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.)

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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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From the Consultant’s Corner 2/21/14

Dusting off Your Physician Compensation Plan: 5 Steps to Creating a Value-based Strategy

For most practices, I suspect physician compensation is not something you are frantically trying to change. However, the sense of urgency may grow as healthcare reform continues to evolve.

As we all know, reform is shifting the focus of compensation from physician productivity (volume) to care quality (value), and payers are beginning to include patient satisfaction and quality as part of various payment reimbursement methodologies. As a result, practices may want to consider aligning their compensation plans with the shift toward value in order to remain viable.

Before we discuss how to align, let us take a closer look at how value-based payment is changing physician compensation. In the past, physicians were paid a percentage of charges or cash collected. More recently, the industry standard shifted to wRVUs (work relative value units) to incent performance. This model uses a point system for services rendered, with the accumulated points converted to a monetary value at the end of each quarter or year.

The wRVU method is almost counterintuitive to healthcare reform as the new emphasis on value disrupts the traditional mindset of “the more services provided, the more providers get paid.” The new thinking rewards quality and efficiency, not performing more surgeries or sending patients for expensive MRIs. In fact, payers see the focus on volume as inconsistent with protocols for quality care.

As you can see, it is a good time to review your compensation plan and ensure it is aligned with healthcare reform. Below are five steps to guide the alignment effort.

1. Find a physician champion. Strong physician leadership can support a smoother alignment process as this individual can address and overcome any physician reservations. Simply put, administrators cannot do this work on their own. A good choice for physician champion might be the head of the practice or a department chair.

2. Form a multidisciplinary compensation committee. If your practice includes several different specialties, you may want to create a committee to review compensation, which includes respected leaders in the practice and representatives of each specialty. This group can communicate to the rest of the practice frequently and transparently.

3. Conduct research and educate the committee. Look for and share information about current payers offering incentives or bonuses based on quality. Good sources of information might be the Healthcare Financial Management Association (HFMA) and the Medical Group Management Association (MGMA) or anecdotal information from other practices in the market.

4. Determine incentive goals and measures. Goals must be fair, measurable, obtainable and lucrative enough to get physicians’ attention. Ideally, you should balance base salary, productivity, quality, satisfaction and other measures. In my opinion, it is best to employ one compensation methodology across the group while the actual measures and goals within the group can vary by specialty. If the practice is already measuring quality for meaningful use (MU), use one or two of those agreed upon measures per specialty. If you are currently measuring patient satisfaction, use a score that reflects how patients feel about the physicians. Regardless of the measures, review incentive amounts to ensure they are meaningful to the physician and specialty.

5. Before launching a new plan, verify your practice can fund it. Make sure you do the math to check that the highest payout scenario is affordable. You also may want to phase the plan in to ensure the goals are captured in the EMR and the plan is doable. Most importantly, design the plan to be adaptable, so it can evolve when you review it annually.

We all know physician compensation plans are a challenge regardless of external influences, such as healthcare reform and value-based reimbursement. While there is no need to rush in and dramatically change your approach, it is definitely time to assess the current landscape and begin planning for the future. Remember, this cannot be done overnight or in a vacuum, especially with all the other priorities such as MU and ICD-10. In my view, the practices that are proactive in aligning their compensation plans will be the most successful going forward.

Johanna Epstein is vice president of management consulting services at Culbert Healthcare Solutions,