Special Contribution from Darrell Ledbetter of Gastorf Family Clinic

Darrell Ledbetter, CPM, is practice manager for the two-physician Gastorf Family Clinic of Durant, OK. On January 4th, the clinic received a $42,500 EHR stimulus check for Meaningful Use of its EHR.

We are very elated to be among the first to be paid the EHR incentive. We worked closely with our Regional Extension Center (REC), the Oklahoma Foundation for Medical Quality (OFMQ), to prepare for the Meaningful Use of our EHR.

The REC initially came to us and said that they were here to help us meet Meaningful Use and that they were at our disposal. Our HIT practice specialist, Crystal Plata from OFMQ, brought information to our clinic that specifically plotted out what we needed to meet the Meaningful Use criteria. It spelled out the core objectives, measures and threshold numerators, and denominator exclusions required for us to obtain Meaningful Use.

We are partnered with e-MDs as our electronic health record. The e-MDs Solution Series version 7.0 was CMS certified on November 12, 2010. After attending the
e-MDs User Conference in July 2010 and attending the classes at the conference on Meaningful Use, it was fairly clear that we needed to work hard to begin ensuring our clinic could facilitate meeting those requirements.

The staff at e-MDs is very knowledgeable and the support center is wonderful. The final rule on Meaningful Use was, of course, not final at that point, but e-MDs had staff that was very involved with establishing those criteria.

We wanted to be on the front lines of the Meaningful Use, so as soon as we found out that the new version of e-MDs Solution Series was certified, we contacted e-MDs to ask if we could be a beta clinic for pushing out the new version. As always, the staff of e-MDs was very accommodating. We received the new version the last week of December and were able to meet Meaningful Use by January 1.

We were contacted by the Oklahoma Health Care Authority in mid-December and were asked if we would mind being the first clinic to get paid with the EHR incentive. Carter Kimble, public information specialist with the Oklahoma Health Care Authority, called and stated that our clinic’s name kept coming up as being on the cutting edge of meeting the Meaningful Use requirements through different agencies within the state.

So with that in mind, we really wanted to push forward and meet the requirements as quickly as possible. We wanted to assist the OHCA in getting the information out that there really was money out there for the program, and encourage other providers to participate.  We really feel that this is a worthwhile program, and pushing forward with the Health Information Exchange will be very beneficial to providers nationwide.

As soon as the CMS registration opened on Monday, January 3, 2011, we submitted our registration online. We then completed our patient volume documentation, showing that the patient care volume was greater than 30% Medicaid recipients. With that information, we knew that we would meet the criteria for participation in the Medicaid EHR Incentive program.

We then, with the assistance of the OHCA, completed our Registration and Attestation with the OHCA on Tuesday, January 4, 2011. Having documented and completed the requirements for upgrading to an EHR that had been certified to meet Meaningful Use, we were then presented with a check on Wednesday, January 5th. The actual funds will deposit directly through electronic funds transfer next early next week.

The initial investment in the EHR  software was five years ago, which was $26,652. Each year we have licensing fees of close to $7,000.00. This does not include the computer equipment, hardware, etc. We have 12 computers with the software on them, either laptops or desktop workstations. We have ordered a new server to upgrade our system, which will cost $6,500, and periodically have to replace other workstation computers or laptops, add memory, etc. 

So basically, this initial check will almost pay for the initial investment. If we continue to meet Meaningful Use, hopefully we will be eligible for the incentive payments for the next five years.

News 1/13/11

Practices that spend more operating expenses on IT are better performing than their peers in terms of profitability and cost management. That conclusion comes from MGMA, based on the results of its annual Cost Survey report.

Take those findings and consider the results of this recent Practice Fusion-sponsored survey. Forty-one percent of small to mid-size practices report they are doing worse this year compared to last, though 26% say their practices are doing better. HIT purchases, anyone? The Practice Fusion-sponsored survey was based on Internet responses from a mere 100 physicians, so it’s a bit hard to gauge the relevance of the findings. However, these results ring true: physicians say their top worries are practice administration issues, insurance and reimbursements, and difficult patients.

Speaking of Practice Fusion, I attempted to send an e-mail blast for my interview with CEO Ryan Howard on Tuesday. I messed up, so if you got a worthless link, my apologies. In case you don’t know much about Practice Fusion, it is one of the free EMR alternatives on the market and Howard was very forthcoming with details of its unusual model. Worth a read, if I do say so myself.

meridianEMR says it has signed on 1,000 urology providers for its EHR. The company added 85 new providers in December, including 28 from Urology San Antonio.

SynerMed, a 7,000-provider member MSO in California, aligns with athenahealth to offer preferred EHR services to members at a negotiated discount.

The Healthcare Billing & Management Association announces new officers and board members, including President Jackie Willett of Intermedix.

The California Health Information Partnership and Services Organization (CalHIPSO) says that it leads the county in REC enrollments with over 3,000 California primary care providers. CalHIPSO is tasked with assisting 6,187 primary care providers achieve Meaningful Use by 2014.

Radiology Associates of Sacramento adds Merge iConnect, giving providers the ability to view current and historical images from any application that stores an image.

The US Supreme Court upholds an IRS ruling that requires medical residents to  pay Social Security taxes. Mayo Clinic argued that residents are students and are thus exempt from Social Security withholding. The court disagrees, finding that medical residents are full-time employees. Taxing 100,000 medical residents, who typically earn about $50K a year, will bring in about $700 million annually.

HHS is working on an interactive dashboard to track the performance of RECs and allow them to share best practices.

The 15-physician Central Florida Pulmonary Group contracts with ChartLogic for its EHR Suite, including a patient portal and mobile application.

There’s a communication gap between primary care physicians and specialists, according to a Center for Studying Health System change study. Though almost 70% of primary care physicians claim they usually forward a patient’s history to consulting specialists, less than 35% report receiving the information. And, 81% of specialists say they almost always send back consult reports, but only 62% of the primary care docs receive them. Specialists using HIT were more likely to report receiving and sending consult reports, though curiously the same pattern wasn’t seen among primary care doctors. Kind of makes you wonder if insurance companies really don’t get some of those claims the first time.

Seacoast Radiology (NH) issues a press release saying an office server containing personal patient data and billing information for 231, 000 patients was hacked last November. Turns out that the likely culprits were rogue gamers looking for bandwidth to play the military video game Call of Duty: Black Ops.

E-mail Inga.

HIStalk Practice Interviews Ryan Howard, CEO and Chairman, Practice Fusion

A few weeks ago, I asked Practice Fusion to provide clarification on their number of users. They were forthcoming, and initially provided this response:

• We currently have a bit over 50,000 users and 5 million patients on the system.
• About 40% of those are MD/DO level users.
• The remaining 60% are in the NP/PA, nurse and staff categories.
• We bring on 200 new users each day and 500,000 patients are uploaded to the system each month.
• The list is regularly scrubbed of accounts that match specific inactivity criteria.
• We track activity level closely based on a couple different metrics. Mostly how many patients they have imported to their account and how many charts they’re pulling. We would be able to see that they were inactive because there weren’t any chart pulls. When account is scrubbed from our system for inactivity or by request, we don’t count their patients in our stats.

This information led to more questions. I spoke to Ryan Howard, CEO and chairman of Practice Fusion of San Francisco, CA.

I had sent over a number of questions and understand that you actually wanted to go over the questions over the phone rather than e-mail. Do you have those?

I don’t have them in front of me. We can definitely go through them. The net is that I did see them, so I am familiar with what you are talking about, and more than happy to answer questions.

I’ll be really transparent. With sharing our numbers, there’s going to be a balance of (1) my ability to run my business, and some things are strictly confidential, and (2) what’s standard in the sector. Some of your questions definitely dug deep and, I mean, I would just push back and say, “Of those questions for each of our competitors, what do you know?” This level of detail isn’t commonly shared, so, what I’m asking in advance is to take that you into consideration. I’ll give you what’s appropriate. We’ll dig a little deeper than I usually would.

Sure. I guess the biggest two areas of questions really have to do with the number of providers using the system and number of providers getting on. And based on some of the information you had sent over, the numbers just didn’t add up for me, so I just wanted to get a handle on that. The numbers I was given said about 40% of your users are MDs or DOs, which doing the math, I would say equates to about 20,000; and that you’re bringing on a total of about 200 new users a day; in other words, about 80 new providers a day. I was just trying to understand if my math was correct. If you back out 80 new providers a day, the numbers suggest that you’re adding 29,000 new providers a year, which doesn’t quite sound right if you only have 20,000 total providers. I’m just trying to get a feel for the actual number of doctors today and how many are being added. And then, how do you actually count a provider? Are they actively using the system and how is that math done?

What you need to keep in mind is the cadence of our growth has changed over time. From a static perspective, Practice Fusion is currently bringing on about 200 users a day.  It’s a little over that. Now about six months ago, we weren’t, though, right? Or a year ago we weren’t. So our velocity is faster at any given time. If you look at our growth curve, it kind of looks like a sloped hockey stick.

In 2010, we had around 500% growth on the physician side and on the patient side and on the volume side. Through our platform, we see about 1.3 million patients a month. That specifically means that doctors and practitioners on the system are seeing and pulling 1.3 million patient charts a month.

OK.

The net is that the data is accurate. I stand by those numbers, they’re right. Six months ago we were probably bringing on 100 users. Right now it’s more like 230 users a day to 250.

And a “user” means they’re actively going in, documenting charts, that type of thing? They’re not just loading it on there and testing it out?

There’s always a long tail of users testing the system that aren’t officially active. We only count an active user as a user that is actually seeing a specific benchmark of patients.

One of the things that’s interesting is that we know historically that two-thirds of all enterprise installations just fail. There’s a safe assumption that two-thirds of what other Big Iron vendors say about their user numbers is inaccurate. There are systems that have been abandoned, there’s been attrition, or users didn’t have successful implementations.

Because Practice Fusion has one Web-based, SaaS-based platform, I can pinpoint instantly how many users we have in our system. Internally, we have reports that the system outputs every single day and we know how many users were on Thanksgiving Day, how many users are on right now, and no one else — not many other guys — can do that.

The other thing I don’t talk about a lot is that we decommission any account that hasn’t been active within six months. There are rules around that in the system and there are some exceptions – we don’t just lock away an account that might be activated. For the sake of having sound data around the metrics, we have a process where, let’s say you logged in the system, you kicked the tires and you no longer wanted the system or you just didn’t use it, we would decommission your account. So our actual registered user number for this year is larger than what we reported. You have to factor in the decommissioned accounts. I would guess that takes a lot of the hyperbole out of the numbers for you.

Basically we left 2009 with 25,000 users. Forty percent of those guys were practitioners, so 10K practitioners, that sounds right off the top of my head. And then we’ll walk out of 2010 with about 60-65,000 total users, and again, we’ve maintained around that 40% number, so it’d be more like between the 24 and 28,000 practitioner number.

I was also looking at the number of patients. Do you have any feel for roughly how many patients a provider sees on a daily basis? Because, the numbers I received indicated something like a half a million patients being added per month, which is 16,500 patients per day; which came out to be about one new patient a day per provider. The math didn’t quite work there. I’m wondering if you have a feel for how many new patients a day a provider sees?

The numbers that we gave you were what was reported in our press release, that we’re currently adding about half a million patients to the system each month.

Right.

So I think again it kind of goes back to your original question. Our growth rate has not been consistent through the entire year; that is has increased significantly. So just to do a straight division on that doesn’t really make sense.

OK. About how long does it take do you think your average provider to get up and running live? What’s the average go-live time?

The go-live time is a little over a month right now, and we spend a lot of time on analysis to make sure that users are getting better at it. It generally depends on the user’s aptitude, but across the board, it’s about 30 days. It’s doing a go-live, it’s become fully active, it’s seeing 100 patients. That is our definition.

Seeing 100 patients?

There’s some different rationale around that number. Once the user has seen 100 patients, there’s a wide belief internally — based on analysis and product managers spending time with the users and our implementation team’s insight — that that user has mastered the system. They know it inside out. They don’t need any further training. The flip of that is that from the data side we know that the attrition rate at that point becomes single-digit percentage, so the user knows the system so well that they’re not just kicking the tires anymore because the data showed that.

And, if a provider wants to discontinue using the service, can they get an electronic version of all those patient records and any chart notes they’ve done?

So, if it’s only just inactive – they registered and they didn’t put any real data in the system – then we decommission them and then we give them a notification. Now, if someone has data in the EHR, we have a bunch of different methods for them to get their data out of the system. But if someone’s only put a few patients in, we generally will have a conversation with them and we’ll make sure that there’s no data in the system and we can export anything that has been entered. We can and we do export data, but my point is that generally a user who decides to leave hasn’t entered anything real because they are in the evaluation stage themselves.

Do patients’ charts stay on the system indefinitely? Do you ever take them off?

It’s a case-by-case scenario.

OK. One of the things I also noticed looking at your Web site is that your EHR is currently has modular certification as opposed to the complete certification. Are you helping clients get the additional programs they need to meet Meaningful Use requirements or do you anticipate getting full certification?

We’re 100% committed to full certification here at Practice Fusion. It’s listed all over our Web site and all of our users are up to date on that. So, modular certification for us is just the first step.

I know you’re privately held, but at what point do you anticipate the company will become profitable? I mean, with 500% growth, that’s pretty tremendous growth.

We don’t disclose any financial information, sorry. Unless you want to invest. And then if you want to invest, we can.

I have a spare million – I might.

Perfect. You’d be my best friend.

Good. Is there any other information on the company or what you’re doing that may be able to shed some light on your secret sauce and how you guys are operating?

We stand behind “what you see is what your get.” I think there’s a German philosopher that said… one of his old quotes was along the lines of, “All truths are violently opposed, ridiculed and then widely accepted as the truth.”

We’re doing something that’s counter-intuitive to the market, right? I mean the traditional EHRs that are available today, they’ve been there for 20 years. There’s nothing different, nothing innovative between Allscripts, eClinicalWorks, and almost any other vendor you look at.

What we do, again, is sort of counter-intuitive. It’s directly aligned with all the major initiatives today. All the data is in one central system. Data can be shared doctor to doctor real time. Patients can access the data very quickly in their own personal health record. The data can be queried; answers are within the data and the database. And what we’re doing is really unique on – not just the architectural model – on the business model as well and it’s incredibly progressive.

The sector is obviously upset by it, it’s disrupting the status quo and it’s real… I have more physician quotes – I can send you hundreds of quotes and hundreds of references. So the proof’s in the pudding. What other vendor can do that? I can literally share more people with you who are happy with us than any other vendor.

So, you and I can talk all we want, but I like let the community speak for me. It’s been a really incredible ride and we’re really excited about it and we think next year it’s going to be really, really interesting becoming the de facto standard.

Actually, I do have one other question. As a provider, is there anything I pay to Practice Fusion out-of-pocket other than if I want to have the version that doesn’t have the ads?

Nope. That’s it. It’s the philosophy on my side is to keep the product entirely free. As long as I’m leading the company, the product will always be free.

This may be a question you can’t answer, but how many providers, percentage-wise, take you up on the offer and actually are willing and able to pay for the no-ad versions?

[Laughing] We will never, ever tell that, sorry.

Never, ever, OK.

Never, ever, ever. It’s such a cute number, too. I told you you’d be captivated by it, but my background’s psychology. Human behavior’s great, and it’s just so telling. That one piece of data you can tell so much about the market, but I just can’t do it.

News 1/11/11

From Matt Cassell: “Re: Cerner Ambulatory. Great article on Cerner PowerWorks products. I think you’re right on target with your overview. I sold the product for over a year and I even spent time with Dr. Goldstein a few times in his office. Nice work.”  Thanks, Matt. The Cerner folks, by the way, said they would be responding to a couple of the comments and questions posted by readers.

Greenway Medical Technologies selects DiagnosisOne to provide clinical decision support for its EHR deployments.

Pulse Systems is named a solution partner for Virginia HIT, the REC for the state of Virginia. I tried to figure out the names of other selected vendors, but couldn’t find any details on the REC’s web site.

Gastorf Family Clinic (OK) is one of the first practices in the country to receive an EHR incentive check. The two-physician practice, which uses e-MDs’ EHR, was issued a check for $42,500 just two days after registering for the HITECH program.

Speaking of HITECH registration, CMS says 4,000 providers registered for EHR incentives in the first four days after its site went live on January 3.

Nuesoft Technologies announces the availability of Nuetopia, a service that combines EHR and medical billing software with RCM expertise. Nuesoft says practices should anticipate a 10% increase in net payment by subscribing. Nuesoft, by the way, is a HISsies nominee for Most Fun HIT Vendor. They certainly make some fun videos, like the one above, featuring Tony DaLuzza, aka “Tony Two Times.”

Billing and practice management service provider AdvantEdge Healthcare Solutions acquires competitor AMSplus, Inc., a division of CBay Systems.

WebPT, an EMR used by about 5,000 physical therapists, closes on $1 million in Series A VC funding. WebPT intends to use the funds to expand its product development, sales, and marketing teams and to build up its support infrastructure.

The Doctors Clinic (WA) launches Sage Healthcare’ patient portal, giving patients access to their medical records and supporting online appointment and prescription refill requests. The 80-physician clinic is implementing Sage Intergy EHR.

The Connecticut State Medical Society estimates that almost 40% of its doctors are now using EMRs, with larger practices leading the charge. Cost remains the biggest barrier. The medical society’s president predicts more smaller practices will consolidate or join larger groups in order to  afford new technology.

Please join me in shouting out a virtual hello to HIStalk Practice’s newest Platinum sponsor, Emdeon. The Nashville, TN-based company provides revenue and payment cycle management solutions that reach an impressive 340,000 providers, 5,000 hospitals, 600 vendor partners, 1,200 payers, 60,000 pharmacies, and 81,000 dentists. That’s more connections to payers, providers, and vendors than any other healthcare business. At HIMSS last year, Emdeon had the Harlem Globetrotters shooting baskets in the center of the booth. At MGMA, they partnered with an alligator conservation group and sponsored photo ops with an alligator (which I took advantage of). In other words, they strike me as a fun and creative bunch, which is exactly the kind of sponsor we love. Thanks, Emdeon, for your support!

A healthcare attorney shares some advice for physicians contracting with vendors for new technology. Some of the details he recommends to be spelled out include include who owns the  copyrights for customized software; defined dates for delivery and proof of operability; specified time periods for vendors to fix problems, as well as the consequences for missing deadlines; expectations for support response times and upgrades; and who holds the source code for any software in escrow. Plenty of vendors don’t like lawyers like him since it slows down the closing process and makes everything more complicated.

 E-mail Inga.

Intelligent Healthcare Information Integration 1/7/11

2011: Here We Go…

Ok, the New Year is here, and along with it, the onset of the deluge of EMR adoption resulting from ARRA/HITECH/Meaningful Use. Right?…Right?

Well, as the old Chinese philosopher said, “We’ll see.”

While I’m a huge fan of all this high tech mumbo jumbo and its associated doohickeymabobs, and I think, at least in Ohio and maybe another state or two, the RECs will be doing some bust-their-humps work to get docs online and digitally engaged, I’m still personally very inclined to agree with the aforementioned unnamed Chinese guru. It’s gonna be an interesting next few years in HIT-dom.

Meanwhile, patients keep coming and docs keep doctoring and my colleagues and cohorts at OHIP’s REC (Ohio’s primary REC) keep slaving away to try and figure out how to get all of us in healthcare, providers and patients alike, into not just the New Year, but finally into the current millennium.

And, me? I believe that this is all heading the right direction. It is way more complicated than most HIT sales folks want potential buyers to believe, but it is totally doable. And, it is totally worth it – even if your vendor leaves you seeking a new EMR just when you thought you were really getting into a good groove (…he said, with only the slightest hint of snark).

Back out on the EMR hunt, I remembered a tool I first became familiar with well after I had already started using an EMR. It’s a tool designed to help providers evaluate their practices’ current state of readiness, calculate the strategic workflow changes necessary, and guide the resulting EMR/EHR selection process. No, it really isn’t designed to be used for those practices that are already digital and which are considering a jump to a different system, but I wondered if the insights it provides might be helpful nonetheless.

I learned it back in 2009 when its primary visionary brought it to my attention at that year’s Pediatric Office of the Future exhibit. He asked me to take a look and provide comments. I became a big fan, but primarily from an academic perspective as I didn’t really need direct help from the tool, but felt many of my non-tech-infatuated colleagues might. It seemed to provide all of the better parts of an HIT consultant service, but at much lower cost and at a self-determined pace.

So, remembering its design, I decided to step back and look at this tool with my own needs in mind.

The short take? I’m an even bigger fan. I have discussed a few ideas with the developers some redesigns they might consider for future iterations to direct a side-path for practices seeking to change not from paper to EHR, but from EHR to EHR. Nevertheless, a more intimate deep dive into this tool has me decidedly happy with my decision to look at it from my “new needs” view.

It isn’t designed to be all things to all people. It doesn’t cover all the potential EMRs and EHRs out there. It doesn’t even try. (Would you?) But it does help providers, especially small practices, consider many of the ramifications and decision points necessary when considering a transition to an EHR, whether newbie or veteran. And, it does so in a very cost-effective, time- and workflow-conscious fashion.

The tool? Welch Allyn’s EHR Prep-Select. I can’t say it’ll be all things to all providers heading down this EHR hunt road, but I can say – with even more personal insight than ever – that it is one of my favorite recommendations when colleagues ask me about ways to help prepare for digitization.

“May all your troubles last as long as your New Year’s resolutions!” – Joey Adams

Dr. Gregg Alexander, a grunt in the trenches pediatrician, directs the “Pediatric Office of the Future” exhibit for the American Academy of Pediatrics and is a member of the Professional Advisory Council for ModernMedicine.com. More of his blather…er, writings…can be found at his blog, practice web site or directly from doc@madisonpediatric.com.