Pretzel Logic: Have Sympathy for Your Vendor 11/8/13

Well, the season is upon us again. I’m referring of course to Meaningful Use certification and attestation time, when ONC and CMS determine who’s naughty and who’s nice. Actually with the new HIPAA rules and proposed Accounting of Disclosure rules, it’s the Office of Civil Rights who will determine who’s naughty….and who’s naughtier. But that’s another story.

You may have heard from your EHR vendor or experienced firsthand or seen recent press coverage on the difficulties that vendors are experiencing with certifying their systems to support Meaningful Use Stage 2. Headlines such as “Stage 2 proves challenging for vendors” and “Fewer certified EHRs for Stage 2 may pose problems for hospitals, doc practices” may sound like normal vendor whining. But when the normally sunny and always encouraging Dr. John Halamka jumps on the criticism bandwagon, you know there might be some trouble underfoot.

I know, I know, it’s hard to have sympathy for vendors when you clinicians have a million MU hoops to jump through, but hear me out. First I need to point out the difference between attestation and certification. Attestation is governed by CMS and refers to what providers have to do, while certification is determined by ONC and refers to what EHR vendors have to do. In theory, certification is synced with attestation, meaning that ONC doesn’t require vendors to provide tools that do anything more than what CMS is asking providers to use them for. In practice, it’s too hard for the government to resist the temptation to use the MU regulatory lever to get vendors to do more, so there are some certification hoops that EHR vendors have to jump through that most clinicians are totally unaware of. Further, certification for Stage 2 is made even more complex by crudely constructed certification definitions which get amplified by messy testing requirements permeated with cumbersome “make-work”. Here are a couple of examples.

A significant evolution in the development of EHR systems is the idea of modularity. The MU program encourages development of certified “EHR modules” focused on a single EHR function (like e-prescribing or quality measurement), which in principle allows users to mix-and-match EHR components according to their own needs and preferences. Kind of like Google’s Android Market or Apple’s App Store. Great concept, but it makes sense only to the extent that the modules are well defined. As it turns out, they’re not. (sigh)

Take the certification requirement for exchanging transition of care summaries. It’s actually broken into two certification requirements, one for sending and the other for receiving. The original idea, forged in the Direct standard, was that this would basically be secure email. Yet, the ONC rules require much more than that. In order to get certified for sending and receiving clinical documents, ONC requires that the EHR component has to be able to create the standardized clinical document as well as deliver it to the intended recipient, and it has to open and parse the document after it has received it from the sender.

That’s like saying that Gmail should be required to generate spreadsheets, or Fed Ex should only be able to deliver parcels that they package, or that cable companies should only be able to deliver programming that they create. What would happen in such a world? Well, Gmail would be very clunky, Fed Ex probably wouldn’t exist, and we’d probably see even less competition in cable services than we do today as these artificial restraints force TV programmers (like HBO) to be married to distributors (like Comcast). In all cases we’d get less choice, higher cost, and lower quality.

Similarly, in the EHR market, the artificial restraints created by the transport certification rules are forcing bundling of secure email with basic EHR services. The result is that small focused vendors of secure email are getting blocked out of the market unless they enter alliances with larger traditional EHR vendors, because the secure email vendor applications don’t create clinical documents. And while some traditional vendors, like Epic and Meditech, are implementing their services in a way that allows their customers a wide variety of choices, most other traditional vendors either are locking their customers into proprietary approaches or haven’t yet figured out what to do because the certification rule is so darned complicated and unnatural.

Another example is the certification requirement for clinical quality measures. I have personal experience in this area because my company has a quality data analytics business and we recently got certified for MU Stage 2. There are 64 MU Stage 2 ambulatory clinical quality measures, and we decided to begin by getting certified for 26 of them based on our customers’ immediate needs. As part of the testing process, we were given ONC-provided dummy patient data on 22 fictitious patients, and we were required to generate each of the 26 measures on the panel of 22 dummy patients. OK, so far, so good. Unfortunately, it didn’t stop there.

The certification rules also require that we slice and dice the patient panel and associated clinical information and put each of the results of that slicing and dicing into separate standardized “QRDA” files. So for each measure we had to calculate the measure on the full panel of patients, and then stratify the results on four dimensions: race, ethnicity, gender, and payer. Then we had to generate a physician-level standardized file (a QRDA3) which contained all measure results for all 26 measures, and then show the breakdown of each measure by race, ethnicity, gender, and payer. Then we had to generate a separate standardized file (a QRDA1) for each patient in each measure, and each patient file could only include the clinical information relevant to a specific measure. So if the same patient had diabetes and hypertension, we had to parse the medical record and create a diabetes measure file with only the diabetes information, and a separate hypertension measure file with only the medical hypertension information. I’m not joking.

The result was that we had to generate 122 persnickety, fussy report files, and that was only for a patient panel of 22 dummy patients. A typical ambulatory physician has an active patient panel of 2,000 patients, some of them very clinically complex. Generating measures on such a panel would require the EHR to generate thousands of stratified result files per physician each time the measures are calculated. I assume that someone somewhere intends to make excellent, society-enriching use of such finely minced information, but right now it’s not clear who that would be. Certainly not the physician.

It turns out that even CMS finds this output too hard to handle. Up until a few days ago, the Pioneer ACO program required that quality measures be submitted according to the QRDA approach beginning in January 2014. Many vendors have been hard at work developing these reporting functions. On November 5, CMS backtracked and announced that they could not accept the QRDA formats and all reporting for January 2014 would revert back to a manual web upload process. Doh!

These two examples are just the tip of the iceberg. They cover only five of the 49 required certification modules for Stage 2-compliant technology. I don’t have enough energy or patience to describe what lies beneath the other 44 requirments.

One of James Joyce’s readers is said to have commented that Ulysses was very difficult to read, to which he is said to have replied, you should have tried writing it! For Stage 2 MU, the same might be said for EHRs – they may be hard to use, but they are getting ever harder to program. My point in expressing sympathy for EHR vendors is not to cover up or apologize for their mercenary tendencies. Rather it’s to simply point out that there is stress on all sides right now. So if your vendor seems to be fraying at the edges consider showing them a little patience and maybe even give them a smile. And then, by all means, get right back to letting them know that their product is barely useable, their prices are too high, and their support stinks.

Micky Tripathi is president and CEO of the Massachusetts eHealth Collaborative. The views expressed are his own.

News 11/7/13

Full implementation of HIT in 30 percent of community-based physician offices would reduce the demand for physicians by four to nine percent, according to researchers from the Johns Hopkins Bloomberg School of Public Health and The Commonwealth Fund. Other predictions, based on a review of previous studies include:

• Physician demand could decline an additional four to seven percent if care was delegated to NPs and PAs and supported by HIT.
• The use of HIT could reduce regional shortages of physicians by enabling as much as 12 percent of care to be delivered remotely or asynchronously.
• If HIT systems were adopted by 70 percent of practices, the estimated impact could more than double.

Kareo hires David Mitzenmacher (Volusion) as VP of customer success and Nitin Somalwar (Flurry) as VP of engineering.

Epocrates’ Bugs + Drugs app reaches 100,000 downloads in less than a month of its release. Epocrates, whose parent company is athenahealth, pulls clinical and billing  information from athenahealth’s data warehouse to track antibiotic resistant bacteria.

A CMS email this week included this FAQ about the EHR incentive program:

Can an eligible professional (EP) or hospital charge patients a fee to have access to the certified EHR technology (CEHRT) solution that is used to meet the meaningful use objective of providing patients the ability to view online, download and transmit their health information?

My initial thought was that if my EP tired to charge me to view or download my records, I would fire him/her. My second thought was that if this is truly a “frequently” asked question, then there are probably providers already charging patients these fees.

Here is what CMS had to say:

We do not believe it would be appropriate for the EP or hospital to charge the patient a fee to access the Certified EHR Technology solution regardless of whether the solution is in the form of a provider-specific portal, an online personal health record, community portal or some other solution.This is consistent with the position taken in the Stage 1 final rule (75 FR 44358) and reiterated in the Stage 2 final rule (77 FR 53999) with regard to the meaningful use objective to provide patients with clinical summaries of office visits. Access to the Certified EHR Technology solution would be provided to satisfy the requirements of the “view online, download and transmit” objective, rather than in response to a request from a patient. We note that the charging of fees for health information provided in response to a patient’s request is governed by the HIPAA Privacy Rule.

HIMSS Analytics recognizes 50 of Truman Medical Centers (MO) ambulatory clinics with its Stage 7 Ambulatory Award.

Email Inga.

Practice Wise 11/5/13

What happened to my EMR vendor?

Where’s your product? With so many products on the market, is yours on track to MU 2014 certification?

As of this writing, there are 3,439 products listed in the Ambulatory Practice Type on the ONC-CHPL with 2011 certification and only 125 with MU 2014. Some of these listings are single products with multiple iterations, so the number is somewhat inflated. However, the disparity is not. If you have a product that met MU 2011, are you sure your vendor is going to be ready for MU2014? What are they telling you? Have they given you a timeline and a preview or a roadmap?

What’s going to happen to all the EPs who have attested for 2011 and won’t be able to attest with that same software for 2014? As a consultant I’ve been preaching this since day one (disclaimer, we also sell and support a 2011 and 2014 certified product). But many of my consulting engagements center on helping practices with workflow optimization on different products. I cannot tell you how many times I’ve had doctors tell me that their criteria deciding on which product to buy is “I’m buying product X because they are a big company.”

My response has always been:

• What’s their core business?
• How many EMR products do they sell? Is your product their prime application or one they acquired because they wanted the client base?
• What is their funding?
• What’s their track record in business? In this industry specifically?
• How many installs do they have?
• How many upgrades do you get annually? If not annually, what is the upgrade frequency?
• How have they handled earlier regulatory changes?

Current studies show that one out of three EPs that attested with a 2011 Stage 1 EHR are potentially not on track with their current vendors to attest for 2014 Stage 2.

Have you attested for Stage 1? Did your vendor assist you? This could be a good predictor of how likely you are to meet the next stages. We’ve assisted several EPs who’ve been audited by CMS for their Stage 1 90 day attestation. Those who had attentive vendors with solid products and good support were able to pass the audit easily by providing the proper documentation. However, we have a few that had vendors with little understanding of the audit requests and how to provide supporting documentation for their own products. Those providers failed their audits. They are in the market for a new product.

Nearly one third of ambulatory EMR vendors certified for Stage 1 have not had a single attestation to date. The year 2014 is predicted to be a banner year for EHR replacement purchases. Practices are looking for products that are easier to use, and can meet MU, PQRS, and other regulatory initiatives. If this describes your current position, choose wisely. Look at the vendor’s attestation rate, interview their customers (Google any vendor – you should be able to find both happy and unhappy customers). Don’t just rely on references they give you and industry surveys.

Ask questions specific to the mandated programs:

• How difficult/easy is it to attest using their product in Stage 1?
• Are they MU certified for 2014? If not, what’s their roadmap? Ask their current customers how true their release projections are.
• Will you be able to attest easily with their product along with your original product if you make the change mid-year?
• How much training and support do they provide for the various programs? Is that training live, web, video? What does it cost? Will they stand by you in an audit?
• Are they able to report via EHR for PQRS?  If not, will you report via claims or registry? What are the costs and extra time requirements for these?

Changing EMR products is just as costly as or more so than your first purchase. You’ll likely have additional costs for data conversion that you might not have had the first time around. Do your homework; you don’t want to keep changing products. Besides being costly, it’s disruptive to your practice and your patients only have so much patience with your ongoing practice disruptions.

Good luck!

Julie McGovern is CEO of Practice Wise, LLC.

News 11/5/13

From Chloe: “Re: ZocDoc. Really questioning their HIPAA compliance. Carecloud should be very careful about ZocDoc breaching HIPAA of its customers’ patients. Several weeks ago I made a doctor’s appointment through ZocDoc, and received an email from the practice stating that the appointment time I booked on ZocDoc was not available (no integration obviously with scheduling) and proposed alternate times. The email thing was a little sketchy by itself from a HIPAA perspective (did I give consent to email me when I booked online? I don’t know.) Things went from bad to worse when someone from ZocDoc left me two voicemail messages apologizing for my rescheduled appointment! Why is ZocDoc leaving me messages about my doctor’s appointments? From my perspective as a patient, I don’t have any relationship with ZocDoc, and why is some guy calling me about my doctor’s appointments? Maybe I didn’t read ZocDoc’s terms of use well enough – and maybe there’s something there where I gave up my patient privacy by booking through that site.”  Has anyone else had a similar experience? Today I attempted to schedule an appointment through ZocDoc with two different doctors, but neither appeared to be  participating in the service. I suspect provider participation varies by geographic region, but it doesn’t look like I will be using it any time soon, regardless of HIPAA compliance.

Vista Equity Partners, parent company of Vitera Healthcare Solutions, acquires all the outstanding shares of Greenway Medical common stock for $644 million, completing the merger of the two companies. The new company will be privately held and operate under the Greenway brand with Tee Green (Greenway) assuming the role of CEO and Matthew Hawkins (Vitera) as president. I interviewed Green and Hawkins when the merger was first announced in September.

The AMA offers free toolkits for electronic funds transfers and electronic remittance advice, including information on how to get started with electronic transactions, guidance on IT solutions, and questions to ask vendors. An ACA provision requires insurers to standardize their business practices for EFTs and ERAs by the first of the year.

Ocean Beach Medical Clinics go live on NextGen EHR in early December.

Lawmakers consider a draft proposal that would phase out fee-for-service billing in favor of a rewards-based  payment system. Key components include:

• A freezing of physician payment rates for 10 years
• Paying doctors five percent bonuses each year from 2016 to 2021 for agreeing to participate in shared-savings, bundled medical services, or other alternative payment methods
• After 2023, increasing reimbursement by two percent a year to doctors opting for alternative payment systems; those opting for fee-for-service payments would get a one percent annual increase in reimbursement.

About half of clinical decision alerts are overridden by providers and about half of overrides are classified as appropriate,according to a study published in JAMIA. The most common alerts to be overridden were formulary substitutions, age-based recommendations, renal recommendations, and patient allergies. While 53 percent of all overrides were classified as appropriate, the likelihood of overriding an alert varied widely by type. The authors recommend refining alerts in order to reduce alert fatigue.

CMS blames the government shutdown on the delayed release of the 2014 Medicare physician fee schedule. Traditionally the payment rules for a new calendar year are released around November 1.

Email Inga.

DOCtalk by Dr. Gregg 11/4/13

The Nightmare After Halloween

My youngest son wanted to watch Tim Burton’s oddball Halloween/Christmas animated movie “The Nightmare Before Christmas” on Halloween night. We did. Little did I know it would the harbinger of dreadful things to follow.

I awoke the following day, sipped coffee, caught up on email (again learning that Barrister J. Tongai had $20 million ready to send to me for safekeeping), and readied for what seemed like any other day at the office. I should have heard the ominous music begin to swell on my life’s soundtrack.

When I arrived at the office, everything looked normal enough. The staff’s good morning greeting sounded routine and pleasant. The lights were on and the cichlids were silently swimming in our waiting area aquarium.

However, when I rounded the corner into our main work zone, I stopped dead in my tracks. Everywhere I looked I saw piles of paper! Charts and chart notes, faxes and physical forms, school notes and sticky notes, letters and legal papers – all strewn about in some monstrous organizational pattern which I had long ago forgotten.

I’m not ashamed to say I shrieked, just a little.

My office manager, Maggie, looked up and asked, “You OK?” I silently trembled, minimally shaking my head. “What’s wrong?” she again queried me. Still dumbstruck, I felt myself fall back a half step, almost losing my balance before catching myself by grabbing a counter.

The rest of the staff now noticed and turned to see what was up, still acting as if nothing was amiss. The horrified look on my face must have been evidence enough, for they all said, almost as if scripted and in near harmony, “What’s the matter?”

I shook my head again, quickly, trying to stir some words from my throat. I let out only a small whimper at first, but was able to find my tongue shortly thereafter. “What the hell is going on here?” I asked with more of a plea to my voice than I intended.

“What do you mean,” asked Kim, my salt-of-the-earth nurse.

“Where on God’s green earth did all this paper come from? Where did those charts come from? Why is this place such a chaos of wood pulp?” The questions rolled out in a near singular sentence.

The staff all looked at each other with eyes that bespoke their befuddlement (and possible curiosity about my sanity.) “What do you mean?” questioned Kim yet again. “We thought we had cleared through a lot of the stacks from yesterday. This looks good compared to how it looked an hour ago.”

I could feel my knees begin to buckle. I looked about. All I could see were piles upon piles. There were lab results in piles, consultant notes in piles, radiology readings in piles, patient phone call messages in piles, prescription requests in piles, unsorted faxes in piles, charts upon charts in piles. Piles and piles of paper, everywhere.

Then I noticed: no computers! The desktops were gone. The laptops were gone. The tablets were gone. The high end scanner was gone. The insurance card scanner was gone. The credit card scanner was gone. The patient touchscreen registration portals were gone. No digital anything anywhere my eye could see, save the fax which was busy spewing forth ever more paper.

It took only a moment before the full weight and meaning of this fell upon me like a load of wet cement: I had lost virtually all connectivity! (Except for the fax machine, though it’s paper and ink consumption only served to deepen the impact of the moment.) My lab interface was gone. My immunization registry connection was gone. Our online scheduling was gone. Our secure patient email was gone. Our barcode scanning and supply chain management was gone. Our digital referral capacity was gone. Our website was gone. Our HIE interface was gone. OUR EMR WAS GONE!

“NOOOOO!!!” I screamed in absolute horror. “This can’t be happening! What’s going on here? This is unthinkable! No. No. No…”

Maggie arose and grabbed me by the arm, leading me to a chair. She sat me down and said, “Dr. A., you seem a little more off today than normal. Why don’t you take a minute to sit and maybe take a few deep breaths? You just sit there and we’ll bring you a cup of coffee. Barb, get Dr. A. a coffee,” she directed. “I’ll grab your stack of charts from yesterday so you can finish them up while you compose yourself.”

She reached over and lifted a stack of twenty some charts about a foot and a half tall from the morass of chart piles. As she turned to carry them over to me I jumped from the chair and ran screaming bloody murder toward the door. I didn’t see the PDR sitting on the floor before my foot found it and sent my head into the wall.

When I awoke, I was snuggled in my bed with my smart phone alarm just beginning to buzz.

Rubbing the sleep from my eyes, I made a promise to myself to never, ever again watch The Nightmare Before Christmas, son or no son.

From the trenches…

“I am the shadow on the moon at night. Filling your dreams to the brim with fright.” – Oogie Boogie in The Nightmare Before Christmas

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).