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?

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…

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.

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.

ICD-10 requires a high degree of coding specificity and detailed documentation that will be essential for proper coding and accurate reimbursement. If physicians do not have advanced technology in place, the documentation process could be a huge drain on physician and staff productivity.

EHRs can certainly help providers create thorough documentation. Most EHRs offer point-and-click technology allowing clinicians to produce detailed chart notes. The need for accurate and complete chart notes is certainly not a new requirement; likewise physicians have long sought charting solutions that are user-friendly, intuitive, and functional at the point-of-care. With the introduction of ICD-10, EHRs must also be capable of producing documentation with a high degree of specificity and ideally offer the appropriate codes.

Is it realistic to expect this level of sophistication, and ease-of-use, within an EHR?

Quite simply, the answer is yes. In fact, several commercial EHRs already offer this technology, well in advance of the ICD-10 deadline. In addition, there are a number of technologies and software development kits (SDKs) that can be added to existing EHRs to make the product ICD-10-ready and capable of handling future requirements.

As organizations prepare their EHR for ICD-10 and future requirements, here are five key considerations:

1. Does your EHR include content and tools combined with structured coded data to manage ICD-10?

ICD-10 requires users to capture additional, new clinical data to meet coding and billing regulations and to qualify for governmental incentive payments. Rather than pumping significant money to train physicians on ICD-10, educate current staff, and hire additional coders, it could be a perfect time to either invest in an EHR solution that has ICD-10 already imbedded, or enhance your existing EHR to include ICD-10 codes. An EHR solution that is ICD-10 ready can address many of the expected transition challenges by increasing provider and coder efficiency, reducing the need for additional coders, and lessening the risk of costly coding errors.

2. Is your EHR capable of managing the inevitable HIE Data Tsunami?

In addition to being an invaluable tool for addressing ICD-10, EHRs can also facilitate clinical information exchange and manage the anticipated onslaught of data from HIEs. While your organization is considering the time and resources required for the ICD-10 transition, it is also the perfect time to consider how well your technology will address the inevitable tsunami of data from new and maturing HIEs.

Consider a typical office visit: a patient arrives with multiple active problems, including diabetes, congestive heart failure, arthritis, and depression. In addition to reviewing the patient’s history, the provider may access clinical data from the hospital’s system or a local health information exchange. This wealth of clinical information will be increasingly valuable to providers as they develop patient specific treatment plans and create detailed chart notes. However, the mountain of data may also overwhelm providers if they must manually sift through every item to identify the elements applicable to the current visit. To overcome this challenge, providers need technology that makes sense of the available data and presents clinicians with the relevant information in a usable format at the point of care.

3. Does your system map to all terminologies? Offer intelligent prompting?

The onslaught of information brought on by HIE requires EHR technology that must include mappings to a wide variety of terminologies, such as ICD-9, ICD-10, SNOMED, LOINC, and RxNorm, and offer intelligent links between the various reference standards. Then, as a physician reviews the patient record and creates an electronic chart note, the system should propose an ICD-10 code based on the patient’s specific history, current findings, and the documentation. When such technology is in place, physicians don’t have to manually sort through data, nor worry about their coding proficiency. Instead they can focus on the patient.

4. Does your EHR allow for future updates to address new requirements?

Not only is it essential for an EHR to be ICD-10 ready, but it should also provide content and tools to address future requirements. If an EHR is flexible in its design and easily adaptable to new requirements, it can be easily updated with minimal disruption to physician workflow and patient care. This is an important consideration in evaluating a new EHR given that new requirements and mandates are most certainly inevitable.

5. Is your system easy to use and does it get used? Does it work for clinicians?

If you are looking to your EHR to answer ICD-10 and MU requirements, it is of course, important that clinicians actually use the EHR. If you have an EHR that is not used by clinicians, then it certainly will not be a good tool to meet ICD-10 and other requirements. If your EHR is not getting used, now might be a good time to find out why. EHR adoption and satisfaction is always higher if clinicians have tools that are intuitive, easy to learn, and easy to use. If the system works great and is interoperable, but the interface is hard to use, you might want to consider making enhancements to make it easier to use..,, Or if the interface is simple, but there are too many steps and systems that have to be accessed once the physician gets into the EHR, then perhaps your engineers should look at ways to assimilate, sift and make data more usable at the point of care.  When investing in a new EHR, providers must look beyond aesthetically-pleasing screens and consider the overall product design. The EHR workflow should be intuitive to clinicians and chart note creation should be simple. It is also important that physicians have a hand in evaluating the product’s ability to assimilate disparate clinical data and present usable information at the point of care. Buy-in from end users is important and as we have found, critical to success.

Dave Lareau is Chief Executive Officer at Medicomp Systems, inventor of the MEDCIN Engine, a robust clinical data engine embedded in leading EHRs throughout the world.

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.

Fortunately, all of these standards have already been mapped to link physician and nursing information. The capability now exists to integrate physician and nursing documentation and care capabilities as well as provide links between a patient’s clinical diagnoses and nursing care.

To create this functionality, all existing nursing standards were evaluated to identify the best candidate for use at the point of care in computerized systems. The Clinical Care Classification (CCC) system was selected and 182 CCC Nursing Diagnoses were linked to the more than 55,000 clinical diagnoses. Linking the CCC and clinical diagnoses makes it possible for all members of the care team to generate a list of nursing diagnoses based on the physician’s clinical diagnoses for that patient.

In addition, CCC Nursing Diagnoses are linked to CCC Nursing Interventions and to more than 1,760 specific nursing actions. Also, a starter set of customizable documentation protocols has been developed for each of the nursing actions.

One of the most significant aspects of this work is that the same concepts in the nursing protocols are linked to the physician content where appropriate. Coordination of care has arrived.

David Lareau is Chief Executive Officer of Medicomp Systems, inventor of the MEDCIN Engine, a robust clinical data engine embedded in leading EHRs throughout the world.

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:

1. Fewer transition challenges and expenses. Without ICD-10 automation tools, physicians and coders will require extensive training on the new code set and providers may need to hire additional coders. Coding errors are likely, especially during the transition. When coding tools are part of the clinical documentation process, less provider training is required because physicians are offered appropriate codes based on the patient’s history and current documentation. Coding accuracy is enhanced, meaning fewer claim corrections and faster claim processing and payment.
2. Physicians save time. ICD-10 automation tools, particularly those that can sift through a patient’s complete history and identify items relevant to a current visit, can save physicians considerable time. More than ever before, providers have access to vast amounts of clinical data from health information exchanges, hospitals, labs, and other providers. Technology exists today that will sort through the data – regardless of the original source and terminology – and create logical links between clinical information. This means that when a physician reviews a patient record and creates a chart note, the system not only advises the provider of relevant history but also considers the historical data when proposing ICD-10 codes.
3. The coding process is more efficient. When the system automatically prompts providers with appropriate codes during the documentation process, physicians can remain in the chart entry area while identifying the accurate codes. Coders             don’t need to review the documentation to assign codes, nor hunt for codes themselves.
4. Codes are more accurate. The use of automated ICD-10 technology can result in more precise coding when both a patient’s current visit and relevant clinical history are considered. Codes are identified and entered correctly at the point of care, resulting in more accurate and timely reimbursement. When codes are accurate the first time, providers and staff do not waste time and resources making corrections.
5. Workflow is smoother. ICD-10 coding technology allows providers to identify correct codes while documenting a patient visit at the point of care. Physicians sign off on charts immediately, rather than interrupting the care process to hunt for codes or waiting until the end of a long day to complete coding and close charts. Providers save time and are assured that documentation and coding are final as soon as the visit is over.

The move to ICD-10 will challenge healthcare providers. The implementation of solid automated ICD-10 coding tools can ease the transition pain.

 David Lareau is CEO of Medicomp Systems, the inventor of clinical content, technologies, and mappings, which improve EHR usability at the point of care while satisfying all documentation and compliance requirements. 

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.

Clinical data exchange, however, is inherently complex. Medications, diseases, procedures, and other medical concepts each follow unique coding and classification systems, such as RxNorm, LOINC, CPT, ICD-9, and ICD-10. The use of standard terminologies improves interoperability between disparate systems because similar concepts can be linked together. A common language for clinical terms is thus critical for the efficient exchange of data between health systems, physicians, labs, pharmacies, and other venues of care.
With technology in place to facilitate data exchange, individual physicians are now flooded with vast amounts of clinical data. While this wealth of information is a boon to healthcare, its value is not fully realized unless providers have tools to decipher and organize the information in a usable format at the point of care.

Consider the typical patient exam. Physicians can access patient-specific data from their own EHRs, as well as HIEs, labs, and hospitals. If a patient has multiple complications, such as diabetes, heart disease, and neuropathy, the clinical history may be extensive. A doctor simply does not have time to wade through all available information to identify the specific elements relevant to the current encounter. To maximize the value of clinical data, providers require clinical filtering tools at the point of care.
Clinical filtering tools identify, translate, and sort a patient’s history, regardless of the original source. When this type of technology is embedded within a practice’s EHR, the physician can create a chart note, input findings, and quickly pinpoint the historical clinical details relevant to today’s visit – all without ever having to leave the documentation screen.

The care process can be enhanced further with the addition of clinical prompting technology that considers details from the current encounter and cross-references it with empirical data. While documenting at the point-of-care, physicians can be presented with information that can support diagnosis, help to develop the most appropriate treatment plan, and provide critical data for compliance and reimbursement.
While access to more clinical data is a critical first step to enhancing patient outcomes, physicians need additional tools to efficiently manage the information. To improve patient care and enhance outcomes, clinicians must also be armed with advanced filtering and interpretation tools, preferably, at the point of care.

David Lareau is Chief Executive Officer of Medicomp Systems, inventor of the MEDCIN Engine, a robust clinical data engine embedded in leading EHRs throughout the world.

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.

Up to this point, the use of clinical terminologies has focused on reporting, such as tracking a certain number of measures for Stage 1 MU reporting. Later MU stages will likely call for providers to submit the detailed data in reference terminology format. The number of mappings required to support this functionality is currently more than 500,000 and will eventually be in the millions as the number of PQRS measures increase.

While the use of standards offers numerous benefits, the implementation of clinical terminologies adds a layer of complexity to the documentation and reporting process. These complexities only increase with the introduction of new care models that require the exchange of clinical data and even more reporting requirements.

Several new models, for example, require that all persons involved in the care of a patient coordinate their efforts. This includes physicians, nurses, allied health professionals, home caregivers, and even patients themselves. Currently different types of providers use different data definitions: physicians employ terminology such as ICD-10, ICD-9, Snomed CT, RxNorm, LOINC, DSM-IV, and CPTs, while nurses use terms like NANDA, NIC, NOC, ICNP, PNDS, and CCC. Creating an integrated picture of patient care can be quite challenging when terminology is inconsistent.

The proliferation of Health Information Exchanges (HIEs) will also impact the use of terminology standards. Within five years providers will be expected to routinely receive and update their records based on an increasing volume of incoming transactions from other providers and HIEs. This exchange of clinical data has the potential to greatly improve the care process, but only if the information is easily discernible at the point of care, and not just as an array of data points in Snomed, RxNorm, LOINC, and ICD formats.

Medicomp understand the challenges associated with inconsistent terminology. That is why we continue to expand on the hundreds of thousands of intelligent links we have already created between the reference terminology standards and the MEDCIN concepts that providers use at the point of care. Currently our mappings cover more than 99% of the volume of all transactions in each domain, and within the next year Medicomp’s Coding Service will include the ability to do “reverse-lookups” from any supported reference code (such as SNOMED) to MEDCIN, and then filter incoming codes using the MEDCIN diagnostic index.

Medicomp is also working to create new functionality that integrates physician/nursing/allied health documentation and care planning. We have spent the last five years designing utilities that integrate physician and nurse documentation and offer the ability to quickly and intuitively input clinical information at the point of care. We will launch the results of these efforts later this year in a module that ties nursing actions with detailed protocols. These protocols will link with the same MEDCIN concepts that have been tied to physician documentation in our previous MEDCIN offerings, including the MEDCIN prompting engine.

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.

It’s important to keep in mind that CDS tools don’t make the actual clinical decisions for a physician, but support a physician’s own decision-making by sifting through existing data and presenting the most relevant information. As more clinical information becomes available online from EHRs and health information exchanges, providers will rely more heavily on CDS technologies to identify the most pertinent information for a given situation.

Medicomp has spent over 30 years building and perfecting CDS technology within our MEDCIN Engine. MEDCIN is powerful technology that is imbedded in numerous EHR systems, as well as in our new Quippe product.  What this means is that the MEDCIN Engine works behind the scenes to identify clinically relevant data based on thousands of scenarios. EHR users are then presented with usable information at the point of care.

Having MEDCIN incorporated into Quippe gives physicians CDS tools within an intuitive documentation and patient management platform. The knowledge engine adapts to the unique clinical presentation of each patient and gives providers all the critical information needed for compliance, reimbursement, and caring for the patient.

The CDS tools become even more powerful when Quippe is imbedded into an EHR, such as InteGreat EHR. As a physician enters a patient encounter in InteGreat, the power of the MEDCIN Engine comes alive. MEDCIN is mapped to thousands of medical concepts in a wide variety of reference and billing terminologies, including LOINC, RxNorm, SnoMed Ct, ICD, and CPT. During the documentation process, MEDCIN searches its extensive knowledge base, as well as patient-specific data from lab and test results, previous therapies, and history. The Engine integrates and interprets the data, then offers the physician highly relevant information to aid with diagnosis and treatment plans. With the swipe of a fingertip, the physician can incorporate these suggestions directly into the encounter documentation.

Though Stage Two Meaningful Use is not finalized, look for the ONC to add additional CDS objectives in the core measures.

David Lareau is Chief Operating Officer of Medicomp Systems. Since 1995, Lareau has lead the company’s operations and product management and helped to grow Medicomp’s business and product line.