Quality Metrics

Crossing the Quality Synapse: Interoperability is the Neurotransmitter Propagating 21st Century Healthcare

Yesterday at the 2010 ONC Grantee Meeting in Washington, D.C  I was invigorated by the optimistic energy, realistic networking and paucity of pessimism from over 1,000 participating grantees whose collective repository of health IT knowledge is astounding.   And it got me thinking, maybe the Institute of Medicine (IOM) got it wrong and that it is not actually a chasm...maybe we are...crossing the quality synapse?

Imagine for a moment that electronic health information is a charged impulse using health IT neuronal circuitry to propagate 21st century healthcare.  This neuronal circuit provides the infrastructure needed to enable charged impulses of the right information on the right patients to be sent or received wherever it is needed, whenever it is needed.  However, as we physicians know, the neuronal circuit is made up of many individual neurons that are not physically connected to one another.  Each neuron can individually propagate a charged impulse along its long, tubular-shaped axon, but the axon ends blindly at its terminal end.  Between it and the next neuron there is a space, called the synapse, across which the electrical impulse cannot travel.  This constraint prevents an individual neuron from transmitting the electronic impulse to its final destination.  On the other hand, an absence of such constraints and uncontrolled releases of electrical charges between the neurons of our brain would result in seizures.   So, some type of trusted intermediary is needed to enable the neurons to talk with one another in a standard and controlled manner...to be an interoperable neural circuit that coordinates and directs the traffic of electrical charges to their permitted destinations.     

In medicine we recognize the complexity of this synapse.  Although we have learned much about it, we remain humbled by what we do not yet know.  What we do know is that at the "receiving" end of a neuron there are tiny tentacles, or dendrites, that stick out into the synapse toward the "sending" neuron's axonal terminal.  When the charged impulse reaches the axon terminal, the action potential stimulates the chemical release of neurotransmitters from the terminal into the synapse.    The neurotransmitters physically travel across the synapse to the dendrites.  At that point the neurotransmitters become a catalyst for the transformation of the chemical process back into an electrical one.  The new electrical impulse travels from the dendrite into the neuronal axon and propagates down to the next synapse, where interoperability will again have to occur. 

Health IT interoperability is the 21st century neurotransmitter that is catalyzing the transformation of the healthcare system.  Without interoperability we know that electronic health information is severely devalued as it remains trapped in individual silos, just as an an absence of neurotransmitters would limit electrical impulses to a single neuron. 

Concurrent with ongoing neuroscience research on the complex synaptic neurotransmitters, medical researchers used what we already knew to initiate trials and studies in an effort to improve psychiatric care.  Breakthrough research demonstrated that a synaptic deficiency of one of the neurotransmitters in our brains, serotonin, can cause depression.  Through additional trials and experience we then discovered that SSRI medications, which elevate serotonin levels by inhibiting their "reuptake" in the synapses after being released, are useful when treating people with depression and other mood disorders.   Similarly, a deficient level of interoperability between EMRs depresses our ability to transform our healthcare system.  We need to use what we already know about interoperability to initiate trials and studies in an effort to raise our interoperability to optimal levels that will propel our healthcare system into the 21st century.     

Enhance Safe Use of EHRs By Aligning Implementation To Quality Goals

Safe use of electronic medical records (EMRs) is enhanced when physicians focus their EMR implementation on quality of care improvements.  Effective communication among the staff about these key goals creates a positive environment that serves as a catalyst for successful use of the EMR.  In addition, large healthcare systems and small physician offices are both less likely to encounter patient safety issues when they align their health information technology (IT) strategies to quality of care goals.  

Case Study:  Several years ago the leadership of an Accountable Care Organization (ACO) formed between a local healthcare system and a multi-specialty physician group began working collaboratively on a common vision for patient safety excellence.  System-wide integration and use of medication reconciliation were top priorities.  The EMR used by the hospitals have an ambulatory component that meets all of the critical requirements determined by the physician board members.  If implemented, the ambulatory and hospital EMRs could be integrated and share the same master patient index, drug formulary, medication index, allergy index and set of clinical decision support rules.  However, the physician board, influenced by several leading opinion-makers who favored an alternative EMR, convinced ACO leaders to allow the physicians to purchase their own ambulatory EMR and use system resources to purchase and develop a data repository that could send/receive (bi-directionally) and store data between multiple sources.  The vendors involved promised they could provide the infrastructure and tools necessary to capture and manipulate the data.  Two years later a patient suffers a severe anaphylactic reaction after receiving an antibiotic injection in one of the physician offices.  An investigation reveals that although the EMR had properly displayed the allergy, the antibiotic order had not triggered an allergy alert.  Further research reveals multiple ways for an allergy to be entered into their customized, bi-directional medication reconciliation tool that would successfully display the allergy in the ambulatory EMR, but not trigger an alert during the ordering process.  Their conclusion is that the use of different EMRs with multiple drug formularies, multiple medication and allergy indices and different clinical decision support rules is more complex than anticipated.  They suspended use of the medication reconciliation tool until they could determine whether they could more effectively execute their current strategy.

Key Points:  Effective organizational characteristics and a focus on quality of care are important catalysts for safe EMR use.

Cultivating a culture of safety, promoting transparent communications and alignment of strategic planning with prioritized goals to improve quality of care are examples of organizational characteristics that facilitate safe EMR use.  In this case the organization did well creating a shared vision with common goals/priorities regarding quality of care.   However, organizational alignment fell apart when the unbalanced interests from one part of the organization created the perceived need for an alternative strategy.   Although the new strategic plan was plausible, the organization did not have the resources or organizational discipline to effectively execute plans that were considerably more complex.   It will be paramount for ACOs to effectively manage such issues in the future.  Similarly, even the small, individual physician practice is more likely to be successful with an EMR implementation when they develop a strategy to improve quality of care through the implementation of an EMR.  

ARRA Clarification Opens Door of "Meaningful Use" Incentive Payments for Physicians in Hospital-Based Outpatient Clinics

On April 15th President Obama signed into law legislation that allows the Department of Health and Human Services (HHS) to include physicians who treat patients in hospital-based outpatient clinics among the physicians eligible for “Meaningful Use” incentive payments.   These incentives are authorized by the HITECH Act portion of the 2009 American Recovery and Reinvestment Act (ARRA).   Under ARRA, “hospital-based physicians” are not eligible for health IT incentive payments because they depend “substantially” on a hospital’s “facilities and equipment, including qualified electronic health records”.   The new legislation clarifies the definition of “hospital-based” so that it may include physicians working in hospital outpatient clinics as opposed to the inpatient units, surgery suites or emergency departments.

As I wrote in “Academic Physician Incentives Needed to Catalyze White Coat-Driven Transformation of Medical Practice Using Health IT”, it appeared that the original intent of ARRA eligibility was misinterpreted by HHS.   The new clarifying language resolves this issue.


The new bill’s clarifying language:




(1) MEDICARE.—Section 1848(o)(1)(C)(ii) of the Social Security Act (42 U.S.C. 1395w– 4(o)(1)(C)(ii)) is amended by striking ‘‘setting (whether inpatient or outpatient)’’ and inserting ‘‘in- patient or emergency room setting’’.

(2) MEDICAID.—Section 1903(t)(3)(D) of the Social Security Act (42 U.S.C. 1396b(t)(3)(D)) is amended by striking ‘‘setting (whether inpatient or outpatient)’’ and inserting ‘‘inpatient or emergency room setting’’.

(b) EFFECTIVE DATE.—The amendments made by 15 subsection (a) shall be effective as if included in the enact- 16 ment of the HITECH Act (included in the American Re- 17 covery and Reinvestment Act of 2009 (Public Law 111– 18 5)).

(c) IMPLEMENTATION.—Notwithstanding any other 20 provision of law, the Secretary of Health and Human 21 Services may implement the amendments made by this 22 section by program instruction or otherwise."


So, the change in section 1848 looks like this:



‘‘(i) IN GENERAL.—No incentive payment may be made under this paragraph in the case of a hospital-based eligible professional. H. R. 1—355

‘‘(ii) HOSPITAL-BASED ELIGIBLE PROFESSIONAL.—For purposes of clause (i), the term ‘hospital-based eligible professional’ means, with respect to covered professional services furnished by an eligible professional during the EHR reporting period for a payment year, an eligible professional, such as a pathologist, anesthesiologist, or emergency physician, who furnishes substantially all of such services in a hospital setting (whether inpatient or outpatient) inpatient or emergency room setting and through the use of the facilities and equipment, including qualified electronic health records, of the hospital. The determination of whether an eligible professional is a hospital-based eligible professional shall be made on the basis of the site of service (as defined by the Secretary) and without regard to any employment or billing arrangement between the eligible professional and any other provider.



Under these changes hospital-based physicians remain excluded from ARRA incentives, but the definition of “hospital-based” physicians changes from those who practice in inpatient or outpatient settings to those who practice in inpatient or ER settings.   This still excludes pathologists, anesthesiologists, ER physicians, hospitalists and others who see most of their patients in the ER as outpatients or as hospital inpatients.   But this opens the door for HHS to interpret ARRA to mean that those who practice in hospital-based clinics using ambulatory EMRs are eligible…a setting common for many academic physicians and others who are closely associated with the ambulatory side of hospitals.   This is really good news for many physicians who work in hospital-based outpatient clinics whether they are in academia or private practice.

Setting Practice Goals for Ambulatory Electronic Medical Record (EMR) Leads to Implementation Success

Selecting an EMR: Ready, Set…Go Compare! is a series of blogs that serves as a resource for physicians who have decided to select and implement an ambulatory electronic medical record (EMR).

The selection and implementation of an electronic medical record (EMR) in a physician practice is a complex and expensive effort.   An important factor for success is the early development of EMR goals that identify what the practice wants to achieve by implementing an EMR.  These EMR goals create a common vision that everyone in the practice can understand and share.  Involving a broad representation of each discipline within the practice during the development of EMR goals will create a team-oriented environment and "positive energy".   Such an effort will naturally involve a lot of communication between the staff and physicians.   Sharing a common vision, creating a team environment and maintaining effective communications help create trust and promote buy-in for this complex endeavor.   Weaknesses in any of these areas are known pitfalls that can sabotage an implementation.

EMR goals will help the practice make better decisions, keep the EMR implementation activities on track and act as a catalyst that keeps the project moving forward.   When important decisions are discussed, dialogue on how well the various options align with established goals is valuable.   When one person or a group of people get diverted onto rogue activities, a good project manager, with a finger on the pulse of planned project tasks and on the EMR goals, will proactively identify these and re-align efforts back to the goals.   During difficult times the EMR goals can become a rallying point for the practice to hang on to until smoother days arrive.

What are the best kinds of goals to develop?   In general a practice will discuss goals that relate to ways to improve patient care, become more efficient or be more productive.   But it is helpful for the EMR team to focus on developing a set of EMR goals that is really meaningful to them.   Every physician practice is unique and every physician practice has a different set of priorities.   Goals that are meaningful to the practice are more likely to unite the physicians and staff and and remain useful throughout the EMR implementation.

Ideas for EMR goals may be developed by discussing questions such as the following:  

  • What are three things most important things the practice wants to achieve with an EMR?
  • What three changes will be most meaningful to the practice?
  • What three quality improvements do we want the EMR to help us achieve?
  • What three gains in efficiency are desired with the new system?
  • What changes, if any, are expected with regards to productivity?
  • What financial impact is expected?
  • What else is desired to be gained or lost?
  • What is expected to not change significantly?

The following suggestions may be helpful for the EMR project team to consider when developing EMR goals:

  • Invite participation and/or feedback from all of the physicians and staff in the office
  • Goals should be challenging but also realistic—they need to be achievable
  • The best goals are meaningful to the physicians and staff
  • Gain insights on EMR "Best Uses" (how other practices have successfully used EMRs to improve care or gain efficiencies)
  • Identify current workflows and processes that are bottlenecks or cumbersome; consider how an EMR could facilitate an improved workflow for those processes
  • Consider other future workflow redesigns that your practice could benefit from based on EMR "Best Uses" insight
  • Instead of focusing on the technology, focus on the workflow or process
    • "Implement and use an e-prescribing tool" is focused on technology
    • When this goal is viewed from the process perspective it becomes, "Reduce time spent refilling prescriptions"; now it becomes more meaningful and is measurable
  • Consider starting with broad goals (related to quality care, efficiency or productivity) and then refining them to more detailed, meaningful goals
  • Not all broad goals can be refined— but they may still be considered important milestone goals
  • Broad goal examples:
    • Improve revenue per patient visit
    • Improve our revenue cycle
    • Decrease amount of time spent on phone
    • Qualify for "Meaningful Use" incentive payments
    • Improve adherence to preventative care guidelines
    • Perform patient satisfaction surveys
  • Related but more specific goals might be:
    • Increase charge capture by X% (through EMR's chart documentation and intelligent charge capture)
    • Decrease the number of accounts receivables days
    • Reduce pharmacy call backs by using e-prescribing
    • Send the identified Meaningful Use quality reports to CMS as specified
    • Identify and notify diabetic patients who have not had an HgbA1C in the past year
    • Improve patient satisfaction by a certain percentage
  • Selecting a smaller number of specific, meaningful goals will likely be more satisfying than a large number of broad, ambiguous goals
  • At least some of the goals should be measurable and baseline measures known
    • i.e. for the aforementioned e-prescribing goal, spend a couple of days tracking time spent refilling paper prescriptions, then repeat 6 months after EMR implemented
  • Other goals should be quantifiable:
    • i.e. track total # of patients that were recalled for being deficient on a HgbA1C lab
  • Prioritize the list of goals
  • Document pre-implementation measurements
  • Develop a plan and timeline to assess goals post-implementation (i.e. 2 weeks, 6 months, 1 year later….)
  • Share these with everyone in your office; perhaps some can be shared with your patients
  • Remember to measure the progress toward goals after the EMR implementation


EMR Selection Guide provides an outline of additional topics on the selection process

EMR Implementation Guide provides an outline of topics on the implementation process