It is the final month of what has been economically a very tough year. Oncology centers and practices continue to face declining reimbursements on all service lines, and most have had either flat or lower revenues. Financial strife is a reality in this economy. Going forward, it is unclear what changes will emerge with the new Obama administration in 2009. Clearly, healthcare is a front-burner issue, and perhaps the Medicare program will be expanded to become “Americare.” Many private payers are reporting lower profitability. In the trenches, many hospitals reported declining profits in 2008. 

Contributing further to the current gloomy outlook, the recently released 

• 94% of respondents said the time they devote to nonclinical paperwork has increased in the last three years. 

• 63% stated that non-clinical paperwork led to less time spent with patients. 

• Only 17% of physicians rated their practice’s financial position as “healthy and profitable” (62% of surveyed physicians were practice owners; 34% were solo practitioners). 

Time spent on non-clinical issues continues to increase and put pressure on time with patients. More than ever, physicians are facing enormous challenges in their quest to find ways to deliver the best possible care at the lowest possible costs. I believe that the current economic environment will drive consolidation in the oncology space to gain efficiencies of size and scale and also for potential leverage with payers. Reimbursement models are starting to change with the advent of personalized medicine and the need to secure compensation for disease management and lower utilization of services. 

One increasingly clear answer to many of the questions and challenges confronting modern practice can be found in the careful adoption of IT tools. Technology tools can help ease workflow pains while enhancing care and quality. IT is the major enabler of both doing more with less and being more effective. To derive maximum benefit, practices must ensure their IT tools do one (or more) of the following: enhance revenue cycle management, support disease management to help contract with payers, or help provide care with fewer staff. 

Revenue cycle management has to be optimal in a business like ours with thinning margins. There is no room for major errors. This level of performance requires comprehensive, carefully implemented systems that support care delivery. There are many new tools from practice management systems vendors, claims clearing houses, and standalone remittance analyzers. 

Accumulating sufficient capital to invest in IT is a major issue for clinical practices (especially the small- to mid-sized practices). It is possible that the Obama administration will allocate some funding to support financing EMR adoption; during the campaign, he talked about spending $50 billion over five years to promote the adoption of EMRs and other information technology. However, given the current financial and budget outlook, whether that will happen is anyone’s guess. It will most likely be necessary for providers, payers, and other groups to come together to really build the IT infrastructure deep enough to succeed at a high level of performance in this environment. 

There is still time for your practice to make significant hardware and software investments by year end and still realize the tax benefits. This is also a time to reflect and refocus on the core value propositions for our patients and our organizations. We have an opportunity to come through these times retooled and more effective than ever before. Happy holidays, and see you in 2009! 

, a large oncology practice based in Dallas/Fort Worth, TX. He is also CEO of 

, an Internet services company that supports the patient/provider network with technology solutions. Readers can visit 

 to learn more, and can e-mail Dr. Sharma at 

Articles

It is the final month of what has been economically a very tough year. Oncology centers and practices continue to face declining reimbursements on all service lines, and most have had either flat or lower revenues.

Opportunities and Challenges: A Time to Reflect at the End of a Busy Year

The decision makers in your organization who are tasked with translating strategic directives into the tactical principles and processes that will guide the creation of your IT architecture must make many ground-level choices that will have profound long-term effects. However, nearly every decision they make will be influenced by organizational and industry-level data and technical standards.

Decisions affected by standards can involve things as simple as which operating system your staff should be using—should you keep running Windows XP or migrate to Windows Vista? Are the software tools you are currently using capable of running on Vista? Is it better to hold off and wait for the release of Windows 7? Is it better to purchase “best of breed” applications that might meet some of the practice’s unique needs and then figure out how to connect them, or buy comparatively generic systems that are more integrated but perhaps have less developed vertical space?

Decisions made when setting organizational data standards and putting into place the processes that guide data capture and archiving represent a unique opportunity to capture information as a byproduct of workflow. However, because clinical data lose their value over time, the organization must decide which data it most wants to capture and for how long the data should be retained. Is a mammogram image scanned from four years ago still needed for immediate access today? How will your organization separate the main data system, which holds immediate critical data, from the storage and archiving systems?

This is also the opportunity to be forward looking and try to anticipate changes that may affect the industry in the near future. How will information from genetic testing and recurrence risk tools and other decision support tools be captured and integrated into decision making? How will information about high-risk breast cancer patient populations be handled and tracked?

On a larger scale, there are constantly evolving industry-wide data and technical standards that affect how disparate software products and systems transmit and share data. Standards are the foundation for interoperability; when well-defined standards are in place, information can be shared among providers, payers, and other groups, even if it originates from different computer systems. Standards can enhance patient safety, promote quality improvement, and facilitate data mining and evaluation. Standards can also reduce the cost of implementing and maintaining systems and can maximize the return on investment by optimizing the utility of the various tools.

There are several groups and organizations responsible for developing and enacting data standards. The American National Standards Institute (

) is a private nonprofit organization that oversees the development of voluntary consensus standards for products, services, processes, systems, and personnel in the United States.

) is an international, all-volunteer organization of healthcare experts and information scientists involved in the development of international healthcare standards. The name “Health Level-7” is a reference to an Open Systems Interconnection (OSI) reference model with seven layers: (1) physical, (2) data link, (3) network, (4) transport, (5) session, (6) presentation, and (7) application layer. HL7 is also a term used to refer to some of the specific standards created by the organization. HL7 and its members provide a framework (and related standards) for the exchange, integration, management, sharing, and retrieval of electronic health information.

Digital Imaging and Communications in Medicine (

) is a standard for handling, storing, printing, and transmitting information in medical imaging. It includes a file format definition and a network communication protocol. DICOM enables the integration of scanners, servers, workstations, printers, and network hardware from multiple manufacturers into a Picture Archiving and Communication System (PACS).

If we want to be able to register a new breast cancer patient, fill out HIPAA forms, document the clinical visit, look at her mammograms and CT scans, review lab results, schedule a follow-up visit, bill and collect for the services, and share the information with providers at other sites, and do it all in a paperless environment, every one of these standards will be involved. Beware the small vendor that tries to sell you on its homegrown tool that does not adhere to these standards. Your data could end up in a locked box, impossible to share with other providers and healthcare stakeholders.

Dr. Sharma is CEO of Texas Cancer Associates, a midsize oncology practice based in Dallas/Fort Worth, TX. He is also CEO of HealthIT, an Internet services company that supports the patient/ provider network with technology solutions, and founder of NextGen Oncology, which works to provide next-generation solutions for the diagnosis, management, and treatment of cancer. E-mail Dr. Sharma at 

The decision makers in your organization who are tasked with translating strategic directives into the tactical principles and processes that will guide the creation of your IT architecture must make many ground-level choices that will have profound long-term effects.

Oncology Outlook: Setting Standards in Healthcare IT

In preparing an organization for IT transformation, the most important step is organizing and managing people. Even in an IT-enabled environment, it is still the people who get things done, or who are often the fi rst indicators of something being amiss. 

The biggest reason that IT projects fail is lack of buy-in from staff . Many times, embracing IT transformation also means embracing a culture of change. It is a perpetual path that requires new ways of thinking and relating. The fundamental human communications and interconnections of the organization are altered. How will interactions with patients be aff ected? How will things be different if many direct personal communications are transformed into sending an e-mail or instant message embedded in the workflow of an EMR tool? If the organization does not accept the changes in tools, it doesn’t matter how carefully they were selected.

It is important to have a clearly defined management team that will drive the IT initiative with careful prospective planning. Apart from the obvious process of hardware and software selection, this group is key to helping set expectations and managing and supporting staff through the changes.

The composition of the IT management team needs to be representative not only of IT technical experts, but also various areas of the organization that will be impacted by the changes; most importantly, the clinical areas need to be represented. The ideal clinical personnel are well respected by their peers and also have some understanding or interest in IT. The most successful IT transformations are frequently led by a physician champion who can bring other clinicians along. Mid-level providers and nursing staff in a busy clinic are often aff ected most, and it helps to involve them early in the planning process. Many times, it is out of these personnel that clinical super users are created.

These super users are not only an accessible resource for other staff , but they can also provide insight into why the effort is so important to moving forward. Lab, pharmacy, operations, and revenue cycle managers should be considered. We not only want to provide great care and service, but also get paid for the work we do in the environment of perpetually declining reimbursements. Not all of these members need to be present at every meeting, but input from all the key areas is important.

Potential pitfalls of planned changes need to be identifi ed as early as possible. It is diffi cult to get an IT project back on track if there are one or two major disasters, and the organization loses enthusiasm and faith that the transition eff orts will lead to a better set of processes and a more effective organization.

Most organizations carve out time for IT planning as a part of the workweek. Because it is diffi cult to move these initiatives forward with a group of volunteers working after hours or spending uncompensated time away from other activities that generate income, compensating the team for their time is important and is a way of communicating the commitment to transforming through technology.

The IT planning team will develop its own agenda for adoption. However, some key areas include:

- If things get more diffi cult why do we need to put in the effort to accomplish them?

- How can the organization best prepare for these changes?

The IT management group will take the executive drivers and direction and expand them. Once the people are organized and their needs addressed, the remaining principles and processes will guide the crystallization of the IT architecture. Th is is the point at which true IT architecture planning is ready to begin!

In preparing an organization for IT transformation, the most important step is organizing and managing people.

Oncology Outlook: End-users Should Ultimately Drive IT Adoption

The evolution of the clinical care of breast cancer patients has been a leading model for clinical cancer research and the management of other solid tumors. As we start on the path of defining the optimal IT architecture for the care of our cancer patients, breast cancer serves as an excellent model in community cancer care. The journey of each breast cancer patient is unique and complex. For most patients, the path begins with the initial screening imaging studies (mammography or MRI) followed by biopsies, surgery, adjuvant radiation, and chemotherapy.

Many elements of this journey are common to many types of cancer patients. However, in a manufacturing model, if the whole cancer service line is a factory, then breast cancer represents a factory within a factory—a focused factory, if you will, that provides the unique services needed by breast cancer patients.

The term “focused factory” was introduced in a 1974 Harvard Business Review article authored by Wickham Skinner in the midst of a productivity crisis. The model proposed focusing each plant on a limited set of products and technologies. As summarized by R. Anthony Inman, a factory focused on a specifi c product can outperform a conventional plant with a broader focus. All the equipment, supporting systems, and procedures can concentrate on a limited set of tasks for one set of customers. The focused factory concept has been applied to healthcare. Specialty hospitals and ambulatory surgery centers (ASC) are examples of the success of focused factories. These facilities are not organized by medical specialty but for the total needs of the patient. How do we apply these principles to the care of our patients?

How do we build IT systems that are based on an architecture that can support our goals?

In the last two columns, I discussed the importance of focusing on value for the customer (best outcomes for the lowest cost) and a great service experience. If one looks at the breast cancer patient’s journey, the volume of information and images that need to be shared and discussed is enormous. Today, IT systems are clearly the key enabler. The barriers are costs and knowledge of IT systems and their implementation. Improvements in efficiencies and quality of care can be gained with better communications and reductions in variation. However, the central enabler is the IT platform that supports this functionality. What does it look like? What are the components? What pieces are currently available? How do we build it?

Currently, your organization has an IT architecture, even if it is completely paper- and fax-based. A great place to begin IT adoption is to take a snap shot of the current architecture and then go through the process of developing an executive direction for what things need to look like in the future.

Drivers for executive direction can vary for diff erent organizations and in diff erent markets. These need to be carefully thought out. Universal drivers for the care of cancer patients and for breast cancer patients in particular include:

		Assimilating decision support tools and algorithms at the point of care

		Developing a clinical data repository of mineable data

Going through the architecture planning process forces one to ask certain questions. This prospective planning of what is to be built enhances the likelihood of success while minimizing the risks of poor planning with resultant strategic disasters. Once there is a snapshot of a future architecture, only then can a migration plan with budgets be constructed.

Even once the architecture is built, the process continues into an assessment phase of how well the architecture works. What are its dependencies and vulnerabilities? How would recovery occur in the event of a disaster? How are future technologies that are still far on the horizon going to be assimilated? IT architectures are not the business. IT systems are the key tool that support the goals of ideal care.

In the next couple of columns, I will look at the breast cancer patient’s journey as the factory that needs to be supported.

Jivesh Sharma, MD, is CEO of Texas Cancer Associates, a midsize oncology practice based in Dallas/Fort Worth, TX. He is also CEO of HealthIT, an Internet services company that supports the patient/ provider network with technology solutions, and founder of NextGen Oncology, which works to provide next-generation solutions for the diagnosis, management, and treatment of cancer. E-mail Dr. Sharma at 

The evolution of the clinical care of breast cancer patients has been a leading model for clinical cancer research and the management of other solid tumors. 

Jivesh Sharma, MD

Articles

Opportunities and Challenges: A Time to Reflect at the End of a Busy Year

Oncology Outlook: Setting Standards in Healthcare IT

Oncology Outlook: End-users Should Ultimately Drive IT Adoption

Oncology Outlook: Breast Cancer Care: A Focused Factory with an Evolving Architecture