Intelligent Healthcare Information Integration 3/16/10

“HOST YOUR EMR LOCALLY!” the Web Yelled Today

Here I sit, typing away between patients, grateful that we haven’t had to yank the old pens and papers from their dusty shelves. We’re still seeing patients, still point-and-clicking away, capturing data and making appointments with ease, but not because we’re just so darned connected. Actually, we’re not.

I just got off the phone with our high speed DSL provider, a company with whom I’ve been well-pleased these past four years. After the expected interminable on-hold time, I was told by the very first rep with whom I was connected that she had just received word of a large area problem affecting our service. We had been issued a “Level 4” status (as if I’m supposed to know what that signifies) and the repair worker bees were busy getting to the problem. “They have three days to correct the problem,” she told me.

Not knowing just exactly who had granted them those three days and uncertain as to what little old me could do if the problem persisted beyond the allotted period, I gratefully thanked this pleasant rep, realizing she was just another worker bee who had no more she could offer. (She was likely on her way to many more calls about the very same issue and I didn’t envy her at all.)

Four more patients seen and digitally scribed since that last paragraph, four more who won’t need to have their info re-entered at a later time nor scanned in and, thus, essentially worthless, digitally speaking. Seven patients scheduled for follow-up or for a new appointment, work which won’t need duplicated once we rejoin the Web. In the meantime, the ISP home page which I had opened twenty minutes ago is about two-thirds loaded. (Dialup was never so slow.)

My EHR is Web-based. We could have gone the ASP route. Personally, I love the “cloud” concept and see real value for many “softwares” as a service. But, perhaps it is the geek in me who wanted his own servers, perhaps I’m more of a control freak than I care to admit, or perhaps I just knew I’d be happier with locally hosted speed and reliability. Any which way, I chose to host at home and, especially right now, I’m really happy with that decision.

Full disclosure here: Yes, we’ve had problems with our servers. Yes, we’ve had down time from RAID failure. The difference, and why I’m still a fan of local hosting for our purposes, is that when those occurred, I had some control. I could call for help, boots on the ground, and see what needed to be done, swapped, or replaced. Today, I just sit and wait while the worker bees are hopefully buzzing their way to the honeycomb cell which is the source of our hive’s disruption. I have no clue if three days will pass without being hotwired to the Web. Hector’s pup, I can’t even get my daily news jolt! That’s almost as bad as a lack of coffee. (Maybe I want to restart my daily newspaper subscription?)

Interestingly, Google searches still work like a charm, fast as ever. Score one for the cloud. Still, I’m listening to the Web yell, “Keep your hosting local!” while I handwrite another prescription that I am unable, today, to e-prescribe.

From the trenches (wondering when, or if, this will get through to the Web)…

Who cares about the clouds when we’re together? Just sing a song and bring the sunny weather. – Dale Evans Rogers

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 3/16/10

CCHIT files its comments on the Interim Final Rules and warns that the currently proposed standards might slow the pace of EHR adoption. Dr. Mark Leavitt points to the omission of standards for receiving lab results and for exchanging clinical standards, even though widely support standards already exist. CCHIT also says that some of the proposed functions are too microscopically defined, while others are still undefined.

Meanwhile, CCHIT says it is suspending any initial or incremental modular testing until it has an accredited Stage 1 ARRA test script to use. A note on their website also indicates that CCHIT is “confident” about its prospects for becoming accredited.

And, Drummond Group re-affirms its desire to be certified as a authorized testing and certification body. The company is making internal preparations and plans to be ready for EHR testing later this year.

The Senate passes legislation that would allow certain hospital-based physicians to qualify for incentive payments under ARRA. The amendment excludes ER physicians or those furnishing substantially all their services in an inpatient room. However, the legislation would make eligible physicians working in ambulatory facilities owned by hospitals. The provision was part of a jobs bill that now moves to the House for further consideration. If you recall, the House had included similar wording in a bill a couple weeks ago, but it was stripped at the last minute. Don’t spend those stimulus pennies yet.

After delaying the release its numbers, athenahealth posts a decline in profits and jump in revenue for Q4 and 2009. athenahealth restated its financials going back to 2005 as a result of an internal accounting policy review, initiated by the company, and related to the timing of amortization for deferred implementation revenue. For Q4, revenue grew 33% over 2008’s numbers, to $54.4 million; for the year, revenue jumped 38% to $188.5 million. Reported GAAP net income, however, fell 84% to $4.3 million in Q4, compared to $26.8 million a year ago; annual net income fell from $31.5 million to $9.3 million. The $.17/share earnings were in line with analyst expectations.

Vitalize Consulting appoints Tim McMullen its executive VP of sales. McMullen most recently served as a VP at maxIT Healthcare and was a national VP and partner with First Consulting before that.

Sales types be warned: physicians report that their offices are visited by up to 20 sales reps each week from the pharma or medical device industry. No wonder doctors have no time to hear about your best-thing-since-sliced-bread EMR. Half the physicians say they require or prefer reps to schedule one-on-one appointments.

Edge EHR Corp. announces plans to acquire Goal Software, a provider of practice management software for the eyecare industry. Edge is hoping some of Goal’s 700 providers add its EdgeEHR application.

One hundred percent of primary care doctors in Denmark use EMRs and almost all medical communication between providers, specialists and hospitals is electronic. The government made EMR use mandatory in 2004, and in 2009 doctors were required to use email to communicate with patients. To spur adoption, the government used financial incentives to physicians, including faster re-imbursement and payment for patient-doctor email consults.

Marquette General Health System plans to deploy McKesson’s Practice Partner EHR to its 140 employed clinicians across 30 owned physician practices. In addition, the hospital expects dozens of independent affiliated practices to adopt Practice Partner as well. The hospital will integrate the EHR with its Paragon HIS.

BCBS of Western NY and Blue Shield of NE-NY are the latest carriers to agree to cover telehealth services for patients connecting to providers via the American Well Online Care platform.

AdvancedMD hires William H. Stone as its VP and GM of Billing Services. Stone joins AdvancedMD after 11 years at MED3OOO where he served as corporate VP of Business Development.

A Gerson Lehrman Group report suggests that EHR adoption is growing faster than once predicted. Physicians have finally begun to realize that they will have little choice but to go electronic in order to maintain a viable professional existence. Physicians are now concluding that if they must do it, they might as well get as much from the federal government as possible. The report suggests we will soon see a “tipping point” toward widespread adoption of EMR. Perhaps, although it seems the “experts” have been saying we’ve been on the verge of a tipping point for the last 10 years.

CapSite sent over a copy of their very juicy 2010 U.S. Ambulatory EHR Study, which looks at the market’s response to the HITECH component of ARRA. The company sees an opportunity of more than $1 billion in net new business in the 1-10 provider space and $2 billion across the whole ambulatory EHR space. In other words, when we hit that tipping point, it’s going to be mighty big. The report is a good read, if you want to get a handle on today’s market.

E-mail Inga.

Intelligent Healthcare Information Integration 3/12/10

EMR. Cart. Horse.

Outcomes and quality reporting and meaningful use – cool.

I mean, really, is there a doc out there who doesn’t think improving patient outcomes or obtaining and sharing useful data or using any tool in their arsenal “meaningfully”  isn’t just plain, old, common sense, good stuff?

However, all these sound just about as logical to a physician as “you need to eat your vegetables”  sounds to a child. Sure, we all want to grow big and strong; we get that. But, if the veggies don’t taste good, if they aren’t presented in an eye-friendly way, if they make a medical practice “gag,” how many docs are going to be enticed to “eat what’s good for them?” Seems a lot like trying to inspire six year olds to eat plain Brussels sprouts.

What started out in with Dr. Larry Weed taking his POMR (Problem-Oriented Medical Record) and SOAP Note brilliance and extending it to digital “data acquisition and retrieval systems” which would extend the brains of physicians helping them make more accurate diagnoses and more effectively deliver “proper care” has gotten completely kerflobbled.

Instead of using computers to do what they do best in helping medical care providers do what they do best, we have skipped right over the logical progression that the good Dr. Weed envisioned some 40 years ago. We wonder why we are now trying to figure out why HIT isn’t being devoured by doctors. We’ve placed a plate of barely warm Brussels sprouts before the healthcare child; now we’re trying to bribe and even threaten punishment if he doesn’t eat.

Instead of keeping the healthcare provider providing healthcare and extending his mental powers onto peripheral brains with tremendous storage and retrieval strengths, we’ve twisted the focus toward turning doctors into mere data input devices. Instead of empowering physicians, we’re eviscerating their strengths and training and minimizing their cognitive clout. Instead of using digitization to maximize our doctors’ capacities, we have seen it used to detract from their mission and delimit their mentations.

In 1997, Larry wrote:

“The meteoric shower of medicine’s scientific achievements can overwhelm a doctor’s mind. A patient has no assurance that his or her doctor is able to take into account all relevant scientific knowledge and integrate it with detailed data about the patient’s own condition. Yet few doctors, patients, or policy makers recognise that modern information tools can become the loom for weaving these two bodies of knowledge into a fabric. In fact, few recognise the dimensions of the problem.”

Recognizing “the dimensions of the problem” and righting the course we now follow won’t be easy, by any means. But, at least for the foreseeable future, computers won’t be able to make the myriad of associations and subtle nuance recognitions required for accurate medical diagnoses on a per patient basis. The brains of our healthcare providers still outshine the petafloppiest supercomputer.

You have a chance of getting a child to eat Caramelized Brussels Sprouts with Pistachios and Red Onions just as you have a real chance of broad EMR adoption if you present something attractive, tasty, and “good for them” if you keep the focus upon enabling doctors’ strengths, not detracting from them.

Before we start reporting, measuring quality, and worrying about outcomes, how about we enable the doctors’  mental machinery and figure out how to make their data capture requirements unrestricting of their abilities to continue to care for us as we go about gathering enough data to meaningfully use?

From the trenches…

“It is the good horse that draws its own cart.” – Irish Proverb

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 3/11/10

From: Phased “Re: Dr. Alexander and Meaningful Views. I was excited to read your blog post about Meaningful Views, and helping physicians delivery better quality care, by providing tools and rich data that is easy to digest, accessible, and fast to access. From my perspective, it seems that the main focus for a majority of companies and industry folk, is simply revolving around the “Meaningful Use” buzzword, and the reimbursement incentives. Not so much around helping the ACTUAL population responsible for making the healthcare system better!!”

The ONC officially publishes its proposed rule establishing two certifications programs to test and certify EHRs. Organizations wanting to qualify as an “ONC-Authorized Certification Body” for the “temporary” program would be required to submit an application and demonstrates its competency to test and certify EHRs. CCHIT has not been granted grandfather status for testing, though they will likely be one of only a few organizations ready and able to qualify under the new program. Creating the temporary program would allow EHR programs or modules to be certified as early as this summer, and thus eliminating uncertainty as to whether or not a particular product is “certified” for incentive programs. The temporary program would expire the first quarter of 2012 and replaced with a permanent program that would designate an outside agency to certify organizations.

Quest Diagnostics and Surescripts team up to form an integrated service that combines lab and prescription information available to connected physician. On the surface the announcement doesn’t sound like much, but when you consider that Quest has 150,000 connected physicians and Surescripts has 170,000 active subscribers, that’s a lot of providers that will now have electronic access to both lab and prescription data.

Annapolis Pediatrics selects Sage Intergy suite to automate its clinical and financial operations. Annapolis Pediatrics is a four-location, 21 provider group.

Physicians Practice Organization (IN) implements MedInformatix Enterprise Practice Management and EMR to 14 of its 17 affiliated clinics.

By 2012, 81% of physicians are expected to use smartphones, according to a Manhattan Research study. Of those smartphone users, half will utilize the devices for administrative functions, learning, and patient care.

The Ohio House of Representatives passes a bill that would create and test a patient-centered medical home. Participating physicians could be eligible for reimbursements up to 75% for any HIT system purchased for the project, including training and technical support required for the medical home conversion. The bill now goes to the Ohio Senate for consideration.

Here’s some fuel for the naysayers who claim automation doesn’t improve quality of care. Canadian researchers find that computer reminders sent to physicians during routine electronic ordering or charting improve yield smaller improvements than expected. A review of 28 clinical trials yielded a median improvement of only 5.6%.

ASG Software Solutions and CTG Healthcare Solutions form a partnership that leverages CTG’s implementation and training expertise to install the ASG-MedAppz EMR.

Ingenious Med announces a new application for BlackBerry smartphones that will allow physicians to access the charge and data capture applications within their IM Practice Manager software.

CNNMoney takes a look at the EMR field, pointing out that the industry is ripe for consolidation. Of today’s 300 to 400 vendors, look for some of the bigger players to purchase smaller companies. Often the large vendors are not interested in catering to smaller practices, which works in favor Internet-based EMR vendors who typically  can offer providers a lower-priced alternative. None of this is particularly new news if you been in the EMR world awhile. What is interesting is that the main stream press is focusing attention on our space like never before.

CMS posts additional public comments to the proposed meaningful use definitions. The public still expresses concern that the bar is set too high, especially in the early years. Other comments suggest the government needs to re-think such areas as interoperability, the definition of eligible provider, and specialist requirements. Here is a sampling:

The requirements for meaningful use are too restrictive to be of any value to most specialty physicians. Only a complete EHR will provide the value we are all looking for. Primary care physicians are about the only ones that can take advantage of the incentives and therefore will be the only ones adopting EHR’s. Specialty practices all have something to contribute to a complete and comprehensive EHR; leaving them out will only result in a lot of money spent with very little gained. I think there’s still a lot of work left to do to incent all necessary groups to participate.

The incentive is flawed when you consider that the current EHR technology is built on the current healthcare business model, which most agree is suspect and requires reform. Change the business model first, then adapt new EHR technology with incentive.  Meaningful use objectives and measures for EP’s are unrealistic and if they are anything like PQRI are meaningless. Therefore the incentive is likely not achievable for many physicians.

As a community hospital employing 150 outpatient PCPs who utilize hospital-based billing, we find the ruling of our ineligibility for the outpatient EHR incentive program non-congruent with the stated objectives of this program. Conceptually, hospital-based billing is a separate and unrelated issue from the capacity to develop and use outpatient EHRs in a meaningful way to improve patient safety and quality. We strongly urge a reconsideration of this issue in order to align the incentives of our institution with the goals of the Office of the National Coordinator.

E-mail Inga.

HIStalk Practice Interviews Joel Feinman

Joel A. Feinman, PhD is a psychologist and Board Chair, President and Associate Medical Director for Valley Medical Group, Greenfield, MA.

Give me some background on your practice.

We’re a primary care practice – multispecialty. We have four centers. We have about 60,000 patient charts; about 60 providers; about 350 staff; in western Massachusetts.

What kind of technology are you using in the practice, in terms of your electronic medical records and billing software?

We’ve been an athenahealth practice since the end of 2000, using their practice management system. Then we brought up athenaClinicals one year ago, so we’re totally integrated on athena right now.

Are all your physicians actively using the EMR piece of it?

All of our primary care and MDs are using it. The only folks who are currently not using it routinely are our optometrists and our behavioral health therapists. But, all of our MDs are using it, all of our PAs, NPs. Our psychiatrists use it to prescribe and order, and get lab results. The subspecialties, such as rheumatology, podiatry, endocrinology, are all using it as well. The other thing we should say is we have our own physician’s office lab, and so the laboratory’s up. We have our own in-house radiology systems, so our radiologists use it as well. Although, for radiology, they’re using an athena interface at the moment; it’s not directly integrated.

And your lab is integrated?

We have a results interface, but the orders are not interfaced, and the lab information system is LabDAQ. It’s not integrated on the order side, but it is on the results side. The important part is that whenever one of our physicians orders a lab, there’s a process to get their lab into the EMR, and then into the lab information system. Then the result comes back to their inbox in the EMR. That part is solid.

Usually, when practices are moving to EMR, the biggest problem tends to be change management – changing the behavior of the clinicians. How did you overcome that?

We did this in several phases because this is our second EMR. We had a previous EMR that we were basically a beta customer for. We thought it was further along than it was. So, we went from paper records to this previous EMR, and a lot of the sweat and strain, I think we kind of got it over with in that transition. But, you never get over all of it.

We got people used to using the devices that they’re using. We got people used to figuring out, “What’s the stuff I really need to see in the EMR?” We got people just used to the idea of using this kind of technology. That system didn’t work well, so after about a year and a half, we began to search for the next system.

By then, athenaClinicals had matured quite a bit and we decided it would be better to have a totally integrated system than one that would have an EMR integrating with our practice management system, via interfaces. So, the change management really was about the first system.

I think the change from the first system to athena was fairly easy because, number one: people were used to the devices. They were used to having an electronic system, and they were searching for some relief from the system that didn’t work well. We brought everybody up, I think, within a week. The first EMR, we brought people up in stages – one health center at a time. Whereas, when we went to the new EMR, the athenaclinicals product, we had to bring everybody up at the same time. It went very smoothly compared to our first time around.

I understand that Valley Medical was recently certified as a medical home. Tell me a bit about that qualification process.

We belong to a physician practice organization from one of the local hospital’s groups. They came out and they did a practice assessment for us where they went through all the different standards and elements that are required for the NCQA certification for medical homes, and they actually rated us – how we would rate against the standard.

After that practice assessment was completed and we got our results, we realized that a lot of the processes and procedures and policies that NCQA was looking for were already in place, in terms of Patient-Centered Medical Homes standards. It was a no-brainer for us then, to move forward and actually become certified, and actually apply to be certified and review our records and commit.

After we finished the practice assessment, then, of course, there were areas that were highlighted that we needed to either tweak the policy, or make slight changes. Or, maybe even create a new process that we hadn’t thought about it. So we went through a six-month period of looking at how we deliver care to patients and what areas we needed to improve upon – writing new policies, rolling it out to the staff, re-measuring and making sure that the new process was incorporated into the daily workflow of our staff.

Then, after that was completed we did some mock chart reviews just to see how we would measure up against the standards for the chart reading portion. Again, we did pretty well in that. It highlighted some areas that we needed to improve on as far as how we document. Not that we weren’t providing the care, but we needed to improve how we’re documenting it in their medical record.

One of the major areas that we found that we didn’t do well was documenting progress towards patient goals. We didn’t have goals for the patients. We weren’t good about saying, “We want you to reach this goal, and this is how we’re going to help you do it.” So, we had to go back to the physicians and the practitioners and the clinical staff, and everybody worked together to document what was necessary. We did that for about three months, I would say. We re-measured and kept looking and seeing how people were doing with the changes. Then, we actually set our survey date.

In the meantime, we were compiling all these documents and putting them in a folder, like an electronic folder that would be submitted as part of our certification process. Then we had a chart review, and that took three days. It was a pretty intensive chart review. It was basically 36 charts for each medical provider – MD provider – in our primary care practice. The charts had to be of patients that were seen for our three clinically important conditions. What they mean by clinically important conditions is usually the conditions that you see the most patients for, or are the most chronic in your population, or would have the most benefit of being managed better.

Our three clinically important conditions were diabetes, hypertension, and coronary artery disease. After we compiled all the chart review results, the whole package got submitted to NCQA and it was about a 30-40 day waiting period before we found out if we had passed. We passed with flying colors.

You mentioned in here that there was a lot of information that you had to compile along the way. How did the EMR facilitate that?

The EMR facilitated that because it was very easy to go in and take screenshots of different areas of the electronic medical record. If we needed to show that we manage our patients who have a different language, we could go in and take a screenshot of the actual field in the EMR that document the patient speaks Spanish, or that the patient needs an interpreter.

Do you think that if a practice did not have an EMR it would be possible, or challenging to do a qualification?

I think it would be very challenging. I don’t think you actually have to have electronic systems, but I can’t see how anybody would pull that off without one. It would be very time consuming and very difficult. Even more important than meeting the qualifications for NCQA, I can’t see how you could have a Patient-Centered Medical Home without some way of aggregating information, making it available to point-of-care and updating it constantly; having it available whether you’re in one building or another, having a medication list that’s accurate and up-to-date and readable; having a problem list that is accurate, up-to-date, and readable.

So the issue of getting yourself certified, I think, would be very hard to do that on a paper system. But the more important issue is how you take care of patients. I don’t see how you can do that anymore without some kind of electronic system that actually works.

The other thing the EMR affords you is that you can template things so that you know that the important parts of the documentation aren’t going to be missed. When you have a piece of paper, you can write anything on a piece of paper. But if you have an actual templated visit for say, diabetes, that goes through X, Y, and Z of what needs to be covered at that visit, it prompts the provider to make sure that they cover all the bases.

I assume that you’re also going to be trying to qualify for the ARRA stimulus money?

Yes.

How has your use of the EMR changed now that we have a clearer idea of what the Meaningful Use requirements are going to be?

I don’t think it’s changed at all. I think that the product itself was designed, set up, and actually works, in a way that will meet the Meaningful Use criteria – maybe with a couple of tweaks here and there. We haven’t changed the way we’re using it, but we did just bring up our patient portal. I think that is one way that we’re going to hit a homerun with Meaningful Use.

That’s just one of the things that’s so useful for us about athena is they’re busy scanning the federal regulations to make sure that their product is going to meet this criteria. For example, the patient summary, we always were able to provide the patients a summary of their visit, but the system has now been configured so that it’s really easy to track that we’ve given that information to the patient. So yes, we’re sort of catering to that Meaningful Use, but mostly we’re just using the EMR to take care of our patients.

Even with all these opportunities for stimulus funding and whatnot, there are still many physicians who are avoiding adopting EMR. What do you think needs to change in the industry to increase physician adoption?

For the smaller practices, I think even the stimulus money itself probably doesn’t get a doctor or a doctor’s practice to the point of saying, “I absolutely have to do this, or else.” There’s a lot more money that physicians will have to spend to get EMRs up and running than will be reimbursed by stimulus dollars. I think most practices are realizing that you simply cannot manage in a paper world anymore. If they haven’t hit that reality yet, they’re going to hit it soon. I think that’s going to drive them as much as the stimulus dollars, to some electronic system.

Plus, I’m really hoping that we get to the point in the healthcare system where there is some kind of master plan that allows sharing of information easily and accurately, and securely. So if my mom’s in the hospital in Florida, and her doctor is in Massachusetts, that ER can pull up her med list.

When I’ve talked to small physician practices, what they tell me is they’re waiting to know what the data exchange is going to look like, what information has to be kept. Everybody’s afraid of signing up with an EMR that’s going to disappear or not going to meet Meaningful Use, or not going to be able to be used in any of these regional information exchanges. I mean, it’s like all the people that invested in the Betamax video players, and then they went away because the VCR ones took over. People are afraid to invest in the Beta.

In Massachusetts, for instance, there’s already legislation that’s mandating physicians have some electronic system by 2013. I think the handwriting, clearly, is on the wall; I think a lot of the stuff is what you talked about before about change management. It’s a money issue. There’s the “assure me that this is really good for my patients and I’m going to have some real benefits from this.” Then, there’s “Oh my god, how do I actually make this happen?” That’s a big hurdle.

But, the more practices start doing it, the more other physicians are looking around at their colleagues and saying they need to get on the bandwagon.

Have we reached the tipping point yet, or is that still to come?

Well around here, I think we’re close to the tipping point. There are still a lot of practices that haven’t made the plunge yet, but they’re getting very serious, so I think it is coming. The other thing is people are probably getting tired of being badgered by the 50-60-70 companies out there – advertising and calling them, and sending them emails. At some point, that herd is thinned out to 5 or 10.

Practices will be fine as long as they’ve done enough homework and confident that the one they’re buying is going to be around for the long haul. I think we’re pretty convinced that the one we have is going to be around for the long haul.