DOCtalk by Dr. Gregg 4/1/13

Sunny Side Up? Nope. Scrambled.

I’ve started to see that the world healthcare information technology is just one big pile of scrambled eggs – metaphorically speaking, of course.

Consider the metaphor: scrambled eggs are an amorphous conglomeration of congealed albumen and yolk, nutritive albumin protein and embryo all swirled up into one, often incompletely cooked, goo. Scrambled eggs often have lots of other non-egg-related matter thrown in – like ham, or onions, or cheese, maybe some spices or a little milk – all swirled together and intermingling haphazardly.

Now, compare and contrast time:

Consider the cooked egg world’s opposite – the sunny side up egg. It also may be incompletely cooked sometimes, but it is a structural antonym to its scrambled cohort. It has the lovely yellow yolk nestled serenely in the center, caressed and protected by the surrounding proteinaceous white. The two components are discrete, yet complementary. Together they make the dish, but their borders are well-defined.

Either scrambled or sunny side up eggs can be cooked fully or served up with just a touch of “slime” left. Some folks prefer the drier, “well done” type while some of us are happy with a little remaining mucusy texture. (I admit it sounds less appetizing when written as such.)

Now, metaphor hop back with me to the world of HIT:

Look through the multitude of realms which HIT involves or touches: healthcare, technology, legislative, financial, legal, and more. All of these can be further broken down into subgroups such as mHealth, telehealth, inpatient, outpatient, e-patient, privacy and security, insurance and billing, regulatory, education, etc. Each of these can be subdivided even further into things like mobile apps or client server tools, real-time or store-and-forward, acute care or long-term care, primary care or urgent care, empowerment or engagement, HIPAA or data sharing, and so on and so on and so on.

There is nothing about MU or HITECH or HIT (or, perhaps, even US healthcare in general!) that comes even close to a sunny side up, well-defined and harmonizing balance of distinct collaborative elements. It’s a mishmash. It is one giant pan full of goo and goop and value-add ingredients all churning about and “intermingling haphazardly.” And, it’s anything but fully cooked; there’s a slew of slime.

I know lots of well-intentioned folks are busy trying to get some regulations and some standards into place to help define and refine the hootenanny of interplaying elements in the enormous HIT space. And that’s probably good. But when I look around the massive HIT frying pan, I’m pretty sure we’re going to have to be happy eating our “eggs” scrambled for quite some time – and with plenty of mucus.

It’s been said that you can’t put toothpaste back in the tube. You actually can, but it’s a major pain in the tukhus. Similarly, it’s pretty near impossible to unscramble your eggs.

If the good folks trying to regulate and standardize are trying to regenerate sunny side up HIT eggs from our current scramble…well, doubtful. If they’re trying to harmonize the ingredients…well, that’s probably possible.

Of course, we could always throw away the current batch and start – more gently – with some new, fresh “eggs.”

(Yeah…right.)

From the trenches…

“The world is wrong side up. It needs to be turned upside down in order to be right side up.” – Billy Sunday

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 4/2/13

Rep. Diane Lynn Black (R-TN) proposes legislation that would amend certain requirements and penalties for the MU program. Some of the provisions  in the Electronic Medical Records Improvement Act include:

• An option for certain providers to participate in specialty registries that offer real-time data instead of reporting on nine or more clinical quality measures
• A shortened reporting period for Medicare EHR payment adjustment applications from two years to no more than one year
• An exemption from penalties in years 2015 to 2017 for EPs who are solo physicians or near retirement
• The ability for rural healthcare providers to be defined as EPs and participate in the MU program
• A more formalized appeals process for providers that receive penalties

Our HIStalk Practice reader survey will be open for just a few more days. Your feedback is important to us, so thanks for taking a moment to answer a dozen easy questions.

Legal experts recommend that physicians pay closer attention to requirements under the Americans with Disabilities Act (ADA) as practices shift to EHRs and other computerized tools. To avoid violations and lawsuits, providers must consider whether such tools as online scheduling, bill payment, or Webcasts will accommodate disabled patients and employees.

St. Louis Oncology will implement Benchmark Systems’ practice management system.

More physicians are suing former patients and their relatives over negative ratings and reviews posted on the Internet. Personal blogs, as well as consumer-driven Websites like Angie’s List and Yelp, allow patients to write critical comments about their physicians. Some lawsuits have resulted in patients removing the negative comments; other cases were dismissed because judges ruled that patients’ comments are protected under the First Amendment. Sounds like the real winners here are the attorneys.

E-mail Inga.

HIStalk Practice Interviews Michael Lovett, SVP and Ambulatory Division Manager, NextGen Healthcare

Michael Lovett is SVP and Ambulatory Division Manager of NextGen Healthcare of Horsham, PA.

Tell me about yourself and the company.

I am the senior vice president and ambulatory division manager for NextGen Healthcare and a member of the QSI Executive Committee. In my role, I am responsible for developing and implementing the ambulatory division’s strategic plan and ensuring that this plan is aligned with the company’s strategic direction. I also oversee day-to-day operational functions within the division and coordinate efforts across departments to promote operational efficiencies and achieve company goals. I am also responsible for shared operational policies and procedures to improve tools and solutions for client-facing organizations companywide.

NextGen Healthcare Information Systems is a  wholly owned subsidiary of Quality Systems and provides integrated clinical, financial, and connectivity solutions for ambulatory, inpatient, and dental provider organizations.

Everybody talks about product usability and ONC seems interested in transparency in that area. What efforts does the company make in terms of usability and how do you see market demand affecting that?

Those are two great questions. Recently, we launched NextGen Ambulatory EHR 8 Series. It is our most advanced, easy-to-use, and transparent system ever. It has a new user-friendly interface, standardized framework for all templates, and streamlined navigation that is faster and reduces training requirements. It helps providers set the stage for patient-centered, collaborative, accountable care – key drivers in today’s changing healthcare landscape.

In addition, the 8 Series gives providers the tools they need to meet healthcare reform initiatives like Meaningful Use Stage 2 and ICD-10. Our new EHR system features automated outcomes reporting, enhanced disease management workflows, and precise content for over 25 medical specialties. At our most recent user’s group meeting, we received extremely positive feedback. We already have existing and new clients seeing its benefits. In fact, we have reports from clients who have reduced training time by about 50 percent and workflow from days to hours. Others have been able to see more patients.

With the complexity of today’s reforms, the market is hungry for solutions that are fast and easy to use while addressing the demands of compliance, quality, measurement, and reporting. In addition, the recent ONC 2014 certification of our ambulatory EHR includes requirements for and validation of user-centric design principles. To me, this provides another strong, positive answer to your question about our product usability and transparency.

A number of vendors are selling ambulatory systems through hospitals that either encourage or force their owned and affiliated practices to use the selected product. Does that trend worry you?

Not at all. Because of the success we have across so many specialties and up and down the size scale of practices, we have run into this a lot. The depth of our content and the ability to deliver appropriate workflows for the physicians give us an advantage over the hospital vendors who are trying to work their way into the ambulatory footprint. If hospitals are to have successful deployments, the physicians must see the positive benefits, which means it must fit their workflows. In many cases, “encourage” is just a euphemism for “force” and that never works out well in the long run.

Connectivity and interoperability are also key benefits to our solutions. We already have ambulatory practice clients who became part of a hospital system and who work seamlessly across the existing hospital’s platform. And, we offer both hospital and ambulatory HIT and EHR solutions so our company strategies align perfectly with this trend.

Athenahealth and Greenway did particularly well in the recent KLAS report. How are your offerings superior to theirs?

Now you’re trying to get me in trouble with my friend Tee. Jonathan will surely disagree with me, but we are superior to Greenway and athena in a number of ways, from the number of providers and leading edge practices we have as clients, to the content, ease of use, and functionality of our products and services.

While we understand a few of our 80,000 providers are not fully satisfied, we have made and continue to make great strides in increased satisfaction. The response at the user group meeting was great. Our internal satisfaction polling there showed very positive results.

A key point to note is that within the KLAS report, over 90 percent of our clients consider us as long-term partners. They see us as experts who can help them more easily connect with colleagues, hospitals, and payers; attest for MU2 and beyond; transition to ICD-10, and thrive in a pay-for-performance reimbursement model. All while improving care.

In the end, prospective buyers must realize that the survey firms are only talking to a small subset of the client base — in the case of KLAS, just 200 clients out of over 3,500 — and surveys should be used as one of many parts in the buying decision. In turn, it is our responsibility to stay close to the pulse of our clients through direct interactions and be responsive to their needs. The new account management programs we are implementing will help us make great strides with that. In fact, in the Black Book Rankings, announced on March 16, 2013, our NextGen Ambulatory EHR came in first place for highest client experience and customer satisfaction for several categories, including independent physicians associations with less than 150 physicians and physician group practices with over 250 physicians.

The company’s stock has fallen about 60 percent since April 2012, a time that has been quite favorable for some EHR vendors. How has this impacted company priorities?

Over the last year, many EHR venders have had their ups and downs. Our strategies and priorities, however, have remained on target. Our company is focused on the future delivery of healthcare including pay-for-performance accountable, collaborative care. We continue to develop our broad range of innovative and integrated ambulatory and hospital products and services. As a result, our award-winning solutions rank us as one of the top four EHR vendors in Meaningful Use attestations.

From the Wall Street perspective, we have seen many new investors buy into long positions with our stock. That means that they believe in the vision and the strategic plan that was introduced by our board at the last annual meeting. That gives us additional confidence that we are focused on the correct initiatives and as we deliver on those our stock performance will reflect that.

Do you see your inpatient and ambulatory offerings as two distinct lines of business or are there plans to integrate the offerings?

They are elements of a complete, comprehensive, and integrated HIT and EHR offering. For example, our EHR and practice management solutions are fully integrated and connected to our hospital and dental solutions. Moreover, our development team is unified under one organization for all of our divisions, thereby ensuring alignment of and innovations across all product and business lines.

Some are calling for EHRs that are open and that allow the use of third-party apps to add or change functionality. How would you summarize the state of openness of the EHR market and NextGen Healthcare’s interest in incorporating that capability?

Charlie Jarvis, our VP of health reform, and I sit in numerous meetings in DC where the subject inevitably turns to interoperability, connectivity, and data sharing. There are some vendors that simply can’t do that very well at the discrete level. We have always been and continue to be willing to work with other vendors where appropriate. We also have many interfaces for a variety of devices.

Interoperability is not new to us. We have been exchanging discrete data through our exchange with numerous vendors for some time. Our HIE and EDI solutions have been providing access to all available relevant patient data to help providers improve care quality and patient safety. With NextGen HIE, providers can collect, store, and securely share patient information, regardless of what EHR platform it may be stored within, bridging the gap between hospitals and physician practices while providing a channel for communication between communities.

What’s your opinion on HITECH and how do you predict it will impact physician systems in the future?

The HITECH act stimulated an incredible amount of EHR adoption across the ambulatory physician market.  As a result, most medical providers — 70 percent — have now adopted or are in the process of installing EHR systems in their practices.

With high EHR adoption, the biggest challenge now facing providers is how to configure their EHR system to produce the outcome data needed to demonstrate their value-based care performance against objective medical criteria. Just as important is the interoperability between systems needed to compare these objective data points among healthcare providers. Without connectivity and interoperability, providers will find collaborative and accountable care more difficult to achieve.

As a result, the EHR industry is now vigorously supporting movement to standards that will create information highways that make health data readily available and easily interchangeable. Until these standards are fully in place, the challenges of data sharing will continue to be experienced across the entire industry.

In addition there are a large number of providers who purchased a solution that could only offer them a tool to enable the first stage of Meaningful Use. Many of those vendors don’t have the operational, technological, or financial resources to enable their clients to advance to the next stage. Because of this, the replacement market will continue to heat up. For providers in that situation, they will look for vendors that can offer them solutions that deliver more than just stimulus payments, but real function that transforms their practice. NextGen Healthcare is a vendor to help them be transformative. In fact, our NextGen Ambulatory EHR version 5.8 is now ONC 2014 Certified as a complete EHR to get our clients to Meaningful Use Stage 2. We are one of only three vendors to achieve that distinction at this time.

News 3/28/13

From BeatleJuice: “Re: EHR purchasing tips. Vitera offered some tips for practices shopping for EHRs. Their way of suggesting how to go about purchasing an EHR is a recipe for a disaster. There is only one way to separate the wheat from the chaff and that is for physicians to perform random reference checks with other physicians.” I agree with BeatleJuice that reference checks are an essential part of the evaluation process. Mostly vendors willingly provide prospects with the names of their happiest clients, but savvy shoppers should dig deeper into their personal network to get opinions from “random” users. A site visit or two to other practices is also a worthwhile investment of time.

A consulting firm finds that hospital-owned physician practices around Kentucky are losing as much as $100,000 per year per doctor. Losses tend to be higher the longer a hospital has had employed physician groups and the more physicians that a hospital employs. To turn things around, consultants recommend that hospitals expand the use of remote care technology to reduce treatment costs for patients in rural areas, plus make physician payment plans more flexible. Déjà vu from the 1990s.

The NCQA launches its Patient-Centered Specialty Practice Recognition (PSCP) program, which extends its PCMH recognition program to specialty physicians and requires provider commitment to improving access, communication, and care coordination. Sixty-four organizations have enrolled as early adopters for recognition in 2013.

The Wall Street Journal looks at the use of physician-patient e-mail communications, which patients generally love and physicians often shun because of the lack of reimbursement and concerns with privacy and security. Maryland OB/GYN Mark Seigel, MD is a proponent of e-mail communications, saying the biggest benefit is the goodwill it generates:

“It improves the reputation of my practice. I get very good ratings online.”

Lutheran Family & Children’s Services (MO) will implement practice management software from Benchmark Systems for its obstetrics practice.

MED3OOO names Judy Stovall from PriMed the winner of its video case study contest.

There is still time to participate in our annual HIStalk Practice reader survey, which is different than the HIStalk survey we ran a couple weeks ago. It takes one minute or less to answer and your input is appreciated!

ADP AdvancedMD launches a Website that provides a timeline for practices as they prepare for the ICD-10 transition.

E-mail Inga.

HIStalk Practice Interviews Michael Brozino, CEO, simplifyMD

Michael Brozino is CEO of simplifyMD of Alpharetta, GA.

Tell me about yourself and the company.

I’ve had the good fortune to work with very large companies and much smaller companies. After working for Kodak in their digital imaging division for 10 years, I took a risk during the dot com boom with PACS start-up ALI Technologies.

I learned a lot about the importance of company culture. We had some extremely passionate people driving performance for both the customers and the company. The complete alignment on the vision and execution required resulted in an acquisition by McKesson and number one market share. I spent another nine years with McKesson in a number of challenging and rewarding roles ranging from launching new products to running the marketing department.

It’s been an interesting switch to go from the largest health IT company in the world to something much smaller, but I really like being able to establish a culture that is passionate about connecting with customers and finding new ways to solve their challenges. It’s such a nimble environment. We can talk directly with customers and then turn around and integrate their comments and needs into the product.

simplifyMD was formed seven years ago and remains privately held. We have a brand promise of a simple experience that is foundational to everything we do, both externally and internally. It is core to our culture. We serve an established customer base of dozens of practices that range from one to 75 physicians per organization across a number of specialties.

I’m very proud of the fact that we’ve had a 100 percent success rate for our physician base that chose to attest for Meaningful Use Stage 1. It confirms that we’re meeting the physicians’ needs for an EHR and providing the support they need to complete attestation, all while meeting our brand promise of simplicity.

Which companies are your most direct competitors and why do you think your offerings are superior?

There are hundreds of EHR companies out there, ranging from monolithic to freeware. We fall about in the middle with a cloud-based SaaS offering that takes a lot of the burden off of a physician or practice manager. We like to say that it’s “your forms, your charts, your workflow,” and we mean it.

The key to our success is that we make the process of EHR adoption easy. You’ll see the word “simple” in so many things that we say when talking about the simplifyMD EHR solution. We’ve done everything we can to make it simple to buy, simple to learn, and simple to use.

What we’ve seen with so many EHRs is that they require a great deal of attention from the physician during the exam process. Instead of focusing on the patient experience, the physician is staring at a screen and interacting with hardware.

simplifyMD lets doctors be doctors. They can interact with patients and focus on the patient’s needs rather tending to the computer. simplifyMD requires virtually zero clicks during a patient encounter but still allowed us to facilitate 100 percent MU attestation for practices that desired to do so. Our approach is truly unique and remarkable because it doesn’t force a technology-focused workflow onto a practice or physician.

Everybody talks about product usability and the ONC seems interested in transparency in that area. What efforts does the company make in terms of usability and how do you see market demand affecting that?

Typically EHR systems have been created by programmers who know what data is required but ignore how a practice actually operates. They set up a rigid system to collect and process information and then are surprised that physicians resist adhering to a new set of rules and procedures. I believe that’s why you hear so much about physician frustration with EHRs.

We took the opposite approach. By letting a practice use its existing forms and workflow, we eliminate the need to learn a new system and speed adoption. We continue to listen to the customer and update the software every 90 days based upon requested usability enhancements. So rather than forcing physicians to adapt, we help them adopt.

The fact that we are the easiest to use EHR on the market is confirmed by our customers, multiple product reviews, and even KLAS. Usability is our lifeblood. Practices use their existing charts and forms and follow their existing workflow, which makes adoption easier. Physicians can still use paper if that’s preferred and write, type, or dictate to complete forms. Yet the system captures deep outcomes data on patients for analysis and inclusion in larger research data sets.

Do you believe all specialties are adequately represented in Meaningful Use and in EMR design?

If you ask a specialist, they will probably say that Meaningful Use is insensitive to their discipline’s specific needs. In reality, it’s very difficult to address every aspect of every specialty. From an EMR design standpoint, there are some very good systems that focus solely on a specialty area, such as radiation oncology, that have very complex workflows. That complexity also means lengthy installs and high price tags. At simplifyMD, we strongly believe that there are aspects of workflow and information use that are unique to specialties and we serve 30 different medical disciplines.

What makes each specialty unique is the type of body area, specific diseases, and conditions it focuses on, and the reason they’re special is that their workflows for diagnosing and treating are different. Because we allow each practice to use their own forms, their own workflows, and their own specialty-specific charts, we’re able to adapt to the specialty rather than asking them to adapt to our technology. simplifyMD also makes multi-product and device integrations easier, so in those rare cases when our solution can’t adapt to their specific requirements, we simply integrate with their unique devices and software extensions.

Some have speculated that further Meaningful Use stages will consolidate the EMR market as less-capable vendors either stop trying to keep up or sell out to a competitor. How do you see that playing out?

When new market opportunities open up you see a lot of activity from a wide range of companies, and healthcare is no different. The promise of obtaining incentive pay brought a lot of new companies into the EHR marketplace, many of whom had no experience in the heavily regulated healthcare market. They slapped a label on some data collection software and called it an EHR.

Practices made their decisions based on the three Ps: panic, promises, and price. They knew they needed to get to attestation and they were in a state of panic. A lot of companies were making a lot of promises, which vaporized during actual use. And since everyone is looking for a good deal, it was natural to select the low price solution.

Now they are reluctantly looking at replacement products and it’s a much wiser marketplace. After being forced to adapt to how their EHR software worked, physicians are seeking a solution that allows them to maintain their practice’s workflow while still moving towards Meaningful Use Stage 2 certification.

The opportunistic smaller solutions providers are starting to fade away. The large companies that added healthcare to their product set are either seeing success and will continue to develop their solutions, or will find the regulatory environment so stifling they’ll sell off that portion of their business. I believe that in two years there will definitely be fewer, but much better companies selling EHR solutions.

How does your company address privacy and security issues given your cloud-based platform?

Based on the preference expressed by a customer, we support both cloud-based and on-premise deployments. Our basic privacy requirements are founded, of course, on existing HIPAA regulations as well as the new Omnibus rules recently released. simplifyMD’s technical security strategy starts with banking-style authentication and encryption that follow NIST controls such as sophisticated firewalls and security training for our staff. On top of that we added Department of Defense style anti-hacking tools.

Realizing that there is no 100 percent guaranteed security solution, we built deep auditing and tracking tools in addition to the HIPAA-compliant security foundation so that if there ever is a data leak or spill, we can find out which customers are affected and meet our reporting requirements quickly.

What does your five-year plan for the company look like?

Our formula for success sounds simple, but in actuality can be difficult to implement. First, you start with a solid product that customers really need – and we certainly have that at simplifyMD. Next you deliver what you promise. We’ve seen so many practices that are disillusioned because the promises they heard during the sales process weren’t fulfilled by the product. We just don’t do that. And finally, you support the heck out of it.

Our current focus is on Meaningful Use Stage 2 certification and development work is well underway. All requirements will be met over the next two releases. And because we push those releases out automatically through our cloud-based platform, the impact on our customers will be minimal.

Probably one of the hottest topics in the field of EHR is how to facilitate patient access and interaction with their personal health information. That’s an area that we plan to address in the future, focusing on how to simplify the process for both patients and physicians.

Another industry hot button is the integration of mobile technologies into EHRs. The need to maintain security while facilitating bi-directional communications is a challenge and one that we are currently tackling.

What will not change is our culture. We will continue to be a passionate group of people focused on creating customers for life. We do that with outstanding service coupled with a product that is easy to learn, easy to use, and meets the evolving needs of our customers.