Intelligent Healthcare Information Integration 5/1/10

EMR Mythbusters

Last autumn, at the annual meeting the Ohio Chapter of the American Academy of Pediatrics, I had the tremendous good fortune of giving a talk in tandem with Dr. Andy Spooner, CMIO of Cincinnati Children’s Hospital Medical Center.

I’m not sure I’ve ever felt that being asked to give a talk was a blessed event, but this one broke the mold. Perhaps it was the topic, perhaps it was the meeting, but most likely it was the partner, Dr. Spooner. (I like to think maybe it was a mutual camaraderie and synergism, but I’m pretty sure Andy deserves most of the credit!)

We had been asked to sit on a panel discussing “Technology in Pediatric Practice.” This morphed from the panel to just he and I discussing some of our favorite rumors, half-truths, and misconceptions about EMR adoption and use. We borrowed/adapted the title from one of my favorite geek TV shows. (Props to Jamie, Adam, and all the gang at M5).

There was a pretty good sized crowd and the talk seemed well received. Audience participation was enthusiastic, and afterwards, folks asked us how many times we’d done this before, if our “routine” was fully scripted, or if we might be taking this on the road. (“First time”, “complete ad lib”, and “our agents are taking a meeting on it”, respectively.)

I think what made it so enjoyable for me was the lack of formality and the easy give-and-take rapport between Andy and me. Plus, it was an interesting tête-à-tête: his CMIO, larger center experience and my small practice, trench gruntness. Perhaps most significantly, Andy’s just a very fun person despite his brilliance and a curriculum vita that’s longer than most PhD theses.

Anyway, I bring this up here because we were asked to record our EMR Mythbusters talk for Nuesoft’s Monthly Podcast Series and it was just recently posted. As these hallowed pages are for the “Practice” side of the infamous HIStalk, maybe some of the readers might find our banter worth noting because, while I realize HIStalk Practice readers know all this stuff, there are loads of providers who are still considering EMR adoption and who are trying to fathom our brave new HIT world, especially with the nitrous boost currently being injected by HITECH. Maybe you know a few of them who might enjoy a sort of fun look at some of the HIT issues they’re trying to fathom.

Warning: It is a retake of the full meeting version, around 53 minutes. You may want to bring some popcorn!

From the trenches…

“The first myth of management is that it exists. The second myth of management is that success equals skill.” – Robert Heller

Addenda: 1) Neither Andy nor I have any financial relationship with Nuesoft. 2) There’s a bit of a volume level change several minutes in.

Dr. Gregg Alexander, a grunt in the trenches pediatrician, directs the “Pediatric Office of the Future” exhibit for the American Academy of Pediatrics and is a member of the Professional Advisory Council for ModernMedicine.com. More of his blather…er, writings…can be found at his blog, practice web site or directly from doc@madisonpediatric.com.

News 4/29/10

Regional extension centers may have difficulty finding staff with adequate experience in both software implementation and work-flow adaption, according to a new Health Affairs study. The authors also question the sustainability of RECs due to inadequate funding. Similar programs in Massachusetts and New York have spent $60-80,000 per physician; the proposed federal funding for RECs averages about $6,400 per physician.

Perhaps the Wide River Technology Extension Center in Nebraska has figured out a way to address the experience issue, as well as maximize training dollars. The HIE will offer physicians and staff discounted rates for online HIT and EHR training through Health IT Certification. Great way to train lots of folks at once.

The director of compliance coding at Hickory Cardiology Associates (NC) claims A/R days have dropped from 60 days to 45 since moving to ZirMed’s RCM solutions.

The Alaska EHR Alliance selects e-MDs and Greenway Medical as the “best choices” for the state’s healthcare providers. ACS Healthcare Solutions was the managing consultant for the selection process, which lasted eight months and started from a pool of over 250 EHR vendors.

Ingenix is integrating medical reference materials from Krames into its Ingenix CareTracker EHR system.

AdvancedMD Software adds Akamai Technologies’ Web Application Accelerator service to speed access of its Web-based solution across the Internet.

Three health clinics affiliated with Ephraim McDowell Health (KY) go live on LSS Systems’ practice management and medical records system. The clinics are also able to share data with the hospital’s Meditech software. The hospital plans to roll EHR to eight additional clinics by the fall.

The 58 employed physicians of Mercy Hospital of Portland (ME) are adding Allscripts’ EHR to run with the already installed Allscripts PM product.

The NYC Regional Electronic Adoption Center for Health names Greenway Medical one of its preferred providers of healthcare technology solutions.

Two Virginia practices, an internal medicine practice and a podiatry group, sign up for Benchmark Systems EHR.

Lourdes Medical Associates (NJ) selects athenahealth to provide its RCM services for over 100 providers in its network.

McKesson announces availability of 12 new templates for chiropractors for its Practice Partner, Medisoft, and Lytec MD physician systems. For the next 11 months,  McKesson is also offering chiropractors a rebate with purchase.

Sinai Medical Group (IL) is implementing NextGen’s EHR and PM products and expects to go live in August. Sinai’s faculty group practice includes almost 200 physicians.

A Practice Fusion-sponsored survey finds that patients see an average of 18.7 doctors during their lives. The 18-24 crowd averages a mere 8.3, while folks over age 65 have seen 28.4 physicians. Of course the point is that’s lot of clinical data, mostly on paper, in a lot of different doctors’ offices.

PHR vendor NoMoreClipboard partners with  Sevocity to offer Sevocity EHR clients an integrated patient portal option.

athenahealth celebrates Superhero Day, following the outcome of an employee bet. After being diagnosed with Type 2 Diabetes, a 360-pound athenahealth employee asks the management team for some weight loss motivation. The execs agreed to dress up as superheroes for a day if the employee lost 100 pounds within six months. Spiderman wins the bet and Jonathan Bush has the opportunity to wear Spandex.

E-mail Inga.

HIT Vendor Executives on HITECH and EHR Innovation

We asked several EMR and consulting executives the following question:

What will be the effect of the HITECH Act in terms of short- and long-term EHR innovation?

Victor Arnold, Managing Partner, AsquaredM

What I am hearing from clients is that they are just doing their best to get an EHR up and going, let alone worry about innovation. That means to me the impact is going to be long term — once people figure out what they have, what it *really* does, and then, what they need to do. This will probably take a couple of years to settle in, by my estimate.

Clinical processes are extremely variable, even within a given institution. And the “need to do” is going to be a problem for everyone. I am sensing that people are just now realizing how “one-off” their clinical processes are internally and what a monumental job they are going to have in figuring out, and then deriving, a “common” clinical work flow.

This is the next great hurdle for the EHR. Once they get past congratulating themselves for implementation (clients) and sales (vendors), then they have to make is sustainable. That means some level of standardization. That will drive the innovation.

A counter force that will dampen innovation will be the mainline vendors. This is not to say they aren’t willing to be innovative, but rather they will be in a “guns or butter” situation with R&D versus support budgets, once they get their sales to the point of revenue recognition. This may leave room for an agile vendor that is capable of rapid development to grab a place, or more likely, innovation will come from third party firms that cover the space between vendors and clients and can offer services to clients that address needs that vendors are able to handle. This has been common in the HIT space for years and will probably be in play again.

Rob Culbert, President, Culbert Health

In the short term, EHR vendors will focus on two primary activities: developing functionality to support Meaningful Use and client implementations. The reality is that resource constraints will hinder innovation over the short term. 

In the long term EHR vendors will benefit from having product developers heavily involved in the implementation process and will have a much better understanding of clients needs to drive future development. 

As more practices achieve MU, best practices and advanced informatics capabilities will drive a new wave of transformative innovation focused on clinical quality and outcomes management.

Girish Kumar Navani, CEO, eClinicalWorks

The HITECH Act will probably have a bigger impact on adoption than innovation. We believe that companies will, and should, continue to listen to their customers and build their products accordingly, so with or without the HITECH Act, companies will continue to innovate and make their products more affordable and easier to use.

Tee Green, President, Greenway Medical Technologies

As electronic health record software providers, we have always used our research and development capabilities, both in terms of funding and priority, to drive innovation. And I feel I’m speaking for most of the industry here as well. It’s a matter of seeking the competitive edge and of course advancing healthcare outcomes.

I believe that in union with public health agencies and federal standards boards we have led innovation and paid attention to standards to the point that innovation has made the goals of the HITECH Act realistic for individual care providers and for the creation of a national health information network.

Within the current and anticipated CMS and ONC proposals as well as deadlines and timetables it’s important to remember that the HITECH Act is a foundation for an unlimited potential. In terms of future innovations either short- or long-term, as the HITECH Act provisions take hold, the research and development Greenway is undertaking will continue to utilize customer communication avenues to collaborate on advancements in interoperability, usability, and reporting methods, all to improve point-of-care efficiencies and patient safety. That’s where we see the overriding points of continued innovation.

Greenway’s integrated platform for clinical, financial, and administrative workflows is designed as an innovative foundation allowing for rapid customization of customer and industry requirements. From that foundation comes the ability to add data points and expansion. Within our PrimeSuite EHR  comes PrimeResearch, which advances clinical trials and research and therefore better medicine. Innovations in genetics and mobility and revenue cycle management are also being realized in the short term.

I think the greatest long-term innovation is going to come from within the sensibilities and experiences of care providers. As we drive more and more important data capabilities to them, providers will want more, and together that will fuel collaborative and innovative thinking. It’s a dynamic we’ve realized since our founding by practicing physicians, and I know that the HITECH Act is providing unlimited horizons for innovative leadership.

Hayes Management Consulting, Peter J. Butler, President

The HITECH Act will have a positive impact on EHR innovation in both the short and long term. Providing financial incentives to implement EHRs will speed up EHR adoption. In order to stay competitive in the marketplace, EHR vendors will need to provide innovation solutions and product offerings now that can achieve meaningful use.

With new projects like the Strategic Health IT Advanced Research Projects (SHARP) Program, funded through the HITECH Act, organizations including Harvard and the Mayo Clinic will receive $60 million in cooperative agreements to perform advanced research in healthcare information technology.  Projects under SHARP will help address some of the barriers facing organizations when implementing EHRs and will foster data sharing and collaboration which are essential components to improving healthcare.

Jay R. Anders, MD, CMIO, MED3OOO, Inc.

This is a very interesting question. The HITECH act has a lot of vendors scrambling to both monitor regulations as well as develop functionality that will be needed to certify under Meaningful Use.

In the short term, EHRs will have to adapt quickly to an ever increasing bar proposed by the Meaningful Use regulations. Some vendors will not survive this rapid transition. Innovation functionality will be limited to meeting regulatory requirements and will focus will be placed on truly long range innovation.

In the long term however, focus will shift from meeting regulatory requirements to actually creating products that physicians can use to not only reduce their workload but augment the quality of medicine. Advances in physician decision support and evidence based population health management will start to appear. Also, technology advance in speech recognition and parsing medical text into codable data will mature to the point of being useful.

So the bottom line is: short term, get it installed and paid for. Long term, make it something physicians can really use.

Scott Decker, President, NextGen Healthcare

In the short term, all EHR vendors have to make adjustments to their products to ensure they meet the criteria for meaningful use (MU) – it’s the degree of change required that varies across vendors.

Providers should take note of the amount of work their prospective EHR partners still have to do before choosing one to help them demonstrate MU. NextGen Healthcare has already been helping customers with efforts to achieve MU on time and I am confident the feature sets and flexibility of our software will be able to meet the standards. NextGen EHR version 5.6 is already a CCHIT Certified 2011 Ambulatory EHR and our ePrescribing product holds the highest level of certification available. We have also already demonstrated exchange of data as described in the criteria.

Over time, more regulations will arise and further innovation will inevitably be required of all EHR vendors. Those that are continually innovating though, outside of the latest incentives, will have a head start and be able to start helping clients early. For example, to augment our existing Healthcare Information Exchange product, we developed HIE Connect, so that providers can plug their NextGen EHR into any established HIE and share patient data in real time. At the same time, our NextGen Patient Portal already enables interactive care between the patient and his or her doctor, helping to meet several of the patient access and information exchange criteria for meaningful use.

Betty Otter-Nickerson , President, Sage Healthcare

HITECH is driving physician interest and slowly beginning to drive adoption rates of EHR products, which will in turn make additional investment in those products possible. HITECH also places emphasis on how physicians use EHR.

Our industry’s challenge will be to continue innovating its products so that they become easier for customers to use and less obtrusive to implement, while providing services that make for a seamless integration of information technology into the patient care process. Providing a seamless transition for customers is our primary focus, and should, I expect, eventually, drive any remaining hold-outs toward adopting an EHR.

However, in the short term, HITECH may improve the effects of CCHIT, which historically seem to have stifled innovation to some extent. CCHIT certification has required building features and function for which there is not necessarily a demand in every case, but, nevertheless, must be built to "pass the test".  Also, certification has leveled the playing field to a certain extent since all vendors must offer a number of the same core features.

HITECH should provide opportunity to drive technological innovation as vendors continue setting themselves apart from the competition and add value for improving patient care. Innovation requires investment and resources, which we’re continuing to apply even as we maintain our CCHIT certification, and look toward supporting Meaningful Use.

Evan Steele, CEO, SRSoft

The answer depends on how you define innovation. If you define it as finding new and better ways to help the end-user (i.e., the physician), there is no question that meeting the demands of HITECH will sap innovation in the EMR industry for a long time. As vendors chase increasingly stringent—and ever-changing—government criteria, they will have few resources left to enhance their products in ways that address what physicians want, and really need.

Under the HITECH Act, the government defines what sort of innovation is needed. There will certainly be innovation by EMR vendors as each tries to find a way to align its software with the HITECH criteria.

However, this type of innovation, which is not accompanied by improvements in workflow and productivity, does not help physicians in their daily delivery of patient care. Unfortunately, finding innovative ways to meet these criteria will consume the lion’s share of vendors’ development time and resources, with little or none left over for the innovation that is sorely needed — innovation that would transform failure-prone EMRs that obstruct doctors into user-friendly ones that actually help them.

Physicians are clamoring for products that are easy to use and increase their productivity, letting them provide better care to more patients for higher total revenue in the face of growing demand and declining reimbursement rates. Coming up with those products will require real innovation.

News 4/24/10

CCHIT extends 2011 Ambulatory EHR certification to a couple of new products, the first additions since January. CureMD EHR Version 10 is now fully certified. while NeoMed EHR 3.0 receives pre-market certification.

The Alaska EHR Alliance selects e-MDs and Greenway Medical as the “best choices” for the state’s healthcare providers. ACS Healthcare Solutions was the managing consultant for the selection process, which lasted eight months and started from a pool of over 250 EHR vendors.

Olympic Medical Center (WA) plans to take two clinics live on GE Centricity EMR this week.

Sevocity EHR says that none of the 200 providers who have implemented Sevocity over the last year have asked to take advantage of the company’s implementation guarantee program. The program allows providers to cancel their EHR contract within 60 days of implementation and receive 100% of their money back. Wisely, Sevocity requires providers to document at least 100 patient visits during those 60 days before requesting a cancellation. If a physician documents that many visits, he/she is likely to have gotten over the initial frustrations common with any new EHR.

MGMA adds Navicure to its AdminiServe Partner Network. As a network partner, Navicure will extend MGMA members special terms and discounts for its clearinghouse solution.

National Billing will serve as a certified consultant for practices transitioning to Practice Fusion’s EHR program.

The American College of Physicians speaks out in favor of EHRs, saying they are critical for effective reporting on quality measurements.

athenahealth signs a business process services agreement with IBM to provide voice, data, and administrative support for athenahealth’s RCM services.

An Indianapolis geriatric clinic cuts its “missed specialist referral” rate 20% after implementing a system that generates automated reminders to primary-care physicians if specialist scheduling doesn’t occur in a timely manner. Researchers estimate that 50% of patients fail to receive the specialist treatment recommended by their primary care providers.

Coastal Orthpaedic Associates (SC) selects SRS EMR for its 14 providers.

A group of Massachusetts General Hospital dermatologists determines that online visits are as effective as in-office visits for acne patients. Patients participating in the online study sent their providers digital photos of their skin and answered online questions on their condition. Physicians spent about the same time per patient evaluating online patients as they did in-office patients. Patients, however, spent much less time using online alternative.

Salesforce.com will provide an EMR for this week’s free healthcare clinic at the Los Angeles Sports Arena. Volunteers will enter patient records into 35 laptops and e-mail them to healthcare providers for follow-up care. Over 6,300 people received care at last year’s event.

The Raleigh, NC paper says Allscripts plans to hire about 500 people in the coming year, including about 250 in Raleigh.

The American Academy of Pediatrics  names Christoph Lehmann, MD director of of its new Child Health Informatics Center. He is tasked with the development and implementation of medical informatics programs to help pediatricians and pediatric hospitals adopt EMRs and other healthcare technology.

The AMA launches an online resource to help physicians recoup money from UnitedHealth Group following the insurance carrier’s legal settlement for price-fixing allegations. AMA’s online program will help physicians determine eligibility for reimbursement and will facilitate claims filing. The settlement made more than $350 million available to compensate physicians and patients.

A pediatrician blogger offers seven reasons why medical practices have yet to adopt EMRs. The noted items include a couple we have heard many times before: price and usability. However, he also points out that the lack of dominant players and too many product choices makes the selection process confusing. Doctors also realize that because of the size of the investment, they are locked in with their choice for a while once they settle on a solution. Finally, interoperability is mentioned as a concern. I’d also throw in the reason (excuse?) that many physicians are hoping that someone else will step forward with a checkbook to pay for the project (the hospital, perhaps). Any others?

E-mail Inga.

Intelligent Healthcare Information Integration 4/24/10

Intelligent EHR Help

Many if not most of you reading these pages are already EHR savvy. You have either struggled through the process of swapping your trusty old pen and paper for some version of digital data collection or else you’re on the side of the suppliers of the necessary paraphernalia for HIT. While I hope you’ll enjoy this post, I really hope you’ll consider sharing it with one of your friends or colleagues who aren’t yet on the electronic bandwagon.

For those providers out there who’ve made the switch, remember back to the Days of Decision? (Maybe that should be Days of Indecision). Remember all the hours of frustration spent just trying to find out what information you needed in order to even begin to figure out what sort of system might best suit your needs? Remember when “you didn’t know what you didn’t know” about EMRs?

For the vendor folks out there, how much more valuable would a potential new client be if they were fully prepared to make the switch to an EMR? Wouldn’t a medical practice that had all its ducks rowed up be much more likely to have a successful install, one that doesn’t revert to the dreaded “Failed and De-installed” file?

If we’re honest with ourselves, there’s no such beast, yet, as a perfect EMR. They all have issues and areas of weakness. But, it isn’t the “not ready for prime time” phenomenon that derails many installations. The main circuit breaker to blow, preventing many, if not most, successful transitions from pen and paper to digital seems to me to be lack of adequate preparation and support.

So much emphasis has traditionally been placed upon EMR/EHR selection. If more practices were adequately prepared for the gigantic operational switch that is to come with an EMR, then failure rates would fall and purchased systems sitting on shelves collecting dust would be less frequent.

Of course, larger centers and institutions have IT departments, educational staff, and committees ad nauseam to assist in the preparatory process. (Some still don’t prep up very well.) But, smaller practices, where the vast majority of healthcare in our country is delivered, have no such support teams to task with these time-consuming chores. A doc or two, perhaps an office manager, is saddled with taking on the tremendous task of trying to determine what their little organization needs to get “digified” and then must sift through scores, hundreds even, of available products.

Consultants are available and can provide the help needed, but they are often somewhat beyond the means of smaller practices. This is especially true if a practice needs “full service” planning, selection, and negotiation assistance.

EHR selection tools are available, and I personally like several of them, but their roll is more limited, their focus being upon the actual selection of an EMR or EHR.

But, as many of us can attest, the planning portion is often the key element in successful EMR adoption. Poorly done, it can sink the most enthusiastic advocate’s plans. Taking the time before implementation to define the practice’s current situation, determine how key workflow and staffing issues will be altered, delineate technology needs, and calculate capital requirements can dramatically enhance the opportunities for successful EMR implementation.

This, however, is very tough to do when you’re busy taking care of patients and meeting the day-to-day demands of a small business. That’s why I got very excited when I discovered a new tool designed to fill this need, one that is both affordable and considerate of the needs of a small practice.

Having already implemented our EHR, I can’t bear first hand witness to this tool’s full prowess. I did convince the developers to allow me access to their web portal, a key component of the product, which gave me a deeper view than just a demo or white page. From this access, from my personal past experiences, and from the innumerable conversations I’ve had with colleagues seeking to demystify this digital dilemma, I can say that it appears to fit the old bill of “just what the doctor ordered.”

They have consolidated a ton of information, organized it into guided steps and phases, and built, essentially, a correspondence course for EHR preparation and eventual selection. It is a “hand holding,” but in the very best sense. Getting started with figuring out what you need is a huge hurdle; having an affordable tool to assist you in starting the race on the correct foot is huge. This product provides guidance, helps you find and organize the information you’ll need, and know what work within your own practice is necessary.

Not insignificantly, this particular instrument also includes real, live consultants, vetted by the MGMA, to assist with the inevitable questions and unique practice issues. Their time is used more efficiently as much of the legwork is done via the guided “homework” laid out in the online program. Additional consultant time is available, for an additional fee, if required. There’s even a higher end version where you can have the consultant act as the complete project manager.

The developer of this “homeschooler tool” is has their eye upon profit, to be sure. However, at the proffered price, they obviously aren’t going to ring any big bells at the NYSE from this product alone. The motive, which isn’t hidden or obtuse, comes from enhanced connectivity: the more digitally connected a practice is, the more likely they are to seek digitally-connected tools. Thus, Welch Allyn – you know, the folks whose name is probably on the otoscope you or your doctor uses every day – saw fit to try and assist practices with EMR adoption by developing their “EHR Prep-Select Program” as they now have a passel of products which you’ll only want if you’re down with things digital.

In preparing this piece, I Googled and Binged about a bit. There may be other such tools available, but I wasn’t able to easily find anything similar. Actually, the landscape doesn’t appear all that different from when I first began my EMR search earlier this decade. There’s lots of information to be found, but sorting through what is necessary and valuable for me and mine versus what is salesmanship and schlock appears just about as daunting as ever.

Having a full-time, industry-savvy consultant help walk you through this morass would, obviously, be preferable. Larger groups and institutions are well-served by such professional guidance. Even I used one for my final contract negotiations and was very satisfied with both the cost and the service. But, as a solo doc, I would never have been able to afford the five figures it would have run to engage a consultant for full preparatory planning. Such a tool as this, though, appears to be a “next best” option at a fraction of the price.

I have absolutely no desire begin the process again myself – believe me! – but I can say with unequivocated assuredness that, if I were, I would absolutely consider such a helpmate. The time savings alone would be well worth the investment.

By the way, if anyone knows of similar tools or services, I’d really appreciate hearing about them.

From the trenches…

“The rule is perfect: in all matters of opinion our adversaries are insane.”  – Mark Twain

Dr. Gregg Alexander, a grunt in the trenches pediatrician, directs the “Pediatric Office of the Future” exhibit for the American Academy of Pediatrics and is a member of the Professional Advisory Council for ModernMedicine.com. More of his blather…er, writings…can be found at his blog, practice web site or directly from doc@madisonpediatric.com.