In my last article, I told you about an experience my colleagues and I had on a business trip in Thailand. My friend needed new contacts, and didn’t have a chance to get them before he left DC. Since we were meeting in Bumrungrad, one of the leading medical tourism hospitals in the world, he decided to put them to the test, [blinking profusely the whole time, I might add.] With minutes, he was registered, seen by a nurse, seen by a doctor, tested and given a prescription for new lenses. M-i-n-u-t-e-s. Try finding that in the U.S., where I always end up spending three hours to get 30 seconds with a doc.

So how does a hospital get to this lightning speed of service? Is there some sort of intergalactic wormhole patients enter to defy time? Well, there kind of is. It’s their HIT system, and it tracks patients from registration all the way to medication pickup. I sat down with their Chief Technology Officer Chang Foo to get the story on it.

Me: Chang, give me the numbers. Just how efficient is this place?

Chang: We see about 4,000 patients a day, and half of them are walk-ins. And it takes them about 17 minutes to see a doctor.

Me: And how do you make this happen, IT-wise?

Chang: It’s an interesting story – in 1997, we took the lead to replace all our paper and film with a whole new IT system. We didn’t patch up old systems and try to make them work together – we started from scratch. At that time the Asian financial crisis had hit. We were an organization using many disparate systems, and most of them were very expensive. We commissioned a team to design a system that was integrated from end- to-end. So now, we don’t have separate files for triage, pharmacy, imaging, etcetera. One file follows the patient – and the whole system is interfaced instead of integrated.

Me: Hospitals are putting in new systems all the time. How did you end up with this system that cut patient wait times by…what was it…

Chang: Thirty-nine percent.

Me: Whoa. Thirty-nine percent.

Chang: Yes – well, I believe our difference was in our R&D approach. We didn’t look at the IT system first. We looked at hospital process – and we studied it in great depth. In fact, it was two-plus years before a line of code was actually written. We took that long to develop a data model, understanding the processes within the hospital. We hired experts from all over the world – pharmacists, front office people, back office professionals, every position along the way in the patient experience. They became ingrained in the process, and their insight into each specialty area was translated into a system that works. We also engaged our doctors and nurses, since they’re on the front line. And we have a very strong senior management team that supported us during R&D, and continues to do so. That makes a huge difference.

Me: Can you give me any specifics on how the patient will see the difference, besides by looking at the clock?

Chang: For example, at most places or organizations you register at a single point of entry. Our system was like that – we had a single point of entry where all patients would go before they actually went to a specific clinic. We found out that a lot of times there was a bottleneck related to registering at a single location. So we started experimenting with putting registration kiosks and outlets in various areas of the hospital and even in the clinics themselves — because a lot of times patients know what problem they have and they can go directly to a specific clinic.

Me: So basically, your success can be attributed to an integrated application design built using a process-oriented approach.

Chang: Yes, the design and approach definitely helped us succeed.

Me: One last question, Chang. You seem to have a little bit of a cough going on. Shouldn’t you get that addressed?

Chang: Yes, I certainly should.

Me: So I guess I’ll see you back here in about 17 minutes or so?

On a recent trip to Thailand, two colleagues and I saw efficient hospital workflow in action. Just for kicks, let me present the following, in a single act.

Act 1, Scene 1:  A group of jet-lagged Americans sitting in a conference room at Bumrungrad Hospital in Bangkok. One of them begins to make faces at his colleagues.

Colleague #1: “Are we doing something to annoy you?”
Blurry-eyed Guy: “I meant to get my new contact lenses before I left DC.”
Colleague #2: “We’re sitting at one of the leading medical tourism hospitals in the world. Why don’t you put them to the test?”

Act 1, Scene 2: Blurry-eyed Guy walks up to outpatient clinic and explains the problem. They tell him he will need a prescription and ask him if he wants to be seen. Discouraged, and forgetting where he is, he starts to walk away when the receptionist says they can see him right now.

Six minutes later: He has been registered in their system, has received his laminated ID card, and is in one of the treatment rooms going over his history with the nurse.

Another 10 minutes later: He’s been seen by the doctor and is on his way back to join his colleagues with his prescription in his pocket.

Act 1, Scene 3: Back in the conference room.

Colleague #2: “So, did you manage to get an appointment”?
Soon-to-be-not-Blurry-eyed Guy: “Not exactly.”

Can you imagine that same thing happening in a large U.S. hospital? Next time I will share some thoughts on why Bumrungrad is different…

The words “single payer” are among the dirtiest in healthcare’s lexicon — but mostly here in America. Some of the other countries operating either single payer or so-called dual systems that essentially pit a public option against private care have seen certain measures of success. And that is among the reason that some other countries, such as Singapore, have superior healthcare.

So contends David Lareau. As CEO of health IT vendor Medicomp Systems, Lareau regularly globe-treks to service and search out customers and, along the way, witnesses myriad health systems from the inside. Lareau spoke withGovernment Health IT editor Tom Sullivan about the competitive virtues of a thriving public option, how the U.S. healthcare system stacks up against some of the superior nations, and why low-cost incentives are not aligned with care delivery outcomes in a fashion to bend that cost curve.

Q: In your travels and experiences, which country has the best healthcare and why?
A: Probably the best and most efficient one I’ve seen is in Singapore. It’s only my opinion based on what I’ve seen – I’m nowhere near a healthcare policy analyst – I just go based on my experiences with people in the trenches, administrators, talking to patients about workflows, costs. The reason I say Singapore is that even though their Gross Domestic Product per capita is higher than the U.S., their average healthcare spend per capita is 28 to 30 percent of the U.S.

Think about that: Their per capita GDP is 20-30 percent higher than ours but there per capita healthcare spend is 30 percent of ours; not less, of ours. As I go to countries like that, even the National Health Service in Britain and Australia, they’re 45 to 50 percent of our per capita healthcare spending.

And one of the things in Singapore is they have a dual system. About 50 percent of their care is delivered by an integrated delivery system called Sing Health, which is a private system. About 50 percent — and it varies year-to-year so it could be 40-60 one year — is handled by the Singapore Ministry of Health hospitals. What that does is set up a natural completion for what constitutes cost-effective care. And if one of those gets out of whack with the other, market forces and demand tend to bring it back into alignment.

Q: One of the things you mentioned is the GDP. It’s among the most-cited struggles of the U.S. healthcare system, that it swallows 17 percent of the GDP while other countries manage on 7 or 8 percent but, taking the global perspective here, is the GDP really a good measure? We’re talking about an incredibly complicated number…
A: The other judgment we use is the per capita healthcare spend and that’s where the real misalignment occurs. The latest year for which I have numbers is 2009 but per capita healthcare spend, according to WHO, if the U.S. is 100, China is 4, Malaysia is 9, New Zealand is 36, Singapore is 28 percent, Thailand is 5, Australia is 45 and the U.K. is 46 percent.

Q: Particularly given that disparity, how do people from those countries you just named view the American healthcare system?
A: They think we’re a bunch of litigious fat slobs sitting around watching TV getting inundated by pharmaceutical commercials who then go to the doctor, demand that medication, get it if we have an employer-based health plan for somewhere between $10 and $30 regardless of what the cost of it is. If the doctor can add on a few tests, and maybe have the diagnostic equipment in his or her office and make a little money for that, everybody profits — maybe not the patient’s health — but we don’t see measurably better outcomes for the U.S. model of care than we do in other countries.

Q: Which might be more about the citizenry than the system itself…
A: And the senior people in China are starting to look at the way we are and they’re not going to have the litigation problems we have but the one problem they will have: KFC is the fastest growing restaurant chain in China. Over the last couple years they’ve opened up a new KFC in China almost once every two days. So they’re coming in our direction. All they need to do is spend three of four more hours a day in front of the TV and they could turn into us.

Q: I’m chuckling but it’s really not that funny…
A: I keep seeing this over and over again. Because of the way they deliver with this dual-model of public hospitals competing with private hospitals for the same patients, in some regard, that leads to a natural competition and also means that, at least in the public sector, they actually have some sort of incentive to help patients manage their own health. I’m not saying that they’re active in it but the patients seem to not assume that there is a pill or procedure to cure every ailment — and here in the U.S. the tendency seems to believe “I’ve made myself sick. Now you fix me and somebody else is going to pay for it.”

I watched the whole healthcare debate in the U.S. over whether there should be a single payer or not. All I can tell you is that in most of the countries where there is, the per capita healthcare spend is less than it is here — and that’s not the only reason, it’s all the other stuff I just mentioned also.

Q: So why is single payer such a dirty phrase in America when it works for some other countries?
A: We can’t talk about it because it’s viewed by people who are against it as a government takeover of healthcare and the advocates of it point to some of these other models and say “we do not have the means to control the costs if there’s not somebody who’s driving the cost down and in the U.S. there’s such an incentive to do more for a patient whether or not it leads to the best outcome.”

If the docs do extra procedures, they get paid more. If they prescribe more pills, the insurance companies and the pharmaceutical companies make money. In the hospitals, there’s a much higher proportion of for-profit hospitals in the U.S. than in these other countries and we have the liability issue. If you don’t do something that the patients see you should have, they might come after you. I just don’t see malpractice ads on TV in other countries, or ads encouraging people to ask their doctor about a specific drug.

Q. What have you learned about the various levels of government involvement in healthcare outside the U.S. in terms of what works and what doesn’t?
A: The government has to set some standards and at least some sort of a parallel system. If you’re going to try and provide care to everybody, you’ve got to have some entity that provides care that is not compensation or volume-based but is just care based, like the public hospitals in Singapore, like the public hospitals in Thailand. We say we have public hospitals here but we really don’t have that many and our version of that are the academic medical centers which are really almost as much about research as patient care, so the government has to establish some minimum floor for standards of care and provide a way for people to get access to it. We don’t do that here. Once you do that, have a mix of private and public hospitals, you don’t have to have all single payer, you can have an effective way of establishing what a care baseline is. Now, we’re attempting to do that through the Affordable Care Act, not based on care but based on coverage, the minimum coverage a plan should have. That’s different than setting minimum standards for how healthcare organizations operate to provide that care.

Q:  Based on that, it sounds like the lack of a public option in the ACA might be something you consider an Achilles Heel?
A: I think it is. I think it is. Remember when Medicare prescription drugs was put in under the Bush administration, one of the things left out was to provide them with the ability to negotiate pricing because that would expose the massive profit on some of these drugs which the pharmaceutical companies say “we need the profits on these drugs to offset the costs of uncompensated development on these other drugs for rare diseases.”

It’s all caught up in emotions. But unless you have a viable option for low-cost care efficiently delivered, I think you’re going to have trouble bending that cost curve down because the incentives to do so are not aligned with the delivery of outcomes-based care. They’re just not yet. We’re still talking about it.

HHS’s proposed delay for the ICD-10 transition has spurred both support and criticism from various professional organizations, including the AMA, HIMSS, and the AHA. Despite disagreement on the compliance timeline, most stakeholders agree the new code set will reduce inappropriate coding, facilitate better care management, and improve reporting.

Regardless of the deadline, providers and payers are already evaluating potential IT upgrades and considering training requirements for coders and clinicians. The move to ICD-10 will affect both clinical and billing operations; workflow changes are inevitable. For physicians, changes in clinical documentation requirements may be one of the most significant challenges. Read Full Article →

Historically physician and nursing systems and workflow have often been parallel, but independent of each other. Physicians and nurses must be able to share information to provide coordination of care.

For example, physicians must comply with standards such as ICD-10, ICD-9, Snomed CT, RxNorm, LOINC, DSM-IV, and CPT, while nurses employ terminology like NANDA, NIC, NOC, ICNP, PNDS, and CCC. With so many different standards in place, creating an integrated picture of patient care can be difficult at best. Read Full Article →

In just over two years, the US health system will shift from the ICD-9 to ICD-10 transaction standard. The move to ICD-10 will undoubtedly result in better insight into individual patient conditions and create a wealth of data to assess the efficiency of healthcare delivery, population disease states, and the quality of care. However, the increase from 14,000 to 68,000 unique codes promises to be both expensive and challenging in terms of IT system updates, training for staff and physicians, and potential losses in productivity.

To minimize adoption challenges, providers are considering advanced technologies for identifying the most appropriate codes. Automated coding tools – particularly those embedded in an EHR, can maximize practice efficiencies and streamline the coding process. Consider some of these benefits: Read Full Article →

If physicians have access to more clinical data, does this mean that patient outcomes are enhanced? Possibly, but only if providers can retrieve the most relevant information quickly,in a logical format, and at the point of care.

More clinical data is available to physicians than ever before. New government initiatives encouraging electronic data exchange and advanced technologies make it easier to translate disparate but related clinical concepts from multiple sources. Read Full Article →

In 2003, the National Committee on Vital and Health Statistics (NCVHS) recommended the first set of clinical terminologies as national standards: Snomed CT, RxNorm, and LOINC. At that time the use of these reference terminology standards was voluntary, as it officially still is.

Medicomp, however, has long taken the approach that reporting and compliance based on these standards will become mandatory by 2015. The requirements to demonstrate Meaningful Use (MU) and to track PQRS standards are just the beginning. Read Full Article →

If you have achieved Stage One Meaningful Use requirements or are planning to attest in the future, you are likely aware of the required core measure for implementing and tracking at least one clinical decision support (CDS) rule. The goal of this measure, along with maintaining active problem and medication lists and recording vitals and smoking status, is to improve the quality, safety, and efficiency of patient care.

So what exactly is CDS and why is it important?  In simple terms, CDS gives physicians the clinical information they need for decision-making tasks.  For example, during a patient exam, CDS tools can provide prompting to help a doctor determine a diagnosis or select an appropriate treatment plan. Alternatively, a provider may use CDS technology to improve documentation or identify billing codes or determine the most relevant data to forward to a specialist. Read Full Article →

Advances in technology, health reform laws, and federal stimulus funds have facilitated the creation of health information exchanges (HIEs) across medical communities and are promising to make clinical data more accessible to providers at the point of care.

HIEs are designed to aggregate and move patient information electronically between various healthcare information systems. The ultimate goal is to give providers the data required to better manage the health of individual patients and their patient populations. An efficient HIE infrastructure results in safe, timely, and effective data retrieval in real time and at the point of care.

While the concept of HIEs sounds great, the reality for providers is that soon they will be flooded with vast amounts of data which will need to be identified and interpreted. Though new interoperability standards are being introduced, information will still be presented in a variety of formats, such as ICD-10, SNOMED, LOINC, or RxNorm. In order to effectively and efficiently treat patients, physicians will need tools to make sense of the available data and indentify the relevant elements for a given clinical encounter. Read Full Article →