News 1/20/09

The compliance deadline for ICD-10 is pushed to October 1, 2013. Stakeholders generally agreed that an October 1, 2011 deadline was inadequate time to prepare for the transition.

I love this quote from the administrator of a 12-doctor orthopedic group in Michigan: “One doc I know compares getting an EMR to going from outdoor to indoor plumbing,” he said. “It makes a huge difference eventually, but there’s a mess for a while.” This comment appears in a Crain’s Detroit Business article that highlights how practice administrators are struggling to manage practice finances without compromising patient care. Guarding costs and leveraging computer technology are key strategies at the moment.

If you’re a dermatologist in the DC area, you are probably too busy to be reading this. The upcoming DC festivities create a three-fold increase in the Botox and microdermabrasion business.

Allscripts Professional earns CCHIT Ambulatory 08 certification.

Physicians in Tomball, TX are receiving real-time patient updates via mobile devices. Tomball Regional Medical Center is providing its physicians with the Clinical Xpert Navigator solution to notify them of critical patient information. It’s the former MercuryMD MData solution that is now offered by Thomas Reuters.

Blue Cross Blue Shield of Michigan lays off 1,000 employees and wants average rate increases of 55% for individual plans, claiming it’s on track to lose $1 billion in the next three years.

Over 200 physicians at University Health Associates clinics (WV) switch to electronic medical records over the weekend, along with West Virginia University’s hospital sites. The health system has spent $90 million on the complete Epic EHR project.

In what appears to be a growing national trend, a rural, hospital-owned Colorado clinic prepares to close its doors. Doctors in remote areas find that lower patient volumes and lower reimbursement rates are not adequate to cover their rising insurance premiums and to pay off big student loans. Will the new administration offer these rural clinics additional funding to help them stay in business?

We’re hearing a few more specifics about what Congress is considering for the HIT component of an economic stimulus bill. House leaders want to set a December 31, 2009 deadline for a set of initial HIT standards and are promising up to $65,000 per physician in provider incentives. Hospitals that become fully wired would also be eligible for incentive payments. Penalties for those not adopting HIT would come into effect starting in 2016. The Congressional Budget Office believes such incentives would increase HIT adoption to 90% for physicians and 70% for hospitals over the next 10 years. One of the biggest potential road blocks continues to be how to address privacy concerns.

Here is a report that Congress and Obama might have missed. The results of a recent study by Kaiser Family Foundation and the Harvard School of Public Health indicate that most Americans don’t consider HIT spending a priority. Seventy-seven percent of the 1,628 surveyed recommended that HIT spending decrease or stay the same.

The Heart Group (PA) picks SRS for its EMR solution. The 37-provider group says they passed on the hospital’s EMR offering because they did not think SRS was intuitive enough. Goes to show you that free (or almost free) is not necessarily cheap enough.

South Jersey Healthcare (NJ) chooses Sage’s Intergy EHR solution for its affiliated physicians. The health system will subsidize the cost of the EHR, as well as interfaces to the hospital’s IS/HIE.

In Nigeria, identical twins Pam and Gyang Dareng give up their careers as medical doctors to take up professional golf. Seems like there should be some funny punch line in there somewhere.

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Intelligent Healthcare Information Integration 1/19/09

The Big “O”

"O." No, not Oprah. Not Overstock.com. Not even the big "O."

"O" as in Obama. A short jaunt around the web HIT postings, blogs, and news items these days quickly provides an overview of the impact of "O" on the current state of healthcare IT. For an industry that appeared to have become somewhat stalled with abysmal reports on EHR adoption; standardization that seemed be slowing product innovation; and CHINs, RHIOs, and HIEs (with a few exceptions) failed or failing, the promises of the great and powerful "O" were like a shot of B12.

The incoming "O" has made lots of promises about advancing HIT, including megabucks and another of those "chicken in every pot" type remarks to provide an EHR for every American by 2014. (Believe that one?) Fifty billion dollar promises and a president who wants us all to electronify has been like the jolt of lightning awakening Dr. Frankenstein’s lifeless monster.

While it is encouraging that the new administration will have a much greater understanding and focus upon the importance of IT for healthcare, it seems O’s broad HIT promises have many abuzz that HIT is now poised to become an “overnight” success. (Like so many “overnight” success stories, it has admittedly been some quarter century we have been trying to achieve HIT stardom.)

Don’t get me wrong – I am all for the impact of the O-factor. The almost unbridled optimism that seems to have developed (even in some die-hard, conservative Republicans) for what the new administration may bring is quite contagious. The fact that O isn’t even in office yet and has already begun to steer the course of our country is quite impressive. The fact that so many initiatives seem to be under consideration is (and I don’t use the word cavalierly) awesome. Our country — cripes, the whole world — needs this optimism. We have some pretty major messes and we need some can-do folks at the helm.

What concerns me is the little “o”s, the folks who take what the big O says and immediately apply it to their personal agenda. Everyone sees the glory road to success as being whatever route leads past their own door. At the recent eHealth Initiative 5th Annual Conference in Washington, D.C., many vendors, politicos, and HIT proponents seemed quite enthralled that the 50 Big Ones promised by O over the next five years was the stimulus needed to finally push HIT past the tipping point. Of course, most of them also had a pretty specific idea about where that money needed to go to achieve the tip, usually somehow related to their current ambitions or agendas.

So, do I have my own agenda? Am I another little “o”? Of course. But, I’m trying to maintain a certain amount of historical perspective, too. The past 25 years have shown us that pushing HIT on both physicians and the general public is somewhat akin to pushing mules. You don’t get too far too fast. Merely telling a mule why they must move doesn’t work too well, either. Changing people’s expectations, processes, and workflow requires carrots, not whips, and turning those changes into habits is a derivative of time.

Hopefully, O and his people know this and just won’t throw those ever scarcer dollars to the little "o"s in hopes that what they’ve done before will somehow now work just because there’s money to burn. Yes, oh yes, we do need healthcare information integration and the technology it requires. But, what we really need are some disrupters to take advantage of this opportunity, to provide some innovative thought and leadership, and to figure how to turn “pushing mules” into riding race horses.

Dr. Gregg Alexander is a grunt-in-the-trenches physician and admitted geek. He runs an innovative, high-tech, rural pediatric practice in London, OH, and can be reached at doc@madisonpediatric.com.

An HIT Moment with … Gregory Spencer, MD

An HIT Moment with ... is a quick interview with someone we find interesting. Gregory Spencer, MD is an internist and chief medical information officer at Crystal Run Healthcare in Wallkill, NY.

Describe your practice and what changes, good and bad, that your EMR brought about since it was installed several years ago. 

When our group was founded 13 years ago, we were a single-site medical practice with nine providers and 35 employees. We have grown 20-fold since then and are currently are a 170+ provider multi-specialty group with nearly 1,000 employees and 11 sites. We are opening an ASC this summer. Our growth was mostly from hiring individual physicians and not from mergers of existing groups.

We bought NextGen in 1999. The changes  in the EMR since that time have been massive and positive. Initially, the NextGen product was more of a tool kit to help you develop your own EMR. Now there is an extensive template set that comes off the shelf with the product.

The company has grown almost as quickly as we have. They had a rough patch a few years ago where their sales staff outpaced their support functions. They have improved and are doing much better in that regard. NextGen’s product also had issues with speed and scalability in the past, but this too seems overall better.

Practices that don’t have EMRs worry about the physician time they require and the perceived value they provide in return. What is your experience?   

EMRs require a lot of time and money to set up and maintain. Once you are facile, EMRs are a lot more efficient than handwriting, but not so much for those who dictate everything. 

The value EMR that can return is real, but is largely untapped by most users. Using as many bells and whistles that the product has is more important than you think. Population management is just starting to be done, as an example.

The predominant value EMR returns is most not monetary. You could probably save money by throwing a bunch of low-level file clerks and transcriptionists at an office. You cannot do certain things without EMR, no matter how much money and people you throw at it.

Beyond your EMR and practice management systems, does your practice use other practice applications or connections to outside data sources or information exchanges?

Yes, lots of them. We have a home-grown patient portal for patients to request appointments, meds, etc. We use Televox to confirm over 1,000 of our patient visits a day. We extensively use MS Exchange and Outlook with BlackBerries for remote clinical communication. 

We have Orchard for our laboratory information system and are in the process of implementing Carestream as a RIS/PACS  We use Citrix both within the office as well as for remote access via its web VPN. We have our own data warehouse that we use for business intelligence as well as clinical purposes.

What do new doctors coming into the practice think when they see the technology?  

We have hired 27 doctors in the last six months and will hire another 20 more by the summer. New hires uniformly consider the EMR a positive and often is a deciding factor in selecting our practice. We have merged with a few other groups. Established physicians definitely have a harder time with the EMR. 

Have patient outcomes or patient satisfaction been affected by using an EMR?  

Yes. We have demonstrated improved rates of mammogram, PSA, and other clinical parameters with a care manager program that uses the EMR. We track patient satisfaction, but have no "before/after" data for comparison.

News 1/15/09

From Musing: “Re: EMR economic incentives. Let’s say I am convinced that Congress and Obama will get their acts together and come up with some kind of economic stimulus package that includes an HIT component. If I am a doctor, why would I want to spend my dollars today if Uncle Sam might be willing to help with at least a portion of it a few months down the line?” Quite the conundrum, but you will probably find out soon one way or the other.

A patient sues her doctor for failing to provide a sign language interpreter for her office visits and wins a $400,000 settlement. In light of that, a provider of American sign language relay services decides it’s a great time to announce its LifeLinks package, which provides remote translation services. To use the service, the practice sets up a computer with a webcam. When needed, the physician and patient receive face-to-face video access to interpreters and sign language specialists. Clients pay only for the specialists’ time.

A physician shares details of how an employee embezzled $50,000 from her over a three-year period. I’m always amazed how often this occurs. The stories always seem similar: the doctor is consciously providing the best quality care in a busy practice and defers all business activity to a trusted employee. If someone is determined and greedy, they’ll figure out a way to outsmart even the best computer system.

A Canadian woman files suit against Purdue Pharma for $31 million, claiming she became addicted to their drug OxyContin. She’s applied for certification as a class action on behalf of all OxyContin users in British Columbia.

Economic conditions lead to an increase in bartering goods for medical services. A couple of Maryland doctors have been bartering with patients since opening their practice three years ago and believe it has helped grow their business. Typical exchange items include office supplies, staff meals, plumbing work, and other goods and services.

AAFP President and family practice physician Ted Epperly is a fan of electronic medical records. "I’m a big proponent. We’ve had an EHR in our practice here in Boise for four years. It’s revolutionized my practice. I’m more efficient. I make fewer errors. My data are more retrievable. I can give feedback to both my practice and that of my colleagues and the residents I’m fortunate enough to be able to train."

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Is EMR not the silver bullet after all? Booz Allen Hamilton and the Federation of American Hospitals release a report that concludes HIT emphasis needs to be on improving electronic communication among patients and providers rather than getting EMRs installed. Among other key points, the report recommends focus should be on e-Rx, electronic results, and medical imaging. Also, payments should tie to desired outcomes. In addition, patients need access to their records and have a way to communicate with their physician about them.

HHS announces rollout of an improved version of the Surgeon General’s family health history Internet site called My Family Health Portrait. It was built to follow data exchange standards that will allow it to exchange information with practice EMRs.

A Las Vegas physician who planned to retire soon is shot dead in her medical office exam room by an 80-year-old patient who then killed himself. Police have not determined a motive.

The ambulatory care sector adds 14,000 jobs in December, despite the country’s overall loss of 2 million jobs. Hospitals added 12,000 positions and long-term care/home-health grew by 2,000.

The State of California investigates Kaiser Permanente and the protocols it uses in its call centers. The investigation stems from complaints of mishandled calls that compromise patient care. The state wants copies of the call scripts that Kaiser’s unlicensed staffers use to make medical decisions. Kaiser claims the scripts are proprietary.

City employees in Warwick, RI receive free enrollment in a PHR program that gathers basic health information into one secure place and releases it to appropriate healthcare providers. The ER Card is developed and controlled by the individual, containing only the information they choose to enter. The patient is responsible for keeping it up to date and the record will not include doctors’ notes. The city seems pretty proud of this great new employee benefit. Perhaps they haven’t heard of the little company in Redmond, WA that offers a similar free service via the Internet.

The doctors at Johns Hopkins University’s Wilmer Eye Institute know all about HealthVault, since HealthVault’s Be Well Fund is underwriting their automated patient reminder trial. Wilmer Eye will use MEMOTEXT to send glaucoma patients customized reminders via e-mail, text message, or phone call, reminding them to take their medications. The trial is designed to measure if automated reminders improve adherence to prescribed medication regimes.

President Bush’s physician, like several other members of his administration, gets a last-minute obscure government job, appointed to finish a term on the US Air Force Academy’s Board of Visitors.

Staff working the ED at Waseca Medical Center (MN) wear white coats and stethoscopes, but they aren’t doctors. The hospital interprets state regulations requiring physician assistants and nurse practitioners to be supervised by a physician as meaning it’s OK to have that doctor available by telephone if needed. A 2007 survey said that one in seven rural hospitals staffed their EDs entirely with PAs and NPs.

Incoming HHS Secretary-designate Tom Dashchle wants Congress to shift the nation’s healthcare model to emphasize wellness and prevention by providing more support for primary care doctors. "Every country starts at the base of the pyramid with primary care and works their way up until the money runs out. But the United States starts at the top of the pyramid and works its way down until the money runs out, resulting in a lack of primary care and wellness."

Ben Brown with KLAS Research claims that healthcare’s speech recognition market is on the verge of a "long-term growth curve of adoption.” Brown predicts adoption rates will continue to climb because speech recognition provides a “clear” ROI. Also, look for it to be increasingly integrated with EMRs.

The Agency for Healthcare Research and Quality launches a Web site that advises clinicians and consumers on emerging drug therapies. The site also provides access to education and information resources designed to improve healthcare quality, safety, and effectiveness.

Here’s a cool new iPhone application for the pathologist on the run. The Institute for Medical Informatics, Rikshospitalet, Oslo University Hospital develops a remote application for the review of pathology images on the Apple iPhone.

The Duke Endowment awards $99,000 to Caswell Family Medical Center for the purchase of an EMR. Caswell Family is a five-provider practice in North Carolina.

Former MedComSoft VP Mary Torrance joins Electronic Healthcare Systems to serve as EHR consultant for the CareRevolution product.

Telephone equipment maker Nortel Networks files for Chapter 11 bankruptcy protection .

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Joel Diamond 1/14/09

I love the pick-up line from The Wedding Crashers: "Some people say that we only use 15% of our brains. I say that we only use 15% of our hearts." Interacting with many of my colleagues who have adopted an EMR in their practices, it seems that most of them use only 15% of what should be the system’s capabilities.   

I recently asked a friend of mind why he hasn’t utilized many cool features like e-prescribing and a patient portal. He sheepishly answered, "To tell you the truth, I am just too damn busy. I wish that there could be some way that this technology would just make me feel like I was making a bigger difference in people’s lives and let me spend more quality time with patients."

With this in mind, I read last week’s National Research Council on Healthcare IT report with keen interest (BTW, Mr. HIStalk did a great job of summarizing the report).

The council’s esteemed panel recommended to "organize incentives, roles, workflow, processes and supporting infrastructure to support and respond to opportunities for clinical performance gains. Focus on identifying, prioritizing and managing changes in process and workflow."

Wow … that is so much more impressive than my friend’s quote!

I hope they didn’t spend too much money concluding what every front-line practitioner considers obvious. Let’s face it, most physicians are tremendously dedicated and work long hours. Any down time is spent squeezing precious extra minutes with patients, following up on tests, and calling families. Occasionally, there is even time to do preventive health.

To be fair, I would say that the technical accomplishments to date represent 15% of our needs. Let’s start working on the other 85%.

Joel Diamond, MD is chief medical officer at dbMotion, adjunct associate professor at the Department of Biomedical Informatics at the University of Pittsburgh Medical Center, and a practicing physician at UPMC.