DrLyle’s Meaningful Discussion about Meaningful Use 8/26/09

As we all know by now, our federal government is promising up to $44,000 to ambulatory physicians who use a “certified EHR” in a way that fulfills “meaningful use”. The smoke is swirling more than ever around “certification” right now, but things are beginning to get a bit clearer on “meaningful use”. However, there are some concerns from real-world physicians, so let’s hope there are still changes to be made.

Let’s dig into the three “areas” which the HITECH Act specifically says will define Meaningful Use: (1) e-prescribing, (2) interoperability, and (3) data reporting. I will review each one, discuss the potential downsides of current definitions from a “real world perspective”, and suggest some ideas which might allow for more effective approaches to getting the results we want.

E-Prescribing

First, there is the ubiquitous e-prescribing. Everyone understandably loves this term. It implies faster, better, safer prescriptions as compared to hand written scripts. They are legible and there is drug-to-drug interaction checking. My concern here is that the government seems to want to make this equivalent to EDI (electronic data interchange). In other words, they are saying e-prescribing is ONLY fulfilled if the prescription is sent electronically to a pharmacy. So if I use a system that creates and maintains a computerized prescription with decision support, but I print it out for the patient — that does not count??? Unfortunately, this is how the government defined eRx for past reward programs (e.g. Medicare e-prescribing bonuses).

I’ve been creating prescriptions with various EMR systems for almost a decade. I get drug interaction checking, I get legible prescriptions which are saved in my system forever, and I print them out for patients so they can take them to the pharmacy of their choice. It would seem this fulfills the real needs and ideals of e-prescribing, so why make us jump through the final hoop of mandating that I send it electronically to a pharmacy?

Realize I’ve got nothing against the concept, in fact – I sent the world’s first electronic prescription to a pharmacy in Jan, 2000 (really – check it out). However, there are a lot of limitations with this strict requirement. First, not all patients know which pharmacy they are going to use, which means we can’t send it, or we have to spend extra time with the patient looking it up – but unfortunately, PCPs are in short supply, and that is really not the best use of our time.

Second, not all pharmacies accept e-prescriptions. Seriously — even the big chains (e.g. CVS, Walgreens) have individual stores that are not yet set up to accept these. And as of today, they might not accept it for certain types of controlled substances.

Third, most EMR systems are not well designed for EDI (e.g. it adds extra steps to the physician’s workflow, if it is available at all). So why is the government not rewarding physicians who do all their prescribing within their EMR, but simply print out the prescription? My suggestion to is that the government needs to think about expanding the definition of e-prescribing to include any system that includes these three components: (1) structured storage of the medications, (2) some form of drug interaction checking, (3) fulfillment of a legible (e.g. computer-generated) prescription by printing, faxing, or electronic submission. And then let the marketplace and users determine the best way to make these things happen.

Interoperability

Second, there is the issue of Interoperability. I’ve commented before that I think we obsess too much on this topic in search of the perfect world that allows all doctors to have all information on all patients all the time. Guess what? We usually don’t need ALL the information and we certainly don’t have time to wade through it all. Rather we need the relevant information, and often in a summarized format.

For example, we would rather hear “Patient went to ER for abdominal pain 1 month ago, turned out to be a virus”, versus having to review every vital sign, note, and lab result done that day. In the former, the patient could tell me this in five seconds, while in the latter, I would have to wade through dozens of screens and documents to try and get to the same idea.

Of course, I’m not saying that it is useless for EMRs to talk to one another (there is research saying it may cut down on extra tests), but it certainly is not the panacea that is always depicted in the classic anecdote of a man traveling to California and then getting hit by a car (or having an MI) and going to an ER and everything could have been better — if only someone had his EMR data!

In actuality, this is a rare event. The reality is that when it does happen, the patient or family tells the ER what they need to know the majority of the time, or they call the patient’s primary care doctor and get a nice summary via phone or fax. Quite honestly, even if the ER doctors had access to some ultra-secure national database of information, it is unclear if/how they would use it, and the truth is they would still likely call the primary care doctor to confirm anything since there can be so much garbage in-garbage out in those systems.

In other words, while there are some administrative efficiency benefits of disparate EMRs talking to one another, no one has actually found that there are significant quality or efficiency benefits. So let’s focus more on getting them working in each office first, ideally integrating them with labs and other local systems, and worry about regional and national integration down the road.

So my simple suggestion for this topic is to reward physicians who can ensure they have their lab and practice management data in an electronic format. Don’t worry whether they share it with others, just make sure they can get access to it themselves. Now combine those with the prescription data above and you have the makings of data warehouse that can actually support quality improvement programs.

Of course, if you are looking for some national interoperability also, then how about funding these options? I’d suggest it would take less than $10 million to do either of them!

• Require all US citizens to keep a slip of paper in their wallet with their allergies, medications, major problems, and the contact info for their doctors. It’s cheap and ubiquitous. That’s the first place paramedics look whenever they find an unconscious person. If you want to be helpful, allow people to fill out this form online, store it online themselves, and then print in wallet fashion. Or if want to be really fancy, allow them to store it on their driver’s license. My driver’s license currently gets scanned when I pick up Sudafed for my kids, so surely the government can figure this out.
• Create a national repository of all medications prescribed by all pharmacies. I this is possible since some companies offer this service already and many states already do it for narcotics (i.e. I can look up any patient’s name and view all narcotic prescriptions they picked up in the past year). That way, if someone goes to the ER, the ER providers can access this government database to check on all the meds the patients have picked up at the pharmacy. And ironically, this is actually more reliable than getting access to a doctor-created medication profile since the ER wants to know what a patient is really taking, not just what was prescribed. Let’s face it, this would be much quicker, cheaper and more consistent than trying to get all physicians to use an EMR, keep all meds up to date, and then integrate all those systems together!

Data Reporting

Finally, there is the Data Reporting component. OK, no complaints there — that is a good idea. We can’t improve quality without measuring things. Just don’t require that the reports have to come directly out of the “certified EMR”. Similar to PQRS, if a doctor can get you the data by doing a manual review or using a separate database, then let them do that. Many EMRs do not allow for easy data reporting, so many organizations are already pushing data into an “Enterprise Data Warehouse” for reporting instead. Additionally, there are assorted companies that allow for high level quality reporting by interfacing with a physician’s practice management system, their lab system, the payor’s systems, and local pharmacies. They then allow the physicians to access and use that data in ways that quite honestly are better than anything their EMR can give them. And isn’t that what we want?

So in summary, let’s keep the focus on rewarding the ends, not just the means, and we will have a much greater likelihood of moving in the right direction, both with respect to EMR adoption as well as with other innovative ways in which we can use information technology in healthcare.

Lyle Berkowitz, MD is a practicing internal medicine physician, a healthcare IT consultant (www.DrLyle.com) and founder of the Szollosi Healthcare Innovation Program (www.TheSHIPHome.org). He blogs regularly at The Change Doctor (http://drlyle.blogspot.com/).

News 8/25/09

Open-source software for physician offices may be gaining popularity, but this AMA article provides insight to some of the potential pitfalls. Risk of failure is higher than with mainstream alternatives; however, risk can be reduced by selecting software that has been around awhile, has a significant number of developers, has a history of providing regular releases, and is installed in a good number of practices. I’ve yet to see any PM/EMR solutions for the ambulatory world that I’d consider a safe bet, though I believe that Practice Fusion has been fairly successful. Most practices would be safer to go with a mainstream solution unless they have a super-techy doctor involved who wants to spend time tinkering with the computer system.

Speaking of the AMA, President J. James Rohack, MD launches a new blog entitled, “On the Road with Dr. Rohack.” Rohack travels 200 days a year, thus the on-the-road reference. He plans to write about AMA’s efforts to make an impact on issues important to patients and physicians. The first post is a little bland, but maybe Rohack will let some personality come through after he’s been writing awhile.

The HIT Standards Committee recommends using either ICD-9 or SNOMED to meet 2011 EMR standards, but wants to incent providers to move to SNOMED by 2015.

An Epocrates survey of medical students has some interesting findings from tomorrow’s doctors. They like mobile devices, with 45% of them using an iPhone or Touch and 60% of the non-users saying they’ll buy one of those Apple products within a year. They give medical schools an A- (up from a B) exposing them to technology, with 84% saying they’ve had EMR exposure and 90% saying use of an EMR will influence their practice choice. Over 70% of them give the US healthcare system a C grade or lower, and 90% say that information from drug salespeople are not credible (Mr. H paraphrased this finding to say the students believed the drug reps were “scumbag liars”; however, I don’t believe that many people would consider former enthusiastic cheerleaders and hunky football players liars.)

A couple of large medical supply companies say their second quarter sales were up, leading some experts to claim better economic times are ahead for office-based physicians. On the other hand, the uptick may simply be the result of higher sales of infection control supplies and antiviral medications for the upcoming flu season.

Also on the rise: the cost of health insurance. Between 2000 and 2009, the cost of a family premium provided by an employer increased 95.2%. And, plans today have higher deductibles and co-pays. Unfortunately, our incomes have only grown an average of 17.5% over the same period.

The Canadian Medical Association has a new president who is pushing for all physicians to go paperless by the end of 2011. During Dr. Ann Doig’s inauguration speech, she stressed that EMR is one of the keys to fixing Canada’s healthcare system. (That line has a familiar ring to it.)

Much to the pleasure of many clearinghouses, CIGNA Healthcare announces it will drop its five-year exclusive claims clearinghouse contract with Emdeon Business Services as of January 1, 2010. CIGNA names Ingenix as one clearinghouse from which it will accept claims and says other connections will be announced next year.

Depressed? Try sending an instant message to your therapist. Researchers conclude that “online cognitive behavioral therapy” (which sounds like a fancy way of saying you are IM’ing with your therapist) is an effective means of treating depression.

A camouflage-adorned robot helps stateside physicians check on patients as far away as Baghdad, Iraq. Dr. Kevin Chung, who heads the Army’s only burn intensive care unit, uses the “Chungbot” to monitor remote burn victims and to train nurses.

Community Health Centers and FQHCs continue to take advantage of ARRA stimulus funds to upgrade and expand their centers. Last week we noted that NextGen signed on a number of facilities and now eClinicalWorks announces the  addition of 37 new sites. The stimulus package included $851 million in grants so centers could purchase new equipment or HIT systems. HHS anticipates almost 400 clinics will add or expand EHRs.

The state of California awards $1.5 million loan repayment grants to 16 physicians providing care in underserved areas. Isn’t California on the verge of bankruptcy?

Modern Healthcare releases its annual list of the 100 Most Powerful People in Healthcare. Mr. H is noticeably absent (despite my lobbying efforts). President Obama tops the list. Other notables: David Blumenthal at number six; KP’s George Halverson at number 12; CCHIT’s Mark Leavitt at number 58; and the AMA’s James Rohack at number 95.

A man hunting through a dumpster for aluminum cans finds a paper goldmine instead. A Greensboro, NC man comes upon 623 medical charts in an area dumpster, complete with Social Security numbers and copies of drivers’ licenses. The records originated from a practice that had hired a third party to move the charts to a warehouse. No word yet how the charts ended up in the dumpster.

Meanwhile, HHS officials and members of an HIT panel provide assurance that the privacy and security of electronic health records are a priority. In fact, last week the HHS rules that providers and insurers must notify patients if their EHR records are breached, and, alert the media if it affects more than 500 people. I’m guessing the ruling does not apply to paper charts found in dumpsters.

The Ohio Senate considers legislation requiring nurses, doctors, and other healthcare professions to take cultural competency training. Other states apparently have similar laws on the book. Why target just health professionals? Aren’t there also bigots in government, education, and the local grocery store?

E-mail Inga.

Intelligent Healthcare Information Integration 8/22/09

The Over/Under of EHRs

If you be a betting man or woman, you know the over/under is a wager made relative to some predicted number or stat for a given game, series, team, or player. The bettor guesses whether the actual result will be higher or lower than the predicted number, wagering accordingly. The classic example is the combined score for a particular game, say a football game, where the bookmaker predicts the combined final score for both teams and gamblers ante up on either a higher or lower alternative. (Just one of so many great ways to bet your booty away!)

While considering an Over/Under for EHRs, I realized that many EHR vendors have an entirely unrelated set of “overs” and “unders.” Thus, the Over/Under of EHRs:

• Overpromising: EHR sales folks are known far and wide for promising that their system will not only meet your every EHR need, it’ll clean your windows and some will reportedly make toast.
• Underdelivering: Many EHR end users have dirty windows and their bread grows mold waiting for the heat.
• Overcrowding: Crowdsourcing is a powerhouse for innovation and development, best by invitation, not demand. It is not a replacement for first solidifying a product for an optimal end user experience. For EHRs, it should be used to create finesse, not rework clumsy development.
• Underdeveloping: See “Overcrowding.”
• Overestimating: The real pace of “go live” for many practices is far slower and the time to “fully live” often far longer than vendor rep guesstimates.
• Underestimating: Tech heads think their in-depth understanding of the geek world somehow elevates them above the lowly techno-illiterati. The illiterate can learn; the arrogant will find humility a much steeper learning curve.
• Overasking: EHRcos, break your molds! Stop asking only each other what works. Ask outside your boxes.
• Underasking: Don’t EHR developers want to know what motivates and inspires the not-yet-adopted, their largest market target? While it’s always easier to ask those who speak your language, it doesn’t always lead to the insights of “cross-culturalism.” Talk to non-users, not just the techheads. (Also, see “Overasking.”)
• Overextending: More installs means more profit, regardless of the actual support personnel per user ratio. VC pressure may often have a role.
• Undersupporting: Take a lesson, EHRcos: Call Godaddy.com support. Bob Parsons may be rather sexist and not everyone’s cup of tea, but the man understands how to take care of customers.
• Overcharging: Just as so many gripe over the excesses siphoned from our healthcare dollars by insurance company middlemen, many EHRcos seem bent upon oversucking the same marrow.
• Undereducating: With all the grand tools available for training these days (live web conferences, “easy bake” high def video creation, eReaders, etc.,) it amazes me how many providers will agree to a week or two of onsite “education” for something as complex as total workflow redefinition.

OK, time to play bookmaker. Using the 80/20 Rule, if we say 80% full adoption of 80% of available digital utensils, I’ll propose (somewhat from my hiney) the Over/Under for EHRs: 2015. Ladies and gentlemen, place your bets.

I think that only daring speculation can lead us further and not accumulation of facts. – Albert Einstein

Dr. Gregg Alexander is a grunt-in-the-trenches pediatrician and geek. His personal manifesto home page…er..blog…yeh, that’s it, his blog – and he – can be reached through http://madisonpediatric.com or doc@madisonpediatric.com.

News 8/20/09

Healthcare IT coordinator David Blumenthal e-mails a letter promoting EHR as a critical element for healthcare transformation and urging support for the ONC’s work. “As a primary care physician for over 30 years, I spent the first twenty shuffling papers in search of missing studies and frequently hoping, during middle-of-the-night emergencies, that I knew enough about patients’ medical histories to make good decisions.  All that changed when I began to have access to patients’ electronic medical records.  It made me a much better doctor.  I would never go back, and neither would the vast majority of American physicians who have made the leap into the electronic age.”

Over 2,500 GE Healthcare employees from the Milwaukee area are volunteering to help paint, clean, organize, and provide landscaping for local schools. This is the 15th year GE has participated in this single-day volunteer event.

Iowa physician Dr. Jim Selenke offers this sound advice for physicians installing EHRs: become your own technical specialist. “Any physician who has used a computer and is patient and willing to watch and listen to instructions can easily maintain a system.”

Marshfield Clinic (WI)  receives a $13.8 million Medicare bonus after demonstrating significant savings in a CMS Medicare demonstration project. Marshfield showed it was able to improve quality of care at a lower cost than other other regional providers. The clinic’s medical director claims EHR was one ingredient necessary for success.

MD-IT, a provider of medical documentation software and services, acquires the medical transcription unit of Moretti Group. MD-IT now has 12 offices across the country and serves 6,000 physicians nationwide.

Former A4/Allscripts executive David Bond gets out of healthcare to develop a social networking site for teen athletes, earning kudos from former boss John McConnell (who did the same, now running his string of high-end golf courses).

Practice management and RCM provider Avisena announces a 148% increase in quarterly profits, compared to the same period last year.

Caritas Christi Health Care (MA) sells off its physician-office laboratory business to Quest Diagnostics. The deal includes an agreement to link Caritas’ EHR to a shared information exchange so physician practices can access Quest-processed test results.

United Healthcare and the state of Colorado introduce a new telehealth program to help physicians connect to rural and underserved areas.The Connected Care program anticipates facilitating 4,800 specialist visits per year, using a combination of audio and video technology.

MDeverywhere plans to market provider credentialing services, coding audits, and related consulting services from DoctorsManagement.

Tenet Healthcare contracts with physician rating service DrScore.com to provide patient feedback on 185 of its doctors. Dr.Score will collect and analyze online data from patients across three physician networks. Tenet may bring on an additional 185 doctors in the fall.

PM/EMR provider Sajix announces its own “STIMULUS INCENTIVE” program for existing HIT providers and physicians. The company provides few details in their press release, other than to say it provides an “incentive” to the doctors replacing current PM/EMR products with Sajix’s products. However, since the company uses all caps when referring to the program, you have to assume it’s a great deal.

HealthGrades claims it’s the #1 doctor-ratings Web site by an “enormous” margin. The site receives more than seven million individual visits each month and currently includes more than 900,000 patient surveys of doctors.

3M introduces an electronic stethoscope that uses Bluetooth technology to wirelessly transfer body sounds to software for further analysis.

The AMA offers tips for reducing the expense of accepting credit and debit cards. Physicians are encouraged to shop rates, negotiate lower rates, and pay attention to added fees. With typical rates around 2% to 5%, practices can keep costs at the low end by having processors bid for their business.

Americans are living longer than ever, according to the CDC. In 2007, the average American lived to 77.9 years, up from 77.7 the year before. Women still live longer than men (80.4 years versus 75.3 years for men) but the gap is narrowing (7.9 years for difference is 1979 but only 5.1 years today.)

NextGen Healthcare reports that over the last few months 12 community health centers have selected NextGen’s EHR and PM solution.

E-mail Inga.

News 8/18/09

HealthPort files for a $100 million IPO under the Nasdaq exchange. HealthPort was formed two years ago with the merger of SDS and Companion Technologies and last year merged with ChartOne.

Atlanta Women’s Specialists promotes its on-line services that include patient access to their personal medical records. The 11-provider group also encourages direct e-mail access with its physicians. The practices utilizes Allscripts Professional EHR.

Pediatrician Dr. Wendy Frieling joins IT service company PHNS as a regional account executive supervising the delivery of the company’s IT and business process services.

Ophthalmic Imaging Systems posts $2.9 million in net revenues for the 2nd quarter, compared to $3.2 million a year ago. The net loss for the quarter was $4 million, compared to last year’s $400,000. The company blames the revenue decline on lower sales and the loss on increased debt following its merger with MediVision.

A Florida medical magazine covers the history of EMR vendor DoctorsPartner, which says its PM offering was Best in KLAS 2007 and its EMR #2.

Dartmouth College plans to use a $3 million federal grant to develop a telehealth system to monitor patients through mobile phones and wearable wireless medical sensors.

Cielo MedSolutions selects Medfusion’s patient portal solution for use with its disease management patient registry. Cielo will integrate Medfusion’s portal solution to notify patients they are due to schedule a preventative or disease management appointment or to follow-up on a ordered test or procedure.

Over 600 participants traveled to Austin, TX last month to attend e-MDs 5th annual User Conference & Symposium.

You knew someone was bound to offer a “Cash for Clunkers” program for EHRs. MedPlexus offers a stimulus package that grants payments for $3,000 to $5,000 for doctors who replace their previous EHR and/or practice management platform with MedPlexus’ SaaS solution. Creative marketing (sort of) though I wonder if the program really offers pricing that is all that special.

Senators Mark Udall and Kay Hagan introduce a bill to address the shortage of primary care doctors in rural communities. The Rural Physician Pipeline Act would give medical schools resources to establish or expand rural training programs, including recruiting students from rural areas who desire to practice in their hometown or other rural communities.

The Oregon Health & Science University is addressing the physician shortage problem from a different angle. OHSU’s Physician Re-Entry Program is designed to help doctors coming out of retirement re-qualify for licenses. A dozen doctors have completed the program since its inception in 2006.

It’s clear from Friday’s excellent recommendations to HHS by the Certification and Adoption Workgroup of the HIT Policy Committee that they want major changes made to EHR certification. Some of the high points:

• HHS certification (notice they didn’t call it CCHIT certification) is not intended to be a seal of approval.
• A new certification process should be developed that focuses on Meaningful Use rather than specific functionality points (that change will let specialty EMR vendors certify their products).
• Certification should include all privacy and security policies that are in ARRA and HIPAA.
• New highly detailed interoperability and data exchange specs should be created.
• “Test harnesses” should be created so that providers can test their own software.
• Multiple certification organizations should be allowed, with NIST accrediting them.
• ONC should define certification criteria, not the organizations performing the certification testing.
• Certification criteria will be updated no more frequently than once every two years and certification should be good for four years.
• “Lock down” requirements should be eliminated to level the playing field for open source systems.
• Since Meaningful Use definition is imminent, HHS should create a preliminary certification that would be valid through 2011.
• Interesting quotes: “There has been criticism that CCHIT is too closely aligned with HIMSS or with vendors. While we did not see any evidence that vendors were exerting undue influence on CCHIT, we also understand that the appearance of a conflict is important to address … Most vendors advocated for a minimal approach to certification, complaining that CCHIT has ‘hijacked their development effort’ and that they are developing features/functions that nobody will use.”

The takeaway: if the recommendations are accepted, CCHIT’s role will be diminished and shared with other certification bodies, none of which will be allowed to create certification criteria; certification will move away from a detailed product design to focus instead of how EHR products are used; and CCHIT cannot shake its reputation for being controlled by a few big vendors and HIMSS. It’s pretty clear that CCHIT may well have an ongoing role in the government’s HIT policies, but not at the level of influence it has enjoyed until now. Finally, someone says no to HIMSS.

E-mail Inga.