It used to be so simple.


A patient arrived at the office, the clinicians analyzed their problem, performed a service, and sent a bill. Next.


Even though I am wildly overstating the simplicity of fee for service (the method described above), at a very basic level it is pretty straightforward. The complexities primarily originate from the fact that we have over 1,000 health insurance companies each with slight variations (a single payer system would be a lot easier).


Even though fee for service (FFS) hardly seems simple, the future may be significantly more complex. We all know the reason: under the current system, which is dominated by FFS, the nation is approaching spending 20 percent of GDP on healthcare, an unsustainable level for individuals, companies and the country (on personal note, my premiums have doubled in the last five years—ouch.)


The one thread throughout all payment reforms schemes is an increased burden on providers and their organizations to deliver higher quality and lower cost care. This will require a significant transition in delivery models—the way medical work is done. More on that later. 


Here are some of the new payment modes on the near horizon.


Bundled Payments: instead of receiving a fee for each specific service, a bundled payment defines a flat fee that will be paid for a particular episode of care. Let’s say a patient is diagnosed with congestive heart failure or needs a new knee, under bundled payments a fee would be calculated for the diagnosis and then divvied out to the various providers that care for the patient. To prevent underutilization of services, quality measures are attached to payment. To prevent over-utilization, the fee is fixed and may specifically define what is allowed for a patient with a particular episode—anything above that will not be paid. It encourages coordination because all providers are on the hook for achieving desired outcomes. Although the details of this approach are daunting for any organization that has not fully integrated hospital, primary care, and specialty services, it does get the incentives right. If providers are getting a fixed fee and are judged on outcomes, the incentive is for efficient, high quality care. The devil is in the details which will mean some pretty sophisticated IT to operationalize it.


Modified Capitation: under a capitated plan providers receive a flat monthly fee for every member that is assigned to them. Version 1.0 of capitation got a black eye because of the overzealousness of some plans in restricting care as a means of controlling costs. In the new iteration of capitation, quality performance measures have been added so that plans and providers are incentivized to keep care standards high as well as keeping costs low. Patients are risk-adjusted (with an associated modification of fees), so that providers are not punished for having an unhealthy panel. I love the basic simplicity of capitation (like all of these systems, the under the hood details are brutal) and it can be lucrative for practices that perfect the model. Since providers are taking risk, they have strong incentives to keep people healthy. It does favor integrated delivery systems or medical homes that are actively coordinating care across settings. The challenges: collecting and managing to quality metrics and dealing with difficult, non-compliant, chronically ill patients. 


Hybrid Models: Some schemes will blend fee for service plus either rewards, penalties or supplemental fees to drive the right behavior. Example: providers that transition to a patient centered medical home (PCHM) may be eligible for monthly per member care coordination fee. This is a great idea since a huge hunk of medical costs are driven by individuals with chronic illnesses bouncing through the health care system. A fundamental principle of medical homes is help the chronically ill navigate this maze more effectively and with better outcomes. Physicians on FFS that are part of larger group or ACO (accountable care organization) may be able to participate in gain sharing in which bonuses are provided based on the ability of the group to achieve annual cost savings while meeting specified quality metrics.


Whatever ends up sticking, provider organizations will have to adopt their operations to fit the payment model. ACOs and the Patient Centered Medical Home (for primary care) are the two most prominent examples of modified delivery systems built to fit the new payment models.


Where are we now in payment reform? Still very early in the transition. Advocacy group Catalyst for Payment Reform recently reported that only about 11 percent of medical payments are outcome or value based. Report is here.


Since we are now in period of experimentation with new payment models, it is premature to predict what methodology will prevail; over the next five years there will be detailed analyses of pilot projects using these systems to see what works and what doesn’t. One thing is certain: the existing system will not stay the same.


What do you see coming down the road for healthcare payment reform?


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

There are really two aspects of sharing of patient information—directly with patients and between providers. We are going take a look at both in the next couple of blogs, but let’s start with providers.


Provider-to-provider sharing is by far the more crucial dilemma to be solved. Nothing against the average patient, but the overwhelming majority are ill-prepared to fully consume and act on detailed and often confusing medical information (although the concept of shared decision making may help—but more on that in another blog).


Providers are pretty experienced at sharing with each other. Every time a referral is sent from primary care doc to specialist there is some degree of information exchange. And the technology that they use—phone and fax—are pretty good. User friendly, reliable, ubiquitous—a hard combination to beat.


So what’s the problem? While fax and phone are Steady Eddies, there is plenty of room for improvement. Phones are wonderful for nuanced conversations, but very inefficient for quick logistical tasks. Faxes are reliable but can only be stored within an electronic medical record as an image as opposed to discreet data. Both phone and fax are foundational elements of the old world, not the new world. You can’t do big data with fax machines.


We’ve making progress. Prodded by Meaningful Use incentives and new EHRs, healthcare providers large and small doing a much better job of electronically communicating within their own organizations. But electronic exchange dramatically breaks down when providers attempt to communicate with providers across the street. The problem is that the infrastructure for conversations between organizations is woefully incomplete.


Part of the challenge is a HIPAA security artifact—providers don’t have the freedom to send a traditional email and with an attachment of the last progress note.


Also, communication systems don’t work unless the overwhelming majority of providers have them. That’s why telephone and fax have been so successful and persistent; they are easy to use, everyone has one, and they are cheap. This is tough competition. 


The current nascent efforts are a mixed bag; secure email is cumbersome, poorly integrated with EHRs, a pain in the neck to use, and has spotty penetration. The Continuity of Care document (CCD) provides a reasonable standard for electronic patient summaries that can travel back and forth between EHRs.


However, before I can send a CCD from my EHR to your EHR, a CCD integration needs to be built between our two systems. There appears to be no universal CCD integration. Each EHR to EHR CCD interface is built one at a time. With 200+ EHRs out there, that’s a ton of integration work—hardly the recipe for universal and seamless sharing.


Health information exchanges (HIE) offer the most promise. Conceptually, they are right on; a secure, digital infrastructure, broadly designed for information exchange among trusted parties all seeking to manage patient care. HIEs are not perfect. Business models are problematic (public exchanges will probably flop when the government money runs out and the privates exchanges will have to morph to be more inclusive). HIEs also have room for improvement on the work flow side (i.e. referral management tools), so that average provider can perform specialized information sharing tasks quickly and easily.


Despite these issues, some form of HIEs will be the information highway for health care, allowing much improved provider communication and care coordination. But just like the real interstate highway system, it will take a lot of money and time to build. Don’t throw away that fax machine just yet.


What do you think?  


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

One of the ways that hospitals and health systems are attempting to woo independent doctors into their camp is by offering sweet deals on electronic health records (EHRs).


Here’s how it works: the hospital has negotiated a package price from an ambulatory EHR, typically as a hosted or cloud based model (which means that you will be accessing it via the internet as opposed to installation on a local server). They have deployed it among their employed physicians and theoretically have the kinks work out.


To increase “alignment” with independent physicians, they begin offering the EHR often at attractive prices (usually on a per provider per month charge). Should you bite?  


Maybe. Besides a good price, a hospital sponsored EHR typically offers a nice local service package consisting of hospital staff available both via phone and on-site. Additionally, these EHRs often include an integration package of hospital interfaces to labs, HIEs, or ADT systems. If the lion’s share of your lab business and inpatient admissions are directed to the hospital sponsor of the EHR, subsidized integration is a real advantage from a cost, convenience and support perspective. Additionally, hospital-sponsored EHRs may offer advanced analytics in terms of quality and outcome reporting that will increasingly become a part of medicine as we transition from fee-for-service to accountable care. Hospital sponsored EHRs allow you to outsource a complex task to a competent third party.


What’s the downside? The primary disadvantage is that you are giving up a good deal of your freedom and independence on a mission-critical portion of your business. Example 1: While a hospital sponsored system will offer some flexibility in configuration, you are likely to be bound by certain conventions and standards established by the hospital. It is also likely that meaningful changes will either be impossible or time consuming, since they have to be considered in the context of the system as a whole. Example 2: What if your relationship with the hospital sours? Certainly the value of hospital interfaces diminish if you are no longer doing much business with the hospital. Getting hospital staff to craft new interfaces to competing labs or hospitals may be both problematic and expensive. Switching EHRs is never easy; a troubled relationship with the hospital is not going to help.


Finally, while hospitals are increasingly getting in business of supporting ambulatory practices—for many it is a new thing. There is no guarantee that hospital service will be great.


How do you decide? Independent of any of the details of the offer, the decision primarily rests on the type of relationship you wish to have with the hospital/system. If you see your future inextricably entwined with the hospital (including the possibility of a buy-out), then purchasing an EHR from them is worth pursuing.


If on the other hand, maintaining the independence your group is paramount and you have the wherewithal to assume the burden and responsibility of independence, then buying an EHR from a hospital is probably not a good idea.


What questions do you have?

One of the great strengths of our healthcare system is its specialization.


It is also one of its great weaknesses.


Here’s why: since there is such a proliferation of ‘-ists” (neurologists, cardiologists, pulmonologists) a primary care doc (particularly in urban settings) feel obligated to send the patient to the local specialist every time he encounters an issue beyond the scope of his expertise or practice.


Traditionally, the PCP (primary care provider) writes a referral, hands it to the patient on a piece a paper and….moves on to the next patient. In many instances, there is no tracking of whether the patient completed the referral and what happened if the patient did go.


Why is this a problem? Well, in the old model of visit based medicine—it really wasn’t a problem. The system was (and still is) based on individual encounters between various providers. Since the primary care provider (the main source of referrals) has no specific financial incentive to coordinate with others (other than professional courtesy), American healthcare does not have a well developed model for tracking the transition of patients from provider to provider (the buzzword for this process is called care coordination).


However, in the new world of accountability--as exemplified by accountable care organizations (ACO) and patient centered medical homes (PCMH), primary care practices are supposed to know if you showed up for the cardiology referral and what happened when you went there.


In this new model, patients will have a “home” (a primary care practice) that is responsible for helping patients navigate the system if they are referred out and working with patients and specialists to make sure that referral appointments are kept (or at least understand why they are being neglected). Moreover, the primary care practice will be expected to consolidate the reports from consultants so that they have global view of their patients.


The clinical and financial reasons for this are sound; patients that neglect completing their referrals may be compromising their health. Compromised health can lead to expensive interventions (like emergency ED visits or inpatient admissions) that might be avoided with better coordinated care. 


This new and long overdue focus on care coordination exposes one of the fundamental weaknesses of our system; we do not have a good way of electronically communicating information between practices. Yes, there is secure email, but it is not universally distributed and used and has no real work flow component. The Continuity of Care (CCD) is great start for creating a standard for distributing clinical summaries, but will not be enough for managing the subtleties of care coordination.


There seems to be the misguided notion that somehow the EHR will fill this void, but that is pipe dream; at its heart an EHR is internal documentation tool—not a means for communicating between practices. Some wags think the HIE (health information exchange) will provide the infrastructure. I wouldn’t bet on it—an HIE is too complex and expensive and was not intended as a workflow tool.


In the absence of software based communication methods, practices use people, fax, and telephone. This is going to change—and the cloud is going to be enabling technology. The cloud allows the development of light, subscription based, work-flow enabled applications that can be rapidly and inexpensively deployed. It is no longer necessary to build a behemoth IT infrastructure in order to get things done. We already have an infrastructure; it’s called the internet.


Insightful companies are starting to pickup on this. Clarity Health Services in Seattle is offering a web-based care coordination platform that is starting to create some noise. Athena Health recently acquired a cloud based care coordination company (Proxsys) to complement its EHR and billing service offerings. There will be more.


What questions do you have?


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

At a certain point in the lifecycle in any business, the predominant business model gets exhausted.


Medicine is a case in point. The dominant U.S. business model—visit based, fee-for-service—is slowly buckling under the crushing cost burden it is imposing our society.


Although it will take awhile to transform this $2 trillion bloated behemoth into a system that offers better care at a lower cost, there are flurry of movements under way that are both interesting and promising. One of the most interesting and most promising is the patient centered medical home (PCMH).


What is it? It is a primary care practice that puts together a mix of people, process, and technology so that patients get better care and better customer service.  It also intended to help increasingly burnt-out providers step off the 30 visit a day rat-race and reconnect them to a more satisfying and less frantic patient care model.


At the people level, the PCMH emphasizes teams of care providers vs. strict reliance on the physician for all clinical and patient decision making. The teams consist of doctors, PAs, nurses, medical assistants—and even administrative staff. This does not mean that the receptionist is making diagnoses, but rather provides the basis for a more coordinated effort to meet patient needs both before and after the visit. A simple example: a patient is referred to a cardiologist. Did they go? Has the practice received the documentation of the visit? Physicians are not going to track this, but a team member certainly can.


At the process level, the PCMH require practices to think about their practices not as a visit factory organized around the availability of overworked providers, but as a patient-centric service center, where it is easy for patients to make last minute appointments and communicate with the care team as question arise.


A PCMH also brings an element of practice accountability to patient care: Am I managing my diabetics effectively?  Are my cardiac patients adhering to the recommended meds? This is a distinct switch from the predominant model of reactive medicine to a proactive approach. This can have a big payoff for the management of chronically ill patients that consume much of our health care dollars.


It is impossible to implement these people and process changes without technology. The technology centerpiece of the medical home is the electronic health record (EHR), which provides not only a repository for patient information, but can also trigger preventative reminders based on the patient’s condition, plus practical tools such as e-prescribing. The EHRs make the patient record universally available to anyone with access to a workstation—a critical requirement for team based care.


While EHRs are very well suited to individual record keeping, they may not be as well suited at looking at populations of patients (i.e. How many of my diabetic patients are well controlled for HgA1c?). To help answer these questions some PCMHs may use a disease registry (more technology) to track patients.  Finally, since patient engagement and easy access to providers is a core element of the patient centered medical home, many are adopting patient portals and secure messaging to provide an alternative to traditional phone and fax communication.


Does the PCMH work? At least one study suggests that they do. Research done by Seattle-based Group Health’s medical home pilot (published in Health Affairs in May of 2012) indicated that medical home patients (when compared to patients in traditional Group Health practices) had 29 percent fewer ER visits and 6 percent fewer hospitalizations, with a net savings of about $10 per patient per month. The data also suggest improved patient satisfaction and happier providers.


The downside: setting up a PCMH is hard work and expensive (team based care means more practice FTEs per patient). However, the PCMH model that is not going away and is fully aligned with the necessary shift from quantity to quality in American medicine. It is the right approach.


What questions do you have?


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

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

One of the more challenging aspects of electronic health record (EHR) ownership is switching from an old EHR and to a new one. This process of moving from old to new is called conversion, and it ain’t easy.


The problem is the data. After a few years of use, a practice will have accumulated a fairly prodigious level of patient data (notes, prescriptions, problem lists, correspondence) and will appropriately want to move as much of that over to a new system.


Unfortunately, there are no consistent industry standards that dictate how EHRs should store data, so practices are left with the less than optimal solution of complex, custom conversions that map data fields from the old EHR database to the new EHR. Custom and complex always equal expensive in the EHR world.


So what’s a practice to do? Here are a few guidelines.


Make sure that you are switching for the right reason. It is easy to scapegoat an EHR for an implementation that failed due to the practice and not the EHR. Since switching systems is significant undertaking, it is important to clearly understand the desired outcome of a switch. A five star EHR cannot transcend a dysfunctional practice.


Be a conservative converter. Because of the variability in database structures between EHRs, the more information that you try to move from one system to another the more expensive, time consuming and challenging it gets. Start with the easy stuff, like patient demographics (name, address, etc.). Patient demographics are easy because the data is generally structured the same way between different EHRs. Structured data is always easier to move. Clinical data that may be structured in your existing system include discreet items such as medications, allergies, problems, and lab data. Non-structured data include narrative free text that is commonly found in progress notes.


Start the discussion with your EHR vendors (existing and new). A conversion is collaborative activity between the old and new EHR vendors and the practice. Your existing EHR vendor will be responsible for creating an output file of your patient data (for which there will be a fee) and your new EHR will responsible for importing that output file (also a charged item). The practice’s responsibility is to decide what gets moved. In order to understand what is possible and at what cost, you really need to get all three parties together to play in the same sandbox.


After considering the various options, it is possible that the best choice—due to cost and complexity reasons--is not to convert. In this case you would be treating the old EHR primarily as archive of historical information that would be manually transferred to your new system. You would use the same conversion strategy that you use with paper charts—transcribing data from one system to the other you see patients.


While there is extra work during this transition time, it does give you the opportunity to start fresh with clean data. The primary wrinkle here is making sure that you retain access to your old EHR data. For client-server systems, this is no problem since the data is resident locally. However, for internet based EHRs, you will have to negotiate either limited access or a copy of your data since it is stored outside of the practice in the cloud.


Watch the video below for more information on EHR conversion. What questions do you have?


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

Meaningful Use was always meant to be a progressive process. The wise heads that designed the program had the good sense to realize that their lofty goals in shaping physician behavior around a piece of somewhat alien software (the EHR) would not be achieved in one fell swoop—even if you were willing to pay docs to offset some of the inevitable pain.


That’s why the program has three stages, spaced both by time and difficulty. Stage 1 (which we are currently in) has been the gateway drug, providing rich incentives to induce providers without an EHR to make the leap and to convince experienced EHR practices to structure their processes to comply with the regs.


The goal all along was get everyone on an EHR, with the sound reasoning that it is impossible to build a modern, evidenced-based, data driven, population oriented health care system on a foundation of paper charts.


It’s worked. Stage 1 has helped significantly drive EHR adoption, as droves of previously reluctant providers realized this would be last time the government was likely to richly pay them to do something they would eventually have to do anyway. And Stage 1 not only paid well, but it was fairly easy.


As should be expected, the preliminary Stage 2 requirements released early this year ups the ante a bit. While these requirements are not final (CMS is in the process of the reviewing public comments and is expected to finalize Stage 2 this summer) most wags agree that the final MU2 will be similar in spirit and scope to the published preliminaries.


How does it up the ante? There are two major ways:


•    Providers are required to do same things that they were doing in Stage 1 on more patients. Example: Stage 1 required that you recorded demographics, vital signs, and smoking status on 50 percent of your patients. Stage 2 requires you to record the same parameters on 80 percent of patients. The point is to make certain activities a habit (if you were doing something on 80 percent of your patients, is they any reason that you wouldn’t do it on 100 percent?).


•    Requirements that were optional are now required. Meaningful Use requirements are structured as core items (which are all mandatory) and menu items (you make choices from a list). This allows you to avoid some of the more challenging requirements. MU2 moves items were menu in MU1 to core. Example: Drug formulary checking (the process of determining whether a prescribed medication is on a patient’s health plan formulary) was optional in Stage 1; it is required in Stage 2. The intent is to force providers to branch out and use new capabilities within the EHR. A good portion of the proposed changes in MU2 involve this shift from optional to mandatory including fairly challenging new requirements for med reconciliation, transition of care, patient education and clinical reminders.


While it is probable that the final regulations will be tweaked in response to public comments, the overall direction and spirit of regulations is unlikely to be modified. The direction is pretty clear: the Feds want providers and practices to improve their EHR competence. If Stage 1 was the gateway drug, it was also the bike with training wheels. In Stage 2, it’s the same bike, but no training wheels.


What questions do you have?

The best medicine is collaborative. Particularly with specialization and increasingly complex and powerful therapeutic technologies, providers have to work with each other and with patients and families to get the best outcomes.


And the lifeblood to any effective healthcare collaboration is information.


A number of organizations, like Kaiser or Mayo, with healthcare IT systems crossing both ambulatory and inpatient environments, do a pretty good job of moving information between members of the care team—making collaboration efficient and useful.


However, for the majority of our currently fragmented healthcare system, the state of art of provider collaboration is surprisingly 20th century with a touch of 19th century thrown in. The most common collaboration methods are face to face and phone. For routine communications and reporting between providers, fax still remains prominent. E-mail, which is ubiquitous in the business world, is relatively rare in healthcare, particularly when it comes to provider to patient discussions.


Why the lag? There are a couple of good reasons; personal health information (PHI) is both sensitive and highly regulated and therefore requires careful handling (hence the reluctance to use unsecured email).


Secondly, healthcare information is locked into disparate computer systems or on paper, making it labor intensive and inefficient to share with other providers that don’t work at your shop.


Fortunately, we are starting to see some of this change. The technology is generally ready. Encrypted, secure email systems are now available and designed for both provider to provider and provider to patient communication. Standards for healthcare data communication have been established that cover lab data, images, patient summaries, and prescriptions. Health information exchanges (HIEs), which would provide a pipe for all of this data to be moved between separate organizations within a community are being built across the country.


Since technology is no good if no one uses it, the government is providing incentives through the Meaningful Use program for providers to actively use these information sharing tools. Examples: in the latest draft of the Stage 2 Meaningful Use guidelines, providers are required to electronically submit summaries of care for >10 percent of their patients when they are referred to another provider. There is a requirement that practices are able to electronically communicate with their state immunization registry. Sixty five percent of prescriptions have to be sent electronically. Providers are required to provide tools (i.e. patient portals) so that 10 percent of their patients can communicate with them electronically.


This is great start. Stage 3 Meaningful Use requirements (which have not yet been defined) will continue to up the ante, with additional requirements designed to incentivize electronic communication and collaboration.  Improvements in hardware and infrastructure will help make powerful tools such a video-conferencing more practical and widespread.


The way we pay for health care will also drive collaboration. The recent flurry of activity around accountable care organizations (ACO) provides a model that rewards provider groups that carefully managing patient welfare throughout the care process. ACOs can’t succeed without collaborative tools.   


At a certain point, the network effect kicks in, and information rich collaboration becomes the standard of care. Although it has been a painfully slow process that has been 20 years in the making, we are getting much, much closer.


What do you think?

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

One of the most important decisions that a doctor will make when in transitioning to an electronic health record (EHR) is their personal computing device. By personal computing device, I simply mean piece of hardware they use to enter data, review patient charts, run reports and all the other IT stuff that they will need perform in the era of Meaningful Use.


The good news: there are lots of choices.
The bad news: there are lots of choices.


Let’s break it down into two simple paths: tablets and PCs (such as laptops or “convertibles” that can be used as tablet but offer a keyboard too).


Here’s a simple checklist that you can use in making your choice.


Data entry flexibility: Are you comfortable with the data entry method of the device? Does it offer you options of different ways of entering data (i.e. real keyboard, virtual keyboard, digital pen, mouse, voice recognition, and handwriting recognition)? Flexibility not only gives you the ability to determine the method that you feel most comfortable with, but also allows you to mix and match in a given encounter (i.e. use digital pen for  a drop down problem list and voice recognition to record the subjective portion of the note). Tablets are very sexy, but in terms of sheer flexibility, PCs have the advantage.


Versatility: Is the device that you are using to go mobile from exam room to exam room equally useful when you are wrapping up at the end of the day in your office?  Or when you go home? Note: tablets are great mobile devices, but tend to less optimized when you aren’t mobile for routine tasks like printing that PCs do well.


EHR compatibility: There are very few applications that are built specifically or “native” to the tablet environment. That doesn’t mean that client server or web based EHRs won’t work on a tablet, but it may mean that it doesn’t work quite as well as a PC; it is worth checking before you commit.


Battery life/Battery management: Keeping your mobile devices fully charged is critical to smooth operation at the clinic; battery life of the device is important (the longer the better), but  having the flexibility to swap out the old for a fresh battery (so you don’t have to wait for the recharge) is also a plus. This is standard feature for most PCs—and not for tablets.


Screen size/display: Is your device the right size for you? Is it the right size for your patients? Providers need to balance size vs. weight. There is a right answer here—just what ergonomically works for you.


Final thoughts: For any practice that exceeds one physician, hardware decisions have a group element as well, which means that there has to be some compromises and trade-offs to meet the greater good of the practice as a whole. In this context, flexibility is king, since physicians are highly variable in their data entry preferences. In the flexibility argument, PCs always win.


Watch the below video for more information on selecting the right healthcare device. What questions do you have?

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

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