HIStalk Practice Interviews Neil Zimmerman

Neil B. Zimmerman, MD is a physician with National Hand Specialists of Baltimore, MD.

Give me a bit of background on your practice.

We, my partners and myself, have a very, very large hand practice. I think we might be the biggest in the country. In fact, I know it’s the biggest in the country at the present time. We’re affiliated with the National Hand Center in Baltimore. My office, which is nine physicians — we’re all hand surgeons.

“Hands” is a bit of a misnomer, but hand is the entire upper extremity, fingertips all the way up to the shoulder. We are a combination of orthopedic and plastic surgery specialists who just do upper extremity stuff, but that can involve arthritis, nerve compression like carpal tunnel, a lot of microsurgery or tissue transfers.

The way that the practice works is that it’s a very, very high volume practice; on a typical day starting at 8:30 a.m. until about 5:00 p.m., I see somewhere between 40 and 50 patients and I do that three days a week. My partners’ practices are similar.

Needless to say, we were anxious — beyond anxious — to even make a transition into electronic medical records of any type, simply because of the volume. It is a complex practice; it’s not cookie cutter as far as these patients. A lot of them are second, third, fourth opinions. A lot of them are legal matters that require all these long reports that we have to write.

We were highly trepidatious about a lot of the programs that were out there. The physicians were totally maxed out as far as what we could do seeing patients. We did not have, physically, any face-time available for the patients.

My office manager, another person, and then myself looked at a lot of these different electronic medical records systems. Every one of them came in there and they said, “Well, here’s what we can do for you. We can do this template, and that template.” I said, “Time out, hold it. My job and what I’ve been trained to do, and what I enjoy doing and how I really make a living is not the clerical or support end of this. It’s my face-to-face time with these people and being able to listen to them and care for them and interact with them.”

I said, “If I’m just going to be doing a template here, there’s no way I can do what I want to do.” I said, “We need somebody who’s going to respect that.”

These folks from SRS came in there and said, “OK, our job is to let you guys do what you do. We’ll figure out the rest that goes with it.” It probably took nine months, six to nine months. We talked to the transition team. They called and we had conference calls. We dissected the way that everything in our office moved. From patients getting in the door until me seeing them and taking care of the notes. We were, at that point, doing regular transcription; and we discussed how the transcription came back and how it was routed it and everything.

I’m sure as every other medical group, we had one or two guys that were interested in making a change and seven guys who weren’t. Some of which were vehemently opposed to the electronic medical records of any type. We had long, extensive planning on how to move forward through this. Instead of trying to intimidate people into using it, we used the carrot approach. I started with the guy who sits next to me who was also upbeat and really up on the thing.

We went from having a group of nine people who didn’t even want to be in the same room with any electronic medical records to try and decide who would be next to get on the band wagon with doing this thing. It has worked out extraordinarily well for us.

We were real careful, as far as our integration, inasmuch that I didn’t want to do everything. I figured we could just get up and running with our EMR system and hold off on the e-prescribing. I’m an orthopedist mainly, so with additional radiography we’ve got coming this upcoming year, we just didn’t want to do too much for fear of breaking it down.

Among orthopedic practices, we had heard so many nightmares. It’s like, “Oh my God, I can’t see patients,” the doctors are saying. “We’re not doing this, forget it, I’m outta here. Just let me take care of patients and take the thing out of my office,” and that kind of stuff. So we were really worried about this thing, but it has worked out just great for us.

What is it that SRS did differently than the other programs that you looked at?

What they did is they looked better from my point of view as a physician. This sounds arrogant, but reality is that it has to be doctor-centric. It has to be based upon me being able to see my patients and take care of them without really changing a lot of what I do in order for me to continue to provide the care I wanted.

For me to sit down, sit in that room, and pull down a bunch of pull-down menus and click-in boxes and do all this typing — that’s not what I do for a living, nor do any other doctors that I know. A lot of people in the hospitals have EMR systems like that and the physicians all dread doing it. But I still carry my digital Dictaphone in my pocket. I see my patients, I crack out my dictation very expediently, and I’m in with the next one. Then my stuff comes back to me, all my paperwork and my labs and everything.

But I’m very, very mobile now. I never know when I’m done with surgery. Some days it’s 1:00 p.m., some days it’s 4:00 p.m., but I just said, “Okay, I’m out of here,” because I can take my laptop, or I can even use my home computer and just VPN into our system and I’ve got every piece of paper that I can if I’m sitting in the office. For me, it got me out of the office today — I was done at 1:00 p.m. — it got me out about three hours earlier because I wasn’t sitting doing all my stuff there, which I normally would be, or taking home all those charts.

How do you interact with the EHR? What type of information are you looking up? And what information are you actually keying in?

I’m keying in very little, looking up a ton. I have it with me at all times. I have a tablet when I’m seeing patients or when I’m in the operating room. I go and I look at it before I even talk to anybody, to review their medical history. I mean, I know what procedure I’m doing, but I don’t remember all the little details like who’s allergic to what or exactly what the numbers of their nerve studies were.

I go to the computer, I look at their name, and I remember what their nickname is. If they’re allergic to something. And then I go out there and I look like I’m a genius. They’re like, “Oh, you remembered I go by Cookie” or something like that. So I make all these little notes to me.

Then when I’m done with my surgery, I dictate my notes. That will come back within a day. Then all I have to do is just quick-sign it because I dictate it to myself. I don’t have to proof it. Some of the more complicated reports that I do, like medical/legal stuff, have three or four pages. I have these IMEs that come with a list of questions from attorneys or insurance companies. I do a bunch of those. I see them in the office and I dictate my report.

A couple days later, it comes back into the SRS system and what I do then is I open up the document, and it opens up into Word, and I edit it. I mean, the regular routine carpal tunnel or kid with a wrist fracture stuff, I don’t need to edit. But these legal ones that someone’s going to be looking at with a yellow highlighter, I go through it word by word and I edit it and do all my other stuff. Then I take the edited document, I send it to my secretary or whoever, who sends it to whoever wanted it. But I can do all that stuff at home now, which is so much better than sitting there doing it on paper.

What practice management system do you use?

We’re using Misys now. We have all kinds of different Misys systems. Do you want to hear how we got to the SRS thing? Because we originally were going to do the Misys EMR. Misys scared us because we were a real early adopter or accepter of their practice management system. They said, “Oh, a couple years we got coming down the line with EHR, you’re going to like it.” They brought it in. I probably looked at it three times. Every time they brought that thing in there it wouldn’t work.

Then they kept saying, “You can do this, you can do this, you can do this.” I said, “I don’t want to do this.” I said, “I want to do what I do.” He was like, “Well, if you use this you have to make a template and do all this stuff.”

Then we went and looked at a couple other practices that were using that system successfully, but it just wasn’t fitting for us. I’m sure it’s fine for some people or for some kind of practices. But surgeons in particular, I think — again this sounds bad; forgive me — there’s a little bit of the personality … it’s a little more of an aggressive personality. It’s like OK, I’ve got to operate on these people, this is the way I want to do it rather than kind of ‘I’ll go with the flow’ thing. I mean, you wouldn’t want a surgeon that came in and said, “Well, I think I could fix this.” You go, “I can fix it.” It’s the same kind of thing. They want the system to work the way they did it.

So anyway, that’s our long story. We’ve been up and running now for 15 months, I think.

Do the SRS and Misys systems integrate?

It’s been great. It was far less of an issue than I thought. It downloaded the demographics from the practice management system. We’re buying a digital radiography system. I looked at a lot of them, but I wanted one that SRS would stand behind. They are marketing one now called Fusion. Reason being that as much as it just totally integrates and slips into that thing and the startup was so good with the EHR thing, I said, “If we’re doing it, these people did such a good job before. This is the one I want to go with.” Next couple weeks we’re changing — some of us are changing — to Dragon as far as with digital dictation. That’s going to be a change for me though.

Did it concern you at all that the SRS is not CCHIT certified?

CCHIT, what’s that?

CCHIT? I guess it didn’t concern you if you’re not familiar with it! It’s a certification that will likely be required in order to get economic stimulus money.

No, and I’ll tell you why. I thought about that, at length, and the information that you’ve got to provide to get that stimulus. First of all, I don’t see how I could ever do that in my private practice because one of the requirements is that I have to be able to distribute to my patients information about preventative care.

It’s like, that’s just one of them, but the information that would be required for me to provide would require probably, a substantial part of another employee, which would override the $40-some-odd-thousand that we would make, if we even get it back, from that stimulus money. So I said, “Forget it.” I said, “It’s a good idea, but it’s cheaper for me to not worry about that and move forward than to try and comply with what they wanted out of that.” So, no, that does not bother me one bit.

I was concerned at first. I go, “What the hell is this all about?” Then I realized and I did some more checking and I go, “No, I don’t want to do that anyway.”

What kind of return on investment have you seen so far?

Probably minimal to none, and I think that I’m about as busy a private practice as you can get, I think. I think the reward is going to come later, but if you’re really honest with the money that you’ve got to put into an EHR, it’s going to be a negative investment for quite a while.

We have not eliminated any employees. We’ve transitioned filers to scanners. We’re going to redo our office, at some point, to have more patient care space, which I actually think is going to translate into money. I’ll tell you what will eventually translate into money, but it’s somewhat non-tangible, and that is that our billing efficiency has gone up, I think in part due to this because we no longer have to play where’s-the-chart to do the billing.

I was worried when I started this that I wouldn’t be able to see as many patients, but my productivity actually went up. But it’s really hard to quantitate that, and that wouldn’t apply to all practices. But we’re lucky enough to have to turn people away. So if we could see more, it’s great. But if we weren’t running ‘at mass’ appointments already, it wouldn’t ever come to be.

Last question here – why do you feel that EMR adoption continues to be so low among physicians?

Honestly, physicians are scared to death; and we’re scared to death about the healthcare thing coming down. We don’t know whether we’re going to get cut big time, or we’re not going to get cut — temporarily. A lot of physicians feel very much under fire. This is the first time in my 23 years of practice that I’m looking at a pretty dismal outlook for the upcoming year as far as income. Even if I see as many patients, I think I’m going to make less money with the same productivity level. That’s the number one reason.

But if you want to turn the clock back to before that whole stuff started, the main reason is it’s expensive. We’re nine people. It’s a nine people, high-volume practice and it costs us a lot of money. I think that’s something awfully large to bite off for a private practice. Especially if you’re really honest and say, “What’s the short-term return? What’s the long-term return?” It’s huge, just because of your productivity and not filing your stuff. Right off the bat, nobody’s writing you a check; you’re not going to see anything back on it. It’s a long-term bond.

I could tell you what some of my partners said. It was, “I’ve been doing this for 30 years. I’m not changing for anybody what the hell I do.” I mean that was a real common one. It’s like, “Screw this. What do I have to spend money for?” Those of us that prevailed said, “OK, long-term, in order to store our files, we’re going to make more money. It’s going to be more lucrative if we do this thing electronically.” But they’re looking for a check that’s not coming.

I hope I don’t hurt anybody by saying that about the return on investment, but that’s the truth. The return on investment is short. I’m not going to tell you you’re going to make a lot of money on it right away, but eventually — maybe.

News 1/28/10

From Willie Morris: “Re: keynote speakers. We have been planning our annual user conference and, in brainstorming about possible keynotes, I wonder if you or your readers might have recommendations on someone new and different to help inspire and entertain our clients this year? We’re obviously looking for someone with understanding and background in HIT/PM/EHR, but the ability to generate laughter doesn’t hurt either!” Interesting question. I’d nominate Mr. H, but he’d have to do it behind a secret screen and use a voice changer. Suggestions, anyone?

Steve Jobs and Apple unveil the new iPad, which Jobs calls a device that sits between the laptop and the smart phone. Jobs claims the iPad is better than the other devices for such things as browsing the Web, reading e-books, and playing video. The iPad will run most of the 140,000 (and counting) applications currently available for the iPhone and will be priced between $499 and $829. At 1.5 lbs, 10 hours of battery life, and a 9.7 inch screen, it won’t be too difficult to carry around all day. It’s too soon to tell what kind of impact the iPad will make in healthcare, but I am sure plenty of vendors are itching to check one out.

Dermatologists and medical oncologists are more likely to communicate with patients online than their peers in other specialties, or so this Manhattan Research report claims. Overall 39% of physician use e-mail, secure messaging, or instant messaging to communicate with patients, which is a 14% increase since 2006.

Duane Reade drugstores and Continuum Health Partners (NY) say that their joint program to place physicians in Duane Reade pharmacies is a success. For the last two years, Continuum has provided physicians for in-store clinics at four Manhattan-area Duane Reade pharmacies. The arrangement does not include the exchange of any money between the company and the health system. Instead, Duane Reade benefits with increased retail sales and Continuum is able to schedule future appointments at one of their own facilities. Officials say that their model is a success, in part because physicians provide the services, rather than PAs or NPs. Look for the opening of another 20 clinics over the next year.

McKesson and HP announce they are collaborating to accelerate EHR adoption among independent physician practices. The companies are bundling McKesson clinical and PM applications with HP solutions and including training, implementation, and local support. The program will be executed through HP distributor Tech Data. Good move, I’d say. McKesson seems to recognize that most practices, unlike hospitals, lack the internal resources required to coordinate the technical aspects of an EHR installation. And, despite how popular SaaS is becoming, there are plenty of providers who still insist on an in-house server. Offering a turnkey solution is going to appeal to a large constituency. HP is also a winner here because it’ll have a chance to increase its footprint in the small physician office space, a market where they’ve not been much of a player.

Speaking of McKesson, they just released their Q3 numbers:  revenue up 4%, EPS $1.19 vs. -$1.12 (although most of that prior year’s loss was because of their AWP settlement). That beats Wall Street estimates. Technology Solutions didn’t do so great, with profits down 11%, although some of that was due to amortization of its revenue management product that went GA during Q2.

As healthcare moves into a digital era, physicians are wondering how much medical record data to provide patients. The debate stems from the fact that patients often don’t understand what they are reading and its context. Patients can become needlessly upset by routine “abnormal” lab result. Providers argue that information to patients should be filtered to  reduce the need to interpret the details for the patient. Of course consumer groups believe patients have a right to see everything. And the debate will continue.

Day Kimball Healthcare (CT) selects athenaClinicals and athenaCollectorM for its network of 200 physicians.

Greenway Medical says that over the last year, more than 30 healthcare systems, PHOs, and IPAs have selected its PrimeSuite for their employed or affiliated physicians. New clients are  include the 1,400-member IPA Genesis Physicians Group (IP), Detroit Medical Center, and Bloomberg Health System (PA).

HHS is encouraging the public to comment on the latest proposed Meaningful Use criteria. Some comments have been posted and I’ve read through most of them. Here’s a sampling of what’s out there:

We are a small rural health clinic with eight providers but have been very aggressive in using information technology. We purchased and installed Practice Partner electronic health system in 2002. All of our providers have been using and completing their progress notes in the EHR since 2004 when we quit pulling paper charts. We have lab interfaces from the external lab vendor and the local hospital. I have only read the first 103 pages of this proposed ruling and have been focusing on what we will have to do to receive incentive payments as an early adopter in 2010. I find myself discouraged that we will ever be able to comply with this meaningful use definition. I also reflect on the last eight years of using the EHR and wonder how a new user of an EHR would qualify as well. Just installing and getting everyone using electronic records is a difficult task. So I believe that this version of meaningful use is too aggressive for the first year. Plus many clinical areas will need IT infrastructure like cabling, networks, servers and workstations installed multiplying the complexity of the first year adoption of the EHR. So, I would like you to consider making the first year measures the use of the EHR with items like Electronic RX, In-Clinic orders (not 80%), Vitals for over 50% of visits and use of the EHR to the point of not using paper charts for the majority of patient visits. Then slowly increase, at an increasing rate, the requirements over the next years. If the goal is to get the majority of clinics using EHRs and to provide incentive funds to help the economy then the first step of incentive payments must be easy to obtain.

All and all, a very thoughtful and compelling post. On the other hand, some of the comments were short on specifics, but straight to the point. Like this one:

This is a steaming pile of crap. If one could imagine what the worst possible outcome of the process of creating these rules could be, this is it. These are rules that only a bureaucrat could love and will not help increase the implementation of EHR. 556 pages?! You are out of your minds if you think this is helpful or necessary. What a waste of time and money… This is so disappointing I almost cried.

I had to smile.

E-mail Inga.

News 1/26/10

Several Florida physicians, lured by a reseller’s promise of ARRA-funded billing software, complain of unauthorized charges and a training session that lasted only one day. The reseller says the doctors “are all in a clique together” and sends cease-and-desist letters to prevent them from going public with their gripes. His trainer says the doctors didn’t know how to use computers and seemed scared to use a mouse. Even one doctor whose got everything free because she’s a former TV reporter was so unimpressed that her promised product endorsement wasn’t enthusiastic enough for the reseller, so he denied her access to her patient records on his server and sent her a software bill. The reseller doesn’t sound like he’s ever heard the term “the customer’s always right.” More importantly, I doubt  these docs did their homework before buying their system and thoroughly checked out both the software and the vendor. And, likely no one handed the contracts to a lawyer for review before signing any agreements.

The American Academy of Family Physicians says the latest meaningful use guidelines pose hurdles to small and medium medical practices and their ability to earn incentive payments. The organization supports the overall goals for meaningful use, but believes the administrative requirements may be too much of a burden for practices.

Sage North America Healthcare appoints Betty Otter-Nickerson as it new president. Otter-Nickerson was most recently COO for the LiveStrong Foundation, aka the Lance Armstrong Foundation. Before that she served in executive roles at various software companies. Speculation had been brewing for months that Sage was looking for someone to lead the healthcare division, so perhaps the segment will now have the opportunity to shift the focus back to its core EHR and PM business. I might add that I like that Sage has put a woman in this top role, since the HIT vendor world seems dominated by men.

Digital Healthcare announces that over 1.2 million diabetic patients received Retasure eye health assessments in 2009.

NextGen launches a Certified HIT Consultant Program, which will provide training certification for implementation consultants. Reading between the lines, it sounds as if NextGen is trying to improve its position in light of the upcoming Regional Extension Centers. The RECs will help end-users with product selection and provide free EMR training. NextGen figures that  if doctors know there’s an option for free training on NextGen, they are more likely to buy the NextGen product. NextGen may lose some revenue on training, but will still have a shot at selling software licenses.

As of the end end of 2009, the iPhone offered 1,900 different applications, which is about 1,600 more than the second place HTC Pro. Experts say that most doctors will select a phone based on the available applications. Just like with EMRs, however, doctors should also consider what they primarily want to use the phone for and its ease of use supporting those primary functions.

RCM solution provider ZirMed achieves full accreditation with the Healthcare Network Accreditation Program from the Electronic Healthcare Network Accreditation Commission.

EHR and HIE vendor Soren Technology selects MedFile as its exclusive PHR vendor. Soren, by the way, says its suite of EHR products is offered at “virtually no charge” and offer “Meaningful Use components.” I have no reason to believe Soren is not a solid product. However, I stand by my advice above that buyers do their homework to avoid potential misunderstandings and frustrations.

If you need a bit of inspiration, read this Partners in Health report of the collaborative efforts to save a Haitian newborn in Port-au-Prince. Along with a team of other heroes, an orthopedic trauma surgeon from Grand Rapids, MI draws 60 ml of his own O negative blood into a regular syringe in order to help save the baby. The baby was stabilized and eventually transferred to an American military hospital. Sadly, PIH Medical Director Joia Mukherjee predicts the situation in Haiti will get much worse very, very fast.

Educators at the University of Illinois at Chicago College of Medicine believe most medical school curricula do not adequately prepare students to diagnose and treat patients using an EHR. The research professors found students had difficulty finding the information they needed and recommend incorporating training in EHR skill.

Later this week we will post another one of our physician interviews. When I asked this latest doctor if he was concerned because his EMR was not CCHIT certified, his (totally serious) response was: “What’s CCHIT?”  I had to laugh a bit at myself and the situation. It served as a great reminder to me that just because you are a clinician doesn’t mean you are living and breathing meaningful use, CCHIT, interoperability, and the like. By the way, we’re always looking for interesting interview subjects, particularly physicians using technology in their practices. If you or someone you know would like to participate, drop me a note.

E-mail Inga.

Intelligent Healthcare Information Integration 1/23/10

PAPER and EMR: An Intimate Conversation

Perhaps within a post enchilada and black bean quesadilla dinner dream, but somewhere, I swear, I overheard the following chat, mostly in whispers, very, very late one night …

PAPER: Pssssst…psssssst…hey, you, digi-boy…you awake?

Electronic Medical Record (EMR): Huh? Wha…? Yeh, guess I am. The newbie musta forgot to log out. What’s up, P?

PAPER: I couldn’t sleep.

EMR: Well, no wonder. You get to nap all day long, whenever you want. Some of us get pointed and clicked on all day.

PAPER: Whoa…hold it, pal, I still have my moments of value. You haven’t taken over everything in this joint, yet. Remember, last week when the power went out? Only me, some cloudy daylight, and a few emergency-powered lights were around to keep the patients percolating through the practice. You closed up shop just as fast as your little UPS could shut you down.

EMR: Yeh, well…

PAPER: And, remember last month when your Internet pipe pooped out? Lotta good “Web-based” does you when the road to it gets washed out.

EMR: I know. It does keep me a tad edgy being so dependent upon somebody’s wires or satellites. Still, for as hard as I work and as much as I can do, I think I more than make up for my weaknesses. Criminetly, you can’t even do your work unless somebody’s holding your hand. You’ve never had the common courtesy of letting someone access you from afar.

PAPER: Yeh? Well, your short-term memory doesn’t hold a candle to mine. All I need to do is see something once and it’s mine. Somebody pulls a plug while you’re listening to a long monologue and that info hits the ethers. Whoosh. Vanished. Shoot, you could even forget a whole days’ worth of data should the nighttime backup fail and some zitz hit your RAID.

EMR: Maybe my memory has a few less-than-solid links, but my cousin has this “fail-back” or “fail-over” or “fail-something” thing that keeps his memory even sharper than yours! Everything that goes into him is retrievable from moment one; you ever try to translate some of that scribble jibberish you call “data?”

But, that is so like you…mentioning the unlikely as if everything should be based upon that. Remember the fire of ’04? Your short-term memory didn’t do anybody any favors that day. Hector’s pup, even your long-term memory was a crispy little critter. Me? A new PC body and my recall was total, complete.

PAPER: OK, fine, I’m sorry. I didn’t wake you to start a squabble. It’s just that all I seem to hear these days is about how wonderful you are, about how you are the future. It has me a little concerned for the practice.

EMR: OK, I’ll bite. How so?

PAPER: Don’t get me wrong; you’re a heckuva nice guy. You’ve got loads to offer and are just built for the 21st century. I know I can’t hold a candle to your overall prowess. But, I’ve done this for years, you know. I remember when we used to always see 30, 40, 50, and sometimes more, patients per day. Sick folks needed our help and we were there to provide it – when they needed it. Now, since you’ve taken over most of the grunt work, we’re lucky to eke out 25 visits…on a good day.

EMR: IT’S NOT MY FAULT! I CAN FLY! It’s these pokey point-and-clickers and those two-fingered typists who are so infuriatingly slow. You know how fast I can run with a full load!

PAPER: I know, buddy, I know. But, regardless of who’s the rate-limiting step, the practice is slowed down; less people are getting cared for and the Accounts Receivables fellow said the cash flow has taken a real hit. I’m worried.

EMR: So what do you think we should do? (Though I’m not sure we have a say in the matter.)

PAPER: Maybe if we work together, maybe if we get them to incorporate a part of me with a part of you…at least for a while until they can get their skills and this whole workflow readjustment thing under control…

Honestly, I know my days are numbered. Shoot, when you’ve been around for a couple thousand years, I’ll bet you won’t look so spry. But, still, while I still can, I want to help. I care about these issues, this practice. I want to help, as best as I can, for as long as I can. I think I still have a few useful services you haven’t outpaced, you know.

EMR: I know you have, Paper, old pal. Maybe we can work together to help the practice find a better middle ground. Use some of your familiarity along with my connectivity to keep things snappy while we work on your retirement plan. Think we could get the organics to listen?

PAPER: Who knows? They’re kind of trendy, faddish, even. Getting them to think as clearly as you and I may be nigh on impossible.

EMR: (Sigh) Don’t I know it…ssssssssshhh…I think I heard footsteps.

From the (dreamy) trenches…

“Coming together is a beginning. Keeping together is progress. Working together is success.” – Henry Ford

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.

EMR Vendor Executives on Meaningful Use and Certification Requirements – Part Six 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 criteria do you expect to be changed after the comment period?

Allscripts – Glen Tullman, CEO

Just to clarify what we’re discussing, there are two rules under consideration within HHS – the IFR and the NPRM. The Interim Final Rule (IFR) relates to the standards, implementation and certification requirements – in other words, what our Electronic Health Records need to be able to do in order to be certified. We are making recommendations for changes which will include the following:

• Requiring use of a patient portal to provide patients with clinical summaries of an office visit . . . why should we wait until 2013 to use portals when much of the population already accesses portals for all kinds of services every day?
• Requiring use of the UNII standard for the management of medication allergies in the 2011 criteria, rather than waiting for 2013.  We are convinced this would dramatically increase quality, and we are not alone.  Why not press the vendors to make these changes now?
• A stricter approach to problem lists (by allowing only SNOMED CT and not ICD-9). This would require changes, including in our own systems, but we know that a single standard would improve patient safety and the quality of healthcare. Again, if we want a better healthcare system, let’s demand it from our vendors.
• Adoption of the new Health Quality Measures Format (HQMF) that will make quality measures and Clinical Decision Support interoperable.  Interoperability is key to allowing our physicians access to the information they need to deliver the appropriate care and avoid duplicate care. Imagine if bank ATMs didn’t interoperate?  It would be impossible to provide access and reliable protections for our money. Why not demand the same standards of care and quality for our health care?
• Disallowing modular approvals of EHR functionality in favor of a more comprehensive approach to certification. We’re opposed to the modular approach because we believe it could endanger patient safety. While we await the next IFR on certification – which we hope will shed additional light on this matter in the coming weeks — we are very concerned that taxpayers might be in the position of subsidizing solutions that simply don’t work and/or don’t work together.   A patchwork of components can never provide the rigor of testing, integration or single-source support and service that a comprehensive solution provides. The Electronic Health Record is not a hobbyist PC built in a neighbor’s basement for playing computer games; it’s a tool that helps in the delivery of the most important profession on Earth – medicine. Imagine if crash testing for our automobiles, another safely issue, was done piecemeal rather than comprehensively. What’s most important is how the components of a system work together.

The Notice of Proposed Rule Making (NPRM) covers the broader Meaningful Use requirements and is a very long and nuanced document that describes what our clients will have to do to earn the ARRA incentives. We definitely expect some changes to the NPRM, especially in the areas where HHS clearly welcomed additional comments.  An example of this might involve the broad scope of clinical quality measures to be submitted by providers or the eligibility criteria for providers who perform services in a hospital setting.We take the position that physicians who provide ambulatory services in a hospital setting should be able to qualify for the HITECH incentives. We suggest that HHS needs to take a closer look at defining criteria for appropriately excluding physicians who work with inpatients from those who are doing outpatient work in a hospital-owned facility. To accomplish this, we suggest Medicare take into consideration whether a CPT claims code is for outpatient services, even if the place-of-service code indicates a hospital setting.

Approximately 25 percent of physicians operate in an environment that is in some way tied to a hospital, and to exclude such a large group of physicians from the HITECH incentives would run counter to the spirit of the legislation and its goals.

Overall, we applaud the difficult work that brought us to this point and we have been, from Day 1, supporters of the concept of meaningful use. Now we have to aggressively push vendors to make their systems better (they will if the Government demands it) and strongly encourage our physicians to adopt these systems, which the ARRA incentives and penalties are doing.

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

It will be no surprise if any criteria are looked at in order to preserve increased adoption. We only hope that the final criteria do not compromise the goal of creating prevention-oriented EHR systems.

Eclipsys – Philip M. Pead, President and CEO

We expect the lack of proven and implementable Quality Reporting standards to result in a dramatic reduction in Stage 1 requirements in this area.

e-MDs – Michael Stearns, President and CEO

Since the IFR becomes effective 30 days after its publication date in the Federal Register (Jan. 13), we do not anticipate that the certification criteria will be modified significantly for 2011, and that feedback will be used to guide 2013/Stage 2 criteria.  However, we do expect additional clarification of the criteria in preparation for the certification process. Having participated in the CCHIT process, we realize the challenges involved with interpreting the test scripts, thus further clarification and definition will hopefully result from the comment process.

We also expect further elucidation from CMS based on the public comments to the NPRM (the second document released in conjunction with the certification requirements from ONC). We do not anticipate that any comments received will substantially alter the criteria and that attaining Stage 1 meaningful use will be relatively straightforward for our current and new users.

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

I would expect we might see some change in areas such as:

• The pace and level of CPOE implementation
• Fewer HIT and quality measures
• More clarity on the definition of hospital-based physicians
• Technical refinements and corrections for the standards and certification criteria
• More precise definitions and guidelines based on submitted comments
• More clarity on interoperability expectations and standards

InteGreat, a MED3OOO Company – Tom Skelton, President

We expect that two criteria will get a lot of scrutiny from a physician compliance standpoint. The proposed requirement for 80% CPOE compliance in an ambulatory setting versus 10% in a hospital setting seems not only unfair, but may not address where the most costly errors occur. We would like to see this be modified to be equal in all settings and backed into on a gradual scale.

As physicians read through these measures, some of these scenarios may not stand out. We expect though that when they begin to apply them to what they do every day, there will be many questions. Ultimately, they are going to look to their EHR vendor to supply a solution that will allow and encourage them to comply. Solo physicians and small groups will need to look for products that are intuitive, as well as easy to implement and use. There will be a shortage of time and talent to implement these systems in the next few years. Therefore, products that are not operational in a short period, will place physicians in a position where they cannot comply. The hard fact is, meaningful use is exactly that…USE. It will be up to the physicians and how they use the EHR, which will ultimately qualify them for the stimulus money. That will require behavior changes for adoption, which in some cases, may be hard to make.

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

We hope that the agency will be responsive to public comments to ensure that the gaps are closed and the ambiguities are clarified in the final rule.

NextGen Healthcare – Scott Decker, President

We do not expect significant changes after the comment period. However, we do want to give our clients and the public the opportunity to voice concerns and suggestions for the best end result. NextGen Healthcare has introduced our Community Forum as a place where people can join with us in commenting on some basic issues around the schedules for achieving meaningful use and ideas concerning the rolling quarter by quarter compliance program in 2011. NextGen Healthcare’s leadership and client advocacy committee has accepted the responsibility to lead this exchange.

Sage – Lindy Benton, Chief Operating Officer

Unless there is a groundswell of nearly-unanimous public commentary on one or the other of the criteria, we don’t see much changing, especially given the fact that the initial recommendations of the HIT Policy Committee were themselves a result of widespread collaboration between multiple stakeholders.

While Sage plans to submit commentary for the purpose of eliciting further clarification, overall we endorse the NPRM and IFR in their current form as a balanced approach to meaningful use based on the current state of healthcare technology and the starting point for most physicians.

SRSsoft – Evan Steele, CEO

Tragically, we do not expect much to be changed by input made during the comment period. All of the major stakeholders surrounding this issue have engaged in various ways, both publically and privately. Points of view have been exchanged, debated, and decided upon. Many of the provisions and criteria in the meaningful use document are no different than they were much earlier. I can’t see today how any comments from any single or set of stakeholders will modify the criteria much from where it is.

Our position is that the criteria, as they are set now, are doomed to a high risk of failure, especially for the high-performance providers. One EHR specification and one set of criteria for all specialties is like trying to have one manual and specification for all aircraft—cargo, passenger, tanker, bomber, glider, Cessna, etc.

SRS will not seek to become a certified product because it would be such a disservice to our clients and future clients. We haven’t found any of our high-performance physician clients willing to make the trade-off of lost productivity for government compliance. Our clients do not want to have a “certified” solution, designed by government committees for the purpose of being able to demand any and all data from every one of their providers…especially when it will have a hugely negative impact on provider performance. They want a highly efficient, productivity-focused EMR that is accessible from anywhere, can be learned in a morning, and immediately improves physician and office productivity and patient care.

The history of EHRs up to this point has been very inconsistent . . . some successes and many, many failures—especially among specialists, for whom this ARRA program does a great disservice. Offering incentives will not help a physician “meaningfully use” an EHR that he/she could not use successfully before. The government’s program has done nothing to change the fundamental problems with the products that have caused the 50%–80% failure rate (recently reported by the lead author of the Milbank Quarterly study on EHR use). The government conceded early in this process that there is a lack of evidence that traditional EHRs reduce costs and improve care—Dr. Blumenthal said in September that he “anticipates an enormous amount of research will be needed to determine the effectiveness of health information technology at the same time as it is widely deployed under the stimulus.” There were no landmark studies supporting the efficacy of EHRs in physician practices then, and there still are none now. The Proposed Rule acknowledges that only 4% of physicians have been able to fully adopt an EHR. Some primary-care physicians are finding some success with the traditional EHRs, but most physicians—and particularly specialists—have not, and will not, be able to do so.

If we at SRS sound like contrarians in the EMR adoption subject, it is only because we feel that the full weight and gravity of the government program is going to cause a lot of medical practices a great deal of pain. The only suggestion I can make is this: I would like the government to acknowledge that the current criteria for meaningful use was not intended for and does not apply to specialists. Absent this change, many specialists will have to choose from among products that are certified, and for most of them it will be overkill and unworkable.

My advice to those who implement and use products and attempt to comply with “certification” requirements: be prepared not only to not qualify for the promised incentives, but also for a negative impact on office productivity and exposure to substantial financial harm.