News 3/30/10

From Friend of Don: “Berwick as CMS chief. WOW, WOW, WOW!!! You know he’ll want to change reimbursement schema from volume to value based on day one. Wonder if he’ll be able to turn that big ship in his lifetime?” Dr. Donald M. Berwick runs the Institute for Healthcare Improvement and is a pediatrics and health policy advisor at Harvard. He’s a big advocate of providing better care at a lower cost believes the government and insurers can increase healthcare quality of efficiency by basing payments on the value of service rather than volume. I also noticed a more obscure fact about Berwick: in 2005, he was bestowed an honorary Knight Commander of the Most Excellent Order of the British Empire for his help reforming the NHS.

Sermo and athenahealth release results from a Physician Sentiment Index that indicates doctors aren’t too happy with the business of medicine. A couple of the more disturbing findings: 59% of physicians think the quality of medicine will decline in the next five years and 64% agree their clinical decisions are being based more on what payors are willing to cover than what they think is best for their patients. Not surprisingly, physicians still think EHRs are too expensive to buy, implement, and maintain. Sermo CEO Dr. Daniel Palestrant explains the results in more detail in this CNBC interview.

eClinicalworks says it has implemented 2,000 providers across 400 independent practices in New York City over the last two and half years. Another 600 providers and 100 practices are in the implementation process.

And in the Midwest, physician network Advocate Physician Partners partners with eClinicalWorks and will recommend eCW’s PM/EMR to its 2,600 independent physicians.

North Florida Surgeons selects Allscripts EHR/PM solution for its 34-provider practice. The practice’s CEO says that a key reason they selected Allscripts was the availability of Allscripts Patient Payment Assurance module to to calculate patient responsible amounts and secure payment authorization prior to surgery.

MinuteClinic names Nancy J. Gagliano, MD as chief medical officer. She most recently served as SVP of practice improvement for Massachusetts General Hospital and Massachusetts Physicians Organization.

Theft of personal health information grew from 3% in 2008 to 7% in 2009. Over 275,000 case of medical information theft was reported in the US last year. With increased EHR adoption, medical identity theft is predicted to increase. Furthermore, criminals use information from medical records for 320 days versus 81 days with other types of identity theft. Medical identity theft also takes twice as long to detect.

In more optimistic EHR news, a new NEJM paper supports the use of EHRs to help physicians make more accurate diagnoses. The physician authors believe EHRs can help diminish diagnostic errors in numerous ways, including:

• filtering, organizing, and providing access to data
• fostering thoughtful assessment and collaboration between physicians and patients
• facilitating the documentation of patients’ ongoing and evolving history
• providing better tools for managing patient problems
• ensuring fail-safe communication and action in ordering tests and tracking the results
• incorporating checklist prompts to ensure key questions are asked and relevant diagnoses considered
• providing automated follow-up systems and patient educational tools.

The authors admit that the current generation of EHRs don’t necessarily provide these benefits, but they envision a “redesigned documentation function” that includes improved tools for making diagnoses.

EMR adoption appears to be trending up for practices with 10 or fewer physicians, with 33% of offices planning to implement an EMR within 12 months compared to 11% in August 2009. I was surprised to see that only a quarter of the groups will seek ARRA incentives and a whopping 63% were unaware or unsure of the meaningful use reporting requirements. I’m assuming that latter group doesn’t follow HIStalk too often.

E-mail Inga.

HIT Vendor Executives on Regional Extension Centers

We asked several EMR and consulting executives the following question:

Now that the ONC has announced the initial grants for Regional Extension Centers, what will be the effect on EHR selection and implementation for both the industry and your company in particular?

Michael Nissenbaum, President & CEO, Aprima Medical Software, Inc.

RECs will be gatekeepers, potentially easing or impeding access for EHR vendors to thousands of physicians, community by community. RECs may reduce the complexity physicians would otherwise encounter in evaluating and implementing EHRs. If a REC simply becomes an extension of one or two EHR vendors, physicians could be denied visibility to appropriate technology. Better: RECs should issue an RFP and assess vendors’ strengths and weaknesses by specialty and practice size. Aprima’s ideal for RECs: 80% of our clients are 1-5 physician practices. 70% are in primary care, RECs’ primary target. RECs offering training must consider EHR vendors that will define a training methodology that fits their resources. That should include product training, certification, updates, and more to ensure the success of the RECs and practices. Through Aprima’s certification training and Learning Management System, the physicians will be prepared to meet the “meaningful use” requirements. Aprima’s EHR includes a library of chief complaints, not a collection of templates. This eliminates customization costs. Furthermore, physicians can chart multiple chief complaints in one entry, accelerating encounters. We’ll empower RECs with tablet PCs so physicians can see how a template-free EHR shortens learning curves. Aprima will be a player in the REC paradigm.

Victor Arnold, Managing Partner, AsquaredM

What I am seeing is that our business should grow a bit from this announcement. It will however, likely be a delayed impact (we are a consulting firm). What we are seeing are the EMR/EHR vendors getting stretched thin by the surge in installations along with the clients getting overwhelmed as they truly begin to understand what they have taken on in terms of process change (clinical as well as administrative) and cast about for assistance to either keep their existing operations moving or to sit in the middle between the client IT staff, the vendor install team and the larger organization to help them really integrate the products in a “meaningful” (pun intended) way.

Brad Boyd, Vice President, Culbert Healthcare Solutions

Based on our discussions with RECs across the country, the EHR selection process has largely focused on two main criteria: functionality to support Meaningful Use and Total Cost of Ownership.  EHR vendors with flexible licensing models will be able to compete for this business based on the total value of their offering as opposed to price alone.  CHS is well positioned to assist these smaller practices with their EHR implementations because of our combination of practice operations and clinical transformation experience, as well as our EHR implementation methodology geared towards maintaining physician productivity throughout the EHR go-live process.  While the potential revenue per physician for implementation services will impact margins, we believe it is imperative to resist the temptation to apply inexperienced yet lower cost resources to these engagements, which is a common approach undertaken by many staff augmentation firms.

Girish Kumar Navani, CEO, eClinicalWorks

RECs are responsible for helping primary care providers in small practices with the adoption of EMRs and to help providers get to “meaningful use”. We have a proven track record of implementations in this market segment. We should do well to meet their needs and we are confident that eClinicalWorks has the experience to partner with the RECs to implement the providers required in the timeframe to meet the project milestones. In addition, we are offering free Webinars, onsite assessment workshops and work-force development programs to train both the practices and the REC personnel to better support the deployment and usage of EMRs. As an example we have demonstrated that working with the NYC DOH on the PCIP project we have implemented 2000+ primary care providers in 2 years. Along with the deployment of the EMRs we have partnered with the PCIP (now a REC) to roll-out Clinical Decision Support for preventive and chronic care management and Quality Measure reporting for national quality measures. To be successful, vendors need to be able to implement the EMR and PM on a short timeline, and provide the necessary staffing of project managers, trainers and support personnel along with a comprehensive solution including clinical decision support and measure reporting. eClinicalWorks solutions should meet this criteria both as a company and as a product.

Eric Fishman, MD, Managing Member, EHR Scope, LLC

A saying that was commonly heard in my prior occupation is that ‘if you ask 2 Orthopedic Surgeons how to operate on any individual condition, you’ll get three answers.’  The corollary, I believe, is that if you ask 32 RECs how they will address their grant obligations to assist physicians with their selection and implementation of EHR technology, I believe you’ll receive 33 answers. Obviously, some of the RECs have already ‘chosen’ their preferred vendors, as they have pre-existing business relationships with one or more ambulatory EHR vendors.  Others are more open minded.  Some appear to be moving at warp speed, with extraordinarily rapid RFI timeframes, and others seem to be putting off every decision until they have received reams of information from all potential participants. EHR Scope, LLC has been providing a meaningful (no pun intended) number of services similar to those that the RECs are asked to perform.  For instance, we have 50,000 data points in our database of EHR vendors, and we have already had substantive discussions with a variety of RECs in which they appear to be interested in utilizing and possibly ‘white labeling’ our matching system for their priority primary care providers. This could be done either through www.EMRConsultant.com in which one of our staff (or their staff) analyzes a practice’s requirements, or through http://www.ehrscope.com/emr-comparison/ which provides real-time answers, 24/7. Possibly of most interest have been our educational videos, a few of which can be seen at http://www.ehrtv.com/category/reality-ehrtv/ and http://www.ehrtv.com/category/educational/ in which we document the process of readiness assessment, vendor selection and implementation. We are expecting a very busy 2010!

Tee Green, President, Greenway Medical Technologies

Our experience thus far has been that REC program managers are seeking much of the same reporting and interoperability capabilities that our practices and medical centers desire, with the extra assurance of the ability to exchange with other systems. The standardization that meaningful use is bringing has been welcome. I think for the industry it’s important to keep the focus on the greater healthcare benefits these networks bring, both to underserved populations and the spreading of best practices. It’s also very important for the industry to remember that RECs need to be sustained well past the initial funding years, and that we need to help achieve that. We at Greenway have taken heart in the actual language of the REC funding act, which states in part, “The ultimate measure of a regional center’s effectiveness will be whether it has assisted providers in becoming meaningful users of certified EHR technology.” That’s where the main goal comes full circle; if that is achieved, than Greenway and the industry has done our job.

Hayes Management Consulting, Peter J. Butler, President

The flurry of implementation activity will certainly kick up some dust among vendors, consultants, RECs and physicians. The question is, what will be there when the dust settles? Will it be well executed EHRs that are nicely connected to the practice management system, with staff well trained and physicians supported? Will the $5,000 have been enough?  Hayes is often called in during the middle of an implementation that needs help due to unforeseen costs and resource needs. We work on improving communication to physicians, clarifying goals, and shoring up understaffed help desk teams that aren’t able to respond adequately to users. The RECs are not simply implementing EHRs. They will need to manage the physicians expectations, and build a communications and training infrastructure to ensure a successful phase 1 execution. The effect of RECs on the industry and on Hayes will depend on the RECs’ ability to be successful at this with the funds allotted.

Jay R. Anders, MD, CMIO, MED3OOO, Inc.

The regional centers set up by ONCHIT are to be advisory in nature. Since the certification of EHR technology, most physicians look for the certification first then look at functionality, ease of use, ease of implementation and cost. Once the meaningful use certification becomes final, this will also become a criteria. Physicians will look for advice from consultants and peer references. I don’t think the regional centers will play a great role in helping choose a particular solution. They may play a bigger role in the implementation, especially when it comes to changes in physician behavior that will have to be accomplished to reach meaningful use. Our company has been helping physicians look at their workflow and practice prior to choosing an EHR. This allows for an easier transition into the electronic world. I doubt the regional centers will impact the adoption of our solutions in medium to large practices but may play a role in the smaller groups and solo practitioners.

Scott Decker, President, NextGen Healthcare

It is somewhat hard to answer this question at such an early stage in the evolution of Regional Extension Centers (RECs). We expect about 70 RECs to be created across the country over the course of the coming year and that there may be quite a bit of variability in the model and services provided by each of the individual REC instances. With that said, based on the activity and interactions we have had to date, we do see some trends emerging. RECs are funded by ARRA as implementation and optimization organizations (IOOs) to directly help providers meet Meaningful Use requirements. In this role, they provide complementary and/or alternative services to the implementation programs we offer to new clients. We anticipate RECs will offer additional resources to the market to help ensure the availability of these resources to medical providers to help them achieve a level of EHR usage based on compliance with the 25 criteria for achieving Stage 1 Meaningful Use. We also see the potential for RECs to provide an independent service to our clients who have already completed their EHR implementation phase with NextGen Healthcare, but may now seek additional support on their path to Meaningful Use. Regarding EHR selection, we expect REC endorsement of a specific vendor to help providers increase their confidence that the products they select will meet their clinical needs and qualify for Meaningful Use. Additionally, they potentially provide a streamlined contracting process by pre-negotiating terms and conditions and/or pricing with selected vendors. We do expect that a REC endorsement of an EHR will have the “halo effect” of externally validating the credibility and usability of a product or solution, thereby directly and indirectly affecting purchasing selections. Accordingly, we expect RECs to become an important channel in the market and we are investing significant resources to work with the named and emerging RECs to attempt to create win/win business models for all concerned parties. We look forward to integrating our efforts and significant market experience with the RECs to ensure all current and future NextGen Healthcare clients will achieve Meaningful Use when they are ready.

Andy Riedel, Manager of EHR Marketing, Sage

For those physicians who are actively considering EHR, the RECs may help to narrow the selection, but we anticipate physician buying decisions will continue to be influenced mainly by other physicians.  However, in the area of implementation, the RECs are in a position to fill a much-needed gap, especially around EHR readiness and change management.  Sage customers have had some positive experiences with the QIO/DOQ-IT organizations in this respect, and while the RECs share a similar charter, the potential is far greater this time around, based both on the level of funding awarded and having ARRA/HITECH concurrently driving interest in EHR adoption.  Sage has an installed base of thousands of physicians who are looking to adopt EHR and can benefit from the kinds of services the RECs plan to offer.  We expect to partner successfully with RECs in creating a positive experience for physician practices.

Evan Steele, CEO, SRSoft

Implementation and training is critical to successful EMR adoption. Implementation efforts have had their share of failures, even when they have been conducted by the vendors’ experienced, homegrown, and home-trained experts. When it comes to REC-trained implementation personnel, I have several concerns about what they will be able to add to a process already fraught with challenges. With only six months of training, these implementers cannot possibly be anywhere near as skilled as the EMR vendors’ own team members, who have been working with the companies for years. On which software will these REC implementers be trained to implement? We all know that when you’ve seen one EMR, you’ve seen one EMR! Furthermore, small practices—which lack savvy project managers, lack their own IT experts, and cannot afford to hire outside template designers—are the ones most in need of skilled and experienced assistance to get them across the finish line successfully. Unfortunately, I fear that these practices will also be ones most likely to get relatively untested REC trainers, and I remain skeptical that these implementers, trained for only a short period of time to meet the expected demand for rushed implementations, will be up to the task. The risk is that there will be an increase in what the AMA and 95 other physician societies estimate is an already abysmal 50% to 80% failure rate.

News 3/25/10

From Mobile Man “Re: mobile format. Nice new mobile phone format for HIStalkPractice! Thanks.” You’re welcome and thanks to Mr. H for setting it up. If you have a smartphone, give it a try. It loads fast and looks mighty pretty.

GE acquires MedPlexus, an EMR PM vendor that targets the 1-10 physician practice market. My first thought was why would GE make this purchase given that they already have the Centricity product? However, if I recall my ambulatory EMR history correctly, Centricity EMR is not truly integrated with a practice management product, but interfaces with either the Centricity Practice Solution (the old Millbrook product) or Centricity Enterprise (the old IDX software). MedPlexus, however, appears to be a fully integrated PM / EMR / patient portal solution. It’s also a hosted product, which is possibly a more attractive and affordable solution than GE’s traditional client/server options. And, Centricity EMR has not had stellar KLAS ratings in the last couple of years, so perhaps GE needed a fresh option.

CCHIT says it will adjust its EHR certification programs and reopen applications and testing April 7. Test scripts will be available from the CCHIT website the same day.

Speaking of certification, MacPractice says it hopes to be the first Mac-based EHR / EMR solution to achieve certification, once all the certification guidelines are finalized.

AdvantEdge Healthcare Solutions, a provider of medical billing and practice management services, acquires AHP Billing Services. The purchase will expand AdvantEdge’s offerings in pathology, radiology, and multi-specialty billing for hospital-based and practice-based physicians. AHP is the former billing and coding division of Anodyne Health. Last fall, athenahealth acquired the business intelligence segment of Anodyne Health.

athenahealth, by the way, picks up a new athenaClinicals contract with Hudson Headwaters Network (NY). The 12-location,100-provider group already uses athenahealth’s RCM services.

In yet another acquisition, Ingenix purchases QualityMetric, a health outcomes measurement vendor that develops patient-reported outcomes surveys. 

Medisoft releases Medisoft 16, the latest version of its practice management software. Enhancements include integration with Medisoft Clinical EMR Software.

Lake Region Healthcare (MN) selects Allscripts EHR and PM solution for the 50 affiliated providers of Fergus Falls Medical Group.

Aprima Medical Software announces a value-added reseller agreement with CyTek Corporation. CyTek will offer Aprima EHR/PM solutions to its clients in Kansas and Missouri.

Practice Fusion launches a community page that  allows users to interact in real time with the EHR’s software developers. Users can submit feature requests and suggestions from within the Practice Fusion software and direct them product developers.

Medical transcriptionists are heading to Capitol Hill to educate legislators on the importance of including dictation-transcription in the medical records process. In other words, members of the Association for Healthcare Documentation Integrity and the Medical Transcription Industry Association are asking lawmakers to help make sure the transcription industry doesn’t become obsolete as physicians migrate to EMRs. The organizations are asking that the ONC, when finalizing the meaningful use regulations, explicitly acknowledge that the dictation-transcription process is a viable means for achieving meaningful use.

Reading that story reminded me of my vendor days when EMR was still a brand new product. We would visit doctors’ offices, lugging 20 pounds of PC equipment, and provide product demonstrations of this sexy new technology. Invariably practices would ask the transcriptionists to sit in, since transcriptionists historically were very involved in the medical records process. Usually it took all of five minutes for the transcriptionists to realize that our product was meant to eliminate their jobs. The rest of the demonstration they’d sit back, cross their arms, and send darting glares our way. Ah, the good old days.

E-mail Inga.

News 3/23/10

Tallahassee Memorial HealthCare (FL) chooses Allscripts PM/EHR for its 106 providers and 33 family medicine residents

A recent AMA provides a few tips for physicians wanting to offer online consultations – and get paid for them:

• e-mail exchanges must address specific problems not associated with a prior visit, either on-line or in the office, within the previous seven days
• practices are typically charging about the same as a patient copay for online consults; other practices offer unlimited email options for an established fee
• not every managed care plan allow practices to offer email consults, so check your plans
• have patients sign a consent form describing what services can be rendered through online consults and how they will be billed
• specify an established turnaround time for emails
• make sure the email exchange becomes part of the patient’s permanent medical record.

Dr. Brian Yeaman of Norman Physician Hospital Organization (NPHO) shares details of the EHR database his organizes uses to facilitate record sharing with Norman Regional Health System (OK.) The organizations went live on a connected network in December and is currently installed in 100 practitioner offices. The health system, including the ED is also tied in. Yearman calls the setup “powerful.”

Here’s a smartphone app that sounds cooler than it actually is (at least after my five minute assessment.) The American Society of Health Informatics Managers, Inc. (ASHIM) releases a free application that “enables Health IT Consultants to help physicians select” an EHR. The application, called EHRBook, produces names of products based on a keyword search. It appears you can only put in a single keyword, e.g., e-prescribing, and not something more specific  like e-prescribing, family practice, and CCHIT.  The result is merely a list of vendors and hardly enough data to help anyone actually select an EHR. Perhaps the next version will offer more meat.

A North Carolina doctor sues Secure Telemedicine, a telemedicine company that the doctor says convinced him it was legal to offer medical consultations and write prescriptions by telephone. The doctor claims Secure Telemedicine solicited him to provide consults and provided him with legal opinions that claimed the medical services provided were legal. Eventually the NC Medical Board and four other states suspended his license for prescribing controlled substances without physical exams or any prior physician-patient relationships. The doctor is suing for Secure Telemedicine for unfair and deceptive trade practices and is seeking payment for the damages made to professional reputation, plus treble damages for legal costs.

Zotec Partners announces that four radiology groups have signed five year renewals for Zotec’s billing and practice management tools.

University Physicians & Surgeons, the 200+ member faculty practice of Marshall University’s Joan C. Edwards School of Medicine, selects McKesson’s billing and PM services.

WEBeDoctor releases WEBeVision, a web-based EMR solution for eye care professionals.

athenahealth launches athenaCommunicator, a patient communication service that integrates with athenahealth’s PM and EHRs. The tool includes a web portal, automated messaging services, and a live operator option.

Consulting firm Concordant introduces EHRopt, a Web portal support tool to help physician practices implement EHRs.

Humedica and AMGA subsidiary Anceta launch Humedia MinedShared Ambulatory, as well as Anceta Collaborative Data Warehouse. The tools will provide clinical, operational and financial benchmarking tools and comparative analytics for medical groups.

E-mail Inga.

Intelligent Healthcare Information Integration 3/20/10

EMR: Smaller Office, Longer Road

What’s the absolutely, positively worst thing about converting to an electronic medical record? A few guesses:

• Workflow disruption, redesign, and the general suckiness of changing all you know?
• Template building and its inherent drudgery?
• Loss of income from the reduction of patients seen as you relearn all your tasks?

Nope, nope, and nope.

The absolutely most dreadful part of adopting an EMR or EHR, even if it is a great one with tons of bells and whistles (and, perhaps, more so if it has tons of bells and whistles) is the ever-present knowledge that you aren’t even scratching the surface of this high tech tool’s multiplicitous talents.

Sure, I hate all that other yucky stuff mentioned above. Change is hard, templates and vast amounts of “clicky-clicks” aren’t fun, and, especially as one of medicine’s bottom feeders, income-wise, any pediatrician will tell you there just isn’t much room to tolerate revenue reduction.

Despite the gazillion and one well-documented difficulties with EMR adoption and despite the many, many times I’ve almost yanked the server up from its alternating current roots and sent it flying from one of our second story windows, I continue to be amazed, almost daily, by the tremendous tools I now have within my digital arsenal. But, therein you’ll find the source of my digital dismay.

In a small office (now with two, count ‘em, two, docs and six full or part-time staff) with no IT department (except me) and no education/training division, by far and away the most difficult part of transitioning to an EMR has been, and continues to be, finding the time to learn all about the tricks behind the tools we now possess.

It is sooooooo frustrating knowing we have the abilities to do so much more with what we have. I know we’ll eventually get around to many, hopefully most, of them. But, after a long day deciding how to keep asthmatic kids breathing in smoke-filled homes, deciphering the cryptic histories we often receive, deducing which weird rash we now face, and defending against the latest delay tactic of (fill in the blank) insurance company in preventing payments for services rendered, it’s really, really hard to justify more time away from home and hearth to decode another piece of our enormous EMR puzzle.

Yes, the training manuals are available online, and yes, my support peeps are really good and really friendly, but I want to be able to do this stuff NOW and my daggone limited brain and that stupid only-24-hours-in-a-day limitation are putting up roadblocks to my EHR happiness! (Delayed gratification, be damned!)

Alright, reality bites and I know we’ll get to all that good stuff just percolating away on my servers, waiting for our impending moments of discovery. I just wish my resources — time, brains, personnel — weren’t so “small office confined.” I suppose this is just one of the prices I pay trying to bring big city medicine to my small town and our small practice. Being a small business has its perks, but it sure has its pains, too.

From the (frustrating) trenches…

“Those are my principles, and if you don’t like them… well, I have others.” – Groucho Marx

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.