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Galen Healthcare Solutions: Allscripts Consultants Enterprise EHR


Does your practice utilize the Finish Note task in Allscripts Enterprise EHRTM?  If you answered yes, then this blog is for you. In this article, I wanted to show you two possible outcomes when working in your  v11 Note. You will notice that there are two similar workflows to add and commit clinical data in the [...]


In the past on this blog, we’ve addressed the top data integration challenges as well as the ROI of a results interface. Recently, Health Management Technology featured a related article on the economics of interfaces. The key points from the article were as follows:   Opportunity Cost True Investment Integration is not simple Pitfalls of proprietary Features [...]


 In this demo, we will present Allscripts Enterprise EHR and RelayHealth Portal integration capability. This solution facilitates seamless integration between the two applications, offering single sign-on, messaging between provider and patient,and patient online indicator functionality. Contact us today so your organization can realize the compelling benefits of Enterprise EHR RelayHealth Portal integration.


  CMS released a couple of updates last month regarding Meaningful Use and the EHR incentive program. I wanted to pass this information along to our readers. In their December 7 update, CMS indicated that “HHS announced its intention to delay the start of Stage 2 meaningful use  for the Medicare and Medicaid EHR Incentive [...]


Often times, clients take the approach that their interfaces are functioning as designed and don’t want to risk “breaking” the interfaces by making adjustments. However,  these interfaces may not be performing at maximum efficiency and/or may not be optimized to prevent errors. This issue is magnified for larger clients with a high volume of transactions. [...]


Recently, I’ve seen several clients struggle to understand this issue and I’d like to give some information about what causes it and how to correct it. There are several levels at which a Requested Performing Location (RPL) can be linked to a Billing Location. The highest such level is in the Requested Performing Location Dictionary [...]
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ELINCS Connection


Recommendation: Promote adoption and use of technical coding/terminology and lab data interchange standards.

•A collaborative of public and private organizations is needed to identify a “starter set” of LOINC® codes for the top 200–300 lab test codes in use across the country and to promote its broad adoption and use.
•A large-scale collaboration between ONC, the National Library of Medicine, and private sector organizations should strongly encourage the adoption and use of standards, such as LOINC® and the EHR-Lab Interoperability and Connectivity Specification (ELINCS), that align with standards supporting health IT and meaningful use.
•Medicare and commercial contracts should make incentives available to lab vendors to adopt and use LOINC®.

Full Report is available here.



Every year CAP Today magazine posts a listing of the leading vendors for Physician office link software. This year there are 23 vendors.

Click here to view vendor listing.


SmartlinkEMR in action at a physician practice in Carmel, Indiana.

At this implementation, the application aggregates reports from the Indiana Health Information Exchange (IHIE), LabCorp and Quest Diagnostics into a single database providing a one stop Patient Diagnostics Information System. Office staff are able to find patient reports in seconds instead of many minutes saving them chunks of time throughout the day.

The time savings from office staff is incredible as they report at least two to three hours saved in each workday.


In March 2011 the California HealthCare Foundation, in collaboration with a multi-stakeholder group, completed a draft version of the ELINCS Orders specification. Public comments were accepted through April 11, 2011. The final specification will be published in summer 2011.
Click here to view the draft specification.



The Centers for Medicare and Medicaid Services (CMS) yesterday clarified that a 1988 law setting up national quality standards for medical testing labs does permit the labs to electronically exchange test data, an essential feature of the administration’s health IT adoption plan.

In issuing guidelines on the Clinical Laboratory Improvement Amendments (CLIA), CMS aimed to clear up confusion about the impact of the law on fledgling health information exchanges and networks.

“We have the concern that the interpretation of CLIA has sometimes stood in the way of easy info exchange,” said Dr. David Blumenthal in remarks made yesterday at the Healthcare Information and Management Systems Society annual conference in Atlanta.

In some cases, for instance, providers said they believed the law permitted only physicians who ordered a test to receive the results, according to hearings conducted last year by a panel of the Health IT Policy Committee, which advises Blumenthal.

In its revised guidance, CMS said lab results could be sent to the ordering physician as well as others designated by the physician. That includes providing patients access to their lab data unless a state specifically prohibits it, CMS said.

full article here...



Experts predict a surge in the number of physicians using electronic medical record systems

By dangling as much as $20 billion in front of physicians to encourage their adoption of electronic medical record (EMR) systems during the next few years, Congress has created a new and expensive challenge for the nation’s clinical laboratories. That challenge is the need for every pathology laboratory to establish a high-function interface from its LIS to the office-based physician’s EMR.

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 Thanks to e-Patient Dave for the image. See also the recent report Hospital Incident Reporting Systems Do Not Capture Most Patient Harm which found that "Hospital staff did not report 86 percent of events to incident reporting systems, partly because of staff misperceptions about what constitutes patient harm".


 by John Halamka, Life as a Healthcare CIO We began the meeting by relating our standards trajectory to today's agenda. Our outstanding standards issues for discussion include 1. Content Continued discussion of GreenCDA on the wire and overview of Stan Huff's CIMI initiative Standardizing DICOM image objects for image sharing and investigating other possible approaches (e.g., cloud based JPEG2000 exchange).   Consider image transfer standards, image viewing standards, and image reporting standards. Query Health i.e. I2B2 distributed queries that send questions to data instead of requiring consolidation of data Simplify the specification for quality measures to enhance consistency of implementation. The December meeting included an overview of Query Health and Quality measure standards, leaving the discussion of GreenCDA/CIMI and DICOM to our 2012 meetings. 2. Vocabulary Extend the quality measurement vocabularies to clinical summaries Lab ordering compendium The December meeting included a discussion of the lab ordering compendium, leaving the discussion of clinical summary vocabularies to our 2012 meetings. 3. Transport Specify how the metadata ANPRM be integrated into the health exchange architecture Additional NwHIN standards development (hearing re Exchange specification complexity, review/oversight of the S&I framework work on Exchange specifications simplification).   Further define secure RESTful transport standards. Accelerate provider directory pilots (Microdata, RESTful query/response that separates the transaction layer from the schema) and rapidly disseminate lessons learned. The December meeting included an update on the provider directory and certificate components of transport Our first presentation was an NCVHS update on ACA Section 10109 by Walter Suarez. The Committee emphasized the need to coordinate NCHVS work and HITSC work given that division between administrative and clinical data is becoming less distinct over time Our second presentation was an Implementation Workgroup Update by Liz Johnson about testing procedures that support the certification process. The committee emphasized the need to pilot these procedures, ensuring they are as simple as possible and reflect a practical evaluation of the functionality intended to support policy goals. Next, Doug Fridsma and Rich Elmore gave an ONC update.   Rich Elmore described the Query Health initiative, as referenced in my previous blog post about sending questions to data (rather than sending data to registries).  The committee endorsed the work and noted that further research will be needed to link patients across multiple databases to avoid double counting individuals in quality measure denominators.  The work of Jeff Jonas, as described in my earlier blog post about linking identity. Doug updated the committee about the S&I Framework initiatives - Transitions of Care, Lab Results, Provider Directories, Data Segmentation (for privacy protection), and electronic submission of medical documentation for Medicare review. We then discussed a preliminary framework for HITSC 2012 Workplan to ensure the items in the standards trajectory listed above are completed in 2012 as we continue to prepare for meaningful use stage 3. A great meeting.


 Why aren't we talking about pricing failures? The US, has consistently higher prices than any other country. The 2010 report by the International Federation of Health Plans consists of 23 pricing measures and the pattern is the same across each of these measures.  And a 2010 investigation of Health Care Cost Trends and Cost Drivers in Massachusetts found that "price variations are correlated to market leverage..." Before his departure from CMS, Don Berwick was interviewed by the New York Times and took a "parting shot at waste".  Berwick listed five elements of waste including overtreatment of patients, failure to coordinate care, administrative complexity, burdensome rules and fraud.  Pricing failures didn't make the list.  (Many folks have commented and analyzed the five factors including John Halamka's terrific piece on how EHRs can address these 5 factors.) Then in Berwick's December 7th speech to the IHI National Forum, he adds a sixth element: "Overtreatment – the waste that comes from subjecting people to care that cannot possibly help them – care rooted in outmoded habits, supply-driven behaviors, and ignoring science. Failures of Coordination- the waste that comes when people – especially people with chronic illness – fall through the slats. They get lost, forgotten, confused. The result: complications, decays in functional status, hospital readmissions, and dependency. Failures of Reliability – the waste that comes with poor execution of what we know to do. The result: safety hazards and worse outcomes. Administrative Complexity – the waste that comes when we create our own rules that force people to do things that make no sense – that converts valuable nursing time into meaningless charting rituals or limited physician time into nonsensical and complex billing procedures. Pricing Failures – the waste that comes as prices migrate far from the actual costs of production plus fair profits. Fraud and Abuse – the waste that comes as thieves steal what is not theirs, and also from the blunt procedures of inspection and regulation that infect everyone because of the misbehaviors of a very few. We have estimated how big this waste is – from both the perspective of the Federal payers – Medicare and Medicaid – and for all payers." The addition of pricing failures as a sixth element of waste is a subtle but critical shift for the national conversation.  It should not go unnoticed. Don Berwick defines pricing failures as "the waste that comes as prices migrate far from the actual costs of production plus fair profits."  Think about that:  "far from the actual costs of production plus fair profits".  At a time when total healthcare expenditures consume a huge share of GDP and increasing at rates higher than inflation and wage increases, why haven't pricing failures been on the table?  As we struggle to control costs and improve quality, there is intense focus on utilization, regulation and care coordination. Why not also focus on pricing failures? So why hasn't pricing failures been part of the conversation up to now? Here's how the conversation usually proceeds:  Health Affairs November 2011 article, Large Variations In Medicare Payments For Surgery Highlight Savings Potential From Bundled Payment Programs, "found that current Medicare episode payments for certain inpatient procedures varied by 49–130 percent across hospitals sorted into five payment groups. Intentional differences in payments attributable to such factors as geography or illness severity explained much of this variation. But after adjustment for these differences, per episode payments to the highest-cost hospitals were higher than those to the lowest-cost facilities by up to $2,549 for colectomy and $7,759 for back surgery." Sounds like a clarion call for a focus on pricing failures doesn't it?  Actually, no...  The authors conclusions only speak to cost efficiency and utilization.  "Our study suggests that bundled payments could yield sizable savings for payers, although the effect on individual institutions will vary because hospitals that were relatively expensive for one procedure were often relatively inexpensive for others. More broadly, our data suggest that many hospitals have considerable room to improve their cost efficiency for inpatient surgery and should look for patterns of excess utilization, particularly among surgical specialties, other inpatient specialist consultations, and various types of postdischarge care." So is it time to broaden the conversation to include pricing failures?  At least one health system has realized that "the jig is up". Perhaps it's time to peel the onion a bit...  And take a serious look at pricing failures which deviate "far from the actual costs of production plus fair profits". _______________________________ Background tables from the IFHP report:


by John Halamka, Life as a Healthcare CIO, November 16, 2011 Today, the HIT Standards Committee shifted gears from the Summer Camp work on Meaningful Use Stage 2 and began new interoperability efforts. We began the meeting with a presentation by Liz Johnson and Judy Murphy about the Implementation Workgroup's recommendations to improve the certification and testing process.   These 15 items incorporate the Stage 1 experience gathered from numerous hospitals and eligible professionals.   If ONC and NIST can implement this plan, many stakeholders will benefit.  The Committee approved these recommendations without revision. Next, we focused on content, vocabulary and transport standards. In my October HIT Standards Committee blog post, I noted that HITSC should work on the following projects: Content *Continued refinement of the Consolidated CDA implementation guides and tools to enhance semantic interoperability including consistent use of business names in "Green" over-the-wire standards. *Simplifying the specification for quality measures to enhance consistency of implementation. *Standardizing DICOM image objects for image sharing and investigating other possible approaches.   We'll review image transfer standards, image viewing standards, and image reporting standards. *Query Health - distributed queries that send questions to data instead of requiring consolidation of the data Vocabulary *Extending the quality measurement vocabularies to clinical summaries *Finalizing a standardized lab ordering compendium Transport *Specifying how the metadata ANPRM be integrated into health exchange architectures *Supporting additional NwHIN standards development (hearings about Exchange specification complexity, review/oversight of the S&I Framework projects on simplification of Exchange specifications).   Further defining secure RESTful transport standards. *Accelerating provider directory pilots (Microdata, RESTful query/response that separates the transaction layer from the schema) and rapidly disseminating lessons learned. The November Committee agenda included a discussion of  Consolidated CDA, Quality Measures, and NwHIN Implementation Guides. Doug Fridsma began with a discussion of the Consolidated CDAwork and the tools which support it. The Committee had a remarkable dialog with more passion and unanimity than at any recent discussion.   We concluded: *Simple XML that is easily implemented will accelerate adoption *That simple XML should be backed by a robust information model.   However, implementers should not need expert knowledge of that model.  The information model can serve as a reference for SDOs to guide their work *Detailed Clinical Models, as exemplified by Stan Huff's Clinical Information Modeling Initiative (CIMI) hold great promise.   Stan has assembled an international consensus group including those who work on  -Archetype Object Model/ADL 1.5 openEHR  -CEN/ISO 13606 AOM ADL 1.4  -UML 2.x + OCL + healthcare extensions  -OWL 2.0 + healthcare profiles and extensions  -MIF 2 + tools HL7 RIM – static model designer Their work may be much more intuitive than today's HL7 RIM as the basis for future clinical exchange standards. *Rather than debate whether Consolidated CDA OR GreenCDA(simplified XML tagging) should be the over the wire format, the Committee noted that "OR" really implies "AND" for vendors and increases implementation burden.   The Committee endorsed moving forward with GreenCDA as the single over the wire format.    *We should move forward now with this work, realizing that it will take 9-12 months and likely will not be included in Meaningful Use Stage 2, but it is the right thing to do. Thus, the future Transfer of Care Summary will be assembled  from a simple set of clinically relevant GreenCDA templates, based on CIMI models, as needed to support various use cases.  There will be no optionality  - just a single way to express medical concepts in specific templates. To support this approach, we'll need great modeling tools.    David Carlson and John Timm presented the applications developed to support the VA's Model Driven Health Tools initiative.  This software turns clinical models into XML and conformance testing tools.   The committee was very impressed. Next, Avinash Shanbhag presented the ONC work on Quality Measures  that seeks to ensure quality  numerators and denominators are expressed in terms of existing EHR data elements captured as part of standard patient care workflows. Avinash also presented an update on transport efforts, which include easy to use, well documented implementation guides for SMTP/SMIME and SOAP.   The work is highly modular and does not require that the full suite of NwHIN Exchange specifications be implemented for SOAP exchanges. As part of the ongoing efforts to improve NwHIN Exchange, the HIT Standards Committee is seeking input from NwHIN implementers per this blog post. Finally, Wil Yu updated the committee on the SHARP and other innovation programs.  There will be a great body of challenging work to do in 2012.   What's needed after that?  The next 5 years will include many new regulations as healthcare reform is rolled out.   It's clear that the Standards Committee will have many topics to discuss.


At the October HIT Policy Committee, Charles Kennedy described his work with health systems establishing accountable care models.  His clients "have actual health plan products that are private labeled products with the delivery systems' name on it that they’re selling." Kenedy talked with the COO of one health system that was particularly high cost.  Kennedy asked the COO:  "Why on earth would you want to form an ACO? You’re a monopoly. You’re making tons of money.  You can keep doing this for some period of time." The COO replied “Look I understand that the jig is up.” The COO went on to say "I know how to take $60 out per member per month.  $60 - - out of my cost structure.  I know exactly how to do it.  I never had a motivation to do it before - - until health care reform happened."  Kennedy explained that the COO has now "taken those costs out of his delivery system and because he has a product in the marketplace he gets to reap those efficiencies.  The second thing he said was that 'I never really had a use for health IT until I began to take costs out of my infrastructure'."


 Today the HIT Policy Committee is considering the Privacy and Security Tiger Team recommendations on the Query Health policy sandbox. By way of background, here are the minutes from last month's introductory discussion from the September HIT Policy Committee: Richard Elmore of ONC presented on Query Health, recently launched initiative to develop standards and services for distributed population queries. Guidance from and linkage to the HITPC will be crucial to the success of this effort. Elmore presented the vision of Query Health as follows: ―Enable a learning health system to understand population measures of health, performance, disease, and quality, while respecting patient privacy, to improve patient and population health and reduce costs. The nation is reaching a critical mass of deployed EHRs with greater standardization of information in support of HIE and quality measure reporting. There is an opportunity to improve community understanding of population health, performance, and quality through: Enabling proactive patient care in the community Delivering insights for local and regional quality improvement Facilitating consistently applied performance measures and payment strategies for the community (hospital, practice, health exchange, state, payer, etc.) based on aggregated, de-identified data Identifying treatments that are most effective for the community. Elmore commented that the challenges include the high transaction and ―plumbing‖ costs associated with variation in clinical concept coding (even within organizations), the lack of query standards, and the lack of understanding best business practices. There is also a centralizing tendency that moves data further away from the source, increases personal health information exposure, and limits responsiveness to patient consent preference. Another challenge is that the work done to date, with a few exceptions, has been limited to larger health systems (with large IT and/or research budgets). The goal is to improve the community understanding of patient population health to be able to ask a question, whether it is to a small physician’s office or a larger hospital, and obtain an aggregate result back. Questions could focus on disease outbreaks, prevention activities, research, quality measures, etc. With regard to scope and approach, Elmore explained that Query Health is being structured in a way that is similar to the Direct Project. It is a public-private partnership project focusing on the standards and services related to distributed population queries. The concept is to have an open, democratic, community-driven consensus-based process. There is a critical linkage with the HITPC and Privacy and Security Tiger Team to provide the guidance needed to drive this project. Elmore reviewed a series of user stories to demonstrate how to adjust queries with simple, secure use cases to establish the standards and protocols for patient data that is going to be queried against, the query and case definition, and then getting the results back to the requestor of the information. The organization has a voting group of committed members, the Query Health Implementation Group. There are three workgroups (Clinical Workgroup, Technical Workgroup, and Business Workgroup). In terms of timeline, Query Health is at the requirements and specification stage (the next steps are approaching consensus, and undergoing pilots). Query Health was designed with goals alignment with the S&U Framework, as an open government initiative that is engaging a wide variety of stakeholders. Query Health is also aligned with meaningful use and various standards, as well as with one of ONC’s major strategies, the digital infrastructure for a learning health system. Elmore described the Summer Concert Series, a presentation by the practitioners that have working on distributor queries that highlights the importance of this project. Through this event, a number of challenges were identified, including best practices for data use/sharing, sustainability, auditability, etc. It is hoped that the HITPC and Privacy and Security Tiger Team will provide Query Health with policy guidance and will monitor Query Health’s progress. It is anticipated that the first activity with which Query Health will be looking for such guidance is in the policy sandbox and to ensure that the project is safe, cautious, and conservative for the purposes of starting that initial pilot work. The initial set of policy sandbox ideas has been modeled after previous S&I Framework initiatives in consultation with ONC policy and privacy and S&I Framework leaders and their staff. The concept is that query requests and responses will be implemented in the pilot to use the least identifiable form of health data necessary in the aggregate within the following guidelines: (1) a disclosing entity should have its queries and results under their control (manual or automated); (2) the data being exchanged will be mock or test data, aggregated de-identified data sets or aggregated limited data sets, each with data use agreements; and (3) for other than regulated/permitted use purposes, cells with less than five observations in a cell shall be blurred by methods that reduce the accuracy of the information provided. Discussion Larry Wolf asked how Query Health relates to other activities focused on quality measure initiatives. Elmore indicated that this issue has been raised during the Summer Concert Series as well as in Query Health’s Technical Workgroup. In the next few months, it is expected that decisions will be made as to which standards will be applied. Query Health will be leveraging other ongoing initiatives moving forward. Wolf suggested minimizing the diversity of requirements generated for systems to handle queries and result sets. In response to a question about information exchange, Elmore commented that the assumption is that the information behind an organization’s firewall is identifiable. Only in an instance of a public health permitted use would identifiable data be outside the firewall. Farzad Mostashari noted that Query Health’s strategy has significant architectural and certification implications in the near future. Getting in front of those and considering them early on will be critical. Clarity about the potential timeframe is needed, as it affects work in areas such as quality measurement. The business case for this effort also requires careful consideration. Gayle Harrell noted that there is a tremendous upside to Query Health, but there is also a significant potential for abuse that may frighten the public. She asked about the role of the HITPC in terms of providing input as this project moves forward. Deven McGraw noted that Query Health will be discussed at the next Privacy and Security Tiger Team meeting. Elmore added that the HITPC and Privacy and Security Tiger Team will be relied on to provide significant input for guiding the future of Query Health. He noted that with the exception of public health, where it is already allowed by law today to send some identifiable information, Query Health will be dealing with aggregated information and will not be exposing individual’s information. The project itself will be trying to drive towards enabling a non-centrally planned use of technology that is under the control of those responsible for the data. Arthur Davidson discussed the burden faced by organizations trying to participate in these important population-based efforts to analyze and move towards the learning healthcare system. He asked if there has been a discussion at the ONC level regarding the leadership role that either the ONC or the HITPC might play in harmonizing these various data models. Elmore noted that Query Health’s Technical Workgroup is examining these data models with the vision of some harmonization of standards. It is expected that, from the point of view of keeping it simple for an initial pilot implementation, the pilot will probably create a focus around the clinical record, whether that be an EHR or more of an HIE.

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