EHR Information Lifecycle Model

For those of us familiar with information architecture, records management, enterprise content management, archival, retrieval, and search, the notion of an Information Life cycle is central to the concept of managing information.

This is not a new concept, but it's one that the Electronic Health Care industry seems to still be figuring out. It's also one that organizations need to start figuring out as they tranisition from a paper model to an electronic model. And I'm going to warn you -- if you are in the process of an organizational transition to electronic medical records, and haven't yet considered ILM, this post is going to hurt a little.

At present, the majority of EHR systems that are Commercial Off The Shelf (COTS) have internal mechanisms for user signing, time and date stamping, and then finalizing information. Often times when a clinician is working on a record, that feature is represented by a "file" button within the EHR system that changes the "state" of that document from draft to final. But what did that really do? Obviously, it depends on the system you are using, but here are some generalities.

On one hand, yes, it "saved" the data and created a final version, and then essentially stored all that data back in the database. But is it really a document? What if you want to retrieve that document? Where is that document located? Is it in multiple tables within the backend SQL database, and then reconstructed through a report viewer? How is the "state" of that document preserved?

And how and when does one migrate that document to the next phase of the information lifecycle -- the archival and long term storage phase? And where is that place? What is organizational policy and HIPAA regulation around document retention for the type of document that you have just created? How do you remove that document from your active environment, to an inactive environment in order to conserve space and performance? Where does it ultimately end up?

Any organization familiar with the overflowing chart room, a basement filled with boxes, and the clumsy attempt to scrounge up a specific piece of information in a cluttered room has experienced information lifecycle management in its most basic form.

Now, take the analogy and apply it to an electronic environment and one can quickly see that you've not necessarily solved your document management challenges simply by implementing an EHR - you've just created a different context in which those same challenges exist. Instead of a basement filled with boxes, you've got an old Maxtor 100 GB drive stuck in an outdated server somewhere in the basement.

And this is why, as a part of considering the implementation of an EHR, organizations also need to consider ILM. Do your electronic charts migrate outside of the EHR into a longer term storage solution? How does your EHR actually re-construct an electronic chart? How easy is it to print? How proprietary is the information stored within the system? Physically, where is the data stored? Does your organization understand and have policies dealing with geographically diverse data storage for catastrophic events? Does your organization understand access and performance curves related to frequency of accessing electronic information and how that relates to the cost of storing that information in an active utilization environment vs. migrating that data to a slow disk, low power consumption, stable media environment?

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Patient Portals

Even as organizations work toward transitioning from paper to electronic medical records, the landscape of health care continues to shift all around us. One of the ongoing evolutions in Health Care is managing patient access to information.

Traditionally, medical organizations provide hard copy records to patients upon an exchange of a Release Of Information, or ROI. The patient does this by walking in, signing a document, and then the doctor or hospital provides specific records from the chart to either the patient, or another provider.

The recent push for electronic records ads a new dimension to this process, as more and more organizations create medical records in purely electronic formats. This creates both opportunities, as well as challenges, as both organizations and consumers try and figure out how this dawning age of electronic medical records can improve accessibility to information, manage privacy, and improve quality of care - while at the same time maintaining the highl level of simplicity offered by a traditional paper chart.

For a great discussion on Group Health's Patient Portal, a MCO in Washington State, check out this Health Care Informatics article -- Patient Portals

Operability vs. Interoperability

I can't help but paraphrase a quote that Rendell Requiro, a Technology Analyst at Monterey County quipped when asked about the daunting challenge of creating an interoperable behavioral health care system capable of sharing cross organizational data - "We need to achieve operability BEFORE we can worry about interoperability."

His comment speaks volumes about the real life challenges of implementing EHR's with features and functionality that support the daily tasks of organizational staff, AND are capable of sharing data that can be read, used, imported, interpreted, and utilized by other organizations.

Now, as Memo Keswick (Co-Chair for the National Certification Commission for Healthcare Information Technology Behavioral Health Workgroup) has said, agencies are actually sharing data already between providers and counties, and in many other capacities. So, it's not only possible, but already happening - just in fragmented ways.

What seems to missing is a Nationwide, or even Statewide set of criteria that is widely available to guide organizations towards putting into place standards, systems and technologies that have the ability to integrate down the road.

To me this seems to be a time of tremendous opportunity to define National, State, or Regional standards that allow independent organizations the flexibility to pursue desperately needed technologies and systems in the short term, without fear that the choices they make today will be obsolete in the long run (or in two years).

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Update from the EHR trenches; CiMH Overview

CiMH is California's Ninth Annual National Information Management Conference and the last two days have been absolutely packed with information and experiences regarding Electronic Health Records and systems as they relate to Behavioral Health Care.

If you're in this field, it's pretty safe to say that everybody who works in mental health, drug and alcohol, or local or state government health care (with travel budget left) - which actually is around 370 people - you're either here, or wish you were.

Members from CCHIT, SATAVA, the Federal Government, California Goverment, many counties, numerous vendors, and alot of interested people with great questions and even some answers are immersed in an amazing if not nuanced and highly intellectual dialogue around Electronic Health Records.

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Are you ready for an EHR?

A Few Questions
I'll warn you at this point that if you are looking for a simple answer to the question of EHR readiness, you're not going to find it here. Why not? Well, if you haven't already noticed, I tend to start most of my conversations with a question and that's mainly because I find that although answers are in high demand, their applicability to unique situations (i.e. YOUR situation) is variable at best, and in most cases, not at all. In other words, "If you've seen one EHR project, you've seen one EHR project."

What you will find here are some things to consider, a few reality checks, and a closer look at some of the nuances of EHR's specifically within Behavioral Health Care Organizations (BHCO's).

I haven't really addressed the ONE question YOU should be asking yourself right now, so let me get it out of the way.

Q: "Mr. Dickson, what do you know about this anyway, and what gives you the authority to speak about the subject?"

A: "Please, call me Thad, and take anything and everything you read on this blog with a grain of salt, a pinch of prudence, and a healthy dash of skepticism.

I'm a technology consultant and project management professional (PMP, Dickson, License #281274), working actively on EHR / technology projects with behavioral health care organizations in and around Washington State.

The Project Plan
The first thing to consider regarding an EHR Project is the project plan. I know, it seems obvious, but sometimes the most obvious things are the ones that get missed. Have you developed a plan, and taken measures to ensure that success factors like stakeholder groups, a project charter, the project definition, a purpose and need statement, goals, outcomes, and budgets are in place? How about grant writing plans to support an EHR procurement / implementation process? Do you know what EHR stands for, what it is, how it's different from an EMR or a PHR (see post PHR, EHR, EMR Soup), and specifically what this all means for your organization? Have you allocated / anticipated financial resources not just for the procurement of external systems, but for the development and execution of the project plan? Do you know where your organization is today in terms of computer (hardware, software, network) systems, clinical staff computer literacy (training requirements), and where you would like to go in the future? Have you written this plan down, shared it with stakeholders, communicated it with your board, and incorporated it into your strategic plan?

Motivating Factor
What I find with organizations deciding to embark on an EHR project, is that there is at least one, and usually several motivating factors that precede the decision to start an EHR project. Most CEO's don't sit up in bed suddenly at 3 AM and exclaim out of the blue "Aha! What we need is an EHR!! Let's start tomorrow!" Although, the recently released stimulus bill does suggest that the Obama administration will prioritize Healthcare Information Technology (HIT), which is causing many healthcare CEO's to sit up and pay attention. In the draft plan, $1.5 billion would be allocated for Community Health Centers and health information technology would be given $20 billion to help jumpstart efforts to computerize health records and decrease costs due to medical errors. Read more about the stimulus bill on the Committee on Appropriations website.

[This is a another topic of discussion, and instead of going into it here, I'll suggest you read Dr. Leavitt's op ed on the matter. Dr. Leavitt is chairman of the Certification Commission for Healthcare Information Technology, a nonprofit organization with the mission of accelerating the adoption of robust, interoperable health IT. ]

Another motivating factor may be that your legacy medical billing system broke last week and reminded you, the CEO, that the last remaining person on earth that still knows how to work on that system is out of the country on a skiing vacation, doesn't actually work for the organization, and may not be planning on returning, ever.

Maybe the motivating factor is that your clinicians are complaining of excessive paperwork, long hours, difficulty finding and accessing information, and tired arms from lugging around the stone tablets onto which their client crisis plans are etched.

Yes, I know, you're waiting for the good news, and here it is; You can start somewhere. You can take steps to help your organization become more efficient, improve your clinician's ability to deliver care, and in turn improve the safety and quality of services to your clients. And where do you start? If you guessed "The Project Plan," you are right and you may proceed directly to the list of do's and don'ts.

If you guessed go shopping for EHR's on ebay, bid $895,000 on "Seamless, integrated, easy to install, user friendly, backwards compatible, CCHIT certified, HIPAA compliant X12N 837 transaction friendly EHR system, shipping included, free training" then please re-read section one of this post. Note - CCHIT, HIPAA, and EDI 837 are all relevant guidelines / factors / standards to consider when embarking on an EHR Project, and I don't mean to diminish their importance by virute of mentioning them in the above sentence. My point is that it takes more than just those buzz words for an EHR Project to be successful.

Do's and Don'ts
Where do I start? Here are some basic Do's and Don'ts.

• Do - define the project, parse into manageable components, and develop a scope, schedule, and budget.
• Do - involve your grant writers early in the process of articulating the project definition, what it's for, and why it's needed.
• Do - define what an EHR is for your organization, involve your staff (stakeholders including senior management, IT staff, clinical staff, billing staff, board members, grant writers, medical staff, intake staff, and anyone else I left out) in the process to understand their pain points and prioritize needs. Pay particular attention to project expectation management.
• Don't add the responsibility of managing an EHR project to a full time employee's already hectic work load. It's just too much to ask, too much to do, and goes directly in the column titled "why this probably won't succeed."
• Don't forget that your clients are at the center of your organization's purpose, and that good EHR projects / systems carefully consisder how quality of care can be improved as a result of the project.
• Don't be in a hurry. This will take a while, and how long it takes will depend on how you define this. An EHR project is a journey, with many destinations along the way. This will drive your grant writer crazy, and possibly others. Help your grant writer succeed by creating milestones and looking at an EHR within the context of a program, made up of specific projects, with time lines, budgets, and milestones.

Here's another take on what to expect from an EHR project, provided by the Mental Health Corporations of America, Inc. (MHCA) and Software and Technology Vendors Association (SATVA) in their joint paper entitled "Planning Your EHR System: Guidelines for Executive Management." This was published in 2005 / 2006, but I find its content a good overview, even in a quickly evolving marketplace.

• There is no easy way to move from a paper system to an EHR, but you have it within your power to make the implementation smooth and positive.
• Without CEO/executive management support and involvement chances for success drop dramatically.
• Despite your perception on the front end, your business processes will change, and they will change for the better as a result of EHR implementation.
• Compliance with HIPAA and other regulatory requirements will be much easier to manage and maintain with an EHR than with a paper record.
• You will have more data, especially real time data, available to you.
• The system you choose will be only as good as the effort you and your staff invest in its implementation.
• The culture of your organization will change significantly. Resistance to that change in culture will probably be greater than you anticipate.
• There is tremendous potential for the EHR to enable and facilitate significant improvements in clinical practice, client safety and client outcomes.
• The clinical and economic justification, or the Return On Investment (ROI), will become evident.

So, now that you've made it this far, I'll let you ask yourself again, "are you ready for an EHR?"

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E-prescription FAQ

What is e-prescribing anyway? Like many things within the world of electronic healthcare, it depends on who you ask.

In simple terms, it's the computer based, electronic generation, transmission, and filling of a prescription. If that seems a little too basic for you, let's take a look at the definition that the Medicare Part D prescription drug program offers:

"E-prescribing means the transmission, using electronic media, of prescription or prescription- related information between a prescriber, dispenser, pharmacy benefit manager, or health plan, either directly or through an intermediary, including an e-prescribing network. E-prescribing includes, but is not limited to, two-way transmissions between the point of care and the dispenser."

So now that we have a general idea of what e-prescribing means, why would an organization be interested in having such a system? There's a few good reasons, and let's start with the financial incentive.

In 2009, Medicare will begin offering a financial incentive for prescribers using a "qualified" e-prescribing system. In order for a system to be qualified, it must be capable of performing all of the following functions:

• Generating a complete active medication list incorporating electronic data received from applicable pharmacy drug plan(s) if available
• Selecting medications, printing prescriptions, electronically transmitting prescriptions, and conducting all safety checks (safety checks include: automated prompts that offer information on the drug being prescribed, potential inappropriate dose or route of administration, drug-drug interactions, allergy concerns, or warnings or cautions)
• Providing information related to the availability of lower cost, therapeutically appropriate alternatives (if any)
• Providing information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient’s drug plan

According to the E-prescribing Incentive fact sheet (pdf) available via the Centers for Medicare & Medicaid services, eligible professionals who successfully report the e-prescribing measure in 2009 may be eligible to receive an incentive payment equal to 2% of all of their Medicare Part B (Fee-for-Service, or FFS) allowed charges for services furnished during the reporting period.

There are a few caveats to the program, and organizations clearly need to determine eligibility, as well as look at the ROI related to an e-prescription system before making a final decision. Organizations also need to consider the pros and cons of a stand alone e-prescription system vs. a Electronic Health Record (EHR) system that has an integrated e-presciption component.

That said, there are many benefits to an e-prescription system, and although saving money is good, improving the quality and safety of care is even better.

Additional e-presciption benefits include:

• Improving patient safety and quality of care
• Reducing time spent on phone calls and call-backs to pharmacies
• Reducing time spend faxing prescriptions
• Automating prescription renewal request and authorization
• Increasing patient convenience and medication compliance
• Improving formulary adherence permits lower cost drug substitutions
• Allowing greater prescriber mobility
• Improving drug surveillance / recall ability

By avoiding unnecessary medication injuries, Health and Human Services Secretary Michael Leavitt has estimated that widespread e-prescribing could save as much as $156 million over five years.

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My PHR (Personal Health Record)

Now that we've established a framework for basic terms (see EMR, EHR, PHR Soup) let's take a closer look at the PHR. (For more on the definition of a PHR, check out American Health Information Management Association (AHIMA) and their myPHR page.)

Basically, a PHR is a consumer centric model (theory?) of maintaining health care information, designed to facilitate management of personal health care records / information. One can use a variety of services, tools, and technologies to accomplish this, but the principal is the same - you gather your records, organize them, and maintain them in a place of your choosing. That place could be the trunk of your car, a file cabinet, your computer hard drive, a USB drive, or an online service. Each one of these places has advantages and disadvantages (trunk of car scores high on mobility, portability, and accessibility for example, but other factors such as spare tires, dampness, and the occasional trunk monkey may outweigh the benefits).

Maybe you already do this in some way shape or form, but if you're like me, your health information is not particularly consolidated, organized, or easy to find. I've got dental records here, children's immunizations there, naturopath visits here, supplements there... you get the idea.

There are a number of emerging technology systems that address the creation of a PHR, but I thought I'd see what the big two had for me (Microsoft and Google) as a starting point.

HealthVault (Microsoft)

The HealthVault system links to your existing windows live ID, so I created an account signed in, browsed around, and found it pretty interesting. I'll let you do the same at this point, and we'll talk about it in another post. Note: I'm going to do some more research on privacy my self before I start divulging my personal health information to an online service. I'll keep you posted on what I find, and what I decide.

Google Health

If you have a GMail account, google makes this easy much like Microsoft. I signed in, created an account, and was greeted with a variety of options to input information related to my Personal Health Records. Again, I'm planning to do some more research before I commit, but I still find the concept interesting.

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PHR, EMR, EHR Soup

What's all this noise about a PHR? What does it do for me? Should healthcare organizations care? And what does it have to do with an EMR, an EHR, or any one of the other three letter acronyms that the health care informatics industry seems to be so smitten with?

Well, it turns out alot of people are asking themselves the same questions. So in an attempt to shed some light on the subject, I delved a bit deeper.

First I went to the NAHIT Key HIT Terms Report (that's The National Alliance for Health Information Technology Report to the Office of the National Coordinator for Health Information Technology on Defining Key Health Information Technology Terms, published April 28, 2008).

Through what I can only imagine was some gnashing of teeth, NAHIT managed to put forth the following definitions pertaining to the above acronyms:

Electronic Medical Record (EMR)
An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization.

Electronic Health Record (EHR)
An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization.

Personal Health Record (PHR)
An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual.

In summary, EMRs and EHRs are tools for providers while PHRs are the means to engage individuals in their health and well-being.

And that leads me to the next place of interest, the PHR. More coming on this later.

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