News 5/22/14

The VA’s troubles show no signs of being swept under the rug. The “secret waiting list” allegedly kept at a Phoenix VA facility, as well as the dozens of deaths attributed to its long wait times, has opened a flood gate of justified scrutiny at local, state, and national levels. President Obama convened a press conference to address the issue, saying it’s time to bring “the VA into the 21^st century – which is not an easy task.” U.S. Rep. Tim Walz (MN) has taken a proactive approach in light of the findings from Phoenix, and asked for an accounting of wait times at VA facilities throughout the state. He pointed out during his tour of facilities that “[o]ur nation’s veterans bled enough on the battlefield. They don’t need to bleed at home for preventable errors that could have been fixed with leadership and collaboration.” A national audit of VA facility wait times is underway.  It’s a shame that this Memorial Day will likely see the nation focused on how poorly many veterans are being cared for.

CMS and ONC publish a proposed rule that would slow down the Meaningful Use program by extending Stage 2 through 2016 (starting Stage 3 in 2017) and allowing providers to attest for FY2014 using a 2011-certified EHR. National Coordinator Karen DeSalvo, MD seemed to express concern that EHR vendors would not have their products certified under the 2014 criteria in time, referring to users who would miss the dates “through no fault of their own,” while the bill referred to “availability and timing of product installation, deployment of new processes and workflows, and employee training.” Public comment on the proposed bill will be open for 60 days.

HHS and CDC release the National Ambulatory Medical Care Survey, which finds that 71.8 percent of office-based physicians reported using an EHR in 2012, up from 34.8 percent in 2007. The survey’s findings aren’t unexpected in the areas of EHR adoption and utilization. Larger practices have adopted more robust systems more consistently, while smaller and solo practices have struggled to keep up. More interesting are the facts that between 2007 and 2012:

• Physicians working in practices owned by a medical or academic health center increased by 140 percent.
• The difference in adoption of a basic EHR between the largest practice size category and solo practices increased to 39.2 percent, suggesting solo practitioners may face unique challenges to EHR adoption.
• Electronically sending prescriptions to the pharmacy had the largest percentage increase in availability of the 11 EHR features measured.
• The survey was conducted via in-person interviews and mail-in forms (an irony hopefully lost on no one).

The NAMC Survey results line up nicely with findings from a new Surescripts report on e-prescribing, which reveals that the total volume of prescriptions routed electronically have increased 44 percent, up from 570 million in 2011 to 788 million in 2012.

A more recent survey from the Commonwealth Fund finds that EHR adoption by federally qualified health centers more than doubled from 2009 to 2013, with 93 percent of them running an EHR and 75 percent meeting Meaningful Use requirements. The FQHCs say their biggest EHR-related problems are undertrained staff and loss of productivity.

The federal government considers a national “biosurveillance” system that will give it near real-time access to the private medical information of citizens in the name of national security. Citizens Council for Health Freedom warns that the proposed system, which could potentially pull data from EHRs, would allow the federal government to monitor an individual’s behavior before, during, and after any government-defined health “incident,” and that “anything and everything could become a health threat by the government’s standards.”

A survey finds that patients in Boston experience the longest wait times of the 15 metropolitan markets studied. New patients in the area typically wait just over 45 days to schedule a doctor’s appointment. Denver and Philadelphia take the second and third spots, respectively. Given the fact that Boston is known as a hotbed of healthcare IT and yet its numbers are double that of the other two cities, you have to wonder what sort of systemic problems are taking place, i.e. doctor shortages.

While Hartford, CN, was not one of the markets surveyed for its wait times, the Hartford HealthCare Medical Group obviously realizes shorter wait times are a patient draw. The group announces that patients can now book a primary or specialty care appointment within 24 hours online or by phone. Its online appointment-booking tool is powered by ZocDoc.

This article suggests that physicians like Gregg DeNicola, MD are increasingly paying attention to and acting upon online reviews. After realizing that new patients were canceling appointments because of reviews, DeNicola and his staff at Caduceus Medical (CA) decided to stop ignoring them and instead embraced them. Patients who respond positively to in-office surveys are now asked to leave reviews on Yelp, and practice staff now monitor online reviews daily in an effort to respond to any negative comments in a timely manner. Physicians would do well to take a proactive stance when it comes to online reviews, if only to become more aware of how their “brand” is perceived by patients.

Verizon expands its HIPAA-compliant, healthcare-enabled services, adding five data centers and a wider range of related cloud and data center infrastructure services. The expansion brings its total data centers to seven, now nationwide.

Practice Fusion launches Insight, a free tool that analyzes portions of 81 million de-identified patient records. The analytics tool can potentially provide early signs of seasonal disease outbreaks, shifts in chronic conditions, and diagnoses trends for select patient populations. A paid version offers more detailed analysis, including the market share of drugs within certain subpopulations.

Kareo receives a 2014 Red Herring Top 100 North America award for its innovation, technologies, and commitment to software. The company is among a group of 100 awarded the distinction each year.

Colorado Springs Health Partners (CO) selects CodeBaby’s patient engagement portal solution to offer its patients easier online access to services, and to help it meet Meaningful Use objectives. CSHP seems to be fairly digitally savvy, offering an iTriage symptom checker on its homepage.

Delaware Health Information Network and Halfpenny Technologies partner for the delivery of clinical results to DHIN’s enrolled practices using the EHRs of the physicians and Halfpenny’s integration technology. Founded in 2007, DHIN is the nation’s first statewide health information network, and serves nearly 100 percent of Delaware’s providers.

Accountable Care Options and its physician network earn a $4.2 million bonus from CMS as part of its participation in the Medicare Shared Savings program. The organization achieved a 100-percent quality score and saved Medicare $8 million as a result of its focus on wellness and prevention, and better management of patients with chronic conditions. ACO, which entered the savings program in 2012, was one of only 28 other accountable care organizations to receive a bonus payment.

DOCtalk by Dr. Gregg 5/22/14

HIT Curveballs

As is said: _hit happens. We’ve all heard that phrase (usually the full, four-letter version). It’s a nice, short summation of the inevitabilities of life. No matter what you do or how you plan, life will always throw you curveballs. No matter how well read you are, no matter how highly educated, no matter how credentialed, no matter how exquisitely trained, no matter how closely or loosely you choose whom to trust – everybody gets thrown off stance by an unexpected curveball every so often. (Sometimes, you may even get sliders, knuckle balls, or those throw-you-for-a-real-loop spitballs!)

If you do all the homework you can – study up on types of pitches, watch hours of film on pitchers and their styles, spend innumerable hours in the batting cage, rip yourself with hours on the Nautilus – you’ll still get a ball that you just weren’t expecting. Whiff. Swing and a miss. Steeee-rrrrrr-iiiike!

In the land of HIT, it happens all the time – to vendors and consumers alike. Vendors may not like it any better than their customers, but there is a bit of a difference. HIT vendors get many of their curveballs from regulations, or sometimes from their own poor planning or development. HIT consumers, on the other hand, can get just as many curveballs from regulations, but they can also get really brushed back by those curveballs thrown by HIT vendors. (Vendors rarely get stressed by any consumer pitches, but consumers can’t avoid dealing with HIT vendor pitches.)

Another important difference is that, pretty much across the board, HIT vendors are in this space to make money off of HIT. Consumers, on the other hand, are trying to use HIT to accomplish tasks like delivering healthcare and getting reimbursed for the care they provide.

When a HIT consumer gets a curveball from their HIT vendor, it can really cause the home team strife. It isn’t like the consumer is a reseller; they can’t just find a replacement product to hawk. And, they get no value merely from owning (or leasing) the HIT product. The consumer relies upon HIT tools as critical underpinnings for their mission: to deliver health care. The consumer trusts their HIT to provide the information necessary for medical decisions. They use it to document their efforts and to obtain reimbursement for said efforts. Increasingly, they use it communicate with those for whom they care.

HIT has become central to the mission of healthcare, having become a key member of the care delivery team. If the tools don’t work, if something changes to cause them to work less efficiently, or if they develop “future unfriendliness,” then the care delivery process becomes threatened. That is an unacceptable pitch, for any healthcare team, big or small.

When a provider decides to invest in a HIT tool, it is far more than just a product purchase. Yes, it is an investment of money, but perhaps even more significantly, it’s an investment of time, energies, workflow construction, staff training, sometimes patient orientation and training, and more. The entire healthcare delivery system for that provider office is impacted by these tools. When one of the chosen HIT vendors throws out a curveball – via acquisition, merger, business failure, or product development redirection – the swing-miss impact is felt throughout the practice, from their figurative fingers to their metaphorical toes.

The impacted providers must now either:
(a) hobble along with their lame duck tool for as long as they can,
(b) find a replacement tool into which they can invest even more time, money, energies, workflow construction, etc.,
(c) pull out what’s left of their hair and go back to reliable, old pen-and-paper and suffer the MU consequences, or
(d) find an ACO to wash away all their operational and financial woes.

Being at the plate when one of these vendor pitches comes past is thoroughly frustrating. Whoosh. Whiff. Steeee-rrrrrr-iiiike!

(And there’s no ump with whom to argue the ruling.)

From the trenches…

“Baseball is a game where a curve is an optical illusion, a screwball can be a pitch or a person, stealing is legal, and you can spit anywhere you like except in the umpire’s eye or on the ball.” – Jim Murray

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, an HIT and marketing consultant, and sits on the board of directors of the Ohio Health Information Partnership (OHIP).

News 5/20/14

HHS representatives weigh the pros and cons of a new program that will use Medicare data to alert public health officials to the potential needs of vulnerable patients during a disaster. HHS tested parts of the program in three states, and is looking to take it nationwide. Critics are concerned about the security of patient data, but ONC head Karen DeSalvo, MD has said the program protects patient privacy and that its benefits outweigh its risks.

The VA’s troubles continue with the resignation of Undersecretary for Health Robert Petzel, MD. In accepting Petzel’s resignation, VA Secretary Eric Shinseki said, “As we know from the veteran community, most veterans are satisfied with the quality of their VA healthcare, but we must do more to improve timely access to that care.” That statement seems questionable given the fact that at least 40 veterans died waiting for appointments at a VA facility in Phoenix, which has also been accused of maintaining a secret waiting list.

In other health data news, the Colorado Rural Health Center launches the Health Awareness for Rural Communities Data Bank to enhance access to streamlined data sharing and collaboration for rural healthcare providers, communities, and other interested stakeholders. The data bank is a collection of over 100 population health measures, as well as demographics, indicators, and projects from the state’s 47 rural and frontier counties. It’s refreshing to hear of big data projects like these that boil patient health information down into usable and hopefully effective population health management tools.

Business administration costs, not physician salaries (as highlighted by the recent release of Medicare physician payment data), are the real cause of skyrocketing healthcare costs, according to a New York Times article. It points out that healthcare is staffed by some of the lowest and highest paid individuals in any industry, with the compensation of health insurance executives topping over $583,000, general physicians reaching $185,000, and EMTs reaching just over $27,000. Perhaps the most telling statement in the piece comes from Abeel A. Mangi, MD cardiothoracic surgeon at the Yale School of Medicine: “Most doctors want to do well by their patients. Other constituents, such as device manufacturers, pharmaceutical companies and even hospital administrators, may not necessarily have that perspective.”

Physicians interested in the transparency of their payment data – Medicare or otherwise – may want to comment on the CMS Open Payments Program, which in September will publish payments that drug and device manufacturers have made to physicians. Those physicians interested in reviewing their open payment data must register with the CMS Enterprise Portal by June 1 for the opportunity to correct any  data discrepancies beginning in July. Physicians who have been less than pleased with the opaque nature of the Medicare physician payment data may want to go over this particular set of information with a fine-toothed comb, if only to equip themselves with explanations for their pharma and med device ties when the media come calling.

Scott Gottlieb, MD gives his two cents on the publication of open payment data: “Washington has little faith in American physicians, and sees a need and a license to regulate just about every aspect of medical practice, even trinkets doctors receive. There’s a clear view that doctors can’t be trusted to have any financial interactions with drug and device makers, no matter how small or simple these transactions. A free mug is as likely to influence a physician’s judgment as a $50,000 consulting fee.”

The National Committee for Quality Assurance recognizes Heritage Valley Medical Group (PA) physicians for their use of evidence-based measures in diabetes care. Ninety-three percent of the group’s 125 employed physicians met the standards for NCQA’s Diabetes Recognition Program. The group participated in the program after a community health needs assessment found that diabetes care was a top concern.

Oncologists list the pros and cons of moving from independent practice to hospital employment. The downsides seem to outweigh the benefits, with one physician venting that, “You don’t make decisions anymore. If you are a physician and you want to buy a widget, you have to go and get permission. It requires an act of Congress.” Loss of autonomy, “having a million different bosses,” longer wait times for on-site lab results, and higher patient copays were also mentioned.

Solo neurologist Robert Steg, MD explains the reasons why he closed his solo neurology practice, citing the requirement to move to a cost-prohibitive EHR as the final straw. The “Near future” category in the chart above ties into his EHR concerns, since Steg’s inability to purchase one would have prevented him from operating within the hospital’s ACO, and gaining referrals from its network.

In additional ACO news, HackensackUMC Mountainside (NJ) announces the formation of Mountainside Medical Group, a network of physicians employed by the hospital. The rise in hospitals creating physician groups  (not to mention investing in urgent care and retail clinics) may seem counterintuitive, but actually plays into the business model of ACOs and their need for coordinated care between physician and hospital networks.

The local paper takes a deep dive into the world of physicians, EHRs, HIE, and Meaningful Use in Michigan, which in 2013 saw  48 percent of its office-based physicians on an EHR. Michigan’s numbers are on par with the national average, according to the ONC. The state’s physicians are likely similar to many others in that the plethora of EHR vendors, and implementation and maintenance costs,  have left many unsure of which way to turn in terms of achieving interoperability to drive HIE efforts.

Tenet Healthcare (TX) announces that it will double the number of its nationwide MedPost Urgent Care centers by the end of the year. Kyle Burtnett, senior vice president of Tenet’s outpatient services, says the move is part of Tenet’s broader strategy to grow its portfolio of outpatient facilities, as well as to expand into “faster-growing, less capital intensive, higher-margin businesses.”

Even public health departments are getting in on the urgent care action. The Rhode Island Department of Public Health announces it will allow CVS to open MinuteClinics in seven of its pharmacies to provide more accessible and convenient care to consumers via a trusted brand name. MinuteClinic is the first retail clinic provider to achieve three consecutive accreditation awards from The Joint Commission. Primary care physicians have expressed their concern, however, commenting that the proposed clinics may erode their practices and further threaten an already beleaguered business model. The health department has incorporated those concerns into 22 stipulations the clinics must meet to set up shop. The guidelines also mandate that the clinics use the state’s EHR.

Athenahealth CEO Jonathan Bush releases his new book, “Where Does it Hurt? An Entrepreneur’s Guide to Fixing Health Care,” amidst continuing debate around the valuation of the company’s stock. While the book has yet to hit the best seller lists, the company got a bit of an uplift recently from analyst Mohain Nadu, who explained that because of athena’s cloud technology advantages, the company can introduce new services and technology much faster than a traditional software vendor. Perhaps Nadu was obliquely referring to Epic, which hedge fund manager and stock naysayer David Einhorn recently called out as one of athenahealth’s biggest threats. It goes without saying that Epic is neither public nor based in the cloud, and for what’s it worth trailed behind athenahealth in the 2013 Best in KLAS Overall Software Vendor award.

My Medical Inventory offers a new Web-based tool to help physicians better manage medical supply inventory. Julio Guerra, MD developed and tested the software in his practice, ultimately deciding to commercialize it based on positive feedback from his office staff.

GloStream introduces GloComplete, a revenue cycle and practice management service that incorporates the company’s EHR and practice management solutions. The company already has 40 practices and 120 physicians using the new tool, and expects an overall growth of 30 percent by the end of the year.

Valence Health launches the Valence Partner Network, a group of health services firms that will offer integrated solutions to Valence Health clients, including more than 30,000 physicians. Founding network companies include Aldera, Dubraski & Associates, Emmi Solutions, Limeade, Navitus, and Warbird Consulting Partners.

IBM announces that Modernizing Medicine is one of three partner companies that will release “Made with Watson” apps this year. The company offers specialty EMRs and is developing an iPad app that will guide physicians through a patient encounter to provide evidence-based medicine suggestions.

Readers Write: Technology Could be Great Equalizer Under ICD-10

Technology Could be the Great Equalizer under ICD-10
by Tom Giannulli, MD, MS

As an internal medicine physician, I get the best of both worlds. I have relationships with my patients like a family practice provider, but I get to treat more complex conditions and deal with challenges like a specialist. I love what I do, and I am not the only one. Recent studies show that many providers love their specialty and would choose it again. In the Physicians Practice 2013 Great American Physician Survey, nearly 80 percent of physicians said they were fairly happy with their choice of specialty. In addition, given the chance, they would roughly do everything the same way again. However, we are all practicing different kinds of medicine, and we face different kinds of day-to-day challenges.

The switch to ICD-10 is no different. I have no doubt that come Oct. 1, 2015, we’ll all wish we were practicing in a simpler specialty like physical therapy, which uses a small handful of codes.

It is too late to change specialties, but it isn’t too late for physicians to change their attitudes about technology. Now is the time for them to get over whatever is holding them back and embrace what technology can do for medical practices. The recent ICD-10 delay has actually given practices a little more time to prepare properly.

One of the main reasons for the delay was the concern about physician practice readiness. When a recent MGMA survey evaluated preparedness around ICD-10, more than 90 percent of respondents indicated they were concerned about changes to clinical documentation, coding, staff productivity, and changes to clinical productivity.

The right technology could be the solution, and now practices have adequate time to choose those solutions and implement them effectively. Consider the five ways that technology can simplify workflow for physicians and help a practice prepare for ICD-10:

1. Billing and practice management software should be able to run an ICD-9 top codes report. This eliminates the need for your staff to dig through claims to identify top codes, speeding the process of code mapping.
2. Software vendors should be preparing the systems to submit claims to payers so that practices don’t have to connect with each payer or clearinghouse individually.
3. The EHR should offer tools to help ensure the most complete and accurate documentation possible. With click-to-pick menus and customizable templates, physicians can more easily get documentation up to snuff for ICD-10.
4. Eliminate the possibility of a 10-page superbill. For complex specialties, ICD-10 could easily mean a superbill that is three or four times the length of what practices have now. Not only does the practice have to update the paper form, but healthcare providers will have to wade through and complete it by hand for each visit. An EHR allows providers to complete a superbill by clicking and picking the codes. It can even suggest codes based on the notes and auto-fill codes based on entering the first few characters. With an integrated billing system, physicians can send the electronic superbill with the click of a button.
5. Access code-mapping crosswalks. Software should offer users a crosswalk so when an ICD-9 code is entered, the equivalent ICD-10 code can be easily found. It doesn’t entirely replace having access to coding handbooks, but it can often make things faster and easier than doing it by hand every time.

There are a lot of reasons to consider implementing an EHR, and even more to choose a solution that offers integrated billing, practice management, and EHR. The change to ICD-10 is just one of those reasons, and certainly one of the best. According to the MGMA survey, more than 80 percent of practices know they need to upgrade their EHR or practice management systems to make the change to ICD-10. Don’t wait. By choosing the right software now, practices may able to mitigate some of the challenges and achieve a successful transition.

Tom Giannulli, MD, MS is CMIO at Kareo of Irvine, CA.

News 5/15/14

Black Book Rankings announces that Kareo ranks first among small physician practices for integrated EHR and billing systems. The firm also recognizes Modernizing Medicine as the top dermatology EHR for all practice sizes.

CMS reminds Medicare EHR eligible professionals that 2015 hardship exception applications are due July 1, 2014.

The ONC approves the American National Standards Institute for a second three-year term as ONC-Approved Accreditor for its HIT certification program. It’s hard to believe the certification program has only been around since 2011, and fully operational since 2012. It would be interesting to see how much money vendors have spent on certification since the program’s inception, and how that value compares to incentive money providers have received for Meaningful Use attestations.

New Jersey-Health Information Technology Center Meaningful Use Director Bala Thirumalainambi sends a tweet congratulating Seema Rao, MD (NJ) on successfully attesting in the earliest possible 90-day period to Meaningful Use Stage 2. Rao, one of only a handful of physicians nationwide to attest thus far, is a solo practitioner who had most of her patients on a patient portal from the day she implemented her Practice Fusion EHR.

North Carolina’s HHS signs a data use agreement with the NCHIE as part of a House bill that requires hospitals to submit the demographic and clinical data of Medicaid patients to the HIE, allowing DHHS to monitor services and patient safety.

Athenahealth finds itself in the same “quagmire” as Facebook and Tesla, with its fundamentals “severely out of wack” when compared with its value, according to SeekingAlpha.com. The three companies, “valued solely on the basis of being able to grow extremely aggressively,” are going to get snapped back to company basics and thus more realistic valuations. Athenahealth is a bit of a different beast than the other two businesses, however, since it finds itself in a crowded marketplace fueled by MU incentive dollars, destined for further consolidation.

EClinicalWorks announces at its Health Center Summit that more than half (580 of 1,147) of Federally Qualified Health Centers use its products, four of them being Davies winners.

The Corporate Whistleblower Center urges healthcare accounting or Medicare coding “insiders” to contact them with proof of fraudulent Medicare bill upcoding because “the reward potential for this type of information can be enormous.” A quick perusal of the center’s website reveals it to be affiliated with the consumer advocacy group America’s Watchdog. Based on their domain names, both groups seem to be for profit. Physicians should be wary of working with an organization that highlights the ability of whistleblowers to “Get Rewarded for What you Know.”

Speaking of whistleblowers, Boulder Community Health (CO) investigates stolen patient records for the third time since 2008. The records of at least 30 victims have been mailed to the center by an anonymous whistleblower, who seems to be using the covert correspondence as a means to highlight the “the easy access that the hospital and their partners provide for someone with bad motives.”

Integrated Medicine Alliance (NJ) is featured in the local paper for its patient-centered medical home business model, which comprises eight primary care practices and three urgent care centers, all within 10 miles of each other and all on the same Vitera Intergy EHR from Greenway. IMA also employs eight care coordinators as part of its PCMH efforts.

A Texas-based pain management clinic selects PPJ Enterprise subsidiary Professional Billing Service to provides its billing, collections, and practice management services. Based on previous statements from PPJ Enterprise’s CEO, it seems likely the company initiated the sale thanks to exhibiting at an industry trade show. Mr. H (and likely many other busy providers) might find the plethora of healthcare IT events nearing comical proportions, but vendors obviously still finding benefit in participating.

A local paper reports that HealthSpot is well on its way to installing more of its private telemedicine kiosks in pharmacies and public buildings for easy access to physicians via a recent investment of $18.3 million from 27 investors. Physicians that see patients via the kiosks are pleased with the technology, but think it is a good diagnostic fit only for certain conditions. HealthSpot is focusing on the public areas of pharmacies and retail clinics right now. It seems these types of kiosks would lend themselves well to population health management initiatives if they were placed in truly public areas like community centers, libraries, and churches.

The California Urological Association designates Acentec a business partner for its member physicians seeking HIPAA compliance and IT management services. CUA’s 475 member physicians represent 52% of the state’s board-certified urologists.

NextGen receives the Surescripts White Coat of Quality Award for the third time. “Receiving the White Coat of Quality Award again underscores our commitment to not only applying best practices to the use of e-prescribing technology, but also to continuous quality improvement and training of prescribers,” says Sarah Corley, MD chief medical officer at NextGen. Surescripts also awarded this year’s designation to 50 other entities including software vendors and health systems.

CureMD announces the latest version of its EHR and practice management solution. As with many EHR companies looking to differentiate their products from the crowded marketplace, CureMD designers say their focus on usability and accessibility make this iteration ideal for tablets.

The Advisory Board Company says in its earnings call that it paid $25 million to acquire HealthPost, a physician finder and appointment scheduling site that will be rolled into the company’s Crimson analytics offerings used by 1,400 hospitals. HealthPost has $1 million in annual revenue, and is break-even on the P&L side. According to Advisory Board Chairman and CEO Robert Musslewhite, “HealthPost is a cloud-based ambulatory scheduling solution that enables health systems to reduce referral leakage and track new patients by using it. It does it with what we felt like was a market leading SaaS technology that enables physicians and consumers to identify the right provider of care, based on certain criteria, especially in terms of geography and it makes it a very easy one-click appointment booking experience for either the provider or the patient. So we’re excited about it. In terms of how we’re going to roll it out, it’s still TBD. I imagine we will have a program launch coming from it, then more news on that down the line.”

Not sure what to call your next academic medical event? This handy flowchart from PHDComics might help.