EHR project communications and an opportunity missed.

I often sit at home during the evening I wonder how they could get it so wrong. As my father frequently says-"There's always something." The outstanding feature of the communications plan for our EHR project is that there doesn't seem to be one. It isn't as if best practices for communication in project management circles are unknown or hard to locate in publications. Ready for my short laundry list?

Icons show up suddenly in our EHR without written explanation or training on appropriate use. Single-sign on is being implemented in stages apparently. Many clinicians were never informed of this or even know what it is while others are already using badges to login to the system. I just noticed today that new hardware has been installed on the ward workstations. When I call the help desk to open a ticket for help in our EHR the request seems to go into a maw, never to be implemented or addressed. Order sets seem to be modified willy-nilly, wiping out user defined preferences and frequently removing functionality that is need for good patient care and safety. I'm just getting started but I'm relative certain that this sounds familiar to many of you.

So is there a solution? At my institution, I fear not. I have been offering my opinions about communication for over six years but I always seem to be beating my head against a brick wall. The best way to address this problem is to begin at the beginning. Every HIT project should have a well-defined communication plan. The plan should follow SMART principles. Multiple stakeholders should be considered in creating the plan and their input should be incorporated into the design. Communication should be bi-directional, comprehensive, and utilize multiple modalities to distribute important information. Finally, this should be a written plan that is periodically updated as communication needs and technology change.

By the way, last month we passed an important milestone-one year since the EHR went live. One might have expected a major celebration for this substantial achievement. Instead, there was almost no discussion of the event by administration, hospital staff, clinicians, or the community. I think this was an opportunity lost.

Electronic Prescription of Controlled Substances in Arizona

One of the blog posts that has recently been most popular was from last April on the electronic prescription of controlled substances. Now it is nearly a year later. So what has been happening in Arizona? Unfortunately, I was busy doing clinical work so I missed a recent committee meeting but I have access to a final draft of a proposed electronic prescription of controlled substance (EPCS) program for Arizona.

The interim final rule by the FDA was published in 2010. I suspect adoption has been slow for any of a number of reasons. IT departments in hospitals and clinician practices are overloaded trying to comply with requirements for the various flavors of Meaningful Use. The complexity of Stage I requirements has steadily grown as they depend on the year when attestation first takes place and ongoing annual compliance. Stage II of Meaningful Use with its new requirements, especially for information exchange /consumer engagement, kicks off this October. Also, planning for the change over from ICD-9 to ICD-10 is also requiring increasing attention.

Provider electronic prescription systems need substantial overhaul in order to comply with FDA requirements. Prescribing workflows that include utilization of the required digital certificates are still being developed. Vendors are busy modifying and testing their systems to enable Meaningful Use compliance. Furthermore, the requirements of Meaningful Use do not include EPCS so there is little incentive to expend resources on this capability.

Finally, there are a number of burdens on pharmacies. Their computer systems need to be upgraded in able to accept and manage EPCS. Other than clinician and customer demand, they have few incentives to do this. Pharmacies are also responsible for arranging third party audits of their controlled substance prescribing systems. The infrastructure needed to perform these audits needs to be developed. Unanswered is how the associated costs will be shared.

Under state leadership and stakeholder involvement, Arizona is poised to move forward on EPCS. The approach will be multi-pronged. Initially, an environmental assessment will be undertaken to study clinician and pharmacy readiness. Next, a limited pilot program at 5 sites will be funded using state resources to develop EPCS capabilities. Educational outreach will be undertaken to spread knowledge on availability of EPCS and answer questions about program requirements. Outcomes will be closely monitored and reported back to organizers. Ultimately, lessons learned will be used to encourage and facilitate EPCS throughout the state.

What will be hot in HIT in 2013? My thoughts.

Meaningful Use: Health IT departments will be dealing with every stage of Meaningful Use. Those who haven't attested for stage 1 will be considering whether to move ahead. They will need to calculate what will be needed to be successful. Those who have already earned their first incentive payments will need to track their annual performance on Meaningful Use and Clinical Quality Measures to continue to be eligible. Meaningful Use Stage 2 regulations have been completed. Offices and organizations will need to look ahead to become thoroughly familiar with the requirements. Software upgrades will probably be necessary to keep up with the escalating requirements. For example, availability of a patient portal will be almost indispensable. Also, arrangements will need to be in place to enable health information exchange with outside organizations whether this is via Direct or a more full-blown HIE mechanism. Finally, it will be important to monitor the on-going discussions concerning stage 3 in the Federal Advisory Committees on Health IT throughout the coming year. Preliminary plans for stage 3 have already been published but I am sure there will be some changes before the final regulations are set.

Tapering down of ONC financial support for HIT programs: The HITECH Act provided federal funding for many ONC initiatives. With the current fiscal crisis and spending cuts likely in the future, many of the activities sponsored by ONC will necessarily need to be scaled back. Already at the last meeting of the HIT Standards Committee in December Doug Fridsma discussed the new directions for the Standards and Interoperability Framework with much of the activity being transferred to the private sector. Support for other programs such as the Regional Extension Centers, Health Information Exchange state grants, Workforce development, Beacon Communities, and SHARPS grants face the end of their promised funding. Continued operation of these programs after the next year or so is doubtful. Progress on achieving major federal HIT policy goals will depend upon developing new sources of funding for these vital programs.

Health Information Exchange: Progress on achieving wide-spread health information is reaching a critical mass. Stage 2 of Meaningful Use mandates the use of HIE technology to qualify for incentive payments. State and private initiatives are becoming more mature. In some regions of the country, full-blown HIE is a daily reality. For many communities however, HIE is still a distant goal. My opinion is that Direct, even with its many limitations, offers the most satisfactory short-term option for many eligible providers and hospitals. Infra-structure, technology, and standards adoption are hurdles remaining to be overcome. To gain and maintain consumer trust, much progress still needs to be made on the policy, people, and technology fronts to address unresolved issues related to patient consent. A number of competing transport standards vie for more wide-spread adoption. And few of the larger HIEs have solved the conundrum of grant-free sustainability. A cultural transformation must occur for individuals and organizations in the health care system of the US to fully embrace the value of data sharing. Furthermore, they must be willing to pay for the capability.

ICD-10: Planning and training for implementation in 2014. This is a tough one because of previous uncertainty and future unknowns. We do know that implementation in the U.S. of ICD-10 was postponed from October 1, 2013 for one year to 2014 as announced by Health and Human Services Secretary Sebelius . We also know that the U.S. is one of the last major countries to introduce ICD-10 (ICD-10 was approved in 1990!) Recently there has even been some talk of skipping ICD-10 entirely and going with ICD-11 instead. The final revision version is due in 2015. A significant problem is that changes in the diagnosis coding system affect almost every clinical software application. Upgrading software to comply with ICD-10 requires substantial time, effort, and expense. Training will need to permeate through almost every level in the U.S. health care system. Moreover, false steps in adoption have the potential for substantial clinical and financial impact. I empathize with the organizations that are trying to dance to this confusing lead.

Mobile Health: This is an easy pick. Mobile health has been making headlines for several years and the momentum just seems to be growing. Smart phones, tablets, and small laptops are leaders of the pack. Almost every major vendor is designing mobile friendly applications for their EHR software. Mobile devices in concert with wireless-enabled products are poised to revolutionize remote monitoring of such things as weight, blood sugars, oxygen saturation, exercise, pacemaker function and others. Continuity of care is enhanced when home health caregivers use mobile computing to review and document in a patient's EHR. Innovative uses for mobile devices are being developed at an accelerated pace. But mobile devices bring with them new risks. They are easily lost or stolen and are one of the major sources of data breaches. Users may not be well-versed in the special security risks associated with use of their personally owned devices. Organizations face substantial challenges in centrally managing the security risks of these personal devices. There are satisfactory solutions available such as protecting the devices with strong passwords, encryption of personal health information, user training, and remote wipe technology. Security policies should be reviewed to assure that mobile device use is addressed. And the annual security risk assessment required by HIPAA would be incomplete if mobile technology is not considered.

Social Media: I am not a participant in social media, other than email and this blog, so that makes me both a dinosaur and a non-expert on the subject. You won't find me on Facebook and I would not be caught tweeting. Nevertheless, I think that the tide of the current social media blitz will continue to rise. The health care industry has jumped on the social media bandwagon. Many organizations are using it for advertising and self-promotion. Potentially, social media is a good method to distribute patient specific education materials and provide resources for self-management of chronic diseases. Patients will look to social media for links to clinical trials and other medical research information. Increasingly social media outlets will be used to collect and disseminate consumer feedback on the performance of individual providers and health care organizations. That is sure to keep many clinicians on their best customer relationship behavior and it may even help improve the quality of medical care in the U.S.

All in all, 2013 should be an interesting and challenging year for Health IT. I hope you will join me periodically and consider my thoughts on the journey.