DOCtalk by Dr. Gregg 2/17/13

Byproduct versus Focus

Byproduct was walking merrily down Fifth Avenue when he ran smack dab into Focus.

“Hey! Focus, my old friend!” Byproduct bellowed. (He had always been a rather boisterous fellow, most notably when extolling his own virtues.)

“Hiya, Byproduct,” Focus smiled. “My, don’t you look fine in your William Fioravanti bespoke tailoring and sparkling Harry Winston accoutrements!”

Byproduct beamed unabashedly. “Yes, indeed. Times have been very good, very good, Focus. Here in the States, the whole healthcare digitization issue has had me rolling, simply rolling in it!” he exclaimed.

Focus could see Byproduct’s chest swell as he crowed of his success. Always keeping his eye on the ball, Focus drove straight past the huff and fluff to wring the core of Byproduct’s message to the fore when he said, “Yes, here in the U.S. documentation has been creating more mountains of offshoot data than anyone ever imagined. Too bad, isn’t it?”

“What?! Too bad?” roared Byproduct. “My God, man, this is the heyday of all heydays. Me and the missus are getting ready to purchase our fourth far-too-large mansion. We’ve a passle of private jets and a mountain of Maseratis. We’re heading off to tour the world for the next two months. If you call that “bad,” then I’m happy things are so bad!”

With a glint in his eye, Focus went on, unfazed by Byproduct’s blustering. “Well, my old friend,” Focus said, “I wouldn’t be away too long. It seems there are changes afoot in the world of healthcare documentation that may just derail your digital data heydays.”

Just the slightest bit of air slipped from Byproduct’s swollen chest as he asked, “What do you mean? What could possibly derail this wonderfully massive data capture behemoth I’ve masterminded?”

Focus replied, “Oh, it isn’t that capturing more and more data won’t continue, my dear Byproduct. It’s just that the glory days for healthcare data capture are waning; a new day for healthcare data is dawning and it’ll be all mine.”

“Bullhockey,” said Byproduct. “From coding and billing to Meaningful Use, what could be more important than data capture? Healthcare data piles are growing exponentially; if I was a stock, I’d be bigger than Apple.”

“True, my old pal, true. But from Imhotep and Hippocrates to Pasteur and Mostashari, healthcare data collection has never been the true driver. It’s always been a byproduct – a necessary element, for sure – but nonetheless an offshoot of the true mission of healthcare. That true mission,” continued Focus, “has and always will be the care of people’s health. That’s why it’s called ‘health care.’”

Byproduct looked momentarily flummoxed, but quickly regained his bravado. “Nice try, my naïve Focus, but this train is running full throttle. Everyone knows that it’s the data collection that gets paid. Data capture is what HIT is all about. The days of pen and paper created mountains of irretrievable pulp-based records that may have held interesting content, but which were becoming impossible to utilize. Everyone knows,” he continued, “that digital data capture is the key to making that content accessible.”

“You are, as always, so correct and yet so misguided, dear Byproduct,” came the now impassioned Focus. “Data capture is imperative for the logarithmic growth of health information. Information technology can do wonderful things with all that data, wonderful things which were previously unthinkable. The problem isn’t data capture, per se; the problem is that data capture has become the sole focus of so many who are now involved with healthcare.”

“So you’re saying that data capture is important, but not central?” Byproduct asked quizzically.

“Exactly,” replied Focus with emphasis. “People’s lives aren’t sets of data points; they’re stories, stories full of nuance and subtleties. The same is true for their health. That’s why they call them ‘medical histories.’ Technology has not been invented which can truly capture those stories and yet it’s those stories which provide the core of health meaning. It’s those stories with their vagaries which provide true value. It’s those stories which people tell to their doctors and nurses and such and it’s those stories which give those healthcare providers the keys to understanding, diagnosing, and treating.”

“But EHRs are all designed to capture discrete data, Focus. They are all predetermined, point-and-click input portals. Without that, it’s just uncapturable, typed-in text. How can you possibly create predefined elements to cover every possible nuance?” questioned Byproduct.

“Ahhh, my dear colleague and cohort, there indeed is the crux,” agreed Focus. “Perhaps it’s the design of data capture that has blurred the vision for HIT. If data input were rehumanized, allowing people to tell health stories instead of inputting predefined phrases and terms, then the true meaning of the data – the story – could be preserved. Data capture can be improved and can be done more on the back end, after the story has been told.”

“Not possible,” retorted Byproduct. “Everyone knows that it’s templates and dropdowns that rule the worlds of HIT data collection. Providers will just have to figure out another way to share your so-called ‘stories.’ You can’t template that.”

“No, not using your approach you can’t. But, there are new ways to document coming, new digital tools that can capture discrete data while allowing the medical story to be told. I’m betting your heydays are numbered, my old friend,” consoled Focus. “These new methods might just bring me, Focus, back to the fore of healthcare.”

“Balderdash!” snorted Byproduct. “I’m just too big to be stopped!”

“So were TWA and Pan Am at one time,” Focus replied. ”Have you seen Quippe? Or how about CLiX?”

From the trenches…

“It is very difficult to get people to focus on the most important things when you’re in boom times.” – Jeff Bezos

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 2/14/13

From Orpheu: “Re: HIMSS picks. Have you picked out any HIMSS sessions that be might better-suited for someone working in the ambulatory world?”  I’ve have just started wading through the HIMSS schedule and with over 300 session options it is a bit overwhelming. My must-see list so far is not ambulatory-focused: Bill Clinton, Farzad Mostashari, and James Carville and Karl Rove. HIMSS has dozens of options to appeal to physicians and practice administrators, including sessions on patient engagement, ACO participation, mobility, telehealth, and of course Meaningful Use. I am actually curious what sessions intrigue readers so drop me a note if you have suggestions.

CMS offers guidelines for individual eligible providers and group practices to avoid the 1.5 percent PQRS payment adjustment in 2015.

NYC Mayor Michael Bloomberg announces that the use of eClincialWorks EHR by 3,200 NYC primary care physicians has led to better outcomes in terms of high blood pressure management, diabetes, and tobacco control. EMR use also spurred a 290 percent increase in preventive care services between 2008 and 2011.

Southeastern Health (NC), which uses eClinicalWorks EHR across 30 locations, adds ecW’s Care Coordination Medical Record to advance its ACO-related objectives, coordinate care, and evaluate population health.

Greenway CEO T. Green reports that the company added 750 providers in its second quarter, up 30 percent from a year ago. Green also noted that over 300 customers are now using Greenway’s new RCM platform. Greenway’s Q2 results: revenues up 12 percent, EPS $0.00.

CVS leads Wal-Mart in the retail medical clinic race. CVS operates about 630 Minute Clinics and is opening an average of  three new facilities every week. Wal-Mart has less than 130 clinics and 26 fewer than a year ago. Both Walgreens and Target, which operate a combined 400 clinics, plan to open additional facilities this year.

E-mail Inga.

News 2/12/13

Capario realizes double-digit revenue growth from its provider base in 2012 and says it significantly increased adoption of its portal application. Capario also notes that 100 percent of its clients participating in KLAS’s annual satisfaction survey believe the company keeps it promises and say they would buy from Capario again.

Vitera Healthcare Solutions hires Kermit Randa (Surgical Information Systems) as EVP of sales and marketing.

Athenahealth earns the #8 spot on Fast Company’s list of the World’s Top 10 Most Innovative Companies in Healthcare. Forbes says athenahealth “stands out” among other EMR companies because theirs is “a system that doctors actually like to use.” Teledoc, a provider of phone and video medical consultations, came in at #9.

Practices should set expectations early for the distribution of MU payments, suggest industry consultants. The decision should ideally be made prior to attestation so providers know whether they are allowed to keep incentive funds or if they are expected to return monies to the practice.

TransforMED, the AAFP subsidiary that supports practices transitioning to PCMHs, announces the retirement of president and CEO Terry McGeeney, MD.

SimplifyMD launches simpleStart, a program that allows medical practices to  go from a demo of the simplfyMD EHR to live clinical use in the same day.

An AHRQ study finds that projects funded under the “Enabling Patient-Centered Care Through Health IT” initiative have shown that healthcare outcomes are positively impacted when HIT is used to create or enhance patient-centered care.

The Huron Valley Physicians Association selects e-MDs as a preferred partner to provide EMR solutions for its 500 physician members.

Don’t miss the interview we did this weekend with SRSsoft CEO Evan Steele, who discusses a range of topics, including Thoma Bravo’s recent investment in the company, “usable” EMRs,  and MU. Steele has been an outspoken critic of the MU program and shared a few of his concerns:

• The government’s Meaningful Use program has sapped innovation out of the EHR marketplace, and it will continue to do so for the foreseeable future if CMS continues churning out overly complex rules.
• The government has set the development roadmap for all EHR companies with its Meaningful Use certification requirements and the compressed timeframe for development and implementation.
• As Meaningful Use has piled on requirement after requirement, physicians are drowning in program-related minutiae.
• Not understanding the complex requirements has kept many from even attempting to participate, and many who are managing to muddle through are suffering tremendous losses in productivity.
• Dissatisfaction is even greater among specialists. They were included as an afterthought in what is basically a primary care program, and many resent reporting on requirements that are irrelevant to their practices.

E-mail Inga.

HIStalk Practice Interviews Evan Steele, CEO, SRSsoft

Evan Steele is CEO of SRSsoft of Montvale, NJ.

Tell me about yourself and the company.

I grew up in Long Island and now live in New Jersey. I am 47 years old, have been married for 22 years, and have two children, one a freshman in college and the other a freshman in high school. I am obsessed with productivity, even in my personal life. Little things that waste time drive me crazy. For example, when my wife and I prepare dinner together, I can’t resist commenting as she slices carrots one at a time while I am lining up bunches of five and cutting them with one chop.

After earning an MBA from Wharton, I spent a few years on Wall Street as an investment banker. I left banking, didn’t like the lifestyle, and went to work with my brother, managing his high-volume, multi-site ophthalmology practice in New York City. Based on that experience, in 1997 I started SRS, an electronic medical records company with a commitment to physician productivity, a focus that to this day underlies all of our product development efforts.

The first version of SRS had a huge and positive impact on the productivity of my brother’s practice by simply replacing productivity-sapping paper charts with highly efficient digital ones. His practice quickly became the model of efficiency for a high-volume specialty practice, so we started marketing the product to other physicians. Today, the SRS EHR is used by 5,200 providers, mostly specialists, in 49 states. Vermont is the holdout.

Thoma Bravo just invested in SRS. Why was the timing good for SRS and how will it impact the company?

The investment from Thoma Bravo will accelerate SRS’s growth and prosperity and help us build on the success we have achieved over the past 15 years. I’m a big fan of getting help from those who have more experience than I do. As SRS grows from 5,000 to 10,000 to 20,000 providers, we will benefit from their help in scaling the company so that we can continue to provide the excellent products and service that our clients have come to expect.

Thoma Bravo invests over $4 billion in technology companies like SRS. Their operating partners have vast experience in technology, finance, operations, sales, and marketing. Several of these talented individuals are now on the SRS board.

Thoma Bravo will provide significant guidance and financial support for acquisitions that will expand the breadth of the SRS product suite. We have already begun the search for companies to acquire that will offer significant benefits to our physicians.

You have been outspoken in your criticism of the Meaningful Use program. What concerns you most about the program?

It is true. I have not been shy about expressing my concerns regarding Meaningful Use. But first let me tell you what I like about the program. The incentives have definitely encouraged EHR adoption and the program has pointed the industry in the right direction in terms of interoperability by establishing standards that allow a physician using any certified EHR to communicate critical clinical information with physicians using any other certified EHR.

What concerns me most about the government’s Meaningful Use program is that it has sapped innovation out of the EHR marketplace, and it will continue to do so for the foreseeable future if CMS continues churning out overly complex rules. The government has set the development roadmap for all EHR companies with its Meaningful Use certification requirements and the compressed timeframe for development and implementation. As vendors burn through their precious development resources meeting the ever-expanding government standards instead of improving their core products, they are failing to respond to the needs of physicians.

Large vendors, by their nature, find it difficult to innovate, and they are so busy meeting all of the requirements that they have no time to step back and increase the usability of their software. Small vendors may be more flexible, but they don’t have any spare resources to direct toward innovation. There are very few mid-sized vendors like SRS that have nimble data and interoperability platforms written in the latest Web technologies. These companies are still innovating, albeit within the constraints of Meaningful Use-stressed resources.

My other big concern relates to the negative impact that Meaningful Use has on physicians, which has led to rampant dissatisfaction. As Meaningful Use has piled on requirement after requirement, physicians are drowning in program-related minutiae. Not understanding the complex requirements has kept many from even attempting to participate, and many who are managing to muddle through are suffering tremendous losses in productivity. Dissatisfaction is even greater among specialists. They were included as an afterthought in what is basically a primary care program, and many resent reporting on requirements that are irrelevant to their practices.

What efforts is the company making in terms of product usability and how do you see market demand affecting that?

Physicians are pining for what they deem “usable” EHR solutions. In a recent survey, almost 2,000 physicians were asked “Do you take more time to enter exam data into your EHR, compared to paper charts?” A full 73 percent answered yes. In what other industry does technology replace paper and leave three quarters of its users with productivity reductions? Online bill payment is faster than paper checks, envelopes, and stamps. Googling an article is faster than wrestling with the microfiche in the library. Sending an e-mail is faster than snail mail. Yet most electronic health record systems are actually slower than inefficiency-laden paper charts.

At SRS, we define usability as meeting the data and quality measurement needs of physicians while increasing their productivity. Poorly designed EHRs that waste physicians’ time drive them nuts. At SRS, we have over 50 developers and a staff of business analysts who devote an inordinate amount of time analyzing how physicians think and work, all before the first line of code is written. We obsess about things like minimizing clicks, using screen real estate efficiently, limiting unnecessary pop-ups, and providing keyboard shortcuts for repetitive tasks, all of which improve physician productivity. This ensures that our software is the most intuitive, the most ergonomic, and the most efficient for the physicians.

How are specialists’ EHR needs different from those of primary-care physicians?

Specialists typically see higher volumes and generate more revenue per patient visit. They are more significantly affected by small changes in productivity. Consequently, a productivity-focused EHR is vital to serving the increasing demands of a growing patient base and to maintaining physicians’ incomes. Also, specialists largely provide episodic care, and therefore up to a third of their visits are with new patients. This means that a specialist EHR needs to be really efficient at new patient intake. Unfortunately, most EHRs in the marketplace were designed for primary care physicians. This makes it very challenging for specialists.

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

The competition in the high-performance specialist market is highly fragmented and there is no single competitor with which SRS competes regularly. The SRS offering is superior in terms of usability, speed, and focus on productivity, as evidenced by the testimonials on our website and the increase in sales of our EHR as a replacement for existing software. Using my carrot-cutting strategy as an analogy, SRS is the five-carrot EHR in a world of one-carrot technologies.

Another factor contributing to SRS’s success is that our clients are universally happy with their EHR and therefore promote SRS among their colleagues. We have been very successful at creating an amazing client experience by investing heavily in our eager-to-please support staff and our topnotch, on-site developers, both of which have earned us the highest ratings for customer service and satisfaction.

Our entire support team is located at our corporate headquarters. They are a highly certified technical team, holding 53 Microsoft certifications collectively, which means that when they get on the phone, they provide the technical expertise required to answer virtually any client question. They clearly provide a superior experience compared to many of our competitors that have overseas support reps who read from a script, often a very frustrating experience for the caller. We have an open checkbook policy in our support department to ensure that we deliver the highest level of client support in the industry.

Our entire development team is also located in our office. Because we are a stone’s throw from New York City, we draw software development talent from a vast metropolitan area and can attract some of the best and the brightest in the industry.

As more EHR vendors consolidate, how will your business be impacted?

Vendor consolidation will result in increased sales for SRS, as physicians will seek more appropriate alternatives when they are not satisfied with the EHR that is foisted upon them when their original vendor is acquired and their technology is phased out.

How much of your business is driven by product replacement and what factors cause the practices to seek new vendors?

Thirty-one percent of 2012 new license sales were replacements and 46 percent of our sales pipeline is replacements. We had always anticipated that this would occur, but we didn’t expect that it would happen so soon.

The primary factor causing practices to seek new vendors is the sharp loss of productivity stemming from their existing EHR systems. Accelerating the replacement trend is the fact that physicians rushed to purchase EHR systems so they could get their Meaningful Use incentives, and in their rush to purchase, they did not do the proper due diligence to find out whether their EHR was appropriate for their practices. Our sales pipeline is filled with large specialty practices that ran out and purchased popular, primary care-focused EHRs only to find out after suffering the pains of implementation that there is not a lot of success with those products among physicians in their particular specialty. These practices are desperate to get out from under the productivity-sapping effects of their EHRs.

Where do you see yourself and the company in five years?

I will still be In Montvale, NJ, serving as the CEO and chairman of the board of SRS. SRS will still be a key player in the HIT industry, one of the survivors of the inevitable shakeout that will occur. The winners will be the few EHR vendors that improve quality of care while increasing physician productivity.

News 2/7/13

Forbes recognizes Kareo as the 58th most promising privately held, high-growth company in the country.

CAQH launches a universal electronic funds transfer (EFT) enrollment tool for allows providers to enroll with multiple payers through a single online process.

AHRQ and CMS announce a new EHR format for children’s health that includes recommendations for child-specific data elements such as vaccines, prenatal and newborn screening tests, growth data, and child abuse reporting. The format is designed for EHR developers and providers who wish to augment existing systems with additional features or to build new EHR systems for the care of children.

United Health Centers of the San Joaquin Valley (CA), an FQHC, selects WellFx’s online social platform for its patients and employees.

EClinicalWorks will invest $25 million over the next year to enhance and expand its patient engagement tools under its Health & Online Wellness (healow) business unit. The first product is a soon-to-be-available free mobile app for patients.

The Boston Globe, by the way, profiles eClinicalWorks and the launch of its patient engagement initiative.

Navicure extends its partnership with the MGMA AdminiServe Partner Network through 2015, which gives association member preferred pricing for Navicure’s claims management technology.

An AHIP survey finds that the percentage of medical claims filed electronically has increased from 44 percent in 2002 to 94 percent in 2011. In 2011, 93 percent of electronic claims and 79 percent of paper claims were processed within two weeks.

The Charlotte Observer looks at the shared medical appointment model that allows a single provider to treat a group of patients with similar medical conditions. Proponents say the model allows more patients to see a physician on shorter notice and gives patients the opportunity to learn from one another. Zeev Neuwirth, MD, CMO for Carolinas HealthCare’s physician services group, likes the shared appointment model, saying,

“Our research shows that patient satisfaction was as good as, if not better than, if patients are seen individually. And the outcomes are the same.”

E-mail Inga.