DOCtalk by Dr. Gregg 2/3/13

Is Meaningful Use Becoming “Lost In Translation”?

From dear Dr. Jayne in her “Curbside Consult” on HIStalk to enigmatic SRSsoft CEO Evan Steele on EMR Straight Talk and more, the phrase “runaway train” keeps popping up in descriptors of the current state of Meaningful Use. I’m on record as a fan of Meaningful Use, but I’ve been seeing some signs, both external and internal, that have me concerned.

First, the external.

As mentioned above, the increasing clamor in the HIT blogosphere seems to be congealing around a core concept that MU has gone (or is going) off track. Not only are smart folks like Jayne and Evan questioning MU’s current trajectory, we’ve even got some of the original stalwarts for HIT who helped craft our technological rail lines making increasing queries about our train’s timetable and rail network design.

The New York Times article, “In Second Look, Few Savings From Digital Health Records” from January 11, 2013, states , “While there is strong evidence that electronic records can contribute to better care and more efficiency, Dr. [David] Blumenthal said, the systems in place do not always work in ways that help achieve those benefits.”

Later in that same piece, David J. Brailer, MD, PhD is on record as saying, “The vast sum of stimulus money flowing into health information technology created a ‘race to adopt’ mentality — buy the systems today to get government handouts, but figure out how to make them work tomorrow."

How many vendors are spending all of their developmental resources solely addressing MU? I know that every vendor with whom I’ve spoken this past year or two is spending the majority of their dev teams’ time on this. Some are spending all of their dev time on it. If everyone’s development is focused upon MU, that sure doesn’t leave much room for creativity and new “meaningfulness” that may not yet have been considered.

Now, the internal.

More by happenstance than plan, I was the first provider in the State of Ohio to receive payment for Stage 1 Meaningful Use via Medicaid. (I was ready for it, for sure, but I just happened to be looking at e-mail when the sign up announcement came through.) I was grateful to receive it, believe me, because margins in small town pediatrics are about as skinny as a heroin-addicted runway model, i.e., deathly thin.

However, since my lovely EHR was sunsetted, I’ve declined to pay for server software upgrades needed to upgrade to the last version my EHR will ever have. That version would allow for Stage 2 achievement. But this expense just doesn’t make sense to me at this point. That money would basically turn the Stage 2 incentive monies into a pass-through, more for a software vendor’s benefit than my practice’s. (And, it makes even less sense if my next EHR is cloud-based!)

I’d prefer to just find my next system upon which to grow, so that any the Stage 2 incentive dollars that pass through to someone else are at least supporting a system with which I’ll be moving forward. (Finding that next system, the one that’s right for me and mine, is a whole other story!)

But, since being on hold, I’ve also noticed that the lower dollars incentivizing Stage 2 seem less motivating. As I spend more time looking at systems, I spend more time thinking about MU hoops. The more I think about Stage 2, then Stage 3 (and Farzad’s talking Stage 4 stuff), the less incentivized I feel.

Don’t get me wrong. I love the potentials and all of the truly meaningful stuff that connected EHRs will allow, once we’re all connected. The problem is, I’m starting to doubt that a federally-legislated definition of “meaningful” will actually play out as was once hoped by all the brains that crafted MU and all of us who have supported it or who even just went along.

I still support the overall idea of Meaningful Use. I’m just wondering if the meaningfulness part has started to get lost in translation.

There’s a part of me that envisions Bill Murray and Scarlett Johansson, standing somewhere off in the wings of an imagined HIT train station, snickering.

From the trenches…

“But the good news is, the whiskey works.” – Bill Murray as “Bob” in Lost in Translation

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).

HIStalk Practice Interviews Jim Riley, President and CEO, Capario

Jim Riley is president and CEO of Capario of Santa Ana, CA.

Tell me about yourself and the company.

Capario is a physician office revenue cycle management company. Our mission is to simplify the healthcare reimbursement process, making it easier for providers to get paid faster and more accurately.

A lot has changed in the past three years. We have emerged from a corporate reorganization with a healthier sense of purpose and increased focus on the provider side of our business. As a result, we’re seeing double-digit year over year growth in that segment, and have just completed our strongest year ever as a company both financially and operationally.

Our focus is on the physician office market, which includes practices of all sizes. Our business is divided between direct sales into physician offices and partnering with PMS/EMR systems to offer wrap-around services to their customer base.

For me personally, I’ve been around the healthcare space for over 15 years. I love the vibe within Capario right now. We’re really finding our momentum. Even with over 20 years in this business, our growth is better than ever, client satisfaction scores are high and climbing, and we just have that startup feel. It’s a fun time for me.

There’s been a lot of activity in the revenue cycle market, including product changes, regulatory requirements, and changes in service-based companies. How would you characterize the major differences in RCM today vs. a couple of years ago?

Even as recently as a few years ago, I think most players in the revenue cycle space were still focused on rounding out traditional offerings – a proper tool to do the basics like claims management and tracking. For the most part, everyone has those tools now.

Looking ahead, most of us are focused on providing solutions to help providers get paid, whether it’s tools to bill patients or collect payments or enhanced suites of services to help providers identify and combat denials. With cost pressures in the physician office space, it all comes down to helping providers understand the financial health of their practice and to collect the most possible from every dollar they bill.

The other big difference is the volume of changes that are coming at this industry. We see change as the only constant within the next 3-5 years. There are more and more regulations and standards coming down the pike that could really revolutionize this space, including ERA, EFT, HPID, attachments and more. 

These are just the start. Provisions put in place with the Affordable Care Act call for new standards to be proposed no less than every two years. Providers will need to continually stay on top of these changes in order to grow and adapt with the market.

Small practices are often too busy taking care of patients to network with other practices and stay on top of vendor and regulatory news. How does your marketing plan address getting your message in front of people in those practices?

This is a great question. We’ve really been shifting our focus over the last couple years to offer more educational services. You’re exactly right — practices are often too busy to hear a hard sales pitch. They need to know what changes and trends are affecting them and what they need to do about it.

To that end, we strive to be a good partner and raise these issues to practices through webinars, video on demand learning, etc. This year, we’re also beginning to offer courses that carry CEUs as well. We’re confident that even with this less direct marketing approach, our customers will still hear our message and will know that Capario is a solid choice for them when they are in the market for a solution.

Capario also tends to do a lot of proactive messaging. We allow customers to sign up for customer notifications via our website. These are targeted messages around activities happening in the industry as well as real-time messages around the status of certain payers and transactions being available. We’re often complimented on providing this service to our customers. To us, it just makes good business sense. The more we all know, the better we can all make decisions.

EMRs get all the attention, but for practices and physicians themselves, is it financial and administrative applications that can make or break their opportunity to keep serving patients?

Truthfully, they are both important. As a physician, you have to take advantage of EMRs and all of the power they possess to revolutionize healthcare in this country. While it’s a big adjustment for many practices, there’s no question that the benefits are ultimately there.

What’s ironic is the number of practices embracing EMRs that still have very little technology around the business side of their practice. I’m constantly amazed when we talk to physician practices and find out how few of them really know how they’re performing as it relates to their revenue cycle, especially in the small to mid-sized markets.

Due to the cost pressures we’ve previously discussed, it’s imperative that every practice has a set of tools that can put key performance indicators at their fingertips. EMRs are needed to help improve the health of patients, but good RCM tools are needed to manage the financial health of the practice.

What are the trends of practices demanding and using “Pay Now” services?

I would say that for most practices, the ability to easily bill and collect payments from patients is at the top of their priority lists for 2013. The facts are just too great to ignore. Nearly 25 percent of payments are coming directly from patients. That number is going to continue to grow.

More and more employers are also advocating high-deductible healthcare plans, HDHP, as a way to control costs, and they’re really starting to gain widespread adoption in the last few years. HDHPs are not just plans for the young, single, and healthy employee any more. I even switched my family over to one this year. It just made financial sense.

However, these moves mean more and more of the first dollars reimbursed in healthcare are coming from the patient. This is a radical shift in just the last few years. Physicians on the whole aren’t ready for it. It brings in an element of consumerism that they haven’t had to think of before. For example, many of us pay our bills online now, but most practices do not have a way to collect payments online. Practices need flexible solutions that will help them answer this critical need.

What regulatory and payment trends do you think will most affect your company and customers over the next 2-5 years?

ICD-10 will be huge for the industry, no question. While 5010 was a change to the technical formats, ICD-10 will be a change in the way physicians and payers conduct business with one another. That said, I have confidence now that the industry is behind the new compliance date next year. I don’t think anyone is under the impression it will be delayed again, and most are taking the courses they need and making adjustments to their billing and coding processes to be ready.

Also, the continued shift of payments moving from insurance companies to the patient is going to continue to trend in upcoming years. This is a reality that the physician office space will need to have solutions to address.

Beyond that, there isn’t any one single regulatory trend – it’s more just the volume and pace of changes coming. As I look out over the next few years, there seems to be something coming at least every 12 months. These changes can and will make a huge difference to the healthcare space

News 1/31/13

From LightsOut: “iPractice Group. The company posted a notice on its Website that it has ceased operations as a result of ‘depressed sales in the late 4th quarter leading to insufficient funding to continue operations.’” Between market saturation, practice consolidations, and MU requirements, I am certain that iPractice will not be the only EHR vendor to close up shop this year.

Huron Valley Physicians Association (MI) chooses eClinicalWorks EHR for its 600 providers. eClinicalWorks also announces that Holyoke Medical Center (MA) is adding eCW Care Coordination Medical Record for advancing ACO and PCMH objectives.

The website Software Advice scrubs CMS data on MU attestations through October 2012 to identify the top ambulatory EHR vendors. Epic, Allscripts, and eClinicalWorks had the most complete EHR MU attestations and accounted for 42 percent of all attestations. A total of 355 vendors had at least one attestation, though two-thirds of all attestations came from the top 10.

MacPractice and RT-MediBus integrate their MacPractice PMS and RT-MediBus EHR programs.

Cara Buckhaulter, a medical billing and coding consultant with Nuesoft, offers some tips for boosting practice revenues, decreasing rejected and underpaid claims, and reducing claims A/R days. Recommended steps include verifying insurance, submitting claims daily, following up promptly on rejected or unpaid claims, reviewing codes semiannually, and monitoring financial reports monthly.

Medical Office Today profiles NextGen customer Associates in Women’s Health (KS) and its use of NextGen’s NextPen digital pen technology.

SOAPware will implement the ELLKAY connectivity bridge for its EHR clients to provide integration with third-party PM systems.

CPA B.J. Hoffman suggests some internal control procedures to prevent fraud, waste, and abuse in medical practices. The bottom line: physicians should regularly review key financial documents and staff should segregate financial tasks to ensure proper checks and balances.

E-mail Inga.

News 1/29/13

From Tiffany: “Re: iPractice Group. You wrote a very nice blurb about our booth and presence at MGMA in San Antonio. Thought you might find it interesting that the company laid us all off on Friday and is filing bankruptcy.” Unconfirmed, but other readers have shared similar news. Mr H and I have e-mailed and called the Nashville headquarters but have received no response and all content has been removed from the company’s website. IPractice, which is (or was) a reseller for Greenway, moved to a new 30,000 square foot headquarters in October, made a big splash at MGMA, and in November was attempting to raise $10 million in additional equity.

Athenahealth files notice that it will lay off 36 employees in its Birmingham office, effective March 6. Birmingham is the location of Proxsys, the care coordination systems provider that athenahealth acquired in 2011. Margo Hendrickson, athenahealth’s VP of HR, sent us this note:

As a high growth company we are always looking to apply efficiencies to the way we work. While it is incredibly difficult to let people go from what otherwise is a growing employee base, our intent and commitment to shareholders is to align investment with business growth opportunities. This focused set of employee restructuring will allow us to achieve several critical business scaling and financial objectives that otherwise we would struggle to meet. At athenahealth, we are committed to ongoing team growth; in the past year alone the Company has grown its U.S. employee base 28 percent adding a total of 473 new employees to its U.S. total of 2,140.

Pioneer Medical Group (CA) signs an agreement with McKesson’s MED3OOO division to jointly own and operate an advancement management services joint venture that will offer physician group management, operations, administration, hosted technology, data warehousing, and other services for provider groups, physician networks, employers, and hospitals.

First Databank releases the FDB State and Federal Controlled Substances Module, which facilitates the e-prescribing, dispensing, tracking, reporting, and claims processing of controlled substances.

American Medical Group Association (AMGA) reports the addition of 51 new medical group members in 2012, representing 13,600 physicians. AMGA represents 430 group practices and 130,000 FTE physicians.

Billing service and collections provider Horizon Financial Management will use state and local tax incentives to establish a new 20,000 square foot headquarters in Merrillville, IN. The company plans to invest $1.9 million on the new facility and grow its staff from 60 to 276 by 2016.

Vitera Healthcare Solutions will give practices using its Vitera Stat PM/EHR product access to DiagnosisOne’s CDS content and patient education materials at the point of care.

As of the end of 2012, Medicare and Medicaid had paid over 175,000 EPs more than $3.3 billion in MU incentive since the program’s inception.

E-mail Inga.

HIStalk Practice Advisory Panel: Social Media, Security Practices

The HIStalk Practice Advisory Panel is a group of physicians, ambulatory care professionals, and a few vendor executives who have volunteered to provide their thoughts on topical issues relevant to physician practices. I seek their input every month or so on an important news development and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a practice, you are welcome to join the panel. Many thanks to the HIStalk Practice Advisory Panel members for willingness to participate.

For this report, I asked panel members about social media in their practice and privacy and security measures.

What social media tools are being used in your practice?

We’ve had to tighten things up due to fear of lawsuits or other problems. We encourage our providers to only use the official practice website or official practice-based Facebook and Twitter accounts. There are a couple of physicians who use personal Facebook accounts and have patients who have friended them, but that’s discouraged.

Website with vetted patient education content, Twitter, e-mail – with marked restrictions (until we engage our portal) and patient communications portal (pending).

We have a very basic Facebook presence and starting to do some rare tweets. But right now we believe our patients really want connectivity rather than content,  so our focus is on making sure it is very easy to send in messages via our secure portal.

Employed clinics have a Facebook presence to make general announcements about clinic-sponsored community events, new services, and physicians joining the group. Periodic reminders about seasonal flu shots are also posted. There is very little social media usage among the private practice clinics within our market.

Patient portal is in place and gaining adoption. We also use YouTube to distribute videos of clinic providers, the clinics news, and leadership messages. Some use of LinkedIn and other social media for recruiting. Still discovering ways to leverage the social media. This is an example of a YouTube video we use to promote our medical group in the community:

What security and privacy measures are in place in your practice? For example, encryption, passwords, remote access, antivirus, backup/recovery processes, etc.

All of the above including mandatory machine encryption and mandatory antivirus measures etc.

Passwords with complexity requirements, fingerprint scanners, Norton 360, Avast Antivirus, Malwarebytes Anti-Malware, LogMeIn Pro, daily incremental local backups to external hard drive, weekly full backups to external hard drive, off-site storage of redundant external backups, pen tablets not allowed to be taken off-site.

Employed clinics follow the enterprise-wide policies and procedures for security and privacy. Those policies address encryption for all devices, minimum password complexity standards, frequency of password changes, non-reusable passwords, antivirus protection active and definitions up to date, OS and application security patches applied, redundancy/backup protection, business continuity and disaster recovery, and employee required annual training on HIPAA security, social engineering, phishing, etc. These policies align and in some case are even more stringent than the regulatory requirements to protect the information and system assets of our enterprise and patients. Daily automated audit systems are in place to notify the appropriate personnel of devices that do not comply with policy.

Unfortunately, for most of the private practices that I have visit, they do not fully comply with the basics of existing regulations regarding security and privacy of electronic patient information, systems, and access. Private practice clinics (especially the small to medium sized clinics) do not have the internal expertise nor resources to accomplish what a larger organization can do with pooled resources. Some clinics are relying on the HITECH REC services or third-party providers to monitor and accomplish some or all the tasks necessary to be compliant with regulations.

We use passwords and antivirus. Remote access is allowed only from home. Not sure if we encrypt. We did not have a backup system initially. We did discuss that once in a staff meeting at which it was decided that another database would be added at another site for backup, but I’m not sure if that ever materialized.

VPN, encryption, daily back-up, antivirus.

We are part of a larger AMC, so lots of the regular network stuff – passwords, virus protection, backups. For remote access, we use dual authentication with a token. In our exam rooms, we set up a system that automatically secures the exam room computers when the door is opened, thus ensuring security when the doctor or nurse leaves the room. Has worked out great!

On the encryption front, we have a disk encryption product on our laptop machines called Credant. The software is a hybrid encryption product that only encrypts some of the files on the laptop, leaving others — like the OS — unencrypted. They say that this is better when compared to full disk encryption because only the user who is logged into the machine has files that are decrypted, whereas full disk encryption products decrypt all of the files for all of the users on successful login.

I think there may be a weakness in it because the whole drive is not encrypted. Given time, I’d try to hack it to see if it fails to encrypt files that it should. So hopefully it is doing a good job. I’m aware of a few cases where users have lost data because the keys were corrupted or something else went wrong with the encryption product.

We use whole-disk encryption for all portable devices and only allow PCs on the network (no BYOD, unfortunately) for making the security easier. Passwords must change every 45 days and cannot repeat for 24 months. Remote access is available with either hard or soft tokens. Antivirus is in place. We do allow users to be administrators on their own devices, but if we suspect trouble, we will then remove those rights. We assume you’re innocent until you mess up. We back up the EHR database nightly and every two weeks a backup is sent to some kind of secure bunker, I think in Nebraska. We randomly test the backups to make sure they are actually usable.