Practice Wise 9/17/11

Compassionate Expectations

Boy, I never thought I’d have such a love-hate relationship with a word as I do this one: expectations.

It’s been a long, hard summer in my world. We’ve been buried in Meaningful Use software upgrades and a rush of new practices starting up.

Who said all the small practices are selling to the hospital systems? Not in my neck of the woods! We usually start up one or two practices a year. We’re on #6 this year and they keep calling, and they all want to be open in three months. But I digress …

I started this summer with great anticipation of MU product releases. Although I knew that the upgrades would be arduous, what I didn’t anticipate fully was the varying degrees of expectations — met and unmet — around these upgrades.

My greatest expectation was that our clients would be thrilled with over 450 new features and functionality in their software. So thrilled, in fact, that they would embrace all the free training we offered and be enthusiastic at upgrade. We delivered a fully certified MU product in time for them to attest for Phase 1 this year if they desired. I was confident we met their expectations, in spades!

Suffice it to say that we met our own expectations of what we thought they wanted. But in the end, everyone had different expectations and perceptions of how this would play out.

In our experience, doctors expected us to provide an amazing product and it would just work. They wouldn’t have to learn anything new, even though it did a gazillion new things. Practice administrators expected their staff to participate in the training we provided and sign off when they actually did it. What we found is many signed off and never really did the work. When we showed up post-upgrade, they were lost and expected us to do training on the spot while we were troubleshooting technical issues.

Everybody in the practice had differing expectations and it was our challenge to meet them all.

Our own expectations of how our software vendor would handle their product release and ensuing support was the surprise of the summer. I have been doing medical practice software support and consulting for 11 years now and it hasn’t all been wine and roses. We expected reduced response for our support cases since our vendor was as overwhelmed as we were, but they didn’t leave us hanging.

They even pulled off a few miracle saves. A big was bug found at our favorite client’s office, a show-stopper that brought them to their knees. The developers fixed it in 48 hours.

Of course, the doctor’s expectation was that the code should haven been rewritten before end of business the same day it was found. I was praising the 48-hour miracle and she was complaining that it took so long. Our expectations were clearly out of alignment.

Just when I realized the toll this was taking on my staff and our clients, I was moved by the HIStalk post by Ed Marx on 8/17/11 titled Connect. This article motivated me to take action — first with myself and my staff, then with our customers.

It was posted the day before our quarterly user group, an informal meeting with all of our customers to check in, share ideas, and work together towards solutions. We were all feeling a little ragged from the first round of upgrades. Customers still waiting to be upgraded were anxious.

I started the meeting by sharing Ed’s discussion of compassion. It really touched a nerve (I still had a few left). It helped me refocus on what our intentions are. We are here to help providers and their staffs provide excellent patient care. We are not purely consultants with solutions. We are partners in the patient care they provide.

With this as the theme, I started our meeting on a different tact.  I did a level-set of expectations for all of us. It was a gamble, but I spoke from the heart to my customers about the challenges we were facing, the stress of the upgrades and their reactions to the changes, and the challenges within their own practices. I showed compassion for myself, my staff, and most of all, for our customers. How the interruptions of software changes often take their focus off caring for their patients while they battle data entry in their EHR.

They shared the same. It was transformative. We found commonality in purpose and compassion for each other.

We have continued to soldier on through the remaining upgrades. We continue to remind ourselves that compassion for the role and position of everyone involved is the key to getting through stressful encounters when they arise.

Did I mention that my Outlook crashed this summer during all this stress? I guess my expectation that this awesome piece of software can hold an unlimited amount of data (48,385 messages in fact) in a .pst file was unrealistic. Luckily, I have a compassionate engineer on board who took pity on me and didn’t berate me (too much) for not deleting more than three emails a day for the past nine years, and not launching our mail server years ago! We are currently planning a migration and setting appropriate expectations, because you never know how these things will go.

It’s been a great summer. I’ve learned to set clear expectations and practice doing so with compassion, every day. Thanks, Ed!

Julie McGovern is CEO of Practice Wise, LLC.

News 9/15/11

From Cleve Van Valen: “Re: Jonathan Bush. Hate to say it, but Jonathan Bush makes my CEO look like he is driving a horse and buggy.” I assume Cleve is referring to our recent interview with JB and athena’s MU transparency initiative. The transportation reference reminded me of this cartoon produced for the 2008 HISsie awards, which features Jonathan Bush in a DoLorean sports car, a la’ Back to the Future. It still makes me laugh.

McKesson introduces McKesson Practice Choice, a Meaningful Use-certified, Web-based integrated EHR/PM solution for small, independent primary care practices.  The company also announces McKesson Practice Care, a service line that offers patient-centered medical home consulting in conjunction with AAFP’s TransforMed and available exclusively for practices running Practice Partner, Medisoft Clinical, Lytec MD, and Practice Choice.

Practice Management Associates (VA) selects the ADP AdvancedMD PM for RCM services.

The 14 physicians of Sandhills Pediatrics (SC) receive $184,000 in government incentives for their Meaningful Use of the SRS EHR.

The Physician Services technology division of Inland Northwest Health Services (WA) announces plans to offer implementation and hosting services for Greenway’s PrimeSUITE EHR/PM solution.  INHS serves and connects 38 hospitals and over 4,000 physicians on its HIE.

Practice Fusion forecasts that 5,000 of its eligible provider customers will qualify for 2011 Meaningful Use incentives worth up to $90 million. That’s a big number, especially considering that through July only 4,491 EPs, regardless of EHR, have received MU checks. On the other hand, HHS Secretary Kathleen Sebelius reports that 80,000 providers have applied for funds, so perhaps the 5,000 EP estimate is on target.

Medicaid managed care provider AmeriHealth Mercy launches a program to offer its network providers free mobile technology. Physicians will have access to care alerts and e-prescribing at the point of care using the NaviNet Mobile Connect platform.

Phreesia introduces an electronic Medicare Annual Wellness Visit form, which can be presented to patients during check-in.

Integrating telehealth tools with care management for chronically ill patients may result in significant savings ($312 to $542 savings per patient per quarter.) The coordinated approach may also improve health outcomes.

Speaking of telehealth, Mount St. Mary’s Hospital and Health Center launches a telehealth practice to address acute health issues and follow-up care, as well as provide chronic care virtual visits. Mount St. Mary’s says its Online Care practice, which uses American Well technology, is the first medical group in the country to be formed as a telehealth practice.

E-mail Inga.

News 9/13/11

From Lauren Alaina: “Re: exemption from 2012 eRx penalties. Providers can access the exemption request form at www.qualitynet.org/pqrs. In the ‘Related Links’ box on the upper left, click on ‘Communication Support Page,’ which displays the online form.  Once a provider finds the site, the process seems pretty straightforward!” Thanks, Lauren. Apparently the portal just went live last week. It looks like it will take providers about a minute to file an exemption.

HHS, AT&T, and the American Association of Diabetes Education announce a diabetes self-management training project that uses mobile health technology. AT&T is contributing $100,000 to cover the cost of 150 smartphones for diabetes educators, who will use a video application on the mobile devices to educate patients.

AT&T, by the way, names its first CMIO, rheumatologist Geeta Nayyar MD, MBA. She most recently served as principal medical officer at Vangent.

North Clinic (MN) chooses eClinicalWorks EHR for its 84 employed providers. The clinic will integrate eCW with Epic’s in-patient system at a nearby hospital (North Memorial, I am guessing.)

Wasatch Pediatrics (UT) integrates Phreesia’s automated patient check-in solution with its existing Greenway PrimeSUITE EHR/PM product.

In its first three months of general availability, NaviNet signs up more than 1,000 providers for its PM/EMR solution.

The 317-provider Piedmont Clinic (GA) partners with MD On-Line for electronic claims submission and RCM services.

The100-provider Wilmington Health (NC) will integrate its Allscripts Professional EHR with Humedica MinedShare’s clinical analytics solution. Wilmington Health will also join Ancenta, AMGA’s collaborative data warehouse, which was co-developed with Humedica.

Kareo partners with MD-IT to offer an integrated solution with Kareo’s PM/RCM software and MD-IT’s medical documentation solution.

American Well and Numera announce a strategic collaboration that will deliver real-time health monitoring over American Well’s telehealth network. During online visits, providers will have live access to biometric information through Numera’s gateway. Clinical information can then be captured and stored as part of a Continuity of Care Record.

ENT and Allergy Associates (NY) integrates Intuit Health’s patient portal with NextGen’s EMR, giving its patients the ability to complete medical histories online prior to appointments.

Ophthalmology EMR provider Integrity Data Solutions promotes Chris Moore from COO to CEO.

US doctors, particularly orthopedic surgeons, earn more than their counterparts in Europe, Canada, and Australia. Primary care doctors are paid 27% to 70% more than their foreign peers, while orthopedic surgeons earn 70% to 120% more. The difference in earnings is attributed to higher fees rather than factors such as higher practice costs, volume of services, or education debt.

McKesson announces the creation of a new division, McKesson Specialty Health, which will focus on improving the health of community-based physician practices and their patients.

E-mail Inga.

DOCtalk by Dr. Gregg 9/9/11

An Operational Luddite

Tech-oriented I am. Born geek I was. So how bizarre it feels to note that today I declare myself a Luddite.

Not a traditional Luddite in the current sense who eschews all things tech and opts to forego modernity in the information age by going about sans smart phone, without an e-mail address, and reading books that really are books … you know, made of paper and ink. (Really. Real ink!)

And not in the historical sense from the earlier backlash against the Industrial Revolution in the late 1770s and early 1800s when mechanized looms, or “stocking frames,” threatened to bring mass chaos to the world and the rather mythical Ned Lud (later exalted to “King Lud” or “Captain Lud”) first destroyed such a loom in a still-unclear fit of rage or passion.

No, I like my tech. I cringe when my power goes out, when my smart phone battery starts flashing less than 5% battery remaining, or when I’m assaulted by some insurance company multi-page form that I must complete … gulp … by hand!

My “Ludditious” nature centers around the current trend for all things healthcare going conglomerate: hospitals buying up solo and small group practices willy-nilly; ACOs appearing almost like morel mushrooms out of the droppings of not-so-distant failed doctor-hospital coops of the late 20th century; HIT talking heads portending the end of the small “onesy-twosy” doc practices.

I’ve worked in large institutions, and even now, with some of my other current dealings, I have to try to work within large organizational frameworks. Much, if not most of the time, I personally find these “frameworks” to be more spider web than scaffolding. Navigating many larger bureaucracies has often reminded me of advanced trigonometry. I know some folks get it with ease and grace, but it’s akin to an Escher landscape when I look.

In fact, I mentioned to my little “onesey” practice staff (all three of them) yesterday that I’ve come to believe that any group of people beyond about five in a work environment just seems to have a pall or haze of bureaucratic entanglements that seem virtually unavoidable. And the really weird part for me is that individually, many — even most — of the folks who make up said bureaucracies are all good folk with good intent. But get five-plus people involved in an endeavor and you can just watch the red tape, boring meetings, and meaningless uselessness start to almost magically sprout, just like morel mushrooms from the dung – overnight.

Being a small business owner is tough, no doubt. Sleepless nights wondering if you’ll make payroll in the morning, stretching yourself micron-thin, lack of certain freedoms of escape — all weigh notably on the “con” side. But if I can keep my head above the red ink water, I will proudly try to maintain my “Operational Luddite” status and avoid the ACO / hospital-acquired / multi-provider group bandwagon.

The cons for this entrepreneurial work style are there, but the “pros” are just too fun. We can make a decision, act on it, decide if it works or not, and make a new decision that builds upon the successes or failures of the prior one – and we can do all that without one single meeting, PowerPoint, org chart, or study. Heck, I don’t even have to ask anyone for permission, no less a board or committee. I can make experimental choices – some mistakes, some huge successes – and then redirect as soon as the needs change. Snap — just like that.

So, if all of healthcare is going to conglomerates, to ACOs, and to “big-buy-the-small” corporations, I think I’ll just have to accept the fact that, at least in one sense, I’m a Luddite, an “Operational Luddite.” I like being a “onesy.”

From the trenches…

“Bureaucracy is the art of making the possible impossible.” – Javier Pascual Salcedo

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).

HIStalk Practice Interviews Jonathan Bush, CEO, athenahealth

athenahealth just released online dashboards indicating the performance of its athenaclinical physicians against individual Meaningful Use criteria. Athenahealth CEO Jonathan Bush provided some insights into these measurements and their implications.

Tell me what the numbers show at this point.

The numbers show things like it is very awkward and difficult for doctors to ask patients about their race or ethnicity when it is not central to their visit, which it rarely is. They show another that it is extremely damaging to patient throughput for a doctor to print a clinical summary and then have to explain what it is to a patient after they have already had their visit. Those are the kinds of things that the dashboards are showing in the small.

In the large, it is showing that there is a very long tail on every well-meaning piece of centrally-administered legislation, much of which, when viewed in the day-to-day reality, seems ridiculous. But I think the fact of the long tail and the size of the investment – certainly more than $44,000 worth of work per doctor – is the big idea that is emerging. That is what we are seeing so far.

I think we are also seeing that it is doable, that it can happen.

For athenaclinical clients in particular, what are you finding they need to be doing differently?

It varies widely from practice to practice. The big aggregate ones that are toughest for us are the race and ethnicity question and the clinical summary question. But with the clinical summary, because we are athena, we can just take that on ourselves because the practice isn’t doing it. We can just add it to the portal and text the patient and say that it is there, or call them on the phone for the practice, and thereby guarantee that they meet that standard. In that example, we are taking it completely out of the practice workflow.

athena is unique for several reasons in this Meaningful Use example. We know in real time whether doctors are meeting the standards or not. That is both a strength and weakness.

It is a weakness because it is easily auditable. Doctors could be called out if attested inappropriately. But it is good because we can see real time and can fix it right away.

Our fix options are really threefold: 1) we can alert the practice as to where they are they are and give them encouragement; 2) we can change the application so that practices don’t need encouragement, it just happens easily; or, 3) we could actually take the work out of the workflow and do it ourselves in the practice’s name.

In the example of race and ethnicity, we can move it in the application upstream to the patient self check-in and hopefully they will capture it there. Or move it out of the exam and into the pre-exam intake step and require the nurse to ask and put a script around it saying we are required by the government to ask you, which would make it easier.

In the example of the clinical summary, we can say screw this, it is too hard because it slows down the checkout process. Let’s send to patient over the website the same day with a lot of explanation online.

It seems like some of the issues are less about product inefficiencies and more about workflow issues. I would think that would be something that crosses over to all EHRs.

That is an interesting point you make. I think that one of the big things being indicated is that differences between the products of the vendors and the process of the buyers are going away. There is a convergence there.

What makers of healthcare information technology in the future are going to need to sell is good process. Whether they use the web or apps or flying trained pigeons is irrelevant to the customer. The customer needs the change in process. They need the process discipline. They need the new information, no matter how the vendor is going to get it there. That is the product. In the future, they are probably not going to get paid until that happens.

How are you measuring the data?

All of our clients, all of the time, are in one living, breathing instance of our application. We have instrumented all the Meaningful Use data into medical records fields that have been instrumented centrally to trigger this central scoring system. Some aspects of athenaclinicals are medical record fields that an individual doctor has decided she wants to manage and capture herself. But the Meaningful Use fields and other financially-wired fields are administered centrally by athena so that we can know when the standards are met.

This is another problem with traditional, isolated software EMR. The fields are not all instrumented such that they can easily connect to reporting so you know how you are doing.

Do you intend to share this information with CMS or others in the Washington crowd?

I want to share it. I think one of the many good intentions behind the HITECH Act was to generate some transparency around the medical office practice — who has process control and who does not — and reward the ones who do. It has been watered down a lot, but that is the underlying intention. I want the folks in Washington to see how much work they have generated with this, to show how they have generated more than $44,000 worth of work by this.

But I also want them to make sure they make it fair, because I represent 30,000 providers that have actually done the work. They are meeting the standards, either through their subscription fees to us or by obeying the pop-ups that athena asks them to do. Either way, our work is theirs because they have paid for it. I want to make sure they get credit. I don’t want anybody who hasn’t met the standard to be able to attest and get the money without doing the work.

That is the second thing I am going to say — show me how you are going to audit this. I want our clients to prepare for audits now. I want to make sure you audit more than your fair share of our clients and I want you to do the audits so you don’t just distress our clients. I want you to audit everyone else so nobody attests without really doing it.

Furthermore, let’s get away from this attestation thing if you are not really going to do thousands of audits. Then I want you to stop attestation as part of this larger trend of making unreasonably and obscene rules with massive penalties for non-compliance, and then not auditing, or auditing in such a random way that it really, really, really hampers innovation and creativity and excitement in the healthcare space.

If you want information: ask for it, be ready to receive it, and then pay for it as it comes out. Don’t say, “I will pay you if you promise me I will receive, it even if I don’t receive it.” It’s like “don’t ask, don’t tell” — it is the most absurd and embarrassing way because you create distance between what a doctor attests to and what is true.

Whereas if you just say the data is provided, here it is. Provide the clinical summaries here. Put them in the data base here. Data storage is here. If you need those clinical summaries, put them here. Let me see what you gave them.

Or race and ethnicity. If it is so important for us to slow down the visit and ask for race and ethnicity, then fine, then ask us what the race and ethnicity mix of our client base. If we don’t give it to you, then don’t pay us. But to say, “I want you to be able to tell, me but I am not going to ask you, but if you don’t tell me if I do ask you — which I won’t — then I’ll put you in jail.” That is a really messed up conversation.

What about Stage 2 Meaningful Use?

The second part of the feedback, for Stage 2 — let’s not do attestation. Whatever you ask for in Stage 2, ask for it and use it. Actually move to trading in this clinical performance information and whatever you can receive and use on your side. Pay for it as it comes out. If you can’t, don’t pay for it. Tell the Teabaggers that you saved some money. But don’t just give it out to everyone, whether they do it or not, and don’t not receive it and use it.

It reminds me a lot of the great federal program to pay farmers to pump their milk out onto the road. You got to be kidding me. That is just such a waste. You are paying thousands of doctors around the country to collect this data that will never be used by anyone. It is so embarrassing.

What do you hope the reaction of other vendors will be?

My fondest wish is for a group, ethically-based mass suicide amongst all our traditional software-based competitors. Barring the mass suicide, I am shooting for a reluctant movement towards their own transparency. What is their answer? I am hoping the Ingas of this world will ask them, “Why can’t you tell me what percentage of your doctors are where on these 20 metrics and how does society gauge you if you can’t?” And let them come up with an answer.

You know, Deloitte will provide a middleware that will allow Allscripts users to know how they are doing against other people. It will be free for your first six months. I don’t know, but some answer where they start to move towards competitive positioning based on outcomes, based on the performance of the use of their application. Right now, it is based on demos and golf outings with CFOs. It is just so dumb.

I am glad you are focused on it and I hope you do ask all the other vendors and get them on the phone and say, “I want to know how you are doing, how you are measuring it.”

It is a very dangerous game when reality and talk start to separate. It is a very slippery slope. Once reality and talk are a little bit separated, it is very easy to get a lot separated. That is when you get with the horrific Medicare audits and terrified people who won’t tell the truth and law firms whose professional advice is to not ask the government if they are compliant with this or that reg so they don’t show up on their radar. These things happen all the time today.

Whereas if attestation in general did not exist, but instead reality existed and reality was paid for, the product was delivered and the product was paid for, a lot more people would be attracted. Entrepreneurs and others would be attracted to healthcare. I do not subscribe to the idea that there should be fewer entities making healthcare IT because they are too many to manage. That is the loopiest idea I have ever heard.