Joel Diamond 11/26/09

Thanksgiving Edition

"When it comes to life the critical thing is whether you take things for granted or take them with gratitude.”-G.K. Chesterton

Back in the day, I used to moonlight in my local Emergency Department on Thanksgiving and Christmas. It was nice to hear both patients and staff compliment me on my dedication. Some would be a bit more realistic but equally sympathetic for my willingness to “give your Christian friends a break on the holiday”.

For me, it allowed me to — I need to be careful as my in-laws sometimes read this blog — extricate myself guilt-free from an otherwise wonderful family experience, “Isn’t it nice how he gives his Christian friends a break on the holidays”. The real truth is that the emergency department was relatively quiet and I got paid time and a half.

Ahh… the holidays. The memories linger in one’s mind as if they were yesterday. While most of you think about overeating followed by loosened belts in a tryptophan-induced stupor, I think of arriving to my ER shift having three patients waiting with a turkey bolus stuck in their esophagus. Sometimes administration of IV glucagon worked, but oftentimes I would have to rouse one of the gastroenterologists away from their own family gatherings to relieve the gluttonous patient endoscopically.

Who amongst up doesn’t invoke emotional images of Native Americans sharing their bounties with Pilgrims when they think of beer and the deep-fried turkey? I think of 2nd and 3rd degree burns. And I wipe the tears from my face recalling the Norman Rockwellish scene of an entire family during the holidays, all hooked up to IV fluids and festively filling emesis basins as a result of and undercooked meal and resultant food poisoning.

My shift almost always concluded with some alcohol-induced injury. Drunk and alone on the holidays. This is when you begin to re-examine your own sense of Thanksgiving. All joking aside, working in healthcare during the holidays is a privilege, as it is easy to take for granted all that we are blessed with — food, shelter, family, friends, and health.

Want to really be depressed? Walk through a hospital cafeteria this season. The juxtaposition of holiday decorations and music with the sad and lonely faces of the sick or their visitors is heart-wrenching. Even worse is seeing the half-eaten trays of dying patients. The hospital dietary service’s best attempt to render turkey, mashed potatoes, and canned peas as festive somehow compounds the tragedy in horrific irony.

Today I delivered some bad news to a longstanding patient. After many years of surviving a battle with a second cancer, she had to hear from me that she had yet another malignancy. This is another year that I had to deliver bad news before the holidays. Ethics aside, I sometimes wonder if it would just make more sense to hold off and let them peacefully enjoy Thanksgiving with their families before throwing their lives into turmoil.

I know that this is not a “funny” blog today, but since we are all in the business of healthcare, let us — during this tumultuous year of recession, debate on healthcare reform , global warming, war, and swine flu — take pause and reflect that we are really in the industry of healing.

"Thanksgiving, after all, is a word of action."-W.J. Cameron

 

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 11/24/09

The MGMA sends a letter to David Blumenthal, noting concerns that an inappropriate definition of meaningful use and an ineffective administration of ARRA stimulus funds could result in a failed implementation of ARRA, needless squandering of resources and significant disruption of the health system. MGMA offered several specific recommendations, including instituting a pilot test prior to the start of the program to ensure that the process of demonstrating meaningful use is achievable and practical. The letter also encourages the National Coordinator’s office to monitor the EHR marketplace for cost-effective and efficient products and to ensure fair business practices. To William Jessee and staff: well-done. MGMA is voicing valid concerns that highlight the many gaps in ARRA legislation, and offers logical recommendations. We absolutely need the meaningful use requirements to be achievable and applicable. And, why not do some testing in advance to make sure that HHS, vendors and providers all agree what meaningful use looks like. I am not sure how necessary it is to have the government provide vendor oversight; I mean, if a vendor doesn’t have a product that works, won’t market forces address that?  Still, MGMA did a good job addressing what are likely major concerns of its members.

The House passes a $10 billion loan program to help doctors and small medical practices purchase EMR and other HIT systems. The bill would allow loans of up to $350,000 per physician and $2.5 million for group practices. The bill has now moved on to the Senate.

The emergency physician group at Thibodaux Regional Medical Center (LA) selects PracticeMax to provide paperless coding services. The process requires the ED department scan and upload clinical documentation and patient demographic data, which is then coded by PracticeMax.

Gateway EDI’s plans to increase its employees from 250 to 310 and expand its St. Louis headquarters. The $38 million company grew 35% last year.

MedAptus announces that its system for capturing professional charges is available for BlackBerry smartphones and coming next year for the iPhone.

The 21-provider Golden Valley Medical Center (MO) signs an agreement with InteGreat to deploy InteGreat EHR.

Precision Information Management  Services announces it will offer an ASP version of the Allscripts Ophthalmology EHR Pro and PM software.

Similarly, MedLink International says it will provide a SaaS option for its MedLink TotalOffice EHR.

KLAS says its making its performance evaluations shorter, based on feedback from providers and vendors. KLAS will also begin grouping questions on software into four main categories. The goal of the changes is to eliminate redundancy and focus on questions that best differentiate vendors.

Patients with chronic wounds can now stay at home and still receive treatment remotely from certified wound care specialists. Wound Technology Network and AT&T are partnering to provide clinical staff with smart mobile devices that support videoconferencing tools. When providers are at a patient’s home, the device will allow staff to connect with Wound Technology Network’s tele-health center to help them assess and treat the wound. Clinical staff can also transmit a image for upload into an EMR.

Elsevier announces its ‘All You Need to Make A Difference’ Donation Campaign, which benefits the volunteer physicians at Doctors Without Borders. The campaign provides Doctors Without Borders a free subscription to MD Consult subscription for each paid subscription received through December 18th. Elsevier estimates the campaign could provide as many as 400 subscriptions worth $140,000. If I am interpreting this right, it also could add 400 subscriptions and $140,000 in sales revenue for Elsevier. Is it cynical to feel Elsevier is somewhat exploiting the Doctors Without Borders name in order to boost end of year sales?

More consolidation in the billing service world, with Intermedix acquiring the assets of Texas ER Medical Billing. Intermedix’s EPBS division, as well as Texas ER Medical Billing, provide RCM services for ER physicians.

Office Ally, a clearinghouse providing free claims processing, receives full accreditation from EHNAC.

Now that physicians have the opportunity to earn federal stimulus funds, some hospitals are reconsidering plans for offering subsidies under the relaxed Stark laws. The AMA looks at various hospital programs offering partial to full subsidies, despite the potential for stimulus money. Meanwhile, some hospitals that had not yet offered formal subsidy plans are re-considering their alternatives. Here’s some logical advice: don’t jump into cheapest option without making sure it meets the practice’s needs and has the necessary tools to meet meaningful use criteria.

Inga wants mail.

News 11/18/09

A KLAS report takes a look at Allscripts a year after its merger with Misys. KLAS surveyed 200 Allscripts clients and found declining customer satisfaction in several key areas. The release of v.11 created challenges, though clients on versions 11.1.5 or higher are seeing positive results. About 85% of Misys EMR users who plan to replace their EMR say they’ll go with Allscripts Professional EHR, which is being offered at a relatively low migration price. KLAS notes that Allscripts also remains the “most-considered” vendor in outpatient EMR purchases. In yesterday’s HIStalk I make a somewhat snarky remark about the “most-considered” stat, but a reader pointed out that this particular metric is indeed valuable because it indicates which vendor is getting the “most looks, most RFP’s and most demos” and thus is in the running for more sales.

Meanwhile, Forbes has a nice write-up on Allscripts iPhone app, Allscripts Remote, which gives physicians real-time access to patient data, fast communication with ERs, and the ability to e-prescribe (the article says “e-mail prescriptions,” but I am assuming the author meant e-rx.) Allscripts Remote also made New York Times columnist David Pogue’s eclectic list of the top health-related iPhone apps.

Despite setbacks from high-profile companies like Walmart, the retail clinic sector is on pace to grow 10% over the next two years, then accelerate to more than 30% per year in 2013 and 2014. This new study suggests that patients are willing to use the clinics, especially if it costs less than seeing their doctor and if the location is convenient. The market will continue to face a few challenges, including opposition from physicians who advise patients to avoid retail clinics.

Practice Fusion announces a free PHR to allow patients connect with their physicians and medical records. The Practice Fusion PHR also allows patients to schedule appointments, request prescription refills, e-mail physicians, and share data with other providers.

HealthFusion (no relation to the Fusion company above) launches its HealthFusion Mobile Apps, enabling physicians to use their mobile device to view office schedules and patient eligibility information. HealthFusion’s next release will include a charge capture component.

This Washington Post article provides insight on how actual patients are using the Intel Health Guide home health monitoring system. The device allows patients to easily input such data as blood pressure, weight, and glucose levels. The information is then forwarded to the patient’s physician. The participating patients are part of a pilot program that researchers hope will prove home monitoring programs can improve patient outcomes and reduce costs. Most insurance carriers are not reimbursing patients for the cost of the devices (which rent for about $100/month) or for the physicians’ time.

The Alzheimer’s Association offers its new Comfort Zone program, which helps caregivers track the movements of Alzheimer patients via a Web-based mapping tool. Using technology originally designed to track prisoners, families purchase a $200 transmitter and then pay $43 to $80 for a service plan.

The OMB says that about 5% of federal spending was paid improperly in 2009, including about $54.2 billion for Medicare and Medicaid programs. Those programs actually had improper payment rates of 15.4% and 9.6%. I believe OMB Director Peter Orszag wanted Americans to feel encouraged because better detection methods have uncovered more improper payments than in the previous year. Orszag cites the example of an invalid doctor signature, which was much more likely to trigger an improper payment in 2009 than 2008. Perhaps, but what private industry would tolerate a 15% improper payment rate?

The Amalgamated Order of Real Bearded Santas is lobbying to ensure that the nation’s Santas are given priority for H1N1 flu shots. The Santa crowd argues that most Santas are could be high risk: two-thirds of all Cris Cringles are overweight and one-third are morbidly obese. Not to mention that no one wants the big guy to be sick when it comes time to hitch up the reindeer and deliver presents.

E-mail Inga.

News 11/17/09

Senator John Kerry introduces legislation to help small medical practices become eligible for SBA loans to cover EMRs and e-prescribing costs. Funds would be used for both hardware and software. Under the proposed bill, the SBA would guarantee up to 90% of a loan, with a maximum of $350,000 for an individual and $2 million for a group practice.

Community health organization Neighborhood Healthcare (CA) selects eClinicalWorks’ PM/EMR and Enterprise Business for its 115 providers across 11 locations.

Vālant Medical Solutions launches Vālant Psychiatric Suite 3.0, which the company says is the first and only completely Web-based practice management and EMR suite designed specifically for psychiatrists.

Meanwhile, psychiatrists in Michigan are embracing telepsychiatry as a effective means to treat patients in underserved areas. Videoconferencing tools are particularly valuable to address the critical shortage of child psychiatrists. Only about 200 child psychiatrists are available to help the estimated 500,000 children who need treatment.

Southern Maryland is awarded almost $5 million in federal stimulus money for healthcare projects, including $2.5 million to install telehealth technology in the homes of 250 homebound patients. That’s $10,000 per household, which sounds pretty steep to me.

athenahealth shares hit a 52-week high after announcing the U.S. Patent and Trademark Office awards the company a patent for its athenaNet billing rules engine.

The Heart Institute at Intermountain Medical Center scrubbed its EMR database to analyze the effect of inadequate vitamin D levels. Researchers found that those with low vitamin D were at higher risk for stroke, coronary heart disease, diabetes, depression, and early death. I’m taking my calcium supplements.

A Pennsylvania cardiologist tells the local paper that his practice is 99.8% paperless, two years after going to eClinicalWorks’s EMR. He and the 24 other providers in his group also use Dragon Medical and estimate they are saving almost $200,000 a year in transcription and paper costs. He admits the EMR does not save time because the record takes longer to document. He is still a big proponent, however, because the electronic record is “more complete and immediately available.”

The Internet ranks third behind health professionals and family members as a source for medical advice. The 49-and-under crowd is most likely to search for health information on the Internet before consulting their doctor. I’m actually one of those type patients (and caretaker for family members) who diligently searches the Web for healthcare information. Come to think of it, I did this for my dog over the weekend when I was trying to figure out if her skin rash might be cancer (the vet told me to give her a Benadryl and since then, she has made a miraculous recovery.)

First Citizens Bank agrees to market mPay Gateway’s patient payment system to its physician practice clients.

McKesson announces its new interoperability product, Horizon Connect. McKesson will use its RelayHealth platform to facilitate the exchange of patient data between Horizon users in different venues of care.

A reader forwarded us the results of an AAFP survey of 2,556 family practice doctors rating their EMRs. The full article is available by subscription only and the author admits some unavoidable bias (self-selected respondents, too many vendors to ensure adequate sample sizes for all, and different levels of expectation based on practice size). Readers are warned about taking the results as anything significant. They didn’t really name overall winners, but the closest thing to it placed the top 10 as (1) e-MDs, (2) MEDENT, (3) Praxis, (4) Amazing Charts, (5) eClinical Works, (6) Epic, (7) Practice Partner, (8) Allscripts Professional, (9) Centricity, and (10) Aprima.

Mark Leavitt, M.D., is retiring as chair of the Certification Commission for Health Information Technology effective March 31, 2010. The commission’s board has initiated a national search for a successor. Leavitt says he’s leaving for “personal” reasons and had intended to stay in the position for only five years (he helped launch CCHIT in 2004).

eMerge Health Solutions is a new HIT company hoping to market the wireless, voice-activated system it developed for an 18-physician gastro practice in Ohio. The product sounds efficient: providers wear wireless headsets and create the electronic record while performing colonoscopies. No need for extra staff to take notes or dictate after the procedure. As nifty as it sounds, I think they’d be better off selling the technology to a larger EMR company than trying to break into this market on their own. Too much fear and uncertainty right now.

IQMax announces the release of IQSpeak for the iPhone. IQSpeak integrates with the physician’s patient schedule and allows the provide to dictate on the iPhone.

The CMS paid 85,000 physicians more than $92 million in incentives as part of the 2008 PQRI program. More than 153,600 providers participated in 2008 PQRI, proving the reporting requirement were  too burdensome for almost half the participants. The average incentive amount was over $1,000; the highest single payment was $98,000. CMS paid a total of $36 million in PQRI awards in 2007.

E-mail Inga.

Intelligent Healthcare Information Integration 11/16/09

Sex, Drugs, and EHRs

Flashback, 1975.

Within hours of arriving home from a short tour of the southern states with the wonderful Randy Newman, my roommates and I were called back to our Baltimore-based shop to immediately repack the truck and drive non-stop to Florida. Our sister sound company from Washington state was touring with the Eagles, Linda Ronstadt, and the Charlie Daniels Band and needed some extra equipment for an outdoor show at the old Tampa Stadium.

Thus, the three of us headed right back to load the truck and begin the 24-hour drive: Jack, my towering, hair-to-his-butt sound engineer friend and housemate. Marcy, Jack’s long-time friend and roomie (and now mine) who comes along as moral support and driver keeper-upper. And me, an 18-year-old rock-n-roll roadie and audio engineer from the sticks of southern Ohio living large the rock-n-roll life of the 1970s.

Arriving late to the stadium courtesy of a tow truck for the final fifty miles thanks to a busted front axle on our rig, we find we have but two hours to get showered and settled before we begin set-up. The early morning start is assisted by one of the road crew’s “Drawer of Wonders,” a 10” by 12” by 2” deep drawer in one of the stage cases that, literally, is filled to the brim with every color, shape, and size of pill you could possibly imagine. “Help yourself,” were the only instructions.

The very long day that followed led to a great evening concert under a beautiful Tampa moon. However, many days on the road driving and humping large pieces of sound gear around along with minimal sleep on the nights between had led to a very big fade on my part. I didn’t think I’d be worth anything by tear-down time. Until, that is, I saw Cheryle.

Cheryle (I even found the superfluous “e” sexy) was a 29-year-old Baton Rouge beauty who had come to Tampa to see an old friend. She had long auburn hair that was silky and straight, a seductive southern drawl, and was about the most sensual and sultry creature I’d ever laid my young eyes upon. How she’d gotten backstage I don’t remember, but it was desire at first sight. After some heavy conversational intercourse (and some even heavier necking in a stand of bushes nearby,) it was clear we each had found a soul mate, at least for tonight.

Remember that “big fade” I mentioned? Ha! The sapped-energy sad sack was replaced by a stage-stripping madman. I was heaving giant speaker boxes around as if I’d received transfusions from both Barry Bonds and Mark McGwire. My roommates were in disbelief when I told them I hadn’t hit “The Wonder Drawer,” but was energized by romance. Four legendary days later (thanks to a layover as the axle was repaired,) when Cheryle and I finally left each other’s company, my friends had become believers. They saw how I almost floated to the truck as we headed out.

Flash forward, 2009.

The ex-roadie, sound man, rock-n-roller is now a small-town pediatrician. The only drug drawers I now encounter hold dwindling samples from pharmaceutical companies for my patients or the triptan du jour for my chronic cluster headaches. I have married the woman of my dreams and adore my sons, though I admit to avoiding full disclosure conversations about my past with any of them. Perhaps most amazingly, I have been blessed enough to recognize a prolonged passion that, while not as meteoric as the hormonally-driven adventures of my youth, is nonetheless just as pronounced and just as exciting.

This moment in healthcare time is historic. If you are in healthcare and have even a smidgeon of geek in your soul, I hope you, too, are just as aroused. Struggling through the birth pangs of HIT can be admittedly frustrating and exasperating, but the promise of the “baby” we are attempting to deliver is almost incalculable. The benefits we’ll bring to our patients — to each other! — and the additional insights and knowledge we’ll add to the global healthcare database will exponentially rise once we unravel the HIT Gordian knot. Such an amazing opportunity to help so many people the world over with the combined efforts of each little one of us has never before existed.

Personally, I find that being a part of this early time in the “Age of EHRs” to be as exhilarating and as awe-inspiring as any moment from my youth. It gets me out of bed with rare need of an alarm and helps me overlook the frustrations of our still paper-based medical world. OK, maybe it won’t generate any majorly romantic tales to tell my grandkids, but at least full disclosure will rarely be an issue. Guaranteed, the outcome will be far more world-shaking than any rock-n-roll weekend … except maybe that one on Yasgur’s Farm.

From the trenches…

“I wouldn’t recommend sex, drugs, or insanity for everyone, but they’ve always worked for me.” – Hunter S. Thompson

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.