News 4/5/11

Todd Rothenhaus, MD joins athenahealth as chief medical officer. He most recently served as SVP and CIO of Steward Health Care (formerly Caritas Christi Health Care).

Physician offices added 7,600 jobs in March, representing a 0.3% gain. Total physician office employment is 2.3 million.

Webahn announces that its Capzule EMR is available to solo practices free of monthly charges. Capzule EMR does not display advertisements and does not require revenue sharing, so what’s the catch? The Capzule Web site says the EMR is not (yet) ONC-ATCB certified and does not offer e-prescribing. Also, the EMR does not come pre-loaded with ICD-9 or CPT codes. The “free” option is limited to solo practices, includes only one additional non-physician license, and it includes limited templates and customization options. The standard package costs $150 per month per physician and $10 per month for non-physician users.

The newest generation of doctors want salaried jobs, fewer working hours, and specialties that are conducive to family life, according to a New York Times article. At the same time, doctors are not revered by their patients like days of old. In fact, patients today are more likely to see doctors as interchangeable.

The 80-physician Doctors Clinic (WA) goes live on Sage’s online patient portal.

The Child Guidance Center of Southern Connecticut implements CareLogic Enterprise EHR by Qualifacts’. The purchase was partly funded by a $100,000 private foundation challenge grant.

About 56% of practices have not scheduled testing of the 5010 transaction set, according to MGMA. Less than 4% said they had begun testing the transaction set with health plans. Most disturbing: 23% of survey respondents didn’t know what needed to be done to their software to implement 5010.

I noticed that AAFP opened its annual EHR satisfaction survey survey. AAFP members using commercial EHRs can participate here. It’s not the most scientific survey out there (results are based on physician self-reporting rather than a random sample). Still, the results are interesting and give certain vendors the chance to brag a bit.

AAFP also posts a special report EHRs, which includes a number of articles on EHR use in family practices, details on the EHR incentive plan, and more. I’m not sure there is much new, but the section includes a nice variety of information all in one place.

HIT consultants say practices often underestimate the amount of training required for EHR or reduce training to save money or time. When calculating the amount of time required for training, practices and vendors should keep in mind the amount of data being abstracted from previous systems; integration needs; introduction of new hardware, especially end-user devices; and existing computer skills.

And from a different group of consultants: if you have physicians resistant to structured data capture, find a hybrid approach that blends the ability to capture required structure data elements and provides the physicians the flexibility to document in their own personal manner. The result will be increased physician adoption and better data for reporting and exchanging with other providers. Evan Steele swears he didn’t write the article, but he could have.

There’s still a lot to process about the recently proposed ACO regulations, but one thing is clear: ACOs will need solid HIT infrastructure. The regulations call for ACOs to report on 65 quality measures, so systems will need to be in place to churn out those numbers. In addition, at least 50% of an ACO’s primary care providers be EHR Meaningful Users. Another takeaway: consultants are going to win big, as providers turn to them to determine their needs and assess the value of their potential ACO participation.

E-mail Inga.

DOCtalk by Dr. Gregg 4/1/11

First, a word from our sponsors. Oh wait, I don’t do sponsors. Well, then…first, a word about the title change.

You may notice that Intelligent Healthcare Information Integration has morphed into DOCtalk by Dr. Gregg. That is something I requested because:

1. The original title came from the blog I was just messing around with when Inga first saw it and asked me to join the HIStalk party. I had never intended it for use here, but out of lassitude, mainly, I left it how they originally posted it. (Actually, it was intended as a sarcastic statement on the state of HIT at the time.)
2. The new title seems to be more in thematic keeping with the whole HIStalk Empire. I’m honored to be allowed to use it.
3. Thus, going forward, this’ll be the new overarching tag for my prattle. Just in case anyone wondered.

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Baby Talk

I have been away from the hallowed wall-less halls of HIStalk Practice for a few weeks, but not because I haven’t been writing. Rather I’ve been pretty busy writing (and doing other assorted duties) for healthcare, for information, and for technology. So, though it is healthcare information technology of a sort, this project is really tangential to what most people think about when considering the realm of HIT. But, an intriguing corollary has become evident to me of late that I thought might be worth sharing.

The other project involves writing scripts for animation videos. These are short, about three minutes in length, and the first “Common Conditions” bundle of 14 videos covers a wide range of topics such as dehydration, diabetes, post-op infections, fractures, anesthesia, and even cancer.

Think about that for a minute. In a three-minute story, try to cover the important basics of, say, Type 1 Diabetes. You need to make it simple enough for a child to understand and engaging enough so that they’ll want to watch.

(In med school, I remember professors saying that if you understand diabetes, you’ll understand all there is to know about medicine. I’m not sure that’s really true, but the idea is valid: diabetes covers a whole heckuva lotta turf.)

So, pick about two minutes of diabetes material to try to get the most important points across for the first overview. (You’ll need a minute or so to get the engaging part, the gags, in there.) Make room to explain terms like “insulin” and “glucose” and try to make sure none of it sounds scary. (Hard to do when talking about shots and blood draws with kids.) Wrap it all together in some sort of “story” and, again, you have a hard ceiling of three minutes.

Challenging? Yes. But not undoable, not by a long shot. The tremendously positive responses we’ve received from test audiences verifies that we have been able to meet this challenge.

So, why do I mention this in the HIStalk Practice world? Because I see a very interesting parallel with what is missing in most HIT products, at least most that I’ve ever seen. That is, most providers don’t really want to be techies. They don’t want to talk — or even learn — the language of the geek. Just like most patients (kids or adults) don’t really want to spend their time learning the techno-babble of medicine.

I think exactly the same approach and process could dramatically advance the cause of most HIT vendors. In other words, spend some time really trying to humanize your tech. Not just the product, but also the training, the descriptors, the “Help” sections, your emails to clients or potential clients – everything that goes in front of the mostly non-geek providers. Talk to them in their language. Don’t try to make them learn yours.

I’ve noted a few vendors who seem to have this concept well in hand. For instance, SOAPware has a great online video education library which is easy to access and understand. From SRSsoft, Evan Steele’s EMR Straight Talk does just that. A few of the new iPad EHRs, like ClearPractice’s Nimble, Dr. Chrono, HealthFusion’s MediTouch, Mayo’s VitalHealth, and Quest’s Care360 seem to present in “people-friendly” formats.

And, the recently developed Thomson Reuters Pediatrics (just about to launch) addresses an old pediatric nemesis, weight-based dosing, which is something every provider who treats children needs. Most EHRs either ignore this or do it poorly. It’s something perfectly suited for the talents of a computer which then truly makes Rx’ing kids much simpler!

This isn’t about baby talk. Personally, I don’t do baby talk, not even with newborns. That’s an unnatural language (and somewhat condescending in my book.) This is about talking with people on a level consistent with their needs and experience and giving them useful tools that help them to take advantage of your special knowledge – without making them learn all that you know. It’s about translation. Making things easier to do and understand for people who don’t have the same expertise as you can go a very long way in facilitating adoption.

From the trenches…

“For success in training children the first condition is to become as a child oneself, but this means no assumed childishness, no condescending baby-talk that the child immediately sees through and deeply abhors.” – Ellen Key

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 3/31/11

Epocrates says its mobile and Web-based EHR is in beta at several solo and small physician groups. Epocrates also announces an agreement with Nuance Communication to leverage the Nuance Healthcare development platform to integrate Nuance’s cloud-based medical speech recognition component into that product.

Mission Surgical Clinic (CA), Coast Spine and Sports Medicine (CA), and the Rosen Anesthesia Group (CA) all select the ChartLogic EHR suite.

Physicians at Central Oregon Ear, Nose and Throat (OR) say that  Proxense’s proximity-based security with automatic logon/logoff saves them time and increases security. The system uses a combination of biometrics and RFID to authenticate EMR users. A fingerprint scan is required twice a day. Otherwise, RFID tags verify providers’ identities as they enter a room and shut systems down as they leave.

Mobile charge capture provider Ingenious Med Inc. receives $3.25 million in funding from Council Ventures to fund continued growth. The company has nearly doubled revenue, clients, and personnel each of the past two years.

AMA introduces its first-ever app to help physicians find appropriate E&M codes. AMA also announces the 2011 AMA App Challenge to find the next great medical app, open to physicians, residents, and medical students and offering $2500 in cash and prizes for two winners.

HIMSS and MGMA create a privacy and security toolkit for small provider organizations. It contains a roadmap for practices needing basic information on how to navigate privacy and security laws and to understand the security components of the EHR incentive program.

The Maine REC names athenahealth and e-MDs its supported EHR software vendors and Concordant as its supported implementation service provider.

A big welcome and thank you to Micky Tripathi, who made his HIStalk Practice debut Wednesday. Micky is president and CEO of the Massachusetts eHealth Collaborative and has agreed to regularly educate readers on technology decision-making in medical practices. You can find his debut Pretzel Logic column here.

Happy National Doctors’ Day. I am usually leery of some of these so-called observance days (how many of them does Hallmark invent?) However, Doctors’ Day has apparently been around since March 30th, 1933 when a physician’s wife decided to honor physicians by mailing greeting cards and placing flowers on the graves of deceased doctors. In 1990, President George Bush actually signed a law designating March 30th as National Doctors’ Day. So now you know.

The 50-physician Desert Radiologists extends its billing, PM, and RIS software contract with Zotec Partners.

At least one Washington insider doubts Congress will pass legislation to extend EHR stimulus benefits to mental health providers. Brian Darling, director of government studies at Heritage Foundation, thinks the chances of passage are “low,” especially if Congress does not find other programs to cut.

Less than 10% of Americans use online PHRs, but those that do are most likely to be white, older, and/or wealthier. In addition, of those who sign up, over half are categorized as "very low users" (logging in once at most in the prior two years), while a little over one-quarter were deemed "high users" (logging in 10 or more times). Though the authors of this Archives of Internal Medicine-published study explored the “digital divide” among those adopting PHRs, the bigger issue to explore should probably be why 95% of Americans show little interest in maintaining PHRs.

E-mail Inga.

Pretzel Logic: Technology Decision-Making for Medical Practices 3/30/11

Meaningful Use, Chapters Two and Three

So now that you’ve got Meaningful Use Stage 1 out of the way, it’s time to start focusing on Stages 2 and 3.

OK, I’m kidding. But still, before you jump on the MU “escalator” (as the good folks at ONC like to call it), it may be worth taking a tiny peek at what Stages 2 and 3 might have in store. Not only for the morbid fascination of it, but also because it gives you some hints and clues about what might be waiting for you at the top of the “escalator.”

Where might we look for such clues? Why, the Meaningful Use Working Group (MUWG) of the Health Information Technology Policy Committee (HITPC), of course. This is a federal advisory group that provides advice to ONC on — you guessed it — Meaningful Use.

While the MUWG only makes recommendations and has no ability to create law or regulation, if history is any guide, their recommendations are likely to be the foundation for what eventually becomes regulation. [Full disclosure: I am not formally a member of the MUWG, but as a member of other WGs I do occasionally participate in their deliberations.]

On January 13, 2011, the first recommendations on Stage 2 and 3 were put out on the ONC website for public comment. The comment period is now closed. On April 5, the WG will have a public hearing to discuss the public comments that were received. You can see those recommendations here.

Just what was in those recommendations? You may recall that MU Stage 1 has 25 possible requirements for Eligible Professionals (i.e., ambulatory clinicians), of which you have to meet 20. Start with the 15 “core” set items that are required, and then choose five from among 10 in the “menu” set.

Note: I should point out that I’m going to focus only on physician requirements, not hospital. I’m less familiar with hospital requirements and, unlike hospitals, most physician offices don’t have staff who keep track of all of this mumbo jumbo.

For each requirement, there is an objective, which is what you have to do (“record demographics”), and a measure, which is how much of it you have to do (“for 50% of patients.”) The MUWG started with these 25 Stage 1 requirements and then built from there to get to Stages 2 and 3.

In some cases, they recommended that a Stage 1 requirement just continue into Stage 2, meaning that you just need to keep doing what you’re doing in order to keep getting your incentive payments. Some Stage 1 requirements that were optional “menu” items become “core” in Stage 2. In other cases, they raised the bar on an existing requirement by either increasing the measure (“go from 50% to 80%”) or increasing the scope (“go from CPOE for just medications to include radiology and labs”). And, of course, they also had some genuinely new recommendations.

A summary breakout of their recommendations is above, showing how requirements move from Stage 1 to Stage 2, and then from Stage 2 to Stage 3.

Going from Stage 1 to Stage 2, relatively few measures are left completely unchanged. Everything else is either made mandatory (which is unchanged if you chose any of those in Stage 1) or increased in some substantial way. And, there are six totally new requirements.

Going from Stage 2 to Stage 3, five measures are untouched from Stage 2, while a whopping 24 are increased in some way and six new ones are added to boot.

Bottom line is that, as promised by CMS and ONC, the requirements are increasing over time. Some are increasing in ways that are easy to predict, while others, like new measures, are much harder to anticipate.

Of course, the devil is in the details. The table above (click to enlarge) shows how each of the requirements fares over the movement from Stage 1 through the middle passage of Stage 2 to the distant horizon of Stage 3.

The full descriptions (such as they exist) are on the ONC website per the link provided earlier. You can get a good description of the original Stage 1 requirements here.

So, what you should take away from all of this? Remember, these are just recommendations from an advisory group, so there’s a lot of process between here and the actual requirements that you’ll be responsible for. That said, they are strong leading indicators and do suggest some general guidance.

First, this isn’t an “escalator” or a “fast-moving train” or any other non-weight-bearing analogy. This is a climb, pure and simple. Your committing to this climb is, unfortunately, without the benefit of knowing what mountains, cliffs, whitewater, and mountain lions lay over the first hill.

Second, you can run but you can’t hide. Almost all of what is optional in Stage 1 becomes mandatory in Stages 2 and beyond. Choose what’s easiest and manageable in Stage 1, but don’t be blind to what’s just over the hill.

Finally, beware of the “TBDs,” especially the quality measures. Many have found that the quality measures are their own set of MU requirements. There is a separate Quality Measures Working Group that is hard at work looking at new measures. There is no doubt that we can’t improve what we can’t measure, but it is all too easy for those who are not familiar with EHRs to assume that they yield quality measures easily and accurately. They do not.

One concern that I have with all of this is with the timelines. The first cohort of MU over-achievers can start attesting to Medicare on April 18. They’re going to be required to start on Stage 2 on January 1, 2013. That’s not as far as away as it sounds if you think about the bureaucratic steps that need to be taken and the lead time needed for vendors to develop their products, get them certified, and train clinicians to use them.

I’m also concerned that many of the new requirements are trying to use MU as a lever to accomplish other objectives, such as public health goals and patient engagement aims.

The biggest concern for physicians is that many aspects of these new requirements are out of their control. Hopefully the public feedback to ONC that we’ll hear about on April 5 will quell the attempt by policy-makers to use physicians as the hammer to attack every nail, staple, rivet, and railroad spike.

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

News 3/29/11

Mark your calendars: attestation for the Medicare EHR program begins April 18th. If you are an eligible provider, you must have an active NPI and have a  National Plan and Enumeration System Web access user account. This CMS link includes step-by-step instructions, including screen shots. To date, CMS has paid out almost $37.6 million in EHR incentives and registered 25,217 eligible physicians and hospitals.

The average office-based physician supported $1.3 million in wages and benefits in 2009, according to an AMA report. Collectively, the nation’s 639,000 office-based physicians supported 4 million jobs and $1.4 trillion in economic activity. That’s about 6.2 jobs per physician.

Pulse Systems names family practice physician Tana Goering, MD as its chief medical officer. Pulse also announces that Loudoun Medical Group (VA) will implement Pulse Complete EHR for 170 of its physicians.

More than 40% of primary care physicians are considering leaving their field, though 60% said they enjoy better job satisfaction than they anticipated on their first day of medical school.

Patients taking advantage of $4 generic prescriptions unwittingly hurt the cause of e-prescribing and EMRs because of the way the transactions are processed and paid for. Patients typically pay cash for these discounted prescriptions, so transactions are not shared with pharmacy benefit managers. As a result, health systems are less likely to receive notification for inclusion in patients’ EMRs. The authors of a NEJM report suggest collecting data from pharmacy records in additional to those from PBMs.

The Wall Street Journal profiles  Atrius Health, a Newton, MA-based alliance of five medical groups representing over 800 physicians and about 700,000 patients. Their ACO-like setup has helped reduce costs to the tune of $62 million in 2010. Its collaborative efforts have also boosted quality measures, such as the number of patients receiving cholesterol screening. EMR has played a big role in measuring quality and identifying problems with patient care, as have the use of case managers to monitor chronic conditions and pharmacists to identify problematic drug interactions or cheaper medication alternatives. Still, University of VA professor Jeff Goldsmith notes that not all medical groups and small organizations will have the financial resources to invest in IT and other required improvements: "The idea that this could scale to the rest of the health system is seriously flawed.”

PCIS Gold to will integrate Alpha II’s ClaimStaker software into its medical practice management software.

I mentioned last week that Rhode Island lawmakers were considering a (silly) bill that would ban handwritten medical records. Rhode Island legislators are now considering  a seemingly simple proposal reminiscent of my Economics 101 class. The state is struggling to attract physicians, so lawmakers have suggested that commercial insurance carriers be required to pay a minimum of 125% of Medicare fees. In exchange, doctors must participate in the state’s Medicaid program and devote at least 5% of their work to free care. The state medical society opposes the law, fearing the floors may one day become the ceiling.

Meanwhile in Texas, a state representative proposes legislation allowing providers to opt out of a program that requires them to submit patient information to the state. The information collected by the Texas Health Care Information Collection is potentially sold to third parties for market research or health studies. Representative Susan King says the requirement places an unfunded burden on providers and that the state should not be in the business of collecting and selling information without patients’ knowledge.

EyePrescribe.com partners with DrFirst to offer e-prescribing services via the EyePrescribe.com web portal.

NoteSwift names Nuance reseller 1450, Inc. its exclusive distributor for EHR/EMR-related program. NoteSwift works with Dragon Medical to recognize meaningful data in dictations. NoteSwift then inserts the selected data into a provider’s EHR. NoteSwift only supports Allscripts Professional EHR versions 7, 8, and 9.0, though additional EHRs are in the works.

I usually defer to Mr. H when it comes to harsh criticism. However, after reading this article, I decided I can no longer remain Ms. NiceGirl. A local paper details the struggles of physicians adopting EMRs, yet the journalist clearly doesn’t have a handle on the industry. For example, the article says that EMR software “can range from free to over $800,000.” I’m not sure why $800,000 is the magic number since the price tag can definitely go higher for larger groups. eClinicalWorks software is labeled as “chronic disease management-focused” and “super-specialized,” as opposed to NextGen, which can “cater to almost any need.” Huh? And, I have no idea what this is suppose to  mean: “The (Epic) software speaks multiple languages to enable global healthcare providers to work as a team.” Plenty more examples to convince me never to write an article on geophysics, nuclear fission, or sewing.

E-mail Inga.