Practice Wise 3/13/14

Open letter to EHR users

Now I know for sure this is going to put in me in the unpopular kids group, but I have to say it! EHR users are costing vendors excessive amounts of support time and resources supporting users who refuse to admit they might actually be causing the problem.

I’m not saying this as a rebuke to users who truly have EHR problems and vendors who won’t/don’t address them effectively. However, as an organization that provides both consulting services and direct support, we see this scenario way too often and I think it’s time to address it head on!

For example, a customer complains that the system keeps doing something nefarious and is out to ruin their practice. Vendor asks typical level one support questions such as ‘are you sure you have not hit the (any) key?’ Customer insists they are not hitting that key, and is not shy in stating how offended they are that the vendor would even consider that ‘they’ might be causing their own problem. After hours of support, escalation and development time spent on this issue, customer is audited on site, they hit the key they swear they never hit, and sheepishly say, ‘oh, I guess I sometimes do hit that key’. And instead of swallowing a little humble pie and offering an apology, they deflect by saying something else like ‘but the system does this other thing that is really ruining my practice!’

Seriously, what EHR users really need to understand is that most software vendors have the same goals as they do: to have a successful implementation with expert users who fully utilize the system for optimum use. There are certainly vendors who have badly designed products and poor support. Let’s just assume we are not talking about any of them here.

This behavior is top down in most practices. The most successful implementations and ongoing adoption of all things EHR are in practices where the doctors themselves display a positive attitude about the change, are engaged in the process, and are supportive of their team as they all struggle to grasp the new program and develop the muscle memory that leads to mastery. There are fewer of these practices overall. The general experience is that doctors believe EHR is being forced on them, that no vendor could ever make a product that doesn’t slow them down, that it doesn’t print out documents that sound like they would speak, etc. And when the project starts at that level of negativity, it permeates the whole team.

What happens in an EHR implementation is that a magnifying glass is held over all your processes and procedures. If you are a well-developed process-based organization, this is a good thing, your shining moment. If you are an organization that has just always done things on the fly or ‘this way because that’s how it’s always been done’ and not open to new processes that might actually improve your practice, you will have a hard time hearing valuable recommendations from your consultants and implementation team.

When the internal practice attitude towards the project is negative, the doctors become abusive to their team and to the vendors who support them. I don’t use this word lightly. Talk to any implementation person and they can rattle off a litany of horror stories of doctors throwing fits, calling them idiots, throwing laptops across the room, etc. Here’s my theory (not very scientific, purely observational): doctors are used to being smart and good at what they do. This process unmoors them to some extent. Once they accept the process and decide to move forward, they generally do well the first week of go-live because they believe they shouldn’t know the system, so they don’t typically get snarky that week. However, week two rolls around and they assume that since they are smart and quick learners, that they should have mastered the darn thing, and then the snarky, rude behavior comes out. When the staff sees/hears the doctors abusing the vendors, they do the same when they are frustrated because they believe it’s how to get things done in the practice.

I’ve worked in other industries besides healthcare, and never in my professional life have I experienced this kind of rude abuse by a customer to a vendor as I have in this field.

Here’s my message to providers: we are here to help you. If your practice succeeds, we succeed. Your implementation failure is our failure. We want you to be the best users you can be, and we want you to master the system to the fullest. However, when you don’t speak nicely to us, call us names, make threats etc., we are less likely to want to go that extra mile to hold your hand in your time of need.

I had an IT vendor tell me on the phone the other day that he doesn’t care that the darn doctor can’t access the VPN from home and fixing it is low on his priority list because the doctor is so rude to him and always hangs up on him when he doesn’t get the answer that he wants.

That’s what happens when you’re rude to your support vendors: we tend to put you at the bottom of our priority list. Here are a few ideas of ways you can navigate through this difficult transition, with everyone pulling for your team and working towards your success:

1. Accept that you are changing your processes and getting an EHR. Doesn’t matter why, it just is, so accept it and get over it.
2. Project a positive attitude within your organization, encourage your partners and staff to do the same. Be the champion!
3. Buy the hardware as recommended by your EHR vendor. Don’t try and cut corners and save money buying your own computers and equipment at discount sales if you really don’t understand the hardware specifications. Your IT vendor is not a magician; if you don’t buy what’s recommended, he can’t make it do what you need it to do, and you’ll be frustrated and likely blame the IT vendor and the software vendor.
4. Take advantage of ALL training opportunities offered by your vendor. The more effort you put into your training, the less frustrated you’ll be. This is one area that frustrates the vendors; doctors are ‘too busy’ to do the training, yet want to be masters of the system. It’s not magic; it’s learning. You had to go to med school to become a doctor – they didn’t just hand you a degree. Same theory here!
5. Put effort into doing the customizations offered to tailor the system to your practice. Many systems have great malleability and trainers who can help you design your workflows in a way that helps you document in your comfort zone. This effort on the front end will reduce your stress on the back end.
6. Create a position for an EHR super user in practice. The person’s sole responsibility is to make sure your needs are getting met, your changes are addressed quickly, and is dedicated to you. Treat that person nicely even when they can’t give you exactly what you want. You cannot expect your vendors to drop everything and meet your demands all the time, especially when you make demands and don’t ask nicely for help.
7. BE NICE to everyone. We are all doing the best we can at any given moment to support you! We all have the same goals – your successful implementation and continued success in your practice.

I love working in healthcare and supporting doctors. Some call me crazy! However, I think most doctors really do have the best intentions and just need to know that in the end, it will all work out fine. At least we’re not asking you to work 100 hour/week rotations. You survived residency, you’ll survive this too!

Julie McGovern is CEO of Practice Wise, LLC.

News 3/13/14

From Harry C: “Re: CEHRT Hardship Exception Guidance. The move is not surprising given the number of vendors that are late releasing their Stage 2 versions, giving providers little time to get up to speed. Add in the fact that Stage 2 and ICD-10 must be implemented at the same time is too much for a lot of practices. The hardship will help practices that don’t have enough time to implement all the changes in workflow.” CMS revises its hardship exemption criteria to avoid 2015 Medicare payment penalties, allowing providers to indicate “2014 Vendor Issues” as the reason for the required exemption. I understand that providers are facing the perfect storm of deadlines but I find it ridiculous that CMS indicates it will rubber stamp hardship exemptions for any one that asks, rather than push back the official deadline.

Drchrono announces that its free EHR platform will be certified for MU Stage 2 “later this year.” Drchrono reports that over 60,000 medical professionals use its EHR platform. Given drchrono’s vague deadline for the release, I’m confident that a good number of drchrono physician users will be immediately jumping onto the CMS website to register their hardship exemption.

Physicians recognize the value of EHRs in concept and appreciate better access to remote patient information, but also believe EHRs undermine professional satisfaction and can negatively impact patient care. Those are some of the findings reported in a Rand Study on physician professional satisfaction based on data collected from 30 practices across six states. While less than one in five physicians would prefer to return to paper medical records, providers raised specific concerns about EHRs, including:

• Poor usability that doesn’t match clinical workflows
• Time-consuming data entry
• Interference with face-to-face patient care
• An overwhelming number of electronic messages and alerts
• The inability to exchange health information electronically with all providers
• The degradation of clinical documentation
• Expenses that were significantly higher than anticipated

The authors recommend that better EHR usability be an industry-wide priority and a precondition for EHR certification.

The ONC’s HIT Policy Committee releases preliminary Stage 3 MU recommendations, the majority of which are updates to objectives included in Stage 2. For example, Stage 2 requires providers to give at least 50 percent of patients to view their health information within four days of the information becoming available to the provider. Stage 3 requires providers to make the information available within 24 hours. The recommendations include 19 measures, which is two-thirds of the number included in initial Stage 3 proposals.

Qatar Foundation Primary Health Care Center becomes the first healthcare facility in the country to implement Cerner’s ambulatory EHR.

Greenway’s VP of industry and government affairs Justin Barnes participates in several recent White House summits, briefings, and panels to discuss HIT, patient engagement, privacy, the US economy, and related topics.

Not to take away from Barnes thought leadership and achievements but I was disappointed not to see a single female in the above picture.

University of Colorado Physicians goes live on the DocASAP self-scheduling system.

EClinicalWorks opens registration for its 2014 National User Conference, which runs October 17-20 in Orlando.

The EHR Association elects NextGen Healthcare CMO Sarah Corley to its executive committee.

E-MDs customer John Bender, MD of Miramont Family Medicine (CO) tells Medical Economics that his use of Lean management principles and use of IT have helped him to manage escalating costs and consistently grow the practice 45 percent.

A NIST report says that inadequate workflow integration forces users of ambulatory EHRs to develop system workarounds, suggesting that EHR vendors develop these capabilities:

• At-a-glance physician views of patient schedules
• Task reminders from previous patient visits
• Redacting and summarizing lab results
• Draft creation of patients orders in advance
• Conversion of working diagnoses to formal diagnoses
• Skip or defer tasks when workload requires
• Role-based views of progress notes
• Visually differentiate copied-and-pasted progress note text from newly entered documentation
• Manage referral and consultation messages with specialists
• Track scheduled consults and lab results review

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News 3/11/14

Primary care providers need EHRs to move beyond documentation to interpreting and tracking information over time, according to an AHRQ-supported article.The authors note that EHRs are currently focused on disease rather than the whole person and ignore factors such as personal risk, behaviors, family structure, and occupational and environmental influences. Stage 3 MU focus needs to include not only an emphasis on outcomes, but also EHR functionality, including the expanded use of patient portals, integration with better external applications, and advancement of national infrastructure and policies.

Twenty-two legislators also weigh in on Stage 3 MU criteria and ask HHS to consider ways to reduce health disparities by leveraging HIT. Some of their specific recommendations for inclusion: improved data collection requirements and better use of collected data; increased functionality to support health literacy and communication; and, better access to health information and healthcare on mobile platforms.

Kareo introduces an ICD-10 Success Plan Checklist poster that is in a tasked-based format and helps practices identify specific transition tasks, deadlines, and project owners.

Six Republican senators call on CMS to “immediately clarify details” for its plan to grant MU Stage 2 exemptions to certain providers. During her HIMSS keynote address last month, CMS Administrator Marilyn Tavenner confirmed that the deadline would not be extended, though some “narrow” hardship exemptions would be granted. All politics aside, the senators are right: the clock is ticking and providers deserve some clarity in quick order.

A Government Accountability Office report finds that participation in the MU program increased substantially from 2011 to 2012 but 16.3 percent of EPs participating in the Medicare program dropped out in 2012, as well as 60.8 percent of Medicaid EPs.  Some reasons noted for the dropouts include providers had switched EHRs and weren’t ready in time to submit EHR data; providers were unaware of program deadlines and the need to participate in the program again; and, providers found more difficulties than anticipated going from a 90-day reporting period in the first year to a full-year reporting period in the second year. The GAO notes that estimating future participation in EHR programs is difficult because of various program changes, the increasingly stringent MU measures, and the introduction of penalties in 2015. My guess on EP participation: though providers will continue to embrace EHRs, an increasing number of providers will opt out of the MU program because the financial incentives and avoidance of penalties aren’t worth the effort.

A Chat with Albert Santalo, president and CEO of CareCloud

During HIMSS I spent a few minutes chatting with CareCloud CEO and President Albert Santalo.  Here’s a short summary of our conversation:

• CareCloud achieved 100 percent growth in 2013.
• Currently the company has about 5,000 providers on its system; about 20-25 percent of those are on EMR.
• Santalo expects to add 8,000 new customers in 2014.
• The company primarily targets independent physician offices rather than large health systems with employed or affiliated providers.
• The EHR platform is certified for Stage 2 MU.
• I asked Santalo if and when the company would go public. He danced around the answer a bit but admitted an IPO is something that may happen within the next 18 months.
• While CareCloud has no plans to develop or sell a core in-patient system, the company will look to offer more products like CareCloud Community, which provides patient engagement and care collaboration tools that can be used across different venues of care.
• CareCloud views itself as one of athenahealth’s few direct competitors because both offer a cloud-base platform and a full range of RCM and back-office services. Unlike athenahealth, however, CareCloud customers are not required to subscribe to the full service model. Santalo believes that making the full RCM model optional has helped CareCloud win business with practices wanting to reserve the option of keeping billing in-house.
• Santalo said CareCloud’s KLAS scores are “getting better.” In looking at the KLAS website I believe CareCloud still falls into the “not-rated” category because of an insufficient number of customers ratings.

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News 3/6/14

The pay gap between primary care providers and specialists narrowed from 2012 to 2013, with primary care providers seeing an average compensation increase of 5.7 percent compared to 3.2 percent for medical specialists and 2.3 for surgical specialists. In a survey that considered the physician compensation and productivity at 484 healthcare organizations, one-third of the employers reported the use of quality metrics in their compensation plans.

Gastroenterology-specific EHR provider gMed will add medical content from Health Language into its gGastro platform.

MTBC will integrate its PM and RCM platform with Practice Fusion’s EHR.

The president of medical scribe provider PhysAssist Scribes reports that inquiries for scribes by outpatient medical clinics and physician offices are now five times higher than inquiries from EDs. His company charges $30 an hour for a clinical scribe, compared to $21-$24 an hour for an ED scribe. I think the key word here is “inquiry”: how many family practice physicians are willing/able to spend an additional $200+ a day for a scribe? Most already have all the patients that can handle so telling an FP he/she could be freed up to see a couple more patients a day is probably not a great selling point. Add on top on top of that the never-ending concerns over declining reimbursements and increased costs and the scribe companies may struggle to convert a good number of these “inquiries” to actual sales.

TriZetto Provider Solutions advises customers that it will continue to accept claims in print image, NSF, and legacy formats even after the ICD-10 implementation deadline. How many other clearinghouses will follow suit, I wonder?

Physicians Interactive and McKesson Patient Relationship Solutions will jointly deliver Coupons on Demand, which will provide clinicians access to online cost-saving offers for medications.

HIMSS Analytics recognizes 263 Ohio State University clinics with its Stage 7 Ambulatory Award.

Florida International University’s faculty practice chooses PatientKeeper Charge Capture.

Kinston Pulmonary Associates (NC) will implement NextGen PM and EMR from TSI Healthcare.

Despite the growing number of  employed physicians, results from an ACPE survey suggest work still needs to be done to integrate physicians and develop performance-based reward programs. Less than half of the participating physician executives believe their physicians are fully integrated into their hospital or health system and only half have incentive plans to encourage or reward physicians  for being engaged in practice performance initiatives.

A Chat with Girish Navani, Founder and CEO of eClinicalWorks

I had the opportunity to sit down with eClinicalWorks co-founder and CEO Girish Navani during HIMSS. We’ve met a few times over the years and I always find him to be charming, smart, and down-to-earth. Here’s a short summary of our conversation:

• ECW has signed on about 50 ACOs for its population health management platform.
• The company now serves 100,000 doctors.
• A few years ago the company’s support organization had a number of challenges. Girish believes that the support organization has now been turned around and support is no longer the issue it once was.
• Currently the company has nine hosting centers across the country.
• Look for the company to announce its first international customer in coming months.
• ECW continues to hire new employees, including 100 developers in the last six weeks.
• Of the company’s 3,000 employees, almost 900 are in the Westborough, MA headquarters and about 1,000 are in India.
• After hours live support comes from India and is available 24×7. Business house support comes from Massachusetts, California, and India with the help desk based in Westborough.
• Companies like eCW that serve thousands of smaller practices have a more difficult time getting all providers to attest for MU than a company like Epic , which serves a much smaller number of very large practices.
• Girish believes that the MU program will run its course in the next 12-18 months as more and more practices decide the later stages are financially not worth the effort. He also believes more vendors will decide not to apply for certification because of the amount of development work it requires.
• Next year look for the HIMSS chatter to focus more on new payment models such as bundled payments and risk-based plans.
• This year population health management vendors are hot, but within five years many will have disappeared. Just like we saw with EMR vendors in recent years, some population health vendors will be acquired and others will run out of money. In time population health tools will become a standard feature within most EHRs.
• Health information exchange should not be a “product” but a capability available with all EHRs.
• Girish estimates that his company would be valued at $6 billion if he were to take it public today. However, he still has no plans or incentive to do so. Currently the company has no debt, $150 million in cash, and $300 million in annual revenue.
• Three thousand people attended eCW’s October user group meeting in San Antonio. Girish expects the number to grow to 5,000 for this year’s meeting in Orlando.
• Fun fact: Girish says he still lives in the same house he did when he started the company, though he does have a fancier car (I am told he has more than one Maserati.)

Email Inga.

News 3/4/14

From Hometown Girl: “Re: HIMSS. I couldn’t make it this year but loved your updates. Did you see anything cool for the ambulatory world?” Thanks to everyone who followed along from home. As I mentioned in one of my updates on HIStalk, I wasn’t wowed by any particular offering that I saw. Overall I would say there seems to be more of a blurring of offerings from both the traditional inpatient and ambulatory vendors with both promoting different flavors of products for care coordination and connecting with patients and other providers. One person I chatted with suggested providers are increasingly concerned with what’s going on outside their own walls and the products and services seemed to reflect that.

As usual, almost every vendor believes that HIMSS week is a great time to send out a press release or three. I still have several hundred unread emails in my inbox and fear it will take me all week to catch up on all the news. Hopefully I have caught most of the big stuff.

WEDI, in partnership with EHNAC, will create a Practice Management Accreditation Program to review PM vendors in the areas of privacy, security, mandated standards and operating rules, and operational functions. While I am all for having vendors meet minimum performance standards, is this really the best time to ask vendors to jump through one more hoop to remain competitive in the marketplace? It’s no surprise that we are seeing limited advances in product usability and innovation.

CMS Administrator Marilyn Tavenner told a HIMSS audience last week the October 1 ICD-10 transition will not be pushed back, though some providers may be giving case-by-case exemptions for meeting Stage 2 MU targets. The AMA was quick to issue a statement expressing deep concern “that Medicare does not have a back-up plan if last minute testing demonstrates anticipated problems with this massive coding transition” and warned that “disruptions in medical claims processing will hurt doctors and their patients.”

The ONC issues a proposed rule for voluntary certification criteria for EHRs in 2015, which would be separate from MU regulations. The 2015 edition certification criteria would offer a way for non-MU EHR systems to become certified; would enhance interoperability efforts; would include functionality criteria for patient population filtering of clinical quality measures; and, improve alignment with other HHS programs.

GetWellNetwork debuts GetWellNetwork Ambulatory, which is available on mobile and stationary devices and integrates with EHRs to provide personalized information, healthcare tools, and patient pathways to help patients and their caregivers participate in the patient’s care.

Practice Fusion offers integration between its EHR and AliveCor Heart Monitors and between the Diasend System for glucose/insulin reporting.

Speaking of Practice Fusion, I discussed the company with a couple of different industry insiders at HIIMSS last week and got differing opinions on the companies long term viability. One EMR executive suggested that the company could be a dark horse in the market and noted its KLAS scores were respectable. He believed the free platform would continue to appeal to smaller, independent providers. Another seasoned industry expert was not as confident about Practice Fusion’s viability, noting that neither its advertising model nor the sale of data would provide adequate revenue to sustain the company long term. It’s possible that both could be right, which would leave thousands of “happy” users looking for a replacement system.

Greenway acquires PeopleLynk, which sends patient relationship messages based on EHR events.

Greenway Medical names Phreesia its Marketplace Partner of the Year.

Greenway will integrate DrFirst’s controlled substance e-prescribing software into its Intergy, PrimeSUITE, and SuccessEHS systems

Greenway, by the way, had a good size booth at HIMSS, though maybe not as large as what they brought to MGMA and definitely in a less prominent location.

ADP AdvancedMD announces general availability of its reporting suite AdvancedInsight, which provides physician offices with financial insight into their practices.

ADP AdvancedMD offers an ICD-10 transition program in partnership with Alleon Healthcare Capital to provide preparation resources, product enhancements, and a revenue cycle financing program. The financing program aims to minimize the impact of  revenue delays and helps clients withstand up to 90 days of  nonpayment.

ICD-10 was definitely one of the hotter topics at HIMSS, both on the exhibit floor and in the educational sessions. 3M in particular had a huge booth promoting its ICD-10 readiness tools.

Interestingly ADP AdvancedMD was not an exhibitor this year. Perhaps the expense is too much considering not too many attendees are in their sweet spot in the smaller private physician practice segment.

Nuance integrates its multi-functioning printer scanning solution eCopy ShareScan with NextGen Ambulatory EMR.

Cerner and NextGen achieve bilateral data interoperability between the NextGen Ambulatory Solution Suite and the Cerner Network.

Physician First ACO (FL) selects eClinicalWorks Care Coordination Medical Record (CCMR) to advance its care coordination, population health, and quality health initiatives. West Florida ACO will also implement eCW’s CCMR platform.

The 200-provider Northeast Georgia Physicians Group, an Allscripts TouchWorks EMR customer, achieves Stage 7 on the HIMSS Analytics Ambulatory EMR adoption model.

Allscripts had a big HIMSS presence and was displaying its new tag line,  “The Power of All.” I thought it was a pretty clever play on words and emphasizes their intent to provide solutions across the full HIT spectrum.

DrFirst estimates that its Patient Advisor medication adherence platform delivered  $21 million in prescription savings opportunities in its first three months of operations.

Etransmedia acquires Medigistics, a provider of RCM and A/R management services for healthcare providers.

The AHRQ offers a toolkit to help physicians and their staff prevent problems associated with managing lab tests and results, including suggested processes for tracking, reporting, and following up with patients and avoiding diagnostic errors.

E-MDs introduces e-MDs Cloud RCM services.

PerfectServe introduces automatic electronic PHI filtering capabilities that remove ePHI from the body of messages sent to non-secure mobile devices.

Aprima Medical announces that over 1,500 former Allscripts MyWay customers have migrated to the Aprima platform. A friend told me she was at a reception last week and overheard an Aprima employee joke that Allscripts’ decision to stop supporting MyWay was the best thing to ever happen to Aprima’s business.

More than one-third of physicians have prescribed an app to their patients, according to a QuantiaMD member poll. Almost half of physicians participating say they would never prescribe an app because of the lack of regulatory oversight.

A three-year study of a PCMH demonstration project reveals the model did little to reduce costs and utilization or to improve the quality of care. The JAMA-published study found the PCMH model didn’t reduce hospitalizations, ED use, ambulance services, or costs.

CMS launches eHealth University to help providers navigate various federal eHealth programs, including EHR, ICD-10, administrative simplification, and quality.

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