EMR Vendor Executives on Meaningful Use and Certification Requirements – Part Three 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.

What kinds of practices will be able to reach the 80% CPOE level?

Allscripts – Glen Tullman, CEO

Reaching the threshold of delivering 80% of orders electronically will be easier for physician practices that have had an Electronic Health Record in place for some, giving them time to adjust their previous workflow for orders. Data “get” – receiving information – is always easier at first than data “put,” such as sending orders electronically. In other words, shifting from verbal orders (“Marge, can you draw a lipid profile on Mr. Jones, please?”) to electronic order entry will require patience on the part of physicians, and proactive care on the part of the IT or administrative staff.

That said, as I noted in my response to question No. 2, this transition is not only possible but can be accomplished on a large scale and all at once, if the executive, IT and clinical leaders are all aligned and committed to making it happen — and if the practice has already established full clinical utilization of an EHR. It’s worth highlighting that this requirement is all the more reason for practices to adopt an Electronic Health Record sooner rather than later. The longer they delay, the longer it will take them to accomplish the necessary workflow adjustments, demonstrate meaningful use and qualify for ARRA incentives.

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

We expect that our customers will be able to reach this level without much difficulty.

Eclipsys – Philip M. Pead, President and CEO

I would expect that any physician office, which has implemented a CCHIT Certified Ambulatory EHR will easily be able to achieve this criteria.

e-MDs – Michael Stearns, President and CEO

The ability to reach 80% CPOE is highly dependent on EHR capabilities, training and the ability to create orders easily and without restraint.  This is especially true for specialty practices, as the clinicians may need to incorporate unique orders and order sets during the implementation process.  However, the diversity of order types is lower in specialty practices vs. primary care.  In either case a well designed EHR supported by content that can be modified should enable the majority of ambulatory practices to meet this objective with relative ease.  In our experience adding value to the ordering process by presenting the clinician with decision support generated recommendations has tended to increase the use of CPOE.

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

Those that have a high e-prescribing percentage should be better positioned, as well as those that have focused on using the CPOE functionality in the EHR. I don’t think, at this early stage, we can further generalize by practice size or location.

InteGreat, a MED3OOO Company – Tom Skelton, President

Primary care practices will have the easiest time complying with this requirement. Specialists routinely delegate a much higher percentage of this work to support personnel in the practice. This will be a profound paradigm shift for them. We also recognize that a private practice implementation model is a much different model than a mandated hospital or clinic model. Independent physicians with limited IT resources are going to require more assistance with implementation and a system that is intuitive to use to reach this goal.

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

Physician practices that have already adopted some level of clinical information technology will have an advantage over those that have not. For example, physicians that are already using e-prescribing and need to expand their use of the EHR to include order entry will achieve this requirement sooner.

NextGen Healthcare – Scott Decker, President

We do not think that practice compliance with any criteria will relate as much to a physician specialty as it will to the commitment the physician makes to provide care with health information technology (HIT) as their operating foundation. Part of the EHR selection process for any provider should be a practice workflow assessment with specific emphasis on the manual procedures that will have to be augmented because of the addition of automation. NextGen Healthcare provides several workflow assessment tools to enable a practice to identify these opportunities for procedural refinement.

With the introduction of an automated tool, appropriate changes can be made in the practices’ operations, which will help them comply with meaningful use criteria, regardless of specialty. At NextGen Healthcare, we have always been committed to helping our clients use HIT to practice at the highest level of patient care possible.

Sage – Lindy Benton, Chief Operating Officer

In our experience, those practices serious about tracking orders are most motivated to take on CPOE.  Successful e-prescribers should also find it relatively easy to transition to CPOE for other types of orders.

On the surface, the 80% threshold may look like a challenge, given existing workflows where orders are often handwritten on a script pad for patients and communicated verbally to staff, but we find that anything less than 100% compliance raises workflow issues, since you have different orders being handled in different ways.

So, on the one hand, we would be tempted to point to the benefits of CPOE and say that most practices will see the light and respond to the incentive.  At the same time, we’ve seen firsthand that CPOE is often easier for larger practices that already have a process for orders management (even if it’s paper based).

The fact that there is not a connectivity component associated with this requirement certainly removes a major obstacle, especially in the context of today’s medical communities where health exchange is seldom more than fragmented.

SRSsoft – Evan Steele, CEO

This will be a huge challenge for most providers. Many systems right now have significant issues with things such as the drug-to-drug interaction alerts. Many providers turn this function off because of frequent “false positives” that occur. Perhaps physicians in lower-volume practices, some primary-care practices and non-fee-for-service / salaried providers will be willing to spend the time it takes to customize and use CPOE. High-performance physicians, typically specialists, are far more sensitive to the effects of reduced productivity, and cannot afford the time required to customize and cope with the time-consuming data input for CPOE. The impact of such productivity issues have been totally ignored by the requirements, and won’t be discovered by many providers until it is too late.

Again, the government-sanctioned committees that have created the guidelines have acted in a way that shows almost a negligent disregard for the burdens that will be placed on providers in this process. When this initiative fails to really produce significant improvements in the healthcare system and runaway costs in the US, hopefully they will focus more on the real aspects that can have an impact.

News 1/14/10

From: Big Fan “Re: 100,000 readers. The reason you are about to hit 100,000 readers is because you are a great writer! And I am sure amazingly attractive with great shoes! And you’ve got the good stuff. That’s why 100,000 people have read HISTalkPractice!” As Mr. H can attest, I am pathetically insecure. However, these kind words are making me glow.

From: Money Squeeze “Re: Medicare versus Medicaid and ARRA. What’s your take on the major differences between the Medicare and Medicaid incentive plans?” Thanks to Allscripts who provided most of the above details. Bottom line is that the Medicaid incentive program provides more money for providers that qualify. And if you are a mid-level provider, Medicaid is the only plan to offers a chance to earn funds.

Here are a couple more FAQs on the latest EHR incentive guidelines:

Q: If an eligible professional (EP) meets the criteria for both the Medicare and Medicaid electronic health record (EHR) incentive programs, can they choose which program to participate in?

A:  Yes. EPs who meet the eligibility requirements for both the Medicare and Medicaid incentive programs must elect the program that they wish to participate in when they register. The current recommendations allow EPs to change their program selection one time during payment years 2012 through 2014.

Q: Who is responsible for demonstrating meaningful use of certified electronic health record (EHR) technology, the provider or the vendor?

A: To receive an EHR incentive payment, the provider (eligible hospital, critical access hospital or eligible professional) is responsible for demonstrating meaningful use of certified EHR technology under both the Medicare and Medicaid EHR incentive programs.

This last question puzzles me a bit. Why would a provider think it was up to the vendor to demonstrate meaningful use, unless the vendor perhaps misled them – ?

A New York Times article mentions an upcoming study that concludes that the Danish HIT system is the most efficient in the world, saving doctors 50 minutes per day and the country $120 million per year. They have advantages for that kind of adoption, however: high taxes, free medical care, and different attitudes toward privacy (one Dane official suggests that privacy concerns all but disappear once you are sick.)  Mr. H doesn’t like the model because it leaves little room for greedy capitalists.

Practice Fusion, a company already offering a free EHR, launches its free e-prescribing product.

Flagstaff Bone and Joint chooses the SRS hybrid EMR for its 13 providers.

The VA opens its first “tele-health” clinic in Colorado. The facility will primarily use videoconferencing technology to allow veterans to communicate with doctors in another regional outpatient clinic. The VA has plans to open another nine tele-health facilities across the country.

MEDENT teams up with Cardiac Science Corporation to provide users the ability to connect diagnostic monitoring devices with MEDENT’s EMR.

ITelagen partners with medical distributor Bell Medical Services to promote ITelagen’s EMR and medical billing services.

University Medical Center at Princeton partners with QuadraMed to provide e-MDs EHR to its affiliated physicians.

Kaiser fires an employee who took home an external drive without authorization. The drive, which contained medical information on 15,500 patients, was stolen from the employee’s car. Is it me or does it seem like every time we hear about stolen computers with medical information, the employees weren’t suppose to take the hardware from the office in the first place?

E-mail Inga.

EMR Vendor Executives on Meaningful Use and Certification Requirements – Part One 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.

Were any of the proposed meaningful use criteria a surprise and what effort will be required for your product to meet them?

Allscripts – Glen Tullman, CEO

Since we have been involved in and following the process very closely, there were no surprises.  That said, Allscripts has been very supportive of raising the bar for Electronic Health Record certification for vendors and challenging physicians to aggressively use the technology so we could truly begin to improve healthcare and so taxpayers would get the return on investment they expect and deserve from the billions they’re investing in healthcare IT.  We like the 80% standard on CPOE, the clinical support rules, and the push toward delivering electronic information to patients — if we’re building an electronic healthcare highway, patients need an on-ramp — but we hope that this is simply the minimum requirements and that the Government pushes much more aggressively. We know that vendors and physicians can do more and if we are to address the challenges of quality and cost in our healthcare system, we simply can’t wait any longer.

With that said, Allscripts has a development budget that exceeds the annual revenue of many of our competitors and we will meet and exceed the criteria, once they are finalized.  In fact, tomorrow Allscripts will make an important announcement relative to Meaningful Use and our approach as an organization. Along with the financing programs we already have in place, which bridges the gap until physicians receive their stimulus funding, we believe this new announcement will make Allscripts the safe and easy choice.

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

We understand that the bar has been set low in order to have a high adoption rate. Living in the public domain where our customers have already demonstrated meaningful use has provided us with valuable insight. An example is NYC’s Primary Care Information Project (PCIP), which has 1800 physicians using the system and our payment is tied to the successful deployment of the EMR along with clinical decision support and measurement reporting for aspects of care including diabetes, hypertension and smoking cessation. Some of these data collecting and reporting requirements are more stringent than those set forth under meaningful use

Eclipsys – Philip M. Pead, President and CEO

The meaningful use criteria published in the CMS Interim Final Rule (IFR) are substantially in line with previous guidance with one exception. That exception is the number and scope of reportable Quality Measures, totaling 90 potential measures for general and specialty providers. One of the objectives of meaningful use quality reporting is to leverage clinical data vs. billing data, several of the proposed measures are lacking specifications that meet this objective and several others are in draft form.

Eclipsys expects to meet criteria for the proposed measures with standards and specifications defined, i.e., 76 PQRI measures in our Sunrise Clinical Analytics™ solution, a component of our Sunrise Clinical Manager™ 5.5 release. It’s important to note that the proposed Meaningful Use measures are not all PQRI measures and that there remains 24 Non- PQRI measures which have yet to be defined with complete standards or specifications from the ONC.

Another important point is that the proposed rule will have a greater impact on organizations the longer they wait to adopt.  For example, if an organization decides to “wait” until 2013, they will be facing the HHS mandated update to ICD-10 by Oct 1, 2013 and they will be facing the need to ramp up meaningful use thresholds every year. Only those going live in 2010 will have the “luxury” of upgrades every two years. The way the rule is proposed, those concerned about “rapid” change should not wait to get going.

e-MDs – Michael Stearns, President and CEO

Both our product and policy teams agree that the certification criteria in the IFR document were not substantially different from what the HIT Policy Committee initially proposed several months ago. The proposal that eligible providers need to only be meaningful users for 90 days in the first year was of some interest although we fully anticipate being certified as soon as it is offered this year.  We did notice that CCR was added as an alternative exchange standard to CCD, but fortunately we support both formats.  Tangential to this is the need for additional clarity around transport mechanisms; although there was a high level discussion of SOAP protocol vs. RESTful architecture, we would like to see additional clarification of these issues during the next few weeks. .

Since we have successfully certified each year CCHIT has offered its ambulatory program, our level of effort to meet these ARRA certification requirements will be relatively minor, however we are anticipating further clarification from the public comment process with regard to privacy, security and few other issues.

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

We’re still carefully reviewing the criteria to determine internal implications and customer impact.  We will coordinate our comments with the EHR Association, HIMSS, eHI and other industry groups.  Though we will likely have some specific comments, on initial review, there aren’t many surprises as the newly published criteria relied heavily on the Policy Committee proposal but with the addition of high performance thresholds for many HIT functionality measures.

InteGreat, a MED3OOO Company – Tom Skelton, President

As we have been closely following the meaningful use criteria since it first came out, we don’t find anything in the document that is truly surprising.  It will be interesting what arises during the comment period as other constituencies provide their feedback. Having previously secured certification, we are well on our way towards meeting the newly proposed requirements.  Of course, the bar is being raised, and we have been investing additional resources to make sure we achieve the new criteria in plenty of time to allow our clients to achieve meaningful use.

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

Based on our ongoing visibility into the stimulus requirements, the proposed rule for meaningful use and interim final rule for certification and standards released on Dec. 30 tracked closely to our expectations. The primary exception is that there is now clearly a heavier burden on vendors to deliver certified electronic health record (EHR) systems that not only meet Stage 1 metrics, but scale to meet future requirements for Stage 2 and 3 as well. McKesson is on track from a product roadmap perspective and preparing to submit our EHR products for certification once we have clear indication of the process.

NextGen Healthcare – Scott Decker, President

The proposed criteria released last week did not change a great deal from the recommendations made by the HIT Policy and Standards Committees over the summer, so they were not surprising.  As a matter of fact, we have been developing our suite of products in line with these guidelines since they were first proposed in early 2009 – our CCHIT 2011 certification is proof of that effort to date. Also in 2009, NextGen Healthcare announced a Money-Back Guarantee Program as evidence of our confidence that NextGen solutions will always evolve to meet the requirements for federal stimulus reimbursement programs.

We will continue to analyze the newly released criteria to ensure that our existing clients have the appropriate guidance, tools, and resources they will need from us to achieve meaningful use.

Sage – Lindy Benton, Chief Operating Officer

Since the proposed criteria don’t vary dramatically from what has been previously revealed by ONC, we weren’t surprised by the proposal, except perhaps for the 500+ pages! There are certainly some criteria that we have comments about and we are drafting those now.  Our Intergy EHR product has been ready for certification for months, but we’re waiting until the final criteria for Meaningful Use to be published before we begin the certification process.  So, while significant effort has been required to get the product ready, most of the effort has already been expended.  Since it is not entirely clear yet exactly how CMS expects to receive quality measures data, we do anticipate some level of development and testing in that area.  But overall, we’re in great shape.

SRSsoft – Evan Steele, CEO

There were no real surprises. Unfortunately, it’s a travesty. Much of what was in the new regulations had already been released after the July 16 session of the HIT Policy Committee meeting. The 25 criteria outlined for defining “meaningful use” in Stage 1 will impose significant new burdens on providers, but only after vendors complete the task of development and certification. We continue to have real concerns that these criteria do not address the concerns of specialists and will impose on them the need for a “certified product” that is overkill, unnecessary, and inappropriate for their skill set. Sadly, some specialists will be led to adopt certified technology which in most cases will fail and they will discontinue their participation in the ARRA program. For the rest of the market, adoption will probably fail in 30% or 40% of cases, as it has been up until now.

We have had physicians comment to us that the daunting size of the documents—almost 700 pages between the Meaningful Use and Certification—will make it a discouraging task to even understand what is expected of them. All along our position on the issue has been, and will continue to be: Do what is best for our client base and our market—the specialists and high-performance providers. If they clamored for us to undertake the changes required for them to pursue meaningful use, we would engage it full bore. However, no such demand has emerged. The costs and tradeoffs in productivity and performance that would be required of high-volume, fee-for-service practices would dwarf the meager incentives that the government is offering over a five-year period . . . even if all conditions are met. (For an analysis of the cost/benefit, see my recent blog post). We will continue to deliver what our clients need to run their practices effectively.

The government incentives and requirements are strictly voluntary and all providers should evaluate carefully what will be required of them and what the impact will be on their practice before relying on promises of incentive dollars.

As an added comment, we think that, given the horrendous record of failure and provider-dissatisfaction that has plagued EMR up to this point, the government guidelines outlined in the 25 criteria for “meaningful use” is an appalling display of hubris. There has been absolutely zero consideration or acknowledgement given to the costs and burden imposed on physicians and practices to comply. In fact, it would seem pretty logical to us, given our experience over the past thirteen years, that these guidelines were intended to make qualification for incentives as difficult as possible. Many of those with their EMRs installed today, even if all the updates required under HHS guidelines (and at what cost?) are implemented, are going to find this extremely burdensome, and regret having pursued it. Make note of this today: this is a Pandora’s box of meaningful costs.

News 1/12/10

The results of this new EMR usage survey indicate that 43.9% of physicians use an EMR, at least partially. However, only 6.4% utilize the full functionality of their systems. The survey used a self-reporting methodology, so the results may not be the most statistically valid. Regardless, adoption is clearly on the rise.

athenahealth names Timothy M. Adams SVP and CFO, taking over for the retiring Carl B. Byers.

Athens Regional Medical Center (GA) selects PeakPractice EMR/PM for the 58 physicians in its network. In a later phase the health system will also offer the solution to affiliated physicians. Athens Regional is a current Eclipsys Sunrise Enterprise client.

FQHC Jordan Valley Community Health Center contracts with NextGen to deploy its EPM/EHR solutions, as well as the NextMD patient portal and Quality Systems’ electronic dental record.

MediConnect Global buys PRH company PassportMD. MediConnect provides medical records retrieval, scanning and storage services.  I noticed that Joan Lunden at one time partnered with PassportMD to provide celebrity promotion. No word on the status of her role.

If you want to submit a comment on Meaningful Use criteria, here’s a link. Comments are due by March 15th. Note that the reimbursement document isn’t up yet.

Allscripts extends a guarantee to physicians that its EHR product will meet the final EHR certification criteria. In addition, Allscripts says they’ll extend special financing that includes no payments on EHR purchases for the first six months.

Ingenix also jumps into the guarantee/loan game, announcing that it will offer interest-free loans to practices who buy its CareTracker PM/EMR. In addition to guaranteeing that CareTracker will meet meaningful use technical requirements, Ingenix says it will also help providers qualify for CMS incentive payments. Here’s their best pitch, though: the Web-based CareTracker EHR costs only $23,500 over five years, less than the ARRA reimbursement of $44,000 over five years.

This month marks one year since HIStalk Practice made its debut. Many thanks to the sponsors, especially those who jumped on from the start, when we had no subscribers and virtually no readers. While our numbers aren’t near HIStalk’s level, each month we continue to increase our readership, as well as subscribers. In fact, we’ll likely hit 100,000 total visits by the month-end. Thanks readers, for the continued great feedback.

In case you missed it over the weekend, we ran the first of six questions posed to 10 different ambulatory EHR execs. If you are not yet a subscriber, sign up to your right so you don’t miss the rest of the series.

The number of physicians and staff members employed by practices are expected to continuing growing over the next eight years. Much of the growth is expected in primary care specialties, where shortages are already occurring. The only position not expected to increase is file clerk, thanks to the growth of the EHRs.

Thanks to Sean Weiland and Mohan Naidu from Piper Jaffrey for sending over their recent report on EHR deal flows. The investment firm predicts a large number of stimulus-induced  EHR deals in the second half of 2010 and in all of 2011. Physician groups may put their deals on the back burner until HHS releases the final certification and meaningful use definitions, but look for more “mega-deals” with hospitals. These deals will likely speed physician adoption, as hospitals buy or subsidy EHRs and attempt to establish connections with providers.

The local paper highlights Cook Children’s (TX) newest outpatient clinic, nicknamed the Innovation Clinic. All four of its clinics will go live on athenaclinicals next month.

Allscripts-Misys Healthcare releases its second quarter earnings: revenue grew 32% to $169.3 million, which was in line with analysts’ expectations. Allscripts reported a profit of $15.8 million, or 10 cents a share, compared with last year’s loss of $6 million, or 5 cents a share. Though bookings grew 16%, it was less than analysts hoped.

Allscripts’ sales (and PR) team are working overtime, announcing three new contracts. Renaissance Medical Management Company selects Allscripts EHR/PM for 51 family practice and internal medicine physicians. Renaissance already has 30 affiliated physicians using Allscripts products. Legacy Health (OR) picks Allscripts Care  Management for its six hospitals and two post-acute care facilities. Legacy will deploy the solution on a SaaS-basis. And, Catholic Health Initiatives (CHI) contracts with Allscripts to provide EHR for its 1050 employed physicians. Allscripts solution for CHI’s 7,200 affiliated physicians is pending.

E-mail Inga.

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.