News 9/3/09

From: Curious George “Re: OSHA. I hear that hospitals are definitely on their toes in case an OSHA inspector drops in for a chat. Do you have any information on how many physician clinics are being targeted by OSHA? Have you heard of anyone who has and what their top five non-compliant issues were? I’d like to hear from practice managers what they are doing with regards to OSHA and how many have actually ever been audited, and what your take on this is. How serious is the threat of inspections are in our business because the articles I read were way beyond that book of MSDS pages most of us have stuck somewhere, but rarely update – not to mention all the other issues we could be hit with during a visit.” I’m glad to some asking around. In the meantime, I’d also like to hear from any practice managers (or doctors or consultants) who have opinions on this.

Patient-centered medical home models provide patients better primary care, without adding additional costs. Medical home patients had 29% fewer ER visits and 11% fewer hospitalizations than patients utilizing services in a traditional primary care environment. Group Health Cooperative conducted the one-year study and found that providers relied heavily on e-mail and made the most of technology, including EMRs. Providers also reported burn-out rates 20% lower than the control group.

Time magazine also took a look at the growth of retail clinics and says these practices “are rapidly becoming to the health-care industry what Fotomat was to the camera world.” The Fotomat analogy is particularly interesting given that Fotomat closed its online presence just this week. Of course, the cute little drive-up kiosks closed several years ago as Fotomat’s one-day photo developing service became obsolete with the advent of one-hour photo processing, then digital photography. Which all leads me to wonder if the growth of telemedicine will one day make retail clinics obsolete.

ZirMed introduces a new package that includes eligibility verification, claims management, and electronic remittance, targeting smaller practices with its new ZirMed One product, which essentially bundles three stand-alone products into one.

athenahealth’s Maine Operation Center is named one of the 2009 Best Places to Work in Maine.

Delaware’s Board of Medical Practice sets the maximum rates for copying patient medical records at $2 per page for the first 10 pages. The maximum per page fee declines based on volume and 50 cents is maximum per-page fee after the first 60. Though the costs are currently for both paper and electronic records, the board is considering lowering the fees for electronic records.

Pfizer agrees to pay the government a whopping $2.3 billion to settle a healthcare fraud case. Pfizer was accused of fraudulently marketing the anti-inflammatory drug Bextra and illegally promoting other drugs. It’s the Justice Department’s largest healthcare fraud settlement ever.

Atlanta Women’s Specialists puts out a press release about the benefits of its EMR system, which includes increased staff efficiency and safer care. The practice posts and flags abnormal test results within 24 hour, sends prenatal records directly to the hospital, and exchanges information with other medical practices via the Medicity Novo Grid. The practice will soon deploy smart phones as well.

We are looking for some guest columnists to share their knowledge on HIT in the ambulatory world. In particular, we’d love a clinician who is willing to share his/her EMR journey. If that’s not your thing, but you have other relevant insights to share, let send over an e-mail.

AHRQ plans to collect data from phyicians and pharmacies to identify what accelerates and what hinders the adoption of e-prescribing. The two year study will include interviews physicians, administrators, and pharmacists across 110 different organizations in order to determine what real or perceived barriers can be obstacles for physician practice and pharmacies.

Bridge Community Health Clinic (WI) partners with Healthport to implement practice management, EMR, and RCM solutions.  Bridge is an FQHC serving 21,000 patients a year across three locations.

E-mail Inga.

News 9/01/09

From Dr. T: “Re: Practice Fusion. I was under the impression that Practice Fusion did not have patient-to-MD e-mail.” Back in February, Vatsal Thakkar, MD participated in an HIT Moment and said, “Practice Fusion says it is in their future plan to incorporate e-communications to/from patients that are HIPAA-compliant and/or encrypted. What I am currently using is an add-on from my MS Exchange hosting service called SecureMail. It simplifies the process for users of Outlook such that encrypting a message is a simple click which prompts you to enter the challenge question that the patient can answer to open the email and write back. It also informs you if the message was NOT opened by the end of 30 days (at which point it expires). The vendor is at www.intermedia.net.”

Speaking of Practice Fusion, it is offering free integration with Quest Diagnostics for lab results.

Greenway Medical announces its 11th consecutive fiscal year of positive growth, ending its 2009 fiscal year with a 38% increase in sales over 2008 and 88% over 2007. Ever since I can remember, Greenway competitors have loved to discuss how the privately help Greenway wouldn’t be able to make it long term, that they would run out of money and never turn a profit. While higher sales do not necessarily equate to increased profits (or any profits for that matter), but, you have to hand it to Greenway for its tenacity and continued growth. There are a lot of sunset companies out there that would have loved eleven years of positive growth.

We are indeed fortunate to have Medicity as a new Platinum Sponsor of HIStalk Practice. The company was the first sponsor of HIStalk many years ago and continues as a Founding Sponsor there, which we certainly appreciate. It in inspiring to see how the company has grown, both organically and via strategic acquisitions that include a gem of EHR interoperability technology, the former Novo Innovations (now the Medicity Novo Grid). Other offerings include the ProAccess Clinical Application Suite and MediTrust Clinical Interoperability Platform. Ten years after its founding by Chairman and CEO Kipp Lassetter MD, the company leads the market and will undoubtedly continue its leadership role in RHIO, HIE, and national health network projects (it’s offering a September 4 Webinar entitled Maximizing New ARRA-Funded Federal Grants for Health Information Exchanges).Thanks to Medicity for its continuing support of HIStalk and HIStalk Practice.

Greenway also introduces its new partnership with RelayHealth, giving PrimeSuite clients access to lab results, radiology reports, and transcribed documents from their community health system through Relayhealth’s Virtual Information Exchange.

Supermarket chain Harris Teeter (found mostly in the eastern US) implements a PHR to improve prescription accuracy in its pharmacies. An agreement with Connectyx Technologies Holdings Group gives customers the opportunity to obtain a MedFlash drive for their PHR information, including medication specifics.

Claims clearinghouse provider Navicure adds three South Carolina practices to its client roster.

Physicians who perceive quality problems in their practices are more likely to experience dissatisfaction, isolation, and stress. Doctors in practices that have implemented quality initiatives and evaluated their effectiveness where less likely to feel that way.

eClinicalWork partners with Correctional Medical Services  (CMS) to provider EMR solutions to correctional facilities affiliated with CMS. ECW already provides EHR to Rikers Island in New York.

Speaking of ECW, co-founder Raj Dharampuriya  is interviewed by India Knowledge @ Wharton. He mentions that the company has opened a Mumbai support center to handle US customers that run 24 hours a day, such as a prison. The company will hire 500 people in the next two years, most of them in implementation and support, and will open an office next month in San Francisco. He credits the Indian culture of the founders in helping them focus on their goal of building a business and changing the delivery of healthcare. He still practices medicine part time and says he’s in the top 10% of performers according to BCBS.

If you are feeling the need to get up to speed on the upcoming ICD-10 coding system, you can review the new fact sheet being offered by CMS. I was sure it was going to be something I could use to cure my insomnia, by it’s actually nicely laid out, provides an easy-to-read overview, and includes plenty of graphics.

The MGMA sends the CMS a 12-page letter, providing comments on the proposed 2010 Physician Fee Schedule. Topping the list: MGMA urges urges CMS to accelerate the use of reporting from  EHRs for 2010 PQRI participation. MGMA also believes that groups of any size should be able to report on proposed measures, using a properly structured group practice reporting mechanism.

Three-provider Walker Family Medicine (AZ) selects OminMD for its EMR and practice management solutions.

CMS reports that almost all of the 610 small practice and solo physicians participating in a pay-for-performance demonstration project earned bonuses. The practices are being paid a total of $7.5 million for meeting quality standards through the use of HIT. The average payment was $14,000, with some practices earning as much as $62,500. To qualify, practices had to show their use of HIT improved the quality of care for patients with chronic conditions.

A local paper reports that Outer Cape Health Services (MA) has had a “mass resignation at the senior level staff level” as a result of management reorganizations and cost-cutting measures. The article is published in The Wicked Local, which I envision as of of those freebie newspapers you pick up in the local coffee shop, the kind that includes a listing of what bands are playing at which pubs, and a wide assortment of personals that cover every conceivable dating choice. Anyway, the rather lengthy article places most of the blame for staff resignations and turnover on the  health clinic’s new CEO, who took over the financially struggling practice in January. A disgruntled staffer says the new CEO put morale “in the toilet.” Another says she “humiliates people who don’t agree with her.” Essentially, they all but call her “wicked.” It may not be a Pulitzer Prize-winning piece of journalism, but it’s certainly more juicy than anything in the NY Times.

E-mail Inga.

Intelligent Healthcare Information Integration 8/29/09

Of Spices, Garnish, and Flavor Integration

Cooking, while not my passion, is always something I love. HIT, my passion, is not something I always love. Despite the discrepancies in appreciation, the former can lend insight into the latter. To illustrate, let’s take a little jaunt around the chowder pot…

Not that I am one, but a good chef will tell you the right ingredients make or break the creation of any dish. So, first, we want to insure the freshness and quality of the components which are going into our dish. If we try to build our foundation upon stale or outdated stuff at the start, we’ll only end up overseasoning in an attempt to turn a poor base into something it just never can become: fresh.

Speaking of seasonings, spices cannot be overemphasized. Appropriate use of spices in an intelligent and relational blend is the pièce de résistance, the icing upon the cake. The cake must be scrumptious, but the icing provides the “wow!” So, too, the soup must be solidly constructed from the best stock and the most delightful amalgamation of the finest available elements; however, it is the right use of the spices which elevate mere cold soup to an elegant vichyssoise.

Underspice, and the outcome is bland, lacking in pizzazz. Overspice, and the palate is overwhelmed and confused. But, with attention to the interactions of the flavors – spices with spices as well as spices with main ingredients – the individual elements integrate to transform the dish into a starburst of flavor sensations only achieved by their proper integration.

The heat necessary, at the right moments and at the right temperatures, can bring about the conjoining of flavors we seek, but not if we are inattentive to its application. As with custard, we might even need a bain-marie (a protective pan of water) to help guard our creation from the onslaught of direct flame. But, don’t be mistaken: the flavor sensations we seek will never arise if not allowed the time to assimilate under just the right conditions or if not tempered with just the right fire.

Preparation to the moment of presentation is only partiellement fini. Without question, the garnish and overall appearance of a dish, just like the wrapping of a gift, can turn a meal into a masterpiece. A present may be appreciated, but beautiful wrapping heightens the anticipation of the gift within. So, too, what the eyes see even before what the nose smells or the tongue tastes can greatly enhance (or diminish) the appreciation of even the finest culinary concoction.

Now, for the clarification:

• HIT/EHRs need up-to-date (fresh) ingredients.
• Building upon outdated (stale) platforms and software (ingredients) will yield an EHR (broth) no amount of techno bells and whistles (spices) or gorgeous GUI (presentation) or marvelous marketing and support (garnish) can overcome.
• The oven of time and incubator of “in vivo” use of these tools has cooked a few to finesse, many others to overdone and perhaps best fed to the dog.

A master chef knows a quality meal is only good for a brief period. Most grocery items have an expiration date. Even Budweiser has a “Born On Date” indicating that it has only 110 days before freshness has passed. Maybe EHRs, many of which are well past their prime and only capable of continued use by those tolerant of the dull and tasteless, should adopt a similar ethos to enable continued “freshness” of our HIT banquet.

I don’t even butter my bread. I consider that cooking.  – Katherine Cebrian

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 8/27/09

From Kathleen S: “Re: 100 Most Powerful. Another bogus list — besides, neither Mr. H or Inga were listed, so proof of hot air.” As Mr. H and all the other losers say, we were just happy to be nominated.

Should healthcare providers use Twitter to provide medical alerts and other healthcare information? Would it be effective? What about privacy? Of course the folks at Telemedicine and e-Health think it is a great idea and view it as a potentially valuable means of sharing real-time health information. I doubt I’d sign up.

To your right: details on a free live webinar on how to turn your dictation to data, sponsored by the folks at ALN. The webinar is on Thursday the 27th, so don’t delay.

Greenway Medical enters the community HIT space with the launch of PrimeEnterprise. The solution will enable a community of Greenway customers to share select clinical and financial data.

Real-time insurance eligibility authentication tools appear to be gaining in popularity. Atlanta Women’s Health Group is the latest group to announce it’s installing an application to validate eligibility information the time of service. Clearwave Corporation is the vendor working with the 50-provider, 26-location group.

Michael J. Barry, MD of Massachusetts General Hospital and Harvard Medical School is named president of the Foundation for Informed Medical Decision Making, a non-profit organization that promotes the creation and use of audio-visual decision aids to enhance patient involvement in their own medical decisions. Also, ophthalmologist William H. Ehlers, MD takes over as president of the Joint Commission of Allied Health Personnel in Ophthalmology.

Covenant Medical Center (IA) agrees to pay $4.5 million to settle alleged violations to the Stark Law and submitting false Medicare claims. The federal lawsuit claimed the hospital paid the five specialists “above fair market value” for their services at rates that were “commercially unreasonable.”  The government claims the physicians, who referred patients to the hospital,  were among the highest paid hospital-employed physicians in the entire country. Records show the doctors were each paid between $633,000 and $2.1 million.

The Virginia Tobacco Indemnification and Community Revitalization commission extends a $1.3 million grant to provide EMR capabilities for 37 department of health clinics.

MGMA releases a white paper offering recommendations to promote safety within physician offices. The report discussions how to build a patient safety process and how to establish the practice administrator as a chief safety officer.

Stories like this make me feel like such an underachiever. A Princeton junior and his recently graduated brother are awarded a $100,000 grant to expand an iPhone application to monitor diabetes. Their iAbetes Web 2.0 Diabetes Management System allows patients to record food intake, blood sugar readings, and insulin injections. The application interacts with a Web site that can be accessed by patients and their providers.

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Durham University in England develops a Conscientiousness Index tool to measure the conscientiousness of medical students.The tool examines such things as attendance at lectures, timeliness of work completion, and extra volunteer opportunities. I suppose that if you are deemed highly conscious, you get an extra cord or something.

David Polly, MD the surgeon who famously earned $1.2 million as a Metronic consultant, resigns his board position with the American Academy of Orthopaedic Surgeons. Polly says he didn’t want to be a distraction.

iMedX, a transcription provider and developer of TurboRecord and TurboScribe, purchases competitor Worldtech. The combined entity serves several thousand physicians in hospitals and medical clinics nationwide.

I’m not a clinician and thankfully not a regular patient, yet I appreciate the words of this physician who encourages his colleagues not to forget the human touch, despite the availability of so many high-tech tools. His point is that too many physicians forget the intrinsic value of the physician exam. Personally, I would to feel a human is caring for me and not just machines.

E-mail Inga.

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/).