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.

HIT Vendor Executives on the Final Meaningful Use Regulations

We asked several HIT vendor executives the following question:

What are your general impressions of the Final Meaningful Use regulations and how might the regulations impact your company’s go-forward plans for products and implementations?

Glen Tullman, CEO, Allscripts

The new rules will not have a significant impact on our go-forward plans on products and implementations. We have been expecting this for some time now, and nothing in the final rule has changed what we believed our products would need to accomplish. We’ve guaranteed that our EHRs will meet the Meaningful Use certification criteria and they will.

Moreover, Allscripts has and will continue to play an active role in supporting our clients on Meaningful Use. Our Stimulus program makes it easy for physicians to participate by providing a “no payments for six months” option that bridges the gap until they receive their stimulus funding. And we’ve spent the last year and a half developing and fine tuning processes for accelerating the deployment of our EHRs to help meet the demand we anticipate in this market.

This is a real tipping point for our industry. Some physicians have been hesitant to move forward, waiting until the final rule was out before investing in an EHR and taking advantage of the incentives that the federal government has put in place. Now that the final rules are in place, there is no longer any reason to wait — the time to act is now.

Brad Boyd, Vice President, Culbert Healthcare Solutions

The Final Rule on Meaningful Use has provided a defined target by which hospitals, provider groups, and application vendors must strive to achieve. As a consulting firm whose offering includes vendor selection as well as application implementation / optimization services, we are now in a stronger position to assist our clients with establishing baselines for the Core Set metrics.

For the past four years, our firm has focused on implementation strategies which drive physician adoption, while maintaining or enhancing physician productivity and revenue cycle performance. The biggest impact on our firm and application vendors will be to accelerate the implementation timeline in order to enable clients to achieve the maximum financial incentives provided by ARRA, without compromising the quality of the implementation.

Performance metrics and benchmarking have been central components of our assessment, planning, and implementation engagements. The management adage, “You Can’t Manage What you Don’t Measure” is as true today as it ever was. By focusing healthcare organizations on the measures that drive improvements to patient care and quality outcomes, CHS will benefit both as a consulting firm as well as a consumer of healthcare services.

Girish Kumar Navani, CEO and Co-Founder, eClinicalWorks

We are pleased that the Meaningful Use criteria have been defined. The bulk of the work now will be on educating customers.

Providers need to be informed on the milestones and criteria that have been set forth and the responsibility for that is on the vendors. eClinicalWorks is currently developing tools for its customers to provide them with the education needed to ensure they are utilizing their system in a manner consistent with the Meaningful Use criteria.

Rob Harding, President and CEO, FormFast

The waiting game is over, for now. The announcement of the final rule on Meaningful Use clears a pathway for providers to participate in the government’s incentive program.

But to be truly effective in transforming US healthcare, the process must be extended in two key directions.

First, while the industry is making good progress creating usable digital data within an EHR tool, information portability is in its infancy. Interoperability standards must be further developed and enforced among competing products.

The second key direction speaks to the need for automation of the workflow processes not addressed by the stimulus package. Most of the paperwork burden in the hospital today will not be eliminated through use of an EHR. There are thousands of forms completed manually that never become part of the medical chart, such as corporate contracts, purchase contracts, and human resources documents.

With Meaningful Use regulations in place, FormFast anticipates a return to sanity from the frenzy of HIT strategizing. The final rule places our clients in a decision-making and action-oriented mindset, but it also brings physicians and nurses into the automation end-game. Having influenced those significant players, the organizational culture will evolve to allow automated administrative workflows to ripen.

Tee Green, President and CEO, Greenway Medical Technologies

We feel that CMS & the ONC did well with the Final Rule clearly recognizing the need for a manageable set of requirements, on the care provider side as well as EHR software provider side, vital to the foundation of a 21st century sustainable healthcare system.

Stage One criteria supports the creation of patient data liquidity and a credible, useable electronic health record, which at the same time can be achieved in terms of available functionality in step with the timelines of certification and maximum 2011 incentives. Greenway customers are already poised to achieve the final core and menu sets of requirements, and I think for all of the nation’s Eligible Professionals and Eligible Hospitals, once they recognize Stage One can be managed and achieved, the future goals of a national health information network and improved population health will be widely adopted.

As Greenway stated in its July 14 press release, for our customers, we have guaranteed the certification requirements that will align with the Meaningful Use objectives. From the time our company’s leadership offered functionality testimony in the NCVHS hearings during the early creation of Meaningful Use and onto our current CCHIT certification level, our single-database and interoperable PrimeSuite® EHR platform has been a go-forward solution for current and future customers not only for achieving Meaningful Use stages but for the totality of providing the most advanced and efficient patient care today and in the future in terms of research, preventive medicine and coming payer models.

Robert Kitts, Executive Vice President & Partner, Huntzinger Management Group

Our first impression of the Final Meaningful Use regulations is that it will be much easier to meet most of the criteria (i.e., CPOE 30% on medication orders, two categories of requirements core/menu, etc.).

However, many hospitals and physicians may find themselves struggling to adopt appropriate workflow changes to demonstrate compliance. We continue to work with our clients to assist them in implementing appropriate and certified technologies with a key focus on workflow design. Just utilizing certified technology will not guarantee Meaningful Use compliance.

John Tempesco, Informatics Corporation of America

Changes in Meaningful Use (MU) implementation reduce the minimum standards for adoption, provide more latitude, and allow for a more orderly and incremental approach to implementation. But it’s important to remember that the timeframes have not changed. If health systems and their associated providers have not begun an assessment of their current status in achieving MU and developing a strategy for mitigating gaps, they may be too late.

The final MU ruling has established a minimum standard to participate in the health care industry and a catalyst for additional change. Most likely, accreditation bodies, certification boards, and private insurers will use this to establish more stringent requirements.

Once a cherished competitive advantage, clinical data sharing among health care entities will become essential for meeting minimum MU requirements, and competitive health care organizations will be forced to form symbiotic relationships.

ICA has invested time and focus as MU rules have evolved to provide a component-based offering that enables organizations to start with a base solution designed to achieve requirements for 2011. CareAlign™ can be implemented and used as a base system; its component-based design allows organizations to evolve to meet MU standards for 2011 — and beyond.

Steve Tolle, Senior Vice President, Physician Solutions, Ingenix

CMS’ Final Rule on Meaningful Use removes uncertainty about the capabilities EHRs must support, the functions users must perform, and the measures for certifying physicians and hospitals to receive the federal incentives.

Importantly, the Final Rule sets realistic thresholds that physicians can be prepared to meet for CPOE, electronic prescribing, and other measures. As a result, more physicians will qualify for the Medicare reimbursements.

This is good news, because improving success and reducing the expense and risk of health IT for doctors will be critical to promoting better delivery of health care services — the reason for the federal incentives.

At Ingenix, we focus on the most underserved physician practices — those with 25 and fewer doctors. These practices use EHRs the least, while providing primary care to the most Americans. They don’t have the resources and staff large groups have. Health IT must be simple, save time, and add value from Day One.

That’s the lesson from our Model Office project in Michigan. There, we tested the workflow design, software implementation and training practices that need to be delivered for health IT implementations to be successful. Our resulting rapid-deployment model will support health IT adoption on a national scale.

From a product perspective, CareTracker EHR is ready for Meaningful Use. All 10,000 users have access to those features — that’s the power of the cloud-based model.

This is an exciting time for health IT. The technology has changed. The incentives are here. We can make this simple, and help doctors be successful. That’s our mission.

Jay Anders, MD, Chief Medical Information Officer, MED3OOO

Generally, I was very pleased to see that ONC along with HHS decided to relax the requirements for physicians to comply with Meaningful Use. By having 15 core elements followed up with five elective elements allows more physicians to more easily comply with requirements to receive the stimulus dollars. Vendors on the other hand are still required to meet all of the existing standards in the interim final rule, with the exception of the two that were removed for submission of claims and insurance eligibility checking.

Physicians should be very happy with the outcome of the final regulations. It is interesting to note that even given the relaxation of the regulations that occurred, the federal government will receive information regarding care delivery in the United States in a much broader format than it has ever received a before. This is exactly what the federal government is looking for. We will really not know how these regulations will be complied with until the ambulatory certifying and testing bodies are selected and specific criteria are tested, reviewed, and implemented.

The final regulations really did not change the product plan regarding Meaningful Use. We were planning all along to meet the NIST requirements, which essentially have not changed.

Daniel Rodgers, President and CEO, MedCo Data

Overall, I’m glad that the final regulations are less complex and more relaxed than what had been proposed. In particular, I’m glad to see that the messages between CMS programs are more consistent, and that providers have greater flexibility in their approach to compliance.

The final rules also open the door to potential new revenue streams for some physicians, such as requiring that providers record the smoking status of 50% of patients 13 years and older. Medicare reimburses for smoking cessation, so this is an opportunity to grab a charge capture that many physicians have been skipping.

I’m less happy about how the core objectives are generalized toward ambulatory practices, which poses unique challenges for certain specialties. An example is vitals collection by specialties like dermatology or ophthalmology. This will be a huge workflow drain that could impact patient count. What makes it plausible is that the measure has been reduced to require data from just 50% of unique patients. Careful workflow guidance can minimize the impact, but specialists will need to invest in equipment to collect these measures.

For MedCo Data, our go-forward plans aren’t impacted, other than crystallizing our focus. Since our focus is on designing pathways for practices to fully adopt EMR systems and achieve quality outcomes, we’ve been developing strategies around meaningful use since the first drafts were issued.

Eric Demmers, Senior Vice President, Health and Life Sciences, MEDecision

The announcement of the final Meaningful Use regulations is an important milestone in the proliferation of EHRs in particular, and health IT in general, to support reform mandates and help bring real, sustainable change to the healthcare system. It’s doubtful that the regulations will diminish the impact that the American Recovery and Reinvestment Act EHR incentive program will have on payer organizations or reform efforts. In fact, they offer more flexibility than those that were proposed in January, which should actually help speed EHR adoption.

Perhaps the most important ramification of the final regulations is that they effectively put EHR adoption on the fast track. Well, at least a faster track than any we’ve seen to this point. This will help promote the integration and exchange of clinical data throughout the health care ecosystem which is precisely the direction in which we must be headed to meet the mandates of reform. MEDecision has championed this approach for more than 20 years and, consequently, is very well positioned to accommodate the market’s changing needs. We will continue to pursue our core strategy while making the necessary augmentations to optimally support the evolving health care landscape.

James K. Lassetter, MD, Chairman and CEO, Medicity, Inc.

The final rule strikes the right balance between imposing too many requirements initially and not requiring enough to generate real improvement in the long term. The rule responds to industry stakeholders’ feedback and concerns in such a way that should enable achievable EHR adoption, innovation, and quality improvement.

By resisting pressure to set the bar for Meaningful Use too high, which would have favored more functionally rich EHRs, ONC will foster innovation in both the modular and comprehensive EHR spaces. This will level the playing field for providers, enabling them to deploy EHRs at a pace and depth of functionality that complements their workflow and business needs and positions them to qualify for maximum incentives.

And while we’ll have to wait to see the outcome of the overall effort, it is clear that we’re now set on a path that will lead to new innovations and a shot at a better healthcare system.

Richard A. Mahoney, President, MEDPlus

MedPlus, the health information technology subsidiary of Quest Diagnostics, is pleased to see that many of our Meaningful Use recommendations appear in the final rules, particularly those focused on offering physicians flexibility and a migration path to full EHR usage. The final rules offer physicians flexibility in how they choose to embrace technology, specifically, the creation of a core, plus a menu-type, list of criteria will create a manageable path for physicians to adopt EHRs.

We built Care360 EHR (www.Care360.com) on our scalable, flexible, modular web-based Care360 platform — already in use by more than 170,000 U.S. physicians for electronic laboratory ordering and results and e-prescribing — because we know that physicians are looking to avoid large capital investments and practice disruptions, and value the convenience of accessing critical patient information anywhere, anytime from their PC, laptop, or smart phone.

We strongly endorse the development of interoperable solutions, and Care360  EHR allows doctors to share notes and clinical information. We are pleased to see the patient in the government’s connectivity diagram, and believe strongly that informed patients are empowered to change behaviors and improve health. We continue to expect that Care360 EHR will achieve Meaningful Use certification in the fourth quarter of this year.

Charles W. Jarvis, FACHE, Vice President, Healthcare Services & Government Relations, NextGen

I don’t believe the Final Rule surprised those closely following the Meaningful Use criteria. Many predicted they would stay intact, although with eased compliance requirements. The Final Rule seems to bear this out. For example, the previous 75% e-prescribing obligation is now a more manageable 40%.

Washington sent a strong message: the EHR agenda is for real. In the words of David Blumenthal, the regulations are “ambitious but achievable.”

Physicians and hospitals can now move forward, yet the bar remains relatively high, so it is important to start engaging in EHR selection and executing Meaningful Use strategies as soon as possible.

Going forward, our responsibility is to give our clients the tools and resources necessary to help them reach Meaningful Use. We will also continue to support physicians, hospitals, and critical organizations like Regional Extension Centers, state health information exchanges, and health center-controlled networks (HCCNs), as well as expand our educational offerings through webinars, Meaningful Use guides and videos.

We expect our products to meet all requirements to be designated certified EHR technology. When the temporary certifying bodies are named, NextGen Healthcare will seek gap certification for any requirements not already validated in our preliminary certification by the CCHIT.

Janet Dillione, EVP and General Manager, Nuance Healthcare

I believe the rule-makers did what they said they would do; they listened. They asked for comments and saw a significant response from the industry; they internalized the feedback and were able to react to what they heard. I don’t think the rules were relaxed too much. I agree with Dr. Blumenthal; it is important for these rules to be set at a level where it is possible for every willing provider to have a good shot at meeting Meaningful Use. We now have a clear understanding of what providers and hospitals must demonstrate in order to qualify for the first phase of ARRA EHR incentives.

The core function of Nuance’s solutions, including speech recognition and medical transcription platforms, is to support the use of EHRs in a very simple, important way; by making clinical data capture much more efficient.  Dr. Blumenthal likens digitizing medical records to getting to the top of an escalator. To get to the top (fully electronic health records for every patient), first providers must step on the moving platform going up. It’s at this point where our solutions can ease the transition to EHRS. Because the majority of physicians are accustomed to dictation, the switch to point-and-click templates, where typing and mouse navigation is essential, can be unwieldy and sometimes impossible.

Speech recognition allows doctors to preserve their preferred method of dictating medical records. While there are different applications of speech recognition for the EHR, in most cases physicians use speech recognition as a replacement for their keyboard. Alternatively, physicians can create draft medical records for transcriptionists to review and edit for them. In either scenario medical records are created fast and with limited workflow interruption to the physician. Speech recognition is incredibly relevant to Meaningful Use, because if physicians get hung-up or stalled at the usability step with EHRs, the extended value of the systems will never be realized.

Beyond speech recognition, Clinical Language Understanding (CLU) is an emerging and important component to the future of healthcare IT. There is a fundamental need to support the unstructured data environment that is so prevalent in healthcare today. CLU presents a real opportunity to protect the workflow of the clinicians who are delivering the care while creating an environment conducive to analytics, reporting and to quality measurement. CLU is an extremely exciting, emerging technology that Nuance is investing heavily in and will begin to role out solutions this year.

With Meaningful Use, the government and the provider communities have embarked on a collaborative journey to raise the bar of healthcare delivery. As a member of a vendor community, we are investing in trying to help by getting solutions and tools out into the market that make healthcare IT systems more useable and more widely embraced.  We are working to contribute solutions that empower physicians to seamlessly use EHRs and other healthcare IT solutions to improve patient care.

William O’Toole, O’Toole Law Group

As expected, the final rule made accommodations to the requirements for Meaningful Use. I believe the reductions in criteria, by percentage or other means, is a far better idea than delaying the deadlines for the original criteria by years (although some criteria were dropped from Stage 1). The whole idea is to stimulate the adoption of Meaningful Use, and sooner rather than later.

Lowering the requirements to a more attainable level was smart. It will help maintain focus in the near term, rather than build in an undesirable “time out” period. If the other path were chosen (delaying the deadlines) I believe that many organizations would lose interest and put things off until later. Then when “later” arrives, the original requirements would remain and some would simply throw in the towel and not attempt achieving Meaningful Use.

One of my prior submissions to HIStalk was met with some criticism when I praised the work being done regarding Meaningful Use and those doing the work. I still stand by that opinion. This is a huge undertaking for our country and its health care system, one that I truly believe will work and will benefit “we the patients” in the long run.

Betty Otter-Nickerson, President,  Sage Healthcare Division

Sage recognizes meaningful use as a positive first step in a rapidly changing healthcare economy as it will provide the foundation for a transformed care and reimbursement model based upon long-term outcomes and accountability. Sage is pleased that CMS has made numerous revisions to the final rule after careful consideration of public comments from physicians and the vendor community as we believe that the final rule will make it easier for practices to qualify for meaningful use. However, even with the changes to the preliminary rule, enough remained the same so there were very few surprises to the final language of the rule.

As a whole, the final rule has provided clarification for the future and has offered all of us some much needed direction. Many of the areas that were once gray in the proposed rule have been cleared up in the final rule, making it less complex for us all – vendors, practices and physicians — to understand.

Still, the most pressing difficulty with the final definition continues to be its complexity.  Few if any practices will have the time (and many won’t feel they have the incentive) to read through more than 800 pages and draw tactical conclusions from the ruling. The challenge for the individual provider may be finding what the rule represents and what they need to do and why to qualify for the federal incentives; though the rule is far less complex than it might have been, there is still much confusion surrounding this process. Meaningful use may become challenging for vendors as they attempt to simplify and package systems according to the federal checklist while explaining the operations, system capabilities and reasons for an EHR in the new healthcare economy.

Sage’s plans for go-forward remain the same relative to products and implementation, and we will continue to support those in healthcare and those that practice medicine. Healthcare is about providing care and delivering positive patient outcomes and there is a continued need to emphasize to those of us in the healthcare community that the intention of these changes to the system through meaningful use is to get the care back in healthcare. Meaningful use may be a push toward getting practices to adopt electronic records, but it’s also meant to improve doctors’ work lives and practices by streamlining processes and creating efficiencies. With so much attention being paid to the stimulus dollars associated with meaningful use, let us not forget that we are all working to deliver a higher quality of care and improve the overall health of our citizens.

Todd Johnson, President/CEO, Salar, Inc.

Our consensus at Salar is that the Final Meaningful Use regulations enable more facilities around the country to achieve Meaningful Use for 2011.

This is a positive step in introducing new capital to hospitals for reinvestment in information technology. Hopefully, the result of the eased regulations will be that hospitals can use the funds received by ARRA to invest in the right platforms for the future.

Salar’s Physician Documentation suite is in use today by hospitals who have already achieved proposed Meaningful Use benchmarks beyond the 2011 requirements.  Moving forward, we intend to continue to provide our customers with the solutions that fill their clinical, financial and operational needs for 2011, 2013, 2015, and beyond.

Evan Steele, CEO, SRSsoft

The fact that the final regulations for Stage 1 are slightly less onerous than the proposed regulations doesn’t affect our plans. Measures were only deferred, not eliminated, and the negative impact on physicians’ productivity is still the key issue.

SRS clients have been reaping the benefits of increased efficiency and better patient care/service, along with those of e-prescribing, order management, reporting, integration of lab results, etc. since the company was founded 13 years ago.

Three questions drive our response to Inga’s question:

• How does the legislation impact our clients? The legislation and measures are clearly focused on primary-care physicians and hospitals. Our clients tend to be medium-to-large practices of high-performance specialists, who find many measures irrelevant.
• What is the value to our clients of entering data to meet government metrics? Our focus is on increasing physician productivity, not slowing them down by requiring data entry not relevant to their practice. If a change doesn’t improve productivity, it doesn’t get onto our product development roadmap.
• What options do our clients have? As David Blumenthal reminded providers, “this is a strictly voluntary program.” The choice is: continue on the productivity-improvement path or opt for the Meaningful Use / data-entry compliance path.

The SRS productivity-based hybrid EMR will continue to be the SRS flagship product, but we will offer a migration path to compliance should any clients chose that path in the future. Two options are now in place at SRS, and our clients will always have the choice

Chris Callahan, Vice President of Product Management, Sunquest; Tom Wilson, In-house Counsel, Sunquest

The final rule is largely what we expected, without significant change. It clarifies the requirements for interoperability and adoption financial incentives.

A second rule setting standards, implementation specifications, and certification criteria for determining value with EHR is likewise a good standard. Both rulings have solid foundations, and neither set the bar too high nor too low for the marketplace.

Clients should not be surprised by the lack of movement, as the politics have changed since the original passage of the bill. At the time they were all about stimulus, and now they are largely about deficit reduction. CMS is going to make it hard for providers to get their money. As such, they should not overspend on clinical projects, and should instead be very focused on meeting ARRA meaningful use requirements in their labs.

Sunquest has begun temporary ‘modular certification’ of our products. This will help improve decision making at the point of care and meet the stated goals of Health and Human Services and the Office of the National Coordinator.

Health and Human Services will thus enable eligible providers to combine certified modular solutions in order to achieve Meaningful Use provisions. This effort will deliver added assurance to customers and potential clients that Sunquest products are certified by a respected third party.

Sunquest is also proceeding to expand its current use of Logical Observation Identifiers Names and Codes as the universal standard for identifying medical laboratory observations. These LOINC codes are primarily used for order intake, and Sunquest is ahead of the rest of the industry in preparing to ensure standardization of laboratory information exchange in the most efficient manner possible.

Bruce Cerullo, President and CEO, Vitalize Consulting Solutions, Inc.

I said before, President Obama’s commitment to healthcare IT improvement could be a boon that leads us to better, safer, more available healthcare from health systems and for patients. After Tuesday’s announcement, I believe we’re a couple of huge strides farther in that direction.

No market prefers the unknown because it rarely renders positive effects. Since the release of the preliminary MU regulations and HHS’s subsequent asking for input, the HIT industry has been beset with the unknown: how to achieve Meaningful Use — before the deadlines — if we don’t know final criteria.

Now, we know. That’s good. Much to HHS’s credit, a clearer final regulation has emerged to replace a murky preliminary one.

CIO’s and physicians certainly exhaled after seeing realistic deadline and threshold revisions… Nobody likes being told what to do, let alone to what degree; but if you’ve got to take your medicine, now you get to choose the dose and flavor. Because HHS not only solicited feedback from the industry but used it, healthcare organizations will more aptly and quickly embrace, implement, and execute compliant EHR technology and reap the benefits for their patients and incentives for their survival.

Sean Benson, Co-founder and Vice President, Consulting, ProVation Medical, part of Wolters Kluwer Health

I was glad to see CMS back away from some of the more onerous requirements. Doing so gives providers a real chance to achieve Meaningful Use, which I don’t think was possible previously. In fact, I suspect that if CMS hadn’t eased requirements, many providers wouldn’t have bothered trying. This way, CMS is setting the stage to raise the bar for Meaningful Use down the road.

However, there were several areas that CMS should have addressed but didn’t, which could have negative implications. With its decision that alert fatigue was ‘beyond the scope of Meaningful Use,’ CMS missed an opportunity to deal with a significant obstacle to clinician adoption of CPOE and CDS. Also disappointing was the decision to exclude clinical documentation requirements based on an assumption that physicians who are using EHRs are unlikely to maintain separate paper progress notes. This could create significant gaps in the electronic availability of key patient information.

In terms of our go-forward plans, little will change. We’ll continue focusing on delivering the quality medical content and intuitive CDS needed to comply with Meaningful Use and other mandates. ProVation Order Sets, powered by UpToDate Decision Support , and Medi-Span Clinical both deliver intuitive clinical and medication decision support via CPOE. UpToDate supports the macro goals of HITECH, and ProVation Medical software eases the transition to ICD-10.