An HIT Moment with … Garrison Bliss

An HIT Moment with ... is a quick interview with someone we find interesting. Garrison Bliss, MD, is president of the Qliance Medical Group of Washington, a medical practice that charges patients a monthly fee ranging from $49 to $129 for unrestricted access to its physicians and nurse practitioners.

Describe Qliance’s business model, how it works for patients, and how the concept fits into the debate about healthcare reform.

Qliance’s business model is a sincere attempt to address the central issues in the breakdown of healthcare — the gradual and inexorable destruction of primary care, the growth of insurance distorted medical care, and the loss of personal, unhurried medical visits. 

In primary care, insurance reimbursement systems have consistently undervalued and underpaid primary care providers. Over the last 50 years, this has translated into primary care physician practices mowing through 25-35 patients a day, much to the detriment of both the physicians and the patients. 

By using an insurance vehicle for a low-reimbursement specialty, the ratio of payment to the cost of getting paid is about 2 to 1 (meaning that 50% of primary care money is burnt up in the transaction costs, before even considering overhead costs of the medical practice itself). This has been disastrous. The combination of poor reimbursement and rapid fire low value medical has made primary care a dying profession and has put patients in danger.

When we eliminate the insurance middleman, the quality of life for both doctor and patient improve dramatically. Patients also become the source of physician income and the appropriate overseers of our work. This makes it possible for doctors to truly be accountable to their patients. Service improves, price declines, and physician/patient satisfaction makes a rapid comeback. There is also ample scientific evidence that medical care based upon a strong primary care system is less expensive, more effective, and safer than a care system dominated by specialist care.

What does the "medical home" concept mean to patients and their doctors?

The medical home means that patients know who their doctor is and their doctor knows who they are. It harkens back to better days when medical care was less technical and more personal. It also means that patients have someone they can trust helping them with difficult decisions, someone who isn’t selling them (or their insurance company) an overpriced invasive test, someone who can provide insight and perspective without a vested interest in cranking up their medical care expenses. 

In the case of Qliance, it also means that they have a place to go on weekends, mornings, and evenings that isn’t an emergency room, that has their records, and that will do what needs to be done most of the time without breaking the bank.

What is the advantage for your doctors and what technologies do you use to support them?

The biggest boon for our doctors is the opportunity to practice real medicine at a much more leisurely pace without inviting bankruptcy. 

Medicine is perhaps the most rewarding of all professions, but it can also be a dismal disappointment to go home at the end of a breakneck day knowing that you short-changed every patient you saw. We eliminate this problem. 

We have many technologies — a paperless office; a secure EMR with access from work, home, or anywhere on the Internet; a digital X-ray system with Internet-based radiology backup; an on-site generic formulary; a digital phone system; patient access to physicians via phone/cell/e-mail; a direct digital interface between our lab and EMR; a Web-based answering service designed to get you in contact with someone who can actually help you after hours, etc.

Can the concept be scaled up or replicated?

We believe it can and we intend to prove it.

What are the most important lessons learned from Qliance’s experience?

1. There is enormous power in doing the right thing, but there is no reason to believe that it will be easy.
2. It is hard to go wrong if you build something that works for both patients and physicians.
3. If you criticize entrenched interests, you can expect to be attacked by them.
4. You will be misunderstood. If you can’t handle criticism, you can’t do anything this revolutionary.
5. There is nothing more enlivening than doing the impossible. It is even more fun to do it well.

News 2/3/09

The AMA claims victory after the US Court of Appeals rules that physicians do not have to disclose personal physician payment data. The AMA also launches its redesigned Web site.

Congress take note: a Computerworld article concludes that doctors won’t accept EHRs until costs AND risks can be reduced. Agreed. Doctors don’t want their productivity to suffer. Reducing risk includes providing EHRs that are intuitive and easy to use.

Charlotte Radiology (NC) selects IMAGINEradiology PM for billing and collections. The practice employs over 70 physicians.

Columbia Doctors, The Physicians and Surgeons of Columbia University selects MxSecure as its transcription vendor of choice to integrate with its Allscripts EHR. MxSecure is implementing a custom interface to move transcribed reports into the Allscripts system. Columbia Doctors includes 1,100 medical practitioners.

FQHC Crusader Community Health (IL) chooses the eClinicalWorks EMR/PM solution for its 54 providers and four locations.

The latest post by Dr. Joel Diamond is a must-read. It’s perfect entertainment for the day after the Super Bowl. (Joel says not to feel bad if it makes you laugh).

Dr. Diamond, by the way, is the chief medical officer for dbMotion, which was just chosen by UMass Memorial Health Care (MA) to create a single, interoperable electronic patient record across various IT environments and care areas.

OmniMD’s EMR receives SureScripts certification.

Cambridge Health Alliance (MA) will close six of its facilities and reduce headcount by 8% in reaction to state budget cuts. CHA had already frozen hiring and started laying off 300 employees.

A University of Chicago study finds that 90% of hospitalized patients couldn’t correctly name even one of the doctors taking care of them. Three quarters had no idea and 60% of the rest were wrong. Unfortunately, remembering a doctor’s name isn’t necessarily a good thing. Patients able to name one of their physicians were more likely to be unsatisfied with their care.

Quality Systems, the parent company of NextGen Healthcare, reports a 17% jump in net income in its fiscal third quarter, to $13.2 million. Revenue grew 36% to $65.5 million. The bulk of the earnings came from the NextGen division, which posted $61.5 million in revenue (up 40%) and operating income of $22.8 million (up 28%). About $7.5 million of NextGen’s revenues came from two separate practice management companies acquired last year.

A Chicago-area cardiologist is charged with billing insurance companies over $13 million for services never provided. A second physician is charged with healthcare fraud in a scheme that involved submitting $500,000 in false claims to exhaust patients’ deductibles and collect payments. Must be that Chicago water.

Navigenics develops a physician portal that enables physicians to access the genomic results of consenting patients and incorporate the information into the patient’s personalized health plan.

North Medical PC (NY) lays off 50 employees across clinical and support areas. The practice includes more than 70 providers and over 500 employees.

A Washington University (MO) medical practice becomes the first in St. Louis to operate under the “direct access,” a.k.a. concierge medicine, model. Patients will pay $500 to $5,000 per year. In a letter to patients, the practice said, “We have become increasingly frustrated by a system that forces doctors to see more and more patients each day to cover an increasing overhead dictated by our association with Medicare and private insurance companies. Physicians and staff are buried under piles of paperwork, which has nothing to do with patient care and all too much to do with insurance company profits. We find this situation intolerable. Under the direct access model, we will no longer be participating in any insurance plans.”

An ER physician group at Anne Arundel Medical Center (MD) donates $1 million towards a new emergency department. Doctor’s Emergency Services, a group of 25 providers, is making the donation over the next several years.

Premera Blue Cross introduces a real-time cost estimation and claims adjudication tool to advise patients of their healthcare financial responsibilities.

Misys PLC names Sir James Crosby as an independent non-executive director and chairman designate with immediate effect. It is expected that Crosby will succeed Sir Dominic Cadbury as chairman this summer. Misys also announces its half-year numbers: revenue up 22%, profit more than tripled. The company says 55% of its revenues come from healthcare in the US.

A WV doctor and former town mayor is ordered to repay an insurance company $180,000 for blood tests and injections that patients never received. The doctor blames his billing staff and software, says he has nothing to do with billing, and that judges discriminated against him. He was nailed in 2007 for underreporting income from 2000-2002, when he also worked as a day trader.

Tom Daschle not only underpaid his taxes, he’s also had cozy relationships with the healthcare industry in the form of speaking fees. Among those paying for his speeches: America’s Health Insurance Plans, the National Association of Boards of Pharmacy, and life insurance companies. Obama still wants him to run HHS, but several newspapers think he should bow out. Not likely given that the new treasury secretary (meaning: IRS boss) had tax cheating problems of his own but was confirmed anyway. Honest politicians really are hard to find.

Odd lawsuit: a female plastic surgery patient sues her surgeon and the local TV station for running nude before-and-after surgery pictures of her on the air without her permission. The woman, an image consultant, says she’s lost 75% of her business. “I don’t blame them. Of course, they’d think I’m an exhibitionist freak.”

E-mail Inga.
E-mail Mr. HIStalk.

Joel Diamond 2/2/09

I write this on the eve of the Super Bowl. The outcome of the matchup between the Pittsburgh Steelers and Arizona Cardinals will be known to you before you’ll read this. I thought, however, that this would be the perfect time to reflect on how a physician’s work is never done.

Several years ago, I took my middle son to his first Steelers game. I finally got a weekend free and made sure that someone would be covering all my phone calls. I scored some great tickets and parked my car in town so my son and I could cross the Allegheny River on the bridge in true Pittsburgh style. We both got our faces painted in black and gold and we enjoyed our foot long hot dogs and Cokes. We settled in our seats and got ready for the kickoff. 

Just then, in the adjacent section, I saw a commotion around a fallen and cyanotic man. I looked at my young child next to me and said, “Son, I’m really sorry, but Daddy has to do some work after all." I handed him my cell phone and reluctantly entrusted him to the rabid fans around me.

It’s a strange phenomenon to do CPR on a person as fans cheer around you. Eventually, medics arrived and I was able to intubate and shock the unfortunate man as he lay on the metal bench while his wife looked on. I was drenched in vomit and sweat as the game continued on the field. To make matters worse, the man’s wife told me that her husband was a physician.

You’re probably wondering at this point about my son. Well he decided that it would be a good idea to call his mom. “Where’s your father? He left you alone in the stands with strangers?” she asked him. “Yeah, he’s hanging out with some other people,” he replied innocently. “Can you see him? What is he doing?” asked my confused wife. To her shock, he replied, “Oh yeah, I can see him now — he has his mouth on another man’s mouth.”

The ambulance finally came as the end of the quarter approached. I went back to my section and thanked the people who watched over my son. They asked me if I thought the guy was going to make it. I answered realistically that I very much doubted it. 

Silence fell over the entire section as people realized what had happened. I debated on what to say next.

“But what a way to go!” I shouted.

The crowd went wild.

My God, I thought, only in Pittsburgh.

Joel Diamond, MD is chief medical officer at dbMotion, adjunct associate professor at the Department of Biomedical Informatics at the University of Pittsburgh Medical Center, and a practicing physician at UPMC.

An HIT Moment with … Jim Tate

An HIT Moment with ... is a quick interview with someone we find interesting. Jim Tate is president and eHealth consultant at EMR Advocate, LLC.

What’s the best way to use federal dollars to get physicians to use EMRs in ways that benefit patients?

The current Federal incentive program for e-prescribing that began January 1, 2009 is a good model to also encourage providers to document patient care in an electronic record. I would suggest that starting July 1, 2009 providers would be given a bonus (5%?) for every Medicare/Medicaid charge that was documented in a CCHIT-certified EMR. Reduce that bonus every year by 2% until it becomes a penalty (-5%).

The process would play out over five years and the requirement that the EHRs are CCHIT-certified would guarantee that interoperability would be a part of the adoption wave.

What tips can you offer physician practices for selecting and contracting for EMRs?

• Take your time.
• Designate one physician to become the EHR Champion and assume ownership of the process.
• Talk to peers and ask them which EHR systems they use and what has been their experience.
• Go online and see what other physicians are saying about the systems they are using.
• Consider only systems that are CCHIT certified.
• Narrow your list of vendors down to three or four before calling the companies for a demo.
• If you are not comfortable with your level of expertise, locate a consultant to help with the due diligence and contract negotiation.
• Make sure your expectations are clearly understood by the potential vendor.
• When you ask for a quote, make sure it is for a complete and inclusive system. I have seen physicians sign a contract and then be told three months later that if they want an interface to their in-house lab it will cost $20,000.
• If you are not really sure what should be in the contract find someone who can help you.
• Do not assume anything.
• Everything is negotiable until you sign the contract.
• If you have a timeline for your implementation, make that part of the contract.
• If you want the trainers to have at least one year of experience, make that part of the contract.

You really need to protect yourself and stay in the driver’s seat and do the things that will lead to a smoother implementation that will occur on your terms.

Assuming physicians buy systems that are CCHIT-certified and therefore theoretically interoperable, how will they actually interoperate for patient benefit?

Interoperability can occur to benefit patients in ways that could never have been possible with paper records. The ability to generate, receive, and display CCD (Continuity of Care Document) type files is part of CCHIT’s 2008 Ambulatory criteria. This ability to generate and receive a file composed of a patient’s demographic and clinical information is a good first step to ensure that information can be shared between physicians and different EHR systems.

Another standard of CCHIT certified systems is the requirement that the EHR must be able to receive laboratory results in a discrete format directly into the patient’s electronic medical record. The provider is notified of the presence of the lab result by the system, not by the nurse. The results can be compared, graphed and then messaged to the nurse for appropriate resolution. This leads to fewer steps in the workflow, fewer lost labs and increased efficiency in the process. 

Debate continues on whether today’s EMRs are good enough to be worth massive federal investment. Where do they fall short and what should vendors be doing?

It is apparent that Obama is preparing a massive federal program to accelerate the adoption of health information technology. Currently we are only at the early stages of interoperability and the subsequent ability to exchange and gather data. The capability to exchange and congregate this discrete data must be aggressively expanded to bring added clinical value. Also, the user interfaces of many EHRs are cluttered due to the high level of functionality. Design work needs to be done to make these systems easier for the users. 

What technologies are available today that can help physician practices, but are less expensive and easier to implement than full-blown EMRs and practice management systems?

As a project manager for numerous EMR implementations in both the US and China, I saw the great risk of trying to immediately adopt all possible functionalities in an EHR. We called it the “Big Bang”. It was good for the vendor, usually not so good for the providers.

In many clinics, the workflow has been created over years, sometime decades. To change everything at once is incredibly stressful and can lead to the failure of the EHR being embraced by the users. To implement in a modular fashion has the benefit of reducing stress and also minimizing the loss of productivity that usually takes place with the “Big Bang”.

Messaging, e-prescribing, e-faxing and receiving discrete lab results are all good examples of “first steps” that can get the provider into the electronic arena.

News 1/29/09

From Ken Kercheval: "Re: physician practice EMRs. It is going to be an interesting year. Lots of companies will go away. Like they say, ‘When the tide goes down, you find out who isn’t wearing a swimsuit.’ Indeed." We are curious to see if the final economic stimulus legislation will include a requirement that funding is only available for CCHIT-certified products. If that becomes a condition, that should shake the industry up a bit.

California ER doctors file a class-action lawsuit against the state, contending that unless emergency medicine is better funded, the state’s emergency care system risks collapse. California ranks last in EDs per capita (seven per one million people compared to the national average of 20 per million people.)

Advantage Healthcare Solutions will be the exclusive provider of physician billing and A/R management services for the employed physicians of State Island University Hospital. Advantage will provide services to more than 20 practices and over 150 physicians.

Unlike typical hospital CEO’s, the new head of Cape Cod Healthcare lacks MBA or MHA credentials. Richard F. Salluzzo is actually a physician who intends to continue practicing emergency medicine while overseeing the hospitals operations.

Tennessee expands its medical video network to allow physicians to treat pregnant women in rural counties. BCBS of Tennessee Health Foundation has provided $1.8 million in funding to allow perinatologists to view live ultrasounds remotely.

A study in the Journal of the American College of Radiology finds the biggest area of growth for imaging billings is coming from the private office setting. A review of 10 years’ worth of Medicare data concludes that imaging billings by non-radiologists in private-office settings grew by 63% between 1996 and 2006.

VirtualHealth Technologies, Inc. completes its $1.5 million financing commitment to Private Access, Inc, a developer of privacy management tools for medical information.

New Milford Orthopedic Associates (CT) selects the SRS hybrid EMR for its six-physician, four-office practice.

Transaction service provide MedAvant Healthcare Solutions appoints Troy Burns as CTO. Burns previously worked at Misys and Payerpath.

The Illinois Medical Society and athenahealth agree to extend discounted pricing to medical society members for athenahealth’s PM solution. Approximately 12,000 physicians are members of the medical society.

EMR and PM provider Purkinje is offering free training and installation services for practices signing up during February. Purkinje is a Web-based SaaS solution that costs a flat $399 per month per provider. What is it about human nature that makes us wonder what the catch is? Or why we are reminded of the expression that sometimes "free" isn’t free enough? We don’t know much about the Purkinje product, so feel free to share any insights you might have.

Biopharmaceutical company Favrille and PHR vendor MyMedicalRecords complete their merger, making MyMedicalRecords a wholly-owned subsidiary of Favrille.

Retail prices charged by doctors in 2008 increased 2.9%, compared to 4.1% in 2007, according to the US Bureau of Labor Statistics. Wholesale prices for physicians increased 1.2% last year compared to 4% the previous year.

Noteworthy Medical Systems, Inc., announces a partnership between Portneuf Medical Center, Medical Resources of Idaho, and the Idaho Association of Physicians to form a community-wide HIE for providers in southeastern Idaho.The medical center and IPA are sponsoring the program designed to provide regional physicians access to Noteworthy’s web-based EHR. Leaders anticipate 100 physicians will join the program within the next six months.

HIMSS announces its support for HIT provisions under consideration by Congress.  HIMSS cites three reasons to support HIT investment: 1) the economy will benefit as jobs are created; 2) patients will benefit because of increased safety, and, 3) doctors will benefit because it reduces the current cost barriers.

As you watch the Super Bowl Sunday, consider this (between munching on spicy wings and drinking your beverage of choice, of course):  the headbanging collisions by your favorite football players can lead to impairments in movement and thinking 30 years or more later. If a player suffers multiples concussions, he is more likely to suffer more severe emotional and behavioral problems.  Doctors also advise Super Bowl  TV viewers to be careful.  Emergency rooms are usually busy right after the game, with patients complaining of such ailments as sprains, stomach ailments, and vocal chord damage.

E-mail Inga.
E-mail Mr. HIStalk.