DOCtalk by Dr. Gregg 7/28/12

Days of Whine and Proses

In the midst of just another day of too many patients with far too many unexpected problems squeezed into far too few time slots within which were too few moments to reflect and consider, I had an epiphany: I, we, all of us in healthcare delivery are living in the midst of the Days of Whine and Proses.

The Whine? We are still, as I said several years back, in the very midst of the birth pangs of the delivery of this huge "enfant terrible" known as digital healthcare. We are whining about the fact that this infant was ever conceived, we’re whining about the cramps, and we’re whining about the lack of an epidural equivalent.

We whine because it costs us money. We whine because it costs us time. We whine because it invades our processes. We whine because it intrudes upon our interactions.

We whine when it doesn’t work at all, when it doesn’t work correctly, or when it just doesn’t work exactly the way we want it to. We whine when it is less than perfect even when we don’t really have a true reference for just what such perfection is.

We whine because it is different from what we know.

On this particular day, I found myself in the midst of an unspoken internal whine about a merely tangential HIT issue. I had just realized that all of the prose I was "prosing" as I attempted to document by point or by click, by dropdown or by pop-up, by two-fingered typing or by fat-fingered falter was fairly futile.

My whine wasn’t just bemoaning the fact that the process of digitization of my thought processes was far from an enjoyable experience. And, it wasn’t a whine about the less than optimal ergonomics still involved in mental to machine interpolation.

No, within the soundproof walls of my internal mental monologue was a whine about all of the prose I was digitizing for near eternal salvation to be forever lost within the silent world of HIT Neverland.

Think about it. We spend hours each week away from our families and friends, away from the actual act of caring for the health of our patients (or ourselves), away from sleep or supper just to document items and issues with details, many of which, if not most of which, will never be read by anyone, ever.

Every single provider, every one of us, whether digitally or pen-and-paperly, spends countless portions of our working lives documenting things large and small which will never be noted by another human being as having ever been so documented.

Nobody is ever going to read virtually any of the hundreds of thousands of times I’ve written (or clicked) that a tympanic membrane was clear. Few will ever note any of the tens of thousands of exudative pharyngeal tonsils I’ve documented. Only rarely will anyone ever notice any of the thousands of soft systolic heart murmurs heard over all of those left sternal borders that I so meticulously marked down.

I realize that all of those pertinent negatives and their typically more glamorous counterparts, the pertinent positives, are important to note and to note down. But, just thinking about how many numbers and letters and words and phrases I have documented over the years which no one will ever, ever read and then multiplying that by the millions of healthcare providers across the globe who are doing similarly, I found a whine I had never before considered – that is, we are generating billions, maybe trillions, of these precious pieces of pertinent prose for the purpose of… what?

If a tree falls in the woods and no one is around to hear, does it make a sound?

If a documented finding is never read again, was the documentation of that finding worth the time it took to document? Is the disk space it consumes worth the electromagnetic energy it takes to maintain it?

I’m not even thinking about the appropriate answers to those rather rhetorical queries. I’m just whining… whining about all the prose, all the prose that nowhere goes, here in the Days of Whine and Proses.

From the trenches…

“This is the way I look when I’m sober. It’s enough to make a person drink, wouldn’t you say?” – Kirsten Arnesen Clay in Days of Wine and Roses, 1962

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, directs the Pediatric Office of the Future exhibit for the American Academy of Pediatrics, and sits on the board of directors of the Ohio Health Information Partnership (OHIP).

News 7/26/12

From Old timer “Dr. Michael Stearns. Thought you might be interested in this press release.” Old Timer forwarded me a copy of a press release prepared on behalf of former e-MDs president and CEO Michael Stearns, who was abruptly fired earlier this month. Not unlike e-MDs’ press release announcing Stearns’ departure, Sterns’ statement is short on specifics and does not provide any additional insight into the nature of the allegations, nor whether a lawsuit may be in the works. An excerpt:

“Very little additional information has been shared, but e-MDs claims they received allegations limited in scope to potential violations of company policy. We know with certainty that any such allegations were only partially investigated. My replacement, Dr. David Winn, founder, board president, and majority owner of e-MDs, was immediately reinstated as CEO. I am disappointed that e-MDs took the unusual step of publishing what amounts to unsubstantiated allegations that have not been subject to due process, in particular given the potential harm false claims may have on an individual’s family and on their reputation. Yet, despite this unfortunate turn of events, I am proud of what we accomplished during my tenure at e-MDs and I wish their staff and customers well in the future.”

From Numbers skeptic “Re: attestation numbers. Attestation numbers by EMR continue to look anemic. It might be interesting to show a graph of the number who have attested, divided by the number who use the EMR. For example, eClinical and Practice Fusion each boast well over 50k users; that makes the number who have used the program to successfully attest woefully small.” While the graph you are suggesting might be an interesting data point, I don’t think it would give much insight into whether or not a product is Meaningful Use-friendly. Note that the CMS data does not include attestation data for the 41,000 EPs who have qualified under state Medicaid programs. A provider with a heavy Medicaid population probably has less disposable income and is more likely to select a lower-priced EHR solution, such as Practice Fusion or eClinicalWorks. Also keep in mind that many providers are not necessarily interested in attesting for MU, even though they want a functional EHR. For example, an orthopedic surgeon may want a basic EHR but believes a $44,000 bonus is inadequate incentive for changing practice workflow, if it were required to meet MU requirements. He/she may elect to go with a low-cost solution, or, may implement an EHR better suited for orthopedic-specific workflow. I love to crunch numbers but developing reasonable conclusions can sometimes be tricky.

The 30-physician EyeCare Associates (AL) consolidates 19 PM systems with the deployment of EMRlogic Systems’ activEHR PM solution.

Doctors Access, a PM company and division of iPractice Group, partners with CareCloud to offer its 500 users access to CareCloud’s Doctors Access Pro PM software.

Practice Fusion names Riyad Omar general counsel (NewsRight) and Patrick Dugan (Bloodhound) VP of corporate development.

The American Board of Internal Medicine (ABIM) announces that CMS will include ABIM’s Maintenance of Certification program in its 2012 PQRS Maintenance of Certification Program Incentive, meaning ABIM board certified physicians can earn an additional .5% bonus payment beyond the standard PQRS incentive.

The ONC’s HealthIT.gov Website publishes information to help providers calculate the cost of purchasing an EHR. Key considerations include the cost of hardware, software, implementation, training, and ongoing fees. Based on input from RECs, the ONC estimates the total cost of ownership over five years for an-office EHR is $48,000, compared to $58,000 for a SaaS option.

The AMA launches the Cutting-Edge Contracting Group, an online community to help physicians evaluate and negotiate payment options and contracts with managed care organizations.

E-mail Inga.

News 7/24/12

CMS posts updated data on MU attestations by vendor. On the ambulatory EHR side,  Epic accounts for twice the number of attestations compared to the next closest vendor, Allscripts, whose numbers are a roll-up of four different products. More than 70,000 EPs attested using products from over 300 vendors, but the top four vendors made up almost half of all the complete ambulatory EHR attestations. I used Excel to massage these numbers and just this simple graph was a bear to create. If you like to number crunch, you might want to find a more robust reporting tool.

Providence Health & Services plans to deploy Nuance’s Dragon Medical 360 voice recognition technology across its 250 clinics and 27 hospitals. Over the next year, Providence will integrate Dragon with Epic EHR for the health system’s 8,000 clinicians.

Rep. Michael Burgess (R-Texas) introduces legislation to extend Medicare physician payment rates for one year as Congress continues to work on a payment program to replace the current sustainable growth-rate formula.

CalHIPSO adds Mitochon Systems, Medstreaming, and Meditab/SuiteMed to its list of EHR vendor partners. CalHIPSO’s CIO notes that the new vendors offer “an economical option for small and solo practices that are ready to adopt an EHR.”

Lifelong Medical (CA), Summit Orthopedics (CO), and Midwest Eye Care (NE) implement Indigo Indentityware’s SSO and authentication solution along with BIO-key International’s fingerprint biometric software to access their EMRs.

Arthritis and Rheumatology Associates of Palm Beach (FL) selects TSI Healthcare to deploy, train, service, and host their NextGen System.

Curious: Safe Future ACO, a South Florida organization with a pending CMS application to named an ACO, posts an ad on Craig’s List recruiting physician participants. The posting offers primary care physicians the opportunity for shared savings of up to $100,000 a year.

A June report by the Office of the Inspector General reveals that eClinicalWorks is the single most utilized product by the 1,500 Medicare physicians participating in a 2011 survey.

E-mail Inga.

Practice Wise 7/20/12

To the Cloud!

Many clinics are moving their computing needs to the cloud. What does that really mean? Not all applications in the cloud are created equally.

In simple terms, cloud computing refers to software applications hosted by an application service provider (ASP) that the end users access via the Internet. But not all applications in the cloud are the same. It’s important that practices understand what exactly they are getting when they move their applications to the cloud, and the overall impact on their organization.

No doubt about it, more and more opportunities exist in the cloud beyond your PM/EMR. For instance, QuickBooks Online, Microsoft Office, Exchange Server for e-mail, and many other programs that are used in the day-to-day operations of a practice. Most of these products are purely web-based, meaning you open up a web browser and work directly in it. For most of these applications, the limitations of a web page application are not necessarily rate-limiting factors.

However, when considering moving your PM and/or EMR to the cloud, there are many factors to consider.

Is the application a web-based application, where you log into a website and work directly in your browser? If so, what are the limitations of this type of application?

• You can only view one screen at a time, unless your vendor allows you to log into multiple sessions so you can toggle between screens / pages. This may not seem like a big deal to a provider in an exam room who is primarily charting in one screen. However, it can be an efficiency boondoggle for staff who need to view multiple screens at once (e.g., triage nurses, schedulers, billers).
• Can you scan directly into the application, or do you need to scan insurance cards and other point-of-service scans to a folder on your network and then browse from the web app back to the folder to attach the scan? This can be time consuming and result in mismatched records when done after the fact.

Is the application hosted on a remote connection instead of a web app?

• What does that mean for log-ins for your staff? How many log-ins will they need?
• Can you remote scan to the application server?
• Can you send and receive faxes from the remote server?

We have a few clients who have recently gone with dual remote applications. The PM and EMR are separate apps that are somewhat interfaced (demographics flow from PM to EMR, charges flow from EMR to PM). However, the staff now has five log-ins to access their hosted applications:

1. Their local network log-in
2. PM RDP connection log-in
3. PM application log-in
4. EMR RDP log-in
5. EMR application log-in

We are seeing this cause considerable workflow issues for our clients.  Just trying to keep all their log-ins straight is a challenge. The daily log-in process is cumbersome.

The clinic personnel are not network engineers, they don’t fully understand that when they log in to the various RDP connections, they are now on another server. When they browse and the network file structure does not look the same, it causes confusion and loss of productivity and even loss of documents that they can’t find once they save them.

Each of these log-ins has timeout periods and differing password change schemas, so the time required to keep all connections live can be a considerable effort. Especially on the clinical side, where someone might be logged in, go see a patient without their computer, and by the time they need to chart, have to repeat the 1-5 logins.

Bandwidth, bandwidth, bandwidth! Do you have enough bandwidth to support your entire staff to access your applications via your Internet connection and keep everyone happy with response times? This is a key factor in your success. We’ve seen clients go to hosted environments with DSL connections or a T1. It’s a nightmare! Make sure if you are using wireless laptops or tablets that they too have a strong, solid connection. It will add to your stress if you are fighting both wireless and Internet connectivity.

There are many valid reasons why moving to the cloud is the best thing since sliced bread. Total cost of ownership for IT is the most obvious. Let someone else deal with hardware costs and backups etc.

I’m not saying that the cloud is either good or bad. However, you must do your homework and hire someone to explain all the pros and cons to you. You don’t want to depend on your vendor to show you slick demo that makes it look like you are working directly on your desktop when in a remote session. You need a disinterested party who has nothing to gain financially from you to fully test each scenario and explain the benefits and risks, and help you analyze all your options thoroughly.

We’ve moved several of our key applications to the cloud and kept a few local on our servers. We feel that the mix is good, and our overall uptime and ease of use works well for our environment and uses. Best of luck to you!

Julie McGovern is CEO of Practice Wise, LLC.

News 7/19/12

Ambulatory EMR replacements are up 30-50% this year, especially in larger practices, according to a KLAS report on the ambulatory EMR market. Other highlights:

• Most small practices are first-time EMR purchasers while larger practices are looking to consolidate disparate systems by replacing their EMR vendors.
• athenahealth, eClinicalWorks, e-MDs, Epic, and Greenway are gaining mindshare while Allscripts, GE, NextGen, McKesson, and Vitera are “juggling resources.”
• The most replaced vendors are Allscripts, GE, and McKesson, primarily because of support concerns or lagging product development.
• Vendors winning most with second-time buyers are eClinicalWorks, Epic, and Greenway.

ANSI announces the first accredited certification bodies for the ONC’s Permanent Certification Program for HIT. The accredited organizations include CCHIT, Drummond Group, ICSA Laboratories, InfoGard Laboratories, and Orion Register.

The Arizona State Physicians Association, the Huron Valley Physicians Association (MI), The IPA of Nassau/Suffolk Counties (NY), and Boca Raton Regional Hospital (FL) are some of the new health systems and IPAs aligning with Greenway Medical for its PrimeSUITE EHR/PM solution.

An AT&T-sponsored physician practice technology survey finds that 37% of practices have fully implemented an EHR. Expense continues to be the top reason practices say they’ve not done so.

Health Management Associates partners with athenahealth to implement athenahealth’s solutions for HMA’s 1,200 employed providers. athenahealth will also offer services to the 10,000 independent physicians affiliated with HMA hospitals. athenahealth, by the way, announces its Q2 earnings Thursday and analysts are predicting a 14.3% increase in net income compared to a year ago.

NCQA extends a “Distinction” designation to 60 PCMH primary care practices that collected and reported patient feedback using the Consumer Assessment of Healthcare Providers and Systems PCMH Survey.

SAIC will pay $473 million to purchase maxIT Healthcare, a HIT service company that provides management consulting for eClinicalWorks, Allscripts, NextGen, and other ambulatory and inpatient products. maxHealthIT will be combined with SAIC’s Vitalize Consulting Solutions team.

Recruiting firm Merritt Hawkins predicts that 75% of the nation’s physicians will be employed by hospitals by 2014.

CMS sends the final regulations for Stage 2 of the MU program to the White House Office of Management and Budget, indicating the rule is nearing publication.

TriZetto Group subsidiary Gateway EDI acquires ClaimLogic, a medical claims and payment processing company that serves large practices and the hospital market.

The CDC finds that 55% of US doctors use some type of EHR, with 85% of them reporting being either somewhat or very satisfied with its day-to-day operations. About three-fourths of the physicians who have adopted EHRs say their system meets Meaningful Use requirements.

ADP AdvancedMD deploys its 2012 Summer release, which includes an iPad app, new ICD-10 tools, and workflow improvements for pediatrics.

E-mail Inga.