"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

We've now talked to many of the providers for whom, on their behalf, we submitted quality data to PQRI (via Cielo Clinic). All of the providers we have spoken with have received their reimbursement! Reimbursements have ranged from hundreds of dollars to thousands of dollars, but since it is a formula on allowed charges, of course the amounts will vary.

We've also received comments from people that have previously done the very-manual claims submission process for PQRI that registry submission is the "only way to go". Remember, just by using our product in the normal course of care delivery, we are taking care of capturing the data needed for reporting and, at the appropriate time, doing the data uploads. That's pretty simple and that's how it should be.


Dave Morin
CEO and Co-Founder
Cielo MedSolutions

This is exciting. Through our partnership with DrFirst, our customers will be able to e-prescribe right from Cielo Clinic. Here's an example of what that means at the point-of-care:

Dr. Smith is seeing Pam Doe. Using Cielo Clinic on his laptop, he notices a reminder to prescribe a statin. So, on Pam's Cielo Clinic encounter form, he clicks on the eRx button. This automatically logs him into DrFirst, takes him to Pam Doe's eRx record in DrFirst and updates the eRx record with any changes (like an address change).

Dr. Smith prescribes the statin through DrFirst. He then goes back to Cielo Clinic, where that new prescribed drug is now on Pam's active medication list.

What didn't he do?

He didn't have to jump out of Cielo Clinic, log into Dr. First and find Pam Doe. He also didn't have to update DrFirst with any record changes and he didn't have to update Pam's medication list in Cielo Clinic.

For a busy doc seeing 30-40 patients a day, this is a significant time savings!

We really think this sort of integration is important. Just a simple interface won't do - that doesn't make your job easier at the point-of-care. A subtle but important difference that Cielo MedSolutions understands.

Dave Morin
CEO and Co-Founder
Cielo MedSolutions

Cielo MedSolutions now provides periodic email updates on the implementation of this Act and its impact on an ambulatory care practice. Below is our first update. If you'd like to be on the email list, simply let us know at info@cielomedsolutions.com.

Of course, the usual disclaimers are in place: this is a rapidly changing landscape as no final decisions have been made on the HITECH Act and views expressed in this document are only opinions.

SNOMED-CT is the Problem and Procedure Vocabulary

From the HIT Policy Committee, August 14, 2009, Report From Clinical Operations Workgroup update slides:

“Primary vocabulary standards:
· Clinical problems and procedures: SNOMED CT
· Drugs: RxNorm
· Ingredient allergies: UNII
· Lab tests: LOINC
· Units of measure: UCUM
· Administrative terminology: CAQH CORE and HIPAA”

From the HIT Policy Committee, August 14, 2009, Clinical Quality Workgroup: Progress Report update slides:

"· Multiple versions of measures to provide options
o 2011 – ICD 9 or SNOMED CT
o 2013 – ICD10 or SNOMED CT
o 2015 – SNOMED CT
· Can use internal codes using SNOMED CT expertise to map to SNOMED CT
· EHR certification should require problem list”

Views: it looks as though problem lists will ultimately need to be built with SNOMED CT versus ICD9 or ICD10 and the open question is the year it needs to be done. This could be a significant issue for systems that do not have a clinical thesaurus that can cross-reference problem terms across different vocabularies (in other words, a system needs to be able to know how an ICD9 or ICD10 code maps to a SNOMED code). In addition, registry and EMR systems that only utilize billing files for problem documentation may struggle with using an alternative coding system (problems will still come in from billing files only in ICD9). Because Cielo uses a clinical thesaurus (the ENCODE table mapped to ICD9, ICD10 and ICPC) and one of Cielo’s Medical Advisory Board members is leading a committee to map ICPC to SNOMED, this will not be an issue for Cielo Clinic.

Registries called out as key to ARRA

From the National Committee on Vital and Health Statistics Report of Hearing on “Meaningful Use” of Health Information Technology, April 28-29, 2009:

"Testifiers reported that the ability to get data out of EHRs easily – both for reporting and for creating panels of patients, is difficult with today’s EHRs. However, it was noted that in addition to embedding registry functionality in an EHR, such functionality (and others) may better be delivered through applications and services that are not part of a single all-encompassing application, such as population or disease registries."

Views: This testimony from industry leaders reinforces the growing sentiment that registry solutions are a very viable solution for meaningful use.

Modular Approach Available through EHR-M

From the HIT Policy Committee Review of Initial Recommendations by the Certification and Adoption Workgroup, Paul Egerman and Marc Probst, Intermountain Healthcare, August 14, 2009:

“Recommendation 4 – Flexible Software Sources - provide for certification of components so EHRs can be purchased from multiple sources”

Views: a registry can be certified via EHR-M. You will be able to assemble best of breed components from a variety of vendors to meet meaningful use. You will probably find this can be done at a total price-point lower than a monolith EMR. Cielo is assembling the best-of-breed products that, together, will be pre-interfaced and meet meaningful use.

Submissions Will be Electronic

“CMS noted that only measures that "can be submitted electronically" will be allowed.”

Source: CMS Sheds Light on Meaningful Use, HDM Breaking News, August 14, 2009

Views: electronic submission is good. We predict the constructs in place for registry reporting on PQRI will be used for meaningful use submissions. Therefore, a system already doing PQRI uploads, like Cielo Clinic, should have an advantage.

Dave Morin
CEO and Co-Founder
Cielo MedSolutions LLC

The success of a health care software product can be measured in many ways. As such, I'd like to point out two new stories that tell not only how our customers are using our product, but also reflect the ability of Cielo Clinic to impact care in very different care settings.

One

Jean Malouin MD, Assistant Chair, The University of Michigan Health System Department of Family Medicine, recently presented at the Blue Cross Blue Shield of Michigan Physicians Group Incentive Program Quarterly Meeting on the University's implementation of a Patient-Centered Medical Home (PCMH). In the presentation, she shares their PCMH implementation experiences and illustrates their population management strategies. This, of course, includes many references to their use of Cielo Clinic. I urge you to take a look, it's great educational material on how to implement a medical home and how Cielo can help. Click here to view the presentation from the the Blue Cross Blue Shield of Michigan web site, or click here to download them from this blog entry - /PGIP062009houseahome.pdf

Two

The Joy-Southfield Community Development Corporation runs a free clinic in the City of Detroit staffed by a wonderful group of people truly dedicated to better health care and community activism in the City. Check out their web site to learn more and if you can, please support them!


The free clinic uses Cielo Clinic to manage their patients' screening, prevention and chronic disease management needs. Recently, they completed a study on blood pressure control, hypertension management education and diagnostic profiling among African American women (the full study is described in the link below). Since installing Cielo Clinic (less than a year ago), they've posted some very impressive gains in care quality and the study tells the story! Blood pressure control among hypertensive patients is at 60% (the national goal is 50%). Hypertension management education access increased 143%. Patients with no lab profile is less than 5%. Great numbers, especially with a clinic staffed with volunteers. Much of this success is attributed to Cielo Clinic.

Click here to see their June 2009 Revitalizer Newsletter, which includes an article on the study - /JoySouthfieldRevitalizerJune2009.pdf

Summary

Our customer base consists of free clinics, federally qualified health centers, solo practitioners, group practices, rural providers, integrated health systems and academic health centers. In short, our product is being successfully in almost every conceivable care setting. There's lots of talk these days about usability testing for EHRs, I think the stories above and the breadth of our customer base reinforce what we hear over and over, Cielo fits into virtually any workflow, is simple to use, and drives results.


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

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

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

For me, a very solid theme emerged from the American Academy of Family Physicians (AAFP) Scientific Assembly. (Background: our team attended the Assembly, had a booth at the show and the management team had meetings with various industry leaders and Academy executives).

For primary care medicine, it's all about the Patient-Centered Medical Home. We engaged in more discussions on that topic with providers and practice staff than any other topic, by far.

I stopped by the TransforMED booth (TransforMED is a subsidiary of the AAFP and helps practices transform into Medical Homes) and heard from the TransforMED team that on the first day of the show alone they had more people stop by than during entire previous trade shows!

From the providers and practice staff that stopped by the Cielo booth - trepidation, excitement, confusion and a TON of questions. There is a lot of hope and a lot of valid concerns.

There is no doubt in my mind that this will be the topic of the upcoming year. That being said, I certainly see the need for leadership and education on the topic. There are large looming concerns (reimbursement is at the top) and they need to be addressed and managed now.

From a technology perspective, Cielo will deliver that leadership. We have very strong ideas that come from years of research completed by our Medical and Health Care Industry Advisory Boards and our own backgrounds in technology. Some of them are quite different (maybe a tad controversial) than what you are probably hearing, but they have been proven and they need to be talked about. Choosing the right underlying technology for a Medical Home is a critical decision. There are non-obvious issues that need to be understood.

Sadly, I can't even begin to count the number of providers that stopped by, told us their EMR can't support many of the elements of the Home and asked how we can help (we work alongside EMR and enhance it).

I/we would really welcome the opportunity to talk to you, either face-to-face, over a webinar or as a speaker at your next gathering, about our thoughts on technology for the Medical Home.

Dave Morin
CEO
Cielo MedSolutions

For those looking to adopt a clinical quality management system or registry, a new must read is available in Medical Care, September 2008 - "Impact of a Generalizable Reminder System on Colorectal Cancer Screening in Diverse Primary Care Practices: A Report From the Prompting and Reminding at Encounters for Prevention Project" (Medical Care. 46(9) Supplement 1:S68-S73, September 2008. Subscription required for fulltext).

This study, funded by the National Cancer Institute and Agency for Healthcare Research and Quality, implemented Clinfotracker (the technology on which Cielo Clinic is based) in 12 diverse practices in Michigan to drive improvement in colorectal cancer screening rates. An average 9% increase was achieved in just 9 months.

This paper studies the ability of a reminder system to improve care delivery and also reviews the ability of practices to adopt clinical technology. I think the second part of this study is just as important as the first part!

Dave Morin
CEO
Cielo MedSolutions

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.

I'm asked quite a lot about uploading clinical data directly to CMS to support the PQRI program. Along with the questions we often hear conjecture about the status of the project and what a provider can do. Today I will outline Cielo’s involvement in the programs.

CMS has put forward two programs related to Registries submitting data on behalf of practices for PQRI measurement. 1) 2008 PQRI Registry Test & 2) 2008 Registry-Based Data Submission. Cielo is involved in both the Test program as well as the Data Submission program. Goals of the Registry Test program are to validate a registries' ability to gather, calculate and report on PQRI quality measures. Goals for the Registry-Based Data Submission program are to enable physicians to participate in the 1.5% incentive payment portion of PQRI through an alternative reporting system (their Registry).

Cielo’s involvement in the two PQRI related projects:

PQRI Registry Test Program

The 2008 PQRI Registry Test program was initiated by CMS in early 2008. This program was a “test submission only” program in which no incentive payments were available. Cielo has been involved from the inception of this program including a meeting at CMS offices in Baltimore. As part of our test submission we captured, calculated and reported PQRI measure #1 (Hemoglobin A1c Poor Control in Type 1 or 2 Diabetes Mellitus). We were notified earlier this week that our first submission was validated without error and that we have met the requirements of the program.

Registry-Based Data Submission

In May of this year Cielo self-nominated to be accepted into the Registry-Based Data Submission program. There are NO approved vendors yet. Registries had until May 31 to submit their self-nomination and must go through an interview, documentation and testing process prior to the end of August. Around August 31, 2008 there will be an announcement from CMS listing the registries that qualify. Once selected a registry will be allowed to submit PQRI data to CMS in January and February 2009. Cielo has met all steps involved with this process and awaits an announcement of the selected vendors.

I think it should be noted, though, that there is quite a bit of "devil in the details" and would highly recommend reading about the projects at the CMS website. As usual, it’s never as easy as “just dropping in a registry”.

Chris King
Senior Vice President
Cielo MedSolutions

State-of-the-art software solutions are today architected as software-as-a-service ("SaaS"). This means the software solution is:

• built from the ground up to be delivered via the internet - this is very different than a system delivered via application service provider ("asp"). An ASP-delivered system is one that wasn't built originally to support web delivery but is using additional technology overlayed on top of it to allow that to happen
• hosted at a 3rd party data center
• accessed by the user through a secure internet connection

If you utilize a SaaS product, what does it mean for you?

• You don't need to buy additional hardware or systems software for your practice. You just need your PCs to be able to use an Internet browser and have Internet access.
• You don't need to manage a server and its backups.
• Updates are quickly available to you as they are simply installed by your vendor.
• You'll get better tech and user support, as the vendor can securely get access to the system and its server.
• Implementation is faster and easier because you don’t need to go through the effort of setting up all the hardware and doing all the installation of technology to use the product.
  

SaaS will certainly be the future delivery model for many software solutions. It eliminates many of the soft costs of a technology implementation (usually a 3:1 ratio relative to software costs - you will spend $3 on hardware, infrastructure, support, etc. for each $1 you spend on a software product) and ensures you keep current on the latest software release. For solutions such as Cielo Clinic, SaaS is the best way to get the product in a user's hands.

Dave Morin

CEO

Cielo MedSolutions LLC

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

We're proud of Cielo Clinic's inclusion in the AHRQ Innovations Database. The database documents the success of ClinfoTracker (the former name of Cielo Clinic) in simultaneously increasing quality on a variety of measures. It's a great testament to the power of the product.

See: http://www.innovations.ahrq.gov/content.aspx?id=1771

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

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