Practice Wise 7/20/12

To the Cloud!

Many clinics are moving their computing needs to the cloud. What does that really mean? Not all applications in the cloud are created equally.

In simple terms, cloud computing refers to software applications hosted by an application service provider (ASP) that the end users access via the Internet. But not all applications in the cloud are the same. It’s important that practices understand what exactly they are getting when they move their applications to the cloud, and the overall impact on their organization.

No doubt about it, more and more opportunities exist in the cloud beyond your PM/EMR. For instance, QuickBooks Online, Microsoft Office, Exchange Server for e-mail, and many other programs that are used in the day-to-day operations of a practice. Most of these products are purely web-based, meaning you open up a web browser and work directly in it. For most of these applications, the limitations of a web page application are not necessarily rate-limiting factors.

However, when considering moving your PM and/or EMR to the cloud, there are many factors to consider.

Is the application a web-based application, where you log into a website and work directly in your browser? If so, what are the limitations of this type of application?

• You can only view one screen at a time, unless your vendor allows you to log into multiple sessions so you can toggle between screens / pages. This may not seem like a big deal to a provider in an exam room who is primarily charting in one screen. However, it can be an efficiency boondoggle for staff who need to view multiple screens at once (e.g., triage nurses, schedulers, billers).
• Can you scan directly into the application, or do you need to scan insurance cards and other point-of-service scans to a folder on your network and then browse from the web app back to the folder to attach the scan? This can be time consuming and result in mismatched records when done after the fact.

Is the application hosted on a remote connection instead of a web app?

• What does that mean for log-ins for your staff? How many log-ins will they need?
• Can you remote scan to the application server?
• Can you send and receive faxes from the remote server?

We have a few clients who have recently gone with dual remote applications. The PM and EMR are separate apps that are somewhat interfaced (demographics flow from PM to EMR, charges flow from EMR to PM). However, the staff now has five log-ins to access their hosted applications:

1. Their local network log-in
2. PM RDP connection log-in
3. PM application log-in
4. EMR RDP log-in
5. EMR application log-in

We are seeing this cause considerable workflow issues for our clients.  Just trying to keep all their log-ins straight is a challenge. The daily log-in process is cumbersome.

The clinic personnel are not network engineers, they don’t fully understand that when they log in to the various RDP connections, they are now on another server. When they browse and the network file structure does not look the same, it causes confusion and loss of productivity and even loss of documents that they can’t find once they save them.

Each of these log-ins has timeout periods and differing password change schemas, so the time required to keep all connections live can be a considerable effort. Especially on the clinical side, where someone might be logged in, go see a patient without their computer, and by the time they need to chart, have to repeat the 1-5 logins.

Bandwidth, bandwidth, bandwidth! Do you have enough bandwidth to support your entire staff to access your applications via your Internet connection and keep everyone happy with response times? This is a key factor in your success. We’ve seen clients go to hosted environments with DSL connections or a T1. It’s a nightmare! Make sure if you are using wireless laptops or tablets that they too have a strong, solid connection. It will add to your stress if you are fighting both wireless and Internet connectivity.

There are many valid reasons why moving to the cloud is the best thing since sliced bread. Total cost of ownership for IT is the most obvious. Let someone else deal with hardware costs and backups etc.

I’m not saying that the cloud is either good or bad. However, you must do your homework and hire someone to explain all the pros and cons to you. You don’t want to depend on your vendor to show you slick demo that makes it look like you are working directly on your desktop when in a remote session. You need a disinterested party who has nothing to gain financially from you to fully test each scenario and explain the benefits and risks, and help you analyze all your options thoroughly.

We’ve moved several of our key applications to the cloud and kept a few local on our servers. We feel that the mix is good, and our overall uptime and ease of use works well for our environment and uses. Best of luck to you!

Julie McGovern is CEO of Practice Wise, LLC.

News 7/19/12

Ambulatory EMR replacements are up 30-50% this year, especially in larger practices, according to a KLAS report on the ambulatory EMR market. Other highlights:

• Most small practices are first-time EMR purchasers while larger practices are looking to consolidate disparate systems by replacing their EMR vendors.
• athenahealth, eClinicalWorks, e-MDs, Epic, and Greenway are gaining mindshare while Allscripts, GE, NextGen, McKesson, and Vitera are “juggling resources.”
• The most replaced vendors are Allscripts, GE, and McKesson, primarily because of support concerns or lagging product development.
• Vendors winning most with second-time buyers are eClinicalWorks, Epic, and Greenway.

ANSI announces the first accredited certification bodies for the ONC’s Permanent Certification Program for HIT. The accredited organizations include CCHIT, Drummond Group, ICSA Laboratories, InfoGard Laboratories, and Orion Register.

The Arizona State Physicians Association, the Huron Valley Physicians Association (MI), The IPA of Nassau/Suffolk Counties (NY), and Boca Raton Regional Hospital (FL) are some of the new health systems and IPAs aligning with Greenway Medical for its PrimeSUITE EHR/PM solution.

An AT&T-sponsored physician practice technology survey finds that 37% of practices have fully implemented an EHR. Expense continues to be the top reason practices say they’ve not done so.

Health Management Associates partners with athenahealth to implement athenahealth’s solutions for HMA’s 1,200 employed providers. athenahealth will also offer services to the 10,000 independent physicians affiliated with HMA hospitals. athenahealth, by the way, announces its Q2 earnings Thursday and analysts are predicting a 14.3% increase in net income compared to a year ago.

NCQA extends a “Distinction” designation to 60 PCMH primary care practices that collected and reported patient feedback using the Consumer Assessment of Healthcare Providers and Systems PCMH Survey.

SAIC will pay $473 million to purchase maxIT Healthcare, a HIT service company that provides management consulting for eClinicalWorks, Allscripts, NextGen, and other ambulatory and inpatient products. maxHealthIT will be combined with SAIC’s Vitalize Consulting Solutions team.

Recruiting firm Merritt Hawkins predicts that 75% of the nation’s physicians will be employed by hospitals by 2014.

CMS sends the final regulations for Stage 2 of the MU program to the White House Office of Management and Budget, indicating the rule is nearing publication.

TriZetto Group subsidiary Gateway EDI acquires ClaimLogic, a medical claims and payment processing company that serves large practices and the hospital market.

The CDC finds that 55% of US doctors use some type of EHR, with 85% of them reporting being either somewhat or very satisfied with its day-to-day operations. About three-fourths of the physicians who have adopted EHRs say their system meets Meaningful Use requirements.

ADP AdvancedMD deploys its 2012 Summer release, which includes an iPad app, new ICD-10 tools, and workflow improvements for pediatrics.

E-mail Inga.

Healthcare Informatics 7/17/12

Healthcare Infrastructure Data Models
Option 3 — Health Record Banks

Option 1: The Centralized Repository is described here.
Option 2: The Federated Model is described here.

Think Google Health or Microsoft HealthVault with an actual business plan. The patient controls access to their data and pushes it or allows it to be pulled at their request. Admittedly, I hadn’t heard of this concept until the founder of the Health Record Bank Alliance told me about it, so I can’t say this model is just around the proverbial corner.

When we philosophize from our arm chairs about how healthcare should be, one particular theme always bubbles up: the patient should control their health and their health information. But have we accomplished that, even with the concept of a Patient-Centered Medical Home?

Right now, our healthcare system is centralized. This means that if we go to a well-organized institution, our information and services will center around us as long as we don’t leave. But if the industry follows the disruptive innovation pathway laid out by Clayton Christensen in The Innovator’s Prescription, we will eventually arrive at a decentralized model of healthcare. That means the hospital-centered healthcare will become passé. It also means we need to find a way to deliver patient health information to the practitioner on demand. As in, it is stored with the patient, not the provider.

Personal Health Records (PHRs) would seem to be the obvious solution to this. Due to a lack of record portability and motivation, they have turned out to be duds even to data geeks like myself. I once logged every time I picked at my fingernails and what I was thinking about at the time in order to figure out how to break the habit (willingly), but I logged into my Google Health account (RIP) exactly twice.

The portability issue will be resolved, and thank Meaningful Use for that. Motivation, though? Most of us don’t actively track our health status. We wake up, we subconsciously determine whether we have it in us to survive the day, and then we get moving. A Health Record Bank could potentially provide motivation in the form of payment opportunities.

Let’s say you received a micropayment every time an organization queried your health record for research, public health assessment, or even marketing information. Not enough revenue to generate a career, but it could buy you coffee every now and then. All you’d have to do is maintain your record like you do your checking account. Would that be something you’d be interested in?

Record portability? Yes. Public Health assessment? Yes, with payment. Consider it an incentive payment going to the right people.

Given these three models — the centralized repository, the federated query, and the health record bank — which is the one that will be used moving forward? Even though the proponents of these models act like they are competing models, are they not complimentary in some fashion? Centralized repositories are great for in-depth analysis once the data is actually gathered. Federated queries are good for a small network to share data. Health record banks motivate the originator of information (the patient) to give up the data and spread it in addition to establishing ownership.

An EHR in the hands of the majority is the first step to setting down this path, where these models can interact. But make no mistake, it is not the last. Eventually, EHRs will become the processing tools to send information for expert analysis, not from which to extract information.

Aaron Berdofe is an independent health information technology contractor specializing in Meditech’s Medical and Practice Management Suite and EHR design and development.

News 7/17/12

Cloud-MDs announces plans to integrate its PM/EMR solution with DrFirst’s e-prescribing  software.

Aprima Medical Software releases Aprima Mobile, a smartphone app that provides physicians with access to to key functions and patient data in Aprima EHR.

CMS releases a guide for EPs to walk them through all phases of the Medicaid EHR program.

Greenway publishes a cool infographic that includes a ton of stats and an overview of the complete MU program. Even if you think you have MU all figured out, I recommend taking a second to check out the full graphic.

MGMA offers encouragement to practices interested in creating a social media presence, particularly Facebook:

Participating in social media takes considerable time and effort, so do your research before taking your practice online. And once you’re there, enjoy interacting with your community in another way. It’s a new avenue for sharing information and engaging with your audience outside the office walls.

I found that at least one of my doctors has a Facebook page (above) and an impressive 1,341 likes.

The Washington Post reports online ratings of physicians by patients are generally positive. Nevertheless, most doctors are leery of the more than 50 Websites that permit patients to post online reviews of their doctors.

E-mail Inga.

DOCtalk by Dr. Gregg 7/13/12

Clubbing EHRs Religion

Clubbing, EHRs, and religion: not exactly a triplet of terms that is commonly grouped. But, I see it almost everywhere I look in EHRdom these days. Lemme ‘splain, Lucy…

Taking each as they were writ:

Clubbing

Not the ear-popping, soulless electronic drum beating, Ecstasy-riddled type of clubbing. And, not the too-cute-to-be-believed, little white baby seal murder trade tool, either.

The kind of clubbing to which I refer is the kind that involves people’s predilection to form into Us vs. Them units. We club. We group. We team up and then we team up against.

Little boys do it in tree houses with “No Girls Allowed” signs. Sorority sisters and frat fellows do it. Bloggers do it. Facebookers do it. Republicans and Democrats love to do it. Tea Partiers do it with gusto. Sports teams do it, thrive by doing it. Nations need to do it, especially during an Olympic year or time of war, any war.

Steve Jobs and Apple did/do it best, having turned clubbing into an art form.

Clubbing and EHRs

Almost every EHR I’ve ever come across has a strong element of clubbing. “Our system is the smartest” or “Our system is the most physician-friendly” or “Our system is designed with you in mind, more so than any other system out there” or “Our system will get you the ROI the others only talk about” – these are all themes which seem to have become almost genetically encoded in the current EHR mindset.

Whether they are free or cheap, minimally draining or bank-bustingly expensive, pretty much every EHR company I’ve ever come across thinks they have the best system. Most of them also trash talk the other EHR systems – the opposing “clubs” – almost as much as they up talk themselves, not unlike opposing sports teams. (Take your pick for an example; Browns/Steelers and Ohio State/Michigan are my favs.) Most EHRs try to build more than brand loyalty; they sell a lot of laced Kool-Aid.

EHRs club… a lot.

Clubbing and EHRs and Religion

It probably doesn’t take much ‘splaining to see the connection with religiosity and EHR clubbing. Few things have brought more people together than religion. And few things have brought more people together to assail other similarly grouped people with a differing opinion more than religion. Few things have caused more good and more harm, throughout the entire course of human history, than religion. (This likely being the reason John Lennon tried to “Imagine”.) Religion doesn’t have to lead to harm; it just often gets contorted and ends up there.

Religion is sort of the pinnacle of clubbing… well, aside from Apple.

Clubbing EHRs Religion

In the first sentence, I placed commas between these words though I didn’t in the title. There’s a good reason for that: discussing “clubbing”, “EHRs”, and “religion” is not the same as “clubbing EHRs religion”. (To be PC, Punctuationally Correct, I should have an apostrophe after the “s” in EHRs, but I liked the way it looked without it!)

Face it. No EHR does “EHRing” that much better than any other. Most every single one that I’ve seen does some thing or things really well, maybe even uniquely well. Most every single one that I’ve seen also does some thing or things (usually things, plural) really, really poorly. None of them are worth religiosity. Few are even worth a club.

“Imagine” there’s no EHR religion. Imagine an EHR company telling you the full truth. Imagine EHRs working to build the best solutions and foregoing the paranoia that someone else might copy what you’re doing. Imagine EHRs learning from each other and getting best of breed capabilities shared across the sandbox.

Imagine EHRs remembering that jacked up prices and humongo corporate facilities are a part of the skyrocketing healthcare cost crisis. Imagine EHRs all remembering that we’re in healthcare, that caring is an integral part of what we do. (Many, maybe most, EHRs were started with caring at their core, but it seems as if that has gotten a little lost, a little contorted, in development.)

Imagine buying an EHR made as simple as choosing which type of paper you prefer. All paper works, but some is smoother, some is heavier grade, and some is just fine for the price. The nice thing with paper, though, is you can actually know what you’re getting before you buy. (Plus, I’ve seen very little clubbing in the world of paper, except perhaps for Levenger.)

CEHRR

I’d like to club the clubbing, club the religion, right out of EHRs. “Clubbing EHRs’ Religion” (CEHRR) is a new club I’m starting. I’ve got “I’m a CEHRR” (pronounce it “kûr”, as in “cur”, as in mongrel) t-shirts, coffee cups, and buttons plus a cool little clubhouse. It’s better than any other club. It’s the best club ever! Wanna join?

From the trenches…

“I do not feel obliged to believe that the same God who has endowed us with sense, reason, and intellect has intended us to forgo their use.” – Galileo Galilei

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, directs the Pediatric Office of the Future exhibit for the American Academy of Pediatrics, and sits on the board of directors of the Ohio Health Information Partnership (OHIP).