HIStalk Practice Interviews Joel Feinman

Joel A. Feinman, PhD is a psychologist and Board Chair, President and Associate Medical Director for Valley Medical Group, Greenfield, MA.

Give me some background on your practice.

We’re a primary care practice – multispecialty. We have four centers. We have about 60,000 patient charts; about 60 providers; about 350 staff; in western Massachusetts.

What kind of technology are you using in the practice, in terms of your electronic medical records and billing software?

We’ve been an athenahealth practice since the end of 2000, using their practice management system. Then we brought up athenaClinicals one year ago, so we’re totally integrated on athena right now.

Are all your physicians actively using the EMR piece of it?

All of our primary care and MDs are using it. The only folks who are currently not using it routinely are our optometrists and our behavioral health therapists. But, all of our MDs are using it, all of our PAs, NPs. Our psychiatrists use it to prescribe and order, and get lab results. The subspecialties, such as rheumatology, podiatry, endocrinology, are all using it as well. The other thing we should say is we have our own physician’s office lab, and so the laboratory’s up. We have our own in-house radiology systems, so our radiologists use it as well. Although, for radiology, they’re using an athena interface at the moment; it’s not directly integrated.

And your lab is integrated?

We have a results interface, but the orders are not interfaced, and the lab information system is LabDAQ. It’s not integrated on the order side, but it is on the results side. The important part is that whenever one of our physicians orders a lab, there’s a process to get their lab into the EMR, and then into the lab information system. Then the result comes back to their inbox in the EMR. That part is solid.

Usually, when practices are moving to EMR, the biggest problem tends to be change management – changing the behavior of the clinicians. How did you overcome that?

We did this in several phases because this is our second EMR. We had a previous EMR that we were basically a beta customer for. We thought it was further along than it was. So, we went from paper records to this previous EMR, and a lot of the sweat and strain, I think we kind of got it over with in that transition. But, you never get over all of it.

We got people used to using the devices that they’re using. We got people used to figuring out, “What’s the stuff I really need to see in the EMR?” We got people just used to the idea of using this kind of technology. That system didn’t work well, so after about a year and a half, we began to search for the next system.

By then, athenaClinicals had matured quite a bit and we decided it would be better to have a totally integrated system than one that would have an EMR integrating with our practice management system, via interfaces. So, the change management really was about the first system.

I think the change from the first system to athena was fairly easy because, number one: people were used to the devices. They were used to having an electronic system, and they were searching for some relief from the system that didn’t work well. We brought everybody up, I think, within a week. The first EMR, we brought people up in stages – one health center at a time. Whereas, when we went to the new EMR, the athenaclinicals product, we had to bring everybody up at the same time. It went very smoothly compared to our first time around.

I understand that Valley Medical was recently certified as a medical home. Tell me a bit about that qualification process.

We belong to a physician practice organization from one of the local hospital’s groups. They came out and they did a practice assessment for us where they went through all the different standards and elements that are required for the NCQA certification for medical homes, and they actually rated us – how we would rate against the standard.

After that practice assessment was completed and we got our results, we realized that a lot of the processes and procedures and policies that NCQA was looking for were already in place, in terms of Patient-Centered Medical Homes standards. It was a no-brainer for us then, to move forward and actually become certified, and actually apply to be certified and review our records and commit.

After we finished the practice assessment, then, of course, there were areas that were highlighted that we needed to either tweak the policy, or make slight changes. Or, maybe even create a new process that we hadn’t thought about it. So we went through a six-month period of looking at how we deliver care to patients and what areas we needed to improve upon – writing new policies, rolling it out to the staff, re-measuring and making sure that the new process was incorporated into the daily workflow of our staff.

Then, after that was completed we did some mock chart reviews just to see how we would measure up against the standards for the chart reading portion. Again, we did pretty well in that. It highlighted some areas that we needed to improve on as far as how we document. Not that we weren’t providing the care, but we needed to improve how we’re documenting it in their medical record.

One of the major areas that we found that we didn’t do well was documenting progress towards patient goals. We didn’t have goals for the patients. We weren’t good about saying, “We want you to reach this goal, and this is how we’re going to help you do it.” So, we had to go back to the physicians and the practitioners and the clinical staff, and everybody worked together to document what was necessary. We did that for about three months, I would say. We re-measured and kept looking and seeing how people were doing with the changes. Then, we actually set our survey date.

In the meantime, we were compiling all these documents and putting them in a folder, like an electronic folder that would be submitted as part of our certification process. Then we had a chart review, and that took three days. It was a pretty intensive chart review. It was basically 36 charts for each medical provider – MD provider – in our primary care practice. The charts had to be of patients that were seen for our three clinically important conditions. What they mean by clinically important conditions is usually the conditions that you see the most patients for, or are the most chronic in your population, or would have the most benefit of being managed better.

Our three clinically important conditions were diabetes, hypertension, and coronary artery disease. After we compiled all the chart review results, the whole package got submitted to NCQA and it was about a 30-40 day waiting period before we found out if we had passed. We passed with flying colors.

You mentioned in here that there was a lot of information that you had to compile along the way. How did the EMR facilitate that?

The EMR facilitated that because it was very easy to go in and take screenshots of different areas of the electronic medical record. If we needed to show that we manage our patients who have a different language, we could go in and take a screenshot of the actual field in the EMR that document the patient speaks Spanish, or that the patient needs an interpreter.

Do you think that if a practice did not have an EMR it would be possible, or challenging to do a qualification?

I think it would be very challenging. I don’t think you actually have to have electronic systems, but I can’t see how anybody would pull that off without one. It would be very time consuming and very difficult. Even more important than meeting the qualifications for NCQA, I can’t see how you could have a Patient-Centered Medical Home without some way of aggregating information, making it available to point-of-care and updating it constantly; having it available whether you’re in one building or another, having a medication list that’s accurate and up-to-date and readable; having a problem list that is accurate, up-to-date, and readable.

So the issue of getting yourself certified, I think, would be very hard to do that on a paper system. But the more important issue is how you take care of patients. I don’t see how you can do that anymore without some kind of electronic system that actually works.

The other thing the EMR affords you is that you can template things so that you know that the important parts of the documentation aren’t going to be missed. When you have a piece of paper, you can write anything on a piece of paper. But if you have an actual templated visit for say, diabetes, that goes through X, Y, and Z of what needs to be covered at that visit, it prompts the provider to make sure that they cover all the bases.

I assume that you’re also going to be trying to qualify for the ARRA stimulus money?

Yes.

How has your use of the EMR changed now that we have a clearer idea of what the Meaningful Use requirements are going to be?

I don’t think it’s changed at all. I think that the product itself was designed, set up, and actually works, in a way that will meet the Meaningful Use criteria – maybe with a couple of tweaks here and there. We haven’t changed the way we’re using it, but we did just bring up our patient portal. I think that is one way that we’re going to hit a homerun with Meaningful Use.

That’s just one of the things that’s so useful for us about athena is they’re busy scanning the federal regulations to make sure that their product is going to meet this criteria. For example, the patient summary, we always were able to provide the patients a summary of their visit, but the system has now been configured so that it’s really easy to track that we’ve given that information to the patient. So yes, we’re sort of catering to that Meaningful Use, but mostly we’re just using the EMR to take care of our patients.

Even with all these opportunities for stimulus funding and whatnot, there are still many physicians who are avoiding adopting EMR. What do you think needs to change in the industry to increase physician adoption?

For the smaller practices, I think even the stimulus money itself probably doesn’t get a doctor or a doctor’s practice to the point of saying, “I absolutely have to do this, or else.” There’s a lot more money that physicians will have to spend to get EMRs up and running than will be reimbursed by stimulus dollars. I think most practices are realizing that you simply cannot manage in a paper world anymore. If they haven’t hit that reality yet, they’re going to hit it soon. I think that’s going to drive them as much as the stimulus dollars, to some electronic system.

Plus, I’m really hoping that we get to the point in the healthcare system where there is some kind of master plan that allows sharing of information easily and accurately, and securely. So if my mom’s in the hospital in Florida, and her doctor is in Massachusetts, that ER can pull up her med list.

When I’ve talked to small physician practices, what they tell me is they’re waiting to know what the data exchange is going to look like, what information has to be kept. Everybody’s afraid of signing up with an EMR that’s going to disappear or not going to meet Meaningful Use, or not going to be able to be used in any of these regional information exchanges. I mean, it’s like all the people that invested in the Betamax video players, and then they went away because the VCR ones took over. People are afraid to invest in the Beta.

In Massachusetts, for instance, there’s already legislation that’s mandating physicians have some electronic system by 2013. I think the handwriting, clearly, is on the wall; I think a lot of the stuff is what you talked about before about change management. It’s a money issue. There’s the “assure me that this is really good for my patients and I’m going to have some real benefits from this.” Then, there’s “Oh my god, how do I actually make this happen?” That’s a big hurdle.

But, the more practices start doing it, the more other physicians are looking around at their colleagues and saying they need to get on the bandwagon.

Have we reached the tipping point yet, or is that still to come?

Well around here, I think we’re close to the tipping point. There are still a lot of practices that haven’t made the plunge yet, but they’re getting very serious, so I think it is coming. The other thing is people are probably getting tired of being badgered by the 50-60-70 companies out there – advertising and calling them, and sending them emails. At some point, that herd is thinned out to 5 or 10.

Practices will be fine as long as they’ve done enough homework and confident that the one they’re buying is going to be around for the long haul. I think we’re pretty convinced that the one we have is going to be around for the long haul.

News 3/09/10

Surescripts reports that e-prescribing rates tripled from 2007 to 2009, with an estimated 18% of all eligible prescriptions now being sent electronically. The number of prescribers routing prescriptions doubled from 2008 to 2009, and now includes 25% of all office-based physicians.

In case you missed this last week, CCHIT announced plans to expand its certification programs to Oncology and Women’s Health.

eDr.Rx says their prescription management application will be supported on the Apple iPad device.

Speaking of Apple, the company just announced its Wi-Fi-enabled iPad goes on sale April 3, with pre-ordering starting March 12th. Suggested retail prices for the iPad will range from $499 for the 16B model to $699 for the 64GB. The 3G equipped models will hit the market in late April, though you can also pre-order starting March 12th.

The AAFP sends a letter to CMS, pointing out several details of the proposed meaningful-use criteria that the AAFP finds “unworkable, excessive or redundant, and will actually impede the very goals of the legislations.” Criticized items included CPOE (too much administrative burden on physicians), e-prescribing (too high a threshold), and the providing of electronic records to patients (48 hours is not sufficient time for providers to provide together, especially when weekends are involved.) The AAFP concludes:

CMS should significantly modify the proposed rule to ensure participation by the majority of eligible physicians so that we can continue to transform our health care system rapidly toward more patient-centered, coordinated, comprehensive and reliably high quality care.

Today I successfully whittled my email down by a few hundred, with only a hundred or so to go. Bummer that I am just now reading the invite from some friends who wanted to catch a drink at HIMSS. I suppose the fact that I got at least one email form every HIMSS exhibitor somehow makes for that. Or not. I did miss a few good news items, so here’s your catch-up.

Quest Diagnostics introduces Care360 EHR, a web-based application developed by MedPlus. Quest is offering physicians a 90 day free trial period for Care360 EHR or its ePrescribing solution. While the free trial sounds great, here is why it is not as good a deal for physicians as it sounds. Implementing an EHR is disruptive. Quest is counting on the fact that physicians won’t want to go through the struggle of getting an EHR to work in their practices and then toss it out, only to have to go through a disruption process with another product. I’d also assume that Quest will charge for training, regardless of whether the practice keeps the EMR or not, so all the practice would really get is a three months of service for free.

St. Croix Regional Medical Center (WI) leverages Imprivata’s OneSign single sign-on application to facilitate its use of NextGen EHR.

Indigo Identityware, another SSO provider, partners with gMed. EMR vendor gMed will offer Indigo MD to its physician clients as a compliment to its core product, plus sell Indigo Acute to hospitals.

Take Care Health Employer Solutions, the country’s largest provider of worksite health and wellness services and pharmacy, says it will deploy Greenway’s PrimeSuite at both new and existing sites. Take Care is a subsidiary of Walgreens and operates clinics in several pharmacies across the country, as well as 700 worksite and retail healthcare centers.

The Ohio State Medical Association (OSMA) names NextGen Healthcare its only preferred vendor for practice management solutions, and only one of two for RCM solutions. OSMA members are eligible for special pricing.

NextGen, by the way, inks a deal with Prime Care Physicians (NY) to deploy NextGen EHR and Practice Management for its 104 providers.

Leveraging its Lean Six Sigma expertise, GE introduces a suite of rapid implementation packages for its EMR and RCM solutions. The rapid install process helps practices deploy EMR in as little as 10 weeks. GE also announces Centricity Business “PowerStart,” which sounds like as option for software with standardized options right out of the box, thus reducing file-build time. Again, the goal is to help organizations deploy faster.

Sandhills Physicians, a 600-member IPA in North Carolina, selects eClinicalWorks EMR/PM solution for its physician member practices. The organization pre-purchased an initial 150 licenses. eClinicalWorks also announces an on-demand deployment option that will allow practices to independently install and activate eCW solutions, though training and workflow analysis must still be scheduled. The goal is to increase flexibility and reduce installation wait times.

Epocrates is designing its own mobile and web-based EHR solution, which it will target to the solo and small physician group market. If Epocrates is able to roll out a product that is as easy to use and affordable as its medical terminology application, then it will likely be a big hit. Currently over 900,000 clinicians worldwide use Epocrates’ medical terminology product.

athenahealth and DaVita Inc. join forces to deliver an integrated, web-based EHR and RCM solution for nephrologists. athenahealth also partners with US Bancorp and its subsidiary Elavon to launch an integrated payment processing service to streamline checkout processes for physicians and patients. The new Credit Card Plus solution will link to athenaCollector.

One more athenahealth item: athenahealth and Sermo partner to query physicians’ views on such topics as EHR and the financial health of practices. Early survey results indicate that 80% of physicians hold a favorable view of EHRs, though most believe they are expensive to purchase and maintain.

Mark Newman of EHR Associates weighs the pros and cons of various EHR technologies (particularly client/server versus SaaS.) Good read, especially if you are a newbie.

E-mail Inga.

Intelligent Healthcare Information Integration 3/4/10

Meaningful Views

“Meaningful Views” is a grand conglomerate term (not to be confused with the “Meaningful Ewes” from a prior posting.) It encompasses graphical user interfaces (GUIs) and workflow efficiencies and the minimization of “clicky-clicks.” (Props to Jonathan Bush for that term; it says so much in such a cutesy, snarky way!) Meaningful views are something we all seek, every day, whether via digital dazzlery or paper and pen.

Consider the ultimate goal of medical information: to lead to better heath. My goal, as a physician, is to help my patients lead better quality lives via better health choices and illness management optimization. To accomplish this goal, I need to: obtain data; aggregate, assimilate, and evaluate that data; add interpretive value to that data; and deliver the data’s meaning and true usefulness to the patient. Whether it needs to come from the patient, from a lab test or radiology exam, or from a textbook, professor, colleague, or website, the data I need to digest must somehow be “viewed” in order to be shared and used.

While auditory “viewings” of data are important, more and more in our modern world we are turning to visual information sharing portals. Televisions, faxes, lab/radiology printouts, computer screens – these are increasingly diminishing the verbal-auditory transfer of information.

The exponential growth rate of medical knowledge has long ago exceeded the mental capacity of mere mortals. Thus, how data is presented has become increasingly pressing. We need data views that facilitate our data comprehension. If we were not mere mortals – and perhaps the ultimate goal of all this techno-data-collaboration is to allow this – we could share knowledge via some form of Vulcan mind meld or Borgian collective consciousness. Until that time, in order for us to share the information we seek or need, the presentation of that data must improve.

Face it: we all only have so much time in a day. We need data delivery which is as fast as possible, as efficient as possible, and as easy to assimilate as possible, because we have a lot of things we need to do with that data. Personally, I also want to get home to see my family on occasion. (OK, I also want to have time to catch the latest Mythbusters.)

I want data “views” that make sense. I want data views where I have to do as little as possible to assimilate said data. I want views that allow me to do the things I really want to do, not views that require me to alter what I do in order to accommodate the viewing. If I have to learn how to view the data, if I have to work to visualize the data because it comes in a difficult format, if I have to constantly seek the data I need because it comes in non-standard views, then the data viewing becomes a barrier to my goals.

Workflow efficiency is enhanced by standardized patterns. In my office, for example, each exam room is set up identically and all of the necessary supplies are stored in identical locations within each room. I don’t have to spend any mental energy deciding which room I’m in and where the tongue blades are stored. I can spend that energy thinking about and talking with my patients. It’s little, but it adds up.

When I seek data from a lab report or from a radiology report or from the exam notes of a previous physician, you know where most of my time is spent? Yep. Looking for the data I need. Why? Because the “view” is either non-standard, sub-standard, or, sometimes, flat out crappy.

I recently learned of an initiative to provide cross-platform standardization of laboratory data. This means that whenever I look at a lab report, from whichever institution or provider or EMR or HIE, the data is presented in a regular, logical, and consistent format. The “view” is optimized. Time is spent in understanding the data, not in finding the data. (If you’ve ever had a new lab reporting system thrust upon you where you had to relearn where to look for lab data in the new system’s report forms, you’ll understand). If you can easily see it, you can use it. If you can easily see it, you won’t unnecessarily repeat it. If you can easily see it, you can make meaning from it.

Meaningful use, in my humble opinion, should always revolve about what helps us help patients. Help me spend less time looking for what I need, help me focus less upon data entry functions and clicky-clicks, help me make better decisions for helping more people faster, help me get home to see my wife, sons, and Survivor more often – that is meaningful use for a trench grunt. This standardized look for lab reports, one form of “meaningful views,” would be a great step in that direction.

From the trenches…

“Know where to find the information and how to use it. That’s the secret of success." – Albert Einstein

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.

Intelligent Healthcare Information Integration 3/3/10

While the Gettin’s Good

Here I sit, 6:10 AM, leaving the 2010 HIMSS conference, riding the shuttle toward Gate D25 here in ATL. (Typing that, I feel like Kenny Tarmac; respects to “The Bob & Tom Show.”) As I write this, I realize how freakin’ psychic I am, planning to leave just after one day of show. Not because of anything related to the HIMSS event; rather, because the last time Atlanta had a half an inch of snow, I was speaking to a friend there who was just about in a panic, as was pretty much the rest of lovely Atlanta, at the sight of frozen water. Wouldn’t you know, after arriving back at the hotel last night after a phenomenal HIStalk reception and excellent Eclipsys party with the still-spectacular B-52s, the local newscasters were abuzz with the news of, yup, snow.

Two to three inches was being forecast to hit starting just after my departing plane arrives safely away in Charlotte. Now, being from the frigid north, this piddly dusting doesn’t begin to worry me. However, if a half an inch frightens Atlantians into rolling up the sidewalks, I can’t imagine what enough to cover their shoe tops might do.

My post-HIMSS first-to-mind thought? As a mere grunt from the small town trenches, you might think the colossus into which HIMSS has morphed might be overwhelming. Would be, I suppose, if:

a) I hadn’t been watching all this HIT hubbub bubbling away for over a quarter century;

b) I didn’t know a bunch of really good people involved in this work who attend HIMSS who;

c) Keep introducing me to even more really good people.

Speaking of really good peeps, perhaps the most intriguing – and, perhaps, telling – comment I heard this year came from Pat Downing, one of those nice folks met via another nice folk. Pat, originally from Maryland, has now lived for over ten years in Thailand – Bangkok, to be specific. He’s the original brain behind what has since become Microsoft Amalga. Not being daily immersed in the U.S. HIT world, he notes how his infrequent visits allow a unique perspective upon what’s the haps here when he does make the rounds at HIMSS. This year, his take was disturbing, if not downright ominous.

To wit (paraphrased): I always find that walking the periphery of the HIMSS exhibit hall(s) gives me a view for the new, the innovators, always positioned around the outskirts of the show, those small guys who are bringing along the next big “pops.” This year, though, nothing popped.

Maybe it’s the scramble to address “meaningful use” (whatever that truly is.) Maybe it’s the ARRA funds which seem to have stalled – at least temporarily – the EHR purchase decisions of many potential adopters. Maybe we’re just out of idea men and women who can even pretend to wrap their minds around this ginormous, dysfunctional beast we call healthcare here in America.

But, maybe, just maybe, it’s the lull before the next great storm of disruption which will actually engage the masses of healthcare providers into actualizing the real horsepower of IT. Not technology for technology’s sake, nor technology for the sake of a carrot or the threat of a stick, but technology uptake based upon technology which excites and enthralls, technology which needs no incentives other than its own inherent value. Sort of like my palm Pre. (OK, sort of like the iPhone for the rest of you.)

The fun of the HIStalk reception still lingers, so I’m going with the latter, glass half full possibility.

Best of luck with the “blizzard,” y’all.

(On my way back to where I’m) From the trenches…

“The optimist proclaims that we live in the best of all possible worlds and the pessimist fears this is true” – James Branch Cabell

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 3/4/10

I’m back at home after an exhausting, fun, and educational few days at HIMSS. I have a ridiculous number of e-mails to wade through, but as far as I can tell, there were no earth-shattering announcements, such as company mergers or the like. However, many new product releases, new partnerships, and client success stories were shared. Over the next few days I will digest it all a bit and post more highlights.

In terms of offerings of interest to physicians, I had the chance to look at a few of the EMR vendors. The big name vendors had heavy traffic the whole time, but I have to wonder if the HIMSS experience is worth it if you are a small vendor in one of the small booths and low traffic areas. A lot of those folks looked lonely.

I got a quick peek at SRS and I finally understand its appeal. It does not offer every bell and whistle that you might find in a NextGen or Allscripts product. However, it’s very intuitive, the screen is not cluttered, and navigation is simple. If you want to chart the complete note at the point of care, this is not the product for you. But if you want something that gets your charts electronic, it’s not a bad option. It’s not the option if you want to do complicated data searches since it relies heavily on scanning and transcription. There are limited discrete fields, which also means you don’t have a whole lot of point and click in the documentation process. I knew the product had these limitations before seeing it, but it is strong enough in its design to be an attractive alternative for certain types of providers (especially specialists).

I didn’t see the Sage product in great depth, but it looks like one of the more comprehensive EMRs in terms of its ability to be customized and to accommodate a totally paperless workflow. However, it is not the prettiest EMR out there and a little window dressing might improve its appeal.

If you are a smaller start-up vendor, here’s a recommendation: hire an industry veteran to help you define what is different and unique about your product. This is 2010 and there is no need for a vendor to begin a pitch saying that what makes his EMR great is that it makes patient information available from anywhere and saves on transcription costs and reduces paper. I’m pretty sure that just every HIMSS attendee is aware of that every EMR has that same potential.  When a vendor starts telling their story in this fashion, their credibility is blown and their lack of experience in HIT is exposed.

Here is what seems to be a hot trend: products that can be bolted on to core practice management and EMR programs. The hospital world has been doing this for years, but not so much the ambulatory space. Of course there have long been claims clearinghouse that work with PM solutions, but now vendors are offering easy-to-use and customizable front-end solutions (like Salar) to work with EMRs, all sorts of RCM tools (RelayHealth is big in this area), and business intelligence tools to help doctors with PQRI reporting and the like.

Despite this not so pretty picture, VisualDX was a  pretty sexy product and one of dozens of applications that are newly available for use on a smartphone. VisualDX includes a database of images so a provider trying to identify a particular skin rash, for example, could search through a library of thousands (with pretty precise search options.) A consumer version is also available for all those nervous moms.

For me, the HIStalk party was the ultimate highlight. If you were there, thanks for attending. And endless thanks to Encore, Evolvent, and Symantec, our gracious hosts. If you missed it, I hope we’ll see you next year!

Short post tonight as I get caught up on life! I’m be sharing more, so keep reading.

E-mail Inga.