DOCtalk by Dr. Gregg 4/17/11

Pediatric Tar Pits

Way back in the day when dinosaurs first dreamed of computers to solve their workaday needs, I’ll bet some pterodactyl envisioned that computers would one day actually take the drudgery out of their calculational quandaries and let them focus upon doing the dinosaury things that they really wanted to be doing.

Well, that day is finally, really, honestly here – at least for us dinosaurs who deal with pediatric and neonatal drug and parenteral nutrition. I just enjoyed an hour-long webinar (how often can you say you actually “enjoyed” a webinar?) on the new digital tools that Thomson Reuters has just released: Thomson Reuters Pediatrics and Thomson Reuters Neofax.

Any of you familiar with neonatal care have likely heard of Neofax, a great book – pretty much a “must have” for neonatal care providers – chocked full of drug and nutritional information and complex calculations. It has been updated yearly since 1986 and has grown into a rather thick little paperback tome. (Ugh. Paper.)

Any of you familiar with pediatrics know how frequently drug dosages must be calculated – like virtually every single time on virtually every single child – based upon their specific weight (i.e., weight-based dosing.) And then there’s rounding. Do you round off to the closest milliliter or teaspoon? It’s not as simple as “Take a pill twice a day and call me in two weeks.”

Weight-based dosing rises to new levels of head-scratching complexity when it has to be applied to the multiple components of parenteral feeds (infant formula and TPN).

Many EHRs don’t help with this much. Some do, especially those that really “get” pediatrics, but most either ignore this calculation component, say they have it on the “to do” lists, or do some smaller portion of the process.

What Thomson Reuters has done is not just kick it up a notch; they knocked it into a whole new sphere of computer helpmate-dom. They have provided some heavy duty calculational tools to a robust database of drug monographs (Micromedex) using evidenced-based data to provide one of the best little tools any pediatric or neonatal provider could ever hope for. It is easy to navigate, displays information and alerts cleanly, and has some great tools for incorporation into hospital pharmacies and CPOE processes.

They offer “Basic” versions of each via the Internet which have fewer tools and require a little more end-user input and “Premier” editions which are “Intranet-based” with more bells and whistles and patient-specific capabilities.

The only downsides I have seen are: (a) you can’t get a look at it online without a webinar or a demo; (b) I wasn’t able to get any pricing info yet; and (c) it isn’t the prettiest user interface I’ve ever seen.

Despite these minor issues, it is clean, powerful, easy to understand, full of evidenced-based help, and it will probably knock any pediatrician’s socks off regardless of the GUI. It does just exactly the kind of things computers should do to help us pediatric dinosaurs get on about being better dinosaurs without being mired in antediluvian data and calculation tar pits.

From the tar pits…

“I’ve been drawn into your magnet tar pit trap.” – Kurt Cobain

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 4/14/11

From Kelpie: “Re: the EHR Herd. With regard to the Readers’ Write article posted by Reefdiver, KLAS just published a report focused specifically on how prepared each ambulatory EMR vendor’s clients are for MU. I think it would be very useful to your readers that are looking for some sort of help in ‘thinning out the herd,’ as the article says.” Kelpie is with KLAS and is willing to give providers a free executive summary of the report if they are able to spend 15 minutes participating in KLAS’s research. That sounds like a pretty sweet deal, given the standard provider price is $980. If you are interested, e-mail me and I will forward you Kelpie’s contact information.

The new KLAS report, by the way, finds that nearly 80% of ambulatory care providers are confident they will meet Meaningful Use criteria this year. However, KLAS also notes some significant gaps, including the absence of electronic record sharing for two-thirds of the providers and the lack of clinical decision support rules for almost half the surveyed physicians. Epic and Greenway clients are the most prepared to achieve Meaningful Use.

Nuesoft Technologies launches Nuesoft Mobile, a free app for users of Nuesoft’s NueMD medical billing solution. The app includes charge capture functionality, an appointment viewer, and the ability to attach voice notes and images to patient records.

AMGA starts today in Washington DC. That’s one event I’ve wanted to attend for a number of years, but the timing has never been right. If you are there, I’d love an update and/or photos.

The Montgomery AIDS Outreach (AL) selects SuccessEHS as its PM/EHR solution.

The AMA sends a letter to CMS outlining the federal regulations that physicians find most burdensome. Topping the list are unfunded federal mandates, elimination of Medicare payment for physician consultations, and incompatible and inconsistent quality initiatives.

Epocrates introduces a new mobile drug sampling service, Epocrates Mobile Sample Closet. Pharmaceutical companies will use the service to offer physicians custom samples via their mobile devices.

The Alabama Primary Health Associates (APHCA) partners with Arcadia Solutions, which will provide EHR training and support to APHCA’s 15 community health centers.

Speaking of community health centers, The National Association of Community Health Centers estimates CHCs serve 20 million people each year. That number is expected to double by 2015, in part due to increased funding from ARRA and healthcare reform legislation.

The National Hispanic Medical Association partners with DrFirst to offer its clinical and financial products.

WebChartMD, a transcription workflow provider, integrates its platform with M*Modal’s Speech Understanding technology.

Big Sandy Health Care (KY) receives $255,000 in Meaningful Use incentives from Kentucky Medicaid. Its five community health clinics use Meditab clinical software.

The American College of Surgeons launches an online community to support surgeons practicing in rural areas. The resource will allow remote surgeons to seek advice and collaborate with peers.

Radia (WA) signs a five-year agreement with Zotec Partners to manage the 80-physician practice’s accounts receivables.

After reading this study, I vow never again to apologize for allowing my fashion enthusiasm to occasionally overflow to HIStalk. An Archives of Dermatology-published study by a group of dermatologists finds that 20% of adult patients believe their doctors should wear ties. Furthermore, most patients favor the traditional white coat (the doctor’s “badge of authority.”) And, one third of the patients say their trust in their doctor is influenced by his/her attire. Which is crazier: that patients care what their doctors wear? Or, that doctors actually asked patients for fashion advice?

E-mail Inga.

Readers Write 4/13/11

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!

The EHR Herd, Part I: Is Certification a Helpful Credential for EHR Purchasers?
By Reefdiver

Would you buy a refrigerator that hasn’t been certified by UL? Would you buy a cut of meat at the supermarket that lacks the USDA stamp of approval? Would you purchase an automobile if it was not certified as meeting the minimum government standards for safety?

On the other hand, does the UL certification tell you which refrigerator is right for your kitchen or family? Does the USDA stamp tell you whether the skirt steak or the filet mignon is a better fit for the meal you are planning? Does the EPA approval tell whether the Smart Car or the Durango XLT is better for your vehicle needs?

As of today on the ONC site, there are 375 EHR products certified by all of the ATCBs combined for the ambulatory market alone, of which 262 are Complete EHRs. (Note: I started writing this two days ago and both of these numbers have gone up by significant amounts in the interim, with no apparent end in sight).

Does anyone else find it absolutely astonishing that that many products can pass the certification criteria that meets government specifications for allegedly being able to help providers meet Meaningful Use (MU) criteria? And that the number continues to grow each week? How hard can these standards of certification be if every product passes?

More than 30% of law school graduates fail to pass the law boards each year. Series 7 exams for new stockbrokers have a pass rate that is less than 50%. CPA exams are notorious for being difficult to pass, with the national average being about an 85% failure rate. Years ago, more than 50% of the pilot trainees in my military flight training class failed to earn their wings during the 15-month training program – they were washing out right up to the last weeks of training.

Is EHR certification getting to be like passing the UL test? As long as the product doesn’t produce a massive shock, it passes? A urine test must be statistically harder to pass than EHR certification. 

EHR certification is almost becoming a rubber stamp. Shouldn’t there be some failures with this many product applicants? Or, does certification not measure some critical differentiators, like usability? Given the 50% implementation failure rate so commonly quoted, maybe it’s just a demonstrative example that with technology, it’s much easier to certify functionality than it is to certify usability or practice-appropriateness.  

What other industry can you think of where this situation — hundreds of software vendors with government-certified products for one single class of end users, medical practices — is possible? Software for airline reservations? Enterprise software? Financial planning, spreadsheets, word processing, inventory control, hotel management, software for law firms, tax preparation software?  

Most of these huge software segments have no more than a handful of competitive software products. More than 300 certified software products for EHR, with more coming each week. Sure seems like a lot. Will probably lead to consolidation problems later!

Should the herd be thinned out, or is it better to have so many products certified? The number of choices is daunting for providers, like the cereal aisle at the market. It will be hard for the EHR market to support this many vendors, but a free enterprise system can often result in two doctrines that come into juxtaposition: survival of the fittest (vendors) and caveat emptor (providers). Does certification help either party more?

The other half of this delicate equation is the providers and practices. Their role is to pick an EHR and show Meaningful Use. Most vendors guarantee the desired outcome, but what is the fine print saying and are providers aware of it? 

With more than 300 certified products to choose from, how do providers pick one that is really right for their practice and specialty? The advice being given out there is pretty bland and not very useful for decision makers as far as I can see. Big vendors are not necessarily better than small ones. I’ll offer some thoughts on that later in the week in Part II of this, should anyone be interested.

For now, I hope some providers will respond to my comments. I’d love to hear how you feel about all the EHR products that are being certified and how is it helping you to choose whether and if to purchase one. And,  how you are going about finding one that really fits your practice and workflow best.

News 4/12/11

Capario partners with Data Media Associates to offer customers customized patient statements and mailing, plus a  payment portal.

An analyst with Avondale Partners notes that Emdeon is tracking more than 20 potential acquisitions. The analyst predicts Emdeon will “focus on adding solutions that monetize data from payment integrity, clinical messaging, business intelligence and decision support, and look to expand its RCM suite, and clinical information exchange.”

The State of Hawaii Public Safety Department contracts with eClinicalWorks to provide EHR to the 4,200 inmates in its correctional facilities.

eClinicalWorks, by the way, announces the pending availability of its MAQ Dashboards, which gives practices the data required to illustrate their Meaningful Use of the ECW EHR.

McKesson’s Practice Partner, ABELMed EHR, CureMD, and NCG Medical are named preferred certified EHR vendors by the Ponce School of Medicine REC (PR).

MinuteClinic, the healthcare division of CVS Caremark, partners with Advocate Health Care and Advocate Physician Partners to serve as medical directors for 23 MinuteClinics in Illinois.

The AMA says there are currently about 8,000 health-related apps available through the iTunes store. Wow. The AMA believes that’s not enough, so it  is sponsoring an App Challenge to find new apps. Since first announced March 30th, the AMA has received 60 submissions from physicians, residents, fellows, and medical students.

Please help me in welcoming Julie McGovern as a new contributor to HIStalk Practice. Julie is CEO and founder of Practice Wise, an eight-year-old, Wilsonville, OR-based consulting firm based that focuses on clinical and financial services for ambulatory practices. Find her debut Practice Wise post here.

US adults are strongly in favor of physician EMR use and the electronic exchange of data between physicians, according to a Commonwealth Fund survey. Though only 14% say they can access their records online, 34% can order prescription refills online, 22% can schedule appointments online, and 21% can email their physician.

Of the first 13 states to launch their Medicaid meaningful use programs, only six have issued incentive payments. At least 18 states don’t expect to open their programs until the second half of the year and nine have not yet indicated a start date.

Chartwise Medical Systems partners with consulting firm H.I. Mentors to provide ChartWise customers preliminary reviews of their clinical documentation improvement process, as well as training.

A GAO report finds that when physicians and patients appeal denied claims, reversals were made 39% to 59% of the time. Miscodings and incomplete information on claims were common causes for automatic claims denials.

Nearly 70% of physicians view information from drug company reps as useful in making prescribing decisions, according the Pharmaceutical Research and Manufacturers of America. The results of this survey remind me of a conversation I once had with a physician about the overall product knowledge of drug reps compared to EMR/PM reps. His opinion: EMR reps would be far more successful if they took a few lessons from drug reps. Drug reps tend to be well versed on the specifics of their products and able to articulate their advantages and disadvantages over the competition. Generally they were excellent with follow-up and regularly asked physicians for feedback on their products. I have to admit being irritated by that remark at the time, since I always viewed those of us selling EMRs as one step above the former cheerleaders and football players that moved into the pharma world.  On later reflection I decided the observation had (and still does have) merit.

Modernizing Medicine, makers of documentation software for dermatologists, raises $7.1 million, including $4 million from Speedo swimwear owner Pentland Group. The Electronic Medical Assistant application was designed by a practicing dermatologists and costs $650 a month, plus a onetime fee of $6,000.

E-mail Inga.

Practice Wise 4/11/11

Be Your Own Consultant!

So you’re trying to convince your bosses that they need to purchase an EHR because Meaningful Use makes it so. It feels like Y2K all over again. You know, back in the day when we all used a PM system on dumb terminals (ah, but the UNIX platform was so stable!) and you had to convince your doctors that it was time everyone got a PC and Microsoft Office and the new PM software that could give you four-digit years and save the world.

Déjà vu! You’re in this terrifying role where you have to learn the lingo, understand all the bells and whistles of products that make your head spin. Then, convince a single owner or a board of partners that you understand everything you are presenting to them, and your recommendation is …

Who do you trust to educate you on all of this technology? And to help you not lose your job by making a colossal mistake and costing thousands of dollars and jobs and possibly the meltdown of your practice? I know it sounds like doom and gloom but admit it — this is the stuff that keeps you up at night.

I say trust yourself. You can hire a team of free experts, be one yourself, and thrive in this experience. Admit your terror and reach out to the other terrified individuals in your community. How? Start a user group!

1. Don’t wait. You don’t have to be users of anything to start a group. Don’t wait until you get your software and then decide to start or join one. Start a group of almost-EHR users who all know a little about a lot of things or a lot about some things. Share your knowledge.
2. Invite vendors to present to your group. This is easier than attracting dogs with top sirloin. Trust me, you will need to devise a method for a waiting list.
3. Be selective. Even as a group of users, you don’t have a lot of precious time to waste. Research your vendors and invite those who you think will give you the best bang for your buck. Which is zero, but don’t let that be the rate limiter.
4. Ask the non-EHR vendors. You know, that whole group of support consultants and third-party vendors that are like little seedlings in the spring of EHR adoption. They usually see most of the products as they interface. Better yet; they talk to the end users and hear the complaints and praise of everything. Boy, don’t we love to share our experiences with anyone who will listen?
5. Give them the lunch hour for presentation. Make sure they provide the lunch.
6. Invite real (EHR) users to your almost-users group. They will be your deepest resource (see above, don’t we love to share…). From them you will learn what not to do, who not to waste your time on etc. They’re like parents and you should learn from their experiences.
7. Have different members of the group host your meetings. If your office won’t accommodate the crowd, check out hospital conference rooms (can be reserved in advance), the local medical society (should willingly lend to their participating providers), or the presenting vendor (don’t think of this as giving up the upper hand – you get your needs met, they do their presentation, and nobody is worse for the wear).
8. Don’t limit your group to EHR discussions. This kind of change management doesn’t happen in a vacuum. Your entire practice operations are going through electro-shock therapy. Open up to the whole discussion and ways to help each other through this evolution.
9. Keep it free, short, and worthwhile. You will build an amazing panel of experts that are now part of your team. The president runs the superpower of the free world and even he doesn’t know it all. He has a cabinet of experts who advise him. You can, too.
   

Julie McGovern is CEO of Practice Wise, LLC.