Intelligent Healthcare Information Integration 12/12/09

WOG – World Of Giants

I seriously doubt very many of you will be in any way familiar with a short-lived T.V. series from 1959 called “WOG – World Of Giants.” It was about Mel Hunter, “a ’special’ special agent”, who had been miniaturized to “the size of a six-inch ruler” behind the Iron Curtain. (Exposure to some unknown rocket fuel ingredient was blamed).

I barely remember it, but it etched upon my toddler brain images of the black and white view from mini-Mel’s perspective of the sole of a giant shoe about to flatten him and the freakishly large fangs of a tabby cat about to devour our mini-spy hero. The show was often recorded with the view of the microman, giving young, formative brains a fear of all things gigant-esque.

This week I was reminded of the aforementioned show by three separate events. One dealt with IT, the other two with physicians. Each reminded me that poor little Mel Hunter was not the only hapless soul who has to live in a World Of Giants. The only difference is his giants were measured in physical stature. In the worlds of healthcare and IT, we measure our giants in terms of gargantuan egos.

My recent encounter with the IT WOG (IWOG) came in the form of an exquisitely arrogant and condescending “support” person with a television service provider I won’t DIRECTly name. When I expressed unhappiness that our bedroom’s brand new HD “box” had stopped working less than 30 minutes after the installer had left, he said, and I quote, “Well, it isn’t like you don’t have reception. You have several other receivers that are working which you can watch, now don’t you?” Gosh, really? I didn’t know that. OK, now I feel better that it’ll take two weeks to get another tech out to repair my brand new box.

The physicians’ WOG (PWOG) is literally littered with episodes of WOGiness. Many docs still feel they should “control” their patients and their patients’ healthcare. Many feel offended that anyone might condone examining their track record and comparing them to so-called “best practices” or “evidence-based” standards. “They don’t know my patients or what’s right for them!” Many docs never volunteer to help their local hospitals (or communities,) yet bitch and moan when the hospital administration doesn’t kowtow to their fancies.

Seriously, where else can you bring ten people into a room and get ten completely different opinions (sometimes more!) which are argued with circuitous logic, backed up by conflicting stats ad nauseam, and filtered through gray matter which often refuses to even consider divergent points of view? All of this typically happens with a completely condescending cadence and vocal intonations of downright disdain for anyone who might disagree. Doctors are notorious for their god complexes. But, I swear, IT people are often not too far behind in personal estimation of the value of their knowledge base bank accounts. Hells bells, Helen, even the local computer repair shop guy will often evidence this IT ego elevation.

(Why would anyone ever want to venture into the dual-WOG world of healthcare IT?)

OK, yes, I fully realize I AM a physician and at least a pseudo-IT guy. Maybe it’s my own ego that refuses to see that I am as full of myself as I probably am, but I further swear that most of the time I feel a whole lot like poor old Mel Hunter, constantly watching out for giant falling pencils and carelessly discarded super-sized cigarette butts cast off by the WOG people all about. And I just don’t see the point.

Medicine is, at best, an artistic science. We know far more about how to name medical conditions than we often do about the conditions themselves. People often get better, or not, despite what we pull from our little black bag of medical magic. IT, for all its definitive ones and zeroes with its quantifiable bits and bytes, still often stymies even the most experienced vets. Bill Gates once said he, too, was often frustrated with glitches and ghosts in his machines. So, what’s with all the “ego-tude”?

Truly, there’s not a one of us who couldn’t learn a thing or thirty about a better way to do our jobs or understand our respective fields, is there? So, I suggest we just give up on the pretense that we actually know so very much and abandon our need to make sure that others around us know it. Doesn’t seem all that hard, really … unless … unless there’s a whole lot of IT and medical folks out there who actually feel more like little Mel Hunter than they let on. Maybe all this self-inflation is just an effort to guard against perceived colossal cats and enormous falling filter tips by a whole bunch of folks who, on the inside, feel just like Mel and me.

From the trenches…

“When they discover the center of the universe, a lot of people will be disappointed to discover they are not it.” – Bernard Bailey

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 12/10/09

Physicians are more likely to report information about adverse events through an EHR system rather than a paper-based system, according to this Pfizer-sponsored survey. Participants included 300 primary care physicians, two-thirds of whom use some form of an EHR. Most of the doctors agreed that adverse event reporting through and EHR would improve patient care.

DrScore.com launches its “i Need a Doctor” iPhone application, which provides rating information on about 800,000 doctors. The idea is that the information handy if you find yourself sick and away from home. I’ll be curious to see if anyone really thinks its worth its $4.99 price tag.

Here’s an iPhone application much more likely to be a hit. Nuance introduces a Dragon Dictation application that lets users speak e-mail and text messages, as well as notes to oneself. For now, it is free. Here’s the drawback: apparently the app uploads and stores all your contacts.

President Obama announces plans for the HRSA to administer $600 million to support construction and HIT projects in community health centers. Eighty-eight million dollars is earmarked to upgrade EMRs and other technologies. Great time to be selling to that market.

At its Executive Summit in Las Vegas, Allscripts announces its Professional EHR 9.0 release, as well as Allscripts Remote for BlackBerrys. The 9.0 release includes an enhanced user-interface and expanded disease management capabilities.

Speaking of Allscripts, Community Memorial Health Systems (CA) selects Allscripts’ EHR, PM, and RCM products. Community Memorial Health System will host applications for 70 contracted physicians and a pilot group of 12 community physicians. The health system will also use technology from dbMotion to allow physicians access to a virtual patient record that includes aggregated clinical information from all the heath system’s computers.

David Blumenthal writes on his Health IT Buzz blog that meaningful use criteria will be announced “in a matter of weeks.” Blumenthal also says that proposed plans for a new certification program will be published in early 2010. Is it nit-picking to point out we were promised these details by the end of the year? Hard to believe it’s been 10 months since ARRA was passed.

Former Sage Healthcare executive Maureen Peszk joins Pittsburgh Life Sciences Greenhouse.

The Centers for Medicare and Medicaid takes a look at today’s primary care physicians and concludes most have too few patients to reliably measure significant differences in quality and cost performance measures. The results suggest that today’s typical P4P and quality reporting initiatives may be flawed.

Aprima Medical Software adds HDI Technologies as a reseller to implement and support Aprima’s EHR and PM solutions.

KLAS takes a look at the medical transcription market and pronounces it fiercely competitive.  Most providers have switched providers at least once and vendors must maintain high performance levels to retain clients. Acceptance of off-shore transcription is growing, with 43% of providers willing to risk reduced quality in favor of saving some money.

The North Carolina Medical Society informs members of a security breach involving MedSolutions, the vendor that administers pre-authorizations for certain Medicaid services. For an undetermined period of time, the MedSolutions website allowed anyone accessing the site to see demographic information, including Social Security numbers, of an unknown number of North Carolina physicians. The warning is prominently displayed on the NCMS home page, though I couldn’t find any details on MedSolutions’ website.

The 5,500-member Texas Academy of Family Physicians contracts with RemitDATA to aggregate members’ reimbursement data to provide real-time benchmarking. The organization will use the data to identify and resolve payment trends.

OmniMD partners with 361°md to offer OmniMD’s EMR and practice management products to its client base.

A “team” of researchers from the University of Illinois assesses the safety of walking across a street and talk on the cell phone. The conclusion is that talking on a cell phone is far more dangerous than listening to music on an iPod and the public should be aware and act accordingly. Brilliant work. Did I mention that the University of Illinois is a publicly funded school?

Drop Inga a note.

HIStalk Practice Interviews R. Michael Kroeger

R. Michael Kroeger, MD, FACS is a urologist with The Urology Center PC of Omaha, NE.

Give me some background on your practice.

We’ve been expanding, so I always have to stop and think. We’ve got 12 urologists and one physician assistant. We have one main office, but we have a total of five offices here in this area; and then about four or five outreach locations in western Iowa. We’ve got our own ASC. We’ve got two Medicare-approved operating rooms; an ambulatory surgery center. Within the last year and a half, we got our own CT scanner. We’ve got a bone density machine; conventional x-ray. Our specialty is urology.

What kind of software are you using?

We’ve had a practice management system since we started. This practice was actually created in about 1989, and I think we were both on manual practice management systems at that time. We started out with a company called MEDS that was in Dallas.

After about eight or nine years, in 1994, we switched to IDX for practice management. Then we got a network for the doctors to use for kind of interoffice communication and scheduling. This was the late ‘90s. We were using Palm Pilots and that sort of thing, so it was nice to be able to synchronize up with the scheduling system that we used in the office.

Actually, our vendor that set up the network encouraged us to use Lotus Notes. I know it’s a very powerful program — maybe a little more than we needed. We’ve still got Lotus Notes. We use it mainly just for the e-mail function and are kind of wondering a bit if we should switch to Outlook for compatibility reasons and so forth.

As far as clinical things, there’s nothing we really had that could be considered a clinical application until we got the EMR. Urodynamics has some software involved, but that’s really just single modality there.

It wasn’t until we got the EMR that we had any clinical IT applications. That’s one of the things that we’ve been able to do with this particular application. I don’t know if it would be the same for others, but we’ve been able to create a lot of documentation tools for the ASC that we just created from scratch, basically. They weren’t off-the-shelf kind of applications, and that’s been quite helpful. It allowed us to do most all of our documentation in the EMR. We do some general anesthesia in the ASC and that’s still completely on paper, but pretty much everything else is EMR.

Tell me about the EMR. Which one you’re using and how long? How did you decide on it?

Well we started talking about it in the early 2000s, about 2001 or so. I’ve been interested in it a long time and I saw a demo actually, by Mark Leavitt. That’s the name of the guy that’s now the head of CCHIT. He had a company called MedicaLogic at the time. I went to a VHA meeting and he gave a demo of MedicaLogic and I kind of got fired up about it. This was probably in the mid ‘90s.

We actively started talking about it in 2001. Every year, we’d have long-range planning and next year was going to be the year. It wasn’t quite ready yet … that sort of thing.

We finally, about three years or so ago, got into more of a formal selection process. There was a speaker at our national meeting from The Coker Group who gave a talk and kind of led us to believe that he had had a special interest in urology, and we ultimately engaged him to help us in kind of doing a little hand-holding, I guess, to kind of get us over the hurdle.

Again, we talked about it for many years and really hadn’t taken any action. Then we set up an RFP. I’ve got a hospital job in medical informatics and so I’ve been to HIMSS and that sort of thing, so I had a chance to visit a lot of vender groups. I kind of had an idea of what was out there. They helped us get a short list of vendors.

The hospital that I referred to is a Cerner place. We looked at what Cerner had on the outpatient side. I think I was sort of OK with it. I’m well aware of the limitations of Cerner. I think Laura, our practice administrator, had some real skepticism about some of the scheduling things and so forth. So we kind of scratched that from our list pretty early. At one point we were down to eClinicalWorks and A4, which had just been purchased by Allscripts.

I kind of liked eClinicalWorks; she kind of liked A4. Then I was reading a discussion board, EMR Update, and somehow I ran across Bond Clinician. Somebody had mentioned that they thought it was particularly good for surgical practices. We got a demo from them and thought it maybe was a good …. kind of met in the middle.

It’s a Web-based program. It’s got kind of a different kind of a cool look to it and very customizable and so forth, and so we ended up going with it. We knew it was a small company. I guess I never would have guessed, when we started out, we would have ended up with something like that. I thought we would have ended up with maybe a larger vendor. And now we are with a larger vendor, so it all kind of works out.

So you’ve been up and running now for about how long?

About a year and a half.

Has it been pretty well adopted by all of your physicians?

Well, it’s been adopted by all the physicians. The “pretty well” I don’t know. I think as well as could be expected. There clearly are things that frustrate people. I think most of them are more just the whole dealing with change and so forth, not so much this particular product. 

I think we’ve been fortunate since it still is, in a sense, kind of a small company mentality in terms of the people that are working on this particular product. Even though it’s now under the Eclipsys umbrella, we’ve been able to get a lot of our issues addressed pretty rapidly by the Peak Practice staff, and so we’ve been real happy with that.

How are you and your partners actually putting the information into the system? Are you dictating? PCs?

We’ve created several templates for different clinical issues, although in actual practice, I think most of us use primarily generic templates. We’ve got generic mail and generic e-mail templates. I would guess that over half of the notes are done using those templates.

For certain visits — follow-ups, cancer patients and so forth — you’re always kind of looking for the same set of information on each visit. We’ve been able to use some specified notes for that. Doing the HPI in a structured, clicking template kind of mode is not very satisfying, I think, for most of us, and so most of us do dictation using Dragon or typing.

Some of the guys’ keyboarding skills are really quite, quite, good. So HPI, in Plan, we do a lot of pre-text, either Dragon or keyboard. Everything else we’re able to do mainly with the template, like for the physical exam. That, of course, plays well into the coding aspect.

One of the things that we wanted to do was to be able to improve our coding accuracy. I think we underestimated how much work it would be just to get the thing going. Now we’re kind of circling back and trying to add some of these extra features that we wanted in the first place, like the coding aspect.

But I’m certainly not saying that people don’t complain about it, but I think people like it. They like the access. Since it’s a Web application, if you’re at home, it’s literally just like being in the office. You can access it from the hospital and that’s been so very powerful. So, they like to use it to look up information, but as is always the case, they don’t like putting information in.

Do you have PCs in every exam room?

No, we don’t. We’ve got wireless, convertible laptop/tablets, and that works pretty well. I think there’s some thought that it would be nice to have a PC in every room with a larger screen; particularly when we want to show patients x-ray images and that sort of thing, and we’ve talked about that.

I think sometimes the architecture of your building dictates how successful that is. How large your exam rooms are and whether you’re able to put them in in such a way that you don’t have to turn your back to the patient and so forth, so we’re certainly toying with that idea. But for now, we’ve got something that works and that hasn’t really been a pressing issue for us. But I think eventually, as we get more connectivity to PACs systems and images and so forth, we’ll probably want to have PCs in the room.

Has the passage of the ARRA legislation changed your focus at all in terms of technology adoption?

Well, I think so. Again, we have started on this pathway well ahead of any inkling that that was going to happen. I think it maybe has changed the timetable and maybe helped us focus on making sure that we do those elements that are going to be needed to get the money. I mean, if we’re going to do this and there’s money to be gotten, we might as well make our timetable fit the schedule that will allow us to get that stimulus money.

Sounds like you’re pretty well connected with your medical informatics role and HIMSS. What’s your impression — why do you think EMR adoption still remains pretty low?

I think the main issue’s cost. I think for a lot of people it’s very hard to justify the cost. It’s hard to show that there’s truly any return on investment; and then resistance to change in general, and the fact that it probably is going to slow you down, at least for a period of time. 

Ultimately, I think probably the best you can hope for is going to be time-neutral. I think to argue that you’re actually going to save time with an EMR; maybe some people can do that, but I don’t think that’s a realistic goal, at least at the current level of the technology.

What’s next for your practice in terms of technology adoptions? Do you have any additional plans? Or just tweaking what you have?

We’re not really looking into any other software products in particular. There are lots of things that this product has available that we would like to get back to. Actually, one of the things that we bought this for was it had a surgery scheduling. They call it Surgery Planner. Then when we tried to actually use the Surgery Planner, it really didn’t fit our workflows for a variety of reasons. So we’re hoping that we can kind of circle back with the Peak Practice people and get a project going to make a better surgery scheduling planner.

We’d like to do the patient portal, which is available. We’ve already got access to that. A patient kiosk that gives us access to the instant medical history. They call it IntelliHistory, and we’ve just had difficulty. We’ve tried with a couple of conditions getting that to work and we’ve just had some issues there. Are you familiar with Allen Wenner and Instant Medical History?

No, I’m not.

IMH is just a tool that you can basically put the patient in front of a computer and they’ll take a history. You have to tee it up and say, this is about blood in the urine or this is about chest pain or whatever; and it’ll ask them questions; it’s not just a flat fill-in-the-blank kind of thing. It branches. So if you say, “Yes, I get up at night to urinate,” it’ll ask you a bunch of questions that apply to that, and it will take that and it will actually fill in your history of present illness for you. I think for some patients, that could be a great time-saver.

Wenner argues that actually, you can do a better history by using a tool like that. People might be more inclined to answer honestly through a machine than they would sitting face-to-face with a person about, maybe, some delicate issues. And so I think it’s a great concept. Again, it addresses that data entry issue. You can actually get the patient to enter the data directly for you. But it, again, we’ve had some challenges getting that to work.

Another thing, in our state, the statewide RHIO, which is called NeHII, Nebraska Health Information Initiative — we’re participating in that as one of the pilot sites for that. We are hoping to be able to actually get an interface to Peak Practice so we can selectively pull in data so we don’t have to look it up on the NeHII system and enter it into our system.

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News 12/8/09

From Seeker of Truths: “Re: ARRA funding. All the EHR vendors I’m talking to lately tell me that practices can get their money right now. I’ve heard it so much that I’m beginning to doubt what I know to be true! Am I the only one?” I suppose I shouldn’t be surprised to hear that some vendors may be saying ARRA money is available today. Technically the government is handing out some money, though none of it has yet flowed to providers for their meaningful use of a certified EMR. Perhaps someone needs to remind those vendors that we’re still waiting on the final definitions for meaningful use and certified EMR.

The AMA expresses concern that easily accessible patient records could lead to a decline in care as doctors avoid the sickest patients to improve quality performance scores. I thought the AMA was suppose to advocate for physicians, not diss them. But, I agree that unintended consequences could occur as we rely more on EMRs to measure quality care improvement. I prefer to be optimistic that most doctors will remain more concerned with providing quality care than performance ratings.

Desert Cardiology (AZ) selects Medfusion for its patient-to-provider online communications solutions. Desert Cardiology is a six-location, 10-provider practice.

Hayes Management Consulting announces that more than 50,000 providers are now using its MDaudit Professional compliance audit software. They also just introduce a hospital version of the product.

Healthpac Computer Systems contracts with Alpha II to resell Alpha II’s ClaimStaker claims scrubber software to Healthpac’s office-based physician clients.

Shares in athenahealth hit a two-year high Friday afternoon after the company stated expectations of annual revenue growth (30%) and profits (40%) through 2014.

Cielo MedSolutions partners with DrFirst to provide e-prescribing functionality for practices using Cielo’s Clinic clinical quality management system. Dr. First’s Rcopia solution will be fully integrated into the Cielo Clinic application.

The Bureau of Labor Statistics says the healthcare sector added 28,500 jobs in October, including 4,800 jobs in physician offices and 10,000 in hospitals. A separate survey finds that 95% of the hospital CEOs claim they have a shortage of physicians, with a vacancy rate of 11%. In other words, more than one in 10 physician job openings are unfilled.

Related problem: if 40 million people suddenly get health insurance, rural areas don’t have nearly enough primary care doctors to see them. The reason is obvious: the doctors go into specialties and geographic areas where the pay is better.

The California Nurses Association, the MA Nurses Association, and some members of the United American Nurses combine to form National Nurses United. The new entity represents over 100,000 nurses.

The UK’s Medical Defence Union warns doctors not to respond to “flirtatious approaches” form patients on  social networking sites like Facebook. The MDU advises members of the importance of keeping relationships with patients on a “professional footing.” Could be that the Brits remain more formal than us since I haven’t heard any official warnings on this side of the pond.

Quantros and Allscripts integrate their respective products to create a Web-based care management solution.

The latest story of greed in healthcare comes from Canopy Financial, who provides software to help manage HSAs. Canopy filed for bankruptcy protection after the FBI began looking into alleged fraudulent financial statements that were created as part of a $75 million investment scheme. Co-founder Jeremy Blackburn recently resigned as president after the allegations came to light and his assets have since been frozen. KPMG first discovered the potential fraud after realizing Canopy was claiming that its financial statements were audited by KPMG. In fact, KPMG had never been retained by Canopy to audit its financials. Perhaps one day Blackburn and Charles McCall will have a chance to be roommates.

E-mail Inga.

News 12/3/09

From Golden Creeper” “Re: MD salaries. While doing some research on physician wages, I came across this blog. Found it interesting and just thought I’d tell you.” While not really HIT related, the MD $alaries has an interesting variety of income data, including comparative figures from various parts of the country and other countries, plus suggestions for boosting income (or reduce expenses). The latest post says that physician executives with an MBA earn 11% more than those without a post-graduate degree.

The Kerlan-Jobe Orthopaedic Clinic, which serves virtually all the professional sports organizations in Southern California, agrees to pay taxpayers $3 million to settle a federal lawsuit. The Justice Department charged it with taking illegal kickbacks from HealthSouth Corporation in the form of stock option grants, donations to the Kerlan-Jobe Foundation, and loan forgiveness on equipment leases.

CCHIT certifies four new products under the newest programs announced in October. ABELMed EHR-EMR/PM, Version 11 received certification under the CCHIT 2011 Comprehensive program, while eHealth Made EASY, KIS Track, and Medios earned Preliminary ARRA 2011 certification.

Here’s the difference between the two certifications: the Comprehensive certification program “provides a more rigorous inspection of integrated EHR functionality, interoperability, and security in addition to full compliance with Federal standards.” CCHIT also includes an inspection process in the Comprehensive program that considers successful use at live sites and good usability. Additional certification announcements are pending, per CCHIT. And OK, I admit it — I’ve never heard of any practices using any of these products.

Claims clearinghouse Navicure recognizes four clients for their substantial improvements in RCM and billing using Navicure solutions. Winners of The Biggest Gainer Awards (love the name) included the 24-physician North Atlanta Primary Care, which cut its A/R days by 43% (less than 18 days) and raised its collection rate to 97.4%. The single doctor Spinella Orthopaedics Association, which has a single FTE for billing, reduced its A/R by 30% and cut its over-90-day A/R by 67%. Here’s a nice spiff: all the winners receive six months of free Navicure services.

Johnson Memorial Hospital (IN) will offer eCW to its employed physicians and use eCW’s Electronic Health eXchange to allow access for other physicians and hospitals.

Participation in quality reporting programs requires resources with measurable costs, a fact supported by a recent study in Annals of Family Medicine. A major problem is lack of interoperability among IT systems. Participation is especially difficult for small primary care practices, who often need to hire outside consultants. Physicians in smaller practices also spend more of their personal time after hours collecting the required data.

SK3 Group signs a letter of intent to acquire Medical Billing Specialists for $4.1 million from its owner, Healthcare of Today.

Maryland is spending $100,000 of taxpayer dollars to train observers to keep an eye on doctors. Specifically, the program will teach certain hospital employees how to covertly monitor the hand washing practices of healthcare workers as they leave patients’ rooms. I’m all for clean hands, but can’t figure out why it costs $100,000 to train people to observe other people washing their hands. And why Maryland is using federal ARRA dollars, because I don’t see the connection with economic stimulation. When will the insanity end?

The 18-physician Naugatuck Valley Radiology Associates (CT) claims it’s now 100% paperless following the implementation of a MedInformatix RIS, DR Systems PACS, and Nuance PowerScribe voice recognition.

Dialog Medical expands its partnership with A.D.A.M. to include A.D.A.Ms’ QuickSheets patient education solution in its iMedConent application.

Ping Inga.