News 1/05/10

From H&R Block: “Re: meaningful use. Heard a peer say the following about ARRA: ‘I didn’t decide to have kids because there was a tax break. I’ll take the one they give, but its not the reason to have kids.’” I’ll say this for the tax code: you don’t need to hire an accountant to help you figure out if you have dependents. On the other hand, after a few hours trying to weed through several hundred pages of the meaningful use guidelines, I’m buying stock in consulting companies. But to H&R Block’s point, I’m not sure how many physicians are going to move to an EMR solely to get some cash from the government. The average physician or office manager will need assistance figuring out the requirements. Even using the most sophisticated software, the requirements are no slam dunk and the upfront costs remain high. If I were a vendor, I would get busy developing an alternate talk-track that encourages EMR adoption for reasons other than just qualifying for ARRA dollars.

If only it were this easy. EMR vendor Waiting Room Solutions announces that Ohio Pain Center selects its EMR/PM solution, which it claims “will qualify” the practice “to collect PQRI and ARRA EMR Stimulus incentive monies.” I hope someone has told the clinic to check out CCHIT’s website that says Waiting Room Solutions product “has not been tested against the applicable proposed Federal standards in existence on the date of certification for certified EHR technology of its type under the American Recovery and Reinvestment Act of 2009 (ARRA).” Then, perhaps the doctor might want to read through the meaningful use guidelines.

By the way, the latest proposed rules defer the final definition of “certified EHR technology” until ONC’s upcoming interim final rule. The recommendations do indicate that a “certified EHR technology” is a qualified EHR certified as meeting standards defined by the Secretary. Included are a couple of examples of technology that would NOT meet the definition of a certified technology, including a “complete EHR” that hasn’t been “tested and certified in accordance with the certification program established by the National Coordinator, even though it may be claimed that such technology provides the same capabilities as those required by adopted certification criteria.” The key here is we still don’t have a definitive answer as to which “certification programs” (or certifying bodies) are valid. We have to assume CCHIT certification is valid, since it’s really the only player today, but it does leave the door open for other options.  My prediction is that if a product is not CCHIT-certified (probably at least a 2008 level or higher) then it will be tough to qualify for funds.

Last week, Mr. H provided a great overall summary of the ONCHIT preliminary meaningful use definitions (the Excel version is here), and followed up with some overall impressions a couple days later. Much of the 700 pages is redundant, but here are a few additional nuggets of information that focus particularly on eligible professionals (EPs).

Timing of incentive payments

Payment timing varies depending on the EHR incentive program in which the EP is participating (Medicare FFS or Medicaid) or if it is a hospital. Under the Medicare plan, first-year payment qualification requires the EP to meaningfully use an EHR for any continuous 90 days within the payment year. In subsequent years, meaningful use is required for the full payment year. The final dates related to payment timing are not yet defined, but the earliest possible 90-day period could begin July 1, 2010, which is 90 days before the start of the government’s FY 2011 (October 1, 2010). The latest possible date to start the 90-day period and qualify for 2011 payment would be October 1, 2011, which is 90 days before CY 2011. The committee’s recommendation is to set October 1, 2010 as the start date for the initial EHR reporting period, which means qualification (and payment) could come as early as January 1, 2011.

Amount of incentive payments

This chart isn’t new, but it does reiterate the need for an EP to reach meaningful use during 2012 if he/she wants to earn the most incentive dollars. Using the proposed timetable listed above, EPs must start the 90-day period proving  Stage 1 meaningful use no later than October 1, 2012.

EPs can opt to be in the Medicaid incentive program, which pays a maximum of $63,750, if at least 30% of his/her patient volume is Medicaid. EPs have the option to make a one-time switch between programs (though the total incentive amount cannot exceed the Medicaid cap). One of the nice things about the Medicaid program (aside that it offers more money) is that you can wait until 2016 to start the certification process and still receive the maximum $63,750.

How to get the money

It’s unlikely HHS will be ready to electronically accept data on clinical quality measures for the 2011 payment year (ironically). Thus, EPs will likely be required to “attest” to its meaningful use of an EHR in order to qualify for funds. By 2012, an EP will electronically submit the summary information on the selected quality measures. Look for compliance reviews to validate provider eligibility and meaningful use assertions.

Assigning money to an employer or other entity

EPs can reassign incentive payments to an employer or entity with which the physician has a valid employment arrangement, though an EP can’t assign payment to more than one employer or entity. Not addressed (that I noticed) was if an EP could assign a portion of the incentive money to a hospital that was not his/her employer. That might be something attractive for hospitals interested in subsidizing upfront EHR costs via Stark legislation.

The MGMA says that the proposed EHR incentive program rules are too complex and that medical groups will confront significant challenges to meet the program requirements. “Overly burdensome requirements and needlessly complex administration will only discourage physician participation in the program and implementation of EHRs,” says MGMA president and CEO William F. Jesse, MD.  Meanwhile, HIMSS releases a statement saying the proposals offer more that should be applauded than criticized, and provides clarity of what technology functions constitute a qualified electronic health record. I think I am with Jesse on this one.

Nuance Communications releases the results of a 1,000-physician survey about the incentive plan. Apparently the majority of providers think there’s too much emphasis on data capture and quantitative measures rather than the capture of qualitative information that tells each patient’s unique health history (keep in mind that Nuance sells voice dictation products like Dragon Naturally Speaking). Less than 10% of the physicians said they were confident / very confident that the government’s current HIT measures would result in higher quality patient health records.

More negative opinions from physicians on EMR: the 2009 Physician Pulse Report concludes that physicians are increasingly dissatisfied with EMRs, which they find time-consuming and possibly compromising patient safety.

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.

Happy New Year, by the way!

E-mail Inga.

Intelligent Healthcare Information Integration 1/3/10

Connectiquette

Recently, certain aspects of human interaction related to physicians and/or IT folks inspired some observations on my part (some might call them “rantings.”) As I always hate bemoaning entropy without bespeaking ectropy, I hereby humbly offer up, for your conscientious consideration:

Connectiquette: 11 Rules for an Extropic Future

1. NEVER text and drive. No, you’re not that talented, you’re not that good of a driver, and it won’t “just take a second.”
2. Always remember that the live bodies in your presence are more important, and deserve your attention more, than any distant Tweeter, texter, or avatar.
3. Look at people when you talk with them. While viewing a screen or keyboard, the top of your head is what you present to your patient, client, staff member, mother, etc. Do you really want them to consider your scalp and follicles as the windows to your soul?
4. Looking at the eyes of someone can always tell you far more than viewing their typographical output.
5. If new technology causes new workflow patterns to disrupt your interactions with the “organics” around you, get different technology – OR – adapt your workflow to re-enable your connectedness.
6. Until further notice, carbon / carbon-based interpersonal skills should remain pre-eminent to those required for carbon / silicon-based relationships as well as any carbon / silicon / carbon intercourse, in whatever form.
7. Courtesy still conveys consideration across any connection. Just because someone can’t lay eyes upon you doesn’t mean they can’t see how inconsiderate you are.
8. Patients, clients, customers, co-workers, even friends and family — all prefer being treated “Goldenly.” Do you want others to attend to you as you have been attending them?
9. “Service” and “support,” just like the “care” in “healthcare,” have real definitions. Look them up.
10. “Electronic” does not equal “better.” Some “old” skills and solutions will long outlast the latest, greatest, “better mousetrap.”
11. People are still susceptible to faddism; just because something is Web-based doesn’t mean it’s sanctified, certified, or even smart. Discernment and healthy skepticism are more valuable now than ever.

No, I’m not able to cast the first stone, as I have been just as much a digital sinner as anyone. However, I am repentant and searching for a walk nearer to thee, er, I mean, you … and to all the flesh and blood people in my day to day encounters.

Therefore, I promise: next time we’re out to dinner, I’ll keep my snout out of my smartphone and hope you’ll offer me the same Aretha. (R-E-S-P-E-C-T)

From the trenches…

“Respect is love in plain clothes.” – Frankie Byrne

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 throughhttp://madisonpediatric.com or doc@madisonpediatric.com.

News 12/31/09

From DrLyle: “Re: Dr. Zurhellen interview.Great interview with this doc. Where do you find these guys??? More and more of us are saying what Dr. Zurhellen laid out in one simple sentence: ‘get a single data structure and let vendors compete on the user interface.’ When will the government start listening to this philosophy (increasingly called the ‘iPhone approach)?’” Here is a link to the interview, in case you missed it. Dr. Zurhellen is a pediatrician who wrote his own EMR and is a CCHIT expert panel member. He’s a straight shooter who shared his frank impressions on EMRs, CCHIT, and standardization. As to how we find these great interview subjects, most are recommended by readers. By the way, DrLyle shares some musings on the need for an iPhone-like interface here.

CMS and the ONC release the much anticipated “meaningful use” definitions and other details related to the EHR incentive program, including its final rule for the initial set of standards, implementation specifications, and certification criteria for EHRs. An HIStalk summary is here. Download your version of the 556-page document here and hunker down for a good read. Stay tuned for more on HIStalk and HIStalk Practice over the coming days and weeks.

A study supported by the Commonwealth Fund concludes that EHRs are not adequately improving the coordination of care. Today’s current ambulatory EHRs facilitate care coordination within a practice, making information available at the point of care, but, are less helpful for exchanging information across physician practices and care settings. From one of the study’s co-authors: "There’s a real disconnect between policy makers’ expectations that current commercial electronic medical records can improve care coordination and physicians’ experiences with EMRs.” The study also warns that simply creating incentives to adopt EMRs as they currently exist may result in EMRs being designed for billing purposes primarily, rather than for clinical relevance to patients and care coordination.

In the UK, a three-year-old boy is denied treatment for tonsillitis because the father did not know the boy’s NHS number. The father took the child to a clinic where he was not a regular patient, only to be told his son could not be treated without the proper credentials. Over the weekend, the father called the NHS hotline, who advised against taking the child to the ER. Eventually the father found the card and the boy got treatment when the clinic reopened on Monday. I wonder if this was a single bad incident or a regular occurrence in the UK. In any case, it doesn’t sound much better what we’d offer the family (a long wait in a crowded ER.)

I bet this doesn’t happen enough. Methodist Sugar Land Hospital (TX) hosts a holiday luncheon in honor of the “unsung heroes” of medicine – office managers, PAs, NPs, MAs, and other professionals in physician offices.

Greenway Medical rolls out its PrimeSuite EHR, PM, and interoperability product to Bethesda Healthcare System (FL). So far 12 providers are operational and 550 more have the option to get on board.

Self-pay patients and physicians now have a new online tool to connect with one another. Patients needing a particular service can access the MediBid patient portal  and describe the services required. Interested physicians can then bid for the patients’ care on a case-by-case basis. The doctors set their own price, don’t have a “middle-man,” aka, insurance companies, and can selectively pick patients that “enhance” their practice.

A somewhat related trend: patients bypassing the doctor and going directly to the source for diagnostic tests. Storefront testing centers are popping up to provide screenings for STDs, cholesterol levels, wellness panels, and more. Any Lab Test Now operates 95 centers that offer 1,500 different tests and plans to open 200 more franchises in 2010. Most patients pay for the tests out of pocket.

A Texas woman sues Maybelline, L’Oreal, and Walgreen’s after their line of lip gloss caused her to go to have a severe allergic reaction and go into anaphylactic shock. The woman’s attorney claims that the defendants failed to identify the ingredients used to manufacture the products, which violated governmental guidelines applicable to the sale of “cosmetic devices.”

I’m glad to report I am back to civilization after a week in the backwoods. And excited to have a reunion with my combed Egyptian cotton sheets.

New Year’s Wishes Here

News 12/29/09

The Monterey County Health Department Behavioral Health Division completes implementation of the Netsmart Technology’s Avatar EMR. The $2.2 million project connects over 300 users.

Medical coding software developer CrossCurrent seeks $5 to $10 million in new funding to expand operations and extend marketing efforts for its Incisive MD product.

The AMA offers a new online tool that allows physicians to compare different healthcare plans. The information provides detailed data on Aetna’s Aexcel program, Cigna’s Care Network, and UnitedHealthcare’s Premium Designation program.

Justice or silliness? Mississippi’s governor sends a tweet asking constituents to forward ideas on how to trim state expenses. An employee with the University Medical Center follows up with a tweet suggesting the governor not schedule his medical exams after hours, which requires the clinic to pay 15-20 people to stay open late and leads to overtime pay. UMC fires the employee for violating HIPAA laws.

Mayo Clinic also fires a physician and an allied health staff worker for violating privacy policies.

PhEMR (femur) releases a new version of its EMR that includes e-prescribing functionality and lab interoperability. I’ve never heard of the company, but I think their name is sort of clever.

Increasing the use of IT to reduce medication-related errors and improve medication adherence could save billions of dollars and save lives. That’s the conclusion of a new report by the Center for Technology and Aging, which looked at ways IT could help with the medication-use process among older adults. Some of the new technologies explored include medication kiosks, online medication history tools, mobile phone apps, and wireless POC testing devices.

Clafin Medical Equipment agrees to market Aprima Medical Software to new clients, as well as its 10,000 existing customers.

Wuesthoff Health System opens the first of five Florida walk-in health clinics at the Merritt Island Walmart Supercenter, which will run eClinicalWorks software.

Companies like mPay Gateway, Navicure, and FirstPaid admit that physician adoption for their services remain low, but, all are optimistic for the future. The companies specialize in services that speed patient collections through the use of preauthorized credit cards.

GE expands its Stimulus Simplicity program to include new purchases of its Centricity Business solution suite. The program offers 0% payment terms and deferred payments until 2012.

A research organization says that healthcare consolidation can benefit patients because larger practices have deeper pockets for IT systems and other infrastructures. Technologies such as EMR and better payment systems provide increased efficiencies and result in better customer service. Analysts expect solo and small practice physicians to continue moving to larger groups, especially as payments are squeezed and providers require more capital for practice upgrades.

I’m only semi-working this week since there isn’t much going on in HIT-land and because I’ve escaped to a remote location. It’s quite rustic (I left all the stilettos and designer sweaters at home). I sent Mr. H a picture of my lodgings and he quickly assessed it un-Inga-like. I say that there is nothing like a few nights on a bed with low sheet thread count to appreciate home.

E-mail Inga.

HIStalk Practice Interviews William Zurhellen

William Zurhellen, MD, FAAP is a pediatrician at Putnam Valley Pediatrics PC of Putnam Valley, NY.

Provide me a bit of background on your practice.

This is a two-pediatrician private practice in Putnam Valley, New York, which is a suburb of metropolitan New York, about 45 minutes to an hour north of New York City. It was established in 1975 by me. It’s a community-based, ambulatory general pediatric practice.

I understand you’re using a homegrown EMR. What’s the history there?

I developed an interest in computers way back when the Tandy Model 1 came out. I started writing what was then BASIC from Dartmouth, BASIC programs for that. We wrote a financial program in 1984 and immunization program in 1987 and then launched what would be our current EHR in 1999. It’s had revisions, but the basic format has been the same for 20 years.

Are you the only practice using it or has it been used other places?

There are several other practices that are still using it, although each practice had the right from Y2K on to essentially alter it themselves. In other words, it was a research project on our part and we had other pediatricians — it’s only pediatrics — who wanted to use it. So we installed it for them and set it up for them and then they manage it. It’s self-managed.

So it does general functions like the prescription writing, tracks immunizations, all that?

It does prescription writing. However, with the changes in New York state law, we can’t use it any more because it required the use of micro-printing. Of course, removing the e-prescribing, the goal is to eventually merge an e-prescribing software with it.

More likely, when the right new system comes along that works as well or better than ours, then we will probably migrate to that,  only because the only support for our system is me and I’m 63. I don’t want to be supporting the software when I’m 85.

I understand you’re a member of a CCHIT work group.

I’m part of the Child Health expert panel.

I’m assuming your homegrown EHR is not CCHIT-certified?

No. There’s no intent at this point to have to go and qualify for ourselves because there’s no point in spending $30 to $40 thousand on a regular basis to certify ours.

Do you think CCHIT certification should be a requirement to qualify for government funding?

That’s a big, heavy-duty topic. I think government funding is going to help others purchase EHR technology because I think cost and price is a major issue. I think the government needs to be able to set specifics to prevent people from buying a $10 piece of software that does one thing and say, “We have an EHR.” The only current way to do that is either for the government to come out and spell out things that it must be able to do, but then it has CCHIT that’s already doing it. So, I think it’s reasonable to do that.

On the other hand, I’m not sure, and this is just my personal opinion, that the current software out there is what we all need in the first place.

In other words, there’s not the perfect software?

I wouldn’t buy any one of them right now. That’s because I think most current vendor software offerings are really designed around pay-for-performance and documentation to get paid. I’m a firm believer that electronic health records should be designed to improve the health outcomes of the patient and that payment is a derivative of that, but none of the current systems really track outcomes or healthcare.

Until we retool, in a sense, and prioritize the software in such a way that when you build up a five-, or ten-, or twenty-year database of patient function, you can look at it and see if this type of care enhanced or didn’t enhance the patient’s clinical outcome. There’s never been any evidence that pay-for-performance has any quality impact on any health outcomes, in the long run, on individual patients.

Does your software do that type of tracking, reporting, capturing?

To a certain extent, yes. Not as much as I’d like, but I’m limited by the fact that we’re using UNIX and twenty-year-old data structured software.

And no plans to do a rewrite?

Not at this point. I would rather buy something or acquire something that’s going to be supported by someone other than myself personally. So there will come a time for a transition. But if I wanted to, yeah, I’d sit down and take a year or two years off and write something and become a vendor myself. But no, I’m not interested in that.

Has the promise of money through ARRA and other pay-for-performance programs changed your focus at all in terms of technology adoption?

No, because I think the basic original tenet of trying to move medicine into the electronic world is incorrect. I’m not sure how they’re doing it is correct. The entire ARRA is a trade for information. We’ll give you money to put in records, but in return, we want you to supply us with performance data. Performance does not equal quality.

How is your current EMR helping you do research?

It helps us run the practice, and that by itself is the research. It allows us to track patients, follow health reminders — it pops up when we have pre-indicated that we needed it — it sorts, selects patients based on criteria that we set.

The problem is that, for example, if you were talking about children with asthma, there’s really no great case-mix or outcome definition that’s standardized. Not only that, most information systems are based on tracking an encounter, not an episode of care. That is, if a child has an asthma attack that goes on for two weeks and you try A, you try B, and you finally get it under control, you need to look at that whole episode, not just today’s office visit, last week’s office visit; because then the human being has to manually build a picture of an episode, whereas it could be built into information systems.

How are you inputting information?

Keyboard.

Do you have PCs in every exam room?

Well it’s UNIX-based, so we have a central server, and we have Wyse 350 terminals in every room. It’s all working off the same system. Everybody uses it to run our financial, our scheduling, our messaging; all the background services of the practice.

What would you say if a doctor came to you and said, “I want to go write my own software like you did?”

Twenty years ago, great idea. These days, no — it’s a lot more complicated than that. I mean, a person could, but my own feeling is — and this is speaking as a pediatrician — I’m not a great fan of the idea of what people consider, currently, interoperability. Interoperability, conceptually right now, is the ability to exchange bits of information between one system or another.

If I take care of a child for twelve years and they moved to a friend’s practice in California, it doesn’t do any good for long-term records to send him a snapshot or bits of information. That person should have access to that child’s record in the form that I put it in so he can continue to build on it. That is, whether you call it interoperability or exchange, it’s a different concept because right now people are talking about CCRs, where you can exchange certain amounts of information from on to the other.

It still parses it and summarizes it, so it’s no better than a patient record now where I might have a full chart. Then when the chart moves, I send a summary of the problem list and immunizations. That’s great, but it doesn’t supply any background data on the patient over a year, so it’s not useful in terms of looking at outcomes in healthcare management.

My own feeling is that if we could get a single data structure and let vendors compete on the user interface, then all records would be compatible with all others. For example, say I pick NextGen for my office and I install NextGen. Say, five years from now, NextGen wants to raise its yearly maintenance to $30,000. I have no choice but to pay it because if I said, “No, I’m not going to go. I’m going to switch to Vendor X.” Well, Vendor X can’t access the data structure. They’d have to write a completely new conversion program to take all the data from NextGen and convert it into a format that they can use. That costs money.

Or, if a vender decided, “Hey, it’s not worth it anymore. I’m selling out,” or discontinuing, a doctor’s going to be left up the creek with a set of records with no support anymore because it’s not interchangeable. That’s probably, more than money, at least in pediatrics, the biggest hold-back — the fact that obsolescence and being dependent on a single vendor is not a nice situation for anyone to be in.

What if every TV station had their own proprietary mechanism of sending out TV screens so you got a computer that would get NBC, but it wouldn’t get ABC? It’s the same thing, that there’s no real standardization.

I think that if we address the issue of true standardization, whether you did it on site or did it as a centralized data structure, the patient should have a patient record that starts prenatally and goes through life, and shouldn’t have 15 different ones in different sites.

I mean, we’re talking about healthcare now, not getting paid. That’s what I meant earlier by the current systems are designed for an individual physician or an individual practice and focus on documentation for payment. That’s not quality, not from a patient perspective.

Last question here – your opinion on why EMR adoption is so low?

I think money plays a role in it. Standardization plays a role in it, for fear of, “I’m going to be left holding the bag if somebody decides not to support my system any more.” And if I’m dependent on a single vendor, then I can no longer say, “Well I’m not going to pay the bill any more. You’re much too high for what you’re doing.”? Well, then I’m outta here. You can’t do that when you’re dependent on a single type of software system. There’s no other industry that operates on the same basis.

If you have an inventory system done by one company and you want to switch to SAP, bang — there’s a certain amount of standardization on it. So I think doctors are afraid. There are 315 different systems out there, all running. They may work individually well, but you can’t exchange them.

We’re talking about the ambulatory sector, you see. Most primary care physicians are used to the idea of exchanging a document with an orthopedist and getting a document back from an orthopedist. But within the ambulatory sector, pediatricians want to be able to send the patient’s chart to the new pediatrician, not just a note. I think interoperability’s been taken as any system is equivalent to any other one, when in reality, you don’t operate that way. The child’s entire health record should go.

If a woman had breast cancer and had been getting three years of chemotherapy out of Sloan-Kettering and then she moves to Phoenix, what do they do? Send just a summary document? They have to send the entire treatment summary, and it has to be usable and readable by the receiving system.

So, I think part of the holdup is the absolute cost. I think part of the holdup is the fact that there’s no real perception of what real interoperability or exchangeability or standardization is. I don’t think the vendors are interested in, in my own experience, in talking to the EHRA, or what used to be EHRVA. They’re making quite a bit of money selling systems that are documentation to get paid.

They’re not looking at changing, unless we change the perspective that the purpose of the EHR is not for the physician, it’s for the patient. Well, pediatricians are different than anybody else. We’re the only ones taught to manage patients and practice true preventive care. So these elements, the fact that it has to be designed for quality care, the information has to be mobile. That’s much more critical to us than it seems to be for adult physicians. That’s just us – we’re different.