News 5/6/14

The 2014 Medscape Physician Compensation Report finds that 67 percent of family physicians would choose medicine again as a career, but only 32 percent would stay in the same medical specialty. On the flip side,  specialists with the highest compensation in 2013 report they have the least professional satisfaction. It would be interesting to compare this report to one conducted in the days before HITECH. I’m willing to bet levels of career satisfaction were a bit higher all around.

 
New North Carolina Medicaid Director Robin Cummings shares his thoughts with the Asheville Citizen-Times on the benefits that a predicted 20 to 30 accountable care organizations will bring to the state over the next several years.

Rarely do the worlds of celebrity and healthcare IT collide (Dennis Quaid and his patient safety advocacy work is the only example that immediately springs to mind.) Leave it to athenahealth to add a little red carpet spice to its annual user conference. The company presents its 2014 Vision Award to semi-retired super model Christy Turlington Burns for her work with Every Mother Counts, a global non-profit she founded to promote access to maternal healthcare; and Allen Gee, MD, PhD, a neurologist at Frontier Neurosciences (WY), for his innovative work with telemedicine technology.

Perhaps even more rare is news related to wrestling and the local family physician. Martins Ferry High School inducts Dan Jones, MD (OH) into its wrestling hall of fame.

 
The American Nurses Association celebrates National Nurses Week May 6-12. The ANA’s activities and marketing are timely, given recent research that finds 65 percent of Americans aren’t looking forward to the possibility of being cared for by personal robots in their old age. The Japanese may be a bit more receptive. That country’s government is already promoting the use of nursing care robots for the ill and elderly.

 
ITech and MD-Reports partner to offer billing, scheduling, practice management, and integrated EHR software.

VitalWare launches iDocuMint.com, a cloud-based documentation tool that offers physicians guidance on documenting under IDC-9 and ICD-10, as well as favorite lists by specialty.

Even physicians are getting in on the crowd-funding game. Ophthalmologists Vince Deramo, Brett Rosenblatt, and David Rhee launch an equity crowd-funding campaign in hopes of raising $750,000  for a 20 percent equity stake to fund their digital physician on-call answering system. Their choice of investor-friendly, crowd-funding site ReturnOnChange is an interesting one given the popularity of consumer-oriented Kickstarter and healthcare-centric Medstartr.

Ali Pabrai, CEO of ecfirst, offers physicians seven tips for ensuring that the digital PHI of their patients is secure and HIPAA-compliant. While his advice seems sound enough, it’s interesting to note that he takes vendors to task, calling them “lethargic about embedding encryption capabilities.” Perhaps it’s not just healthcare vendors dropping the ball: Pabrai notes the average business experiences 1,400 attacks per week, of which two ultimately accomplish their purpose.

It’s no secret that private practice physicians are contemplating new ways of doing business, with hospital employment and concierge service models (not to mention retirement) often making the news. Vicki Bralow, DO and Scott Bralow, DO, however, take the “company doctor” approach, starting Affordable Care Options LLC (PA) to provide workplace-based healthcare to employers. Employees have the convenience of a healthcare facility at their office, while employers likely benefit from healthier employees and lower costs. Seems like a win-win.

Mergers and acquisitions continue to be the most sustaining option for some. Northwestern Memorial Physicians Group (IL) merges with Northwestern Medical Group (IL) to form the second-largest physician group in Chicago. The combined group, Northwestern Medicine, has the enviable task of combining medical records from the two organizations. The RelayHealth and athenahealth portals the groups used previously have been replaced in the new organization with Epic MyChart.

Other practices and medical groups take a different approach to making sure they stay in business. David Ming Pon, MD (FL) is accused of stealing more than $7 million from Medicare by falsely diagnosing and treating hundreds of seniors for an eye disease they were told causes blindness.

Some doctors have a bad habit of billing Medicare for the treatment of dead patients, to the tune of $23 million in one particularly lucrative year. There’s obviously a disconnect going on. David Williams of the Taxpayer Protection Alliance says, “If you’re getting a blood test, you should be alive. There’s absolutely no excuse to have blood tests on dead people,” while Bill Cheek of Carmichael’s Pharmacy says billing for the dead is “something that’s unavoidable in our industry.” My reaction can be summed up in one word, best spoken by SNL-era Seth Myers: Really?!

Emerald Physicians ACO (MA) selects the eClinicalWorks Care Coordination Medical Record Solution for population health management.

A report finds that the physician industry generates $26.1 billion in sales revenue and supports $14.8 billion in wages and benefits. A state-by-state breakdown could prove to be an interesting economic development tool for area chambers of commerce.

The House Energy and Commerce Subcommittee on Health, following its hearing last week on the benefits of telemedicine, seeks ideas from from healthcare stakeholders and the public by June 16 to telemedicineideas@mail.house.gov.

A study in Pediatrics finds that placing a trained physician facilitator or coach at pediatric and family practices significantly improves patient outcomes in the areas of obesity detection and counseling, lead exposure screening, and fluoride varnish application to prevent tooth decay.

From the Consultant’s Corner 5/1/14

ICD-10: Now Get it Done Correctly

Since the delay of ICD-10 until October 1, 2015, at the earliest, many healthcare organizations have questioned what the delay means to their existing ICD-10 implementation programs. At the time the delay was announced, most organizations fell into one of three categories in terms of ICD-10 readiness:

• The Prepared
• Those Getting Prepared
• Those Who Remain Out to Lunch

Organizations residing in the first two categories expressed frustration at the delay. They had appropriately taken control of their own fate, identified and managed risk, and prepared or were preparing their organization for this change. The third group, however, either held false hope their EHR/PM vendor would take care of everything, or banked on a delay.

Regardless of which category best describes your organization, the plan forward is simple: Take the newly allotted timeline to get it right.

Many organizations have delayed other important  transformative or IT efforts until after ICD-10, given their limited resources and the work necessary just to achieve ICD-10 compliance. Some organizations took a much broader strategy for their conversion, leveraging this challenge as an opportunity to better enable their physicians and clinical staff to optimize clinical documentation workflows; thus, improving quality reporting and patient outcomes.

With the delay now in place, organizations should absolutely continue implementing their ICD-10 program. They should also use this time to prepare to more effectively compete in the era of expanding, value-based reimbursement models. In addition, organizations should take advantage of this opportunity by re-evaluating project scope.

Identify opportunities to include other initiatives into the ICD-10 conversion program in order to more fully streamline your clinical documentation workflows. Ensure your training program is inclusive of new workflows and EHR functionality, not just coding principles and requirements. Engage payers and intermediaries to ensure your testing program is robust. Expand your use of dual coding and evaluate reimbursement variance to prepare your organization for the downstream financial impacts. Optimize the use of informative, specifically predictive analytics and clinical decision support within the EHR.

ICD-10 poses several risks to a physician practice. Take advantage of the delay to not only ensure compliance, but also to improve your ability to manage your patients’ health.

Brad Boyd is vice president of sales and marketing for Culbert Healthcare Solutions.

News 5/1/14

CMS publishes a final rule that will increase Medicare payments to FQHCs by as much as $1.3 billion over the next five years in compliance with the Affordable Care Act. Beginning October 1, FQHCs will transition from the current fee-for-service model to a daily single rate of about $155 per Medicare beneficiary, which may increase a clinic’s payments from Medicare by a third.

Athenahealth will offer its customers PatientPoint’s patient engagement and care coordination services through its More Disruption Please program.

Physicians reviewing EHRs carefully read the impression and plan section, but only quickly scan details on medications, vitals, and lab results, according to a study published in Applied Clinical Informatics. Researchers recommend optimizing the design of electronic notes to include “rethinking the amount and format of imported patient data as this data appears to largely be ignored.”

Ingenious Med will integrate Entrada’s digital voice capture technology into its mobile application to support the mobile charge capture process.

DrFirst will add electronic prior authorization functionality from CoverMyMeds into its Rcopia e-prescribing, RcopiaMU for Meaningful Use, and Patient Advisor medication adherence platforms.

E-MDs recognizes its customer Jennifer Brull, MD for being named a 2013 Million Hearts Hypertension Control Champion. Brull says that the documentation and reporting capabilities in e-MDs EHR and PM “played an important role” in her practice’s success at achieving blood pressure control rates greater than 70 percent.

Medication adherence could be improved if physicians gave more consideration to medication costs and increased follow-up care for their patients with chronic conditions. That’s the conclusion from Canadian researchers who found that almost one-third of patients fail to fill first-time prescriptions. Medication adherence was found to be more likely if the prescription was for an antibiotic, if the patient was older, and if a greater proportion of all physician visits were with the prescribing physician.

Three boxes of medical billing records from the former Western Berks Internal Medicine (PA) practice are returned two years after they were mistakenly left in a former office and then stored at the home of a maintenance service vendor. Particularly troubling is that during that time no one at the practice ever noticed the records were missing. The 1,800 patient records included clinical information, social security numbers, and other demographic details.

Kaiser Health News highlights the rise of more aggressive billing strategies among practices that are struggling to improve collections. Practices that might have once waited 180 days to refer a patient to collections are now taking action sooner, while more practices are requesting patients pay for any out-of-pocket costs in advance of procedures.

While many physicians may be breathing a sigh of relief over the ICD-10 delay, not all providers are happy about the pushback. Physicians such as New York’s David Weiner, MD, have already invested time and money for several ICD-10 training sessions. Likewise Christine Doucet, MD notes that the delay will force her to eventually participate in a refresher course.

Through March 31, CMS has paid $22.9 billion in MU incentive payments, including $8.6 billion to EPs. For the 2014 program year only 32 EPs had received MU payments, which could suggest a slow-down in participation.

Email Inga.

CMIO Rant with … Dr. Andy

The Problem List: Foe or Enemy?
By Andy Spooner, MD

I love the problem list. But I hate it, too.

I love that I can take a few seconds in the course of clinical care to deposit a problem into a list that ensures that I will not fail to address the matter as care progresses. A patient’s mother says that her child, who is being admitted for pneumonia, has seen a private allergist for an “immune system problem.” She describes no particular symptoms or treatment for this this problem, but she thought she should mention it to me, the admitting hospital physician.

Sounds like something to add to the “do” list. What I need to “do” is to clear up ambiguity and make sure I understand how this issue affects care. So I turn to the computer (yes, right in front of the patient!) and add:

… to the problem list.

(By the way, this is NOT how my EMR records problems. It’s intended to be a vendor-neutral depiction of how one might do it. I used a great program called Balsamiq Mockups—a handy tool when you want to convey a user-interface concept—to make these pictures.)

Later on, after I get a bit more information, I clarify this and add some further detail:

Total time investment: One minute.

Return on investment: This clinical issue is now part of the record and will be part of all future presentations of summary information on the patient. I can pass on this information in handoffs and in record sharing. I can be sure to address it with the patient and family. I can insert it—and all other problems—into my note automatically, if I want, and have instant documentation of the complexity of the patient. I can arrange the order by priority, by organ system, and by whether it is a hospital problem currently.

Larry Weed would be proud.

Another patient comes in with a stack of papers from a referring hospital. I paw through this mound and add a couple items to his problem list:

(I am a pediatrician, after all.)

You get the idea: Every time something new hits my radar, I tack it to the problem list.

Why?

• I can, in the start-and-stop world of hospital care, keep up with all of the issues that affect each patient.
• I can insert all of this information, along with necessary comments, into any note that I write. Instant assessment and plan. Instant support for my E & M code. And no necessity to copy my notes forward, in violation of the latest OIG and AHIMA dire warnings.
• I can go over each issue with the parents, and they can be fully informed of the things I am worried about. By looking at how I have ordered the list, they can tell what I am most worried about, and they might even have some advice for me about how I might realign that ordering based on their own concerns.
• I can sign out to my colleagues by running the problem list for each patient, and I know I have covered everything.
• All the diagnosis codes associated with the problems become available (in my EMR) to select in the billing process. And if the patient goes to an outpatient visit, those codes are also available there.

That’s why I love it. It saves time and ensures that nothing gets missed. It helps in communication. It rises above the tangled mass of notes and results and images to give me (and anyone else who cares) a concise picture of what the patient is dealing with, and how we are trying to help.

It’s a bit like the Getting Things Done approach that David Allen and others espouse, which I’ve been trying to master in my non-clinical work for the past decade. The GTD philosophy is that we are most productive when we move all of our “to do” lists and projects out of our minds and into a system so that we can use our brain for what it is good for (focusing on one thing at a time) rather than what it is not very good at (stressfully juggling long lists of things we need to do). It seems like the problem list might serve well as a way to reduce the stress of having to remember all the things we need to do for a patient, and improve our reliability in taking care of all of those things.

The problem list seems so useful when it’s used well.

But that’s the problem: when it’s not used well, it’s a mess.

Or, more specifically: When the responsibility for managing the problem list is not shared by a broad cross-section of people, it’s a mess. When it’s updated only by a couple of problem-list fanatics like me, it’s great… for a while. But then it falls into disrepair and disinformation in the hands of those who disregard its maintenance. “It’s tedious,” my colleagues say when I suggest that maybe we ought to use this part of our EMR for what it was intended. “Can’t take the tedium.” But copying stuff forward day after day is better somehow? What could be more tedious than that?

As an example of a problem list maintenance problem, consider the following. In March of 2014, I admit a patient to the hospital with this on her problem list:

(I sure hope that this patient has not had continual sepsis for over two years!) A quick click makes this acute problem “Resolved,” but then I notice that the patient has had a dozen ambulatory encounters with this “problem” continually listed as active on the chart over the past 27 months. Wow. And to think the patient could have logged in to our patient portal and seen that diagnosis at any time. Wonder if that would cause any patient/parent concern?

That’s an example of why I also hate the problem list.

Neil Mehta and others hit the nail on the head with a recent commentary in the Journal of General Internal Medicine, EHRs in a web 2.0 world: time to embrace a problem-list Wiki. Everybody contributes to the problem list. No one person is saddled with the tedium. Everyone capitalizes on the information—even the patient. The barrier to the use of the problem list, according to these authors, is that we spend all of our energy creating the note that conforms in the best way possible to the E & M coding guidelines (as we understand them). To a lot of folks, this means blowing in every conceivable fact. Result: Unreadable note. No way to grasp what’s going on with the patient.

I do not blame anyone for wanting to get paid, which in medicine today means creating an E & M-complaint “receipt” for care. But the problem list can be harnessed to help you get paid (by clarifying a rich medical decision-making process), and do so a lot more efficiently, while it also makes our care provision more accurate.

We have to look to –and use — EMR software for the real purposes for which it was intended: a more organized approach to good medical care and medical records. But that’s a harder cultural shift than Larry Weed predicted.

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.

News 4/29/14

Medfusion announces that its relationship with Allscripts has ended “due to unresolved payment disputes.” The termination is hardly a surprise given Allscripts acquisition of the competing JarDogs patient engagement platform last year. Medfusion says it will continue to provide uninterrupted services to the 30,000 Allscripts providers using its products through May 31, 2014; after that time customers wishing to remain on the Medfusion platform must contract directly with Medfusion.

Practice Fusion launches a population health management offering in collaboration with Merck, giving practices a real-time dashboard that compares a provider’s patient vaccination rate with other Practice Fusion providers.

The HIMSS Electronic Health Record Association (EHRA) tells the ONC it opposes the proposed 2015 voluntary certification EHR criteria, saying that by the time the final rules are published there won’t be enough time for vendors to properly code and test enhancements. EHRA also argues that “more frequent certification is not desirable and would be costly.”

AAFP board member Daniel Spogen, MD rants about the administrative hassles of EMR in an AAFP blog post. Among his complaints: EMRs lack interoperability, are not user-friendly, take time away from patient encounters, result in mixed patient outcomes, increase overall costs, and complicate office workflow. I guess his only goal was to fire up his peers since he fails to suggest any solutions and notes that EHR vendors have little incentive to change things.

The Federation of State Medical Boards approves telemedicine guidelines that include a policy to apply the same standards of care for remote medical encounters as for in-person encounters. The guidelines also call for physicians to be licensed where the patient is located; for providers to establish a credible patient-physician relationship; and for an adherence to safety and privacy principles.

Meanwhile, an Idaho medical licensing board has fined a physician $10,000 for prescribing a patient an antibiotic while working for Consult-a-Doctor, a telehealth provider that has since been purchased by Teladoc. The Idaho Board of Medicine sanctioned the physician, who was licensed in the state, for prescribing medicine without an in-person examination of the patient.  A group of  telehealth-friendly legislators are now pushing stakeholders to establish standards for the practice of telemedicine.

Pay-for-performance programs unfairly penalize providers treating large numbers of poor people, according to a panel commissioned by the Obama administration. The panel notes that it is often harder to achieve successful outcomes when treating people who don’t have much income or education because low-income people may be unable to afford medications or transportation to doctors’ offices and the less educated may struggle to understand written instructions for home care and medication use. As a result, the existing payment policies unintentionally worsen disparities between rich and poor by shifting money away from doctors and hospitals that care for disadvantaged patients.

Forty percent of physician practices are looking to replace their existing EHR, according to a Software Advice report. Among buyers replacing their EHR product, the most common replacement reasons: the current solution is too cumbersome and/or integration is needed between applications. Mobile support for tablets and smartphones, e-prescribing, and lab integration were the most desired features among potential buyers. Based on the above time frames, it looks like a pretty good time to be selling EHR if you’ve got a good product.

MGMA Health Care Consulting Group’s Rosemarie Nelson offers insights into the use of kiosks in practices to improve RCM and patient satisfaction and cites several examples of practices that have reduced their claim denial rates and A/R days while also streamlining the patient check-in and registration process.

Email Inga.