Life, The Universe & Healthcare in India

Vidhana Soudha - Bangalore's Capital

It’s been more than a month since I came back from Bangalore, India. When I was last in Bangalore during the month of December, the year was 1994. The internet had not yet really come to the city, no mobile phones, many more trees and no high rise apartments, you could get across the city in about 45 minutes and there were no flyovers,  people rarely, if ever traveled overseas for vacations and the vast majority of people were either engineers or doctors (if their parents wanted their children to be perceived as doing well career wise). You could at least call an ambulance and possibly get to one of the small clinics that were around and hope that the doctor there knew how to take care of you (there were only a couple of private hospitals around then.

That’s not the Bangalore (or Bengaluru as it is now called when the city officials changed the name of the city to reflect the state’s Kannada language pronounciation) that I saw this past December. Everybody uses their mobile smart phones for everything, you need to use Ola or Uber, even if you live here because the number of cars in the city is unbelievable and growing more by the minute, many flyovers across the city and some of them even have stops at the top of the flyover (because someone in government didn’t plan properly), there’s a metro that the government has been working on for a decade (similar to Boston’s Big Dig of old) and if you get into an Ambulance, you may want to say your farewells to your family…as 9 out of 10 times, you will not make it to the hospital in time to save your life. See the YouTube video here for some perspective on what I’m talking about.

There are some solutions to these issues; air ambulances (visions of M*A*S*H) have been touted as one of the ways in which India can get some of their critical patients to their provider facilities.


These though may be only available for the upper middle class to rich and may not be something that regular people can avail of. Tele-Medicine or Tele-Health is an option. One of the premier solution providers talks about “Telemedicine as a service” that has been touted as possibly being able to be offered by local telecom service providers, who can bundle the service along with bandwidth. Healthcare providers can use the tele-health solution as a managed service by paying a monthly subscription fee or on a per event basis.They further say that these providers can market this service to a wide cross section of provider organizations who may be able to offer affordable tele-health services to their populations. Providers can also offer this as a value added service to their patients, and charge them on a subscription basis. An added advantage to this is that healthcare providers do not need to make any upfront capital investment in the technology infrastructure. The challenge is that nearly 70% of India’s population lives in rural areas and there will be vast differences when it comes to access to basic healthcare facilities and capabilities for different regions as well as languages (India became one country in 1947 when different kingdoms, princely states and former British India joined together to become one country…all of these places had different languages, culture and traditions).

The United States’ 911 protocols and procedures as well as the infrastructure that backs it up is probably the best in the world by far. Our country needs to be proud of itself for maintaining this edge on the world. While we still need to improve our value for money, we are making headway, I am positive about that fact. Our Healthcare Information Technology professionals are working hard to continuously improve our provider organizations and their delivery systems as we never accept that we have done our best but continually strive for process improvement. I appreciate our providers more than ever, though we must do a better job of containing costs. My belief is that we may treat many times to avoid litigation rather than do what’s best for the patient. This belief stems from recent personal experience with providers both in India and the US and the vast differences in cost structure administering the same treatment.I had the good fortune of visiting Cisco’s offices in their multi acre campus in the heart of Bangalore and I was extremely impressed with their ability to put tele-health solutions into practice for their own employees. The picture below was taken on their campus at one of the rooms where employees can visit on site for tele health visits with their care provider. The opportunity to save millions of lives in India through basic healthcare facilities is tremendous and many organizations are trying to figure out ways in which they might be able to achieve that objective. Kudos to all those who are working hard to make that happen. image

Happy Earth Day – Healthcare’s Green Initiatives

Earth DayCaring for our environment should be everyone’s responsibility. My Grandfather was what he called a ‘Forestry Consultant” and focused on reforestation in the 1970s and the 1980s. He founded a
National Park in the southern Indian city of Bangalore my family’s home town where he was very interested in the cultivation and use of bamboo for use in everyday life. The ability for us to think of ways use less plastic and have more biodegradable products will give future generations an opportunity to live a better life.

When I first heard about Earth Day (and bought a T-Shirt with that on it back in the 90s), it didn’t have as much meaning to me as it does now. As the world’s population grows and we need to think about how we can better utilize our limited resources to nourish and clothe the people of the world, we need to think about better conservation methods. Healthcare is also not immune to this, though going green in Healthcare IT is not a straight forward process. One way that healthcare has been better at conservation is the implementation and use of electronic health records, the biggest Go Green initiative ever by healthcare provider organizations. Tele-Health initiatives means that now, people in rural populations or anywhere for that matter, do not have to drive to a specific location for things such as specialist referrals and can cut gas emissions and improve population health. Data centers have leveraged the concept of server virtualization and reducing the carbon footprint of those data centers and also reducing hardware costs and power consumption. (Don’t forget to join us at our CSO HIMSS Spring Conference focused on mHealth and Tele-Health. Click here to see the agenda and register for the event – Not to be missed)

I’ll take this opportunity again to wish everyone a very Happy Earth Day!

The Wrap: Healthcare’s Look Back at 2014

Looking back on 2014As we look in the rear view mirror back on 2014, the year that was supposed to change our coding and billing systems, we see that ICD-10 dominated the news with it’s postponement in April and CMS’ subsequent new date of October 1st, 2015. Over the last few weeks though, I’ve heard rumors of yet another delay, this time due to the new political climate in Washington, D.C. These rumors are unsubstantiated, so I would keep them as such. I would record it as a risk to the program for those seeking to restart their ICD-10 initiatives.

Healthcare provider and payer organizations were in “shock and awe” (shocked and many people saying “awww”) at the same time, and high number of provider organizations deciding to postpone their programs indefinitely until the new date was announced and many just restarting the programs either late in the year or planning on doing so in the beginning of the new year, 2015.

The mission of provider IT organizations changed. Just as it was in the pre and post-Y2k days, organizations now wanted to get actual intelligence or analytics from the large systems that they had implemented at such great cost. We came full circle and Analytics started coming to the forefront during the year and it matured after all of the interest, talk and presentations  of Big Data, Business Intelligence and Analytics over the last few years. Leveraging actual data for case studies that I know of this year on Population Health Management and better response times in the ED.

In a recent article in Clinical Innovation and Technology, it was reported that ” as of November 2014, 11,478 eligible professionals and 840 hospitals have attested to Meaningful Use Stage 2. In total, 15,481 new EPs and 221 new hospitals have attested in 2014″. The healthcare provider ecosystem was able to move forward despite some inertia at the beginning of the year.

Many organizations also realized that their infrastructure needed to be updated with projects such as XP to Windows 7 migration; something that needed to occur due to the end support in April by Microsoft of their well known Microsoft XP Operating System.

Consumer health devices starting to get mainstream traction with products like Fitbit and Google Glass starting to look at possible mHealth applications for providers in the future.

The vision and ‘utopia’ of an Interoperable Healthcare ecosystem received a major boost with The Office of the National Coordinator for Health Information Technology releasing it’s “10-Year Vision to Achieve An Interoperable Health IT Infrastructure” by 2024. This would be a baseline for future infrastructure development across the United States and possibly even a starting point for world leadership in healthcare systems and infrastructure interoperability.

What a year it has been and we have so much yet to come in 2015 and beyond.

We don’t “Lobby” in Healthcare IT, we “Advocate”

As someone who grew up in other countries before becoming a naturalized American, there’s always been some kind of fascination when it comes to what is called “lobbying” in the United States. I’ve never been able to understand it as it always seems that it goes against the grain of what I’ve always thought of the United States through history books and the Founding Fathers, whom I so admire for their simple vision that has overcome the tests of time. Yet, hiring professional lobbyists in the United States is perfectly legal and healthcare has been leveraging this legal loophole for sometime now. Just this year as an example, lobbying has come into the news through the change in the regulatory date for ICD-10 from October 1st, 2014 to October 1st, 2015. Most believe that this was the result of pressure from care delivery professionals that wanted more time to get their act together (I for one was against this).

Recently, it was reported in “Modern Healthcare” (September 10th, 2014) that Epic retained a lobbyist and as it was reported the filing said that it was “to educate members of Congress on the interoperability of Epic’s healthcare information technology.”

Last week, HIMSS delegates from across the country had their yearly visit to Washington D.C. for their HIMSS Policy Summit, held during National Health IT week where (as reported by Healthcare IT News) HIMSS had certain asks of the nation’s representatives, which were:

  • Minimize disruption in our nation’s health delivery system emanating from federally mandated health IT program changes.
  • Fund the National Coordinator for Health IT to achieve interoperability, improve clinical quality and ensure patient privacy and safety.
  • Expand telehealth services to improve patient access and outcomes and decrease healthcare costs.

The role of politics and healthcare will remain inextricably tied to one another. As we continue to move through this paradigm shift, these areas will ultimately focus on the future of our country’s care delivery and outcomes and the way that we, the patient, will receive our care.

EHR implementations – A walk in the park…right?

Successful EHR implementations…is that an oxymoron? Can anything be called successful when there are so many stakeholders with so many differing opinions on what “successful” actually is? Ultimately in my mind, if the patient is served in the way that can help their care provider efficiently manage their care in way that aids in the recovery process, I would believe that the medical record has done it’s job and therefore the provider has had a successful group of initiatives.

Hearing of yet another CEO of a healthcare provider who has resigned in Georgia over the poor rollout of the EHR only emboldens critics of the move towards electronic health records. With the reluctance by many physicians to make this change, leveraging a CMIO will allow for an individual that exudes empathy towards their challenges. Building a strong strategy and having a good working relationship with a vendor or a set of vendors will help your chances of success greatly. Realizing that this will be a collaborative organizational endeavor is the first step in the road to success. Reaching out to organizations that have done this before and being able to “not reinvent the wheel” will greatly assist your team.

Many IT and provider organizations seem to think that reaching out is a weakness. It is actually, in my opinion, shows strength of character as show you want to make sure that your patients have the best possible care through efficient processes and use of resources. I heard of an organization in one of the Carolinas recently that refused assistance from another provider who had completed their EHR implementation. I wondered what would possess them not to take them up on their offer. I’m proud that our Ohio organizations collaborate and I have personally seen instances of positive information and best practices sharing that I know this to be true.

Defining an implementation time line that is realistic, but also does not drain your resources and allowing for risks, both negative and positive that could affect it. Leveraging outside groups to give you an understanding of budgeting for your initiative (such as attending HIMSS conferences, both chapter and national) would help in this task. Being able to get the appropriate stakeholders and clinical personnel to document clinical workflow requirements, both in terms of software requirements and hardware or infrastructure needs. Many forget the budget for hardware and will need to work with operational and administrative staff to understand the full extent of their current workflows that require such things as bar code scanners, medication dispensing stations, zebra printers and the requirements for PC or laptop distribution and deployments along with the needs of authentication due to comply with their states board of pharmacy requirements.

Understanding the needs of Revenue Cycle and not setting go lives around such things as, for instance the new date for ICD-10 go live (now October 1st, 2015) is crucial in being able to appropriately utilize as much of the same resources for a single initiative as possible.

Being good change managers and training the practices in as many aspects of the initiative as possible, keeping in mind that it is easy to forget the functionality of the new system and having patience during the cutover process are keys to this long, but in my opinion, ultimately needed endeavor.



Is DEFCON 1 the new normal for Healthcare?

I remember when I first heard the phrase DEFCON 1 (in the 80s movie, WarGames). These days, I think attributing that to healthcare seems relevant with all of the issues surrounding Privacy and Security. Continuing with my post from last week, it brought to mind that providers may be getting increasingly frustrated about how much they have to deal with over the last few years and how much more they need to focus on security than they did in the past after their clinical applications implementation and the new HIPAA Omnibus regulations. Recognizing that healthcare IT leaders these days have somewhat limited authority, but an enormous amount of accountability, it’s difficult to see why many would want to take that position.

A Healthcare IT leader has to think about so many situations such as how to encyrpt every device, and how to manage and secure data integrity & try to develop multi-layered defense mechanisms for the clinical and operational applications that a provider now has to manage. What about protecting their data center from internal and external attacks?

Will we ever be perfect? With the new issues around Internet Explorer (I’m updating the blog using Chrome by the way), the issue of security, continues to dominate the healthcare headlines. This along with the continued use by many provider organizations of XP after Microsoft said that they will discontinue support for the operating system after April 2014.

What do we do? Is this the new normal? Dr. John Halamka of Harvard Medical & Beth Israel in an interview recently at HIMSS 14 with Healthcare IT News  discussed this (while mentioning that that he had 14 different work streams in his privacy and security efforts) the need for access based on what you do rather than who you are and said that there will always now be some vendor who will announce that there is a new vulnerability that everyone needs to watch out for.

Information Security Officers will need generals defending their provider fortress. With more devices accessible by technologies like blue tooth, a rogue employee walking through a facility possibly wrecking havoc and changing information of patients, there has never been a need for solid fortress-like defenses than ever before. All this as well as providers try to have better, more meaningful engagement with their patient population!

But then again folks, we’re just getting started…




The Rise and Fall (and possible Rennaisance) of Healthcare Information Security

Information SecurityThe healthcare IT headlines have been screaming about the lapses and dysfunction of information security. With the reported data breach at UPMC, the reported breach at Cottage Health System last year, the news from Healthcare IT News that “Nashville, TN based Cogent Healthcare also recently reported an incident when a site the organization was using to store patient data had its firewall down, that exposed the PHI of approximately 32,000 patients and the attack recently at Boston Children’s Hospital’s reportedly by the group known as Anonymous, brought to the forefront, the need for a better defense strategy of healthcare’s security infrastructure, protocol & policies across the spectrum.

How many provider CEOs, CIOs, CFOs and VPs of Medical Records think about their organization’s plans for organizational continuity if they should have to defend against hackers or update their infrastructure? H.ow many know of the ability to wipe data off a remote tablet or device? The physicians all want these lighter, “easier to use” devices that can help put in their clinical notes faster and allow them to see their 30 to 40 patients (depending on the physician) a day without lugging around the heavy laptop all day.

I’m sure that not many had really thought about a renowned hacker group trying to hack into and access the medical records of a children’s hospital (until now). I’m quite sure that when sitting in a board room and discussing the investment of time & organizational resources to defend against these possible situations, while it has been taken with the utmost seriousness, the prevailing thinking is “this won’t happen to us” attitude.

Well, it can and it will in this new, cyber age. In Healthcare IT News article, it mentioned  Verizon reported that the majority of data breaches were from the theft or loss of unencrypted devices. Do we need to take healthcare information encryption to a whole new level?

In addition, is two factor authentication enough or do we need to start thinking about multi-factor authentication? When deploying the infrastructure for a healthcare provider in our region we focused on tap badges and deployment of tap badge readers versus fingerprint scans as part of the two factor (something you have, e.g. a badge and something you know, e.g. a password) authentication stipulated by the Ohio Board of Pharmacy requirement. Maybe the time is appropriate to think about a 3rd factor (something that the user is and add their finger print or retina scan…yes, I know, we’re getting into sci-fi realm here). All this will take time to finally get implemented and as costs of security and defense of systems mounts, so will the costs associated with our healthcare. Ohio for instance has probably spent close to a billion dollars taking into account all of the healthcare providers in the state and their implementations over the last few years of EHR and the supporting infrastructure to run it appropriately. This investment will take years to achieve the ROI. Imagine if we need to now, start thinking about further securing our healthcare information and needing new standards for that? Will this kill any push towards the cloud?

While organizations like Microsoft thought this through and are primed for this wave when they acquired Phone Factor in 2012, this latest wave of breaches, penalties and attacks on healthcare infrastructure will surely make more than a few to sit up and take notice, not only about the opportunity to improve in an insightful and cost effective way, but continue to prioritize patient safety through security. With HIPAA notification requirements having become more stringent as of the fall of 2013, care delivery organizations should seriously plan dress rehearsals or “fire drills” to prepare for a new age of information defense. Where’s an “ethical hacker” when you need one?



Healthcare’s sign of the times – Big Data, Analytics and Patient Profiling.

To profile or not to profile.Analytics and Big Data are in everything now. They are used for online couponing to analyze your buying patterns, in your (sic) email  and what your likes and dislikes are, in your browser with pop ups and in your social media. It has been in healthcare by the industry leaders, but was going to get more penetration as soon as the industry realized that they would have to get to know their patients through Patient Engagement initiatives as part of Meaningful Use Stage 2 where it is mandated that 5% of patients view, download and transmit their own health data, healthcare provider organizations who are concerned about that percentage of their patient population, can leverage analytics to help drive that engagement. Now that predictive modeling is the hot button topic of our healthcare IT times, I have given a lot of thought towards patient profiling and how that will progress over the years through better ways to collect, transform and present patient engagement data.

Building an enterprise data warehouse within a healthcare delivery organization brings together the many disparate systems that hold data become integrated into a single source of truth for operations, clinicians and the consumers of the data or analytics. The ability and focus now by many in the healthcare ecosystem that the way to progress is through the process of integration of disparate data, much also from legacy systems where the data was never was never clean and easy, but organizations now think that having this data will give them an edge in a newer, more cost conscious care delivery ecosystem

How much of a risk are you really and how effectively can a care dlivery organiation manage their costs and quality of care when dealing with a patient that may have the likelihood of hospitalization and possibly be re-admitted in the near future and a risk to the organization, especially for an ACO?

Physicians have the opportunity to prevent these patient readmissions utilizing profiling techniques that currently, may be exactly what large CPG or retail organizations already do well. Making sure that the ED (Emergency Department) as one of the most expensive locations for care that an organization has the ability to be increasingly efficient without losing the high quality of care that it requires to be for the community. Being able to keep patients away from using the ED’s facilities and be able to have regular ambulatory visits by identifying their conditions or health characterists early on and leverage newer technologies such as tele-health (Ohio HB 123 was recently passed here in Ohio covering just that topic and effective 5.20.2014) can lower the costs for an ED and make the delivery of care more efficient and target care for specific, previously identified patients more pro-actively.

Profiling can allow a physician to help lower the cost of medications that a patient is prescribed by reviewing and substituting equivalent, lower costs medications for the patient based on the information at hand. Medications account for one of the highest areas of healthcare costs today.

I sum up today’s blog post by reminding everyone that whether you work for or are a healthcare provider, a vendor, a professional services firm or a consumer of healthcare services, you have your work cut out for you. My encouragement goes out to everyone as I know and have seen how busy your day to day lives are and I have also seen how EMR teams, reporting and analytics teams and functional managers are tasked with many times doing the seemingly improbable tasks of getting all of the work effort completed in the short time frames that they have and somehow, it all comes together. For those of you in a state (clue, NC) the South East coast, United States who I know have gone Big Bang at all locations with everything live this past Friday morning with your EMR, my hats off to you, for you are one of those teams that have worked countless hours to make the seemingly impossible, seem doable. Collaboration and good team dynamics is the key. Don’t forget that!

Oh, and if you are viewing this from an XP machine after April 8th, well, you better unplug your computer from the internet because Microsoft has stopped supporting XP. Talk to your IS&T team if you are in an organization and think about options for a different platform.

MU gets a Breather! Healthcare Providers heave a sigh of relief!

MU breather1 Marilyn Tavenner, the CMS Adminstrator announced last Thursday at HIMSS ’14 in Orlando that CMS would be flexible on “hardship exemptions” for meaningful use requirements, which I am sure the healthcare industry heaved a collective sigh of relief.

Expectations were high for this to happen as it had been suggested earlier that this was to come.

In reviewing the CMS document titled “Payment Adjustments & Hardship Exceptions Tipsheet for Eligible Professionals” that was last updated in  October 2013 has hardship exemptions for eligible professionals with the following information:

EPs can apply for hardship exceptions in the following categories:

*Infrastructure — EPs must demonstrate that they are in an area without sufficient internet

access or face insurmountable barriers to obtaining infrastructure (e.g., lack of broadband).

 New EPs

— Newly practicing EPs who would not have had time to become meaningful users can apply for a 2-year limited exception to payment adjustments. Thus EPs who begin practice in calendar year 2015 would receive an exception to the penalties in 2015 and 2016, but would have to begin demonstrating meaningful use in calendar year 2016 to avoid payment adjustments in 2017.

Unforeseen Circumstances

—Examples may include a natural disaster or other unforeseeable barrier

Patient Interaction:

1.  Lack of face-to-face or telemedicine interaction with patients

2.  Lack of follow-up need with patients

Practice at Multiple LocationsLack of control over availability of CEHRT for more than 50% of patient encounters 

With the number of initiatives currently under way at every single care delivery organization, ICD-10, optimization, Patient Portals, Patient Engagement, workflow optimization and so on, we continue to move at, what can only be considered, lightening pace through this decade as we regain American dominance in the healthcare technology sector and then shift our focus to lowering the cost of care delivery and leverage process improvements, better preventative care options.

With current clinician retirement trends the way that they are, I also foresee a great need for qualified physicians and clinicians over the next few years and migration to the United States for technology savvy medical professionals from other countries could assist with this demand in major population centers across the country.

Cloudy with a chance in Healthcare!

Cloud Computing Types courtesy Wikipedia.
Cloud Computing Types courtesy Wikipedia.

Over the last couple of years, the cloud (distributed) computing concept has received a lot of traction. It’s ability to leverage virtual, scalable hardware for information systems can alter the costs associated with the high cost of healthcare in the United States today. It has been a source of discussion by many in the mostly technology conservative care delivery industry.

At a recent discussion with a care provider’s IT infrastructure department, I discussed with them, the factors that would influence their adoption (or lack thereof) of cloud based infrastructure. Their first response (to my “What about leveraging the cloud?”) was, “Well, what do you mean when you say “Cloud”? We already have our own private cloud that we manage ourselves”. Further discussion on this yielded the apprehension of the team to adopt the cloud and all that it had to offer. Was it that they did not want to change? Or that change was arriving all too quickly on their doorstep and they did not have the opportunity to test it out to see if what the cloud offered would be beneficial to them?

One of the factors that came out during our discussion was that the cloud is ‘the’ perceived security risk. Your most precious asset, data is now not in your control. Loss of control is the factor there. Reliability and security must be top priorities in the planning and selection of cloud services for the healthcare industry. When building your requirements for the cloud adoption, ensure that your solution obviously meets HIPAA regulations first and foremost. Bandwidth issues will be something that would affect the quality of care you would receive as a patient. During an infrastructure deployment in 2012 for an Ambulatory infrastructure implementation, the team I was part of physically went to several clinics around the city to make sure that the standard two factor authentication tap badges and devices were deployed at all those locations prior to Ambulatory go live. At one clinic, we discovered that the authentication process took a long time to register, but this was due, in part we realized to their bandwidth connection. Where other clinics took less than a second or two, this one took as long as possibly 8-10 seconds, which is a life time when you are focused on many patients each day. If applications are stored in the cloud, IT departments fear that the speed of the “pipe” would slow considerably the further away the application is stored from the actual usage site. Essentially, performance issues are the concern.

Reliability and security are essential factors in building your requirements and with the new HIPAA Omnibus RUle, that gives Cloud Service providers better opportunity to show their customer prospects that they are now better served by it. Healthcare IT departments must carefully plan the deployment of a pilot phase for this initiative with technological champions at clinics where physicians, operational staff and other clinicians are open to new ideas and ways of reducing costs and increasing efficiency for the organization.

The PMO can work with the clinic champions, Network Services, Security, Change Management and EMR analysts to understand what their roles and responsibilities need to be to carefully and successfully roll out this project. After the billions of dollars spent over the last few years to achieve Meaningful Use Stage 1 at many hospitals and the purchase of software and infrastructure to support that software, the sunk cost of implementing those initiatives would deter many provider organizations from moving ahead with cloud based initiatives, unless they have been asked to make steep cuts in their IT budgets by hospital operations. Those cuts could necessitate the IT organization looking at alternative options to manage their budget and the adoption of the cloud has a chance. For systems integrators and cloud services vendors, the opportunity is to have a well thought out solution that you collaborate with your healthcare customers over and have patience, keep educating and collaborating with your provider customers and truly listen to their concerns by demonstrating to them that these concerns, while valid, would be functionally taken into consideration and part of your overall solution.