News 4/22/14

The USA Today highlights the dilemma of rushed physician exams, which creates frustration and tension for both doctors and patients. As long as the pay for performance model dominates the market,  primary care physicians will continue to feel pressured to squeeze in as many patients as possible into their schedule. The implied “fix” is to change the reimbursement model, which will no doubt take time. No mention is made of the how EMRs, patient portals, and other technologies impact the situation, but obviously HIT alone isn’t the cure.

Orthopedists were the most highly compensated physicians last year, earning an average of $413,000. Cardiologists, urologists, and gastroenterologists took the next highest spots while family physicians were near the bottom at $176,000. The same Medscape survey found that 35 percent of employed physicians spend at least 10 hours a week on paperwork; only 26 percent of self-employed physicians spend more than 10 hours a week on admin tasks.

Maine’s HealthInfoNet HIE offers providers access to the state’s Prescription Monitoring Program through the HIE’s portal, giving clinicians a single sign-on to both systems.

Steward Health Care System (MA) selects athenaCoordinator Enterprise to enable care coordination for its employed providers and their patients.

Wikipedia tracks flu outbreaks up to two weeks faster than the CDC, according to Boston Children’s Hospital researchers. Using an algorithm that collected data on how many of 35 flu-related Wikipedia pages were viewed, researchers were also able to identify flu-related activity with 17 percent more accuracy than with Google Flu Trends, which was recently criticized for overestimating the incident of flu.

GetWellNetwork announces details of its GetConnected 2014 conference in Chicago June 3-5.

The CEO of scribe staffing company PhyAssist reports his business has grown from 45 scribes in 2008 to 1,400 today and expects demand to increase as more providers adopt EHRs.

Surescripts awards DrFirst and 31 of its EMR partners that have integrated Rcopia e-prescribing software within their EMR with its White Coat of Quality Award.

An AHRQ report on health information interoperability finds that MU criteria falls short of achieving MU in any practical sense and recommends that Stage 3 be used to advance interoperable health data infrastructure. The JASON report also recommends that Stage 3 require vendors to develop, publish, and verify APIs that allow third parties to build on them with new applications and that EHRs should have enhanced encryption and fraud detection capabilities.

The Society for Adolescent Health and Medicine recommends that EHR developers consider the special needs of adolescents when designing and implementing systems to ensure patients’ access and confidentiality requirements are met. In order for adolescents to realize the benefits of EHRs, providers should also advocate for adolescents’ specific privacy needs.

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News 4/17/14

US physicians produced $1.6 trillion in direct and indirect economic advantage in 2012 and supported an average of more than 13 jobs apiece, according to an economic impact analysis by the American Medical Association. Some outside observers question the accuracy of those figures but there’s no denying that doctors make a big financial impact on the economy.

MHMD Memorial Hermann Physician Network (TX) will deploy DocbookMD’s mobile communication solution to connect its member physicians with one another and with other area providers.

Kids First Pediatrics Group (GA) integrates PatientPay’s electronic billing and payment solution with its Greenway PrimeSUITE practice management system.

EyeFormatics will bundle ZirMed’s RCM solutions within the EyeFormatics EMR.

Jacob Reider, MD, the ONC’s deputy national coordinator, will provide the keynote address at the 2014 Aprima User Conference in Dallas August 8-10.

Forget Weight Watchers, Jenny Craig, and pricey gym memberships. Boston doctors now have a new option to offer their low-income patients battling obesity: bike riding. The city’s “Prescribe-a-Bike” program allows doctors to write “prescriptions” for patients to buy a $5 yearlong membership to the city’s bike-share system. The list price is $85 for an annual membership.

I liked number crunching and data analysis, even when the final output doesn’t mean much. Case in point: Steven Posnack, who is director of the federal policy division for the ONC, posted on his personal blog some fun findings using details from the recently released Medicare payment data. He cross-referenced the payment data with MU payment data and determined what EHRs were used by the highest paid EPs (based on their Medicare payment data.) What does this tell us? Not a whole lot other than which systems are more commonly used in hematology/oncology, ophthalmology, and cardiology – the three specialties with the highest reimbursements. Altos is an oncology-specific EMR; NextGen and MDIntelleSys are widely used by ophthalmologists, and cardiologists use a variety of systems. Even though this chart doesn’t tell us a whole lot, Steve proved that provider details from multiple data sets can be linked – which may beget juicier output as people keep crunching the data.

Nordic Consulting begins a three-year sponsorship of the complimentary wireless Internet access at the Madison, WI airport. It’s definitely a clever marketing tool directed at all those Epic customers popping into town for training.

A systematic review study published in Perspectives in Health Information Management finds that e-prescribing in the ambulatory care setting improves patient safety, increases efficiencies, and saves money, but implementation costs, alert fatigue, and privacy/legal concerns remain barriers to adoption.

Florida is the latest state considering legislation changes to increase the use of telemedicine and establish requirements for providers who treat patients remotely. Proponents say that an expansion of telemedicine would reduce healthcare costs and improve patient access to physicians.

A NueMD ICD-10 survey conducted prior to the official delay shows that the majority healthcare professionals participating wanted the ICD-10 transition to be pushed back or canceled.

A review of clinical trials reveals that a doctor’s bedside manner can greatly improve patients’ health, aid weight loss efforts, lower blood pressure, or manage a painful symptom. Researchers found a “statistically significant” effect on outcomes when physicians had some sort of relationship-based training, such as building empathy and making eye-contact. I’m not sure I ever before realized how closely patient care parallels dating and marriage.

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News 4/15/14

AAFP President Reid Blackwelder, MD offers an interesting spin to last week’s disclosure of Medicare payment data. Blackwelder notes that while the release may make some family physicians feel threatened, he points out that the “action taken by CMS will provide a great opportunity for the Academy to highlight the complexity of care that family physicians provide.”  Blackwelder likely hopes the payment details will positively impact family physicians’ bottom lines, noting that the data reflects the disparity in compensation between specialists and family physicians, who “are near the bottom of the list in terms of payment.”

Meanwhile, the AMA emphasizes that CMS released “raw data with little context and considerable limitations” and offers some points of clarification to help physicians answer questions from inquiring patients. Key points include:

• Medicare payments don’t equate to a physician’s personal income. Physicians also have practice overhead and receive payments from other sources.
• The released data may be not include all services performed, could contain errors, and could include figures related to services rendered by residents or other providers.
• Claims data does not provide implicit details on outcomes.

Finally, let’s just hope the financial winners in all this are not the lawyers specializing in healthcare fraud cases. Not surprisingly, so-called whistleblower attorneys pounced on the data in hopes of expanding existing cases against providers and pharma companies and in search of leads for potential new lawsuits. I see a flood of late night commercials in the works urging medical billers to call a special toll-free number to report employers’ billings that might to be out of line with the rest of the industry.

Sermo reports that its online community has grown to 260,000 US physicians, which represents a 30 percent increase since October, 2013.

The 260-provider Phoebe Physician Group (GA) selects athenahealth for EHR/PM and care coordination.

Shenandoah Medical Center (IA) will deploy Allscripts Sunrise solutions, including Allscripts Sunrise Ambulatory Care.

DrChrono raises an additional $2.69 million in convertible debt funding, giving it overall funding of $6.77 million. The company offers a free EHR platform and says  60,000 physicians are “signed up” to use their program. I assume that number includes me after I took about 30 seconds to register my “family practice.” The website says that  DrChrono is Stage 1 certified, however Stage 2 certification is not mentioned. Regardless of my doubts, investors seemed to have found their story compelling enough to pony up additional funds.

CMS offers guidance on how providers can take advantage of the new Attestation Batch Upload option, which allows multiple EPs (and hospitals) to submit attestations in a single file through CMS. Incentive payments are provided to individual providers and not to medical groups or hospital systems, even if attestation is submitted in batches.

Here’s a different twist to the standard privacy breach. A former administrative assistant at a Tennessee urology practices sends a competing practice the names and addresses of 1,114 patients so the competitor could solicit business. No data commonly used for identity theft was provided, nor any clinical information. So far no word on possible charges filed against the terminated employee, nor the competing practice.

The Boston Business Journal names athenahealth the top publically traded Massachusetts software company with the largest market capitalization at $5.5 billion. Nuance Communications was a close second with a market cap of $5.2 billion.

Talksoft Corporation makes its appointment reminder app Talksoft Connect available for Android devices. The app allows patients to confirm or request a reschedule, alerts patients of a payment due, and offers automatic entry and alarms on a device’s calendar.

AdvancedMD introduces the 1.5 version of its iPad release that includes image capturing within notes, patient search enhancements, a refreshed interface for iOS 7, and faster messaging capabilities.

A Texas family physician finds professional satisfaction after ditching insurance and charging his largely uninsured patient base a flat $50 fee per visit. The “direct primary care” model isn’t new but may find new popularity from physicians opting to avoid administrative overhead and billing hassles. Unlike the concierge model where doctors charge higher annual fees and spend more time with fewer patients, Laredo physician Gustavo Villarreal, MD (above, in front of his paper charts) sees 40 to 60 patients a day and says the change has made him feel like he’s a doctor again.

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News 4/10/14

HHS releases data for over 880,000 healthcare providers who collectively received $77 billion in Medicare payments in 2012. The agency notes that “with this data, it will be possible to conduct a wide range of analyses that compare 6,000 different types of services and procedures provided, as well as payments received by individual health care providers.”

Look for many more reports like this one published by The Wall Street Journal as organizations begin downloading and manipulating the Medicare payment data. The WSJ determined that the top one percent of the 825,000 individual medical providers accounted for 14 percent of the $77 billion in payments, and 344 providers received more than $3 million each.

I’m not sure the average physician needs to be too worried that a nosy neighbor will now be able to figure out what the government has been paying him/her because downloading and manipulating the data isn’t the simplest exercise. The data is available in a tab delimited file format which I am sure works great if you have statistical software to do the manipulations. Most folks don’t, so they’ll have to download an Excel version of the data. The files are broken down by the letters of the alphabet and are still huge (“S,” for example, is 168MB.) Because of the size, each file takes a couple minutes to download. When I tried to download a second file/letter of the alphabet, it caused Excel to crash, though admittedly I had quite a few other windows open at the time. But, let’s say you successfully download a file. The next step would be to filter about a million (seriously) lines of data to find a particular physician and then figure out the appropriate payment figure (submitted amount vs. payment amount).  Even if you pick the correct reimbursement figure, you’d then need to multiple it by the correct number of encounters (even more difficult to decipher). Of course, keep in mind that the each provider’s data excludes procedures performed on fewer than 10 Medicare patients, so probably whatever final number you derive, it’s probably incomplete.

The HHS OIG reverses an 2011 advisory opinion that had allowed athenahealth to charge $1 to providers not on the athena network for processing their test orders. The termination means that athena can no longer distinguish between in-network and out-of-network providers and will therefore charge $1 for all orders. In reconsidering its position, the OIG concluded the arrangement could violate anti-kickback statues. Meanwhile, athenahealth calls the reversal a “setback” for sustainable HIE.

Lakeland Regional Health Systems (FL) will expand its use of Allscripts ambulatory EHR and PM, utilize Allscripts managed services, and implement Allscripts Payerpath financial management software. Last year Lakeland acquired Clark & Daughtrey Medical Group, an existing Allscripts customer.

e-MDs adds PDR Brief to its EHR, giving users enhanced drug information and alerts from PDR Network.

CMS develops a Stage 2 Meaningful Use Attestation Calculator to help providers determine if they can successfully meet Stage 2 requirements by identifying a pass/fail summary for each measure.

Individuals posing as patients covered by private insurance were more likely to secure a new-patient appointment with a primary care physician than other “secret shoppers” posing as patients covered by Medicaid or uninsured, according to researchers from the Perelman School of Medicine at the University of Pennsylvania. Researchers placed a total of 12,907 calls to 7,788 primary care practices to secure new appointments. Eighty-five percent of patients with private insurance obtained appointments, compared to 58 percent with Medicaid, 79 percent with no insurance but willing to pay in full with cash, and 15 percent with no insurance but willing to pay $75 or less at the time of service.

An Institute of Medicine report recommends including information on patients’ social influences and behavioral habits in their EHRs, arguing the data can help improve outcomes and advance public health research efforts.

Harmony Healthcare IT, which provides support for 3,000 Medical Manager PM systems, partners with ZirMed to provide users an ICD-10-ready claims submission solution. Wow, who knew there so many practices still running Medical Manager?

Independence Blue Cross (PA) and the physician practice arm of dialysis provider DaVita launch Tandigm Health, a new healthcare business model that aims to reduce care costs of chronically ill patients by working to keep them out of the hospital. Tandigm will offer primary care physicians higher reimbursement rates and access to analytical tools and real-time data  to help patients better self-manage their conditions, as well as provide monitoring tools for use in patients’ homes. The press release is short on details so it’s unclear what penalties the participating physicians will incur if care costs don’t decline.

Health plans must honor physician requests to use the Automated Clearing House (ACH) Network to conduct EFT and ERA transactions, according to a CMS administrative simplification email update. CMS also notes that health plans cannot charge a fee or use any other method to encourage a physician to use an alternative payment method other than EFT through the ACH Network, and, physicians are not required to use EFT.

Since I hate robocalls, I’m thinking about sending a link to this story to all my doctors. Vanderbilt Medical Group (TN) reports a 50 percent response rate for text message appointment reminders, compared to a 30 percent response rate for robocalls. The higher response rate and the associated backfilling of cancelled visits has translated to 50 fewer no-shows per day.

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CMIO Rant with … Dr. Andy

CMIO Rant with … gives CMIOs a place to air their thoughts or gripes. Yours are welcome.

The Great Prescription Pad Race
By Andy Spooner, MD

Which is more usable: a prescription pad or a computer?

That’s a no-brainer. For writing a prescription, the pad wins, hands down. Consider its features:

• Instant-on. No booting up. Just reach in your pocket and you are ready to go.
• Compact, lightweight. Did I mention your pocket?
• Self-documenting. No need to print a summary describing the prescription.
• No irritating pop-ups with irrelevant alerts.
• Patient-centered. The pharmacist can fill in missing information (liquid or tablet or capsule? brand or generic?) based on patient preferences.
• Flexible. Can be taken to any pharmacy. No need to route it to a specific place, or even to ask the patient about a preferred pharmacy.
• Streamlined. No need to worry about pharmacy benefit management rules. The pharmacist can sort all that stuff out.
• Information-persistent. If the family has a question about an apparently erroneous prescription, they can read the details right off the prescription when talking to the after-hours nurse.
• No record-keeping clutter. Patients can just tell us about their prescriptions next time we see them. They could just bring in the bottle or something.

With all of these advantages, surely only the geekiest of pencil-necked CMIOs would advocate an electronic method of prescribing, right?

Of course not.

The prescription pad is easier only if we define the work as the minimum possible activity that a doctor can do to get a prescription into a patient’s hands. The truth is, we are not done with the task of prescribing when we hand the slip of paper to the patient. If we think we are, then the pad seems far easier to use—more usable—than any electronic health record or e-prescribing system.

The above competition is absurd, of course, in an era when, according to the CDC’s National Ambulatory Medical Care Survey, over 80 percent of office-based physicians in 2013 used electronic prescribing. That rate rose from less than 60 percent over the past three years. E-prescribing is here to stay.

But we still hear about how unusable electronic medical record systems are. In The Atlantic this month, we read that a doctor who sees 14 patients a day spends “1-3 hours” each day entering orders. Assuming that each patient needs some orders for health maintenance (screening lab work), prescription renewals, and maybe a few diagnostic tests and referrals, it’s hard to take that statistic seriously. It’s clear that the writer is irritated at his EMR, and there may be some legitimate design or implementation issues with it. But 1-3 hours of ordering per day? C’mon.

Somewhere between the slapdash paper prescription and the three hours of daily ordering is the truth. Managing clinical information takes some amount of time, and some of it should be done directly by physicians. Some of this activity serves a “compliance” goal that you may not like, but all of it is a part of building a system of healthcare that serves a worthy goal.

If we insist that all clicks are wasted time, then we can’t have a conversation about usability, because under the prescription pad scenario, the only usable computer is one you don’t have to use at all.

On the other hand, if we insist that our current systems are bad because of hyperbolic, data-free assertions about how the EMR is making our lives miserable, we are similarly blocked from making productive plans to improve usability because, well, it’s just too darn much fun to complain.

My thesis, then, is that EMR usability is not as much about design as about expectations. Variations in what these expectations ought to be between different perspectives will lead to unproductive conversations (or no conversations at all) about what it means to have an EMR that’s easy to use.

All I know for sure as a CMIO is that physicians want all of this stuff to be easier to use. We also want these systems to read our minds, but that’s at least a couple of versions away, if I am understanding the vendor presentations at HIMSS correctly.

Andy Spooner, MD, MS, FAAP is CMIO at Cincinnati Children’s Hospital Medical Center. A general pediatrician, he practices hospital medicine when he’s not enjoying the work involved in keeping the integrated electronic health record system useful for the pediatric specialists, primary care providers, and other child health professionals in Cincy.