My friends who have nicknamed me Dr. Knowledge or the Voice of Reason have seen me on those rare moments when the synapses were firing on all cylinders. There are others who have seen me in my less than knowledgeable moments.

For instance. There was the time I took my three young children to the movies. Upon returning home we heard the calming sound of water flowing; only it wasn’t calming since our home was not built with a stream running through it. After looking in the basement and seeing water streaming through the ceiling, I called our builder’s hot-line. I was furious at them and so told the handyman as he looked at the exposed rafters.

Undaunted, and convinced that the pipes were fine, he proceeded to the first floor to source the leak. I saw water coming through the wall and ceiling of the conservatory and gave him another piece of my mind—something my mother had always cautioned against so as to ensure I still had some left in case I needed it. We headed upstairs, through a bedroom, into my son’s bathroom. By this time we were wading. The sink faucet was in the on position, the drain was in the closed position, and I was in no position to blame the builder.

I learned that my son had been doing a ‘speriment with the soap. He told me it was my fault he didn’t turn off the faucet before we left because I told him, “come down stairs right now.” He no longer does ‘speriments in the sink and most of the waviness in the wallboard has subsided.

I hate being wrong, especially in front of an audience. Once I have an opinion about something, the planet has to shift on its axis before I’m likely to reconsider. I’ve found that to be true with building strategy to support a business that is undergoing radical change, especially when people are asked to consider not doing something, or are asked to consider doing something differently. There’s way too much, “That’s the way we’ve always done it,” and, “That’s the way corporate told us to do it.” What in your strategy would benefit if someone considered doing something differently?

This presentation was delivered 12.10.09 in NJ.

http://www.slideshare.net/paulroemer/em-rgemcy-medicine-event-121009-joint-ppt-final

At some point, hopefully in the not so distant future, physicians, clinics and hospitals will reach for the ARRA/HITECH Act carrot, adopt a certified EHR and demonstrate meaningful use.  One proposed requirement for meaningful use that will likely pass through the CMS rule making process is the requirement allowing citizens to receive their personal health information (PHI) is a digital format.  Once citizens have their PHI, we may begin seeing greater adoption and use of independent Personal Health Platforms (PHPs – Chilmark’s preferred term for PHRs, reasons why).

With that in mind, here are the top 10 things that citizens need to consider in choosing their PHR/PHP to store, access and share their PHI or that of their loved ones.  Note: This list is in no particular order as everyone has a slightly different tolerance for risk, usage needs, etc. Also, we are assuming that even the most basic PHP/PHR supports storage of the minimum data sets for base demographics, contact info, med lists, allergies, procedures and some family history.

1) Privacy: PHI is arguably the most private and personal data that you may control in the future.  Falling into nefarious hands could prove disastrous to you and possibly your family. Therefore, when evaluating a vendor’s solution absolutely read the fine print of their privacy policies.  A good rule to follow is the easier the policy is to read and understand, the more likely it is a good policy,  Overly complex verbiage with loads of legal speak is a yellow flag – be careful. Lastly, seek to understand what might happen to your PHI should your PHP provider be acquired, or worse, go out of business.

2) Security: Once your PHI is stored on a PHP vendor’s servers, how secure is it?  First, insure that the vendor uses https, secure socket layer (SSL), 128 bit encryption. Secondly, best to go with a vendor that asks you to create a password that is comprised of letters, numbers and maybe even characters.  Third, seek a vendor that stores your PHI in encrypted format on their servers.

3) Sharing: What sharing capabilities does the PHP vendor provide should you wish to share your records with another (health proxy, your physician, another family member)?  Are you able to share discrete aspects of your PHI via data tagging features within the PHP/PHR or does sharing simply mean complete and total access to the entire record?  Though rarely found today in most PHPs/PHRs, Chilmark foresees a future need for discrete sharing to protect sensitive aspects of one’s full longitudinal record (sexual history, genetics, family history, preventative visits, labs, etc.). A vendor providing such capabilities today is forward thinking.

4) Standards Supported: A PHP’s/PHR’s support of common clinical standards (CCR, CCD, NDC) will become increasingly important as the adoption of EHRs by clinicians takes hold.  Not only will support of standards facilitate a citizen’s ability to obtain their PHI and upload it to their private, personally controlled PHP, but may also facilitate automatically receiving PHI in the future.

The data will also be in computable form.  Accurate, computable data will enable other apps within a PHP to execute various functions (health guidance, alerts, etc.) on your behalf creating a richer more personal system.  Note, while standards are important for automating data retrieval and use, be sure that the solution also provides the ability to upload unstructured data such as your personal notes, advanced directives, health proxies and the like.

5) Access: A PHP/PHR is of little use if you can not readily access it in an emergency or via more than one modality. Most PHPs have some form of “break the glass” feature should one end up in the emergency room unconscious.  Similar to sharing, evaluate exactly what would be shared in such a situation.  Does the solution provide access to the complete record, or can you create a specific personalized ICE form that has only the most critical information an ER doctor would be looking for – usually med list, allergies, basic demographics/profile, and recent lab results.

You will not always be in front of your computer when you need to access some aspect of your PHI, say during a doctor’s visit, on travel, etc. thus another thing to look for is the solutions ability to support access via a mobile device. With the advent of smartphones such as the iPhone, Chilmark foresees a future when many of the better PHPs will have an app that easily connects to the citizen’s host PHP.  That day is not here yet, but several desktop/web-based solutions are currently developing apps for the iPhone and Google’s Android mobile operating systems.

6) Partners: Few citizens are seeking only a digital file cabinet for their PHI, yet that is what the majority of PHP/PHR vendors provide today.  A key part of the problem is simply resources as most vendors of such solutions are small companies that cannot afford to create the multitude of apps that citizens may seek to make their PHI data actionable and their view into the PHP more personalized. These vendors need partners to bring such richness to their solution.  Strength and depth of partnerships are also often a key indicator of the relative health of the PHP/PHR vendor – strong partnerships=good healthy, growing company.

7) Biometrics: Few solutions support the ability to automatically upload biometric data (glucose, blood pressure, weight etc.) to a PHP.  This is counter to what is actually occurring in the market as more consumer-facing digital,  biometric devices are introduced and hospitals increasingly turn to such devices to facilitate remote care.  If you currently have a chronic condition (diabetes, hypertension, etc.) that requires some form of monitoring, seek only those solutions that provide this capability.  For others, such as athletes who wish to record heart rate this may be a “nice to have” feature.

8.) Personalization: Unfortunately, the vast majority of PHPs/PHRs in the market have terrible personalization capabilities with most solutions being generic systems with simple generic templates designed for the least common denominator.  Therefore, seek solutions that provide a rich set of personalization features, either through the vendor or their partners, allowing you to easily create a system that meets your specific needs.

9) Provenance & Portability: Provenance provides the ability to insure your records are kept intact and that any changes (edits, modifications, notes added) made to them are accurately recorded and an audit trail is produced.  This is particularly important not only for your peace of mind, but also for a physician’s. Portability simply refers to your ability to take your records with you should you decide to move to another solution that better meets your current and/or future needs. When assessing portability, keep in mind what standards (e.g., CCR, CCD, NDC, etc.) are used when exporting your data to insure that your PHI is easily transferable to another system.

10) Engaging: At the end of the day, a PHP/PHR is of little use if you do not actually use it.  Seek a solution that you’ll actually enjoy using, one that provides a multitude of benefits well beyond simply and conveniently storing your PHI.  Are there specific features, widgets and apps you know you’ll have fun using to track your health or the health of a loved one? Does the solution help you complete a specific job far easier than how you are doing it today? Think automatic production of summer camp health forms for your children or allowing you to schedule an appointment with your doctor online.  Is the solution actually easy to use?  If you need to think too hard to accomplish even simple tasks, pass on the solution, it will only get worse.

There you have it folks, those top ten things should get you well on your way to picking a PHP/PHR that is best for you and your family.  Sure, there are a number of other things that could have been included or might have replaced one or two of the above but base on our knowledge of the market, this list is the best starting point in your selection/evaluation process.

Maybe, in the not so distant future, we’ll create our wish list for Santa of what we want to see in a the PHP of the future.  Stay tuned.

In our last episode we covered proximity technologies for authentication to clinical workstations in healthcare. This entry is the much more futuristic and exciting Biometric episode.

While speaking with hospital personnel about what type of authentication technology is most appropriate, people’s minds seem to wander to the movies.

When we talk about fingerprint biometrics I’ve had two people actually ask about faking the fingerprint or someone “cutting off a finger to gain access”. To which my reply both times was:

“If you have an intruder willing to cut off someone’s finger to gain access to patient’s records, you have much bigger problems than patient privacy or HIPAA.”

But biometrics are so bleeding edge and have been around in movies for so long there is always a little ‘Mission Impossible’ to it.

"Must... get... Tom Brady's knee surgery records. Only 6 seconds left."

Biometrics can eliminate the need for multi-factor authentication because it solves the much better “who are you” question instead of the “what you have” or “what you know” questions, which can be shared. Some state laws may still require the user to enter a pin or password for drugs (especially narcotics access).

You can’t steal a hand or eye (leaving aside the murderous evil-doers mentioned above) and you can’t borrow it. You know for certain who accessed that system.

For ‘warm and fuzzies’ in the security department, you have your technology.

More importantly, you can’t forget your finger/eye/hand at home or at the last workstation as you can with various card technologies.

But what is really useful? Practical? Cost Effective? PROVEN???

What makes sense for a hospital? First, a little background data. Keep in mind that a large part behind these technologies is not necessarily acquiring the data (fingerprint, vein scan, etc.) but more the algorithms and methods of storing and comparing the captured data to the existing database.

Fingerprint

Fingerprint has been a known biometric identifier since 1788 when a German by the name of Mayer made the discovery that fingerprints are actually unique to each individual. The process to identify the ridges on the fingers and match them for identification purposes was very cumbersome until computers helped the process. As technology developed, other methods of identifying the prints made the process quicker. For instance, many technologies don’t focus on the lines themselves but on the minutiae points on any given finger. See illustration.

Different types of minutiae points.

Any one of those items will be a minutiae point. The computer then maps them, which makes the comparison easier as the computer now has a much smaller sample set of points to compare as opposed to trying to compare the location and length of lines.

Some fingerprint technologies make it even easier by using the location and reference of those points and turning it into a unique number using complex algorithms, which makes it even easier to search. This is the method that Symantec Workspace uses with the SagemMorpho biometric. Some call this a ‘one to many’ match technology. Searching for a number is much faster than ‘one to one’ matching of prints. Funny enough, as you look across the web; there is some contradicting information on the specific terminology of ‘one to one’ or ‘one to many’. As long as you get the “fastest”, you are all set.

It is also important to mention the two major types of fingerprint scanning technology.

Capacitive: Uses the electrical current transferred by the pressing of two  plates to generate the image of the ridges in the fingerprint.

These are rather cheap, compact and a pain in the butt .

Capacitive sensor common on many modern laptops.

Many laptop manufacturers integrate capacitance scanners into their laptops these days. The problem with capacitance is the error rates (both false positives and false negatives). Capacitance scanners are also the easiest to trick or fake. You can even find youtube videos of people fooling them using gummi bears.

We often have customers ask if we can use the scanners already built-in to their computers. Our answer: NO. Even if the algorithms were the same, we wouldn’t want to for the sheer annoyance the users would suffer and then there’s the sheer volume of false positives.

About 5 years ago when we first started down the Single Sign-On path and before we got into complete “Access Management“, I was doing a demonstration at the national  HIMSS conference (I think it was in San Diego) with capacitive fingerprint sensors. I would put my finger down and be into the system… great!  But then a nurse asked what would happen if she put her finger down? “Nothing” was my reply. So she did. And got in… as me! Not only was it embarrassing. It was a wake-up call. No matter what the manufacturer told us about accuracy rates, that was unacceptable. We vowed to not mess with those things again. We don’t have those issues at all with optical.

Optical: Optical fingerprint scanners are simply using camera based technology (Charged Coupled Device or CCD) to gain the image and then compare it. Optical scanners are usually a bit larger than capacitive scanners and the good ones are more expensive. Optical scanners are far more accurate (depending on the manufacturer) and a bit harder to trick than capacitance.

If you choose to use optical scanners for authentication, be aware that the bigger the platen (area for image capture), the more likely the user’s finger is to be captured correctly the first time and user experience is a huge factor in the acceptance of these technologies. In this case, bigger is better.

Palm (Vein) Scans

By far the coolest is the vein scanning technology that companies like Fujitsu are pioneering. The user holds the hand above a near Infrared signal that is bounced back to the device…except where the veins are actively transporting deoxygenated blood which will absorb the signal, giving a vein pattern that is unique to the individual.

Palm Vein Scan

This is awesome technology for Healthcare (almost). It is zero-touch and secure. It has been used in Japan ATM machines for the last 3-5 years. There is some question as to the speed and it needs to mature a little bit as far as how the devices are going to integrate with a desktop, but it’s pretty darn close.

Unlike fingerprints, the veins are inside the hand and will not wear off. This means that every user that has a live hand can be enrolled.

The real gotcha or ‘almost’ is cost. Right now at $1000 a device, it is just not cost-effective yet to put on all the devices a clinician might access.

Added Coolness: Even identical twins will have different vein scans.

Another side benefit is that if someone cuts off the hand, there is no blood flow and thus no vein signature. Whew…  now I have a really good answer to those murderous villains trying to access your Aunt Betty’s  heart history.

We’ll have to wait to see how the Mission Impossible team fakes palm vein scans.

Iris/Retinal

Another movie favorite is Iris Scanning. A digital picture is taken of the iris, converted to a digital template and is matched against others. The algorithms currently developed make it the fastest authentication method for finding a ‘one to many’ match.

Retinal Scan

For computer authentication in healthcare, Iris scanning is problematic. Mounting the scanner is important and fraught with peril. Simply mounting to the monitor is not usually good enough since most monitors now have thin bezels and are often way to far from the user for the scanners that make sense from a cost standpoint.  Since image quality is key to the process, cheap scanners are not acceptable.

There is also the tricky part of keeping the users still for the brief duration of the scan and I don’t see many doctors and nurses standing in one spot for long, do you?

Due to these limitations, there have been very few manufacturers doing the software development to integrate iris scanning into their products.

It makes for a good movie scene, such as in Angels & Demons when the good Doctor’s eye is cut out to get access to the deadly anti-matter, but retinal scanners are only looking for a picture and cannot detect between fake eyes and real ones.

Healthcare Use

At the moment: based on cost, usability, availability and track record my opinion is that Optical Fingerprints are the best biometric method of authentication.

As I mentioned above, the practicality of iris scanning in the healthcare setting just isn’t there.

I’ve seen optical fingerprints used for authentication in hospitals for more than 5 years now with the only major concerns being cost (of big optical scanners), enrollment and infection control.

Palm Vein Scans might be there soon enough, but the cost needs to come down.  Palm Vein scans look to be positioned to eliminate the complaints we have now with fingerprints mentioned above and give the added benefit of being able to enroll everyone (except amputees).

Given all the discussion about the difficulty and expense of converting a practice or hospital to electronic health records, it is refreshing to hear from someone at the front lines who says, in effect, “just do it.” Dr. John Mattison, CMIO for Kaiser Permanente,  speaks from experience, having gone through the conversion process five or six times in different settings. Dr Mattison spoke at the Telecom Council of Silicon Valley’s Mobile Health Forum last week. Under his leadership, Kaiser Permanente was able to convert all their fifteen thousand physicians to EHRs within three years. “EHR conversion is about leadership and change management.  I hear about a lot of first timers scanning paper into electronic records. The problem with that is that scanned images are not searchable. You just need to abstract the older records where necessary and only scan very selectively,” said Mattison. Kaiser Permanente’s kp.org  EHR which is based on Epic now has three million users.

Dr. Mattison also talked about the key role smartphones will play in healthcare. “Smartphones are the wellness delivery channel of the future. This is going to explode; it is big and it is soon,” he said, indicating also that the mobility of the consumer will drive the development of new solutions. He highlighted some gaps in current smartphone technology that will need to be filled in order to facilitate healthcare workflows: status aware protocols for SMS when someone is away from the phone and mobile standards for role-based access, for starters. Dr. Mattison also discussed the role of social media in mobile, participative healthcare and the need for a “sustainable, lifelong model of privacy” where health information is easily quarantined from other social media interactions.

If the smartphone is going to be the wellness delivery channel of the future, I would add that today’s phones as application development platforms still have a ways to go. In developing mobile clinical applications you quickly run into the problems like fast, secure roaming across disparate networks. Maintaining application state and secure user context when roaming from the hospital WiFi network onto a commercial cellular network — like when the physician leaves the hospital to go to lunch and has an application open all the while — is problematic on a number of the main smartphone platforms. Currently Windows Mobile is the only platform with a full-on mobile VPN, though that is likely to change. Support for workflow applications, where a user is really interacting with multiple applications in a seamless way, is still limited for third party developers. RIM seems to understand this need better than the other vendors.

Your thoughts on other barriers or enablers to widespread use of smartphones as a healthcare platform?

As John points out in his post called “All I Want for Christmas is ARRA EHR Stimulus Answers“, we are all waiting for those answers from the US Government on the EMR certification process.

Who wants to place those bets on when something will be announced? My thoughts are that something will be announced either Tuesday, December 22nd or Wednesday, December 30th. Please don’t sit at your computer and hit your refresh button every 10 seconds waiting for an update on those days. Whatever is posted will not kick-in until the beginning of 2010 anyway.

Once that announcement is made, the details will be sung across the land like the Whos in Whoville did on Christmas morning. I can already hear the tune…Fah who for-aze! Dah who dor-aze!

The Digital Practice

I’ve been reading a number of articles about open source EMR solutions for medical practices. One that I saw recently was Why Buy Open Source (Free) EMR Software. I know that open source has its place but I don’t think it’s in a medical practice. Many analogies come to mind when I think about an open source Electronic Medical Records system being used to track and store my medical history. I wouldn’t want a bunch of weekend mechanics working on my car, trying to make it more fuel efficient or functional based on what they think I need.

I did a quick search to see what the pros and cons are for open source software. Now I’ll tell you that I’m not going to read 1,420,000 entries on this subject. If you have the time, please feel free. Here’s the search link:  Google Search – “pros and cons of open source software”

Some of the prominent entries I found on purchasing software created by a vendor in the industry are:

• Focus – Who is designing the software: developers or medical practice staff? In many cases, it’s the developers. They create features based on their perceptions of what the business rules and business needs are.
• Development – How well are the open source development procedures.
• Testing – Is adequate  testing of new functionality being performed. Will it crash when I update my application.
• Support – Many open source solutions are developed by programmers that do the develop on the side or in their free time. If a new module or component is not working after being installed, who do you call for support?

All-in-all, it is up to the practice to decide which direction is the best for the medical practice. It is the responsibility of the practice to weigh all the pros and cons, and to understand the cost or value of the solution they are getting.

- The Digital Practice

Since the Canadian and U.S. stimuli directed fuding towards electronic medical records (EMR), we’ve been following developments in the area as part of our Biotech Trends series here on the blog and have noted successes and failures.  A few recent stories highlight risks and benefits:

A recent Scientific American story (H/T @mikesgene) turned an analytical eye on the University of Pittsburgh Medical Center’s implementation, the current iteration of which started in 2004.  Case studies have been an important part of the EMR narrative, and many so far have focused on Kaiser Permanente’s implementation, which is the world’s largest civilian system, so it’s nice to see an in-depth analysis of a different experience.  The article closes with a quote from  National Institute of Standards and Technology (NIST) Director Patrick Gallagher, who says the stimulus effort

“is about using technology to bring health care information together to reduce medical error, reduce the need for testing, put information in front of patients, and put information in front of researchers.”

A FierceHealthIT story reported on an initiative by the American Telemedicine Association, which is running a demonstration program with DocTalker Family Medicine.  DocTalker, founded by Dr. Alan Dappen (partnered with @drval) is providing remote health services to Association members and employees.  It’s being pitched as an employee benefit that can promote worker health and productivity by reducing the need for office visits and providing round-the-clock responsiveness. 

Telemedicine’s role in EMR also features in this story about a pacemaker developed by St. Jude Medical that allows patients and doctors at the Montreal Heart Institute to get data and alerts from the device, which also transmits cumulative data to the doctors in advance of patients’ follow-up visits.

With all of these electronic data floating around, security is key, but it remains an elusive target.  Dan Vorhaus tweeted about a ModernHealthCare.com article that highlights numerous security breaches this Fall.  Microsoft’s purchase this week of Sentillion, which focuses on EMR security, was for an undisclosed sum but you can bet it’s key to Microsoft’s EMR strategy.

Does anyone remember how many of each type of animal God told Moses to put on the ark? Are you sure? For those who missed it, Noah built the Ark, Charlton Heston built the stone tablets.

One word can make the difference between right and wrong, especially if the question is big enough. Who is asking the questions that are shaping your firm’s EHR strategy? Do you know the name of the person? What question are they asking? Is it the right one?

As noted in early blogposts, there are active discussions in several countries, notably the US, UK and Australia, about the wisdom of large scale EHR projects.  A recent Millbank Quarterly study examined hundreds of previous studies on EHR implementations and, according an HealthBeat article (http://www.ihealthbeat.org/articles/2009/12/14/study-ehr-adoption-does-not-always-lead-to-efficiency-gains.asp), the researchers involved in the study suggest that “small, local EHR systems tend to be more effective and efficient compared with larger systems.“   As I have argued in past blog posts and my most recent Healthcare Information Management & Communications Canada “Last Words” article, healthcare delivery is an ecosystem that consists of many co-operating players and not a single enterprise.  Hence, the suggestion that local systems are mroe “effective and efficient” is not suprising to me.

Mike

A common practice among analyst firms such as Chilmark Research is to make annual predictions of what is in store for the coming year.  Chilmark will be making its own predictions for 2010 in the next couple of weeks.  Unfortunately, what most analyst firms do not do is reflect on their previous predictions and assess where they hit the mark, where they completely missed it and those partial hits.  Chilmark differs here in that we actually find it quite instructive to perform such an assessment for it both gives us some satisfaction when we get it right, but more importantly, provides us some humility and lessons when we get it wrong.

Following is our humble assessment of our 2009 Top Trends & Forecast post which was published in late December 2008:

Healthcare not Immune to Economic Woes: HIT – Indeed, 2009 has not been kind to the overall economy with unemployment rates still hovering in the 10% range.  Though healthcare is one of the few sectors that is actually hiring, truly a bright spot in this economy, certain sectors of healthcare have been anemic, especially HIT as physicians and hospitals await the final definition of meaningful use before plunging in and adopting a certified EHR, whatever that is.  As per our forecast, the market for Revenue Cycle Management (RCM) apps remained robust in 2009 and HIE apps did fairly well.

Health 2.0 Companies Shrivel on the Vine: MIXED – In retrospect, not a very insightful forecast as the cost to create and maintain a Health 2.0 company are not that significant, thus it may take sometime for founders to call it quits and close up shop.  And as many close their doors, there are plenty of others inspired to create some form of Health 2.0 app that will appeal to the masses, or at least a large sub-group (think diabetes, weight-loss, etc.) coming in to take the place of those before them.  We still hold to our basic premise that those who will succeed long-term will be characterized by: strong competitive differentiation, a revenue model that is not solely dependent on advertising, and a clear and compelling go-to-market strategy with a clear value proposition and partner network.

Retail Health Clinics Gain Traction, Corporate Clinics Stall: MIXED – Rather than turning to retail clinics in these times of uncertainty consumers continue to turn to those they trust, their primary care physician.  Despite the flu season and the ability to get your flu shot virtually anywhere, including the airport, retail clinics actually saw some contraction with one of the leaders, CVS’s MinuteClinic actually rationalizing the number of clinics it owns.  CVS’s claims that this was in response to an initial over-build, but more likely is a result of tepid demand.  Walgreens, CVS’s main competitor is the leader in providing on-site corporate clinics.  Despite their strong presence in the corporate clinic market, they have been noticeably quiet in recent presentations and quarterly reports saying little if anything about their success in this market.

Virtual Visits a Mixed Bag: HIT – American Well certainly appears to lead the pack for virtual visits (they seem to show-up at every event out there and the press is having a lovefest with them) and are the consummate marketers of virtual visits, but despite this, Chilmark still does not see a vast and growing market for such services, yet.  Virtual visits will indeed grow at a fairly rapid clip as physicians look for new ways to further engage their existing patients/customers, where a level of trust has been established.  The market growth for ad-hoc virtual visits, such as American Well, MDliveCare, etc., will continue to be modest at best until consumers become more familiar and comfortable with this approach to delivering care.

Dossia Ramps-up: MISS – Though predicting that Dossia would ramp-up its services with more go-lives of consortium members, such was not the case. While Dossia has done a lot of work in 2009 and claims that this work was necessary prior to others beyond Wal-Mart going live on the platform, Chilmark thought that at least by now, employers such as Intel, Pitney-Bowes and other advocates for the Dossia platform would be introducing their employees to Dossia during their annual benefits fairs in the fall.  To date, we have seen nothing more from Dossia and it continues to remain an enigma in the Personal Health Cloud market.

Chicken and Egg Scenario Plays-out for GHealth and HealthVault: MIXED – Google did add support in Google Health for unstructured data (ability for users to add advanced directives), but beyond that no further strides to support other standards outside the still limited bastardized version of the CCR standard currently in use. Chilmark also thought that Google would become more aggressive in attracting other data providers and partners, but this has fallen far short of expectations. Predictions for HealthVault were much more on target with its efforts to go international (Telus-Canada), the coupling of Amalga and HealthVault together (New York Presbyterian & Caritas Christi), the addition of many more partners and most recently, the roll-out of the consumer health widgets on MSN.

New HIE Models Leveraging Cloud Computing and SaaS Gain Traction: HIT – In the last few months, leading HIE vendors Axolotl, Covisint and Medicity have each announced their own Platform as a Service (PaaS) model, a combination of cloud computing and SaaS. Clearly, these leading vendors see the writing on the wall: HIEs will be pivotal solutions in the future roll-out of HIT supported by ARRA stimulus funding.  Now the question is: How will traditional EHR vendors respond?

Continua Compliant Devices Hit the Market with Little Impact to Anemic Telehealth Growth: HIT – Despite the hoopla regarding Continua and its certified devices (there are five today and one adapter) that were to storm the market, the use of biometric devices by consumers to facilitate telehealth remains by and large in the testing phase.  There has been no broad roll-out, and very little in the way of ARRA funding is targeting this area despite the pleas of some.

Dreams of Big Fed Spending on HIT Do Not Materialize: MISS – Complete and total miss now that the feds plan to spend some $44B on HIT in the coming years to wire up physicians, hospitals and clinics.  Couldn’t get any farther from what has actually come to pass in this forecast, but it remains to be seen just how successful this federal largess will be in the successful deployment and implementation of HIT.  A very tight schedule with a number of hurdles to overcome – keep your fingers crossed that not too much of tax payer dollars will ultimately be wasted.

mHealth Continues Expansion, Most Apps Lame: HIT – mHealth is seeing increasing attention with an increasingly large array of apps being made available, from simple text messaging apps from the like of FrontlineSMS targeted for NGOs in developing countries to increasingly complex, useful and expensive apps such as the $189.00 app, Proloquo2Go, which was a top iTunes seller in 2009.

Adding it all up, Chilmark Research did a reasonable job of forecasting 2009, with five hits, 3 mixed and 2 total misses.  Hope you’ll forgive the blunder/complete miss on the HITECH Act and we’ll strive for a more accurate forecast for 2010, which will be forthcoming within the next couple of weeks.

Have you ever done any sort of group problem solving exercise like Outward Bound to help you to think as a team? Suppose there was an exercise for healthcare and IT executives, whose goal was to get the executives to think about how to best deploy can EHR system. To do this they are given a problem and access to ‘technology.’

Here is the scenario and the rules as they are presented to the group. They are given ten dollars. The executives are presented with a bathtub filled with water, and told that the winning team will figure out the best use of money and time to empty the bathtub. Also available to them is a bucket which costs ten dollars and has a hole in it, a four-dollar cup, and a collection of wooden spoons which are free.

Any idea what the right combination is? Is there a best answer? Bucket? Cup and spoons? How would you solve the problem? Sometimes the best answer is so obvious it’s silly. Kind of like call centers? What’s the best use of the available tools? Faced with the option of buying more technology to solve the problem, when was the last time you saw someone refuse the funds?

Figured it out?

Pull the plug from the drain.

In many cases, we already have everything we need to solve the problem, we just need to know how to use it.

Just like Dorothy in the ‘Wizard of Oz.’  She had the ruby slippers the entire time, she just didn’t know how to use them. I think most EHR strategies can be improved without spending requiring millions more in technology.

That’s my story and I’m sticking to it.

Hi there blog readers!

I’m Nathaniel and I will be the new Caring Blog Editor. My main goal as the Caring Blog editor is to create an informative blog with an open forum for readers to post their thoughts on issues in health care. The best part about being able to voice your thoughts on health care is that this blog will discuss several aspects of health care from direct patient care to politics and technology in health care.

After researching articles and journals about the growing need for long-term care for the baby boomer generation, I have found it surprising that there will hardly be enough facilities to support all of them in need.

According to the CDC’s statistics on nursing homes in the US there are currently approx. 16,100 facilities in the county. Of these facilities they can only house a combined total of 1.7 million residents which is currently only at 86% capacity. With another article I read, it is estimated that by 2025 the age of the population of 55 will be approx. 40 million people!

How can we as health care leaders, consumers, and advocates, prepare for the demands in the near future? Obviously one solution is to build more facilities; however, this can only be done if you have the personnel (Nurse shortage and small population) to run the facility and have the necessary space to build/add-on.

One shift in health care that I foresee, will be that of more home care patients as long-term care facilities start to only allow only those that desperately need 24/7 skilled nursing care. With this change, I think that the government needs to realize this shift in the health care bill. Currently the politicians are looking at cutting funding for Home Health Care. That’s fine a dandy for the time being but what about when the number of citizens needing home care increases dramatically?

What are you thoughts on the issues of the aging population and limitations long-term care?

While there is increasingly less doubt that a system-wide revaluing and rebuilding of our primary care infrastructure will both reduce health care costs and improve health outcomes, there is less certainty with regard to the contributions of the high-tech elements of health reform. A recently released study by researchers out of Harvard Medical School scheduled for publication in the American Journal of Medicine suggests that despite Congressional support of more than $19 Billion, claims of increased efficiencies attributable to hospital computerization (EMR) “rest on scant data.” The study was based on a review of over 4,000 hospitals over a 5-year study period. The hospitals examined were at various stages of EMR implementation and capability, and ultimately even the “100 most wired hospitals” (as defined by an independent ranking of hospital computerization) are seeing neither cost savings nor significant increased administrative efficiencies. Additionally, the study found no appreciable difference between these “leaders” and the full study sample. In addition, researchers from Massachusetts General Hospital have also just released a study with a similar design and a conclusion that there was “little difference in the cost and quality of care” between those hospitals who had adopted EMR and those that had not.

While each of these studies can be challenged to some degree given the personal agendas of the authors, they leave me more convinced than ever of my previously held opinion that the jury is simply still out on EMR. There are clear advantages that should be obtained from the adoption of health information technology (HIT), but the entire enterprise is compromised by poor design. EMR’s are designed with the goals of the individual user, physicians and hospitals, as the focus. I think of this focus on management of individual patient records, coding technology, billing and the like as design based on micro level goals. Instead, the objective should be to meet the goals of the health system at the macro level. This is the functional equivalent of asking each airline to invest in separate, non-interoperable systems to control air traffic, and then expecting airline safety to improve. In fact, it is my opinion that the only way to control, and potentially reduce health care costs and improve outcomes at the system level through application of HIT is through the creation of a standardized, universal, completely interoperable system, or at the very least, the development of technology that allows the currently disparate systems to communicate as an interoperable information system.

How does one depict the complexity of the mess being presented as the national roll out plan of electronic health records (EHR) via the national health information network (N-HIN) using Health Information Exchanges (HIEs) designed by Regional Health Information Organizations (RHIOs), with the help of regional extension centers (RECs) without Standards (Standards) and with N too many vendors?

Class?  Ideas?  Class?

If this looks dumb, undo-able, unimplementable, uninteroperable–it’s because it is.  your vision is fine.

Remember the idea behind all this is to get your health record from point A to point B, any point B.  It’s that little word ‘any’ that turns the problem into a bit of a bugger.

Find yourself in the picture below, pic a dot, any dot (Point A).  Now, find your doctor, any doctor (Point B).  Now figure out how to get from A to B–it’s okay to use a pen on your monitor the help plot your course.   That was difficult. Now do it for every patient and every doctor in the country.

Now, do you really think the DC RHIO-NHIN plan will work?  If EHR were a Disney park, who’s playing the Mouse?

The doctor will see you now. Or at least in the few seconds it takes AT&T to relay your vital signs over its broadband network.

The telecommunications giant has big plans to establish a foothold in the “telehealth” industry, an emerging field that links patients and physicians across the country via video and medical-information technology.

“These days, everybody is talking about medical care: Who gets it? Who pays for it? Who decides?” said Robert Miller, executive director of technical research at AT&T and a 40-year veteran at the company’s Florham Park research labs. “But few people are working on a technology solution that would lower costs and make medical care better at the same time.”

AT&T scientist have spent the past year working on prototypes of products aimed at the home health care market. The idea is to make everyday household items “part of the network cloud,” said Miller, holding up a pair of fuzzy bedroom slippers. They look perfectly ordinary, but they are actually one of many telehealth products in the pipeline at AT&T.

Question:

Do you think that organizations outside of health care should join the health care market with their technologies or should they remain separate?

To read the rest of this article please visit:

http://www.nj.com/business/index.ssf/2009/12/att_develops_household_items_t.html

Swimming with guppies

Got the new bike, got the new bike shoes, got the uni (uniform-not unitard).  I’ve written about my desire to compete in a triathlon.  Actually, I miswrote.  My desire is not to compete, it’s more accurately a desire not to make a fool of myself during the swim, more specifically not to drown.

The swimming is one of those events where having the coolest outfit doesn’t help, as there are no coolest swimming outfits (men do not let men wear Speedos).  There aren’t enough North Face labels for me to wear to make me look like I know what I’m doing in a pool.

What to do?  Here’s my thinking.  I made a new friend, and as a bonus, she happens to be pretty sharp on the pharma side of healthcare.  She swims—fast.  She swims—a lot.  Did I mention she swims?  Longtime readers know I like to color outside the lines.  Maybe I could hire her to take my place during that part of the race.  Then we get back to the issue of the uni.  One way or another that becomes an issue for one of us.

She offered to teach me.  Lesson one was today.  Lesson two will begin right after the EMTs finish their CPR on me.  Rule one, no matter how cool you think you are, you can’t breathe under water.  That took a few laps to master.  More breathing, stroke, legs.  Lots to learn.

“Let’s get a pool boy to help you not drag your legs,” she suggested.

I have difficulty passing up the opportunity to comment.  She could see I had the broccoli in the headlights look in my eyes.  “You hold it between your legs and it helps you float.”

I scanned the pool.  There we the two of us…and the lifeguard.  “It looks like he’s busy,” I offered somewhat sheepishly.  “Besides, if that’s what it takes, I think we’re both better off if I drag my legs.” (A little un-PC pool humor, but why not, I was already wet and being out swum.

So, what does this have to do with why we’re here?  Here’s the take away.  Sometimes, no matter how smart, no matter how big your ego, you need help.  Sometimes it makes a huge difference to have someone on your side who’s been there, done that, got the T-shirt.

Not with me yet?  A guy (man or woman guy—send me an email and let me know when we can let go of this PC thing and just write) is walking down the road, not watching where he’s going, and he/we/she/it falls into a deep hole.

An engineer walks by.  “Help me,” shouts Hole Person.

The engineer thinks for a moment, writes some ideas on a piece of paper and tosses them into the hole.

Several hours later, a finance guy walks by.  “Help me out (literally)” yells Hole Person.  The CFO tosses down a cheque (I use the Canadian spelling to distinguish it from someone from the Eastern Bloc as it would make no sense to toss another person into the hole.)

Days later, Hole Boy (not the same as Pool Boy in case anyone is still reading) is at the end of his rope.  The work plan failed. The Check bounced.

A consultant passed, saw the man, and hopped into the hole.

“Why did you do that?  Now we’re both stuck.”

The consultant smiled in a Grinch-like fashion—please see prior blog for the segue.  “I’ve been down here before, and I know the way out.”

Kind’ a like a swim coach.

EHR projects have more zeros than you can count.  What if you could hire someone who knew the way out?

I may know someone who can help.

(n.b. Pelosi, Reid, and the term Payor may be changed to the names of your favorite vilans without materially altering the story.)

Every Congressman
Down in Congress-ville
Liked Health reform a lot…

But the Payors,
Who lived just North of Congress-ville,
Did NOT!

The Payors hated Health Reform! The Congressional reform season!
And as everyone’s heard there is more than one reason.
Was it the fear of losing their monopoly right.
Worried, perhaps, that Congress might indict.
But I think that the most likely reason of all
May have been that the uninsured took them all to the wall.

Staring down from their man-caves with indemnifier frowns
At the warm lighted windows below in the town.
For they knew every Congressman down in Congress-ville beneath,
Canted an ear to hear them gnashing their teeth.

“If this passes, they’ll kill our careers!”
“Healthcare reform! It’s practically here!”
Then they growled, the ideologues nervously drumming,
“We MUST find a way to keep Reform from coming!”
For, tomorrow, they knew…

…Stumbling home from the tavern at a quarter past two                                                                                                                 What each Congressman, intern, and page might just do

And then all the milieu. Oh the milieu, the milieu
The thing the Payor hated more than mom’s Mulligan stew.

Then all the Congressmen, the left and the right, would sit down and meet.
And they’d meet! And they’d meet!
And they’d MEET! MEET! MEET! MEET!
Implement full provision; cover pre-existing…how sweet
Which was something the Payors couldn’t stand in the least!

And THEN
They’d do something Payors liked least of all!
Every Congressman down in Congress-ville, the tall and the small,
Would stand close together, their Healthcare bells ringing.
With Blackberrys-in-hand, the Congress would start pinging!

They’d ping! And they’d ping!
AND they’d PING! PING! PING! PING!
And the more the Obligators thought of the Congressman-Health-Ping
The more they each thought, “I must stop reform-ing!
“Why for all of these years we’ve put up with it now!
We MUST stop health Reform from coming!
…But HOW?”

Then they got an idea!
An awful idea!
THE Indemnifiers
GOT A WONDERFULLY, AWFUL IDEA!

“I know what to do!” The CEO Payor laughed in his throat.
And he made a quick Congressional hat and a coat.
And he chuckled, and clucked, “What a great Payor raucous!
“With this coat and this hat, I’ll look just like Saint Bacchus!”

“All I need is a pass…”
The Payor looked around.
Since Congressional passes are scarce, there was none to be found.
Did that stop the old Payor…?
No! The Payor simply said,
“If I can’t find a pass, I’ll make one instead!”
So he called his aide Max. Then he took some red paper
And he dummied up the pass and he started this caper.

THEN
He loaded some bags
And some old empty sacks
On a Benz 550
And he rode with old Max.

Then the Payor called, “Dude!”
And the Benz started down
To the offices where the Congressmen
Lay a-snooze in their town.

All their windows were dark. Quiet snow filled the air.
All the Congressmen were dreaming sweet dreams of healthcare
When the Payor came to the first office in the square.
“This is stop number one,” The old Warrantist – a winner
And he slipped passed the guard, like sneaking to a State Dinner.

Then he slid down the hallway, Harry Reid was in sight.
Reid was chumming Pelosi, he planned quite a night.
He got nervous only once, for a moment or two.
Then he realized that the leadership hadn’t a clue
Then he found the Congressional stimuli all hung in a row.
“These Stimuli,” he grinned, “are the first things to go!”

The Payor slithered and slunk, with a smile somewhat mordant,
Around the old Cloakroom, and looking discordant!
There were copies of the bill stuffed in jackets and on chairs,  He even found a copy tucked under the stairs
And he stuffed them in bags. Then the Payor, very neatly,
Started humming a tune from Blue Cross rather Cheeky!

Then he slunk to the Senate Chamber, the one facing East
He took the Senators’-copies! … didn’t mind in the least!
He cleaned out that Chamber and almost slipped on the floor.
Saw an Internet router, and thought of Al Gore

Then he stuffed all the copies in the trunk of his Benz.
And he thought to himself, “Why don’t I have friends?”                                                                                                                    “There’s always TW,” he said with no jest                                                                                                                                                    But TW’s being chased by reporters, those pests.

The Payor spotted the Grinch having trouble with his sacks
And he lent him a hand—he offered him Max                                                                                                                                           Max was quite pleased, for he knew this December,
That the Grinch would become the Payor’s board member.

The Grinch was all smiles–he’d made quite a killing
Offering to help pillage if the Payor was willing.
He stared at the Payor and asked, “New glasses?”
The Payor simply smiled, saying “These people are such (You did that to yourself, not me.)

And, you know, that old Payor was so smart and so conniving
When he next saw Pelosi he found himself smiling!
“Why, my dear little Nanc’,” the Bacchus look-alike stiffened,
“Botox in this light makes you look like a Griffin.
“I’m taking these home,” he said pointing to the copies.
“There’s a comma on one page that looks way too sloppy.”

And his fib fooled the Griffin. Then he patted her head
And he gave her a wink, and he sent her to bed
And as Speaker Pelosi shuffled off to her army,
HE said to himself, “What a waste of Armani!”

Then the last thing he needed
Was to mess up HITECH.
Then he went to HHS, the DOD and the VA,
Stuffed mint jelly in their servers so that they would not play

And the one EHR
That still worked in the DC
Was the one bought from CostCo and tucked under the tree.

Then
He did some more damage
To HIEs, and the N-HIN

Leaving PHRs
Far too trashed
For a doctor who did knee-shins!

It was quarter past dawn…
None in Congress were his friends
All the Congressmen, still a-snooze
When he packed up his Benz,
Packed it up with their copies of reform in those bags! Stacked to the leather ceiling,
Manila envelopes with name tags!

Three miles away were the banks of the river,
He was poised with the bags all set to deliver!
“Pooh-pooh to the Congressmen!” he was Payor-ish-ly humming.
“They’re finding out now that no Reform is coming!
“They’re just waking up! I know just what they’ll do!
“Their mouths will hang open a minute or two
“The all the Congressman down in Congress-ville will all cry BOO-HOO!”

“That’s a noise,” grinned the Payor,
“That I simply must hear!”
So he paused and the Payor put a hand to his ear.
And he did hear a sound rising over the snow.
It started in low. Then it started to grow…

But the sound wasn’t sad!
Why, this sound sounded merry!
It couldn’t be so!
But it WAS merry! VERY!

He stared down at Congress-ville!
The Payor popped his eyes!
Then he shook!
What he saw was a shocking surprise!

Every Congressman down in Congress-ville, the tall and the small,
Was singing! Without any health reform at all!
The Congress didn’t care, a few were disgraces,
All they wanted, it seemed, was TV with their faces

And the Payor, with his Payor-feet knee deep in the muck,
Stood puzzling and puzzling: “Man, there goes my bucks.
It could be about healthcare! It could be global warming!
“It could be Al Qaeda, Afghanistan and desert storming”
And he puzzled three hours, `till his puzzler was sore.
Then the Payor thought of something he hadn’t before!
“Maybe Congress,” he thought, “simply needs a free ride.
“Maybe Congress…just needs to look like they tried.

And what happened then…?
Well…in Congress-ville they say
That the Payor’s small wallet
Grew three sizes that day!
And the minute his wallet didn’t feel quite so tight,
He whizzed in his Benz passing through a red light
And he brought back the copies of the bill for reform!
And he…

…HE HIMSELF…!
The Payor calmed the whole storm!

‘Twas the night before reform when all in the House

Were Tweeting and blogging and squawking like grouse

Their bill filled with zeroes and commas and flair

In hopes that the Senate would soon be there

The voters were restless, and in need of good care,

And they whined and they pleaded and they yelled ‘don’t you dare’

“Don’t sidestep this issue, don’t do it for votes”

“Don’t kowtow to payors or we’ll be at your throats.”

With Pelosi and her Botox and while Reid took his nap

Didn’t care if the people put up with their (you rhyme it, I’m pretending to be neutral)

The docs sat on the sidelines, bemoaning their fate,

While payors dressed like succubi caroled “ain’t this great?”

On the lawn of the White House there arose such disdain

As the public fought reform from ‘Frisco to Maine.

MSNBC, neigh now Comcast, buttressed their base,

And Fox, aka Rupert, said it was all a disgrace.

The words on the pages of the newly printed bill,

Hid nuance, erudition, obfuscation, and skill,

Do not read the details, adjectives and signs,

Do not worry how it impacts your bottom line.

We are here to pretend we did that of import,

To Hell with Medicare, Medicaid and the sort

It’s voters we want, It’s our doxology, our mantra,

And this year silly people, this year WE are Santa

On Boxer, on Biden on Fienstein they came,

And we chortled, berated, and chided by name.

“What about seniors, and sick people” we cried?

“What about uninsured, don’t you care if they died”

“This is about people you meet on the street.

People who must choose between their meds and to eat

It’s about Lipitor, Xanax, Prozac and Viagra,

It’s about doing what’s right, do what’s right or we’ll bag ‘ya”

And then in a twinkling I heard in my head,

The gnawing and chiding of Congress, who said,

We cavorted and sucked up, the best we knew how,

We spent bucks, made payoffs, and said the time is now.

Festooned all in new regs from NHS to VA

There were those who suggested, this is not going to play,

HITECH and ARRA are not making it fun,

RHIOs and RECs will soon come undone,

We’re paying the hospitals to do EHR

We know it seems silly, like we lowered the bar

If that doesn’t work we will tax them instead,

Make them spend gobs of money, make their budgets bleed red.

Spend it, refund it, and print new money now,

Buying Canada would be cheaper and easier but wow

They want to sign something, sign it soon, sign it fast,

But don’t assume that they’ve read it from first page to last,

We could’a been more like France, like the Swiss or the British

Make us more European, make our rich people skittish,

The tall socialist exclaimed as the dems shifted right,

Will Obamacare fail, have I lost all my might?

EMR-resistant staff can be a major hurdle in successful implementation. Let’s discuss some of the reasons staff can be less than happy about your decision to use electronic medical records. 

1. “Our current paper system works fine; why do we have to change?”

People will always question the need for change, especially when it is perceived that the there is no personal benefit derived from the change.  The staff must understand how transitioning to electronic charting enables them to do their job more efficiently.  You will not receive the same excitement about EMR by telling the staff the financial benefits as you will the practical benefits.  Every staff member will recognize the personal benefits of immediate chart retrieval as they have all had the experience of “hunting” for a lost chart.  Another point of frustration in paper charting is interpreting various handwriting styles; charting electronically solves this issue.  A third key selling point is the ability to auto-populate the fields in the Rx Lab Order and the transfer of diagnosis and procedure codes from the exam room to the fee slip at checkout.

2.  “I am not computer-savvy.”
It is common to find a generational challenge with new technology.  While a portion of staff members have grown up emailing, texting and using the internet as their first choice for information, you could have staff members who are very uncomfortable using computers.  It is crucial to use baby-steps with these individuals and patiently provide the extra support they need to become confident in charting electronically.  

2.  “Paper chart documentation is much faster.”

When beginning to use an EMR system it will take more time to document until you get past the learning curve.  That is a fact that must be accepted and planned for.  Not only is the whole clinical staff learning a new way of documentation, every patient that comes in the door, both established and new, must have all of their patient history entered into the EMR.  The great news is that after the first visit, the patient’s history automatically pulls forward for quick review and update.   A suggestion is to use ExamWRITER only on new patients for 2-3 weeks before going 100% live with ExamWRITER.  Using this method the staff feels “out of their element” only with new patients and can go back into their paper chart comfort zone for established patients.  After using ExamWRITER on new patients for 2-3 weeks the transition to electronically charting all patient encounters will be easier as the program will be more familiar.

Whenever I walk through a clinical floor and watch doctors & nurses access their computers I get a particular movie scene in my head. I apologize but I’m going to geek-out for a second:

In Star Wars IV: A New Hope there is the scene where Luke, Leia, Han & Chewie are trying to escape from the Death Star, there are two quick sequences:
One where Luke actually uses his blaster to close the door as Stormtroopers follow closely behind, only to realize a second later that the controls he blasted were the only way to extend the bridge to bring them to safety.

Password not Verified. Please try again.

The other sequence is where the Stormtroopers are chasing Han & Chewie and the Stormtroopers are yelling “Close the blast doors, Close the blast doors”. Then the doors get closed with them on the wrong side and they yell, “Open the blast doors, Open the blast doors”.  Who are they talking to? How does the entity on the other end of the communication know which of the 10,000 plus doors on the Death Star they mean?

The scene with Luke sticks out for me because I also have a vivid memory of a Doctor in a local hospital literally hitting his keyboard as hard as he could and (nearly) yelling “That was the right password!” (I left out an expletive.)

The keyboard did not survive and the doctor had to go find another computer to abuse.

Arthur's Holy Grail was a little different. A little cartoonish, if you ask me.

The holy grail for most clinicians is not having to ever remember one of the 10-20 passwords their systems require for access. Now, that isn’t always realistic (especially with some state’s eRX policies) but Single Sign-On solutions like Symantec Workspace Corporate or Imprivata OneSign can bring that down to one or two.

But if the hospital really wants to get close to that Holy Grail, they need some sort of hardware device to help. (For my idea of the complete Holy Grail, see previous blog post: SSO vs User Experience.) Right now those options include:

1. Active Proximity Device
2. Passive Proximity Card (‘Pop Cards’)
3. Biometric (finger, palm, iris, facial)
4. SmartCard

In a three part blog series, I’m going to cover all of them. With Part I, we’ll start with both types of Proximity, since they all too often get confused as the same thing.

Active Proximity

Active proximity devices usually require two pieces of hardware to work. A device attached to the computer and a device that the user wears (usually attached to a lanyard around the neck) which will have a built-in battery that extends the range of the proximity device to as much as 3-10 feet.  The device is always sending a signal and when the user comes within the radius, the device attached to the computer detects the user device and credentials can be automatically entered or a login screen can be presented with username already filled in.

The concept is great: the device the user wears sends out a constant signal that gets picked up as the user walks near a computer. The computer can then be programmed to automatically log the user in with minimal to zero interaction. This is soooo close to the Holy Grail but it can get rather problematic in close quarters (like an ER) where multiple proximity devices are close enough to the reader to cause unintended log-ins and sometimes login the wrong user. In those intances it gets to be extremely frustrating.

Active Proximity Pros

• Easy to use
• Zero Touch (no infection control issues)
• Speeds up log-in process
• addresses the “something you have” part of authentication

Active Proximity Cons

• Bulky
• Battery maintenance concerns
• Multiple user conflicts
• Unintended log-ins
• Does not address “what you know” part of authentication
• Cost

Passive Proximity

Passive Proximity devices require a USB hardware device attached to the computer and the user to have a prox card (or ‘pop’ card).  The card is held a few inches from the card reader and the reader passes card number to the SSO system. The system can then automatically log the user in or at least present the login screen with the username already filled in.

A very large number of facilities already use this technology for physical door access. Extending this technology to computer access will make a lot of sense because users are already accustomed to swiping the card to open a door and they don’t have to get used to another device. Adoption by physicians and nurses has been very high compared to other forms of technology.  RFIdeas is the vendor we use due to their ability to read all types of existing proximity cards from various vendors.

Passive Proximity Pros

• Easy to use
• Leverage existing physical access system
• Users probably already carry a prox card
• Zero Touch (no infection control issues)
• Speeds up log-in process
• Addresses the “something you have” part of authentication
• Least expensive method of hardware authentication

Passive Proximity Cons

• does not address “what you know” part of authentication
• lost cards

Both forms of proximity have their use cases. Passive proximity, due to low cost and the fact that most hospitals already use prox-cards for door access, tends to be the preferred choice. For active proximity we see the problems with unintended log-ins will often negate the benefits in the real world.

We are seeing more facilities leverage passive proximity in a scenario where the user will be able to tap their card, enter a password and get into the system. In some facilities we will configure the system so that the users will not have to enter a password again for the next 2-6 hours.  This gives a level of security in that if the card gets stolen, it is only good for a short amount of time. For states and hospitals requiring dual authentication, some SSOs like Workspace corporate will allow the hospital to use dual-authentication only for the pharmacy application. This is pretty darn close to the Holy Grail and nearly eliminates the doctor getting getting irritated because the machine can’t remember his password correctly. I’ll do a more comprehensive side-by-side once after all 3 parts of the authentication series.

Part II is next: Biometric Authentication for Healthcare.

We had a very successful event for medical practices in the Denver area on Tuesday that gave practices Ten Smart Things You Can Do To Build Your Practice in 2010. Dana Fox, of Strategic Edge Partners was our national speaker that folded each sponsor’s business into the event. Representatives from a variety of practices came to learn more ways in which they could increase their revenue while lowering overhead.

The sponsors for the event were:

Cutera – http://www.cutera.com/

PatientNOW – http://www.patientnow.com

Strategic Edge Partners – http://www.yourstrategicedge.com/

Vaser – http://www.vaser.com/

Additional events will be scheduled nationally in the coming weeks. Stay tuned to http://www.aestheticmarketing2010.com/ for dates and times.

With all of the talk about Electronic Medical Records (or Electronic Health Records) the common practice may become very confused about what to do.  Should they wait until a common format is released, or should they move ahead and purchase in order to receive a tax credit before the year ends?

With the American Recovery and Reinvestment Act, qualified professionals (physicians, dentists, optometrists, podiatrists, and some chiropractors) can realize up to $44,000 in Medicare incentives (or $63,750 through Medicaid) through “meaningful adoption” of a certified electronic medical records software system. The EMR software stimulus is a substantial incentive to adopt your new EMR in 2009-2010 in order to demonstrate meaningful use of your EMR and lock in your EMR incentive payments.

The key to choosing an EMR is first and foremost going to rely on the support and development potential of who you choose to partner with.  Having a company that can support your Practice Management System (which includes EMR) and assist you to truly realize the gains that are offered by it is crucial to your success.  The common problem that we have found is simply that there is not local support in this area (Stockton, Tracy, Modesto and surrounding areas) and so many companies are not utilizing the true power of these systems if utilizing them at all.

BOSS has recently been working with Mac Practice in order to offer an affordable yet very powerful solution. We have seen quite a few practice management systems demonstrated and this is by far the most powerful and simple system to use.  The key for our clients has been the ability to adapt the exact same forms, fee slips, etc. that they are using in their current paper charts and mirror these in the EMR environment.  This feature decreases the learning curve substantially.  And while we recommend that they switch to a Mac environment in order to drive down their IT costs as well as improve the simplicity, this software will work on the PC as well.  In almost every case this practice management software is 50% less if not more than other software being considered from other vendors.  And combined with our ability to locally support practices from IT to set-up this is a very attractive offering.

Mac Practice can develop their software much faster than the majority of the PC based software on the market due to the fact that they are programing for a common controlled platform.  There is only 1 company that makes the Mac, and with this, they only have to write their software for one system.  With the PC world there a more variables in programming simply because of the vastness of platforms (various brands) available all using different brand hardware.  While the major players in the practice management software development world will turn revisions out to adapt to the new common criteria once it is released, Mac Practice will as well.  The difference in Mac Practice and these major players is mainly price and not robustness.

With interface capabilities to the iphone or ipod touch for doctors to view their schedules, view patient contact info, tap to email patient, tap to call patient, create new patients, post charges, view daily reports, view referring doctors, create new reminders, view patient Rx history, to name a few, further enhances the depth of this product.  If you have seen the ads for Mac Vs. PC on television, this concept is carried across to the Mac Practice software in the user experience.

BOSS is very happy to be working with Mac Practice in order to bring this powerful solution to the area.  We can set-up demonstrations directly from Mac Practice for those that are interested in finding out more.

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