News 06/25/09

From: Al Borges “Re: New CCHIT certification options. CCHIT is simply trying to defuse the argument that certification costs too much. The only thing is that: the cost of earning the certification can be overwhelming; most folks that have non-CCHIT certified EMRs don’t care about CCHIT nor do they care about HITECH; and, they still shut out commercial non-c-EMRs out there in the market. Other countries are way ahead of us, and none of them rely on CCHIT, even though Canada, Europe, and SE Asia did try to do certification schemes like CCHIT.”

Epocrates claims its mobile clinical reference software is the most helpful safety technology for physicians. Sixty percent of the 2,000 physicians they surveyed reported avoiding at least one adverse drug event per week using the Epocrates software. About one-third of US physicians use the application.

Physician compensation did not keep up with inflation last year, according to an MGMA survey. Primary care doctors reported a two percent increase in compensation (or –1.73 percent adjusted for inflation.) Specialists saw an adjusted decline of 1.59%, with internal medicine faring the worst with a 3.37% adjusted decline. Gastroenterology and pulmonary medicine were among the few specialties posting moderate compensation gains.

On the rise: the use of signing bonuses to attract new physicians. Eighty-five percent of searches offer a signing bonus, which average $25,850.

Signing bonuses may be the key to replacing older family practice physicians practicing in rural communities. Eighty-one year Dr. Kenneth Spady says he can’t find anyone willing to take over the rural Washington health clinic he’s run for the last 52 years. The suggested reason is no surprise: a shortage for primary care providers as more doctors opt for the higher paying specialties.

Doctors fail to tell patients about abnormal test results seven percent of the time, or a rate of one out of every 14 tests. Practices using EMR had lower failure rates than those using paper. However, offices using a combination of paper and computer records had the worst overall failure rates.

Bridges to Excellence launches five new reward programs to assess improvements in the diagnosis and management of chronic diseases. The programs provide incentives that reward physicians and practices for adopting better systems of care, including the adoption of HIT.  Bridges to Excellence also announced it will utilize IPRO’s Clinical Data Portal to accept chart data directly, or, via an EMR and score data against clinical measures.

For $3,000, ophthalmologists and optometrists can purchase an EHR that incorporates electronic prescribing. Compulink Business Systems is offering the Eyecare Advantage Essentials and E-Rx products, which sounds like an “out-of-the-box” application that does not allow for customization. Compulink also offers an ophthalmology-specific PM plus a more robust and customizable EHR.

HealthCare Partners Affiliates Medical Group (CA) acquires Northridge Medical Group, an IPA serving 24,000 patients in Southern California. With the transaction, Healthcare Partners Affiliates Medical Group will include 1,200 employed and affiliated physicians and server over 680,000 patients.

Massachusetts takes top honors at Surescripts’ Safe-Rx Awards, which recognize the top e-prescribing states. Massachusetts providers send 20% of prescriptions electronically, followed by Rhode Island at 17%. Vermont was named the most-improved state. Surescripts also recognized the top individual e-prescribing physicians, include three using stand-alone e-prescribing software and three using EMRs. Interestingly, 44% of Vermont’s e-prescriptions were generated by Allscripts users, as were three of the six top prescribers. A fourth provider utilizes Eclipsys Practice Solutions.

The high rate of EMR de-installations in the Phoenix area leads analysts to conclude that small physician groups need solutions that are more simple and affordable. Though the Phoenix market at one time was adopting faster than other regions, de-installations are now rising as physicians complain of training, functionality, and cost issues. Is this a trend unique to Phoenix or something we will see repeated across the country? I predict the latter.

Does technology create a new etiquette for physician-patient interactions? Those of us in HIT focus on how technology changes the way physicians practice medicine. This article points to some of the ways patient behavior is and will evolve as technology seeps into the clinical world. Patients must be increasingly assertive, especially if their doctor has his/her back turned entering information into a computer: patients must be sure to communicate any visual cues their physician might miss. Patients are now armed with more clinical data, thanks to the Internet. Physicians should be prepared to address questions from more educated patients. And, as patients have more access to their own records, they will bear more responsibility for monitoring the accuracy and completeness of their information.  Just ask e-Patient Dave.

E-mail Inga.

News 6/23/09

From Evan Steele: “Re: new CCHIT proposal. Finally, people are listening to the voice of the physician. The recognition that the original CCHIT certification may be overkill for many practices, particularly specialists, and unreachable for others is a positive step. Gayle Harrell made some very salient points at the HIT Policy Committee meeting last week. She cautioned against placing such an extensive burden on physicians that they simply do not adopt an EHR at all, warned that the definition of ‘meaningful use’ must be achievable, and reminded the Committee that specialists should not be left out. We know from the comments on blogs like yours that there is a silent majority out there who are starting to speak up.” Evan is referring to the new recent CCHIT announcement that it is considering three certification approaches to replace its current single one. The options would include EHR-C, a rigorous certification for comprehensive EHR systems; EHR-M, a module certification program for e-rx, PHR, and other technologies; and, a simplified, low-cost option for providers who self-develop or assemble EHRs from non-certified sources.

Beth Israel Deaconess Medical Center embarks on an “open notes” project that will permit patients to read the charts of about 100 doctors. The $1.5 million project aims to understand if having patient notes available online proves to be more useful than objectionable to those patients. I’d definitely read my notes online, though I’d mostly be looking for any suggestions the doctor thought I was fat/stupid/unattractive, etc. Or, perhaps paranoid.

Practice management consultants recommend that physician offices accept credit cards, despite their 3-5% transaction fees. More practices are refusing to accept them, but consultants say they’re worth it compared to the expense and hassles of issuing paper statements and collecting bounced checks.

CMS announces that additional physicians may qualify for 2007 PQRI bonuses, following an investigation of the feedback reports and incentive payments. CMS identified some technical issues that could be corrected. Revised reports will be available to eligible physicians by the fall.

Three Cleveland community health centers are preparing for EMR in advance of pending stimulus funds. The three clinics will receive a combined $2.7 million for EMR and other capital projects. One clinic has already selected NextGen; the other two have narrowed their choices to NextGen and EpicCare.

According to this RWJF study, personal health records provide clinicians and patients insights into daily life that aren’t available solely through clinical encounters.

RelayHealth announces a strategic partnership with Lighthouse1 to help providers automate payments for patients with healthcare spending accounts and consumer driven healthcare plans. RelayHealth will integrate its EasyCDH solution with Lighthouse1’s OnDemand  platform to create the SAS OneCard solution.

CMS names NextGen a qualified PQRI patient registry for 2009, meaning their solution will help eligible physicians submit data based on PQRI quality measures direct to CMS.

Louisiana passes a bill that will set aside $5 million to provide EMR loans to providers (or more accurately, to give the state access to stimulus money).

Document imaging vendor Scantronix and eClinicalWorks sign a partnership deal. Meanwhile, ECW founder and CEO Girish Kumar Navani takes home an E&Y Entrepreneur of the Year Award in New England’s healthcare technology category.

Here is a shocker: patients are at a greater risk of obesity when there are more fast-food restaurants than grocery stores close by. I am thankful that this study is courtesy of the Canadians because I would have been miffed to see my tax dollars spent confirming something so intuitive.

The AMA provides a great list of the the most common and avoidable mistakes for physicians buying an EMR. The single biggest error: doctors not listening to other doctors and learning from their mistakes. Some of the best tips include taking a site visit, checking with practices other than the references provided by the vendor, and allowing for plenty of training.

MGMA reports that the starting salaries for physicians in many specialties are on the rise. Neurologists saw the biggest gain, from $200,000 to $230,000 a year, which is a 15% jump. Neurosurgeons earned the highest salary at $605,000 while pediatricians earned the lowest at $132,500.

Dr. Jay Parkinson is busy developing Facebook-style software for his start-up company Hello Health, a national franchise of clinics he is building that allows patients to e-mail, text, or video chat with doctors over a secure website. His Hello Health website debuts this summer. Mr. H interviewed Dr. Parkinson in 2007, back while he was still practicing and making house calls. Meanwhile, the company’s three-doctor demonstration clinic has treated 700 patients in the last year and 400 have become regular patients. Member patients pay $35 a month, which covers simple e-mail questions, and $100-$200 per office visit (and patients file their own insurance). Time will tell whether or not the model is financially sustainable and if it will attract enough patients and doctors.

E-mail Inga.

Intelligent Healthcare Information Integration 6/20/09

Pool Pumps and EHRs

Never having owned a swimming pool before — kiddie blow-up pools notwithstanding –I had no clue about anything pool when we moved to a home with our first “cement (pronounced “see-ment”) pond.” Being in Smalltown, Ohio, where ‘pool guys’ are something we only hear about on Nip/Tuck, I had no options other than to learn my way around pool care, including chemistry, biologicals, skimmers, hoses, filters, jets, and pumps.

Turns out the pool pump we inherited, besides being old and inefficient, had been wired poorly and was using far too much juice. When our summer electric bills pushed us toward bankruptcy, I studied up on newer pools pumps and decided to purchase a “smart” pump which promised “up to 90% savings” on our electricity tab.

Savvy enough to have a certified-smart, real electrician convert my wiring run and circuit breakers from 120 volt to the required 240V, I chose to do the actual pump installation and final wiring to the outdoor switch on my own. (No, this isn’t leading to a tale of emergency squads and defibrillations!) With a broad smattering of electrical and electronic training and a general understanding of electrical codes, hots, grounds, and safe wiring habits, the job was not the greatest of challenges but was still not the simplest or least nerve-wracking of installations. Fortunately, it powered up without a spark and seemed to work.

Afterwards, I relaxed in the hammock listening with some small sense of self-accomplishment to the much more muted hum of our new, high tech, energy-saving, self-adjusting, computerized pool pump. But, now, with the new, high end tool online and operational, I still had to figure out just how to decipher and adjust all of those new pump-puter settings and codes to optimize my chances of achieving the 90% savings advertised.

The manual seemed complete, all 60 pages of it. Predictably, though, the typically poor tech writer-to-lay person interpretation skills were in full swing, so I found myself looking online for deeper insights and better explanations. This did help, but I’m still not sure if I am using, or even understanding, all of the available digital tweaks and tools this of fancy new gizmo.

You see, I’m sure, where this is heading. With something as relatively simple as a pool pump and with someone who has a generally workable background in electronics and computers, the challenges of digitization and the learning curve for its incorporation are not irrelevant, not even minor. Why, then, is it such a surprise that medical providers, who typically boast minimal-to-no I.T. background, have such trouble adopting, no less understanding, VASTLY more complex electronic healthcare tools?

How are healthcare providers ever going to achieve HIT competency and EHR satisfaction … two weeks of on-site training, hard-to-reach support call centers, and a written-by-techies manual? These are the typical answers which most EHRcos have concluded are sufficient to bring healthcare workers across the digital divide. That’s about what most of us could use to competently install and utilize one of these fancy-schmancy, cement pond pumps. I’m thinking a better training, support, and ongoing education plan might be required for the complexities of HIT.

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 6/18/09

HHS publishes its meaningful use matrix (warning: PDF) with these priorities:

• Improve quality, safety, efficiency, and reduce health disparities
• Engage patients and families
• Improve care coordination
• Improve population and public health
• Ensure adequate privacy and security protections for personal health information

In the ambulatory care setting, the objectives seem achievable (at least the  Year 2011 items.) One big exception may be the use of CPOE “for all order types.” This is not an impossibility, but it does suggests the need for providers and vendors to act quickly. Typically, order-entry is one of the last phases of an EMR implementation, in part because the process tends to slow down the providers. Also, order-entry typically requires interfaces to other systems, such as the lab and x-ray, and, interfaces tend to create headaches, take time to create and perfect, etc. An additional reason to get going on EMR: the year the provider applies for an EHR subsidy correlates to what meaningful use standards are applicable. In other words, if a provider waits until 2013 to apply, he/she will be required to meet the 2013 requirements to receive any funds, and not just the 2011.

Thanks to technology, a marine corporal in Afghanistan is able to witness the birth of his daughter in Rhode Island. The hospital set up an Internet connection and a web cam in the birthing center and the proud dad viewed the birth from a secure location 6,000 miles away.

The Maryland medical society wants the federal government to delay or eliminate financial penalties against offices that do not computerize their records by 2015. Their concern is that too many doctors cannot afford an EMR. The medical society fears fewer physicians will accept Medicare and Medicaid patients because they won’t be able to afford the potential financial penalties.

Noteworthy Medical Systems introduces the release of NetPay, a web-based application that facilitates the collection of all patient payments at the point of care. The product integrates with Noteworthy’s NetPracticePM product and is powered by mPay Gateway.

The AMA adopts principles for EMR breaches: (1) tell the patient; (2) follow appropriate procedures for disclosure; (3) place the interest of the patient first; and (4) give the patient information to mitigate the consequences. Members also drafted a resolution discouraging the government to impose penalties on providers who haven’t adopted e-prescribing, and, adopted a policy asking the federal government to adjust EHR subsidies to account for inflation.

Telehealth company TeleDoc Medical Services names Jason Gorevic CEO. Gorevic joins Teledoc from WellPoint.

An Australian medical blogger provides some great suggestions for physicians considering adding (or updating) a practice website. He writes from personal experience, having just designed a site for his wife’s OB/Gyn group. Even though he is likely writing for an Aussie audience, the information is surprisingly relevant.

CalPERS, Anthem BC, and BS of California team up to launch an e-prescribing initiative in California.

Contacting patients via telephone or the Internet is an effective way to reduce risk factors for coronary heart disease, according to this study. Though telehealth was not found to reduce overall mortality, participating patients were more likely to lower their cholesterol levels, lower their systolic blood pressure, and cease smoking.

The Medicare Payment Advisory Commission (MedPAC) advises Congress to change the way it pays providers in order to achieve better care coordination and efficiency. MedPAC raises several areas for consideration, including more focus on graduate medical education and incentives that promote care coordination. MedPAC also cautions against self-referral in imaging, suggesting that when physicians have a financial interest in imaging equipment, they are more likely to order imaging tests and incur higher overall spending on their patients’ care.

Kaiser Permanente ships a 500-square-foot, 10-wheel mobile medical vehicle to Hawaii’s Big Island. The mobile health vehicle is equipped with KP’s HealthConnect EHR system, a mammography unit, and video telemedicine equipment.

Hayes Management Consulting just published its summer 2009 issue of the Hayes Review Newsletter. Included in the issue: information on health-related self-service kiosks, recommendations for reducing interface errors, and tips on successfully implementing physician charge capture modules.

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DrLyle’s Thoughts on the President’s AMA Speech 6/15/09

President Obama spoke today in front of the AMA, where he quickly got to the routine line about “We need to computerize our medical records and spend more on preventive care”… a popular theme, and yet us pragmatists know we need to do more.

And then, our President said more: “But as important as they are, investments in electronic records and preventive care are just preliminary steps. They will only make a dent in the epidemic of rising costs in this country”. Wow, finally someone admits it! So what do we have to do to make a realistic dent in healthcare costs?

President Obama went on to make it very clear that two things need to happen:

First, “Reform the way we compensate our doctors and hospitals” (which essentially means a shift from fee for service payments to a capitated/P4P system). He elaborates by saying, “We need to bundle payments so you aren’t paid for every single treatment you offer a patient with a chronic condition like diabetes, but instead are paid for how you treat the overall disease. We need to create incentives for physicians to team up – because we know that when that happens, it results in a healthier patient. We need to give doctors bonuses for good health outcomes – so that we are not promoting just more treatment, but better care.” Of course, I am all for a system that rewards quality and efficiency over simple volume of services – it’s the right thing to do and lends itself much more to innovation!

On the other hand, the capitation model got ugly in the for-profit HMO days, so we will need to be careful how we implement this. Fortunately, it is encouraging to see how the Kaiser model has evolved since those days. Just ten years ago, they had a pretty bad reputation for “rationing care” due to their capitated system, but now their patients seem consistently satisfied. This is in large part because of changes Kaiser has made in both care and expectation management, but I think also because the consumer perspective has changed with the Interneting of America… what may have seemed liked “denials” ten years ago (e.g. you can’t come in, a nurse can handle your care over the phone) now seems like a convenience (e.g. would you like to do a virtual visit with a physician extender instead of driving all the way to the office?). Finally, a use of technology that works equally well for physicians, patients and payors!

Second, he said we need to “Improve the quality of medical information making its way to doctors and patients” (which means identify and spread evidence-based best practices). He noted that a recent study “found that only half of all cardiac guidelines are based on scientific evidence. Half. That means doctors may be doing a bypass operation when placing a stent is equally effective, or placing a stent when adjusting a patient’s drugs and medical management is equally effective – driving up costs without improving a patient’s health.” He also quoted the great Gawande New Yorker article on this subject of cost disparities not affecting quality of care (btw- I love that our President is actually reading this stuff!). And then he summarized, “figure out what works, and encourage rapid implementation of what works into your practices”.

Of course, this will scare certain specialists who do a lot of procedures… and since the AMA represents many of those docs- I imagine they will be very wary about this issue (I wonder if there were “boos” at this time?). But, it is the right thing to do – our healthcare system simply can’t survive if we keep paying for every new procedure and test dreamed up by our scientists- why do they get to be innovative and our payment system remains so stagnant!

On the other hand, we need to reconcile this issue with the constant advancement of science that makes America great. Perhaps we can look at other nations to understand how this can be done effectively, or again review Kaiser’s and other stable capitated systems to see how they determine what is the best and most cost-effective treatments they can offer. Some will cry “rationing”, but that is indeed misleading in a nation where we already ration care to so many Americans who are under-insured and non-insured.

So I agree with President Obama – we can do better. It is quite clear that our current system is simply not sustainable long term, nor is it a “fair” system due to its inability to provide access to all Americans. So I hope we will be able to tell our children in ten years that we were part of the movement which allowed us to become a nation where we can provide the best healthcare to all Americans in the most convenient and cost-effective way possible. It is right financially, it is right morally, and it is right clinically. Now Mr. President, just make sure those words move into action.

Lyle Berkowitz, MD is an internist and healthcare informatics expert. He is Medical Director of Clinical Information Systems for a large primary care group in Chicago. He also blogs at Change Doctor.