DOCtalk by Dr. Gregg 4/22/14

Multiview: Prime Cut

Looking around at EMR/EHR options again – or, as always – one thing has begun to really stand out: the value of “multiview.” (In case you don’t know what “multiview” means, it refers to the ability of an EHR to allow the viewing of more than one function, and especially more than one function of more than one patient, at a time.)

OK , maybe the term “multiview” isn’t an industry standard, but I’d argue that it should be. After becoming comfortable with a system that easily allows viewing multiple components of a patient’s record at the same time, and one that also easily allows multiple views of multiple patient records at the same time, it has become virtually impossible for me to even consider any system that only allows a “one patient – one component” (OPOC) view.

OPOC seems comparable to the Buddha’s blind men describing an elephant by only experiencing one “view” of it.

Once you’ve become comfortable with multiple perspectives, with being able to see multiple “stories” at one time, with seeing interrelated parts and pieces, it becomes insufferable when you are only allowed to view the “one story, one element” window format of OPOC that seems to be the general industry standard in HIT.

The good part is that seeing what is available in EMR/EHR systems is becoming easier. More current EHR vendors are now offering “free” or “trial” versions that allow you to “try before you buy.” I love that. There’s no EHR demo, and certainly no EHR sales pitch, that can ever allow a provider to get as full a sense of what it’s like to work with a new EHR as a trial version can. Getting your hands on a system, even with a single “John Doe” test patient, provides so much more useful data on what it will be like to operate within the workflow of a new EHR. Kudos to those vendors who have figured out the value of the EHR test drive.

The hard part for me is looking at otherwise very intriguing systems who offer otherwise great functionality (and even otherwise wonderful pricing), but who are limited by the OPOC view.

Honestly, I don’t think it possible to go backwards. To even consider losing the ability to see multiple views within a patient’s chart at the same time, and especially to consider losing the ability to see multiple views within multiple patients’ charts at the same time, seems to have become a nonstarter. OPOC is a rate-limiting step, to be sure. I can’t seem to move past the consideration.

Even with a system that doesn’t offer all the specialty-specific features I’d prefer, even with a system that doesn’t provide 2014 MU certification (yet), even with a system that doesn’t have all the connectedness I’d prefer – all of this pales when compared to working with a system that allows me to see what I want, when I want, and as much as I want in the resizable, moveable window way with which I’ve so quickly become accustomed. Multiple views of multiple stories are multiply wonderful.

Multiview is one of the most dramatic ways that computerized documentation trumps paper records on a day-to-day-what-really helps-with-patient-care functionality basis. A paper chart requires flipping back and forth; OPOC systems do, too. Multiview allows a provider’s brain to do what it does best: easily view, consider, and synthesize multiple, disparate factors. Gray matter, at least the vast majority of non-eidetic-memory gray matter, isn’t very good at remembering all the little details; computers excel at this. But, gray matter beats the digital pants off of silicon for processing the bejesus out of data when given a multifactorial view. Gray matter can consider connections and nuances related to the human condition that escape even the most sophisticated electronic brains. (Watson, Tianhe-2, Mira, and their ilk may soon overtake us on this, but not just yet. Plus, gray matter is far more portable.)

Multiview has become my documentation standard of care. If you haven’t been fortunate enough to experience multiview in your EHR/EMR system, you’re probably better off. It’s hard to miss what you’ve never known.

For me, I’m now fully spoiled. Anything less than complete multi-manipulable, multi-scalableable, and multi-viewable has become multi-unacceptable. It’s like trying to pretend that chuck roast is fine, that I don’t know the exquisite texture and flavor of filet mignon.

But I do. Multiview is prime cut.

From the trenches…

“I’m very interested in structure, how multiple stories are assembled in different ways; that is what memory does as well.” – Nicole Krauss

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 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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