News 2/16/10

Help wanted: would you please take a few moments to complete our HIStalk Practice Reader Survey? Your input is appreciated and will help us figure out what we are doing right and what we need to tweak. Mr. H told me I should beg for participants, which sort of reminded me of my days working for a vendor. Twice a year, the company would have employees indentify happy customers and then plead with a few to complete a KLAS survey. I’m pretty sure a lot of the execs had bonuses tied to KLAS scores, leading me to to wonder what kind of back-scratching went on with certain big-wig customers. We have don’t have bonuses or back-scratching, but we would be mighty appreciative if you’d take the time to give us your feedback. Thanks.

Siemens says it will continue re-selling NextGen’s PM/EMR products to its customers. The news came the same day NextGen officially shared word of its Opus Healthcare acquisition (which we actually mentioned one day earlier, thanks to a reader’s tip).

MacPractice releases version 3.7 of MacPractice MD, MacPractice DeC, and MacPractice 20/20 with MacPractice EMR. The EMR software now includes the ability to create lab requisitions and track results.

As more physicians adopt point of care payment technologies, look for consumer advocates to raise concerns about liability in the event of incorrect charges. A Kalamazoo, MI paper describes the mPay Gateway service just installed at four area practices. Using mPay Gateway’s system, the practices calculate a patient’s financial responsibility at the point of care, and automatically bill the patient’s credit card once insurance pays. One of the office manager claims the service provides, “greater transparency and peace of mind for the patient.” However, a follow-up op-ed piece suggests there needs to be some sort of safety net to provide patients financial protection in the event a provider or insurance company screws ups and bills a patient incorrectly.

Emdeon CEO George Lazenby shares some thoughts on the use of technology to reduce healthcare fraud and says that the automation of payment processes could save the US could save $30 billion annually. He also mentions this odd fraud case: a doctor’s wife works in her husband’s office until the two became estranged. After the separation, the wife she starts filing fraudulent insurance claims that name her ex as the provider. One hundred and eighty thousand dollars later, someone figures out the scheme and she is caught. Was she motivated by greed? Or, she was a woman scorn and scheming to get her ex in hot water?

Bad news if you are a hospital-associated outpatient doctor hoping to qualify for ARRA meaningful use incentives. The Senate ended up stripping those provisions from the HIRE Act, though it may be addressed in other bills.

A pharma-sponsored survey concludes that physicians are more likely to report drug side effects through an EHR than paper methods. Of the 300 surveyed physicians, half of all the docs and 60% of the full EHR users said they’d be much more likely to submit information about adverse events using an EHR system.

HHS Secretary Kathleen Sebelius and Labor Secretary Hilda Solis continue to hand out HITECH ARRA money, including $1 billion last week for HIEs, Regional Extension Centers, and job training. Forty states and State Designated Entities will receive $386 million to facilitate HIEs at the state level; $375 million will facilitate the development of 32 RECs to train 100,000 providers and hospitals in HIT over the next two years. The $227 million balance will be used to train 15,000 in healthcare, IT and other high growth fields.

A physician posts an editorial in the Wall Street Journal, noting that the “problem with the technology is simple: Doctors and nurses use it to communicate with insurers, not with each other.” The doctor points out that  EHRs are designed to tell insurance companies that a physician fulfilled criteria to bill for a service but, that doesn’t translate into better care. He concludes:

If electronic records are only used to optimize billing and improve chart audits, patients will see little benefit. I doubt my patients received better care from the change.  Electronic records can only play a supporting role in a broader effort to change our troubled system. Until our health care system imagines patients as more than grist for billing, I will happily take my chances with a colleague’s inscrutable scrawl over a phone-book-sized stack of computer printouts.

The current issue of Infectious Diseases in Children asks if pediatricians are ready to go paperless — and then provides a number of solid nuggets to ponder, regardless of specialty. In addition to providing all the compelling reasons for an EMR, the article explores some of the possible challenges: poor implementation, high initial costs, lower income due to lower patient loads during transition, and adjusting workflow to accommodate the EHR. Despite the difficulties, longtime EHR users believe it’s a “huge error” to wait on industry change.

The Texas nurse who was fired and charged with “misuse of official information” for confidentially reporting concerns about a perpetually trouble-prone doctor to the state’s medical board is acquitted. The jury took less than an hour to dismiss the case, with the jury foreman saying, “We don’t feel that what she did was wrong because she had concern for the patients. Nurses are the eyes for the patient.” The nurse and a colleague who was fired over the same incident are now considering adding another claim to their lawsuit against the doctor, hospital, sheriff, and prosecutor: malicious prosecution. Reports are suggesting that the doctor not only peddled quack vitamins, but that perhaps also had previously hired as one of his salespeople the sheriff who went after the nurse.

E-mail Inga.

Intelligent Healthcare Information Integration 2/12/10

Of Mice and…Ducks

We recently left a long road behind us here in our little neck of the trenches. After years of what seemed like almost interminable “training,” one of my staff was caught adding a new network printer to her tablet PC — without any help!

Those of you reading this little saga are all pretty techno-hep and probably don’t think too terribly much of someone performing such a relatively minor and rather simple task. However, here it was celebrated with hoots and haws and all manner of revelry. You see, this was a signpost that we had left a years-long trail behind and were now embarking upon a different path — completely duck-free.

When we started our new, little high-tech, rural pediatric office back in 2006, I had a staff of three: a nurse, a receptionist, and a medical assistant. The receptionist knew just enough on the computer to be dangerous, my nurse didn’t even know how to turn a computer on (literally,) and, during one of our first group computer discussions, my M.A. asked if we would have to use a one of those “ducks, you know, those things you click” with our pen tablets.

We never ended up using any ducks, though we did enjoy a recurring chuckle over that comment. We did begin, from that day, a very long, slow path toward computer literacy which, at times, seemed almost interminable. It began with the basics.

One of the first tasks I assigned was quite simple: play solitaire. They were each given a pen tablet PC and told to take it home and practice playing simple games just to get the hang of using the pen or the TrackPoint. (We kept the focus off of ducks.)

That was a pretty fun way to start engaging their computing experience. Once they had some cursor awareness, we moved on into simple messaging using an in-house messaging system. E-mail was an easy extension from there and then we clicked right on into full-blown patient scheduling, sans paper and pen backup. So far, everything was just ducky.

Zoom ahead a bit on the time continuum and, after a few fits and failed starts with full-blown EHR usage, we became “paperless” and left our crumbled, old paper chart crutches for good. (I say that with only a momentary hesitation as, honestly, there are still days when I just want to grab a pen and scribble a couple of quick notes the old-fashioned way, committed geek though I am.)

Full EHR usage doesn’t mean we are free of performance struggles related to basic PC usage, just that I felt it was time we made the leap. Watching my nurse has, at times, been almost painful; she’s done pediatrics via pen and paper for 30 years. She is a sharp cookie, but PC-ing just doesn’t come naturally to her. She is never one to shrink from a challenge, though, so she continues to plug away. (She is the true salt of the earth and one of the greatest blessings of my life.)

Anyway, the other day I noticed she had a new printer in her “Devices and Printers” folder. I had recently upgraded an older printer, but I hadn’t yet had the chance to add it to her tablet. I asked our office manager (a PC-savvy youngster) if she had added that and she said my nurse had done it all by herself, without asking anyone! I looked over and saw my nurse grinning the biggest, proudest grin and I knew: we were officially beyond the era of the duck!

From the trenches…

“Not the cry, but the flight of the wild duck, leads the flock to fly and follow.” – Chinese proverb

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 2/12/10

From: Miss Lead “Re: NextGen acquisition. NextGen has acquired Opus Healthcare. Just announced internally.” Not officially confirmed via a formal press release but Mr. H verified with a solid source. Read more in HIStalk tomorrow. [Update from Inga: Yup, it’s true.]

NuHealth (NY) signs a $5 million contract with Allscripts to provide EHR, PM and ED solutions across its hospitals and employed physician networks. The health system will also establish data exchange between the Allscripts solutions and the hospitals’ Eclipsys Sunrise, Sunquest lab, and Amicus radiology systems.

Kaiser Permanente earns high satisfaction ratings for medical care and patient satisfaction, according to California’s Office of the Patient Advocate. The HMO attributes its high rankings in part to the use of EMR for tracking medical tests, making records available to all providers, and making information accessible via home computers.

The Senate is considering adding language to its current “Jobs Bill” that would allow some hospital-based physicians to receive ARRA subsidies. Current ARRA language excludes hospital-based physicians, much to the disappointment and anger of ER docs, pathologists, and physicians who practice in ambulatory facilities owned by hospitals. The proposed bill would still exclude subsidies for physicians who perform substantially all their services in an inpatient or ER setting, but, physicians who use ambulatory facilities owned by a hospital would become eligible. For details, see SEC. 620 under EHR CLARIFICATION.

Sequel Systems becomes the latest EHR vendor to “guarantee” its solution will be fully compliant with meaningful use certification criteria. The company says it will credit customers their monthly support fees during any period in which software modifications are  required in order to meet certification criteria. I’m looking forward to seeing how all these guarantees work out. How many providers are going to end up blaming their software vendor when they’re unable to use EHR in a “meaningful” way because the system slows them down too much?

Saint Vincent Catholic Medical Centers (NY) announce layoffs for 32 doctors as of the end of February. The physicians are specialists in ophthalmology, pathology, and neurology and the financially struggling hospital says they may be forced to shut down those departments completely. The hospital is losing money and heavily in debt. The biggest creditor is GE Capital, which is owed $300 million.

McKesson releases a new version of its Lytec MD EHR.The release includes Bright Note Technology, which I checked out at MGMA and thought was pretty slick. There’s also a Lytec Connect feature that leverages RelayHealth technology to provide secure communication between caregivers.

I have been periodically taking a look at the public comments on the latest Interim Final Rules. Some are quite specific, provide logical arguments, and are likely beneficial to all participating in the process to develop the Final Final Rules. For example:

In our 12 doctor Urology practice, we have been enthusiastic E-prescribers since we implemented our EMR almost 2 years ago. Virtually all of our prescriptions are now generated electronically, but not all of them are transmitted to the pharmacy electronically. there are several valid reasons for this:
1. The patient may request a paper copy of the prescription that he can send to a mail order pharmacy or PBM, which are currently not able to receive electronic prescriptions, at least from our EMR.
2. The patient may be given drug samples at the time of an office visit along with a printed Rx. This allows the patient to determine whether he or she can tolerate the drug prior to getting the prescription filled. Since it is not certain that the patient will be filling the Rx, it seems inappropriate to send an electronic Rx to the pharmacy in this scenario.
3. Some patients simply prefer a printed Rx. They may not have a regular pharmacy and may not know for sure where they want to fill the Rx. Also, for some patients, I think it helps them to have a physical reminder to go to the pharmacy.
Arguably a printed Rx generated by an EMR is just as legible an an electronically submitted Rx, and is also subject to the same decision support. Therefore I would suggest that the E-prescribing requirement should be modified in one of 2 ways – either allow providers to count electronically generated printed prescriptions as E-prescriptions, or lower the threshold for electronic transmission of prescriptions to something like 50%.

Some of the comments don’t necessarily offer solutions, but none-the-less provide useful insights about providers’ concerns:

Met this week with providers in the community and discussed timeframes for purchasing systems to meet meaningful use. The consensus was to hold off for at least 6 months. One factor was uncertainty created because there are no certified systems. Perhaps you should have grandfathered CCHIT certification to keep this moving. Another factor was dissatisfaction and discontinued use of the technology because of poor usability, reliability and impact to the providers productivity. Vendors need to substantiate required training time for providers and staff and disclose average time needed for the provider to become proficient. Regarding reliability would like mandated uptime guarantees and service level agreements that address timeliness of issue resolution with substantial penalties as standard contract language. Lastly some providers have home-grown systems that are innovative. With regulation defining meaningful and certified, these system may no longer exist. Would like to see exceptions for privately developed systems, i.e. non-commercial, to become acceptable in some manner without cost. I do not have the solutions on this but the concern is that commercial vendors will prioritize to meaningful use and innovations in technology for patient care may be precluded.

And, there are the ones that I would simply categorize as rants:

NOW THAT I’VE READ THE MEANINGFUL USE DEFINITION (25 STANDARDS / OBJECTIVES) THAT WAS RECENTLY PUBLISHED, IT SEEMS LIKE THE GOVERNMENT PULLED A FAST ONE (AGAIN) BY GETTING EVERONE EXCITED ABOUT THE OPPORTUNITY TO RECEIVE SIGNIFIANT DOLLARS TO PAY FOR THE IMPLEMENTATION OF EMR ONLY TO PULL THE RUG OUT FROM MANY PROVIDERS. WHY IS IT THE PROVIDERS WHO ALWAYS TAKE IT ON THE CHIN? WHY IS IT NOT THE EMR VENORS AND HIGHLY PAID CONSULTANTS, WHO HELP IMPLEMENT THE EMR PRODUCTS, BE HELD ACCOUNTABLE TO THE PROVIDERS WHO TOOK THE STEPS TO IMPLEMENT EMR BUT DID NOT KNOW THE CRITERIA THEY WOULD BE HELD ACCOUNTABLE TO UNTIL AFTER IT WAS TOO LATE. IT’S LIKE THE OLD ADAGE, READY FIRE AND SEE IF YOU HIT ANYTHING. TO INSIST THAT PROVIDERS ARE 100% COMPLIANT WITH THESE 25 STANDARDS 80 % OR WHATEVER THE CRITERIA IS FOR EACH OBJECTIVE IS NOT FAIR. IF PROVIDERS WOULD HAVE HAD THE CRITERIA WHEN THEY DESIGNED AND IMPLEMENTED THEIR WORKFLOWS, IT WOULD HAVE BEEN A MORE LEVEL PLAYING FIELD. I’M SUGGESTING THAT SOME CONSIDERATION BE GIVEN TO THOSE PROVIDERS WHO ALREADY IMPLEMENTED THEIR SYSTEMS AND ARE NOW STRUGGLING TO MODIFY SOME OF THEIR WORKFLOWS IN ORDER TO MEET THE NEWLY PUBLIZED MEANINGFUL USE CRITERIA. ALL THE VENDERS AND CONSULTANTS CARED ABOUT IS IMPLEMENTING BASED ON HOW THE PROVIDER WANTED TO OPERATE THEIR OFFICE AND NOT ACCORDING TO WHAT IS NOW NECESSARY IN ORDER TO MEET THE MEANINGFUL USE CRITERIA.

Best of luck Dr. Blumenthal.

E-mail Inga.

News 2/9/10

Sage Healthcare COO Lindy Benton resigned last week, days before Betty Otter-Nickerson is scheduled to start as CEO. Sage’s John Schoutsen shared this note with us: “Lindy has chosen to leave Sage and to pursue new opportunities. Lindy felt it would be best for Betty to start fresh and form her own, independent views of the business. We’re thankful for Lindy’s contributions while here and looking forward to Betty’s leadership.”

Self Regional Healthcare (SC) selects Allscripts EHR and PM for its 59 employed physicians. Self will also offer Allscripts as the preferred solution for its 200 affiliated physicians.

An Epocrates survey finds that 20% of doctors say they’ll be buying an iPad within a year, good news for the company since it has already committed to creating an iPad version of its drug information software.

Would you please help a gal out and complete our first ever HIStalk Practice Reader Survey? It will take but two minutes of your time and will help us with planning for the next year. We promise to read every single comment you take the time to write and will use the input to make sure we are providing readers the most valuable content. Many thanks.

I think I failed to mention this earlier, but HIStalk Practice had a record month in January. The number of visits doubled from a year ago and the e-mail subscriber count keeps going up. Which reminds me: please sign up for the e-mail updates (top right) so you never miss a thing. And if you are interested in joining the great list of sponsors to your left, let me know.

I’m not sure the world needs another EHR option, but new program is making its debut nonetheless. SharEHR is a SaaS solution that allows users to upload files or scanned paper and converts them to a PDF format. Documents can be shared, sorted, and searched. Actually, I wouldn’t really call it an EHR if that all it does. Surely no buyer would think a product like this offers enough to qualify for meaningful use, right?

Ingram Micro and NextGen Healthcare form a new distribution relationship that gives Ingram the right to recruit, train, and support new partners to provide NextGen solutions.

Four Michigan medical practices select mPay Gateway to provide point-of-care patient payment processing.

Federal Chief Technology Officer Aneesh Chopra announces the Text4Baby messaging service. The free service is supported by a public-private partnership, including most major wireless carriers. To join Text4Baby, an expectant mother only needs to text "baby," or "bebe" in Spanish, to 511411. Subscribers will get three text messages each week at no charge on content timed to a baby’s due date or date of birth and focused on a variety of topics.

Ascension Health becomes the first health system to agree to offer American Well’s Online Care to its patients. Using a phone or via the Web, patients will be able to connect with clinicians affiliated with Health Ministries of Ascension Health.

Dr. David Blumenthal says that he wants to “stretch” the healthcare community to qualify for financial incentives for health IT use, but not “break” the community. The national health IT coordinator also believes that health information management will become a core 21st century professional competency. Blumenthal, by the way, is one of the keynote speakers at HIMSS. Mr. H also invited him to our HIStalk party. If he no-shows, then I definitely plan to no-show his keynote.

Speaking of HIMSS, a couple of people supposedly in the know say that registrations for physicians and their administrative staff are up this year. ARRA-related concerns are behind the increase. I’ve asked the HIMSS folks to verify this and they said they’ll provide some specifics later in the week.

The Roaring Fork Valley Physicians IPA (CO) settles with the FTC on charges of price fixing. The 80-member IPA was accused of anticompetitive negotiating tactics against health insurers by orchestrating agreements to set higher prices and refusing to deal with insurers that didn’t meet its demands for higher rates. The settlement requires doctors to terminate any contracts with insurers reached using the price-fixing tactics. No mention of any more serious hand slapping, so maybe the IPA got off easy.

A telemedicine program at Massachusetts General is improving communications between attending physicians and ICU staff and helping doctors manager PICU patients round-the-clock. On-call attending physicians can examine patients from home and communicate with on-site staff using real-time video conferencing and robotic gear that includes digital cameras and medical scopes attached to patient beds.

A Texas hospital uses a “speed dating” model to match physicians and patients. The Doc Shop program at Texas Health HEB allows patients to spend 30 minutes talking to five or six doctors to find one that best meets the needs of the patient. The model also provides an unusual way for doctors to market and build their practices, sans the shadchan.

E-mail Inga.

Intelligent Healthcare Information Integration 2/5/10

In Defense of Tablets

The good DrLyle recently sent a submission to these hallowed pages in which he stated, “…it is well known that the general idea of using a tablet in healthcare has tried and failed multiple times.” Hmmm…

Now, this isn’t the first I’ve heard of people poo-pooing the pen tablet as less than functionally desirable for doctoring duties. But, it inspired me to offer a defense of our little PT pals, a form factor which works in our office every single day.

Maybe having a desktop PC in every exam room works in an internist’s office, but when I see what the children do (and what the parents let them do) to our beautiful office space every, single day …Hoo Boy! I simply can’t imagine the condition of exam room PCs nor the cost of repair and replacement over time. We have video monitors in recessed wall boxes behind protective Plexiglas panels in each room for patient educational and PR purposes; even those have been pried into. The images of spilled goo and repeated poundings that a desktop would take in an exam room, if unattended by a staffer for even a few minutes, makes me shudder.

Currently, we use Lenovo X200 convertible pen tablets. They fly with Windows 7 and their battery life is much better than the Lenovo X41s we used previously. (Our EHR isn’t completely compatible with Windows 7/IE8, but the speed gain is worth the few glitches or inaccessible items. Besides, compatibility will be full-blown soon and we have a few XP machines around to access those items when infrequently necessary.) We often use them more as laptops than tablets; most of us prefer the regular keyboard and TrackPoint to the onscreen keyboard and pen. Still, the flexibility is there and we do employ all the different configurations at various times.

I haven’t yet seen a data input device — short of a scribe — that works as well as the old pen and paper in a busy, noisy pediatric office. Tablet pens, mice, TrackPoints, voice recognition, trackballs, regular or on-screen keyboards, handwriting recognition — all have their workflow problems. But the TrackPoint and keyboard combination, in our regular day-to-day chaos, works pretty well for us. Voice recognition is becoming a second choice away from the noisy hubbub, though I am admittedly slow getting going with it. (No excuse… just one of those cool things that keeps getting put off while life pressures edge it from the top of my To Do pile.)

It isn’t perfect, our little pen tablet arrangement. But, desktops wouldn’t be either, at least in our world. Plus, we never have an issue with turning our backs upon our patients to address the PC, something a desktop might require and which could sometimes be dangerous with our “rambunctious” clientele.

For now, I stand by — and with — our pen tablets.

From the trenches…

“I know that you believe you understand what you think I said, but I’m not sure you realize that what you heard is not what I meant.” – Robert McCloskey

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.