Taking the Next Steps Toward Meaningful Use

Raths D. The Path Ahead: Taking the Next Steps Toward Meaningful Use. Healthcare Informatics. December 20, 2011.

“At about the same time this issue of Healthcare Informatics hits your inbox, so will the Notice of Proposed Rulemaking for Stage 2 of meaningful use under the American Recovery and Reinvestment Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act of 2009. And if the pattern from Stage 1 holds true, there will be several months of tension as provider and vendor organizations push back against regulators, advising the Centers for Medicare & Medicaid Services (CMS) that the new measures are too heavy to lift.

Because of the tight timelines they were facing, the advisory committees of the Office of the National Coordinator (ONC) didn’t have the benefit of much provider feedback on Stage 1 before they had to make proposals for Stage 2. But with more time at their disposal, CMS officials will no doubt weigh both what providers are saying about Stage 1 and the number of hospitals and physicians participating. (Only 10 percent of the 778 hospitals in a September 2011 HIMSS Analytics survey reported having the capability to address all 14 core measures and at least five of the 10 menu items. Another 31 percent of the hospitals should be prepared to meet Stage 1 of meaningful use shortly, reported HIMSS Analytics, a division of the Chicago-based Healthcare Information and Management Systems Society.)

The turn of the New Year provides a good vantage point from which CIOs and other healthcare IT leaders can take a look back at Stage 1, and as they begin to ramp up for Stage 2 apply some of the lessons they’ve learned. We asked a few CIOs where the pain points are and if there are things CMS could change to provide more clarity and flexibility and reduce the reporting burden.”

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Achieving Accountable Care — “It’s Not About the Bike”

Walker J, McKethan A. Achieving Accountable Care — “It’s Not About the Bike”. N Engl J Med. 2012;366:e4.

“In his memoir It’s Not About the Bike: My Journey Back to Life, seven-time Tour de France champion Lance Armstrong argues that winning the world’s greatest bike race does not depend in the final analysis on sophisticated bicycles. Although advanced equipment is very important, winning depends more on athletes’ riding skills, physical conditioning, and race-day effort.

Accountable care organizations (ACOs) are the bicycles of modern health system reform, attracting considerable attention as promising vehicles for achieving better care, better population health, and lower costs. Indeed, we have argued that health care delivery organizations do need new payment models like ACOs to improve their performance. Yet the success of ACOs — as they are defined by health care providers, private payers, and now the Centers for Medicare and Medicaid Services (CMS) — will depend on whether they can enable and sustain care delivery organizations (the analogue of athletes) to improve their underlying performance.

If an ACO were a bicycle, its wheels, spokes, and gears would be the criteria used by payers such as Medicare to determine providers’ eligibility, the methods used to assign patients to a given ACO, and the manner in which financial bonuses are calculated. These and other key operational issues are important and have accordingly attracted close scrutiny in the past year. Yet the success of ACOs — like the usefulness of bikes — depends on whether they can compel and equip the athletes riding them to improve their performance. It’s not merely about the bike.”

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5 Keys to Building a Learning Organization

Bersin J. 5 Keys to Building a Learning Organization. Forbes. January 18, 2012.

“We announced major news in the $135 billion worldwide corporate training industry this week: after four years of budget cuts, spending on corporate L&D increased by 9.5% last year. This is a major uptick shift in corporate HR spending. Companies now realize that they simply cannot find the skills they need in the workforce and have to reinvest heavily in corporate training.

But how and where should this money go? Should companies go back to the 1980s and build a corporate university again?

The answer is no. Today the world of corporate training has been revolutionized, and in this article I will highlight the five keys to success in building a learning organization.

1. Remember that corporate learning is ‘informal’ and HR doesn’t own it.

2. Promote and reward expertise.

3. Unleash the power of experts.

4. Demonstrate the value of formal training.

5. Allow people to make mistakes.”

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High-Paying Career Opportunities for Cath Lab Professionals

Maloney T. High-Paying Career Opportunities for Cath Lab Professionals. Cath Lab Digest. January 6, 2012.

“Despite a sputtering economy, nationwide opportunities for cath lab professionals to earn higher than average wages exist, with the best-paying positions in the western United States, according to findings from a recent survey. This is welcomed news despite cath labs across the country experiencing decreased procedural volumes, percentage of overtime being reduced, and being asked to do more with less manpower. In fact, the U.S. Bureau of Labor Statistics estimates that the demand for cardiovascular and radiologic technologists will increase about 20 percent between 2008 and 2018, which is a rate higher than other professions. This percent increase should be taken in context considering the COURAGE trial, published in March 2007, which showed a need for optimal medical therapy in stable angina patients prior to stenting, the introduction of second-generation drug-eluting stents in July 2008, which dramatically reduced rates of repeat revascularization, and recent allegations of inappropriate stenting in multiple states. These three stories have led to nationwide decreases in procedural volumes across the country.

SpringBoard Healthcare in Phoenix, Arizona, surveyed more than 1,500 respondents in August 2011 to determine industry compensation among cath lab professionals.

In addition to comparing wages by region, the data reveals how credentials, the service delivery setting and employment type — from management to on-call positions — influence these workers’ hourly rate of pay.”

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Positive Intelligence

Achor S. Positive Intelligence. Harvard Business Review. Jan/Feb 2012.

“Research shows that when people work with a positive mind-set, performance on nearly every level—productivity, creativity, engagement—improves. Yet happiness is perhaps the most misunderstood driver of performance. For one, most people believe that success precedes happiness. ‘Once I get a promotion, I’ll be happy,’ they think. Or, ‘Once I hit my sales target, I’ll feel great.’ But because success is a moving target—as soon as you hit your target, you raise it again—the happiness that results from success is fleeting.

In fact, it works the other way around: People who cultivate a positive mind-set perform better in the face of challenge. I call this the ‘happiness advantage’—every business outcome shows improvement when the brain is positive. I’ve observed this effect in my role as a researcher and lecturer in 48 countries on the connection between employee happiness and success. And I’m not alone: In a meta-analysis of 225 academic studies, researchers Sonja Lyubomirsky, Laura King, and Ed Diener found strong evidence of directional causality between life satisfaction and successful business outcomes.

Another common misconception is that our genetics, our environment, or a combination of the two determines how happy we are. To be sure, both factors have an impact. But one’s general sense of well-being is surprisingly malleable. The habits you cultivate, the way you interact with coworkers, how you think about stress—all these can be managed to increase your happiness and your chances of success.”

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Pointers for Optimizing Radiation Dose in Pediatric CT

Singh S, Kalra MK, Thrall JH, Mahesh M. Pointers for optimizing radiation dose in pediatric CT protocols. J Am Coll Radiol. 2012 January;9(1):77-79.

[Abstract] According to recent estimates, close to 7 million to 8 million CT examinations were performed for various pediatric clinical indications per year in the United States. Children are normally more susceptible to radiation-related risks because of greater organ radiosensitivity and a longer life span to potentially develop radiation-induced carcinogenesis. Although there are uncertainties regarding the lack of substantial data on the long-term radiation risks at dose levels associated with CT scans, it is still our responsibility to limit the amount of radiation used to only what is absolutely necessary. In this article, we review various strategies for reducing radiation dose associated with pediatric CT examinations.

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The Ongoing Quality Improvement Journey: Next Stop, High Reliability

Chassin MR, Loeb JM. The ongoing quality improvement journey: next stop, high reliability. Health Affairs. 2011 April;30(4):559-568.

[Abstract] Quality improvement in health care has a long history that includes such epic figures as Ignaz Semmelweis, the nineteenth-century obstetrician who introduced hand washing to medical care, and Florence Nightingale, the English nurse who determined that poor living conditions were a leading cause of the deaths of soldiers at army hospitals. Systematic and sustained improvement in clinical quality in particular has a more brief and less heroic trajectory. Over the past fifty years, a variety of approaches have been tried, with only limited success. More recently, some health care organizations began to adopt the lessons of high-reliability science, which studies organizations such as those in the commercial aviation industry, which manage great hazard extremely well. We review the evolution of quality improvement in US health care and propose a framework that hospitals and other organizations can use to move toward high reliability.

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When to Give Someone a Second Chance

Schmitt J. When to Give Someone a Second Chance. Bloomberg Businessweek. January 3, 2012.

“‘Everyone deserves a second chance.’ It’s a sentiment that embodies our deepest hopes: connection, achievement, and salvation…

I’ve always believed people deserve one redo, a second chance when life goes back to how it was before you said or did something in haste. We want to give our superiors, reports, and peers the benefit of the doubt. But we can’t kid ourselves. People stray, lie, connive, disappoint, cheat, omit, and betray. They’ll embarrass you and slip into old habits—living in denial and justifying it with a straight face. No amount of time, sweat, or compassion will change that. So where do you draw the line? How do you know if someone has turned the corner—or is just conning you? Here are some criteria I’ve used.”

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Value-Based Purchasing: A Preview

Klein E, Shoemaker P. Value-Based Purchasing: A Preview of Quality Scoring and Incentive Payments. hfm Magazine. January 2012.

“The new VBP program will become effective for Medicare inpatient prospective payment system (IPPS) discharges on Oct. 1, 2012. Under the VBP program, the Centers for Medicare & Medicaid Services (CMS) will adjust each hospital’s inpatient payment according to its performance on a set of quality measurements.

For FY13, hospitals will be scored on 12 clinical process measures and nine measures of patient experience listed on CMS’s Hospital Compare website (www.hospitalcompare.hhs.gov). Scores will be based on both performance during a measurement period and improvement above a baseline period. Scores for individual measures will be combined into a single total performance score (TPS) that indicates a hospital’s demonstrated quality and determines incentive payments based on the level of that quality. Just as a hospital’s case mix index became a meaningful indicator under diagnosis-related groups (DRGs), the TPS will become an important indicator under VBP.

The VBP program involves intricate measures of quality and a rather complicated process for determining the amount of each hospital’s incentive payment.a Beyond this process, three factors will be of primary concern for organizations participating in the program: TPSs, incentive payments and economic impact.

Our study of these factors is intended to offer hospital finance leaders insight into what to expect during their first year under VBP, and to provide interesting observations about the characteristics of hospitals that perform best under the program. Such insights are needed because the final rule regarding VBP does not give hospitals the data they require to compare their TPS scores with those of other hospitals and does not equate TPSs with incentive payments.”

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Trends in the Utilization of Outpatient Imaging after the DRA

Levin DC, Rao VM, Parker L. Trends in the utilization of outpatient advanced imaging after the Deficit Reduction Act. J Am Coll Radiol. 2012 January;9(1):27-32.

[Abstract] Purpose
After the Deficit Reduction Act (DRA) took effect in 2007, there was concern that private office-based imaging facilities would close, that advanced imaging would shift to less convenient hospital-based facilities, and that access to advanced imaging might be restricted. The aim of this study was to see if these developments occurred during the years after the DRA.

Methods
Using Medicare data, outpatient CT, MRI, and nuclear medicine trends before and after the DRA were studied. Procedure volumes performed in private offices and hospital outpatient departments (HOPDs) were tabulated separately. Volumes were tracked from 2000 to 2006 (before the DRA) and from 2007 to 2009 (after the DRA), and compound annual growth rates were calculated for the two periods.

Results
In all 3 modalities, growth before the DRA was far more rapid than afterward. Compound annual growth rates from 2007 to 2009 in offices and HOPDs were, respectively, +2.1% and +0.5% for CT, −1.1% and +1.0% for MRI, and −1.7% and −2.5% for nuclear medicine. Growth trends in all 3 modalities showed distinct flattening beginning around 2005 to 2006.

Conclusions
From 2007 to 2009 (after the DRA), there was more rapid CT volume growth in offices than in HOPDs. Concurrently, there was some loss of nuclear medicine volume in both settings, but the loss was less in offices. Thus, in CT and nuclear medicine, offices actually fared better after the DRA than HOPDs. In MRI, HOPDs fared slightly better than offices. It thus seems that there has been no shift away from offices and as yet no loss of access to CT or MRI after the DRA. However, some loss of access to nuclear medicine does seem to have occurred.

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Importation of Images into the Medical Record from Physical Media

Erickson BJ. Experience with importation of electronic images into the medical record from physical media. J Digit Imag. 2011;24(4):694-699.

[Abstract] The purpose of this article is to describe a system we developed for importing images on compact discs (CDs) from external imaging departments into our clinical image viewing system, and to report on key metrics regarding veracity of information seen on the CDs. We recommend careful attention to the process of CD importation because of the error rate we have seen. We developed a system and process for importing images on CD into our EMR. The importation system scans the CD for digital imaging and communications in medicine (DICOM) images, and collects all patient information seen. That information is presented to the patient for verification. Once validated, the image data is copied into our clinical viewing system. The importation system includes facilities for collecting instances of incorrect data. About 90% of images are now exchanged between our healthcare enterprise and other entities via CD. Data for the wrong patient (e.g., the wrong CD) is seen in about 0.1% of cases, and a similar number of CDs have data for more than one patient on the CD(s) the patient bring to our facility. Most data are now exchanged via DICOM files. DICOM images burned onto CD media are now commonly used for image exchange. However, applications to import DICOM images are not enough. One must implement a process to assure high confidence that the data imported belongs to the patient you are importing.

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Gender Disparity Drives Imbalance in Healthcare Leadership

Hoss MK, Bobrowski P, McDonagh KJ, Paris NM. How gender disparities drive imbalances in health care leadership. Journal of Healthcare Leadership. November 2011;3:59-68.

[Abstract] Low female representation in US hospital chief executive officer positions has persisted for decades. This article addresses gender disparity in professional development, the rationale for gender differences, and practical strategies to address this imbalance. The health care workforce consists of 75% women, but according to two recent surveys, ie, a state survey and a survey of the top 100 US hospitals, women hold only about 12% of chief executive officer positions in US hospitals. Significant and dedicated efforts by both individuals and organizations are necessary to rectify this imbalance.

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MRIs More Likely To Be Negative with Self-Referrals

Shute N. MRIs More Likely To Be Negative When The Doctor Profits. SHOTS: NPR’s Health Blog. December 1, 2011.

“If your doctor says you need an MRI, your health may not be the only thing on his mind. Doctors who have a financial interest in the imaging equipment are more likely to send patients for scans when they don’t have anything wrong with them. That’s the conclusion of a researcher who combed through hundreds of patient records to examine MRI referral patterns.

‘There’s definitely a bias,’ says Ben Paxton, a resident in radiology at Duke University Medical Center, who presented his results at the Radiological Society of North America meeting this week.

Watchdogs have been warning about doctors sending patients for unnecessary scans for a long time. Way back in 1990, the Government Accountability Office found that Florida doctors ordered three times as many MRIs, twice as many CTs, and five times as many ultrasounds if they owned a piece of the imaging service.”

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Rationing and Health Care Reform: Not “If,” but “When”

Kelly AM, Cronin P. Rationing and health care reform: not a question of if, but when. J Am Coll Radiol. 2011 December;8(12):830-837.

[Abstract] Evidence-based medicine and rationing have been increasingly discussed in the context of health care reform recently. Both concepts are frequently the source of heated debate, leading to polarization of different health care practitioners and public parties. In some public arenas, rationing has become a dirty word. The term evidence-based medicine is perceived as being used as a “cover” for rationing. However, rationing is widespread, whether explicit or implicit, and exists within health care. Evidence-based medicine (or imaging) and rationing overlap considerably, and it looks like both are here to stay, given the current state of developed-world health care systems and the proposed reforms. The authors review these entities and argue that evidence-based medicine (or imaging) is one form of health care rationing. Rationing already occurs, and it is important that it be done in a way that provides the greater good for the majority. This article reviews the history of rationing and evidence-based medicine, the reasons evidence-based medicine and rationing are necessary, examples of rationing that already exist (economic), proposed forms of rationing (age based), the need for physicians (radiologists) to be at the forefront of any rationing efforts, and the basis (cost and comparative effectiveness research and evidence-based medicine) and principles of physician decision rationing (optimum outcome-based rationing) in the context of proposed health care reforms.

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First, Let’s Fire All the Managers

Hamel G. First, Let’s Fire All the Managers. Harvard Business Review. December 2011.

“Management is the least efficient activity in your organization.

Think of the countless hours that team leaders, department heads, and vice presidents devote to supervising the work of others. Most managers are hardworking; the problem doesn’t lie with them. The inefficiency stems from a top-heavy management model that is both cumbersome and costly.

A hierarchy of managers exacts a hefty tax on any organization. This levy comes in several forms. First, managers add overhead, and as an organization grows, the costs of management rise in both absolute and relative terms…

Second, the typical management hierarchy increases the risk of large, calamitous decisions. As decisions get bigger, the ranks of those able to challenge the decision maker get smaller. Hubris, myopia, and naïveté can lead to bad judgment at any level, but the danger is greatest when the decision maker’s power is, for all purposes, uncontestable. Give someone monarchlike authority, and sooner or later there will be a royal screwup. A related problem is that the most powerful managers are the ones furthest from frontline realities. All too often, decisions made on an Olympian peak prove to be unworkable on the ground.

Third, a multitiered management structure means more approval layers and slower responses. In their eagerness to exercise authority, managers often impede, rather than expedite, decision making. Bias is another sort of tax. In a hierarchy the power to kill or modify a new idea is often vested in a single person, whose parochial interests may skew decisions.

Finally, there’s the cost of tyranny. The problem isn’t the occasional control freak; it’s the hierarchical structure that systematically disempowers lower-level employees. For example, as a consumer you have the freedom to spend $20,000 or more on a new car, but as an employee you probably don’t have the authority to requisition a $500 office chair. Narrow an individual’s scope of authority, and you shrink the incentive to dream, imagine, and contribute.”

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