DOCtalk by Dr. Gregg 6/29/11

HITECH Guilt

Geez. You hear so many jokes about guilt-inducing religions, culturally-related guilt mongers, and mothers who guilt their children onto psychoanalytic couches, but when have you ever heard of legal, free money inducing guilt-laden angst?

And, yet, here I sit, a victim of “HITECH Guilt.” What is HITECH Guilt? The official DSM-5 axis isn’t available until 2013, but I can give you the Wiki version.

HITECH Guilt, also known as “DED-head Dread” (see below), is an extremely bizarre manifestation induced within a certain group of peoples known collectively as “EPs” who receive governmental financial support for trying to do the right thing. Certain EPs are granted these funds to help offset the costs of doing their jobs more efficiently and with greater chances for “interoperability.” (“Interoperability” is an antiquated term used in olden days to describe the abilities of electronic health record systems to work together, to collaborate, and to share information digitally. It has fallen into disuse primarily from lack of applicability.)

Most of the time, these poor EPs initially strove to achieve digital office information management in order to provide higher quality services – for their patients, for their staffs, and for their own geekoid good. Many invested staggering amounts of their already dwindling incomes to achieve this digitization without any promise of direct reimbursement … well, save those of overpromising sales folks and evangelistic health tech industry bloggers. (Gulp.)

Then, when the tipping point for HIT/EHR adoption seemed almost impossible to attain, along came HITECH. In order to help entice the reticent, governmental funds were found amidst all the red-inked ledgers to incentivize providers to digitize up. Not all providers, mind you. Just those deemed “preferred.”

The plan, in its most basic form, is essentially “carrot and stick.” The carrot is a little money. The stick is the withholding of money, a fair amount of money. The stick is definitely bigger than the carrot. Nevertheless, the carrot is not insignificant, especially for the EPs whose incomes are being assaulted on virtually every front.

For EPs who have yet to fire up the electrons in their patient recordkeeping work patterns, these incentive dollars definitely help lower one primary barrier to adoption by helping offset the costs of the transition. Even if the EHR adopted is one of the “free” systems, there are still significant expenses involved with training, implementing, workflow changing, and productivity “deficiting”, whether temporary or permanent.

For those EPs who were already DED-heads (Digitally Entered Data-heads), this HITECH incentive money was an unanticipated value add. I mean, who doesn’t like getting rewarded for doing something they thought was the right thing to do anyway?

However, with the funds came an unanticipated new form of mental pathology: HITECH Guilt. Despite feeling as if their hard work and attempts to move healthcare into the electronic age were worthy of reward, these mournful EPs now had to face the fact that they were contributing to the government’s staggering budget deficit and are, once all the trappings are cast aside, receiving welfare.

So, as I said, here I sit awash in HITECH Guilt. I got my check and, yes, I cashed it. If I had donated it to some worthwhile charity, I’d feel more “clean.” But, as I also don’t like the guilt associated with the harassing phone calls from creditors to whom I’ve had to delay payments, I chose to take the money. Times are hard in solo primary care. HITECH dough definitely helps keep the wolf (the ACO wolf?) from our practice door, at least for a little longer. Regardless, the guilty conscience lingers.

If you’re a provider who is outside of the EP clan, don’t think you’re missing out; there’s definitely a downside to “living on the dole.”

For my DED-head Dread suffering fellow EPers, there is one other little rationalization that helps:

Every time you see welfare patients come in who have better smart phones than you, notice how the angst melts a wee bit. When their kids have better portable video game players in hand than your kids own, you’ll feel better still. When you see them drive away in newer cars than yours, the guilt virtually disappears.

From the trenches…

“When we played softball, I’d steal second base, feel guilty, and go back.” – Woody Allen

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).

News 6/28/11

From OneHITwonder: “Re: Costco EHR Offering. Interesting Costco EHR offering.” Costco joins competitor Walmart in offering an EHR. Costco is working with Allscripts and reseller Etransmedia to market a complete package for $499 per month.  I am not sure the price is better than what other resellers offer, though I bet none of the others will install four new tires while you shop.

athenahealth purchases a $7.7 million, 396-acre resort near its Belfast, ME operations center. The company plans to use the facility to train employees and clients and for user conferences. Point Lookout Resort & Conference Center includes a bowling alley, 106 cottages, and a gorgeous view of the bay. Having been to Maine in the middle of winter, I am guessing the conference center will be a far more popular destination in the summer.

Indiana University selects the eClinicalWorks EHR for its health centers on the Bloomington and Indianapolis campuses.

Orthopedic Institute (SD) picks SRS EHR for its 38 providers.

MGMA introduces an assessment tool to help practices compare and analyze the four national programs offering patient-centered medical home (PCMH) accreditation.

Speaking of PCMHs, the use of EHRs in PCMHs was found to streamline the care process for Type 2 diabetic patients and patients with cardiac-related conditions.

The NJ-HITEC REC’s list of preferred EHR vendors now includes eClinicalWorks, Intivia, Advanced Data Systems, Amazing Charts, Abel Medical, and PerfectCare EHR.

AAFP announces that registration for its Physicians Direct clinical messaging system is now open. The service, which is $90 a year, allows participating members to send an unlimited number of messages, data files, referrals, and lab results to their clinical colleagues. SOAPware, Amazing Charts, and e-MDs plan to embed the Physicians Direct messaging technology into their products.

CMS says that eligible providers should expect their Medicare EHR incentive checks within four to eight weeks of successfully demonstrating Meaningful Use, or, as soon the EP has met the threshold for allowed charges for covered professional services.

Allscripts jumps into the outsourced billing business with the introduction of Allscripts RCM Services. Like most billing service models, providers pay for the service based on a percentage of monthly collections.

Fifth Third Bank will use Emdeon’s Payment Automation platform to power its RevLink Solutions, which automates the claim and payment posting process. Emdeon also announces that its Emdeon Assistant, Claim Master, and Payment Integrity Services have been awarded HMFA’s Peer Reviewed designation for meeting established standards for product effectiveness, value, and customer support.

Oregon’s Health Information Technology Extension Center (O-HITEC) chooses Mid Rogue eHealth Services to implement Greenway’s PrimeSuite HER, one of its preferred EHRs.

Sixty-one percent of physicians were dissatisfied with their 2010 income. The same report found that between 2009 and 2010,  emergency medicine physicians and psychiatrists had  the biggest percentage gains in income compared to other specialties.

E-mail Inga.

Pretzel Logic: The Quality Measure Conundrum 6/24/11

As many readers noted in my last posting on pain points of MU, quality measures are a separate and not very appetizing kettle of fish. Part of the problem is that policy-makers and users alike have been engaged in a bit of magical thinking – to wit, all we need to do is get docs using EHRs and the measures will basically create themselves.

My friend Dr. Marc Overhage used to compare this type of thinking to the now-defunct theory of spontaneous generation, which held that life could form from inanimate matter (hence the mice emerging from the pot of sawdust). That theory has been put into the dustbin of history. We need to do the same with the theory of spontaneous generation of quality measures.

Though Clinical Quality Measurement (CQM) is just one of 20 Meaningful Stage 1 requirements, in practice, this requirement has felt like a lot more than just 5% of the effort. Whereas one might have expected that the CQM requirement would basically be applying formulas to clinical data that’s already entered into the system as part of clinical workflow, it turns out that there is a fair amount of data that needs to be entered just to meet the measure requirements themselves.

In fact, a recent CSC analysis has quantified this extra effort, estimating that only about half (48%) of the data needed to drive the required CQM calculations would come from data already entered to meet other requirements. Put another way, the CQM requirement is, by itself, like a whole new set of MU requirements.

There are 44 possible measure options for MU Stage 1, from which you’ve got to submit at least six. Three of the six have to come from either the Core Set or the Alternate Core Set, and the additional three must come from the Additional Set, as described below:

• Three Core Set measures: hypertension, tobacco use/counseling, adult weight screening
• Three Alternate Core Set measures (for those for whom core set doesn’t apply): child/adolescent weight screening, adult influenza immunization, childhood immunization status
• 38 Additional Set measures: (EPs must submit three of 38 of these)

(PS — I realize that this barely makes sense, but people, I can do only so much with the material that’s been handed to me!) You can find the full list of measures here, a more clinically relevant list here, and very detailed descriptions that only a mother could love here.

So the MU Stage 1 thing may be adding some insult to injury by asking physicians to do a lot of documentation purely for the sake of measurement. Just what is this additional documentation? There seem to be four categories:

• Higher levels of documentation than suggested elsewhere in the MU requirements. For example, the e-prescribing requirement is that you only need to do it for 30% of your patients, and the requirement doesn’t apply to you if you have fewer than 100 prescriptions per year. However, any measure that relies on prescription information is going to demand that you e-prescribe for 100% of your patients.
• Standardized codification of documentation in ways not required elsewhere. For example, you are not required to have LOINC-encoded labs in your EHR, though your EHR is required to accept them if provided. Well, measures are defined using LOINC codes, so somewhere your local codes are going to have to be mapped to LOINC codes in order to automate measure calculation. Same is true for RxNorm, SNOMED-CT, etc.
• Different types of clinical information than is required elsewhere. Medical history is not a requirement in any other MU requirement, yet many measures have look-back periods that may require entering structured history (such as the results of past screening tests or procedures). The biggest culprit in this category is exclusion criteria, which, if ignored, will go against the physician in most cases by incorrectly including patients in a measure denominator and thus giving the physician less credit than they deserve. While only two of the six Core and Alternate Core measures have some exclusion criteria, a whopping two-thirds of the optional measures (25 of 38) include some type of exclusions. (See table below)
• Different sources of information than is required elsewhere. Attribution rules may hold physicians accountable for activities that happen outside of their practices (eye exams or foot exams, for example).

All of this speaks to the need to have a deliberate and proactive approach to the CQM requirement because the CQM requirement asks physicians and EHRs to do unnatural acts. You would think that EHRs would be capable of such acrobatics – they’re just databases overlaid with user applications, after all – but alas, it’s not so simple.

We’re back to the common refrain that this isn’t solely (or even mostly) a technology problem. It’s a multi-step human and machine process and any misstep along the way leads to the same result – no data, or even worse, inaccurate and possibly misleading data.

We’ve found that giving careful thought to the following sequence is especially important to solving the quality measurement conundrum:

Getting data into my EHR

1. What do I want to measure?
2. What data is required to calculate the measures?
3. Where do I get this data (i.e., is it documented in my office or do I need to get it from elsewhere)?
4. Can I get this data into my EHR?

Getting measures out of my EHR

1. Will my EHR reliably and accurately calculate the measures?
2. Will my EHR allow me to validate (or at least sanity-check) the calculations?
3. Will my EHR reliably and accurately generate a report of the measures?
4. Will my EHR reliably and accurately (and securely) send the measures report to where it needs to go (e.g., CMS and/or state Medicaid agency)?

I will seriously overstay my welcome on HIStalk Practice if I go through each of these in great detail. The most important areas in my view are determining what measures you’re going to report on, developing a robust data acquisition and documentation strategy to support the numerators, denominators, and exclusions for your chosen measures, and finally, determining whether your EHR will be able to generate those measures. You may need to repeat this sequence a few times because your EHR may not be able to easily generate the measures that you originally chose (see table below).

Choosing measures that are most appropriate to your practice is the obvious place to begin. If your practice panel comprises more patients with diabetes than heart disease, choose those measures because you’re more likely to understand them and you may already be doing most if not all of the needed documentation.

Remember that it’s okay if none of the measures apply to you (including the Core and Alternate Core). Not even CMS is going to ask you to recruit patients to satisfy a quality measurement requirement! You are, however, required to submit zeroes as denominators as demonstration of the measures that don’t apply.

And for the optional measures, you can’t cherry-pick three that you know are zero (“Cool! My dermatology practice doesn’t have any chemotherapy, optic nerve evaluation, or asthma patients!”). If you submit zeroes for the optional measures, you are representing that you don’t have even a single patient who would be included in the denominator of ANY of the 38 optional measures.

You’ll want to do a data acquisition and management strategy examining the data requirements for the measures that you think you’re going to choose and then itemizing, one by one, how your office documentation approach is going to enter that information into your EHR. You’ll find that some transactions, like labs or eRX (assuming you’re doing it 100% of the time) will be a foundation for a lot of measures. A structured problem list (ICD-9 or SNOMED-CT) is the other cornerstone that, together with labs and eRX will get you a lot of the way there.

The exclusion criteria are the place to look for landmines. Don’t assume that you’re already collecting enough information to identify qualified exclusions, and don’t assume that a small number of exclusions means a small amount of work – you could easily find that 10% of the information takes 90% of the work.

For example, the numerator for beta blocker therapy for CAD patients with prior MI (NQF 0070) has a number of ways to document that the patient is indeed a CAD patient, did indeed have a prior MI, and did indeed have a beta blocker ordered or listed as an active med. But don’t forget that you need to remove from the denominator patients who have a pacemaker or have had an adverse event associated with beta blockers or any of 14 other extenuating circumstances that would indicate that the patient shouldn’t get this therapy.

Most physicians could go through this in their heads for any one of their patients, but if this process is going to be automated and scaled, it needs to be supported by clear and consistent documentation. By now we’re all familiar with the term Garbage In, Garbage Out. It applies here as well, but in the case of exclusion criteria it’s even worse – Nothing In, Garbage Out.

Finally, before you do all of the hard work to ensure that you have good information going in, wouldn’t it be nice to know that your EHR will be able to do something with the information? Certification provides some confidence, but frankly, not nearly enough. EHRs are required to calculate all six of the core requirements (core and non-core), but only a minimum of any three of the 38 additional measures. So, you could find yourself working hard toward a measure, only to find that your EHR isn’t certified to calculate that measure.

How much variation is there among vendors? More than I expected, actually. I took a non-scientific random sample of 25 vendors from the almost 400 that are certified for quality measures and found the following:

• Only 20% (five) of the vendors I looked at were certified already for the full set of 44 measures (athenaClinicals, e-MDs, Epic, Greenway, and NextGen).
• The remaining 80 percent (20) were certified only for the bare minimum of nine of the 44 measures.
• The three diabetes measures got a lot of vendor attention (at least half of all of the vendors were certified for them), but coverage of the remaining 35 measures was highly variable.
• Half of the 38 optional measures were covered by only the five vendors who covered all measures.

If you want the gory details, they can be found here (click to enlarge).

As a practical matter, this variation is not necessarily an issue in 2011 because it’s basically a paper attestation process, even on the quality measures, and CMS has said that you can attest to measures even if your EHR isn’t certified for them and that you are only responsible for what your EHR spits out – you don’t need to validate it.

That’s all well and good for a process that doesn’t require electronic submission and that isn’t actually using the measures for anything. Electronic reporting is supposed to start in 2012, however, and it’s hard to imagine that your EHR wouldn’t need to be certified for measures that are reported electronically. And even in 2011, you do have to report numerator, denominator, and exclusion for each of six measures and attest that this information was spit out by your EHR. If you choose measures your EHR isn’t certified for, that may not be a pretty process.

So even though you can attest to any measure regardless of whether your EHR is certified for it, that may only be a temporary reprieve until electronic reporting begins. And while you technically don’t need to care right now about what the measure results are, those results may matter more to you once they’re tied to performance incentives, so you’ll want to make sure your EHR is capable of meeting your needs and reporting requirements. With a new set of MU Stage 2 measures on the horizon, it’ll be even more important to know whether your EHR vendor is committed to developing functionality for the measures that you care most about.

Of course, the underlying issue with quality measures isn’t really about the documentation issues or the technical specifications of the measures or the capabilities of the EHRs. It’s about motivation — quality measurement (or any performance measurement, for that matter) is only valid when the users themselves care about it. We can do as much as want to ease the pain, but in the end, quality measurement will only be as accurate or reliable as physicians themselves want it to be.

Micky Tripathi is president and CEO of the Massachusetts eHealth Collaborative. The views expressed are his own.

News 6/23/11

From O-chit: “Re: ONC FAQs. Saw this new question posted on ONC’s FAQ page. Scary to think that some people are still confused. I hope vendors aren’t contributing to the confusion.” The newly updated question: My EHR system is CCHIT certified. Does that mean it is certified for the EHR incentive program? The answer is clearly no, since the incentive program requires EHRs to be ONC-ATCB certified. And I am optimistic that no vendors are knowingly misleading anyone.

The AMA says it will lobby hospitals and healthcare systems to use standardized EMR interface designs to help physicians working at multiple facilities. Easier said than done, I would imagine. AMA made the resolution during its annual meeting this week. It also disclosed that it lost 12,000 dues-paying member physicians over the last year. The decline is in part blamed on AMA’s support of healthcare reform.

Kareo adds e-mail and chat support options for clients on all subscription levels and introduces an Integrated Credit Card Processing service for its PM application.

Sage Healthcare Division adds nine facilities running Sage Intergy On-Demand, Sage’s cloud-based EHR/PM solution.

RCM provider Navicure names Craig Potts EVP of sales. He’s from Fiserv and TenFold.

An analysis of health data breaches reveals that cloud-based EHRs have a pretty good track record compared to both on-site EHRs and paper records. The report also finds that most HIPAA violations result from insufficient internal security, negligence, or theft.

Physician alignment is named the most serious obstacle for organizations trying to form ACOs, as well as for hospitals and physicians electing not to move forward on ACOs. Physician alignment seems like a fairly broad term, but I am assuming that in this case it has more to do with alignment with economic goals than on issues related to patient care.

Forbes columnist Zina Moukheiber profiles Practice Fusion and CEO Ryan Howard, also explores why PayPal founder Peter Thiel has invested in the company.  Before ARRA, Practice Fusion was barely staying alive. Things turned around when new investors surfaced shortly after the HITECH legislation passed. Here’s some insight on Practice Fusion’s plans for making money by offering a free EHR:

Nothing is really quite free, and Practice Fusion needs to find a way to make money. In the fine print of its licensing agreement, there’s a provision which says that by signing on, doctors agree to transfer their ownership of patient data, stripped of identifiers, to the company. Practice Fusion now sits on a valuable load of information that pharmaceutical companies would love to get their hands on to mine it. There are, for example, one million patients with diabetes in the database; the number for obesity is the highest. I ask Howard whether he plans to sell useful marketing information to a company that wants to know, say, in which parts of the country its newly-released drug is not being prescribed. He balks; he wants to make sure he’s not crossing any ethical lines. He’s looking instead at applications, such as helping pharma companies enroll patients in clinical trials, or monitoring a drug following its release on the market. Practice Fusion’s revenues which are now less than $10 million, come mostly from advertising.

A1 Medical Software donates an EMR system to the soon-to-be opened Lee County Volunteers in Medicine Compassionate Care Clinic (FL).  The clinic will provide free healthcare services to the uninsured and under-insured.

E-mail Inga.

Readers Write 6/21/11

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

There has been a great deal of debate among physicians about the true value of electronic records. A survey conducted by MGMA earlier this year found that 78% of medical practices that are still using paper-based records thought they would face a “significant” or “very significant” loss of productivity during EHR implementation, while 56.9% said “insufficient expected return on investment" was a barrier to investing in EHR systems.

In that same survey, however, 72% of physician practices who had completed EHR implementation were “satisfied” or “very satisfied” with their systems. In addition, the survey reported that fully optimized EHR systems led to greater financial benefit.

Despite the results of the MGMA survey — as well as other surveys exploring EHR adoption — the hesitation and concern some healthcare providers still have is understandable. However, as the healthcare industry moves towards becoming fully electronic, deadlines related to new CMS Meaningful Use regulations loom. There is a great threat to further reduced payments to providers who lag behind in technology, which must be quickly realized and dealt with by all physicians.

Paper records do not, by definition, demonstrate compliance with Meaningful Use regulations. With Stage 1 deadlines on the horizon, practices will face lower payments from CMS as a penalty for staying with their legacy paper systems.

However, when you look at real-world data of the costs to create a single new patient chart, the dollar figures provide the evidence and support for EMR implementation. According to data based on a six-doctor practice, the elimination of paper charts in favor of implementing an EMR can reduce the cost of maintaining records by as much as 87% while increasing billings by more than $145,000.

The figures just don’t lie.

A clinic and surgery center that has 14 providers seeing an average of 1,800 patients and conducting 240 procedures per month averages the cost to create a new clinic patient paper chart, factoring in printing, stick-on tabs, copying, and labor, at $5.35. Seeing roughly 75 new patients each day, the organization spends a total of $104,325 annually in materials and labor. Creating a new surgery patient chart costs the organization $16,134 annually, for a grand total of $120,500 between the two.

It is also worth noting that some medium-size practices spend $200,000 per year on labor associated with managing and trafficking paper charts.

Overall, when it comes to EMR implementation, physicians must carefully and accurately weigh the long-term benefits with the short-term hassles. Yes, there is an upfront cost to EMR implementation. Yes, there may be a slow-down in productivity at the beginning while staff members are learning the new system. But if the practice takes its time in knowing what its needs are, the goals it wishes to reach and approaches EMR adoption with an open mind, the sooner it, too can start reaping the benefits.

Keith Slater is vice president and general manager at Henry Schein MicroMD of Boardman, OH.