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.

News 6/16/09

Allscripts and Henry Schein enter a strategic partnership to market Allscripts Professional EHR. Under the exclusive agreement, Henry Schein will utilize its national medical sales force to market the solution nationwide. Henry Schein will also refer other Allscripts solutions on a non-exclusive basis.

Maine Governor John Baldacci signs a bill requiring health insurance providers to cover telemedicine services, including those provided via interactive audio, video, and other electronic media.

A Delaware man walks out of his doctor’s appointment, taking the doctor’s computer with him. A few hours later police arrest the patient after finding the computer in his basement. No word on whether or not patient paid his bill.

GE Capital announces a $100 million commitment to extend no-interest loans to providers and hospitals purchasing GE’s Centricity EHR. The program allows providers to defer payment until receiving government stimulus money, likely in 2012.

Several consultants point to EMR adoption as one of the keys to keeping a practice solvent through the recession. Though the up front expense is high and implementation can be overwhelming, EMRs are required to create the quality reports necessary for P4P. Perhaps, but plenty of doctors will still remained convinced that the costs outweigh the benefits.

VirtualHealth Technologies finalizes an agreement with Silk Information Systems to provide web-based EHR, RCM, and billing solutions with no up-front costs to its base of 1,500 medical practices, through VirtualHealth’s subsidiary Medical Office Software.

In Virginia, large medical groups continue to increase in size, as more doctors give up their independent practices. The trend is not unique to the area, nor are some of the reasons for joining bigger groups: more stability, less responsibility for day-to-day business operations and thus fewer hours. Lower overhead as costs for such things as billing, EMRs, and administrative functions are also a draw. Opponents of the trend fear quality may suffer.

An Indiana ophthalmologist and his wife are found dead at their practice, victims of an apparent murder/suicide. Dr. Philip Gabriele and wife Marcella were indicted last week on federal charges of health care fraud, wire fraud, and criminal conspiracy. The indictment claims the doctor falsely and fraudulently diagnosed cataracts in patients and performed unnecessary cataract surgeries. False claims were then submitted to Medicare, Medicaid, and private insurance carriers. The Gabrieles denied the charges and were suppose to turn themselves in the day they were found dead. No winners in this story.

President Obama addresses the AMA Monday, stressing the need for reform. Some of the speech covered old ground: the need for a comprehensive upgrade to EMRs, more focus on preventative health, and emphasis on cutting costs. Obama stressed he was against caps on malpractice awards (likely not popular with the physician crowd) and discussed his proposed “Health Insurance Exchange” program for the uninsured or for those that don’t like their current coverage.

Sixty-one percent of American adults now look online for health information, compared to 25% in 2000.

A physician shares her thoughts on how social media can expand the physician/patient relationship, as well as help patients and physicians widen illness support networks. A good read if you are already a social media-savvy doctor, or, one wondering if it is worth the investment in time and energy.

The Mayo Foundation for Medical Research and Education and former employee Dr. Peter Elkin are in the midst of a legal battle, with each suing the other party. At the heart of the issue is ownership rights and royalties for natural language software developed by the physician while in Mayo’s employ. The story involves a web of companies, including LingoLogix (a company we profiled on HIStalk) and Cerner (who later bought LingoLogix and has now filed its own lawsuit.)

Next year we hope to make this conference. Last week 350 medical experts and computer game professionals came together for the fifth annual Games for Health Conference. Highlights included games specifically focused on improving cognitive health and the use of gaming to change behavior. It’s just a matter of time before doctors begin handing out prescriptions for Halo 3 and Call of Duty.

An HIT Moment with … Steve Schelhammer

An HIT Moment with ... is a quick interview with someone we find interesting. Steve Schelhammer is CEO of Phytel.

Proactive Patient Outreach is a Web-based service that includes an electronic patient registry, a protocol engine based on nationally recognized guidelines for preventive and chronic disease care, and an automated messaging system that contacts patients who need services. Phytel provides a variety of management and physician feedback reports, and it helps practices qualify for pay-for-performance, PQRI, and medical home incentives. We also have a medical economics team that works with customers to help them analyze their patient population and improve the quality of care.

In contrast, practice management software merely reminds office staff when to contact particular patients for follow up, and those reminders are entered in the system only when physicians order it. What we’ve done is to systematize physician-driven population health management and to make recalls automatic instead of hit-or-miss. In that sense, we’re offering more than technology; we’re providing a health improvement service built around compliance, outcomes, and extending the influence of the physician beyond the visits that patient initiate themselves.

Last year CMS named Phytel a qualified patient registry for PQRI reporting. What does that mean for your average physician client?

What it means is that we can now submit PQRI data automatically from our registry, without physicians having to do anything or worry about which patients they should be collecting data on. It also saves staff a lot of time entering CPT II codes in their billing systems.

The administrative burden on practices was the main reason why only 16 percent of physicians reported PQRI data in 2007. They just didn’t feel it was worth doing the extra work to get the incentive. But in 2008, Medicare raised the incentive from 1.5 percent to 2 percent of charges, and it also provided an alternative method of submitting the data. If you use a CMS-approved electronic registry like Phytel’s, you only have to send in data on 30 consecutive patients with a specified condition—and only two of those need to be Medicare patients.

We extract most of the necessary data from practice management systems and electronic health records, including lab data if a practice has an EHR or a lab interface. Where required information is not in the available fields, our program prompts users to enter the missing data, such as whether a diabetic patient has had an eye exam.

What impact does the ARRA have on Phytel, both good and bad?

ARRA will be highly favorable to our company’s strategic direction in the field of population health management. The legislation requires “meaningful use” of EHRs to qualify for financial incentives, and it’s clear that part of that will be the ability to capture and report quality data. Today, few EHRs—including those with the latest CCHIT certification—have robust registry functions. So physicians will have to combine EHRs with outside services like Phytel’s in order to report performance data, unless they want to devote a huge amount of staff time to data entry or pay for custom reports to show meaningful use.

Also, EHRs do not include automated outreach and patient self-management capabilities. Even if they were combined with a commercial technology solution, they would still lack the ability to tailor the messaging to clinical protocols. It’s instructive that the majority of our customers have EHRs, yet had difficulty in reaching out to noncompliant patients before they used our service.

Physicians don’t need an EHR if they want to use Phytel to bring in patients for needed services. But to the extent that ARRA’s incentives encourage more physicians to adopt EHRs, I believe that it will increase the impact of Phytel. By enabling us to populate registries with more granular clinical data, the spread of EHRs will help physicians pinpoint the patients who really need help and get them to make appointments before their conditions worsen. And that will contribute to better outcomes for their patient population.

What trends are you seeing in regard to provider reimbursement and evidence-based medicine and where does Phytel fit in?

Physicians will increasingly be paid on the basis of their quality and their patient outcomes rather than the volume of services that they provide. While fee for service is still the predominant method of reimbursement, pay for performance and the medical home trend are already shifting a significant chunk of physician income to quality-based incentives. For example, California health plans paid out more than $200 million in P4P incentives to medical groups and IPAs from 2003 to 2007. And Blue Cross and Blue Shield of Michigan recently launched a program that will pay physicians who create medical homes a 10 percent bonus, starting in July.

A key requirement of both P4P and medical homes is that physicians must follow evidence-based-medicine guidelines. Most physicians think they’re doing that, but a broad body of research, including the Dartmouth Medical School studies on variations in care, shows that it just isn’t so. The study that really woke up everybody up a few years ago was the RAND report that revealed patients were receiving only 55 percent of recommended care, on average.

What the RAND study failed to point out is that many patients don’t receive the care they should because they don’t comply with their physicians’ treatment plans. This is a problem that Phytel can help physicians alleviate. By strengthening the physician-patient relationship, by helping doctors optimize the value of each patient visit, and by extending the communication between physicians and patients beyond the walls of the office, we give doctors vital tools for improving patient health.

Phytel is very interested in participating in the emerging patient centered medical home health improvement initiatives. The AAFP’s TransforMED project endorsed Phytel, and I’m on the board of the Patient Centered Primary Care Collaborative, which is promoting the medical home concept at a national level. The PCPCC has more than 400 members, including major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, and physicians.

Many health plans are doing medical home pilots, and some are rewarding physicians who have been recognized by the NCQA as medical homes. For example, Dr. Joseph Mambu, a Phytel customer who qualified for the top level of NCQA recognition, expects to receive a medical home incentive of more than $40,000 through a statewide initiative in Pennsylvania. Judging by the NCQA criteria, we believe that many other Phytel clients could use our service as a building block to qualify as medical homes.

What are some of the more unusual ways your clients are using Proactive Patient Outreach?

Many of our clients are focusing on particular chronic conditions, such as diabetes or congestive heart failure, that generate a lot of morbidity, complications, and costs. And some practices are customizing our protocols in very specific ways. For example, the Holzer Clinic, a multispecialty group in Ohio, has scheduled bi-annual callbacks for older patients with certain conditions, rather than using the four-month intervals recommended by some national guidelines. Holzer’s physicians are doing that because they recognize that for a lot of elderly patients, noncompliance is related to their inability to come in frequently for appointments.

A Midwestern healthcare system gave us very specific parameters to increase the number of patients who were getting recommended flu shots. The practice targeted higher risk populations, including children, adults over 50, and individuals with chronic conditions that would make them vulnerable to influenza complications. Phytel was instructed to contact these patients between Oct. 2, 2008 and Jan. 22 of this year. As a result of this intervention, the system saw a 15 percent increase in the number of patients getting flu shots compared with the previous year. The power of this approach was also shown by the fact that 15 percent of the older adults who were contacted received flu shots, versus only 4 percent of those who did not respond to our phone calls.

The customizability of our protocols is important to physicians. They don’t usually change very much in the national guidelines, but they like the ability to tailor the protocols to their own practice styles and the community standard of care. Pay-for- performance measures also vary somewhat from one insurer to another, so the ability to customize protocols to patients in different plans can help physicians obtain the maximum P4P rewards they’re entitled to.

The most important thing we do, however, is to enable physicians to do population health management at a very high level without diverting scarce resources from their other objectives. Health care is badly in need of technology that can automate the repetitive, time-consuming aspects of preventive care and longitudinal disease management, and that is what we provide.