Bowtie Confidential: How Full Is Your Plate? 6/20/11

The discussion I have most often with clients, especially the C-suite, is about the growing number of federal initiatives and the need to prioritize them all. The list of initiatives includes but is not limited to Meaningful Use, ARRA, HIPAA, health insurance exchanges, health information exchanges, RHIOs, ICD10, Payment Reform, and ACOs.

The list does not include the standard (and just as important) issues such as relationships with medical staff and the board, the recruitment and retention of physicians, reduction in payments by third parties (including Medicare and Medicaid), tighter and tighter margins, shrinking endowments, etc. My apologies to any reader whose concern I have not mentioned.

What should the CEO of a large, complex healthcare organization do about these competing initiatives?

Many require extensive manpower, such as the implementation of an EMR or CPOE system. As of yet, I have not been to a single organization that has a cadre of staff sitting in their office just waiting to work on the next initiative. Nor have I seen an organization that is so capital rich that these type of initiatives can be paid for without a formal internal review, and ultimately, board approval.

It is my suggestion that you do a careful risk analysis of each of the initiatives and determine which ones are really necessary to be done right now.

• Where do you have financial risk (reduction in payments or loss of opportunity to collect additional funding)?
• Where do you have market risk because your competition is moving ahead?
• How much benefit will your organization derive (referrals, downstream revenue, beating the competition) if you provide financial support for your community physicians?

We think that the (proverbial) 500-pound gorilla is going to be the ICD-10 work. When I was in D.C. a couple of weeks back, the rumor (not yet substantiated) was that the federal government may push back Stage 2 of Meaningful Use to allow organizations the necessary time to work on ICD-10. Pushing the dates for compliance for the next Meaningful Use stage would be a great assist to healthcare organizations, as it will allow them to concentrate on meeting the requirements for ICD-10.

We at Hayes have found that far too few of our clients have started to plan for ICD-10. There doesn’t seem to be an accurate understanding of the amount of work that will need to be done.

There is also a general lack of knowledge regarding the financial implications of not being ready for ICD-10. The financial risk can be up to 5% of your monthly revenue. This figure likely dwarfs any of the other initiatives mentioned earlier.

Therefore, given the financial risk, we are advising our clients to move ICD-10 preparation up to the top of their list of priorities. Begin to educate the medical staff and talk to your vendors (almost all of whom will also be affected). Develop a plan so that your organization is ready for ICD-10.

Don Michaels, PhD is vice president, strategic and advisory services, for Hayes Management Consulting and teaches healthcare IT for the Harvard School of Public Health.

News 6/16/11

HHS’s Office of Minority Health and Quest Diagnostics announce a program to donate approximately 75 MedPlus EHR user licenses to physicians in small practices serving minority populations in Houston. The initiative includes subscription fees for 12 months and educational assistance from the University of Texas Health Science Center at Houston REC.

Hanger Orthopedic Group will deploy NextGen Ambulatory EHR and PM at its 675 orthotic and prosthetic patient care centers in 45 states.

PDR Network launches RxEvent, an online network to collect and distribute adverse drug events. The service is targeted at prescribers, who typically don’t report adverse events to the FDA because it is too time consuming. Greenway Medical, athenahealth, and other ambulatory vendors will be integrating the RxEvent reporting into their EHR applications.

Pinehurst Dermatology (NC) contracts with SRS for its EHR solution.

ABEL Medical Software announces a OEM program for resellers interested in selling its ABELMed EHR-EMR/PM product.

Mitochon Systems partners with CollaborateMD to offer Mitochon’s free mEMR product with CollaborateMD’s PM solution.  Like Practice Fusion, Mitochon’s model displays ads within the application’s workflow.  Meanwhile, CollaborateMD claims a solo physician can spend as little as $7 a day for unlimited claims processing, electronic remittance, and patient eligibility.  Call me a skeptic, but  I have to wonder what’s missing in that $7/day solution that includes EMR and PM.

NaviNet introduces NaviNet Mobile to allow pharmacy benefit managers to deliver patient medical information to physicians via handheld devices.

Physician compensation grew for some specialties in 2010 and decreased for others. For example, emergency medicine compensation increased 5.6%, while urology income fell 4.66%. Median compensation for family practitioners was $189,402; invasive cardiologists averaged $500,993.

A Robert Wood Johnson Foundation report finds that 51% of office-treated diabetics in Cleveland received all the care they needed from practices using electronic medical records vs. 7% from paper-based practices. A similar correlation was found for diabetic outcomes.  Mr. H mentioned in HIStalk not being able to find the study methodology, but I dug a little and found this report by Better Health Greater Cleveland. There is a fair amount of difference in the demographics between the EHR practices and the paper practices, with the paper practices including a heavy number of non-insured and Medicaid patients (69.9% compared to 15.8% of the EHR practices.) The paper practices were also twice as likely to have non-white patients (86.5% compared to 43.9%.) When you take those facts into consideration, the EHR-diabetes care correlation does not seem as strong.

In 2009, the number of paid malpractice claims reported in the outpatient setting was similar to inpatient numbers, suggesting medical mistakes are almost equally common in the two settings. The authors of the NEJM-published study recommend more patient safety efforts in the outpatient setting,  including the implementation of e-prescribing systems and EMRs.

HIMSS Electronic Record Health Association (ERHA), a trade association of 46 EHR vendors, submits generally favorable comments on the proposed ACO rules. No doubt the opinion was influenced by the EHRA’s acknowledgement that ACOs will require robust IT infrastructures. The organization recommends that CMS reduce the required threshold for EHR meaningful use providers from 50% of primary care providers to 25% of all EPs. In addition, EHRA urges CMS to reduce the requirement for quality measurement reporting from 65 items to 20 or fewer.

E-mail Inga.

Practice Wise 6/15/11

What if …?

I don’t like the term disaster recovery. When I try to discuss this with customers or in presentations to practice management groups, nobody likes to think of a disaster striking where they live and work. So they don’t do the work they need to do to prepare a Disaster Recovery plan as part of a Business Continuity Plan.

In light of the past months of natural disasters both near and far, this topic is at the top of mind for many.

A disaster recovery plan is an instrument that documents the actions to be taken before, during, and after a disaster. A disaster is any event that interrupts your routine business operations. The primary objective of disaster recovery planning is to protect the organization in the event that all or parts of its operations and/or computer services are rendered unusable. Good planning should minimize the disruption of operations and ensure some level of organizational stability and an orderly recovery after a disaster.

A well-executed Disaster Recovery Plan should:

• Provide a sense of security
• Minimize risk of delays
• Guarantee the reliability of standby systems
• Provide a standard for testing the plan
• Minimize decision-making during a disaster

Last month I was struck by an image on the news. A few medical practice staff (identified by their cheery scrubs) sifting through the wreckage of their clinic in Joplin, MO, pulling out paper charts and handing them off in an assembly line. I know of another clinic in Joplin who is on EHR that is hosted by an ASP. The doctors were able to fire up their laptops from home and contact all their patients letting them know that the clinic was out of commission and give them instructions for their immediate needs.

This is the most extreme form of disaster, and even the best disaster recovery plans can be thwarted in the face of an act of God. If you have one, it is a step towards restoring normalcy. I was struck that the medical staff were wearing their scrubs, their need to retain a sense of normalcy.

There are daily smaller events that interrupt business continuity. When these smaller events disrupt production, they frustrate staff and patients alike. I prefer to help practices write their “What if ___?” plans. It’s easier to imagine the small business disruptions and build on those for a more comprehensive disaster recovery plan as part of your business continuity plan.

For instance, a practice I was at this week had printer issues on a global level, as if the printer gods were conspiring against them. Nobody could print to any of the four printers in this one doc office, for all different reasons. They didn’t have a “what if” the printers don’t work plan.

Everyone was in a panic. Front desk couldn’t print patient forms that required signatures. Back office couldn’t print prescriptions, chart notes, or lab requisitions. They were taking their angst out on each other. Nobody could see through the “disaster” and find a working solution.

How do we help practices write these plans? It can seem a daunting task when you think about the global issues all at once. I recommend taking a less global, high tech approach and take it back to basics:

1. Create a What If _______, how will I_____? document and distribute it to each person in the practice
2. Have them fill in the blanks for each task that they do for a period of a few days or a week so that all their tasks are adequately captured. It’s important to capture as many tasks as possible, no matter how small, because when the process is broken, the smallest task can become a big issue.
3. Have your internal and/or external IT support people do the same.
4. Have your software vendors do the same.
5. Have your other outside vendors and partners do the same (e.g., your bank — if you scan checks to deposit and the deposit scanner or Web site is down, will they send a courier to pick up your deposit?)
6. The compliance officer (sure we know, all small practices have someone with this title!) or the person who is responsible (practice administrator/manager) for daily operations should compile these documents into a comprehensive business continuity plan. For some, this might be, filing them in a binder and calling it a plan. For others, it will be much more comprehensive. There are many excellent websites that offer free disaster recovery and business continuity plan models.
7. DISTRIBUTE the plan! Make sure everyone in the practice has a copy and an electronic copy is stored somewhere off site that you can access if your practice is down. There’s no point in creating the plan if everyone in the practice does not have immediate access to it.
8. TEST the plan. There’s no point in going to all this effort if you don’t know if the plan will work in the face of a disaster. There’s a reason we had all those fire drills when we were in school!

My husband was on the aircraft carrier Nimitz somewhere out in the vast ocean when there was a deck fire. Now when you are out in the ocean, too far away for anyone to come to your aid, and the planes on deck are on fire and blowing up, you have a life and death disaster at hand. He was asleep when the alarms sounded and said he was dressed and up on deck manning his station before he even knew he was awake.

They had prepared for this type of event over and over again, and groaned and grumbled all the time about the hassle of the training drills. But as they were pushing jets off the deck and fighting fires, he realized that all that their continuous training made their reactions in this crisis automatic, and saved the ship and the many lives aboard.

Hopefully none of us will ever face this type of life and death disaster. The point here is to not make this so daunting a task that you avoid it at all costs. Disruptions small and large are just that – disruptions. They can be not just events that cause anxiety, but also a liability for the practice. We can use all kinds of fancy buzzwords and language around the development of a comprehensive plan, but why not keep is stupid simple (KISS) and get the job done?

Don’t wait for a natural disaster or a Zombie apocalypse to think about disaster recovery and business continuity planning. Every day presents us with what if scenarios that we can easily plan for in advance. Start your What if ___? plan now!

Julie McGovern is CEO of Practice Wise, LLC.

News 6/14/11

The ONC names the American National Standards Institute (ANSI) the sole authorized accreditor for EHRs under the permanent certification program.  The temporary program will be sunset at the end of 2011.

The American College of Clinical Information Managers launches itself as a non-profit accreditation organization for medical scribes. The certification process includes testing, proof of employment as a scribe, and a $250 fee, which will be waived through the end of this year. I am not sure if certification will make much difference for scribes working in physician offices, but at least the fee seems reasonable.

The 20-physician River Falls Medical Clinic (WI) attests for Medicare incentive funds for its meaningful use of Cerner’s EHR. The clinic’s medical director says that 70% of the physicians in his area are also on EHRs.

Vermont IT Leaders, the REC for Vermont, announces that 750 primary care providers have signed up to receive EMR adoption assistance. That’s about 75% of all of Vermont’s primary care providers.

The Louisiana HIT Resource Center names SuccessEHS a supported vendor for its REC.

Less than one-third of physicians are expected to remain independent by 2013 as they continue to sell their private practices to healthcare systems. The attraction of larger health systems include greater access to leading edge HIT, facilities, and equipment; a more manageable work schedule; and increased financial stability.

Steven T. Plochocki, CEO of NextGen’s parent company Quality Systems, is named Outstanding Technology CEO in TechAmerica’s 18th Annual High-Tech Innovation Awards.

MedeAnalytics releases a report that summarizes the public comments on the ACO proposed rule. The bottom line from seven national healthcare constituencies, including the AMA, AMGA, and MGMA:

• The ACO program, as proposed, needs revision, not repeal.
• The 65 quality measures in the proposed rule need to be reduced, perhaps to 32, and should include a phase-in period.
• Financial terms need to be more attractive with a standard, minimum savings rate and the elimination of the withhold.
• CMS needs to create a separate model without downside risk.

E-mail Inga.

DOCtalk by Dr. Gregg 6/10/11

HIGH Tech Support

Ohio Medicaid went live last week with their HITECH EHR incentive program, MPIP. Signup availability was announced on the morning of June 1 and I happened to be sitting there when the e-mail came through. So, as I had already done the preliminary stuff at the federal level (which was itself a pretty easy process, I should add), I went straight away to the MPIP link to get on board.

The site was laid out pretty well overall. The process of signing up seemed easy enough. I already had the basic info: identifiers for me, my EHR, and my aforementioned recently-created CMS account. I needed to generate some figures for total number of patients seen during my chosen three-month reporting period, plus determine the number of those patients who were Medicaid insured. Not too hard to gather.

Once I had those numbers generated (and after I had a good, long cry about the fact that my percentage of Medicaid during that chosen period as a walloping 48% !!!) I finished out the process following all the “fill in here” slots and “you are required to do this” red asterisks. When completed, I submitted it … and it went through!!!

Oh,no … wait. Though I did have all four progress areas turn green with a “Completed” check mark, the end summary said I was still “In Progress.” Does that mean it’s “in progress” on their end, or that I still have some unfinished piece of info yet to addend? It wasn’t clear.

I went to their Help section and FAQs, which were actually just links to PDFs. I tried, but my ADHD wouldn’t let me go too long within the many, many pages of their PDF “help” tool.

I could wait, but if it was something on my end, that’d mean unnecessarily delaying my Incentive check. With my 48% Medicaid, you can easily understand why I might need that check sooner rather than later.

I decided to call the support line listed on the MPIP web site. Not unsurprisingly, they were a little busy and weren’t able to take my call right then. I left a voice mail and figured it may take a day or three to hear back. Patients were beckoning, so I left it there.

Later in the day, it crossed my mind that as a member of the board of directors of OHIP (Ohio’s HIE/REC), maybe I should notify some of the important folks there who may want to let folks at MPIP know there might be some glitches worth addressing. I mean, if it wasn’t apparent to me, and I have a bit of an inside track on all this, then I bet others might also find the process a little unclear. So, I e-mailed and/or called a couple of the good folks at OHIP who seemed to appreciate the insights.

A little surprisingly, late in the afternoon I received a call back from MPIP support. A wonderful fellow, Aaron, said they had indeed been busy that day, but he nonetheless took time and listened to each of my concerns or problems. We walked through the process together, I showed him where it appeared confusing to me, and he made notes. I told him I couldn’t tell if I was complete on my end and he assured me I couldn’t be, as they did not yet have anyone in the pipeline for payment.

I told him about the one non-asterisked item I had not submitted since it didn’t appear required. He said, “Let’s try it,” and … VOILA! My submission then popped up on their end as “ready for payment”! WOO HOO!

I hadn’t mentioned to Aaron that I was on the OHIP board until well into our conversation and he had not received any word from any of the OHIP folks I had contacted. Thus, his kind and helpful demeanor was unpretentious and un-persuaded. Ya’ gotta love that in IT support.

Then, within two days of the MPIP help desk call, I had the fun of spending hours and hours with the support folks at two large vendors of wireless routers and the support folks at my ISP vendor, a giant in — or should I say AT? — the telecommunications world. From these three technology firms, I received only attitude, runaround, and resolutionless aggravation.

Tech support calls often a feel like connecting with soulless, uncaring seat-fillers who would rather be somewhere else doing something, anything, else, especially if you have no established relationship with them. But, not always. Not with Aaron at MPIP. He’s high end, HITECH support. I thought he deserved a mention.

Thanks, Aaron. Keep it up.

From the trenches…

“There are no traffic jams along the extra mile.” – Roger Staubach

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).