Allscripts' CEO in 1997, the company was focused on medication management and selling e-prescription technology to small practices. Fourteen years and two major acquisitions (Misys PLC and Eclipsys) later, the company is a major player in the electronic health records market with annual revenue approaching $1 billion. And Tullman has spent those years being a relentless advocate of the use of open source architecture for health I.T. software and pushed his company to develop tool sets to connect its EHR software with virtually any device or software on the market.

However, Tullman doesn't think that his company, or the industry, has really delivered on the promise of EHRs. "Health care is fundamentally an information business, and we are not there yet in terms of delivering all that information about best treatments, best medications, etc. EHRs are just one part of what we need to do. We are focused on creating a community of health. Look at Facebook with its 50 million users and you can see what can happen if we truly connect the entire health care community." To that end, his company's mantra is to "design software that plays across any platform."

Allscripts plans to be a force in that evolution, Tullman says, and the driving force will be innovation. "An expression we use around here is that every day the world turns upside down, and someone who thought they were on top ends up on the bottom. And that can happen to any company that loses that hands-on focus on their client needs.

"Today we're in a market undergoing the single fastest transformation of a major sector of the economy in the history of the United States. You have $30 billion in public funding for EHR incentives, and 70 percent of that money is going to be spent in the next three years. And the way I see it, the entire ambulatory sector has disappeared and we're already in a post-acute world. There's no reason anymore for anyone to buy an ambulatory record when the name of the game is connectivity. The new world is accountable care organizations and medical homes and connectivity, and I feel the world is getting turned upside down for a lot of people in this market."

Government incentive programs have taken the EHR market to new heights, but Tullman says his company is still focused on its fundamental mission of improving health care. Allscripts, along with Dell, since 2006 has spearheaded the National ePrescribing Patient Safety Initiative (NEPSI), a $100 million campaign to deliver free electronic prescribing to every physician in the United States. "We know that initiative is saving lives, and I do consider that our ultimate mission. We don't take ourselves too seriously, but we do take that mission seriously."



Small Miracles

Ted Matthews, CEO, Anson (Texas) General Hospital

Anson General Hospital is a small, rural facility that seemed destined to be bringing up the rear in the race for electronic health records. The 45-bed hospital, with three physicians on staff and a miniscule I.T. budget, doesn't seem a likely candidate for I.T. innovation.

But CEO Ted Matthews pored over the EHR meaningful use incentive program and saw things differently. One of his first moves was to contact 11 hospitals in his area that were using EHRs and asking them how much the technology cost. And that was a discouraging exercise. "Even at the low-end, there's no way we could have afforded an EHR," Matthews says. "But the benefits of being able to work electronically were too good to pass up, as were the incentive payments. So we had to seize the opportunity."

Matthews hit upon the idea of a regional health information organization that would provide economies of scale to acquire an EHR. He percolated the idea then reached out to the Texas Department of Rural Affairs, which Matthews considers a "great friend" of rural facilities in Texas, to see if it would support his vision. The TDRA quickly approved a grant of $500,000 in seed money to Matthews for the project, who then reached out to three competing hospitals to pitch his idea.

"If there was ever a group of hospitals that didn't have the resources to install an EHR, it was our group," Matthews says. Nonetheless, 25-bed Stamford (Texas) Memorial Hospital, 20-bed Stonewall Memorial Hospital, Aspermont, Texas, and 14-bed Throckmorton (Texas) County Memorial Hospital all signed on for the RHIO, which purchased the Web-based ChartAccess Comprehensive EHR from Houston-based Prognosis Health Information Systems. "To a certain extent we share the same pool of patients and we offer similar services, but we're spread across our region. To improve patient outcomes, we needed to share what we're doing."

Though everyone agreed a common EHR made sense, that didn't stop the partners from engaging in grueling months of discussions on virtually every aspect of the shared system. "I'll tell you we had some very intense discussions, especially on the clinical side," he recalls. "Every aspect was a debate, and we had quite a few issues to work out. But it was a situation where we really decided to roll up our sleeves and get it done."

The EHR integrates with the billing, laboratory, pharmacy, radiology and other ancillary systems at each hospital, and serves as a shared repository for all clinical data generated by the facilities. The next step for the RHIO is to extend the EHR into local outpatient facilities; in addition, Matthews says four other hospitals in the region have expressed interest in joining the project.

The partners ran the numbers and expect to qualify for $3.7 million to $3.9 million in meaningful use incentive payments. With the hardware, software, maintenance and additional I.T. support, Matthews says that number represents a break-even point for the RHIO. "We could have sat out here and done nothing, or implement four different EHRs. But with all the benefits we're achieving, I'm surprised more small hospitals haven't followed through on the idea of a RHIO."



New Lines of Defense

Mark Mulvaney, network security engineer, information technology services at Boston Medical Center

Mark Mulvaney started doing desktop support not long after high school with the intention of moving toward a career in network/system administration.

But he found the security landscape intriguing, and over time made a shift to focus on the ever-evolving threats to patient data.

"I wanted to satisfy my desire to understand the big picture but also focus on a specific area," says Mulvaney, whose responsibilities include virtual private network security, malware defenses, two-factor authentication, wireless security and hardware encryption.

Boston Medical, a 639-bed teaching hospital, has more than 10,000 mobile devices in the field. Asked what represents the biggest risks associated with using mobile devices, Mulvaney is blunt: the users themselves. "There are not a lot of users who are really aware of the risks involved with laptops, connecting to unsecured wireless networks, leaving things logged on, being aware of surroundings, etc.," according to Mulvaney.

But security professionals can compound the problem by installing software and policies that interfere with the productivity of end-users and tempt many to turn off encryption and other security measures that they perceive to interfere with their work. Mulvaney's response to security threats posed by end-users and malicious outsiders has been to look beyond traditional encryption solutions and move Boston Medical to self-encrypting laptop drives, which move the actual encryption into the hardware devices themselves. By making the encryption invisible to end-users, encryption keys never leave the hard drives and user authentication is performed on the hardware level.

The medical center has deployed the encryption solution on Dell machines with Seagate encrypting drives and Wave Systems management software. The management application ensures that Boston Medical can prove that data was encrypted if a laptop is lost or stolen.

Mulvaney also is concerned about the rise in targeted attacks. "The random viri and malware that users come across is definitely something to take care of, but it's nothing compared with a targeted attack, where the target is studied and analyzed, and specific actions are taken to fine tune an attack. You always have to be on your toes, since the attacker just has to wait for one opportunity."

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