News 11/12/09

From Jesse Spencer: “Re: EMR reviews. Guess I’m in the minority, but I enjoyed the athenaclinicals review and hope you will do more. I wonder if you mainly heard from vendors who were worried about their own products? As a physician in the trenches who has not selected an EMR yet, I like all the information I can get!” Readers don’t often reveal their true identities and backgrounds, so it’s hard to tell who sent what comments. Vendors are a good guess, as well as consultants who rely on us to remain unbiased (or who resent even vastly experienced amateurs rendering a public opinion based on a quick impression). Who knows, maybe we will sneak in a review from time to time.

Primary care doctors are spending more time with patients, though overall care has probably not improved, according to a new Archives of Internal Medicine paper. The average patient visit was almost three minutes longer in 2005 than 1997. During the same period, physician net incomes fell 10%. The abstract does not mention this theory, but I wonder if any of the extra time can be attributed to providers documenting EMRs at the point of care?

The American College of Surgeons names David B. Hoyt, MD, FACS its new executive director. Hoyt is chairman of the department of surgery and executive vice-dean at the UC Irvine Medical Center.

Walgreens reports big increases in e-prescribing, with about 22% of all eligible prescriptions arriving electronically. The pharmacies filled 4 million e-prescriptions in October, which is 185% more than October 2008.

In its first quarter as a public company, Emdeon announces that revenues grew 10.6% over last year. However, quarterly net loss jumped from last year’s $1.2 million to $7.2 million.

Allscripts contracts with DecisionOne to provide hardware infrastructure support to its clients. Allscripts internal hardware service personnel will integrate with DecisionOne’s field service organization. Sounds like a good move as it allows Allscripts to focus on the software side of the business. Having an internal field service team is less critical in today’s server/PC world than it was in the old days of proprietary hardware.

NIS-Systems (FL) signs on as the latest EHR/PM reseller for Aprima Medical Software.

The healthcare sector added 28,500 new jobs in October, including 4,800 in physician offices.

NextGen Healthcare just completed its user group meeting in Washington DC, reporting attendance of over 2,700 and featuring keynote speakers Newt Gingrich and Howard Dean. The hot topics: ARRA, healthcare reform, interoperability, and patient-centered medical homes.

Initiatives by the American Heart Association and the American College of Cardiology will likely persuade more cardiologists to move to electronic medical records. They can now participate in a national registry that compiles outpatient clinical data.  Officials believe that data collection efforts will be easier for providers using an EMR. Proponents also support the theory that the patient-specific prompts found in EMRs help physicians provide better care.

Google launches a new online map service to help consumers find the nearest locations to receive seasonal and H1N1 vaccines. I did a quick spot check and if you live in Baltimore, Jacksonville, or Los Angeles, you’ll likely find a source. You will see a lot of “temporarily out of stock” messages if you live in Denver, Wichita, Dallas, or San Francisco. Google developed the tool in collaboration with HHS and can be found here.

In a lawsuit involving non-compete provisions and trade secrets, the Georgia Supreme Court rules that a software engineer cannot use trade secrets of his former employer. In this case, the former employer was a medical practice that hired the engineer to customize its medical billing program. The engineer resigned in a dispute and then removed the software’s encryption keys and source and access codes. There’s more to the story, but it sort of makes you want to think twice about who you’re hiring to tweak your software.

Elsevier releases MD Consult Mobile, which provides an entire library of medical content on a mobile device.

I can’t decide if this is goofy or brilliant, but researchers say their cough-analyzing software can diagnose disease by measuring coughs. The application, based on research funded by the Gates Foundation, will run on cell phones or MP3 players.

E-mail Inga.

HIStalk Practice Interviews Bill Henderson

Bill Henderson, FACMPE, is administrator of Upstate Neurology Consultants, LLP.

Give me a little bit of background on the practice.

We’re a neurology practice. We’re obviously a private practice. I’ve got an eight-provider practice that is seven MDs and a PA and we’re in Albany, New York.

What software are you using?

We use Sage Practice Management. We use Sage EHR. We’re running that on a Stratus server. We also run, within the practice, Xen servers for virtual machines. We run terminal services on a Windows 2008 server for remote access.

I run a bunch of other applications, Websense as well as standard kind of things that you would expect in this small network.

We also use Microsoft DPM for the purposes of data backup. Microsoft bought that product three or four years ago and it is a backup product. It kind of reminds you of the Symantec backup product that had continuous protection, only it’s significantly better in that it can do its “data backup pictures” much more often. It writes on the hard drive primarily and it’s far more robust and reliable. At least that’s my experience. I also have it on one of the servers running the practice analytics product that interfaces with the Intergy product — both the practice management side and the EHR side.

How long have you been using the Sage products and why did you pick them?

The practice management side we started in March of 2004. The EHR side we started and we went live on that toward the end of December of 2005.

I had done research for a couple years before we purchased the product. In the end, what finally convinced us to do this was a one-stop-shop, which it was an integrated solution that provided an EHR, a practice management product, and also a scanning interface. It also had the ability to do a lot of the connectivity things we wanted to see developed, such as electronic interfaces to labs and e-prescribing.

From the perspective of a small practice, it’s a lot easier to manage an integrated solution than it would be to manage two solutions — one for practice management, one for EHR. Maybe even another one for imaging, depending upon what’s out there. The product also benefited from the fact the interface could adjust to the work responsibilities of individuals, so that the clinical people using the EHR interface saw the things that are clinically focused; the office people saw the ‘base product,’ or the things that were relevant to the day-to-day billing operations and/or scheduling and/or tasks or communications with patients. So that was positive.

Plus the product also ran on PDAs and it ran on mobile phones. That capability would reduce the number of devices my doctors carried at one time from the three they carried at one down to one, which is obviously a very significant thing.

Tell me a little bit more about the analytical reports that you’re running and the software you’re using. What are the different reports for?

The product is Practice Analytics. It has two distinct features in version 5.5. One is the ability to run reports in what would be considered the standard financial analyses of a practice; such things as charges and collections and the analysis of procedures by provider. But the ability to be able to customize that is very important.

Examples of the kinds of reports we would run under that segment of the product are things related to pay-for-performance. We’re doing CMS stuff right now and e-prescribing for 2009. I’m able to run reports that look at specific procedure codes by a specific insurance carriers, by specific G codes by provider to be able to run tests throughout the year. I’ve been able to do that so far to see that we’re meeting the minimum requirements for reporting for each of those G codes.

So there’s just one example of what I consider to be fairly sophisticated reporting, even on the financial side. The product allows me not only to run reports, but to convert them to graphical charts if I want to do that; or also, to export the data to Excel. That’s fairly standard in a lot of the products that are out there. I’ve used Business Intelligence now for, oh my gosh, about 10 or 15 years. I’ve used Cognos and the like in the past. What I particularly like about this product is it actually allows me to get at each of my data buckets, if you will, so I’m not restricted about what I can necessarily pull out of the data that’s been collected. That’s just looking on the financial side of the product.

Looking at the clinical side, Intergy itself is built on a standardized database called MEDCIN. We had designed a unified template that all of our physicians use. It’s a multi-tabbed template because we obviously see general neurology and we cover a broad number of diagnostic categories. So we’re collecting clinical data on all the individuals that we see, which in turn means that I can run reports on a number of clinical factors, if you will.

I could give you examples of the kinds of things we do. Not too long ago we had a FDA recall on a particular drug and we needed to know who was on the drug; why they were on the drug; whether they would qualify for any humanitarian use, because the company would be allowed to continue it for that. I heard about the recall when the drug rep walked in. In fifteen minutes I had identified everybody in the practice who had that. We were able to contact them and do that because we had that clinical data recorded. In the old days, what that meant with paper charts was you’d have to remember who you had, you’d have to run a report of your diagnosis codes. Then you’d have to pull the charts and actually look. Now you don’t have to do any of that stuff because it’s all built into the data that you’re collecting. So that’s good.

For clinical research work, we can actually really drill down to find such things as the number of patients, by sex, who have a particular diagnosis who have never been on this particular drug and may have these other secondary conditions to see if they may be eligible or someone that should be spoken to at some point regarding the clinical trial. You actually have the ability to data mine clinically in a way that would benefit your patients.

Do you find your doctors are asking you for more and more reports now that they’ve seen the power of them?

Where the power of this product comes in is in the ‘dashboards’ that they’ve introduced in this new version. I use that actually with my doctors and bring into our meetings a laptop and LCD projector. We look at the data and let them see it graphically. You can click on one little button and it changes the look from a graph to a line chart and compare to the previous years. What makes it so exciting is that when you have a report doctors will spend some time analyzing it and then ask questions of the data. Before, if they need you to answer their questions, you would have to turn around and run another report, answer that question, print out more paper.

But now we actually can sit in the meeting look at a particular category of services that we provide; how is our E&M coding compared to last year; how are our neurological procedures compared to last year? We can change what are we seeing, how our population is changing by way of insurer, or where are we seeing people from different zip codes.

Before, you could run those reports — that’s not an unusual thing for an analytical product. The difference here is you can do it on the fly. You just make a couple little quick little changes. Click on what your options are while you’re there looking at the product and you could see how it changes. I could see if my referring doctor patterns changed in the last three months, and if so, how have they changed? Is this hospital providing enough work for us is another question; and, should we continue to work there or is it costing us too much money to see patients there? What you do again by just clicking on the place of service in the hospital and see how that hospital compares. Then you can look at that back over a couple years because now we have data that trails back now for us financially, back to ’04 and clinically to ’06.

Across the board, has the passage of the ARRA changed your focus at all in terms of technology adoption?

That’s an interesting question. I have been a long-spoken advocate within the American Academy of Neurology where I serve on a couple committees, to basically say that we need to have heavy investment in health IT. I felt that way for a long time. People come into my practice just to observe or to see it would say how much time it saves, how beneficial it is. And so for me and for our practice, we have invested heavily in IT all along the way. The new stimulus is nothing more — since we’ve already paid off all of our stuff and we’ve earned the money to do it — it’s nothing more than money coming into the practice. I would say however, that for practices that have not invested at this point, they need to play some serious catch-up to do and I think this bill really incentivizes them to be able to do that.

Why do you think EMR adoption, in particular, remains to be low?

I think pretty traditionally people tend to say the adoption rate for EMR is somewhere in the low 20%. The first thing you have to ask is what’s the average group size in the United States? Some numbers that have floated out there say 50%, at least, are three providers and less. When you’re in a group that’s that small, the costs for providing what I would consider significant IT and health IT is pretty great in comparison to what the revenue would be to a practice. You have to make a decision as to whether you’re going to make that investment or not and there hasn’t been a tipping point.

But the other side of the equation is, up until I had this level of data, the group that had more data than I had was the insurance company. So if I wanted to negotiate contracts, discuss reimbursement rates, I was dependent on the data they could show me about the work that I was doing. Now I’m in a position where I actually have more data than they have about their own patients because not only do I have the billing data, which we both all have — the insurer has it and we have it — but I also have the supporting clinical data and that’s something that they yet do not have.

I’m answering your question in a slightly different way, but having that level of data allows doctors to play on a more level field, if you will, with insurers in terms of the information that they have. And that’s just one example of why it’s hard for me to imagine why physicians have not adopted this. My guess is that the bottom line they look at is the cost. They don’t think their return on investment will be significant enough for them and they make the choice not to do it. I suspect that’s what most groups are doing, but that has not been our experience. So it’s a little bit harder for me to identify with that, although I have empathy with that.

What is your general impression of some of the major changes that may happen in the healthcare technology industry in the next couple of years?

I think one of the first things that’s going to occur is that meaningful use, whose definition has not been finalized yet, is clearly going to extend beyond CCHIT products. It’s going to probably look at what we would call less expensive ones. I think that will make a change because I think physicians will argue that if they can find a less expensive solution, that’s more beneficial to them. I think, however, in the long term, it’ll prove not to be beneficial because I’m not sure how many of these vendors will be in place so to speak, a decade from now.

I think one of the other big changes that will occur is that in exchange for providing money, the government is going to look for access to the clinical data. I don’t think we have actually, as a country, yet resolved the debate as to who owns that data. I think that is yet to occur. I see that as something that is coming down the road and may change.

I think that in the end of the day, a lot of these smaller private groups will merge into larger groups just for the sake of purchasing health IT or doctors may join hospitals or multiple specialty groups for the purposes of getting the benefits without the costs involved in it. Those are a couple things.

News 11/10/09

A Commonwealth Fund survey of primary care doctors finds that the US is way behind other countries in several healthcare categories: access to care, providing financial incentives for healthcare quality, and using IT. Only 29% of practices provide after-hours care (other than the hospital ED). Less than half use electronic medical records, well behind the 90+ percent of several other countries. That’s despite spending twice as much per person as other countries.

Fresenius Medical Care North America, an operator of dialysis facilities, purchases Health HIT Services, makers of the Web-enabled Acumen nEHR for nephrology.

eClinicalWorks adds another IPA to its client list with the signing of Catholic Independent Practice Association (NY). The IPA purchased 150 PM/EMR licenses to connect community physicians and will work with eCW to tie into the HEALTHeLINK RHIO.

Which reminds me of a recent conversation I had with an MSO administrator. We were discussing which ambulatory EMR vendors were making the most inroads into the the IPA and health system market and selling EMRs on a large scale. Some vendors we agreed on: eCW, Allscripts, and Sage. Did we miss any?

New evidence that healthcare providers are not immune to the current economic recession. The 106 year-old Honolulu Medical Group files Chapter 11 bankruptcy, saying it owes creditors over $1 million. In recent years, the practice has shrunk from 40 providers to 11 and owes over $700,000 in rent for unused space. Meanwhile, The Commonwealth Cancer Institute (VA) also files for bankruptcy protection, claiming the slowing economy has delayed patient payments and forced some physicians to leave. Commonwealth’s outstanding debts are over $2.8 million, which includes loans on property and equipment and fees to three doctors.

Consultants in Radiology (TX) deploy eGistics’ Digital Medical Practice Solution for its 14-physician practice. eGistics provides a hosted document management solution.

Sermo launches the Practice Management Exchange, where physicians can exchange business advice and earn CME credits on PM topics. PME was designed for physicians in small and solo practices.

Gregg Alexander, Jon Smalling, and I enjoyed our quick peek at athenaClinicals and have been reviewing feedback from our readers. Most were along the lines of this: “Stick to the knitting and provide what we all like to hear — unbiased and good reporting on the industry.” Another reader accused Mr. H of having  “man crush” on Jonathan Bush, which made me smile since Mr. H doesn’t seem like a “man crush” kind of guy to me. In any case, the critics have spoken and we have opted to shelve the product assessments and will focus our energies elsewhere. We honestly liked the paddles, however, so maybe we will dust them off when we evaluate exhibitors at HIMSS. And thank you for taking the time to share your opinions with us.

QHR Technologies signs a letter of intent to acquire its EMR competitor Clinicare for $5 million Canadian collars ($4.7 million). Both companies are based in Canada and together provide PM and EMR to over 3,000 physicians. Clinicare serves providers in the US as well as Canada.

The AMA officially applauds the passage of the House’s health reform bill, though many physicians want the support rescinded because the legislation interferes with the patient physician relationship. MGMA also praises certain HIT components of the bill, though some HIStalk readers tell us support is far from universal among MGMA members.

Riverside Radiology Associates (OH) signs a five year license renewal for Zotec Partners’ billing, RIS, and decision suite products. RRA claims its billing costs have been cut almost in half since its 70 radiologists first contracted with Zotec in 2005.

In Miami and presumably across the county, physicians are embracing social media tools to update families on surgery patients, to educate consumers, and to share medical information with fellow providers.

According to the medical director of informatics of the 250-physician Fallon Clinic (MA), EMR has not reduced patient wait times, but their Epic MyChart patient portal allows patients to receive care without coming to the office. The practice has spent $24 million in the first three years and says they are providing better care. With the removal of paper charts, clinics also have more room. The practice expects to recoup the $24 million expense “eventually.” For the mathematically challenged, that equates to about $32,000/year for each physician over the last three years. That’s a pretty pricey solution, especially if the ROI is as vague as it sounds in this article.

Text messaging can significantly improve adherence to treatment plans for chronically disease patients, according to a Mount Sinai Hospital (NY) study. Physicians working with adolescent patients who had undergone liver transplants found patients were more likely to take their medications when they received text reminders. Patients had to text back within an hour to acknowledge their meds were taken and avoid having providers contact their caregivers. I am guessing a sample text message might be: “AYEC TAKE RX PLS,” and the reply could be, “K, KPC.”

E-mail Inga.

Intelligent Healthcare Information Integration 11/6/09

Digital Relations

Did C-3PO really understand all the whirrs and whistles that emanated from R2-D2? Did Data really have the ability to feel emotions when he finally had the appropriate chip installed? Did Hal 9000 (or “CARL” in the French version) feel any psychic pain while singing “Daisy Bell” during his death throes as Dave removed his service modules? Questions without answers these are, I suppose, until we more closely assimilate with our computer brethren in our impending Borgian future.

One question that can be addressed now while still in our mere mortal form is: How do we, as mere Homo sapiens, choose to allow digital communications to affect our relationships and interactions?

Much has been written about, and academicians have debated over, the impact of cell phones and emails, IMing and Facebooking, texting and tweets. One element that I think we in medicine must address is the etiquette and ethos we will choose to maintain as we cope with the tremendous impact such an expansion of communication choices brings to the delivery of healthcare services.

When I see ivory tower discussions about the impact of social networking and all tools digital, I am sometimes alarmed at the seeming passivity of the observations and conclusions. Perhaps I am being too harsh; I know social science is one of observation and discussion of the observed behaviors. But, as a clinician of kids, I know that merely plotting their growth, detailing their development, and recording their progress to full assimilation into the world of “adultitude” is not enough. Guidance and modeling of appropriate behaviors is essential to their mental, emotional, social, and moral success.

We are, in essence, in the infancy of our digital development. As a communal infant, we need to consider the future to which we aspire. Just as we attempt to provide guidance to our biological offspring, we, too, need an inspirational archetype. However, there are no roadmaps, no role models with whom to associate and after whom to pattern our behaviors. Thus, it seems imperative that we seek a “best practices” for our digital interactions growth, knowing that it can only be extrapolated and estimated from a non-digital past.

I offer here a completely Ludditian example of a Best Practices (caps intended) communication technique as prima facie example number one:

I have a relatively new friend who, interestingly enough, I met through these pages here on HIStalk Practice. He is a corporate COO who travels to many exotic ports of call as he helps to expand the digitization of healthcare communications globally. One of the most engaging and enjoyable people I know, he has the ability to speak corporate-ese with ease and yet seamlessly transition to “Regular Guy” mode with more wit, humor, and just plain good-to-talk-to-ness than most anyone I’ve ever known. Perhaps it is his ability to shift between these mindset forms that allows him to understand of the value of the old good graces of social intercourse as he pursues advances for its more modern expression. To wit: He is the only person I know who still sends real, honest to goodness POST CARDS! I cannot begin to tell you how it brightens even the dreariest of days to receive a little handwritten message on the back of a beautiful photo from Nourilang Falls in the Jiuzhaigou Valley of China. Even one from someplace more mundane such as Seattle or Denver (no slight intended to those good cities) has a special power and touch few emails or tweets will ever match. The personal “oomph” of these cards is tremendous.

I’m not proposing that everyone start sending snail mail again, though I’m sure the USPS wouldn’t mind. I’m suggesting that as Twitter and Facebook and cell texts and emails invade more and more of all our personal interactions, lessons from the past ought not be lost. Corporations and companies and doctors’ offices don’t create messages; people do. Every communication that emanates from anywhere ultimately involves someone, some person or persons, wanting to connect with some other some-one or -ones. And every single one of those messages has the power to move, motivate, or inspire, but only if the connection, the personal touch, is achieved.

My friend’s good communication graces may seem quaint and outdated, but the power of his message with its ultimately personal touch is undeniable. Simple communication etiquette goes a very long way in empowering connection. As mom always said, “Remember your manners.”

From the trenches…

“Good manners are just a way of showing other people we have respect for them.” – Adam Weber in “Blast from the Past”

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 11/5/09

More than half of physicians claim little or no familiarity with ARRA, according to an Ingenix survey. Only 42% of the participating physicians said they had “some” familiarity with ARRA, which seems like a shockingly low number. For physicians moving to EMRs, investment reimbursement and claim penalties are two of the biggest motivators.

Practice management and EMR provider Raintree Systems and RCM provider ZirMed announce a partnership to jointly market their combined solutions.

Memorial Hospital (MS) plans to install Allscripts EHR, PM and RCM products for its 100 employed physicians.

Ali′i Health Center (HI) selects Aprima Medical Software to provide EHR and practice management software for its 15-physician practice.

Two of San Diego’s largest independent physician organizations are partnering to develop PM and EHR implementation strategies. The article is a bit unclear  about what the partnership really means for day-to-day operations for Graybill Medical Group and Sharp Community Medical Group. However, Sharp had a big rollout of Allscripts EHR/PM just last year, so perhaps Graybill hopes to jump on the bandwagon.

A quick follow-up to athenaClinical’s review posted earlier this week. We’ve gotten some positive feedback about the exercise, as well as pleas to stick what we do best. If you’d like to weigh in, send me a note. We are also asking athenahealth to respond to a few specific issues, so look for that next week.

Express Scripts plans to use Greatwater’s PatientPort kiosk platform in physician offices. Patients will be able to review prescription options via the kiosk with the goal of reducing prescription costs.

ICSA Labs, the Medical Transcription Industry Association and several medical transcription companies form the Medical Transcription Service Consortium. The consortium’s mission will be to develop a interoperability standards for the exchange of transcribed dictated medical records.

A local paper posts a well-written article that highlights the practices of two Kansas doctors. One is an 82 year-old family physician who writes his exam notes on 5×8 index cards and has an assistant create insurance claims on an electric typewriter. The second doctor is on EMR and inputs his patient notes on a tablet computer with a stylus. Both doctors seem quite happy with their situations and the contrast (and similarities) make for a fun read.

E-mail Inga.