Joel Diamond 1/6/10

On Meaningful Use

“The word ‘meaningful’ when used today is nearly always meaningless.” -Paul Johnson

Seems like everyone today is searching for a meaningful experience. Everything from bowel movements to watching a television series needs to be “meaningful”. It should therefore come as no surprise that the meaningful adoption of HIT should also be debated so passionately.

I just plowed through the 500+ page Department of Health and Human Services Electronic Health Record Incentive Program that is intended to define meaningful use and found the exercise to be quite… meaningful.

I know that many of you are cynical about the topic, but think about it. It really makes sense. The government just can’t rationalize massive financial payouts without a precise measure of benefit. OK, I guess there are a few exceptions… Wall Street financial firms for one, but never mind that… and oh yeah, I guess the pharmaceutical industry essentially getting a blank check from Medicare, but ignore that too. It only makes things more confusing.

In Sections 1848 (o)(2)(A) and 1886(n)(3) of the Act, the Congress specified three types of requirements for meaningful use: (1) use of certified EHR technology in a meaningful manner (for example, electronic prescribing); (2) that the certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of care; and (3) that, in using certified EHR technology, the provider submits to the Secretary information on clinical quality measures and such other measures selected by the Secretary.

Now we’re talking! I provide quality care. I use a certified EMR. I’m connected. I just need to periodically send stuff to the Secretary and the cash comes rolling in. (I admit that I’m a bit confused by the “other measures” thing, but I doubt that it’s that important.)

To the uneducated public, the goals and requirements sure seem to be a dose of good old-fashioned common sense. For instance, everyone wants their doctor to “provide summaries for patients for each office visit”. And who couldn’t be moved by this:

“Meaningful use of certified EHR technology should result in health care that is patient-centered, evidence-based, prevention-oriented, efficient, and equitable.”

Sounds lofty, but try substituting a word like “nursing” for “certified EHR technology” in the above quote and you’ll quickly realize why trying to regulate the obvious becomes inane.

Therein lies the problem. Many of the requirements either set the bar too low or seem to be an obvious functionality of EMRs. These include: “maintaining an active medication and allergy list”, or having a chart with demographics and basic vital signs recorded.

Provisions for decision support and information exchange, on the other hand, are worthwhile pursuits, but may be more difficult to achieve.

The CPOE requirements will have minimal impact. Bigger hospitals will figure out how to meet the measly 10% CPOE requirements by mandating use for house staff or emergency departments.

This is my biggest concern about the proposed measures. Much like the current E/M coding nightmare, insane attempts to limit “gaming the system” only serve to create a whole cottage industry devoted to — gaming the system!

I can’t help wondering when the real incentives will occur — that is, when a free-market public, confronted with a transparent medical system, will be allowed to make choices based on “meaningful value”.

In the mean time, I’ll try to get all that I can.

To paraphrase Dudley Moore: “I’m always looking for meaningful one-night stands”.

Joel Diamond, MD is chief medical officer at dbMotion, adjunct associate professor at the Department of Biomedical Informatics at the University of Pittsburgh, and a practicing physician at UPMC and of the Handelsman Family Practice in Pittsburgh, PA. He also blogs on interoperability.

News 1/6/10

HERtalk by Inga

In yesterday’s HIStalk Practice I touched on a few nuggets of information about the latest EHR meaningful use recommendations. I might add it is worth a read because there are some points Mr. H and I haven’t seen covered elsewhere. (And while you are there, sign up for the email updates.) One particularly confusing item relates to the timeline for proving meaningful EHR use in order to earn incentive dollars. I tried to summarize a bit on the timeline for getting money, but because it is particularly confusing, I decided a graphic might help. For those that want to follow along at home, this information is found around pages 23 to 31 in the larger, 557-page document. As I interpret things, to qualify for stimulus money during 2011, a hospital or eligible provider (EP) must demonstrate meaningful use of EHR for “any 90-day period within the first payment year.” The earliest possible start date for that 90 day reporting reporting will likely be January 1, 2011. And, the latest day to start a 90-day reporting period and still qualify for 2011 monies is October 1, 2011. After earning incentive money in the first year, entities will be required to prove meaningful EHR use for a full year, starting on January 1, in order to qualify for second year funds. Thus, if an entity qualified any time during 2011, it would have to continue to prove it used its EHR meaningfully from January 1, 2012 to December 31, 2012 in order to qualify for the 2012 incentive funds. And, if the entity doesn’t try to qualify for the first time until sometime in 2012, then it must prove meaningful use for the full year beginning January 1, 2013, to get the second year funds. And so forth. If someone interpreted things differently (or can explain this better), please advise.

athenahealth signs a deal with Caritas Christi Health Care to provide EHR for its 500 employed providers. Caritas, which already uses athenahealth’s RCM service, will also offer athenaclinicals to 1,200 affiliated providers. Caritas also offers its physicians an option for eClinicalworks. Todd Rothenhaus, MD, the CIO for Caritas confirmed with me that Caritas now plan to offer both products.

I was talking EMR with a girlfriend at lunch today (isn’t that what most gal pals do?) and we agreed that we can’t think of any providers that currently enter 80% of their orders themselves. If we thought hard enough we’d probably have come up with a doctor that uses e-prescribing 75% of the time (but we thought of lots of reasons why a patient and provider might prefer the paper prescription.) And, we couldn’t come up with a single small office group that is currently capable of sending patient data electronically to other providers (often times because the receiver can’t accept the data.) The one bright spot is that the recommendations clearly state that “documenting a progress note for each encounter” is not a requirement for proving meaningful use. Otherwise, the mountain is high.

QuadraMed names Thomas J. Dunn senior VP of sales and marketing. Dunn’s a former Eclipsys VP and spent 22 years at SMS/Siemens.

Ridiculously sad, any way you look at it. An unemployed, unmarried 35-year-old mother of nine sues three doctors and two nurses, after she was permanently sterilized against her will. The mom was delivering baby number nine via a planned c-section and and asked for an IUD to be implanted immediately after delivery. Instead, the doctors performed a tubal ligation.

Cerner lands a couple of big deals with Tenet Healthcare and Universal Health Services. Tenet plans to add Cerner applications in 33 new hospitals, bringing the total Tenet/Cerner shops to 47. Universal will take advantage of Cerner’s remote hosting capabilities to implement the product across 24 acute-care hospitals.

Trinity Health (MI) buys 1,200 bundled EHR/EPM software licenses from NextGen. Trinity purchased 400 licenses in 2006 for some of its employed providers but now plans to roll the software out to all employed providers in its network.

Happy 2010, by the way. The ever-generous Mr. H gave me a bit of time off during the holidays, but now I am back at it. Mr. H and I have each waded through pieces of the latest meaningful use documents, in hopes of becoming industry experts. Unfortunately, at least in my case, more wading is required. I was hoping there might be some clarification about what exactly a “certified EHR technology” is. Of course “CCHIT” is never mentioned anywhere, even though it seems a given that CCHIT will be a requirement since they are the only certifying body out there. Why can’t the Secretary or the ONC come right out and say it’s CCHIT 200x for now. That way buyers know what is required and vendors know what they need to do if they want to participate.

Send Inga meaningful words.

News 1/05/10

From H&R Block: “Re: meaningful use. Heard a peer say the following about ARRA: ‘I didn’t decide to have kids because there was a tax break. I’ll take the one they give, but its not the reason to have kids.’” I’ll say this for the tax code: you don’t need to hire an accountant to help you figure out if you have dependents. On the other hand, after a few hours trying to weed through several hundred pages of the meaningful use guidelines, I’m buying stock in consulting companies. But to H&R Block’s point, I’m not sure how many physicians are going to move to an EMR solely to get some cash from the government. The average physician or office manager will need assistance figuring out the requirements. Even using the most sophisticated software, the requirements are no slam dunk and the upfront costs remain high. If I were a vendor, I would get busy developing an alternate talk-track that encourages EMR adoption for reasons other than just qualifying for ARRA dollars.

If only it were this easy. EMR vendor Waiting Room Solutions announces that Ohio Pain Center selects its EMR/PM solution, which it claims “will qualify” the practice “to collect PQRI and ARRA EMR Stimulus incentive monies.” I hope someone has told the clinic to check out CCHIT’s website that says Waiting Room Solutions product “has not been tested against the applicable proposed Federal standards in existence on the date of certification for certified EHR technology of its type under the American Recovery and Reinvestment Act of 2009 (ARRA).” Then, perhaps the doctor might want to read through the meaningful use guidelines.

By the way, the latest proposed rules defer the final definition of “certified EHR technology” until ONC’s upcoming interim final rule. The recommendations do indicate that a “certified EHR technology” is a qualified EHR certified as meeting standards defined by the Secretary. Included are a couple of examples of technology that would NOT meet the definition of a certified technology, including a “complete EHR” that hasn’t been “tested and certified in accordance with the certification program established by the National Coordinator, even though it may be claimed that such technology provides the same capabilities as those required by adopted certification criteria.” The key here is we still don’t have a definitive answer as to which “certification programs” (or certifying bodies) are valid. We have to assume CCHIT certification is valid, since it’s really the only player today, but it does leave the door open for other options.  My prediction is that if a product is not CCHIT-certified (probably at least a 2008 level or higher) then it will be tough to qualify for funds.

Last week, Mr. H provided a great overall summary of the ONCHIT preliminary meaningful use definitions (the Excel version is here), and followed up with some overall impressions a couple days later. Much of the 700 pages is redundant, but here are a few additional nuggets of information that focus particularly on eligible professionals (EPs).

Timing of incentive payments

Payment timing varies depending on the EHR incentive program in which the EP is participating (Medicare FFS or Medicaid) or if it is a hospital. Under the Medicare plan, first-year payment qualification requires the EP to meaningfully use an EHR for any continuous 90 days within the payment year. In subsequent years, meaningful use is required for the full payment year. The final dates related to payment timing are not yet defined, but the earliest possible 90-day period could begin July 1, 2010, which is 90 days before the start of the government’s FY 2011 (October 1, 2010). The latest possible date to start the 90-day period and qualify for 2011 payment would be October 1, 2011, which is 90 days before CY 2011. The committee’s recommendation is to set October 1, 2010 as the start date for the initial EHR reporting period, which means qualification (and payment) could come as early as January 1, 2011.

Amount of incentive payments

This chart isn’t new, but it does reiterate the need for an EP to reach meaningful use during 2012 if he/she wants to earn the most incentive dollars. Using the proposed timetable listed above, EPs must start the 90-day period proving  Stage 1 meaningful use no later than October 1, 2012.

EPs can opt to be in the Medicaid incentive program, which pays a maximum of $63,750, if at least 30% of his/her patient volume is Medicaid. EPs have the option to make a one-time switch between programs (though the total incentive amount cannot exceed the Medicaid cap). One of the nice things about the Medicaid program (aside that it offers more money) is that you can wait until 2016 to start the certification process and still receive the maximum $63,750.

How to get the money

It’s unlikely HHS will be ready to electronically accept data on clinical quality measures for the 2011 payment year (ironically). Thus, EPs will likely be required to “attest” to its meaningful use of an EHR in order to qualify for funds. By 2012, an EP will electronically submit the summary information on the selected quality measures. Look for compliance reviews to validate provider eligibility and meaningful use assertions.

Assigning money to an employer or other entity

EPs can reassign incentive payments to an employer or entity with which the physician has a valid employment arrangement, though an EP can’t assign payment to more than one employer or entity. Not addressed (that I noticed) was if an EP could assign a portion of the incentive money to a hospital that was not his/her employer. That might be something attractive for hospitals interested in subsidizing upfront EHR costs via Stark legislation.

The MGMA says that the proposed EHR incentive program rules are too complex and that medical groups will confront significant challenges to meet the program requirements. “Overly burdensome requirements and needlessly complex administration will only discourage physician participation in the program and implementation of EHRs,” says MGMA president and CEO William F. Jesse, MD.  Meanwhile, HIMSS releases a statement saying the proposals offer more that should be applauded than criticized, and provides clarity of what technology functions constitute a qualified electronic health record. I think I am with Jesse on this one.

Nuance Communications releases the results of a 1,000-physician survey about the incentive plan. Apparently the majority of providers think there’s too much emphasis on data capture and quantitative measures rather than the capture of qualitative information that tells each patient’s unique health history (keep in mind that Nuance sells voice dictation products like Dragon Naturally Speaking). Less than 10% of the physicians said they were confident / very confident that the government’s current HIT measures would result in higher quality patient health records.

More negative opinions from physicians on EMR: the 2009 Physician Pulse Report concludes that physicians are increasingly dissatisfied with EMRs, which they find time-consuming and possibly compromising patient safety.

athenahealth signs a deal with Caritas Christi Health Care to provide EHR for its 500 employed providers. Caritas, which already uses athenahealth’s RCM service, will also offer athenaclinicals to 1,200 affiliated providers.

Happy New Year, by the way!

E-mail Inga.

Intelligent Healthcare Information Integration 1/3/10

Connectiquette

Recently, certain aspects of human interaction related to physicians and/or IT folks inspired some observations on my part (some might call them “rantings.”) As I always hate bemoaning entropy without bespeaking ectropy, I hereby humbly offer up, for your conscientious consideration:

Connectiquette: 11 Rules for an Extropic Future

1. NEVER text and drive. No, you’re not that talented, you’re not that good of a driver, and it won’t “just take a second.”
2. Always remember that the live bodies in your presence are more important, and deserve your attention more, than any distant Tweeter, texter, or avatar.
3. Look at people when you talk with them. While viewing a screen or keyboard, the top of your head is what you present to your patient, client, staff member, mother, etc. Do you really want them to consider your scalp and follicles as the windows to your soul?
4. Looking at the eyes of someone can always tell you far more than viewing their typographical output.
5. If new technology causes new workflow patterns to disrupt your interactions with the “organics” around you, get different technology – OR – adapt your workflow to re-enable your connectedness.
6. Until further notice, carbon / carbon-based interpersonal skills should remain pre-eminent to those required for carbon / silicon-based relationships as well as any carbon / silicon / carbon intercourse, in whatever form.
7. Courtesy still conveys consideration across any connection. Just because someone can’t lay eyes upon you doesn’t mean they can’t see how inconsiderate you are.
8. Patients, clients, customers, co-workers, even friends and family — all prefer being treated “Goldenly.” Do you want others to attend to you as you have been attending them?
9. “Service” and “support,” just like the “care” in “healthcare,” have real definitions. Look them up.
10. “Electronic” does not equal “better.” Some “old” skills and solutions will long outlast the latest, greatest, “better mousetrap.”
11. People are still susceptible to faddism; just because something is Web-based doesn’t mean it’s sanctified, certified, or even smart. Discernment and healthy skepticism are more valuable now than ever.

No, I’m not able to cast the first stone, as I have been just as much a digital sinner as anyone. However, I am repentant and searching for a walk nearer to thee, er, I mean, you … and to all the flesh and blood people in my day to day encounters.

Therefore, I promise: next time we’re out to dinner, I’ll keep my snout out of my smartphone and hope you’ll offer me the same Aretha. (R-E-S-P-E-C-T)

From the trenches…

“Respect is love in plain clothes.” – Frankie Byrne

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 throughhttp://madisonpediatric.com or doc@madisonpediatric.com.

News 12/31/09

From DrLyle: “Re: Dr. Zurhellen interview.Great interview with this doc. Where do you find these guys??? More and more of us are saying what Dr. Zurhellen laid out in one simple sentence: ‘get a single data structure and let vendors compete on the user interface.’ When will the government start listening to this philosophy (increasingly called the ‘iPhone approach)?’” Here is a link to the interview, in case you missed it. Dr. Zurhellen is a pediatrician who wrote his own EMR and is a CCHIT expert panel member. He’s a straight shooter who shared his frank impressions on EMRs, CCHIT, and standardization. As to how we find these great interview subjects, most are recommended by readers. By the way, DrLyle shares some musings on the need for an iPhone-like interface here.

CMS and the ONC release the much anticipated “meaningful use” definitions and other details related to the EHR incentive program, including its final rule for the initial set of standards, implementation specifications, and certification criteria for EHRs. An HIStalk summary is here. Download your version of the 556-page document here and hunker down for a good read. Stay tuned for more on HIStalk and HIStalk Practice over the coming days and weeks.

A study supported by the Commonwealth Fund concludes that EHRs are not adequately improving the coordination of care. Today’s current ambulatory EHRs facilitate care coordination within a practice, making information available at the point of care, but, are less helpful for exchanging information across physician practices and care settings. From one of the study’s co-authors: "There’s a real disconnect between policy makers’ expectations that current commercial electronic medical records can improve care coordination and physicians’ experiences with EMRs.” The study also warns that simply creating incentives to adopt EMRs as they currently exist may result in EMRs being designed for billing purposes primarily, rather than for clinical relevance to patients and care coordination.

In the UK, a three-year-old boy is denied treatment for tonsillitis because the father did not know the boy’s NHS number. The father took the child to a clinic where he was not a regular patient, only to be told his son could not be treated without the proper credentials. Over the weekend, the father called the NHS hotline, who advised against taking the child to the ER. Eventually the father found the card and the boy got treatment when the clinic reopened on Monday. I wonder if this was a single bad incident or a regular occurrence in the UK. In any case, it doesn’t sound much better what we’d offer the family (a long wait in a crowded ER.)

I bet this doesn’t happen enough. Methodist Sugar Land Hospital (TX) hosts a holiday luncheon in honor of the “unsung heroes” of medicine – office managers, PAs, NPs, MAs, and other professionals in physician offices.

Greenway Medical rolls out its PrimeSuite EHR, PM, and interoperability product to Bethesda Healthcare System (FL). So far 12 providers are operational and 550 more have the option to get on board.

Self-pay patients and physicians now have a new online tool to connect with one another. Patients needing a particular service can access the MediBid patient portal  and describe the services required. Interested physicians can then bid for the patients’ care on a case-by-case basis. The doctors set their own price, don’t have a “middle-man,” aka, insurance companies, and can selectively pick patients that “enhance” their practice.

A somewhat related trend: patients bypassing the doctor and going directly to the source for diagnostic tests. Storefront testing centers are popping up to provide screenings for STDs, cholesterol levels, wellness panels, and more. Any Lab Test Now operates 95 centers that offer 1,500 different tests and plans to open 200 more franchises in 2010. Most patients pay for the tests out of pocket.

A Texas woman sues Maybelline, L’Oreal, and Walgreen’s after their line of lip gloss caused her to go to have a severe allergic reaction and go into anaphylactic shock. The woman’s attorney claims that the defendants failed to identify the ingredients used to manufacture the products, which violated governmental guidelines applicable to the sale of “cosmetic devices.”

I’m glad to report I am back to civilization after a week in the backwoods. And excited to have a reunion with my combed Egyptian cotton sheets.

New Year’s Wishes Here