Intelligent Healthcare Information Integration 1/8/10

“Eep!” said the EP

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

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

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

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

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

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

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

From the (useless?) trenches…

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

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

News 1/7/09

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

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

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

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

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

A: Yes.

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

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

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

A: You are correct. And 2013 for hospitals.

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

A: Payment will be sooner.

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

A:  The reg states “directly”

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

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

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

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

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

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

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

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

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

Aprima adds HIT Systems as its latest reseller.

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

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

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

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

E-mail Inga.

Joel Diamond 1/6/10

On Meaningful Use

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

News 1/6/10

HERtalk by Inga

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

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

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

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

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

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

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

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

Send Inga meaningful words.

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.