News 8/3/10

Interesting data point: private physicians choosing to participate in the Nebraska Health Information Initiative (NeHII) pay about $20 a month to view the database. For $52 a month, they can add e-prescribing. Sounds reasonable.

Tech Data Corporation becomes the latest distributor to offer Greenway Medical’s PrimeSuite solution. Tech Data will make the solution available to its network of thousands of IT resellers nationwide and Greenway will provide the implementation and ongoing support.

EyeHealth Northwest (OR) signs up for NextGen’s EHR and PM for its 11 offices and 30 providers. NextGen says its recently added 18 other ophthalmology clients and now has about 5,000 ophthalmologists and 500 ophthalmology practices using its software. By the way, here are Q1 numbers from NextGen parent Quality Systems: revenue up 24%, EPS $0.42 vs. $0.36, missing on consensus earnings.

The Kansas Academy of Family Physicians collaborates with Welch Allyn to offer its 1,500 members access to Welch Allyn’s EHR Preparation and Selection program. In addition to access to online tools, members will be eligible for special pricing on professional services from Welch-Allyn.

And if you’re in need of a new practice management system, the AMA and MGMA are offering a new online tool kit entitled, “Selecting a Practice Management System.” I wanted to check it out, but looks like both organizations have it in members-only sections . PM vendors can apply for inclusion in the online directory.

To your right: a link to FierceEMR. Mr. H and the Fierce Folks are testing the waters to see if trading links attracts one another’s readers. I like several of the Fierce publications, so take a look if it suits your fancy.

Oncologists will soon have access to evidence-based treatment guidelines at the point of care, thanks to a new partnership with the National Comprehensive Cancer Network and decision support vendor Proventys. The Web-based Proventys CDS Oncology automates the NCCN clinical practice guidelines within clinical workflows.

AirStrip Technologies receives FDA clearance to market its Remote Patient Monitoring solution, including RPM Critical Care and RPM Cardiology. The products allow providers to see vital signs, waveform data, and other clinical information from their smart phones.

While speaking before the House Energy and Commerce Committee’s Subcommittee on Health, AAFP President-Elect Roland Goertz, MD speaks in favor of HITECH grants and technical support for small and rural practices implementing health IT systems. Goertz also asked the committee not to make additional requests of physicians while in the midst of this EHR transition period and asked legislators to consider delaying the required adoption of ICD-10. Bet we’ll be seeing more leaders come forward to ask for an extension of the ICD-10 deadline.

Twenty-one Albany, NY-area pediatric and family practice groups are selected to share a $1 million investment in CDPHP’s medical home initiative. The physician-owned health plan CDPHP picked grant recipients based on their demonstrated their use of EMR and e-prescribing, as well as practice leadership and culture.

athenahealth, iSALUS Healthcare, and MDLand are selected as the preferred vendors for the Indiana Health Information Technology Extension Center (I-HITEC).

This survey suggests that 94% of physicians use smart phones, a figure I find hard to believe. However, there is no arguing that physician smart phone use is on the rise: the same group estimated 59% of physicians used smart phones about four years ago. My phone of choice (the iPhone) was preferred by 44% of the doctors, while 25% liked the BlackBerrry. Not surprisingly, most physicians say they are overwhelmed by the daily volume of communications received by colleagues and patients. I feel their pain.

E-mail Inga (I like pain.)

Intelligent Healthcare Information Integration 8/1/10

EHR Speak

Recently, I learned that a friend, someone whom I admire and highly respect, was dealing with the impending loss of a parent. Combining that with some of my own recent life difficulties, both at home and in the workplace, it got me to thinking about the one truism I have noted when it comes to the really tough life experiences we all endure: there are no magical words of wisdom, no empathizing phrases that really help.

Indeed, most of those often well-intentioned clichés usually sound trite and often even minimize the emotional suffering of the sufferee. They may be the expressee’s way of trying to show support, but beyond “That really sucks” and “I’m here for you,” nothing much else conveys the meaning which may have been intended. They may make the expressee feel as if they’re trying to help, but they often result in making the sufferee feel worse. (I’m betting that any of you who have experienced loss or major life trauma know just the phrases of which I speak, so I’ll forego examples.)

My perverse, geekoid, HIT brain, of course, took this melancholic consideration and immediately made a connection with the world of EHRs. (This is actually sort of sad to admit, that I find HIT-ness even in the face of human suffering…I really need a vacation!)

Here’s sort of how the neuronal path went: 

• Saying what we mean and having what we say actually provide the information – and especially the intended meaning behind it – is often quite the challenge.
• I notice the same difficulty in the electronic medical record reports I receive from other providers.
• From one particular emergency room, I used to get five-page EMR-generated reports to tell me that a patient was seen for an ear infection, prescribed amoxicillin, and told to follow up with me in two weeks.
• From that same ER, I now get two-page EMR-generated reports about a child who presented with skull fracture, cerebral contusion, and seizure-like activity who was admitted to the hospital and the amount of info is about as limited as what is in this sentence.
• Formatted, templated, pre-made medical descriptives seem about as adequate as the pre-made clichés so many people try in trying times to convey their sympathies over someone’s personal loss or other tribulations.

So, what does work? (For medical info conveyance, not personal sympathies.)

Thinking back, the best descriptive, by far — by leaps-and-bounds far — which I ever receive about patient-provider interactions come from the dictated narratives, most typically from consulting specialists. They may have basic formatting, often following SOAP note style or some variant thereof, and they provide a colorful picture, a conceptualization complete with supporting details and even the thought patterns which led to the diagnoses and/or treatment decisions.

If there is vagary (which is still so frequently unavoidable in medical evaluation and diagnosis,) that is also conveyed with the reasoning which makes the vagaries necessary. These dictated notes, most often with a lower page count than even the best EHR-generated document, paint a picture which is easy for my brain to understand and which conveys the complete, pertinent patient encounter information, subtleties and all.

I’m not saying I think every EMR/EHR system and user should use some form of dictation or speech recognition. But, perhaps system designers could start focusing more on “EHR speak,” on how they can enable capturing and relaying the subtleties, the nuances of medical descriptives. These so often provide the real “color” of a patient’s situation rather than just clichéd, templated, rowed-and-columned, formatted data. It’s sort of a Van Gogh versus a paint-by-numbers thing.

To my friend: It really does just suck and my thoughts and prayers are with you.

From the trenches…

“Never does one feel oneself so utterly helpless as in trying to speak comfort for great bereavement. I will not try it. Time is the only comforter.” – Jane Welsh Carlyle

 

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.

News 7/30/10

Global technology and service company Cegedim buys EMR/PM vendor Pulse Systems. Cegedim is a Paris-based company that publishes medical, paramedical, and pharmacy management software in Europe and sees the Pulse transaction as an entry to the US market. Pulse says it will remain independently operated and plans to increase its employee count from 100 to 350 over the next couple of years.

Something to ponder: how meaningful are the Meaningful Use guidelines for ophthalmologists, surgeons, and other specialists that have little need to capture data on either the core or alternate measures? The core measures include blood pressure management, tobacco use, and weight screening; the alternate measures include influenza vaccine and childhood immunizations. These specialty providers have the option to report “zero” as the measurements if the quality measure doesn’t apply.  Doesn’t quite seem fair that the primary care doctors must capture and report on more measures, yet the stimulus dollars they earn are the same as the specialists.

The CMIO for the 800-physician Marshfield Clinic (WI) says the practice has the right technology in place to meet Stage 1 Meaningful Use measures. The challenge remains the operational challenge to get all physicians on board. Example: orthopedic specialists don’t see the value of recording smoking habits (see above). Marshfield uses a homegrown EMR (CattailsMD), which the CMIO says will require “fairly extensive reworking” to meet Phase 2 Meaningful Use requirements.

The AMA releases a statement claiming that no EHR on the market today does all the steps required for physicians to successfully meet Stage 1 Meaningful Use criteria. The AMA also objects to the tight timeline for adoption and the high overall number of measures that physicians are required to meet. Of course, did anyone believe the AMA would fully support the final ruling?

St. John Providence Health System (MI) will offer eClinicalWorks’ EHR to its 3,000 employed and affiliated physicians. St John will host the eCW application as a SaaS model and connect providers to the health system’s inpatient Cerner system.

Banner Health moves three of its Colorado practices to NextGen’s EMR.

Arnot Health (NY) will provide the e-MDs practice EHR to its 150-provider medical group, integrating it with Arnot Ogden Medical Center’s inpatient EMR, QuadraMed CPR.

St. Clair Hospital (PA) offers a solution to provide EHR to its 550 physicians with admitting privileges. Participating physicians will use GE Healthcare’s eHealth Information Exchange technology to access patient data from various sites of care.

SOAPware introduces SOAPware Clinical Suite, which includes a practice management system component.

MBA Medical Business Associates expands its services offerings to include the MyWay EMR system. MBA hosts MyWay for its medical billing clients.

Regular readers may have noted that HIStalk Practice didn’t follow the normal posting schedule this week. My apologies if I messed up anyone’s need for an ambulatory HIT fix or if any news junkies find today’s post less than “fresh.” I likely have missed more juicy items than I found, but I promise to get back on track next week.

Physician offices added about 3,600 jobs in the first half of the year, according to the Bureau of Labor Statistics. In the first half of 2009, however, the industry added 8,000 jobs. Analysts predict hiring to pick up now that Congress passed a Medicare pay increase and health reform.

Ninety percent of doctors are affiliated with at least one hospital. The average physician is affiliated with 1.7 hospitals.

Baton Rouge Radiology Group signs a licensing agreement with Virtual Radiologic Corp. for its eRad Enterprise Connect 3.0 suite. The 25-radiologist group will use the application to unify disparate technologies such as work lists, image views, and reports.

CMS says it will be ready to start handing out incentive checks as early as May 2011. Physicians (and hospitals) hoping to receive funds for the meaningful use of their EHR can begin registering for the program in January.

Clever advertising: a Texas doctor who was not permitted to post traditional signs for his home-based practice buys this old Cadillac ambulance and uses it as a landmark for patients. Very fun.

E-mail Inga.

DrLyle’s Take on the Meaningful Use Rules 7/30/10

In mid-July, the government released the final rules on MU and EHR certification. I was actually at the perfect place for this — the annual meeting of AMDIS (Association of Medical Directors of Information Systems). So we had 200 CMIO-type docs and a panel of speakers ready to talk about this topic. HIT geek heaven!

From my bias of focusing on ambulatory EMRs, here is what I learned at this meeting from listening and talking to some very smart people on the topic and reflecting on everything the past few weeks:

Big picture stuff

MU Rules are reasonable. The government listened to the end users and decreased the expectations on the "Core Rules" (decreased the percentage of eRx required), while putting other rules in an optional "Menu" (i.e. choose five of 10). But be aware, anything optional you don’t do in Phase 1 will be required in Phase 2 in 2013 (i.e. you’ll need to do 10/10 from the Menu)… and they will likely think of more things to add by then.

MU Rules are still not a slam dunk. Even for mature users, there will be work that needs to be done. It is hard to believe that a non-mature user, or users without a lot of resources will be able to easily accommodate everything.

The government seems to think this will really work well and we will see over 50% adoption by 2015. I would love that, but am less optimistic. Best quote I have heard is that MU incentives are like giving someone money to have a baby. You will have a baby if you want a baby. The money is a nice extra, but not the main driver. Change is hard, so I am hoping that while we keep asking vendors and users to add functionality, we consider how we can improve usability at the same time. 

I do hope the government is at least working on a secret Plan B in case 2015 comes and we are only at a fraction of where we need to be (e.g. maybe they give money to innovation think tanks to figure out better EMR user interfaces). If you want to read more about the rationale behind having a Plan B, check out the great Kuraitis/Kibbe blog on this topic.

Per John Glaser, we need to think about MU not as a simple, one-time incentive, but rather as a stepping stone to bigger reimbursement reform. In other words, it helps groups create the HIT foundation for alternative care models and payment reform of the future (e.g. Medical Homes, ACOs). In that future, an EMR is no longer a competitive differentiator, but rather how we use our EMRs will be the differentiator (e.g. care efficiency and improvement, use of clinical decision support, secondary use of data, and patient engagement).

Some details that popped out at me

1. The denominator is now "unique patients" rather than patient visits. So if a patient is seen three times in a year, you just have to fulfill the rule at least once for that patient.
2. Scoring will be done on an individual physician basis, not on a group-wide analysis.
3. To correctly measure many of these details (e.g. give clinical summary to 50% of those who ask) we would need to figure out a way to keep track of who "asks". That seems like a strange request for structured data and certainly should not be what a doctor is spending his time doing. So either we need to make it an easy administrative chore or consider doing it for 100% of people automatically.
4. For patient reminders (for patients over 65), physicians can decide content and format. For example, we can decide to just do colonoscopy reminders and only do it via mailers to patients — it does not have to be electronic. The point is to just prove we can identify patients by age and communicate with them in some way.
5. Patient education: we need to figure out a way to document when we provide these handouts. Some EMR systems may have that built in, but even then, just for the handouts they have. What if I go online and print something else out? Or give them a special handout I have created? We may need to create a special patient education section to document this, but it is again more busy work for physicians (which I am not a fan of!).
6. EMR vendors are on the hook. They are required to ensure some level of MU reporting from their EMRs to get certification. The result will likely be that they will be spending a lot of extra time and money preparing their EMRs and then trying to get everyone to take those upgrades. They will then likely just certify the most recent version of their system.
7. EMR users need to upgrade, due to above point. It is unclear how all current EMR users are going to be able to quickly upgrade their systems in the coming 6-12 months. That takes a lot of planning, time, resources, and money. I wonder if users of "older versions" will band together to try and get their older versions certified, or if the vendor will help at all?

Some good resources

• The NEJM summary from Dr. Blumenthal
• A summary from CSC
• HIStalk full text

Lyle Berkowitz, MD is a practicing internal medicine physician, a healthcare IT consultant (www.DrLyle.com) and founder of the Szollosi Healthcare Innovation Program (www.TheSHIPHome.org). He blogs regularly at The Change Doctor (http://drlyle.blogspot.com/).

Intelligent Healthcare Information Integration 7/26/10

“Next Generation” HIT

My dad was a big fan of the phrase, “Do as I say, not as I do.” Of course, the not-so-subliminal message was simple: I want you, my children, to do better than what I seem to do.

What parent doesn’t want their kids to “outwit, outplay, and outlast” the parent’s best efforts? Once we’ve had our neurological hardwiring soldered firmly into solid pathways, it’s much harder for us old dogs to establish those new tricks. (Yes, “old dogs” includes even those 24-ish years plus — which is most of you, I’d wager.)

Our kids, though, have pleuripotentiality out their young wazoos. They glean, gather, garner, gain, and grow like little black holes scooping up all the light and matter within their reach. If you’ve ever seen an iPad in the hands of a two-year-old or watched a five-year-old zip through master levels of (fill-in-the-blank) video game which you can’t even understand past Hit Start to Begin, then you know how these little sponges take to technology like yuppies took to Starbucks.

After struggling these past several decades through the birth pangs of this giant HIT baby we’re all trying to deliver and listening to doctors and techies and vendors and politicians all accuse each other of being the cause of the slow progress of this birthing process, it makes me wonder if we’re not all missing one huge point. Maybe this baby isn’t meant to be born for us. Maybe it’s meant to be birthed by us, but for the next generation.

So, why aren’t more efforts being directed at giving our little learning maestros tools to help prepare them for a better healthcare life through technology? Well, it warms my pediatric heart to see that some folks out there have started to understand that a better healthcare future can be reached, not by trying to push and prod us old mules, but by giving our children a way to “do what we say, not what we do.”

“Let’s Move!” and the US Department of Agriculture have teamed up to sponsor the “Apps for Healthy Kids” challenge. This competition seeks to inspire app makers to build kid-friendly tools (i.e., games) which will help our progeny think healthier, act healthier, and associate technology with healthcare in ways we probably can’t even imagine.

HealthNutsMedia, a start-up, is one of the competitors. They’re two very successful and talented animators building some amazing new animations and games designed to teach kids about complex healthcare issues via kid-friendly language and kid-engaging media choices. (I love what they’re developing so much I’ve even agreed to help guide their pediatric perspective.)

They’ve entered this challenge with a memory game app (you know, like “Simon” where you had to slap the flashing lights in the appropriate order, in the mean time driving your folks bonkers with the obnoxious, repetitive tones it emitted.) Theirs is called “Parrot Pyramid.” It’s kid fun that also teaches them about food groups and making healthier food choices.

OK, granted this is barely scratching the proverbial surface for what healthcare information technology can actually do in the hands of our children. But, I think using child-friendly media technology (animation, games, apps) and child-level language to promote health awareness and HIT savvy in our children is perhaps the smartest use of HIT I’ve ever seen. If they “do as we say” and build upon these meager beginnings, I’ll just betcha their version of HIT will be light years beyond what us old fogies can ever even hope to imagine.

I hope you’ll consider voting in the Apps for Healthy Kids contest — it only takes a minute to register. (My friends at HealthNutsMedia have asked me to say thanks in advance if you decide to drop your vote for their Parrot Pyramid!)

From the future-hopeful trenches…

“He’s not pining, he’s passed on. This parrot is no more. He has ceased to be. He’s expired and gone to meet his maker. He’s a stiff, bereft of life, he rests in peace. If you hadn’t have nailed him to the perch he’d be pushing up the daisies. He’s rung down the curtain and joined the choir invisible. This is an ex-parrot!” – one of my favorites from Monty Python

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.