EMR Vendor Executives on Meaningful Use and Certification Requirements – Part Two of a Series

We asked several vendors a series of six questions related the federal government’s recent announcement on the latest proposed meaningful use definitions and EHR certification criteria.

Which of the criteria do you expect to be the most difficult for physicians to achieve?

Allscripts – Glen Tullman, CEO

We have heard concerns from a number of physicians, most of whom do not currently use Electronic Health Records, that a few key areas are a concern. Our response is typically that we can show them practices that are very similar to their own who are actually performing the activities in question.

The key areas of concern revolve around the requirement that they enter 80% of their orders in an EHR, since that level of automation requires a significant change in their normal workflow. However, we’re optimistic that physicians using Allscripts EHRs will be successful meeting the measures for order entry. According to a recent KLAS survey, Allscripts was the only vendor with 100% of clients surveyed able to transmit qualifying digital orders. One example is Sharp HealthCare in San Diego, the Malcolm Baldrige National Quality Award-winning health system led by CIO Bill Spooner. Sharp is now placing 100% of their orders electronically using Enterprise, after going live last month in a big-bang implementation of Orders with 350 physicians and 2,000 total users submitting lab and radiology orders using the EHR. So Sharp stands out as a great example of what a world-class healthcare organization with strong leadership and a commitment to success can do to make Meaningful Use work.

Additionally, we have heard physicians are concerned about medication reconciliation – another requirement of the Meaningful Use criteria, as they’re now written. And the requirement that physicians provide “syndromic surveillance reports” is challenging because it remains undefined, untested and unclear. Fortunately, the requirements in this area are fairly minimal, so as long as we facilitate an easy path for testing this for clients, they’ll be successful.

eClinical Works – Girish Kumar Navani, CEO and co-founder

Change is always hard. However, we seem to have a lower and shorter learning curve for our products and services. It is important that we standardize the measures by specialty in a timely manner and the HIT standards group develops a more standardized LOINC mapping for labs.

Eclipsys – Philip M. Pead, President and CEO

The functionality based criteria should be relatively straightforward and are likely part of almost any certified EHR implementation. It’s the Quality Reporting requirements, which require appropriate structured data capture in the EMR and integrated reporting solutions. Additionally, many of the  quality reporting standards are undefined, or ill defined that will clearly be a challenge for suppliers and providers – especially as quality indicators become more directly tied to reimbursement, or when the ARRA “carrot” becomes a “stick.”

As it stands, as a whole, the healthcare industry does not currently communicate health information well, nor does it aggregate it well enough to see patterns and find trends. Labor intensive manual reporting is a huge cost for hospitals and it only offers views of past events. It will become increasingly obvious that HIT design needs to not only provide access to data, but also the seamless extraction of data for comparative and quality purposes in order to help providers prove they are meeting the meaningful use requirements.

e-MDs – Michael Stearns, President and CEO

While we feel that none of the proposed criteria are onerous or beyond what current EHR users should already be achieving, the need to implement 5 clinical decision support rules and tracking their compliance might be a challenge to some physicians. The tools in the EHR need to be able to facilitate this process without a substantial increase in administrative overhead. For this reason we were pleased to see that the initial reporting period for physicians was a continuous 90-day period; this gives our clients — particularly physicians who purchase from this point forward — time to implement and stabilize their usage with core functions before optimizing for meaningful use.

GE Healthcare – Vishal Wanchoo, President and CEO, GE Healthcare IT

Certainly a 75% threshold for e-prescribing applicable prescriptions or 80% for CPOE for orders may be challenging for some, especially in that first year of meaningful use, in addition to the requirement for the authorizing provider to enter the order.

For many practices, the biggest challenge, especially given the many high performance goals, will be achieving broad EHR integration into the practice.

InteGreat, a MED3OOO Company – Tom Skelton, President

I believe that having physicians reach the 80% level on order entry will be difficult to achieve. Many physicians have traditionally relied on support staff for this function and having that function shifted to the physician will be a challenge. It is a big behavioral change, and one that requires further direct investment of physicians time in the process.

McKesson – Dave Henriksen, SVP and GM, Physician Practice Solutions

Our physician customers — especially those in rural areas — tell us that they feel that the bar has been set very high for a number of Stage 1 measures, such as: CPOE for 80% of all orders; clinical summaries provided for 80% of all patient visits; and e-prescribing used for at least 75% of prescriptions. These metrics could be particularly difficult for providers in small practices to achieve, as well as for those that are in the early stages of EHR system adoption. We will include this feedback in McKesson’s public comments and hope to see these requirements relaxed so they don’t discourage eligible providers from moving forward with EHR adoption.

NextGen Healthcare – Scott Decker, President

Criteria related to interoperability will likely present some challenges for physicians. Providers have not been given much opportunity to share data across technology platforms in the past, due in part to a lack of market development and in part to technology gaps. We are pleased to be able to highlight several of our clients as examples of where interoperability is functioning effectively and benefiting patients as a result. We feel so strongly about the importance of sharing data across platforms that we designed our data portal — called our Community Health Solution — to be interoperable from its first installation in Ann Arbor, Michigan back in 2005.

Another challenge for physicians in day-to-day practice will likely be in the area of clinical decision support (CDS). There is broad agreement that such tools are key to realizing the promise of safer, more efficient, and higher quality care for all patients. The challenge is in creating and implementing clinical decision support tools that actually support care rather than distract from it. A successful CDS solution must be flexible (as clinical guidelines change and new ones are added, the support tools must be able to to change in near real time), scalable (technical solutions that could work for a small number of static conditions may not be adaptable across all specialties and conditions), and fit into the mental and physical workflow of the user. NextGen Healthcare has worked closely with our clients to create solutions that we believe meet these real world needs for the busy practicing clinician.

A final point of concern will mostly likely be the physician’s ability to share clinical information with their patients, and in return, allow patients to provide information on their health needs back to the physician. Our experience is that most physicians today do not have systems in place that share information with other physicians and/or patients. For the past several years, NextGen Healthcare has been offering a tool to our clients called NextMD, which allows secure online sharing of information between physician and patient. While not intended to be a personal health record, the module does allow confidential sharing of data along the lines of the 2011 requirements.

Sage – Lindy Benton, Chief Operating Officer

Overall, we think CMS and ONC got this one right by setting the bar at “meaningful” but making it incremental and leaving some fluidity in the first year. We don’t really see any of the criteria as being terribly difficult to achieve, at least individually, but anytime physicians are asked to make changes to workflow there’s a potential for some push back. In total, the stage one requirements certainly represent a change in workflow for some providers, depending on their experience with technology and their starting point, but if the goal is improving healthcare at the practice and national level, change is required.

Through our programs and outreach with customers, and throughout our discussions with physicians during the sales cycle, we keep the focus on the goals that physicians have for implementing EHR in the first place, aside from the stimulus. The physician goals — the ones that are “meaningful” to their practices, are often the most attainable. Sage has been implementing EMR/EHR systems for over a decade and e-prescribing for even longer, so we have a lot of experiences to draw from where practices have made changes, achieved real results, and are doing things that closely mirror the proposed definition of meaningful use.

Sage has carefully reviewed the NPRM and IFR and, in addition to drafting our comments, we are analyzing the implications for our company and our customers. At this point, while not overly concerned about anything in the Stage 1 criteria, we are mindful of those requirements that relate to things outside the control of Sage and the physicians using our product. Depending on how it is interpreted and assessed, the requirement to exchange information with other stakeholders could prove difficult in the context of fragmented, proprietary networks. At the same time, meaningful data exchange is key clinical and operational improvements and one of the most frequently expressed goals of our physician customers.

SRSsoft – Evan Steele, CEO

Before answering this question, it is important to note an overarching issue: “meaningful use” means that providers must not only adopt and deploy an EHR, but they must also use it in what the government considers a “meaningful way.” The process of defining use in a “meaningful way” has taken the good part of a year, but essentially it comes down to just one fact — the government wants to tell physicians what data it wants, how it wants it, and when it wants it. It must be provided electronically and at a level of detail that is only partially spelled out at this time. In order for any such data to be provided to the government, virtually all data from every exam, medication, order, prescription, report, and test, along with diagnostic and demographic data, has to be entered into “the system” for each patient and each exam.

This is a huge undertaking and a huge burden for physicians and their office staff. It forces them to enter every single piece of data about the patient, the exam, the outcome, and the follow-up into a computer terminal and screen. Physicians will be forced not just to enter all their exam data, but to become experts in system “navigation” and tedious data entry. This will slow things down considerably– not just initially, but for a long time. It will cause providers to see fewer patients and will have a negative impact on their incomes, especially specialists and high-performance physicians.

The answer to your question is based on the more than 5,000 providers we have as clients, mostly specialists. They will not be able to gather and input this volume of data into the EHR without a negative impact on the number of patients they can see and on their revenue streams. If they choose to participate in ARRA, they will realize a major hit to their bottom lines right away.

Aside from that meta issue, there are still some daunting challenges in the requirements themselves. Two measures are particularly troublesome:

• The requirement to perform even one test of the ability to exchange clinical data between different entities using distinct EHRs is unrealistic, given the current lack of interoperability even between EHRs of the same vendor.

• CPOE is a deal-breaker for most physicians. It is simply too time consuming. Prescription ordering is workable, but only with the right ePrescribing technology. Inputting all of the other orders will not be embraced by physicians.

Intelligent Healthcare Information Integration 1/8/10

“Eep!” said the EP

Yowser, yowser. Step right this way. Hear that mighty roar! The magnificent ONCHIT is bellowing his fearsome call. Step right up and see the most amazing, most awe-inspiring, most stupendous definer the world has ever seen! You’ve heard of that other great “decider.” Now, see the definer who makes all deciders tremble with uncertainty!

Yessiree, friends and neighbors, this is the chance of a lifetime. Never before has anyone experienced the awesome wisdom and magnificence of such a giant. In only 700 pages, the grand ONCHIT (Captain ONC to his friends) has laid out the biggest, boldest, most comprehensive plan ever to drive healthcare to the realm of tricorders, to help us all boldly go where no man (or woman) has gone before. Watch out, Bones, here we come!

You, too, my dear friends, can join the crew of the Enterprise for EHRs. For a pittance, a mere trifle of an admission fee, you can join your colleagues and cohorts on the next great mission aboard the starship Meaningful Use. For just somewhere in the low- to mid-five figures, each of you can gain entry and join with us bold adventurers as we attempt to conquer earthbound HIT inertia. You, too, can walk about the bridge and watch as Scottie, Spock, and Sulu execute the mission plan of our courageous Captain ONC and effortlessly navigate the way from tellurian paper processes to Borgian interoperability and integration!

What’s that? What’s that you say? Oh, we have some bright comments from the peanut gallery? Speak up, youngster. Speak on up, kiddo.

Ahhhh…OK…This pint-sized opiner says that watching a bunch of overtrained actors move the mock controls of a Hollywood soundstage “starship” is not really equivalent to manually maneuvering the real gadgets and gizmos of busy medical practice’s “bridge.” He says that adding real deal technology to a hectic doctor’s office is as simple as taking a transporter to Honolulu compared to the foot-wearying Trail of Tears required to change entire workplace workflows. He says Captain ONC seems to have forgotten what life in the trenches is like, what an office staff of people who can barely navigate email are up against when told they have to become computer-faced in order to continue to provide health care. Workflow, says he, is the real Romulan Warbird.

Step aside, son, Ya’ bother me. Never you mind the miniscule lamenter, friends and neighbors. ONCHIT has spoken, almost definitively this time, and the word is wondrous! “Use” has never before looked so meaningful. Step right up, step right up. The show’s about to begin. Don’t miss your chance to join the greatest mission ever devised by medical minds anywhere, on this or any other planet. Climb aboard the Starship Meaningful Use. You, too, can become an Eligible Professional. You, too, can ride this HIT rocket to the stars!!!

(Heard from one anonymous Eligible Professional, or EP, who had just paid his entry fee and finally laid eyes upon ONCHIT’s magnificent starship, Meaningful Use: “Eep!”)

From the (useless?) trenches…

“Many ideas grow better when transplanted into another mind than in the one where they sprang up.” – Oliver Wendell Holmes

Dr. Gregg Alexander is a grunt-in-the-trenches pediatrician and geek. His personal manifesto home page…er..blog…yeh, that’s it, his blog – and he – can be reached through http://madisonpediatric.com or doc@madisonpediatric.com.

News 1/7/09

AdvancedMD, a practice management software vendor, acquires PracticeOne, the company behind the e-Medsys software. AdvancedMD needed am EMR solution and PracticeOne is already 2008 CCHIT-certified. Interestingly,the smaller PracticeOne also offers a practice management system, so likely one of the PMs will disappear.

I sat in on a HIMSS webinar today that provided more clarification on the latest proposed meaningful use and certification criteria. The slide presentation can be downloaded here. If you don’t want to go thought the full 700 page of the original documents, the 57 slides provide a pretty good summary. I thought the best part of the session was the audience Q&A and took note of some of the better questions, along with the answers from HIMSS staff members:

Q: What if a group of doctors pools their money together to purchase their EHR, then one of the doctors leaves. What happens to their $44k?

A: The determination of an EP and incentive payments is not based on ownership or purchase of the EHR.

Q: We bill our employed Medicare claims as hospital-outpatient (place of service code 22). Is it true that this rules them out from being eligible for incentives?

A: Yes.

Q: What are the dates of the first reporting period?

A:  For EPs it’s January 1, 2011 – December 31, 2011. For hospitals, it’s October 1, 2010 – September 30, 2011. (Note from Inga: though the certification criteria does say October 1 to September 30 for hospital payments, my interpretation is that the committee is recommending that the start of the first reporting period be pushed to January 2011. The reasoning is that vendors and hospitals would have more time to prepare.)

Q: Am I correct that an EP cannot begin reporting until 2012 and not lose incentives?

A: You are correct. And 2013 for hospitals.

Q:  So what is the incentive for a provider to start in 2011 instead of waiting until 2012?

A: Payment will be sooner.

Q:  To count as CPOE, must the provider personally (hands on keyboard) enter the order, or may physical entry of the order, under the provider’s direction, be done by other staff?

A:  The reg states “directly”

Q:  Do nurse practitioners qualify as EPs? What about physician assistants?

A:  Nurse practitioners only under the Medicaid incentive program.  PAs only under Medicaid in some circumstances.

If you have any questions about the latest proposed guidelines, feel free to drop us a note. Mr. H and I pledge to track down answers from our wealth of experts.

KLAS reports that 85% of healthcare providers believe their ambulatory EMR software will enable them to meet the 2011 meaningful use deadlines. Epic, NextGen, and athenahealth customers expressed the most confidence; SRSsoft and Amazing Charts clients expressed the least. KLAS says that of all the products reviewed, only Allscripts Enterprise had 100% of interviewed clients able to digitally transmit qualifying orders.

Speaking of Allscripts, Mountain States Health Alliance (TN) selects Allscripts EHR/PM solutions for its 300 employed and affiliated physicians.

CMS says that healthcare spending rose at a record low 4.4% rate in 2008 due to the recession, but still reached $2.3 trillion. That spend represents over 16% of the US economy.

MeritCare Health System (ND) says they are looking to add a new EMR and expect to spend $10 to $15 million over the next five years. The organization includes over 400 providers across 42 locations.

Ten-provider Orthopaedic Center of Southern Illinois chooses the SRSsoft EMR after its free trial, saying the docs are saving 30-60 minutes each per day.

eClinicalWorks partners with Krames to offer patient education tools for practices using eClinicalWorks 8.0 software. The patient education will tie to patients’ individual medical records and also be available via the eCW Patient Portal.

Aprima adds HIT Systems as its latest reseller.

The 42 physicians at Asheville Radiology Associates select AMICAS Financials for radiology billing, AMICAS Dashboards for BI, and AMICAS Patient and Payer Services.

George Washington University Medical Faculty Associates (DC) pick RealMed for electronic claims processing and adjudication.

Trinity Health (MI) buys 1,200 bundled EHR/EPM software licenses from NextGen, increasing its rollout to all employed providers in its network.

A man walking to the grocery store finds a bunch of patient medical records scattered on the street. Rather than call the home health agency whose name was stamped all over the paperwork, or even the police, he calls the local news station. The TV station collects the paperwork and pays a visit to the agency. The manager admits a staff member accidentally lost a bag with the charts and wasn’t able to get all the paperwork back. Rather than give the agency the papers back, the TV station contacts the state attorney general. I’m all for patient privacy, but why does it seem everyone wants to get a moment in the spotlight rather than just do the right thing?

E-mail Inga.

Joel Diamond 1/6/10

On Meaningful Use

“The word ‘meaningful’ when used today is nearly always meaningless.” -Paul Johnson

Seems like everyone today is searching for a meaningful experience. Everything from bowel movements to watching a television series needs to be “meaningful”. It should therefore come as no surprise that the meaningful adoption of HIT should also be debated so passionately.

I just plowed through the 500+ page Department of Health and Human Services Electronic Health Record Incentive Program that is intended to define meaningful use and found the exercise to be quite… meaningful.

I know that many of you are cynical about the topic, but think about it. It really makes sense. The government just can’t rationalize massive financial payouts without a precise measure of benefit. OK, I guess there are a few exceptions… Wall Street financial firms for one, but never mind that… and oh yeah, I guess the pharmaceutical industry essentially getting a blank check from Medicare, but ignore that too. It only makes things more confusing.

In Sections 1848 (o)(2)(A) and 1886(n)(3) of the Act, the Congress specified three types of requirements for meaningful use: (1) use of certified EHR technology in a meaningful manner (for example, electronic prescribing); (2) that the certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of care; and (3) that, in using certified EHR technology, the provider submits to the Secretary information on clinical quality measures and such other measures selected by the Secretary.

Now we’re talking! I provide quality care. I use a certified EMR. I’m connected. I just need to periodically send stuff to the Secretary and the cash comes rolling in. (I admit that I’m a bit confused by the “other measures” thing, but I doubt that it’s that important.)

To the uneducated public, the goals and requirements sure seem to be a dose of good old-fashioned common sense. For instance, everyone wants their doctor to “provide summaries for patients for each office visit”. And who couldn’t be moved by this:

“Meaningful use of certified EHR technology should result in health care that is patient-centered, evidence-based, prevention-oriented, efficient, and equitable.”

Sounds lofty, but try substituting a word like “nursing” for “certified EHR technology” in the above quote and you’ll quickly realize why trying to regulate the obvious becomes inane.

Therein lies the problem. Many of the requirements either set the bar too low or seem to be an obvious functionality of EMRs. These include: “maintaining an active medication and allergy list”, or having a chart with demographics and basic vital signs recorded.

Provisions for decision support and information exchange, on the other hand, are worthwhile pursuits, but may be more difficult to achieve.

The CPOE requirements will have minimal impact. Bigger hospitals will figure out how to meet the measly 10% CPOE requirements by mandating use for house staff or emergency departments.

This is my biggest concern about the proposed measures. Much like the current E/M coding nightmare, insane attempts to limit “gaming the system” only serve to create a whole cottage industry devoted to — gaming the system!

I can’t help wondering when the real incentives will occur — that is, when a free-market public, confronted with a transparent medical system, will be allowed to make choices based on “meaningful value”.

In the mean time, I’ll try to get all that I can.

To paraphrase Dudley Moore: “I’m always looking for meaningful one-night stands”.

Joel Diamond, MD is chief medical officer at dbMotion, adjunct associate professor at the Department of Biomedical Informatics at the University of Pittsburgh, and a practicing physician at UPMC and of the Handelsman Family Practice in Pittsburgh, PA. He also blogs on interoperability.

News 1/6/10

HERtalk by Inga

In yesterday’s HIStalk Practice I touched on a few nuggets of information about the latest EHR meaningful use recommendations. I might add it is worth a read because there are some points Mr. H and I haven’t seen covered elsewhere. (And while you are there, sign up for the email updates.) One particularly confusing item relates to the timeline for proving meaningful EHR use in order to earn incentive dollars. I tried to summarize a bit on the timeline for getting money, but because it is particularly confusing, I decided a graphic might help. For those that want to follow along at home, this information is found around pages 23 to 31 in the larger, 557-page document. As I interpret things, to qualify for stimulus money during 2011, a hospital or eligible provider (EP) must demonstrate meaningful use of EHR for “any 90-day period within the first payment year.” The earliest possible start date for that 90 day reporting reporting will likely be January 1, 2011. And, the latest day to start a 90-day reporting period and still qualify for 2011 monies is October 1, 2011. After earning incentive money in the first year, entities will be required to prove meaningful EHR use for a full year, starting on January 1, in order to qualify for second year funds. Thus, if an entity qualified any time during 2011, it would have to continue to prove it used its EHR meaningfully from January 1, 2012 to December 31, 2012 in order to qualify for the 2012 incentive funds. And, if the entity doesn’t try to qualify for the first time until sometime in 2012, then it must prove meaningful use for the full year beginning January 1, 2013, to get the second year funds. And so forth. If someone interpreted things differently (or can explain this better), please advise.

athenahealth signs a deal with Caritas Christi Health Care to provide EHR for its 500 employed providers. Caritas, which already uses athenahealth’s RCM service, will also offer athenaclinicals to 1,200 affiliated providers. Caritas also offers its physicians an option for eClinicalworks. Todd Rothenhaus, MD, the CIO for Caritas confirmed with me that Caritas now plan to offer both products.

I was talking EMR with a girlfriend at lunch today (isn’t that what most gal pals do?) and we agreed that we can’t think of any providers that currently enter 80% of their orders themselves. If we thought hard enough we’d probably have come up with a doctor that uses e-prescribing 75% of the time (but we thought of lots of reasons why a patient and provider might prefer the paper prescription.) And, we couldn’t come up with a single small office group that is currently capable of sending patient data electronically to other providers (often times because the receiver can’t accept the data.) The one bright spot is that the recommendations clearly state that “documenting a progress note for each encounter” is not a requirement for proving meaningful use. Otherwise, the mountain is high.

QuadraMed names Thomas J. Dunn senior VP of sales and marketing. Dunn’s a former Eclipsys VP and spent 22 years at SMS/Siemens.

Ridiculously sad, any way you look at it. An unemployed, unmarried 35-year-old mother of nine sues three doctors and two nurses, after she was permanently sterilized against her will. The mom was delivering baby number nine via a planned c-section and and asked for an IUD to be implanted immediately after delivery. Instead, the doctors performed a tubal ligation.

Cerner lands a couple of big deals with Tenet Healthcare and Universal Health Services. Tenet plans to add Cerner applications in 33 new hospitals, bringing the total Tenet/Cerner shops to 47. Universal will take advantage of Cerner’s remote hosting capabilities to implement the product across 24 acute-care hospitals.

Trinity Health (MI) buys 1,200 bundled EHR/EPM software licenses from NextGen. Trinity purchased 400 licenses in 2006 for some of its employed providers but now plans to roll the software out to all employed providers in its network.

Happy 2010, by the way. The ever-generous Mr. H gave me a bit of time off during the holidays, but now I am back at it. Mr. H and I have each waded through pieces of the latest meaningful use documents, in hopes of becoming industry experts. Unfortunately, at least in my case, more wading is required. I was hoping there might be some clarification about what exactly a “certified EHR technology” is. Of course “CCHIT” is never mentioned anywhere, even though it seems a given that CCHIT will be a requirement since they are the only certifying body out there. Why can’t the Secretary or the ONC come right out and say it’s CCHIT 200x for now. That way buyers know what is required and vendors know what they need to do if they want to participate.

Send Inga meaningful words.