As the headlines surrounding Stage 2 focus on specific interoperability tied to summary of care, information exchange in many forms is really the broader theme as meaningful use helps drive care coordination.


As Stage 2 nears, it’s time to nurture caregivers beyond the historical focus of interoperability as a jargon-heavy, system-to-system infrastructure. Interoperability not as a technical challenge, but a multi-faceted approach to coordinating care and advancing value-based medicine.


Today, we need to think about  interoperability as provider to provider, provider to patient, provider to device, provider to HIEs, registries and public health agencies for example, all tied to integrated EHRs and health IT platforms.


In terms of provider to patient, Stage 2 alone includes four patient engagement measures that call for the ability to exchange information. That’s interoperability with a human face. Taken a step further, if a provider is also part of a CMS Shared Savings program, patient satisfaction scoring – and therefore engagement – also becomes a measure of information exchange and a successful business goal with today’s patient-consumers.


Each of these facets of interoperability – menu items exchanging data with cancer registries, for example – is a technology tied to standards, creating a universal language and a longitudinal patient record, one that encompasses mobile technologies, scalable, flexible and customizable platforms that can expand throughout a care community.


As EHR-driven solutions establish the ability to exchange on all levels, caregivers can take the foundations achieved through meaningful use and apply them to the best fit for their practice, be it a patient-centered medical home, CMS ACO, private payer or hybrid payment and delivery model.


Interoperability is not the age-old debate between nature versus nurture. For true care coordination, it is both.


What questions do you have?


Justin Barnes is a vice president at Greenway Medical Technologies, chairman emeritus of the Electronic Health Record Association (EHR Association) and co-chair of the national Accountable Care Community of Practice (ACCoP).

It is hard to be good at something that you don’t do very often. For many doctors, reviewing electronic health record (HER) contracts fit into this category. If you are REALLY experienced, you may have done this twice, but for many physicians and administrators, they are on a maiden voyage.


Since I am only a pretend lawyer, the following should not be construed as legal advice in the legal sense of the word, but here a few guidelines that I can offer from my experience on the other side of the counter (in a past life I ran an EHR company and did a lot of contract negotiation with practices).


Step #1: Separate the price quotation from the purchase agreement. The price quotation represents a description of what you are buying and the price. The purchase agreement is the document that defines business terms and conditions. For some vendors these are blended together as one document; others will separate them. In either case, it is important that you separate them, so that you can successfully move to Step 2.


Step #2: Understand what you are buying. This would seem obvious, but since EHR quotations are chock full of vendor-specific language, acronyms, arcane product descriptions and other mysteries, I would strongly recommend spending some quality time reviewing it line by line with your EHR rep as part of any negotiation process.


The quotation typically includes how much you have to pay upfront and future payments, annual support and subscription fees and discounts and special offers. The price quotation is important because it is the document that specifies how much you pay and what you get. If there is any misunderstanding, confusion, lack of clarity about price or deliverables, the written quotation is the basis for reconciling those differences. Needless to say, verbal commitments made by a vendor need to documented within the quote. A key point: make sure that you have a clear tally of annual support and subscription fees. Sometimes these get buried in the quote, which can make for a nasty surprise when you get the monthly or annual bill. Which brings us to Step #3.


Step #3: Read the purchase agreement. Unless you have a fondness for stilted language that is intended to obfuscate, reading contracts is not a lot of fun. Thankfully most EHR purchase agreements are usually under 10 pages, heavily padded with legal boilerplate (governing law, force majeure, severability, confidentiality, non-solicitation of employees, etc.) that will likely not be material. However, the purchase agreement does include some very important clauses that will define how you do business with the EHR vendor. A few examples:


•    Dispute resolution: in the event that you are not able to informally resolve business issues, this language describes a more formal process for settling differences.

•    Technical support hours and operating procedures: this provides opening and closing hours for technical support, response time (how long it takes to respond to a support call), resolution time (how long it takes to resolve an issue) and other pertinent items. This may be part of a service level agreement (SLA) that is an addendum to the purchase agreement.

•    Warranties: Do you have any recourse in the event that the product does not work as intended? The Warranty portion of the contract describes what the EHR is willing to offer (most vendors will only warrant that the product will work as described in the documentation).


The point is not so much to alter the terms, but rather to understand them. Should you have your lawyer review the contract? This is certainly not a bad idea, if only to have a set of experienced eyes do a quick scan for contractual anomalies. 


A final note: everything described above is complex work that requires focus. Just like you schedule patients for a detailed physical exam, plan on scheduling a detailed contractual exam before you close your EHR deal.


What questions do you have?


Bruce Kleaveland is President of Kleaveland Consulting and a sponsored health IT correspondent for Intel

Collaboration is nothing new to healthcare, but with more patients to care for, more stakeholders to coordinate, and limited funds, traditional paper, phone and fax communications are woefully inadequate.


Delivering coordinated, collaborative care is not easy. It requires profound cultural shifts, payment restructuring, new roles and responsibilities, redesigned workflows, and advances in information tools and technologies, among other changes. 


If you are interested in fostering collaborative workflows, here are nine steps you should consider that can lead to success:


1.    Communicate the reasons for change

2.    Be systematic

3.    Define new roles

4.    Build teamwork skills

5.    Have physician champions

6.    Understand the workflow impact of new technologies

7.    Match devices to the user, task, environment, and compute model

8.    Help shape the future

9.    Don’t wait


Together with Bill Crounse, Senior Director, Worldwide Health at Microsoft, Intel recently authored a white paper that discusses collaborative workflows and information tools that better meet the demands of today's complex healthcare environments. It shares examples, insights and best practices from organizations that are using collaboration to deliver more coordinated, cost-effective care.


Read the paper: Collaborative Workflows, Coordinated Care: Meeting the Challenges of 21st Century Healthcare.


What questions do you have about collaborative care?

CentraState Medical Center in Freehold, N.J., recently partnered with a group of hospitals to form an accountable care organization (ACO). If their application is accepted, the fledgling ACO will get off the ground in January, so I reached out to CentraState vice president and CIO Neal Ganguly to find out just what it takes to build an HIT supported ACO from the ground up.


Solid Tech Infrastructure

For Neal, it all begins with ensuring you’ve laid a strong technology infrastructure, beginning with the in-patient EMR. That means having a strong system in place—CentraState uses Siemens Soarian—as well as making sure your health care providers are up and running, trained, and ideally using some of the advanced functionalities, such as computerized physician order entry (CPOE).


When establishing the framework, Neal and his hospital partners opted to put their own health information exchange (HIE) in place. Their goal was to avoid being prescriptive. Rather than telling physicians to settle on one EMR, such as eClinicalWorks or NextGen, the team focused on enabling connections to any EMR physicians felt would best suit their practices and workflows.


Unfortunately, that’s when they discovered some EMR vendors are just much easier to work with than others. After spending the better part of a year implementing the initial physician practices, Neal says the ACO team is now rethinking its totally-open approach. In fact, they are considering publishing a list of recommended EMRs based on their experiences with various vendors.


EMR Penetration

Despite the fact that the EMR space is widely recognized as a minefield for both CIOs and physicians, Neal believes EMR penetration is essential to building a robust ACO. Offering assistance to providers with EMR selection, implementation, and, to some extent, the Meaningful Use qualification piece, has proven worthwhile.


“We’ve been very open,” Neal said. “If providers didn’t want our help, we weren’t offended. That’s fine. But as we began to work with EMR vendors, we started seeing that either they were levying huge fees for the interfaces—anywhere from $5,000 or less, up to $20,000—or, in some cases, they just weren’t very interested in integrating easily, or their solutions lack the technical sophistication to integrate easily."


Providers who forego HIT assistance in this regard can quickly become bogged down in nightmarish technical detail that some of the larger, more established EMR vendors seem to have found a way around.


Patient-Facing Technologies

With a strong tech infrastructure in place and EMR penetration underway, Neal says the next key step will be identifying and implementing the right patient-facing technologies. Right now, he envisions a patient portal. But that decision ultimately will depend on a number of factors, shaped in part by what patients might want to have available to them as electronic touch points. Simply viewing test results, or communication with the provider? Access to health information libraries, tests, wellness surveys?


Since feedback from physicians and patients will play a role in shaping the team’s decisions, the group is researching its options, tapping resources such as HIMSS, CHIME, and listserv postings. They’re also soliciting feedback on what others in the industry are doing. Neal anticipates the next to-do item will involve sitting down with a focus group mentality, so they can better model-out how specific choices might play out in their community.


Once the patient-facing tech is in place, he believes it will be a matter of months until the ACO’s users are connected and able to explore clinical practice in a meaningful way.


As a non-clinician, he won’t speculate on how long it might take to see changes in clinical behavior. But he’s convinced that, going forward, business intelligence will be vital on the technology side, as well as from a human standpoint.


What questions do you have?


As a B2B journalist, John Farrell has covered healthcare IT since 1997 and is Intel’s sponsored correspondent.

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