News 11/10/09

A Commonwealth Fund survey of primary care doctors finds that the US is way behind other countries in several healthcare categories: access to care, providing financial incentives for healthcare quality, and using IT. Only 29% of practices provide after-hours care (other than the hospital ED). Less than half use electronic medical records, well behind the 90+ percent of several other countries. That’s despite spending twice as much per person as other countries.

Fresenius Medical Care North America, an operator of dialysis facilities, purchases Health HIT Services, makers of the Web-enabled Acumen nEHR for nephrology.

eClinicalWorks adds another IPA to its client list with the signing of Catholic Independent Practice Association (NY). The IPA purchased 150 PM/EMR licenses to connect community physicians and will work with eCW to tie into the HEALTHeLINK RHIO.

Which reminds me of a recent conversation I had with an MSO administrator. We were discussing which ambulatory EMR vendors were making the most inroads into the the IPA and health system market and selling EMRs on a large scale. Some vendors we agreed on: eCW, Allscripts, and Sage. Did we miss any?

New evidence that healthcare providers are not immune to the current economic recession. The 106 year-old Honolulu Medical Group files Chapter 11 bankruptcy, saying it owes creditors over $1 million. In recent years, the practice has shrunk from 40 providers to 11 and owes over $700,000 in rent for unused space. Meanwhile, The Commonwealth Cancer Institute (VA) also files for bankruptcy protection, claiming the slowing economy has delayed patient payments and forced some physicians to leave. Commonwealth’s outstanding debts are over $2.8 million, which includes loans on property and equipment and fees to three doctors.

Consultants in Radiology (TX) deploy eGistics’ Digital Medical Practice Solution for its 14-physician practice. eGistics provides a hosted document management solution.

Sermo launches the Practice Management Exchange, where physicians can exchange business advice and earn CME credits on PM topics. PME was designed for physicians in small and solo practices.

Gregg Alexander, Jon Smalling, and I enjoyed our quick peek at athenaClinicals and have been reviewing feedback from our readers. Most were along the lines of this: “Stick to the knitting and provide what we all like to hear — unbiased and good reporting on the industry.” Another reader accused Mr. H of having  “man crush” on Jonathan Bush, which made me smile since Mr. H doesn’t seem like a “man crush” kind of guy to me. In any case, the critics have spoken and we have opted to shelve the product assessments and will focus our energies elsewhere. We honestly liked the paddles, however, so maybe we will dust them off when we evaluate exhibitors at HIMSS. And thank you for taking the time to share your opinions with us.

QHR Technologies signs a letter of intent to acquire its EMR competitor Clinicare for $5 million Canadian collars ($4.7 million). Both companies are based in Canada and together provide PM and EMR to over 3,000 physicians. Clinicare serves providers in the US as well as Canada.

The AMA officially applauds the passage of the House’s health reform bill, though many physicians want the support rescinded because the legislation interferes with the patient physician relationship. MGMA also praises certain HIT components of the bill, though some HIStalk readers tell us support is far from universal among MGMA members.

Riverside Radiology Associates (OH) signs a five year license renewal for Zotec Partners’ billing, RIS, and decision suite products. RRA claims its billing costs have been cut almost in half since its 70 radiologists first contracted with Zotec in 2005.

In Miami and presumably across the county, physicians are embracing social media tools to update families on surgery patients, to educate consumers, and to share medical information with fellow providers.

According to the medical director of informatics of the 250-physician Fallon Clinic (MA), EMR has not reduced patient wait times, but their Epic MyChart patient portal allows patients to receive care without coming to the office. The practice has spent $24 million in the first three years and says they are providing better care. With the removal of paper charts, clinics also have more room. The practice expects to recoup the $24 million expense “eventually.” For the mathematically challenged, that equates to about $32,000/year for each physician over the last three years. That’s a pretty pricey solution, especially if the ROI is as vague as it sounds in this article.

Text messaging can significantly improve adherence to treatment plans for chronically disease patients, according to a Mount Sinai Hospital (NY) study. Physicians working with adolescent patients who had undergone liver transplants found patients were more likely to take their medications when they received text reminders. Patients had to text back within an hour to acknowledge their meds were taken and avoid having providers contact their caregivers. I am guessing a sample text message might be: “AYEC TAKE RX PLS,” and the reply could be, “K, KPC.”

E-mail Inga.

Intelligent Healthcare Information Integration 11/6/09

Digital Relations

Did C-3PO really understand all the whirrs and whistles that emanated from R2-D2? Did Data really have the ability to feel emotions when he finally had the appropriate chip installed? Did Hal 9000 (or “CARL” in the French version) feel any psychic pain while singing “Daisy Bell” during his death throes as Dave removed his service modules? Questions without answers these are, I suppose, until we more closely assimilate with our computer brethren in our impending Borgian future.

One question that can be addressed now while still in our mere mortal form is: How do we, as mere Homo sapiens, choose to allow digital communications to affect our relationships and interactions?

Much has been written about, and academicians have debated over, the impact of cell phones and emails, IMing and Facebooking, texting and tweets. One element that I think we in medicine must address is the etiquette and ethos we will choose to maintain as we cope with the tremendous impact such an expansion of communication choices brings to the delivery of healthcare services.

When I see ivory tower discussions about the impact of social networking and all tools digital, I am sometimes alarmed at the seeming passivity of the observations and conclusions. Perhaps I am being too harsh; I know social science is one of observation and discussion of the observed behaviors. But, as a clinician of kids, I know that merely plotting their growth, detailing their development, and recording their progress to full assimilation into the world of “adultitude” is not enough. Guidance and modeling of appropriate behaviors is essential to their mental, emotional, social, and moral success.

We are, in essence, in the infancy of our digital development. As a communal infant, we need to consider the future to which we aspire. Just as we attempt to provide guidance to our biological offspring, we, too, need an inspirational archetype. However, there are no roadmaps, no role models with whom to associate and after whom to pattern our behaviors. Thus, it seems imperative that we seek a “best practices” for our digital interactions growth, knowing that it can only be extrapolated and estimated from a non-digital past.

I offer here a completely Ludditian example of a Best Practices (caps intended) communication technique as prima facie example number one:

I have a relatively new friend who, interestingly enough, I met through these pages here on HIStalk Practice. He is a corporate COO who travels to many exotic ports of call as he helps to expand the digitization of healthcare communications globally. One of the most engaging and enjoyable people I know, he has the ability to speak corporate-ese with ease and yet seamlessly transition to “Regular Guy” mode with more wit, humor, and just plain good-to-talk-to-ness than most anyone I’ve ever known. Perhaps it is his ability to shift between these mindset forms that allows him to understand of the value of the old good graces of social intercourse as he pursues advances for its more modern expression. To wit: He is the only person I know who still sends real, honest to goodness POST CARDS! I cannot begin to tell you how it brightens even the dreariest of days to receive a little handwritten message on the back of a beautiful photo from Nourilang Falls in the Jiuzhaigou Valley of China. Even one from someplace more mundane such as Seattle or Denver (no slight intended to those good cities) has a special power and touch few emails or tweets will ever match. The personal “oomph” of these cards is tremendous.

I’m not proposing that everyone start sending snail mail again, though I’m sure the USPS wouldn’t mind. I’m suggesting that as Twitter and Facebook and cell texts and emails invade more and more of all our personal interactions, lessons from the past ought not be lost. Corporations and companies and doctors’ offices don’t create messages; people do. Every communication that emanates from anywhere ultimately involves someone, some person or persons, wanting to connect with some other some-one or -ones. And every single one of those messages has the power to move, motivate, or inspire, but only if the connection, the personal touch, is achieved.

My friend’s good communication graces may seem quaint and outdated, but the power of his message with its ultimately personal touch is undeniable. Simple communication etiquette goes a very long way in empowering connection. As mom always said, “Remember your manners.”

From the trenches…

“Good manners are just a way of showing other people we have respect for them.” – Adam Weber in “Blast from the Past”

Dr. Gregg Alexander is a grunt-in-the-trenches pediatrician and geek. His personal manifesto home page…er..blog…yeh, that’s it, his blog – and he – can be reached through http://madisonpediatric.com or doc@madisonpediatric.com.

News 11/5/09

More than half of physicians claim little or no familiarity with ARRA, according to an Ingenix survey. Only 42% of the participating physicians said they had “some” familiarity with ARRA, which seems like a shockingly low number. For physicians moving to EMRs, investment reimbursement and claim penalties are two of the biggest motivators.

Practice management and EMR provider Raintree Systems and RCM provider ZirMed announce a partnership to jointly market their combined solutions.

Memorial Hospital (MS) plans to install Allscripts EHR, PM and RCM products for its 100 employed physicians.

Ali′i Health Center (HI) selects Aprima Medical Software to provide EHR and practice management software for its 15-physician practice.

Two of San Diego’s largest independent physician organizations are partnering to develop PM and EHR implementation strategies. The article is a bit unclear  about what the partnership really means for day-to-day operations for Graybill Medical Group and Sharp Community Medical Group. However, Sharp had a big rollout of Allscripts EHR/PM just last year, so perhaps Graybill hopes to jump on the bandwagon.

A quick follow-up to athenaClinical’s review posted earlier this week. We’ve gotten some positive feedback about the exercise, as well as pleas to stick what we do best. If you’d like to weigh in, send me a note. We are also asking athenahealth to respond to a few specific issues, so look for that next week.

Express Scripts plans to use Greatwater’s PatientPort kiosk platform in physician offices. Patients will be able to review prescription options via the kiosk with the goal of reducing prescription costs.

ICSA Labs, the Medical Transcription Industry Association and several medical transcription companies form the Medical Transcription Service Consortium. The consortium’s mission will be to develop a interoperability standards for the exchange of transcribed dictated medical records.

A local paper posts a well-written article that highlights the practices of two Kansas doctors. One is an 82 year-old family physician who writes his exam notes on 5×8 index cards and has an assistant create insurance claims on an electric typewriter. The second doctor is on EMR and inputs his patient notes on a tablet computer with a stylus. Both doctors seem quite happy with their situations and the contrast (and similarities) make for a fun read.

E-mail Inga.

HIStalk Practice Interviews Andrew Baumel, MD

Andrew Baumel, MD is a pediatrician with Framingham Pediatrics of Framingham, MA.

Give me some background on the practice.

We’re Framingham Pediatrics and we’re at FraminghamPediatrics.com, if you want to check out our Web site. We are a six-person pediatric practice. We have six MDs, no NPs or PAs. We have about 10,000 patients in the practice. We’re in suburban Boston just about 20 miles out of Boston. We treat a very mixed population, socioeconomically and demographically.

We’re affiliated with MetroWest Medical Center in Framingham. We’re also a member of the PPOC, which is the Pediatric Physician’s Organization at Children’s Hospital. It’s an over 300 doc group in the surrounding Boston. We recently signed a contract to eCW to put eCW in all the practices in the group.

We had already been with eCW since 2005, so we’re kind of ahead of everyone else and everyone else is being implemented over the next 12 months. But we started with the technology back in 2001 when we were part of an e-prescription pilot from Blue Cross/Blue Shield, and then we moved in 2005 to EMR.

In 2005 I was really looking for just a replacement for our practice management system because ours was going defunct. It was called PSI. It was out of Rhode Island and their company was bought by Pulse and Pulse just assumed well, we’ll just jump to their EMR, but it was not a good product. So I was looking for a new practice management system, looking at a lot of ASP models, and I found a couple EMRs that were actually less expensive than just the fee on the loan, and one of them was eCW. And I actually met the eCW people at Pri-Med’s conference in Boston that year and liked it and I said, “Gee, if I can spend less money and get the whole thing, why don’t I do that?” It’s great.

So we went with it. In February 2005, we went live and I’ve been to four annual user group meetings with eClinicalWorks. Those conferences were amazing. Girish and everyone said, “Just rip us apart. Tear it down and build it back up. What do you want to see in the program? Where can we have less clicks? What do you want?” And the program I was using in 2005 is totally different than the program I was using now. It just keeps evolving and every iteration gets better and better.

A lot of the really cool features I kind of had a hand in, along with all the other doctors at these conferences, such as the patient dashboard. They’ve come up with some really cool things lately. I’ve been really excited about the registry in the patient portal. We have been using registry a lot and it’s really amazing because we really concentrated in the beginning on doing a good job on making the problem list readable and having the problem list be relevant. By doing that, you can run really robust registry reports. We’ve had the patient portal going for the past three months and we’re up to 2,900 patients out of 10,000, which is a nice job, I think.

We’ve been able to leverage that for our notification of the flu shot as it’s coming in, both the seasonal flu shot and the swine flu shot. We’ve been running reports based on children’s special health care needs using our registry searches to send e-blast messages through the portal. For example, last week we got in a batch of H1N1 vaccine and we decided to give it to our sickest patients first, then to asthmatics. With a couple clicks of the registry we found who has asthma. I think it was 500 patients, of which 240 were Web-enabled. We sent out a quick message saying, “The swine flu vaccine is in we’re running a clinic tomorrow afternoon, make an appointment.” Within 40 minutes, we had 55 appointments set.

The future for the portal is amazing because I can send out directed messages to certain subsets of my population immediately and have them respond. For example, there’s one town in our area that doesn’t have fluoride in the water — Ashland, Massachusetts. In Ashland, at the six-month visit, we put all our patients on fluoride. We can send out a message to all our four-month-old patients, and four-month and six-month old patients who haven’t been in for their visit. We send them an e-message that also explains how the fluoride is administered so we don’t have to do that during the visit.

Or, when albuterol went off the market; it went from generic to brand name. We had to switch all our patients from albuterol to ProAir because it doesn’t have any hydrofluorocarbons killing the ozone layer. When patients didn’t get a refill on their albuterol, they would call and ask why. If we had had the portal set up six months ago, we could literally catch every single patient on albuterol with a current prescription and send them an e-blast saying your next script will be for ProAir and this is why. We would have saved so many phone calls.

And, let’s say a vaccine lot or a drug is recalled. I could search my registry for subsets of patients then I can send them out an e-message. It’s just going to be amazing. My partners always ask me, ‘When is this EMR going to make healthcare better?’ Well, this is the answer — being able to communicate in this other way.

I was home yesterday. I got five Web messages and I responded to them from home. It saves phone calls. It was asynchronous communication. And our Web portal saves that conversation as a visit in eCW. On the mom’s end, it saves our conversation in her portal page to always go back and refer to it.

And when I get that Web message, it’s within the patient’s chart, as opposed to an e-mail that the secretary prints out, gives to you, and then you look up the patient’s chart. That’s the thing I’m most excited about recently.

Has the passage of the ARRA changed your focus at all in terms of technology adoption?

Not at all. Most of my colleagues are, like myself, not eligible because we don’t have any elderly patients, so we don’t have Medicare. But I’m the largest Medicaid provider around, personally, and I have 20% Medicaid, which may qualify me for ARRA, but the whole practice is about 12% Medicaid. We’re in an area with plenty of poor patients and we see them, but pediatricians won’t qualify under those restrictions. Plus it’s short money. It’s $44,000 over four years. That’s not a lot of money.

What about pay-for-performance programs?

Well, we’re moving beyond that, actually. We have one of the newest, latest flavor of contracts in the country. PPOC made a deal with Blue Cross/Blue Shield of Massachusetts. They gave us a $10 million grant to do a product for the Patient-Centered Medical Home. Our practice is a leader in the area because we were first with the EMR. We have now implemented the Patient-Centered Medical Home in our practice, mainly leveraging our EMR to do it. We’ve identified all patients with special healthcare needs; we had identified them in the EMR. We’re getting care coordinators in the offices and are now doing initiatives on attention deficit, Down syndrome, and asthma care.

We’re all following evidence-based guidelines, making sure we follow-up. We’re doing referral tracking and identifying critical referrals through the EMR, then checking to see if they were done and if we’ve gotten a note back. We’re following up on how quickly we get back to patients when we’re taking a call at night or when they call the office. We’re doing the whole Medical Home project and we’ve been incentivized by Blue Cross through a contract with the PPOC to do this.

We have these 10 core elements that we’ve had to document and identify and do and measure. We’re able to really leverage the registry and four years of data in our EMR to really become a Patient-Centered Medical Home for our patients.

Why do you think EMR adoption in general still remains low?

I think that it’s pretty hard to put down the pen and paper. Doctors have always done it a certain way and they don’t want to change. Changing’s hard. It takes a few years to reap the dividends of EMR. Plus, a lot of specialties aren’t really geared towards EMR. Whereas, pediatrics is perfect for EMR because every two-month visit pretty much follows the same script. Every one-month visit has the same shots. So many visits are well-scripted and you do and say the same thing over and over and over again. I say the same thing over and over, but I can do one click on a template and it’s all there written for me.

With eCW, everyone can have their own template. Every single note in the system is a template, essentially. I can pull up any note and copy it, so I don’t have the same six-month-old template as my partners do. Everyone has our own so it’s in our own words. So the EMR’s working for me, I’m not working for the EMR.

The problem is that to get there, you have to be interested in doing it. You have to invest a lot of time and effort. You’re not willing to put in that time and effort if you’re a solo-practitioner and there are only two people in the office, or you just don’t have that curiosity to do it. I personally find it fun and interesting and I think it’s efficient. It’s really improved my ability to take care of my patients and now we’re just going to take it to the next level. But most doctors don’t want to make that change; the investment. They’re just scared, and it’s so easy to write it on paper.

I was very involved the e-prescribing pilot with Blue Cross/Blue Shield and 200 doctors got handhelds. And out of 200 doctors, only nine of us used it more than 50% of the time to write scripts. Of those people, six of them were in my office and 99% of our scripts were written on e-prescribing machines — and why? Well, the handhelds didn’t come pre-loaded with our favorites list, so before I gave it to any of my doctors, I loaded all our favorites. It made it easier to use than to write it on paper. Refills were a snap. eCW’s not a turnkey product, but I set up the e-prescribing and I set up eCW to run just perfectly before it got in their hands so they wouldn’t get frustrated. A lot of docs aren’t going to have that because their EMRs are not turnkey solutions.

Then the other very secret thing is that most EMRs stink. When people start using other EMRs and say, “This EMR is slowing me down on patient care; it’s taking me forever to write a note.” Whereas, when I walk out of the room, frequently, my note’s finished because I run the tablet and I’m just writing in the office, using a pen or typing. I get out of the room, maybe I’ll add my treatment thoughts and finish the billing, but my note’s essentially almost done when I leave the room. But some EMRs are so bad and I can’t believe some of these things are still being sold. So in terms of why people aren’t adopting it, well, their colleagues say the EMRs stink.

If people tell me that eClinicalWorks is bad, I say, “Well did you do this? Did you do that? Did you write a template? Did you customize this?” They say, “No, we didn’t, we just started using it.” Well of course it’s not going to be good if you don’t customize it. It comes as a plain, generic thing and then you just have to make a few pick lists and templates, which are really easy to do. They just never take the time to do it. It’s like saying my car won’t start. Well, did you put gas in it? Well, no, we just bought it and tried to start it but there isn’t gas and to won’t run. Well of course not, you have to buy gas. They don’t do the simple, simple things that you need to do to get the EMR running efficiently. So I think it’s going to take a long time before EMR is fully adopted.

And what’s interesting now is we’re moving from the early adoptive phase to the phase where now its large organizations are buying EMRs and forcing their individual doctor practices to use it. That’s going to be a really, really tough phase for the industry because these people don’t want to use it. No one’s enthusiastic. You poison the whole office because if you grumble about it, the nurse’s aren’t going to use it. They’re still going to write you little telephone notes on paper and give it to you. They’re not going to use the telephone encounter. If the doctor’s aren’t enthusiastic about it, it just ruins it for everybody and no one’s going to use it.

So I think it’s going to take a long time. Massachusetts is the most advanced state for EMR in the country at this point, but it’s going to take awhile before everyone adopts it fully. But I still can’t believe that people are buying these bad, bad systems out there.

News 11/3/09

From Evan Steele: “Re: feedback to the government. The government has finally decided to listen to the physicians, upon whose participation the EHR incentives’ success depends. The HIT Standards Committee’s Implementation Workgroup launched a blog / Web site seeking feedback from practices regarding their experiences with EMR adoption, both bad and good. The results will be reported to the Committee on November 19th.” Comment here.

From Greg Anderson: “Re: flu clinic. Thanks so much for the kind link to my blog (via Chip Hart) about the H1N1 flu clinic at my wife’s practice last weekend. However, I wanted to correct two factual discrepancies. I am not the doctor — my wife (Susan Kressly, MD, FAAP) is. And, 18 hours is the amount of staff time we expended in total across all of the activities listed to give those doses. My good faith estimate is that we accomplished the total job in 1/3 to 1/2 of the time that would have been expended in the ‘average’ pediatric practice. To me, the key takeaway for the average observer is ‘look how much work doctors put into what seems like such a simple act, and look how little they get paid for this effort.’” Greg sent over another link that detailed an additional flu clinic’s activities on Halloween. The practice administered 145 flu shots to 114 patients in less than three hours. Based on what insurance is reimbursing, Greg calls the shot clinic a labor of love, and not a way for a pediatrician to get rich. He also adds, “Without an EMR, it has all the makings of a financial disaster, which is why some pediatric practices have elected not to participate in distributing this vaccine.” And, my apologies to Dr. Kressly (the witch in the picture above) for getting her title wrong last post.

Drummond Group, an interoperability test lab, announces that it will apply to become an EHR certifying body once ONC releases its requirements. I think mixing things up a bit and giving CCHIT some competition isn’t a bad thing. Of course it will lead to criticisms that one certification body is superior to the other and the bigger players will feel compelled to get multiple certifications jut to cover their bases. Will other entities step forward announcing they, too, intend to be a certifying body? Could be fun to see what unfolds.

With everyone focused on EMRs and how to obtain stimulus funds, practice management systems have taken a back seat. However, here’s a reminder of some of the basics that every PM system should include. The biggest question most practices likely have is whether to stick with one vendor for EMR and PM or go a best-of-breed approach. I have a bias to the one-vendor approach, primarily because it reduces interface costs and issues that can arise each time one or the other product needs to be upgraded. This AMA article also points out that providers should budget time and money for major hardware and software upgrades every three years, which I think is a wise suggestion.

Quality Systems’ Q2 numbers: revenue up 22%, EPS $0.41 vs. $0.37, meeting expectations on earnings and exceeding on revenue. ARRA is accelerating PM/EMR sales, the company says. Market cap for the company, including its QSI and NextGen divisions, is at $1.74 billion, of which founder and chairman Sheldon Razin holds over $300 million worth.

Athenahealth reports Q3 numbers: revenue up 37% to $49 million, EPS $0.14 vs. $0.14, missing expectations of $0.16.

Speaking of athenahealth, I hope you had a chance to check out our overview of athenaClincals. Dr. Gregg Alexander, John Smaling of Vitalize Consulting, and I had a one-hour peek at the product and provided some of our impressions. Our goal was to go through the same general product overview that athenahealth would provide for a  prospect, then comment on what we saw. It was not intended to be anything more than that, and thus did not include any detail on support, company background, client testimonials, etc. Our intent for this and and future overviews is to let people know what we perceive as the product’s strengths/weaknesses based on what the vendor shows us. Since it was our first one, I would appreciate your feedback. A couple of companies have stepped forward indicating they’d like to participate in our next review, so stay tuned. A special thanks to Gregg and John for their time participating in the demo and providing their impressions. Thanks also to the athena folks, who didn’t really know what they were getting themselves into when they agreed to participate. Incidentally, athenahealth is not a HIStalk or HIStalkPractice sponsor and did not provide us any sort of remuneration.

McAllen, Texas once again makes healthcare headlines. The area’s largest hospital system agrees to pay the federal government $27.5 million to settle allegations that it paid doctors illegal kickbacks to refer patients to its facilities. The government claims that South Texas Health Systems disguised payments to doctors in a series of sham contracts that included medical directorships and lease agreements.

Half of the doctors responding to a British survey say they are too busy typing into the computer to look patients in the eye. One doctor said, “The demands of the patient’s agenda, the Government’s agenda and the requirement that everything I hear, say and do must be meticulously recorded make for an extremely crowded consultation.”

HHS issues an interim final rule that increases penalties for HIPAA violations. The maximum individual penalty for civil violations jumps from $100 to $25,000 and the penalty cap grew from $25,000 to $1.5 million. Will The National Enquirer appeal?

Ambulatory healthcare clinics have had a total of 63 mass layoffs through the end of September, which is eight less than all of 2008. A mass layoff is defined as when at least 50 workers lose their jobs.

Score one for EHRs. CMS announces that in 2010, providers will be able to submit e-prescribing usage through qualified EHR systems or registries. In the past, providers were required to report e-prescribing based on patient medical claims. Providers will also be able to use their EHRs to report PQRI data. Next year’s payments will increase from 1.5% of total estimated allowed charges to 2%.

E-mail Inga.