"Welcome to our company blog. Within these blog posts, we hope to share our insights on clinical quality management, the patient-centered medical home, chronic disease management in primary care, evidence-based medicine, and the use of technology in ambulatory care settings."

- David Morin, CEO and Donald Nease Jr., MD, Chief Medical Officer

I haven't seen this covered in any of the daily health care newsletters I receive, but I certainly think it warrants great attention.

"Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home" is a paper published in the May/June 2009 edition of the Annals of Family Medicine. In it, the authors summarize the findings of the American Academy of Family Physicians' National Demonstration Project where a model of the patient-centered medical home was tested in 36 family practices across the US.

For anyone working toward or contemplating a Medical Home model, you really need to pay attention to the outlined Initial Lessons Learned and Practice Recommendations.

In summary, it shows that moving to a medical home is not easy, in fact, it's really hard to do. And it takes a huge commitment.

Regarding technology, there's a great quote in the paper "For example, it is possible and sometimes preferable to implement e-prescribing, local hospital system connections, evidence at the point-of-care, disease registries and interactive patient Web portals without an EMR." 1

In other words, Cielo Clinic with e-prescribing may be what you need for a medical home.

Cielo is a big proponent of the medical home model and our software supports what it requires. But, I also believe that the items in this paper regarding the transformation process are what's most important to consider if you are taking this journey.

I urge you to read this paper, it's in the Annals of Family Medicine, Vol 7, No 3, May/June 2009.

1 Annals of Family Medicine 7:254-260 (2009)


Dave Morin
CEO and Co-Founder
Cielo MedSolutions LLC

A must-read by e-Patient Dave and his experience downloading his medical data from his hospital into Google Health.

http://e-patients.net/archives/2009/04/imagine-if-someone-had-been-managing-your-data-and-then-you-looked.html

And people still want to use billing data in their patient registry?

Dave Morin
CEO and Co-Founder
Cielo MedSolutions

It seems as if the interest level has risen rapidly on our argument that there are many shortcomings when using billing data and ICD9 for a quality improvement program. I've been involved in numerous discussions about this over the last month and they are, in general, in-line with our thoughts at Cielo; billing data and ICD9 are plain insufficient! Usually, the discussion is with a person that has already undertaken a quality improvement program and found this out after trying to work with their billing data.

To study this further, we are working with a few providers and comparing their billing files to their Cielo Clinic database to look at how a patient's diagnoses align in these two datasets. While I can't release our findings just yet, suffice to say the results of this work are eye-opening. Look for more to come from us on this topic.

FYI - I'd also recommend reading a very good article in the February 2009 article of Healthcare Informatics that discusses this topic.-


Dave Morin
CEO
Cielo MedSolutions LLC

We were recently asked to summarize our thoughts on the shortcomings of ICD9 and billing data when used for diagnoses in clinical quality management systems. I thought I'd share our summary….


Specificity - ICD9, for many diagnoses, does not provide the required level of specificity required for evidence-based care guidelines. An example is asthma. ICD9 cannot differentiate between persistent asthma and intermittent asthma, an important distinction.

Scope – literature has documented that ICD9 can accurately represent approximately 50% of the conditions a primary care provider will encounter. When a condition cannot be properly documented, a provider must choose the “best fit”. This can be a major problem for clinical research and also affects the use of this data for care guidelines.

Accuracy – the needs of documentation for reimbursement leads to incorrect problem documentation. A common example is the need to document a diagnosis of asthma for a patient presenting with wheezing. If the patient is ultimately not asthmatic (which is usually the case), there is no way to “go back” and change their diagnosis on the billing data record. Therefore, when that billing data file is used in a registry, it inaccurately represents the asthmatic patient population. This inaccuracy can exceed 50%.

Completeness - Billing data does not document lifestyle issues like smoking and cannot capture clinical modifiers such as family history and risk factors. These elements are important for care guidelines and can be important data elements for clinical research.

We believe that these shortcomings are solved through the use of ICPC, the International Classification of Primary Care and through the use of clinician-verified diagnoses. A few prior blog entries talk about this and we'll be talking a fair bit more about it in the months ahead.

Dave Morin
CEO and Co-Founder
Cielo MedSolutions LLC

A question we get asked a lot is "what diseases do you support?". The answer is : virtually all. This is the beauty of a table-driven rules engine (our rules engine is the technology that manages all the clinical guidelines you follow. Based on a patient's information, it generates reminders for their due services). All you do is fill out a web form; put in the diagnoses, co-morbid diagnoses or clinical indicators you want to build the guideline rule around and, voila, the guideline is in your system, ready to use. You can set a whole host of other attributes around the guideline, but again, you are just filling out a form. No programmer necessary!

Any disease management system that requires a programmer to "create the rule" is one that won't scale and will require dollars for support of that programmer each time a change is needed. "Next-generation" disease management systems are built with table-driven rules engines.

Dave Morin
CEO and Co-Founder
Cielo MedSolutions

Just read the executive summary of a great paper on the personal health record (iPHR) market written by Chilmark Research entitled "iPHR Market Report, Analysis and Trends of Internet-based Personal Health Records' Market". On page 1-13, the author notes that "iPHRs that serve simply as an online filing system for medical records will become irrelevant"1 and "adoption and ultimately ROI of iPHR solutions will be highly dependent on the ability of a given solution to deliver actionable information to the consumer promoting changes in behavior(s) that reduce health risk(s)."2

This fits nicely with our beliefs; a passive system that simply collects information is of limited use in healthcare. Technology must support the ability to drive positive change in the quality of care provided and must provide actionable data to help drive this change. Whether its in a clinical quality management system like Cielo Clinic or in a personal health record solution, this is a key attribute.

1, 2 Chilmark Research, "iPHR Market Report, Analysis and Trends of Internet-based Personal Health Records' Market", May 2008, pg. 1-13

Dave Morin
CEO and Co-Founder
Cielo MedSolutions

If you've spoken to us in the past, you know we are ardent supporters of a classification system called the International Classification of Primary Care (ICPC). This system, we believe, does a much better job of documenting problems and reasons for encounter in primary care than ICD-9. It also provides an ability to create episode-of-care documentation.



Why would you use it? Well, for one, it will generate a more accurate problem list and allow you to be more effective in care delivery. Second, this accuracy will help you with pay-for-performance programs as we have found a more accurate problem list leads to better documentation and hence better pay-for-performance reporting. Third, accurate problem lists are the cornerstone of a patient-centered medical home and an ICD-9 problem list based on billing data is not an accurate problem list. Fourth, it provides a unique view into symptoms and problems - as documented here in "Characterizing Breast Symptoms in Family Practice".1



1 Eberl, Margaret M., Phillips, Robert L., Jr, Lamberts, Henk, Okkes, Inge, Mahoney, Martin C.Characterizing Breast Symptoms in Family PracticeAnn Fam Med 2008 6: 528-533


Dave Morin

CEO and Co-Founder

Cielo MedSolutions LLC

In case you missed it, please take a look at our letter to our colleagues:

Dear Colleagues,

The last few months have been quite busy here at Cielo MedSolutions. We continue to build a dynamic company that provides the very best technology solutions that are cost-effective, easy to implement, drive improvement and fit the needs of ambulatory care providers nationwide.
In parallel with growing our customer base by 450 percent this year, we've also achieved the following notable milestones:

• Cielo Clinic Endorsed by TransforMED - Cielo MedSolutions and TransforMED are now Preferred Business Affiliates. TransforMED -a subsidiary of the American Academy of Family Physicians (AAFP)- provides support to primary care physicians and health systems that want to transform their practices into Patient-Centered Medical Homes. Cielo MedSolutions' customers will have access to TransforMED's practice transformation services, and TransforMED will encourage the use of Cielo Clinic's integrated patient registry, clinical decision support and population management tools by practices implementing a Patient-Centered Medical Home.
  
• Cielo Selected for PQRI Reporting to CMS - Cielo Clinic has been designated by the Centers for Medicare and Medicaid Services (CMS) as qualified to submit quality data on behalf of eligible professionals for 2008 PQRI reporting. Providers can now directly upload their quality data to CMS for PQRI reporting using Cielo Clinic.
  
• Cielo Awarded a National Cancer Institute Grant - We have been awarded a grant by the National Cancer Institute to study and design a next-generation chronic disease management system. This solidifies our research and development into the future needs of ambulatory care providers.
  
• Cielo Studying LEAN Principles - Through our partner, Altarum Institute, we are studying and documenting the benefits of LEAN principles in relation to the use of Cielo Clinic. This work is being done at a customer site and the knowledge gleaned from it will translate into additional benefits for all Cielo Clinic users.
  
• Cielo Participating in Innovation Study with Community Health Centers - Our hosting partner, the Michigan Primary Care Association, has been awarded a grant by HRSA to study innovation in the Community Health Center market. Four CHCs will be provided Cielo Clinic with tablet PCs and wireless networks to study disease management through the use of technology.
  
• Cielo Success Story Published Online - One of the latest success stories on Cielo Clinic is featured in the Agency for Healthcare Research and Quality's Health Care Innovations Exchange (see http://cts.vresp.com/c/?CieloMedSolutions/6d4251a388/deec28db9b/0e2d81dc0c, keyword "cielo"), an online database of innovations that improve the delivery of care to patients. In this story, you will see how the University of Michigan Health System, Department of Family Medicine, managed thirteen quality measures to high levels of compliance using the product.
  
• Cielo Drives Dramatically Higher Disease Screening Rates - The September 2008 issue of Medical Care, the journal of the American Public Health Association, includes a paper detailing a grant-funded study of using Cielo Clinic to improve colorectal cancer screening rates in twelve practices throughout the state of Michigan. Average screening rates at the beginning of the study were at 41.7 percent. By the end of the study, that rate had jumped to 66.5 percent.
  
• Cielo Supporting Free Clinics - In support of our community, we are engaging with free clinics in the metro-Detroit area to improve care delivery to disparate populations and build a registry of clinical information on the uninsured.
  

In addition to the above achievements, we've also added a host of new functionality and a wealth of additional third-party interfaces to our software-as-a-service product offering. Much of this new functionality is a direct result of our customers' requests. And, we have an aggressive product roadmap and a new group pricing model, both of which we'd be happy to share with you.
Organizations work with us at Cielo MedSolutions not only for of our great technology, but also because of our dedication and our support for the overall success of their quality improvement initiatives. We continue to enhance our solutions by bringing together other technology partners, consultants and best practices to create turnkey solutions for successful pay-for-performance programs, patient-centered medical homes, quality improvement initiatives and clinical integration efforts.

Thank you for being a colleague of Cielo MedSolutions. Please stay tuned as we continue to build a dynamic company focused on the needs of ambulatory care providers. If you haven't had a chance to see Cielo Clinic in the last few months, I urge you to take a fresh look. Simply contact Mike Kleczka at 734-827-1000 x1 or mkleczka@cielomedsolutions.com.

Sincerely,


David J. Morin
CEO
Cielo MedSolutions LLC

If you are evaluating or researching the technology underpinnings of a medical home, you should take a look at wonderful piece (available on the internet) called "Health IT to Support the Patient-Centered Medical Home" authored by Michael Klinkman and Robert Phillips. This slide show accompanied recent testimony they gave to the National Committee on Vital and Health Statistics.

It's probably different than many of the other presentations you've seen on this topic, but what they have to say is very powerful.

Dave Morin
CEO
Cielo MedSolutions

Disclosure: Michael Klinkman is on the Medical Advisory Board of Cielo MedSolutions.

We have begun work on our recently awarded grant from the National Institutes of Health, National Cancer Institute in partnership with the University of Michigan Health System Department of Family Medicine.

In this six month project we will be:

1. Investigating how, in existing implementations, Cielo Clinic impacts prevention and chronic disease care by examining changes in care delivery and clinical workflow, documenting the impact on patient, clinician and office staff satisfaction, gathering feedback from current end-users and researching current and future needs with regards to clinical quality improvement in primary and ambulatory care.

2. Designing a prototype of a next-generation clinical quality management system that is affordable and adoptable, built upon the principles of Cielo Clinic and tracks and manages activities and outcomes at all stages including screening, prevention, diagnosis and treatment, involving all care delivery participants, including patients and non-office care-givers, and delivers proactive prompts and reminders to clinicians regarding required services.

This is a very significant R&D opportunity for Cielo that will result in a state-of-the-art system that takes clinical quality management to a new level.

Dave Morin
CEO
Cielo MedSolutions

Let's say you want to add a new point-of-care reminder to your registry, like lead screening for children in high-risk zip codes. You also want the value of that screening tracked in your registry, and if the result from the screening is out-of-range, add a "lead poisoning" condition to that patient's registry record.

If the generation of reminders from your registry is driven by a small computer program for each reminder, you'd ask your programmer to visit you and listen as to how this reminder needs to work. He/she would go back to their cubicle, figure out how to create the program, write it, test it, give it to you for final review and then get the new program out to everyone. Probably a couple of months effort end-to-end.

If the generation of reminders is driven through a rules engine that gets reminder information from a table, you'd just select the "Add New Reminder" button, fill in a few fields (just like you would fill out a form on any web site), click on "Save" and the new reminder rule would be in effect. Probably a couple of hour effort end-to-end.

I can't stress enough the importance of a table-driven rules engine (the second scenario described above). It certainly will save you a lot of money as you don't need to hire/pay a programmer for each reminder you want to generate.

More importantly, though, is gain from being able to implement reminders in a day - the sooner you can implement a reminder tied to a pay-for-performance program, the sooner you can start collecting on that program.

And, when reminders are really easy to implement, you'll find you can implement all sorts of them on a variety of conditions and really improve the care provided to your patients.

Dave Morin
CEO
Cielo MedSolutions

Type "personal health record" into your favorite search engine and you will be overwhelmed with the number of vendors offering such a solution.

I'm intrigued with the variety of stakeholders offering such solutions; software start-ups, employers, payors, EMR vendors and portal and search engine providers all have a PHR that they think you should be using. I'll bet there 100s of PHR solutions now available.


When evaluating these solutions, a few characteristics are key for adoption:


From the patient's perspective:

• Ubiquity and Patient Ownership - the PHR record is ultimately the property of the patient. It must be transportable into every situation in which a patient needs it and it must be accessible by the patient at any time.
• Adds Value - a record on it's own has value, but a PHR solution that can add value around the record is of great value. Care reminders, links to literature are all examples.
• Is Correct - those that populate from claims data will be populated with data that was never intended for clinical documentation, only for reimbursement. If you diagnose that wheezing patient with asthma and that patient, who is ultimately found to NOT have asthma, sees he's asthmatic in his personal health record, might 1) decide this PHR can't be trusted and not use it or 2) call your practice in a panic asking why you never told him he was asthmatic (and have trust issues with you as a provider).

From the provider's perspective:

• Easily accessed - and I mean "easy"! When the average visit is 16.5 minutes, even one minute to fumble through access of this record will make this a no -deal.
• Complete Picture - a PHR that only tells a part of the story isn't of much value if the provider still has to go back and verify and document everything.
• Is Correct- if it doesn't provide accurate clinical data, there's no reason to use it.

Any PHR vendor that would find any of the bullets above to not be in their best interest is probably one that won't survive. That leads me to think right now that vendors such as Google, Microsoft and Revolution Health probably represent the best strategies, IF they can provide the features above.



Dave Morin
CEO
Cielo MedSolutions

If you haven't yet seen it, check out the Flip Video Camcorder. There an incredible amount of buzz surrounding the product yet it is one of the simpliest camcorders on the market.

Read "Simplicity: What’s Next in Business Software", a recent editorial on sandhill.com. The author argues that the new winners in the software market will focus on keeping their products focused and very ease-to-use and resist the temptation to add so many features they become virtually unnavigable.

Your cell phone now has more computing power than many of the first commercial computers. As such, your cell phone has a host of features that have nothing to do with calling someone. How many of these features do you really use? You probably use, 95% of the time, just the very basics - calling people and maybe texting them.

Why is it then that we think health care software needs to be feature-bloated to be the "right one"? Isn't a simple solution, targeted to the exact needs of a practice, truly the best? I've seen so many software evaluations that focus on how many features a product has, features that we know most users will never use, it concerns me that sight has been lost about why a software solution is needed in the first place.

Aren't our jobs complex enough that we don't need software to add to the complexity?

Quit worrying about "features" per se - worry about the problem you need to solve, worry about how quickly the product can be adopted by your practice, worry about investing in something that can easily carry you forward into the unknown future.

You will find the software answer to these questions is a product that is very focused, very easy to use and very malable.

The Flip camcorder has probably just 10% of the features of the newest, whiz-bang camcorders from the major vendors. It's inexpensive but not the cheapest.

I just searched "camcorder" on Amazon.com and sorted by "bestsellers" - the top 5 bestsellers were all Flip camcorders.

Hmmmmm...

Dave Morin
CEO
Cielo MedSolutions

Data is data, right? Facts and figures presented in some manner. More data is always better than less? Larger reports must always tell you more? Many a job has been justified on generating data. There are many to which generating data is the end-goal.

Each of us is drowning in data. And much of it really doesn't help you do what you do better. Shouldn't that be the point of getting data?

Actionable data is data that you can do something with. It answers not just "what" but "why".

An example: your clinical system generates a report that says your compliance rate with a guideline for measuring A1C levels every six months for diabetics is 50%. That tells you, for half your diabetic patients, you are meeting the goals of the guideline.

Cool! Now, you want to get that compliance rate to 60%.

What do you do? All the report tells you is that 50% are in compliance. You have no idea what's going on with the other 50%, you don't even know who they are. Good luck getting your compliance rate higher.

Here comes the need for actionable data! The data you need to get your compliance rate higher includes:

1. A list of the patients not in compliance.
Yep, this certainly is where you'd start, but this alone doesn't tell you why they are not in compliance. And, it needs to be all the patients not in compliance, even those you haven't seen in years.

2. Details as to why they are not complaint (like: have never been seen, have a lab req but never completed it, refused to do it, have not been asked to do it).
Cool. Now we know what to do for each patient. How do we take action to move forward?

3. Contact information for each of these patients.
Use this info for telephone calls, custom letters, emails, text messages, smoke signals, whatever it takes to reach these non-compliant patients and move them to compliance (Note: Cielo Clinic can generate letters and create call lists but cannot yet generate smoke signals). And, because you know the exact reason each patient is not in compliance, you can have directed communication with them to get to their exact needs.

4. Details on the actions you take.
Track the fact you made calls, sent letters, got more lab reqs out, etc… So, as you continue to work with these patients, you know exactly what you've done to be smarter about it next time around.

Got actionable data?

Dave Morin
CEO
Cielo MedSolutions

As you know if you've spoken with us or spent much time browsing our website, we're big on the fact that Cielo Clinic contains a coded, all-problem registry. Here's a brief description of why that is so important.

Your registry is only as good as its accuracy.

Many registries are built off of billing data. Not a bad place to start you may say. Just take all those people with asthma or depression codes and dump 'em in! Not so fast... Billing data sits at one end of a long process that begins with a clinician thinking, "This patient is wheezing, but I don't have enough yet to make an asthma diagnosis." So the clinician either writes down "wheezing" which gets changed to a billable diagnosis of asthma, or they realize from the start that wheezing won't get paid for and they just write asthma. When that billing data gets dumped into the registry, the patient with wheezing is now part of the asthma registry, and becomes part of the reporting for which one is responsible. Whoops!

If you have a system that allows you to accurately represent with a coded problem what that clinician is thinking, "wheezing" doesn't become "asthma", and your quality improvement efforts are focused with precision on the patients that truly have asthma.

Cielo Clinic contains a rich set of clinical terminology that was built by having primary care physicians record problems using words that make sense to them. These terms are coded, and mapped to a classification system that allows accurate aggregation of the problems into disease categories for quality management. If your quality management system can't do this, you'll spin your wheels focusing on patients that don't have the diseases you're trying to impact.

If you build it they will come - Field of Dreams

OK, maybe it's a bit corny, but that's our reason for having an "all-problem" registry. Clinicians build it by recording the problems they are working with every day. Not just on a select set of patients, but all patients. A lot of work? Not if you are getting something in return. What Cielo Clinic gives you in return is an accurate problem list on every patient, using terms you understand, not up-coded to meet billing standards. Additionally, Cielo Clinic gives you back reminders based on those problems and the ability to "on-the-fly" respond when new guidelines emerge for conditions. Because you've been accurately recording the problems, you have already built the registry for any given clinical disease category.

You're building it, because those new guidelines will come!

Don Nease, MD
Chief Medical Officer
Cielo MedSolutions

When we launched Cielo MedSolutions (www.cielomedsolutions.com) in ’05, we took a long, hard look at the healthcare IT space and realized the following:

1. that the country’s 360,000 primary care physicians were suffering… they were underpaid and overworked;

2. that commercial electronic medical record (EMR) or electronic health record (EHR) software wasn’t the entire answer for making those primary care clinicians’ lives better, partly because this software tended to be designed around the needs and the workflow of hospitals and inpatient medical care (as opposed to ambulatory care), and partly because it tended to record billing data (as opposed to clinical data) in the patient record; and,

3. that existing commercial software tended to be so expensive that the return-on-investment just wasn’t there for primary care providers.

As we scoured the market at the time, we were fortunate to find some existing web-based software –- an example of what we’ve come to call a “clinical quality management” application –- developed by leading clinical researchers at the University of Michigan’s Medical School by the Family Medicine Professors Don Nease, Mike Klinkman and Lee Green. They’d developed and already proven out this software, with the help of NIH grant funding, and were already field-deploying it to manage over 140,000 patient encounters per year in their geographically-dispersed clinics.

What we liked about what we saw with the UM software was that it was built around the needs –- and around the workflow –- of primary care clinicians, and actually helped each physician do a better job of keeping track of the myriad details associated with chronic disease management for her or his thousands of patients, both on the day of a patient visit as well as by facilitating proactive patient outreach.

So, to make a long story long... we ended up exclusively licensing this technology from the University of Michigan (http://cielomedsolutions.com/news-pr-cms-march2006.asp). But -- and we think this is much more important in the final analysis -- we've ended up forming deep personal and professional friendships with the key medical researchers involved. Today, we have the privilege of calling Dr. Don Nease our Chief Medical Officer at Cielo, and Drs. Klinkman and Green both energetically serve on our Medical Advisory Board where they continue to challenge our thinking and provide thought leadership (http://cielomedsolutions.com/about-advisory.asp). On the application software side of things, we've rapidly evolved and augmented the technology we licensed from UM, and the result today is known as Cielo Clinic, a commercial SaaS (software-as-a-service) application for clinical quality management in ambulatory care settings.

Jim Price
Chairman & Cofounder
Cielo MedSolutions

It's not a registry!

Better said, a Clinical Quality Management System, (CQMS) is more than a registry.

Registries traditionally have been database tools built to track patients with chronic conditions. The idea was to take your group of patients with severe diabetes, heart failure, (insert chronic disease of choice here) and track them. How often are they seen? What's the status of their key measures? When did the last have their diabetic foot exam?

Embedded in the above are a couple of assumptions...

First, you've gotta assemble that list of patients. How you do it is huge. Do you do assemble it in the course of delivering care?

Hey Maggie! Ms. Smith is really struggling with her asthma. Let's put her into the registry so we can track her more closely.

That works, but man it's slow!
Do you assemble the registry with billing data? (insert giant sucking sound here) Hoover up some billing data and you've got it, right? After all that's what the payors do to assemble those lists they send us, and we all know how accurate they are. Do you include all 250.xx?

How did that patient get into the registry? They've just got glucose intolerance.

You get my point.

Second, once you've got that list, now you've gotta do something with them. Reporting! This is the golden deliverable of a registry.

Give me the list of everyone that patients that are due for their diabetic foot exams! Oh crap! I just saw Mr. Powell, and he needed one.

Reporting is great, but it doesn't do much for you when you are in the middle of patient care. The other big problem with reporting is you gotta capture the data that you want in the registry and get it into the registry. This is the "Oh crap! I just DID Mr. Powell's foot exam but I forgot to record it for the registry" problem. Registries require a lot of care and feeding.

How is a CQMS different? It contains a registry, but an all-problem, clinician-verified registry. You don't decide how to populate it because you are building it every time you see a patient by recording, updating and correcting their problem list. A CQMS also should be able to deliver reports, but it should also give you something to act on when those patients come in.

Mr. Powell, I see here on my Encounter Form that your due for your foot exam, so let's do that today.

A CQMS should also be able to receive information from other data sources so you don't have to spend valuable time feeding it.

Finally, we believe that a CQMS should integrate into your entire care delivery team. It does that by offering value to every member of the team. Clinicians get their encounter forms with reminders, Nurses get call lists of items that need attention, and administrative staff get reporting of quality measures tell more than the percentage of patients needing services.

A CQMS isn't a registry, it's a whole lot more. You'll be hearing more from us on this. Stay tuned!

Don Nease, MD
Cielo MedSolutions' Chief Medical Officer

Even as veteran tech entrepreneurs and business-builders, it’s safe to say that none of the top business people at Cielo –- neither Dave Morin nor Chris King nor I (http://www.cielomedsolutions.com/about-leadership.asp) –- is in love with technology for its own sake. Yeah, all three of us have built our respective business careers around solving tough problems using technology, some of it pretty super-wazoo stuff. But one thing we’re always in agreement about is, “The technology is never the point!”

In fact, here’s the way I’d put it: At Cielo, one important thing we have in common is that we like to identify large, unsolved customer problems that have potential to be solved by intelligently applying existing, proven, off-the-shelf technology. That way, there’s no technology risk associated with developing and implementing the new solution!

In addition, we believe in the principle that our customers are doing what they’re currently doing for a good reason – that they tend to know what they’re doing. Corollary: the greater the extent to which a company’s “solution” to the customer’s problem requires the customer to change the way they currently do things –- to alter their workflow –- the less likely that company is to succeed in selling their product into their target market. Sounds logical, eh?

Jim Price
Chairman & Cofounder
Cielo MedSolutions (www.cielomedsolutions.com)

I found Dr. Don Nease's recently posted article on the potential of EMRs to impact prevention and early detection quite informative. We agree that there is great value in an EMR, but also agree with Dr. Nease's views as our customers and prospects come to us talking about the gaps in functionality in areas of prevention, screening and chronic disease management. Cielo Clinic fills that gap and works alongside your EMR, bringing better overall value to your entire health information technology investments.

Read at: http://www.preventcancer.org/iDialogue/

Dave Morin
CEO
Cielo MedSolutions

As of late, I've been on a lot sales calls pertaining to the immediate need for a "chronic disease management system" or a "registry". It's great to see that providers and practices are finding they need technology like ours (Cielo Clinic). But, I'm seeing two consistent issues in the approach to selecting a system that concern me.

First is the inability of the prospective customer to document the true clinical and/or business problem to be solved (ensure providers maintain compliance with evidence-based guidelines, build a database of actionable clinical information to improve quality or increase the efficiency of a patient visit, as examples). The problem certainly is not the need for more technology systems to support!

What we normally hear is " my payor said I need a registry to participate in their pay-for-performance program". Yes, if your payor says you need a system and there is financial incentive to do it, you should find one. But, what are the goals of the pay-for-performance program? What system features do you need to support these goals? What is required from the system to fit into your workflow and be usable by providers and staff? What do you need to ensure your solution takes you into the future (in other words, "what's next"?). What do you need to track and report on?

Second is the assumption that the technology, by vitrue of its implementation, is the solution to the problem. The overlay of a technology on a workflow that can't take advantage of it, support it or understand it is a classic recipe for more problems. The technology is not the solution, it's the effective use of the technology that brings the benefit.

These issues transcend health care - as a former technology consultant I've seen these same issues in a variety of industries. I've also seen the disappointment of many a technology purchaser when they find their system doesn't meet their needs, frustrates their staff and just leads to more cost.

Cielo Clinic delivers a wealth of benefits to a primary care practice. When we call on you, tell us what you true clinical and business needs are; we love to discuss and analyze them and we are confident we will meet them!

Dave Morin
CEO
Cielo MedSolutions

AHRQ (Agency for Healthcare Research and Quality) recently published a wonderful paper entitled "Health Information Technology for Improving Quality of Care in Primary Care Settings". The paper looks at "the link between health information technology and quality improvement in a range of primary care settings"1.

To see the document: http://healthit.ahrq.gov/portal/server.pt/gateway/PTARGS_0_1248_661809_0_0_18/AHRQ_HIT_Primary_Care_July07.pdf.

There are many insights and recommendations documented in this piece; if you are looking into technology and best practices to support improving quality of care, it is a must-read. But, there is a specific issue highlighted in the report that "hits home" because we constantly talk about it. Specifically:

1. Page 18 - "another aspect of data structures that continues to restrict improvement activities is the billing and reimbursement coding mindset that permeates much of health care data. For example, in many health IT systems, patients with asthma do not have a diagnosis of asthma; they have a data history of billed visits with a billing diagnosis of asthma. For visits to the clinic that did not involve their asthma (and hence no billing code of asthma was issued), there is no way to relate that visit to their chronic condition of asthma. Additionally, an asthma billing code is often used for a patient who arrives wheezing (whether they have a diagnosis of asthma or not). This may not look like a data problem on the surface, but if you ask the health IT system how many asthmatics are in a panel, the numbers are far from reality."
2. Page 19 - "data structures for billing and documentation are often very different from the data structures that support improvement"
3. Page 13 - "data that are constrained to billing codes may make it very difficult to track the progress of a chronic diagnosis over time"

The paper also discusses that it may be difficult to solve this problem - but we think we have solved it through the use of clinician-verified diagnoses built from a thesaurus of coded clinical terms. We do not rely on billing diagnoses; clinicians capture patient diagnoses at the point of care based on the true conditions of a patient and Cielo Clinic stores and utilizes these diagnoses. This capture is a very simple effort and has a very small time impact on a provider.

Of course, it is quite simple for our system to take a billing file and use it to pre-populate a patient database with diagnoses; we offer to do this during every Cielo Clinic installation. But, we rarely do diagnoses pre-populations as most practices are not comfortable with these data sets for clinical quality improvement.

We feel strongly that a quality program built on billing data will not be successful. Bottom line, billing data serves a different purpose than quality of care data. Billing data was never constructed to support quality of care initiatives. A different data set is needed, period. It needs to be coded, clinician-verified and uncoupled from billing diagnoses. It isn't difficult to build this data set, especially with a tool such as Cielo Clinic, and build it to the benefit of all stakeholders; providers, patients and payors.


Dave Morin
CEO
Cielo MedSolutions

1: Langley J, Beasley C. Health Information Technology for Improving Quality of Care in Primary Care Settings. Prepared by the Institute for Healthcare Improvement for the National Opinion Research Center under contract No. 290-04-0016. AHRQ Publication No. 07-0079-EF. Rockville, MD: Agency for Healthcare Research and Quality. July 2007. Page 1.

Every time an account manager at Cielo makes a presentation on Cielo Clinic, they highlight the fact that a provider can access our software either through a paper or web-based Encounter Form. For those not familiar with our product, the Encounter Form is the interface a physician uses to know what services, screening and counseling are due for a patient at the time of their visit. This Form can be delivered either via a web interface from a device connected to a network or can be delivered by a printed piece of paper. The web-based Encounter Form was designed to be extremely simple, easy to use and requires just a few clicks of a mouse by a provider.

The next item our account managers highlight is that 100% of the providers utilizing Cielo Clinic access it via the the paper form and not the web interface. This includes environments that have laptops and wireless networks in exam rooms and can easily make use of the web interface. It also includes providers of all ages, even the "young ones". No one dismisses the value of the web interface, they just think that the paper form works best for their workflow.

In most cases, the people at the presentation strike a curious look at that statistic and are either 1) shocked and challenge it, 2) insistent that this will not happen at their practice(s) or 3) humored by it and make some sort of dumb joke.

This predisposition to use of paper in the exam room is not something that should be challenged and dismissed but instead something that should be studied. I am a big believer that the value technology can deliver is often confused by people who see it as an end result versus a means of achieving an end result. Our software is not a product that lets a physician use a laptop in an exam room, it is a solution for providing better quality of care to patients. The technology facilitates the ability to deliver this increased quality of care, but, in the end, it is the provider delivering the care, not the technology. Many people jump too quickly to the conclusion that, if only the provider used the technology "correctly" (read: uses a laptop to access everything), they would be much more effiicient and productive.

What we need to learn more about is why providers feel the paper Encounter Form works best for their workflow. Does the use of a laptop or other device take away from physician-patient interaction? Is juggling a laptop in an exam room just too much effort when a simple piece of paper will suffice? Is there an emotional connection to a piece of paper that is just hard wired into humans? Is reading off a screen too difficult? There's lots of questions that can be asked, but I think we will find it all boils down to a few fundamental issues.

We're studying it further and have begun to collect responses. I'll be sure to share what we find.

Dave Morin
CEO
Cielo MedSolutions