Readers Write: Regarding the Nightmare on EHR Street

Regarding the Nightmare on EHR Street
By Frederica Krueger

I find it ironic that the AMA is complaining about the fact that physician documentation in an EHR is "pure torment." Perhaps they believe in the “Hypocritic oath?”

The reason for this documentation torment is the need to record multiple pieces of information that the physician asked or reviewed but that don’t end up contributing to the synthesis of the clinical picture or the plan of evaluation and treatment. Cluttering up notes with such information is often made worse by the formatting afforded by the EHR. It also detracts from EHR usability and patient safety.

The irony is that the underlying cause of this nightmare is the E&M coding system used to bill for clinical services.

And, that the E&M codes are part of the CPT system that is developed and sold by … the AMA!

The E&M coding system was cumbersome and inane long before EHRs became readily available. In the past, it was just too much trouble to document everything that you actually did to meet the E&M requirements and too hard to keep track of all the arcane rules. But everyone naturally assumes that a computerized system should help remind you of these confusing requirements and facilitate recording of the irrelevant info that was already needed for billing purposes.

With EHRs, there is a much greater focus on appropriate recording and coding at the physician level. It’s not surprising that physicians attribute the documentation horrors to the EHR rather than the CPT.

If the AMA really wanted to do something about the torment of EHR documentation, it would:

1. Stop developing (and selling) the CPT manual. In other words, the AMA should put its money where its mouth is.
2. Advocate for a common sense approach to determine whether physician documentation is or isn’t "fraudulent" rather than the current Checklist Menu approach.
3. Recognize that most physicians are just trying to do right by their patients, and that they could do this much more efficiently — EHR or not — without having to deal with the E&M coding system. The crooked physicians will figure out how to scam the system anyway, so why waste time and money and frustrate the rest of us with E&M codes?

Despite the fact that I’ve gone for 30 years of medical practice without joining the AMA, I would sign up in a microsecond as a way of expressing my gratitude if the AMA eliminated (and got insurers and CMS to eliminate) all use of the E&M coding system.

While they’re at it, it would be nice to get rid of the RUC, RVUs and the RBRVS system, but that is less relevant to EHR torture per se.

News 5/7/13

During a CMS Listening Session, AMA board of trustees Chair Steven Stack, MD says EHRs create “an appalling Catch-22 for physicians.” Stack criticized the federal mandate to implement EHR under threat of monetary fine while simultaneously accusing practices of cloning records and committing fraud when using template-based EHRs to create near-uniform physician documentation. While acknowledging efforts by ONC to improve usability, Stack also noted that “documenting a full clinical encounter in an EHR is pure torment.”

American Medical News investigates legal issues facing Allscripts following the company’s announcement to discontinue sales and support of its MyWay product. Anesthesiologist Robert Joseph, MD, initiated a class-action lawsuit late last year on behalf of the 5,000 physicians who purchased the MyWay product, contending the software was so difficult that his practice’s revenues fell 50 percent in a year and caused his office manager to quit. Allscripts declined to return Joseph’s money or let him out of his contract, instead offering him a free upgrade to its Professional platform. Since the original suit was filed, a judge has denied Allscripts’ motion for dismissal. Allscripts filed an appeal, the appeals court ruled in favor of the physicians, and the suit has been allowed to move forward. Meanwhile, Cardinal Health 200 LLC filed a separate suit, saying it paid Allscripts $5 million for 1,250 licenses for MyWay only to learn that it would not be enhanced to support ICD-10 and MU. Cardinal contends it is unable to resell its remaining 994 licenses since Allscripts is discontinuing support. Cardinal also charges that the Professional product is more expensive and difficult to license, implement, and support.

Physical Rehabilitation Network will deploy NextGen Healthcare’s EHR, PM, PatientPortal, and NextPen products across its 100+ locations and use NextGenRCM Services for revenue cycle management.

Greenway reports Q3 results: revenue up 3 percent, adjusted EPS $0.01 vs. $0.08, beating earnings estimates of –$0.02  but falling well short of revenue expectations. The company blames a faster-than-expected shift to subscription-based pricing. Shares are near their 52-week low.

Nearly 600 Medical College of Wisconsin physicians will use SA Ignite’s MU Assistant this year to attest to Meaningful Use using Epic.

CareCloud reports its 13th consecutive quarter of revenue growth and the addition of over 100 clients in Q1, giving the company a client base of almost 3,000 providers.

DigiChart changes its name to Artemis, which the company says “better reflects our mission and vision for the future.” In case you can’t keep your Greek gods straight, Artemis is the goddess of fertility and childbirth, which sounds appropriate for a company that targets its EHR and patient engagement solutions to the OB/GYN market.

Online physician network Doximity introduces an iPad app.

DocuTAP, a provider of EHR/PM technology for urgent care providers, raises $11.9 million in Series B funding from Bessemer Venture Partners.

Aprima Medical Software will interface its EHR/PM system with the Homecare Homebase platform.

RCM provider National Medical Billing Services appoints Lewis Custer (Quest Diagnostics) as SVP of operations.

E-mail Inga.

DOCtalk by Dr. Gregg 5/5/13

Dumbing Down and Smartening Up

Both sides of the healthcare provider/consumer “aisle” are talking about patient engagement and patient empowerment these days. The most interesting part of the recent momentum around these agenda items is that there doesn’t seem to be a whole lot of consensus on exactly what those two terms mean nor how they should be addressed.

On the patient empowerment side, people are talking about putting more emphasis on patient-centered care, making the patient the center of healthcare rather than having the provider or the institution or the insurance company or the technology vendor at the focal point. This seems like a no-brainer considering that the definition of “health” according to Merriam-Webster is “the condition of being sound in body, mind, or spirit.”

I’m not sure how anyone could see health and its care as anything other than a very personal, “patient-centered” issue. After all, body, mind, and spirit are unique to the individual. But, debates continue around who controls a person’s health data and how much access or input a person is allowed into their own care.

On the patient engagement issue, most people are focused on tech tools allowing providers to connect with patients and patients to connect with their health care data. This is important, but it seems to me that it’s not unlike the idea of giving everyone an iPad, but one with a DOS-like user interface. How “engaging” would that be? In other words, what good are patient engagement tools if the information and user experience (UX) aren’t “engaging?”

One thing seems clear: people on both sides are talking about making complex health information easier for non-medically trained people to understand. The impact of helping people to understand their health issues has been validated in numerous studies; when people understand their health issues (i.e., when their health literacy is higher), their health outcomes are better.

I’ve long been an advocate of simplifying medical information into “human-ese” to give patients the best chance of understanding complex medical information. I learned this years ago when making my own patient newsletters, back in the days when “desktop publishing” and “WYSIWYG” word processing were big buzzwords. (Yikes! Self-dating!!) Taking complicated health issues and trying to make them easy to understand and hopefully engaging for non-medically trained folks – and to do so for several such topics all on one side of a single piece of paper – was quite the challenge.

But, there are two sides to every aisle. The needs for understandable medical information in lay terms for lay people are quite different from the needs of providers for using medically complex jargon to communicate profession to professional.

The contentions of those who oppose “dumbing down” medical information have some valid arguments. If all of our medical documentation is to be available via patient portals and their ilk, providers fear that taking time to write all their notes in terms simple enough for patients to understand will take an ungodly amount of time. (And, providers’ time is precious enough as it is, what with all the coding and bullet points and mouse clicks and all!) Plus, some providers fear that the communication of professional concepts will be hampered, impeded even, if all of the complex medical terms used in patient records must be broken down into lay terms. (Imagine trying to sum up the tauopathy known as progressive supranuclear palsy – PSP, the cause of actor Dudley Moore’s death – into layman’s language when including it in a differential diagnosis!)

Me? I truly see both sides. I want my patients empowered; making things understandable for them helps that process. But, I also don’t want to see the simplicity of complicated conceptual discourse via sophisticated technical jargon fall prey to vocabulary Luddism.

It would seem that both sides of the aisle are correct. How we address this with a workable meet-in-the-middle approach is the real question. Bringing everyone onto a level health education and medical vocabulary playing field seems silly. Both of these so-called “smartening up” and “dumbing down” approaches have significant hurdles and/or negative impacts.

Thus, I propose a solution for which I’m far too uneducated (and, given my previous self-dating, likely far too old!):

• How about we set Watson, or a whole herd of smart humans and lesser computers, to the task of smartening up natural language processing to the point where I, as a doctor, can type any confoundedly complex medical lingo I want into a patient’s medical record and their patient portal spits out an NLP-derivation in regular old human-ese?
• Oh … and could we also task some UX experts to present that information in patient portals that are actually visually pleasing and truly engaging?

Just a dumb thought, from the trenches…

“I may be dumb, but I’m not stupid.” – Terry Bradshaw

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, an HIT and marketing consultant, and sits on the board of directors of the Ohio Health Information Partnership (OHIP).

News 5/2/13

Epocrates remains the most popular medical application on both smartphones (70 percent) and tablets (60 percent) among US physician app users. More than a third of the physicians launch Epocrates three or more times a day, with drug references being the primary resource accessed.

First-year guaranteed compensation for primary care physicians in 2012 averaged $180,000, up from $175,000 in 2011. Practices are offering a number of benefits to recruit physicians, including signing bonuses, paid relocation expenses, loan forgiveness, paid vacations, and continuing medical education.

Lahey Health (MA) selects athenaClarity for population health management.

TSI Healthcare recognizes Western Carolina Eye Associates (NC) with a Circle of Excellence award for its use of NextGen EHR to improve patient care.

Navicure reports that its first quarter revenues were 32 percent higher than the same period a year ago. Also in Q1, the company added 247 practices to its client base.

The American Society of Anesthesiologists sends a letter to CMS and ONC recommending that anesthesiologists continue be eligible for exemptions to the MU program. The ASA also asked for additional exemptions to specific MU criteria, such as providing patients with clinical summaries and electronic health copies, and implementing drug-drug and drug-allergy checks.

The 16-physician Steindler Orthopedic Clinic (IA) extends its RCM contract with MediRevv to include claims approval and appeals.

As of the end of March, 255,722 EPs had collected $5.2 billion in MU incentives, representing almost half of all EPs that have registered for the program.

The seven-clinic FQHC Christ Community Health Services (TN) contracts with Priority Management Group to provide RCM services, consulting, and coding training.

HealthTexas Provider Network partners with MediMobile to provide HealthTexas physician groups a mobile solution for billing, coding, and capturing data.

EClinicalWorks reports that 450 health centers, or 35 percent of all the country’s health centers, are eCW clients.

MMIC, a insurance liability provider that also offers HIT services and resells NextGen products, adds the InteliChart portal to its suite of EHR and PM offerings for physician practices.

The number of physician office jobs for medical billers, billing managers, and medical records clerks has declined 25 percent, 23 percent, and 37 percent respectively since 2011 as practices outsource more billing processes and add EHRs. At the same time, practices are now employing more professionals as care coordinators and nurse practitioners. While staff salaries have remained flat or declined in most areas, nurse managers are now earning 10 percent more than they were two years ago.

A Consumer Reports survey of 1,000 Americans finds the most bothersome aspect of doctor visits is unclear or incomplete explanations of problems. Other gripes include slow communication of test results, long waits in exam or waiting rooms, and doctors taking notes on devices without looking at patients.

An analysis of online reviews of healthcare providers finds that patients who post negative comments about their physicians are four times more likely to complain about poor customer service and bedside manner than about misdiagnoses and inadequate medical skills.

NextGen Healthcare launches Comparison Utility, a proprietary ICD-9/ICD-10 comparison tool that is available at no charge to its customers.

Greenway Medical revises its fiscal 2013 outlook because of declining sales and deferred revenues. For the year ending June 30, Greenway updates its earnings estimate of $0.10 to $0.17 on $145-$150 million in revenue to a loss of $0.11 to $0.13 on revenue of $132-$134 million.

E-mail Inga.

News 4/30/13

Syracuse Community Health Center (NY) selects NextGen’s EHR, PM, and EDR for its 16 locations.

The Massachusetts eHealth Collaborative will provide program management services for the Last Mile Program, a Massachusetts eHealth Institute initiative that will connect 50,000 providers to the state’s HIE over the next two years.

Athenahealth names St. Boniface Haiti Foundation the winner of its 2013 Vision Award for working to improve the lives of Haiti’s underserved by providing high-quality and affordable healthcare and education. Athenahealth will give the organization its athenaClinicals EHR solution.

A peer-reviewed article published by the CDC finds that the interface technology of Intelligent Medical Objects is superior to population classification techniques as a disease surveillance tool. The findings are based on a study that showed IMO terminology service was 32 to 42 percent more accurate in identifying coronary heart disease compared to algorithms using reimbursement coding and classification techniques in identifying coronary heart disease.

The Kansas Foundation for Medical care and the AAFP’s TransforMED align to help six Kansas providers adopt the PCMH model of primary care.

Online storage vendor Box takes an equity position in EHR vendor drchrono.

ARS Pediatrics (MO) selects the Benchmark Systems PM solution.

The Primary Care Coalition, which supports healthcare initiatives for the uninsured in Montgomery County, MD, partners with Adventist Healthcare to establish health information exchange between eight safety-net clinics.

The 118-provider South Metro Primary Care (CO) IPA will connect various EHR platforms to the CORHIO HIE beginning with practices running the Amazing Chart and Allscripts EHRs.

Tri-State Orthopaedics (IN) selects SRS EHR for its 24 providers.

Acumen Nephrology introduces Acumen PM, a PM product based on the eRenalMD PM system, to compliment its nephrology-focused nEHR solution.

Physicians are making more money this year than in 2012, but are spending more time than ever on paperwork, according to a recent study on physician compensation. Other key findings include:

• The average compensation for orthopedic surgeons, cardiologists, and radiologists was more than $300,0000, but those specialists also worked longer hours than many of their peers.
• Career satisfaction rates remain steady, with more than half of doctors saying they would choose the same career again.
• Almost 25 percent of physicians are either in an ACO or plan to be in one within a year, up from 10 percent a year ago.

E-mail Inga.