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).

From the Consultant’s Corner 11/2/13

Change Management: The Path to EHR Clinician Adoption

Most of us are excited when we see provider order entry rates of 80-90 percent in our health systems. We should be proud of our users; it’s not an easy milestone to reach when transitioning from old systems or paper. Most of us also realize these target numbers are a poor indication of the overall performance and satisfaction of our clinicians. Let’s face it: we aren’t offering alternatives save for some scribes, emergent and transcribed orders, and perhaps we shouldn’t be.

Unhappy clinicians use the EHR because they have to. Happy adopters put the system to work for them, and demand results. They’re asking for the support to be efficient with the system, yet attentive with patients relevant and accessible data; timely, accurate and functional decision support;  the ability to personalize tools and content; feedback mechanisms driving content localization and formulary adaptation reflecting site needs. Where to begin?

We have strategy meetings seeking readmission rate reductions, clinical integration improvement, population health programs, business intelligence platform development and much more. Are we doing all we can to support EHR usability and functional flexibility with a true governance backbone?

Many of us are re-evaluating our approach to satisfaction or just starting down the path of improving adoption of the EHR. I’d suggest focusing on four themes to manage the change, identify resistance and provide the incentive for meaningful adoption.

1. Improve governance alignment. Many of us have too many committees. While that may not change, we can certainly align our leadership and communication. The Physician Advisory Council, P&T committee, Medical Group leaders, Medical Executive Chair, clinical CXOs, and clinician champions should have a shared adoption agenda and prioritization for improving the EHR. Disconnects between these groups lead to stagnant or slow optimization. Is your vision and elevator story for leveraging technology across the care continuum transparent and similar across your executive teams? Including representation on your EHR interdisciplinary leadership team from these groups brings speed and competency to decision making. We must align our agenda (and re-evaluate team membership) to reach our goals. For those large multi-hospital multi-practice sites, invest in and support a local governance structure that mirrors your corporate team. Build strong bridges with your sites. Develop a reputation of responsiveness and alignment.

2. Develop adaptation guidelines. What does standardization, localization, and adaptation mean in your organization? How much control do your practice sites and hospitals have to flex and evolve your clinical content tools? We have resource limitations, though we can be transparent about our aims. Perhaps you have four lab systems and have yet to standardize the ancillary approach. Perhaps evidence shows different patient population-based medication response so certain formulary variation is valid. Perhaps sub-specialty scope of practice demands different EHR design or content. Clinical evidence may drive order set template creation and the EHR note format may be in a standard design, but don’t wait to be asked for the rules of engagement. Educate your users on the rules of change, who to work with on feedback and why it’s for the benefit of all. Do your sites know your adaptation guidelines?

3. Define user segments and training needs. One-size-fits-all training? Yawn! Technology-savvy residents expect the high-powered EHR. Some long-time clinicians fear the computer mouse. Know your audience, customize your training approach and build a segmentation tool to help. Key segments include your usual hospitalists, PCPs, specialists, surgeons, floor nurses and LPNs, though getting granular is important. Work with your department heads to identify potential super-users, resisters, folks needing basic computer training, and more. Segment those who may act as mentors. Segment those needing 1-1 training support. Identify rare admitters. Flag who will need refresher training. Educate your EHR training team on your new powerful knowledge about your clinician population, and put it to work as you develop curriculum, training classes and agendas. Track proficiency and follow up with refresher courses and e-learning.

Enable practice and personalization. These steps are often forgotten. Get your users in an EHR playground before going live, and even before upgrades. Assist their familiarity with the new features, workflows and tools, but make it valuable time spent. Provide support to personalize their toolsets in the production environment before going live. Help them modify their note templates, add orders to preference lists and create personalized order set templates before working with patients. On day 1, they’ll hit the ground running and appreciate that the system can work for them.

4. Strengthen post go-live communication. Some parents compare an EHR go-live to child-birth; the hard work is just beginning. While you’re going to have frequent newsletters, emails and MEC presentations leading up to an EHR launch, don’t slow down. Gather feedback directly from users to determine key challenges and to prioritize change. Make it easy for clinicians to give feedback by connecting with them in the physician lounge or accompanying them on rounds. Do more than providing an issue or ticket tracking system – stay connected in their world, on the units, in the clinics. Your CMIO and CNIOs should be familiar faces at your sites bringing updates, feedback and asking for more. For those leaders who always wanted to be in a band and go on a road show, you’ve got your shot.

Many of us have a future vision of powerful data warehouses, predictive analytics, evidence-based practice driving improved financial and clinical performance with improved patient satisfaction and care. We’ve seen the bells and whistles of EHR systems, and we have IT teams eager and ready. Let’s show our users we’ve heard them – how can you improve your clinician adoption?

Jaffer Traish is director of Epic consulting at Culbert Healthcare Solutions.