News 3/12/09

Clearly the biggest news story of the day is Wal-Mart’s decision to market eClinicalWorks software and Dell hardware through its Sam’s Club stores. Mr. HIStalk had a short chat with Girish Kumar Wednesday and that interview is posted here and on HIStalk. The Sam’s Club package, which will be available later this spring, starts at under $25,000 for the first physician in a practice and $10,000 for each addition doctor. Ongoing costs will be $4,000 to $6,500 per year. The software will be provided in a SaaS set-up and the Sam’s package includes five days of on-site implementation. ECW representations will provide demonstrations (via Webinar) as well as configuration assistance. Props to ECW and Wal-Mart for an innovative strategy. Time will tell if this marketing approach will succeed, but we liked this comment posted on HIStalk by Steven Tremain: "History shows us that any idea the majority laughs at is one worth watching. Disruptive innovations are in fact the only leaps that have ever changed the world. It may very well fail, but we will all learn from this."

The medical director of O’Connor Family Health Center (CA) claims he doesn’t regret the decision to move to EMR, even though it cost $250,000, cost an army of people to install, and increased the patient backlog and decreased revenue. He is even okay with the fact that two years after implementing his vendor went out business and product support ends in two years.

A HIMSS survey finds that only about one-third of HIT professionals believe the HITECH stimulus plans will reduce healthcare costs.

A New Jersey oral surgeon is on the wrong end of a $10.2 million malpractice award after a 21-year-old patient dies during wisdom teeth extraction. The patient’s doctor had not cleared him for surgery and the lawsuit claimed a diagnosed immunity disorder caused his throat to swell after the surgery. The family’s dentist was also a defendant, but he was cleared.

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Another study suggests that the HIT incentives will not be enough to convince many doctors to purchase an EMR system. As many as half the country’s doctors will take a pass on EMR because the average cost of a full EMR over five years is an estimated $124,000, and, government compensation is a maximum of $44,000. That’s a $14,000 a year deficit compared to a potential $8,500 Medicare reimbursement penalty for not automating. Someone will need to develop some quality ROI calculators to convince many physicians to take the plunge.

This American College of Physician Executives survey indicates more physicians are adopting technology, even though they may not like it. Most physician leaders find EMRs "clunky" and "unresponsive to their needs."  However, EMR use is up from 33% to 64% since 2004, 44% of the surveyed organizations use CPOE compared to 33% in 2004, and 38% use pharmaceutical bar coding, up from 20%.

Check out our latest HIStech Report interview with Cheryl Iseberg, COO of Renaissance Resource Associates (RRA).  RRA provides consulting services on GE Centricity Enterprise, Picis, Epic, and other systems.

Despite otherwise gloomy economic news, physician offices added 6,000 workers in February, according to the Bureau of Labor Statistics. Hospitals added another 6,800 jobs.

We gratefully acknowledge the support of McKesson, a new Platinum sponsor of HIStalk Practice. The company offers pretty much everything a physician’s practice needs, from technology (EHRs and practice management, including the Practice Partner system), consulting services, medical supplies, revenue cycle management, and connectivity solutions. More information here and a page dedicated to the opportunities provided to practices by the economic stimulus legislation is here. We thank McKesson very much for supporting HIStalk Practice and its readers.

A Baystate Medical Center (MA) anesthesiologist who wrote 21 journal articles in the past 13 years has admitted that he made up most of the data he cited. Pfizer paid for his research, which found that two Pfizer drugs were effective in post-op pain. He was caught when the health system determined that he was not approved to conduct human research.

DataMotion introduces a $99 secure email solution designed for the small office market. Preferred9 includes the ability to send email securely and thus meeting HIPAA security guidelines.

A new P4P survey reports that P4P payments have grown to over 7% of physicians’ total compensation and 4% of hospitals, with some physician programs producing 30% of physicians’ compensation. Since 2006, the percentage of programs reporting quality improvements due to P4P has doubled and more than half of P4P programs cite measurable increases in their providers’ clinical quality.

Availity promotes (warning: PDF) Russ Thomas to the role of President and COO. Thomas joined Availity in in 2008 as an executive VP and COO and served as president of Gold Standard before that.

E-mail Inga.
E-mail Mr. HIStalk.

eClinicalWorks To Sell PM/EMR Package Through Sam’s Club – Girish Kumar Interview

eClinicalWorks will sell its PM/EMR package in a pre-configured hardware, software, and services package through Sam’s Club. The offering will offer a fixed price package of Dell hardware (desktop PC or tablet), implementation, training, and maintenance.

Sam’s Club owner Wal-Mart will begin selling the package this spring, with prices starting at $25,000 for the first physician and $10,000 for each additional doctor in the practice. Maintenance fees will be $4,000 to $6,500 per year.

Wal-Mart said it approached eClinicalWorks after using its software in its own in-store clinics.

We interviewed Girish Kumar Navani, president of eCW.

If a physician buys from Sam’s Club, will it be the same product, implementation services, and support that eCW offers directly?

Absolutely. We’re trying to make it simple. Everybody says EMRs are hard and implementing change is hard. We realize that. We’ve been doing SaaS since 2003 and have invested a ton on a data center. We wanted system that is ready out of the box, configured, with content, although it will still require on-site implementation and services. It’s the same in terms of product, services, training, but faster and easier to deploy.

Why would a customer buy from Sam’s? Do they save any money? Can they choose a no-services option?

Wal-Mart used its Sam’s Club division because it has a lot of small business customers as corporate members. They buy ongoing stuff every month, not just simple things like gloves and bandages, but have a corporate account and buy copiers, payroll software, etc. They don’t have to go into Sam’s. You call a corporate number, get an assigned representative, talk to them about what you need, and the item is shipped.

eCW salespeople will still show the product and talk to the customer. There are packages we want to give them that are pre-configured. The customer will not pick blindly – they will still consult with an eCW person.

Will Wal-Mart do its own advertising and marketing?

There will definitely be a significant campaign. They have 200,000 healthcare professionals today as members, mostly as doctors.

Any projections on volumes?

I have to keep that confidential, but there was a lot of planning on the eCW side. Investments have increased, made the company even more ready. This can have a significant impact on how physicians look at, evaluate, and purchase EMRs.

We would like to see taking it away from being a niche sales process, where sometimes we confuse the customer, to make it a very streamlined process so that a customer can make an educated decision. They know how many days to go live, how many days training, cost, etc. eCW does 30 Webinars every week that every customer has access to with a live attendant and all Sam’s members will be able to avail themselves of that.

We believe we are the largest SaaS EMR in the country with 4,000 physicians. If we include hospital customers hosting affiliated physicians and RHIOs, that’s another 4,000. That’s 8,000 today of our 25,000 physicians. We’re trying to leverage that scale to make it easier and cheaper to deploy.

Do you anticipate any product changes?

For primary care, we spent two years working with New York City. We put into the product all the content needed to run a primary care practice – templates, order sets, clinical decision support. That is years of content that we jointly developed. That is all pre-packaged with the product – it’s not just the software any more. On the specialty care, we have about 50 specialty databases.

All of that will be available pre-configured when they sign up. When the trainer shows up, all the content will be there and if we want to change it, we can change it together. We will go live with a comprehensive data repository with clinical decision support at no extra cost for the content.

A primary care doctor can go live with the system as it is, with rich content.

What does this to do the competitive landscape?

We’ve always taken tremendous pride on our leadership on price and functionality. 97% of eCW customers surveyed said their total costs met their expectations when they bought and implemented eCW. 93% of physicians said the EMR met or exceeded expectations. I still have to worry about the 7% and I lose sleep about it more than I take advantage of the 93%, but if a package with those numbers is readily available, people will ask the question: if I’m able to get a comprehensive product that people are happy with at this price point with content and support, why should I spend more?

Price visibility will be black and white. No longer will you see those quotes saying an EMR will cost $300,000. You will see more informed questions, pricing pressure, and frankly, higher expectations if content is provided. I don’t want to take six months to implement PM and another six months for an EMR.

This is a unified product we’re offering, by the way, both EMR and PM. We’re offering five days of implementation on site with the Sam’s Club package and they can buy more for $750 a day plus travel, but our track record is that we can do it in five days.

What are the benefits to eClinicalWorks?

There are many benefits. We want to be a company with 100,000 physicians using our product and 100 million patients whose lives are positively affected by it. There’s a lot more work to be done, but this platform gives us more opportunity.

Intelligent Healthcare Information Integration 3/11/09

Step 2 of the “Official Grunt-in-the-Trenches Complete U.S. Healthcare System Overhaul and National Health Information Network in Five Easy Steps Disruptive Innovation Package”

EHR? PHR? Phooey! How about an IHR?

I know, I know. I’m out of step with my previously stated agenda. I was next going to discuss how we can achieve two thirds of the NHIN by 2010, but, after some inquiries I received and after Mark Anderson’s recent superb article, “Beware, The ICE Age is Coming,” I felt it would now flow more gracefully directing attention toward the foundation upon which we can achieve that near 70% NHIN integration.

First, a disclaimer or two:

1) Some of my favorite people are EHR vendors/developers/marketers/implementers/salesfolk. I enjoy and respect them and what they do immensely.
2) I love my EHR (usually.)
3) Mark Anderson and I, along with several other great folks, have worked together on a few of these ideas for some time now.
4) As yet, there are no financial entanglements which need disclosed. (Damn!)

Now, on with the show…

Unfortunately, the tremendous advantages of a capitalistic system in inspiring new innovation and diversity of product development has given us 3-400 EHRs, any one of which has very little ability to communicate directly with any one of the others. Then, of course, there are the multiple silos being created via RHIOs, HIEs, the old CHINs, etc. Diversity of offerings has led us away from, not toward, the NHIN. The complexity and sheer volume of offerings is intimidating even for seasoned geeks, no less the everyday doc who has trouble with a DVR. Few of the mass required to reach the proverbial tipping point for EHR adoption see it as even being a possibility in their career lifetimes. And, so far, I can’t say I blame them.

To reach the masses, we should be listening to their concerns. I wonder sometimes how many EHR developers actually bother to ask a non-techie-oriented consultant to review their work. If the only folks you ask about product development are those who already “get it,” how do design to entice those who are yet to? I doubt Apple would have survived if they hadn’t seriously taken “Joe Sixpack” into account.

So, as the medical “Joes” have rarely been consulted, is it any wonder most of them have had little, if any, interest in adopting EHRs – especially when what they are promised includes a major interruption in their workaday lives. Changing workflows is a horrendous undertaking, requiring enormous time, energies, and, often, income reduction, at least for a time. There are no “plug-n-play” systems, no turn-it-on-and-do-what-you-already-do EHR wonders. Most current offerings require an enormous effort, hence the prerequisite need for physician champions to cheerlead, coax, and cajole cohorts into the commitment.

I don’t think the majority of my medical colleagues should be treated as cattle, herded, prodded, and driven toward the auction house. (OK, maybe a few deserve that.) But, physicians, it is true, are generally not pioneers. The majority do not blaze trails. They do not lead movements. But, the tremendous attribute which can generally be stated about most physicians is that they respond to need. That’s why many, if not most, became health care providers in the first place. So why is it that this very basic truism has been so glaringly ignored by the world of electronic medical record developers?

If physicians, by their basic nature, respond to need, doesn’t it make ultimate sense to develop a motivational tool that engages this semi-Maslovian drive to entice them into a desire for EHR adoption rather than continuing to “push mules?”

If we’re to stop pushing mules, we must employ strategies that entice – i.e., carrots. We must avoid threatening or intimidating change, as change in and of itself is often frightening. We must utilize tools already familiar, comfortable. We must identify true needs and design strategies to both meet them and to take advantage of them in generating “adoption drive.”

This same argument plays equally well when discussing PHR adoption by the general public. The masses have not swarmed to their use. Why? I believe it is because, just as with EHR design, we have neglected to consider some basic human motivations. Consider the fact that Facebook reached 50 million users in 1/20th the time it took television to do the same. Why? It used a tool which many already owned, with which they had familiarity, AND it met several underlying needs including the desire to interact with others while giving users a little ego boost having a little “Look At Me, World” home on the Web. Basic human motivations: we need to engage them.

To address these oversights and to “stop pushing mules,” I suggest we consider a different approach to healthcare information integration, not focusing upon the technology aspect (very Web 2.0-ey) but rather spotlighting the needs, the use of currently proven tools, and the natural human motivations we can engage to help inspire adoption and continued use.

Thus, the “Grunt-in-the-Trenches Beyond EHR/PHR Grand Healthcare Digitization Project What Ifs:”

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What if…we start with a system designed for the end user, not the giant hospital or RHIO, but for that single grunt in the field so that he or she can provide the services he or she provides in the manner most comfortable for him or her with an electronic interface he or she can enjoy and adapt for his or her unique needs? (Big systems that attempt doing everything for everyone often have poor usability when they trickle down to us grunts.)

What if…we took that end user-friendly provider system, included a general populace-friendly tie in, and pivoted this patient-centered tool around an entire small community and its associated community hospital including everyone including doctors, hospital, EMS, home health, hospice, schools, long term care facilities, police, sheriff, fire departments, emergency management agencies, health departments, employers, and the general public – everyone who might have need for some small piece of healthcare data – utilizing the entire community as a multifaceted motivational driver for adoption? (Patient-centered, but community driven as communities drive individuals. Consider mob mentality, Facebook, soccer crowds.)

What if…we make the wild assumption that sharing health data among providers is no different electronically than it is “paperly,” that what a provider can get now through laborious effort, fax machine, and telephone is essentially the same – only much, much slower? (I know a company who says they can tie legacy systems into a new, integrated system so that even current end users don’t need to buy a new EHR or PHR to participate, identity management is enabled, and security is priority.)

What if…we use an open system (open, not unsecured) that doesn’t create silos and we help health systems and providers understand that patient health data is not “owned” by anyone except the patient, that sharing that info is not counterproductive to corporate profits but rather contributive once all are duly linked? (Healthcare giants must give up the notion that sharing a person’s health data is akin to a traitorous CIA leak. I can’t imagine an auto shop refusing to share someone’s car repair history.)

What if…we design the roll out to the community with something like Java applets (compatible with most cell phones and computers) using push/pull technology to acquire information and participation in small sips, instead of asking folks to drink from the fire hose most PHRs now do? (Of course we’ll use computers, but, cripes, American Idol uses cell phone data collection every week! As there are over 4 billion registered cell phones in use around the world today, doesn’t it make sense to use a tool people already have and one with which they are not intimidated?)

What if…we created several jobs within each community specifically to promote, educate, and assist end users in an ongoing fashion, instead of the two-to-a-few weeks training currently the industry norm? (If the entire community was “going live,” the need for support would justify and, indeed, require local help. Plus, who’d bitch about creating thousands of new jobs these days? FYI – there are some 2,000 such small communities and associated community hospitals across the U.S.)

*************

Mark Anderson laid out quite nicely some of the system requirements and benefits in more detail in his “ICE Age” article. While he limits his discussion to the integration of doctors and hospitals, something he has promoted for some time, here the discussion is for a COMPLETE community system, an entity for which the current lexicon has no definition. We’ve coined the process as Community Healthcare Integration (CHI) which achieves the Integrated Healthcare Community (IHC) utilizing the Integrated Health Record (IHR) – via each community’s own non-profit, by the way. See: http://worldchi.com.

To be clear, the IHR does not negate nor minimize any current EHR or PHR product. Rather, it is an overriding integration of that which currently exists into what I believe is a more accurate reflection of reality. We need specialty EHRs and PHRs; they are operationally helpful and discrete. But, personal health data is not separate and distinct from that data which a medical provider uses. The emphasis upon these two terms promotes a psychological barrier between providers and the general public. The last thing we need is for the application of technology to increase the gap and diminish the trust between providers and the public. There are far too many silos in healthcare already; the IHR model is designed to help eliminate separatization and promote integration. (Can you hear the NHIN segue?)

Still to come:

Step (now) 3: Two Thirds of the NHIN by 2010 (Yes, we will discuss funding & sustainability)
Step (now) 4: Equalizing the Playing Field (“Open” is not a Four Letter Word)
Step (still) 5: Verdant Health

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 3/10/09

A pediatric nurse practitioner provides first-hand details about her practice’s selection and implementation of Epic Ambulatory.

NextGen Healthcare Information Systems announces that the national physician group practice MEDNAX, Inc. is expanding its use of NextGen’s products to include the Enterprise Practice Management solution. Pediatrix Medical Group, now a part of MEDNAX, has been utilizing the NextGen EHR for its office-based practices since 2001.

Physicians at Carilion Clinic (VA) utilize their EMR to develop a disease registry for asthma patients, estimating that it will reduce costs 10% and will help monitor medication compliance, ED visits, and vaccinations.

An Archives of Internal Medicine article says that physicians ignore 90% of the warnings generated by e-prescribing systems. "The systems and the computers that are supposed to make [physicians’] lives better are actually torturing them," the article’s co-author said, adding that a third of the alerts were scientifically unsound or not clinically useful.

CPU Medical Management Systems partners with Gateway EDI to expand its electronic claim processing capabilities. CPU serves over 10,000 physicians.

EMR-generated colonoscopy reminders work better when sent directly to patients instead of reminding their doctor, a new study finds.

A new doctor-run wiki is up and running. The Medpedia Project is a free online medical information platform, written and maintained by health experts and founded by the Harvard, Stanford and University of Michigan schools of medicine, along with the Berkeley School of Public Health. The tool is available to consumers as well as physicians.

Family Health Care Clinic (MS) becomes one of the country’s first health facilities to receive a chunk of taxpayers’ money since the passage of the economic stimulus bill. The $1.3 million government grant that will be used to open three clinics in an under-served area of rural Mississippi, creating an estimated 70 jobs including 30 full-time positions. In the mean time, Portneuf Medical Center (ID) has applied for nearly $4 million to continue work on the Telemedicine Network, which really sounds like an HIE and not telemedicine.

Nearly 300 student members of the AMA participate in a Lobby Day at Capitol Hill to urge Congress to protect patient access to care, ask for medical school debt relief, and to stop Medicare payment cuts.

An Arkansas doctor who had been sanctioned by the state medical board is arrested after over 100 fully automatic weapons, a canister of grenades, and two grenade launchers were found on his property. Authorities say the arrest is not tied to the investigation of last month’s car bombing that wounded the chairman of the state’s medical board.

Worcester Polytechnic Institute launches a three-year study of four different HIT systems in various stages in installation. Two of the organizations are in the US, one is in Canada, and the other in Israel. Using a $750,000 grant, the study will investigate how implementing HIT systems in primary care impacts providers, their patients, and the operations of the healthcare delivery systems. Findings will be used to develop new insights and best practices for future HIT implementations.

The  100+ physician Virtua Medical Group (NJ) selects GE Centricity Business Advantage for revenue cycle management.

An LA Times columnist says America’s Health Insurance Plans, which claims to now support universal healthcare, is really just asking for the same old stuff: to have the government pay for treating the sickest patients, to cut pay deeply to doctors and hospitals, and to be able to offer cheap, low-benefit policies without having its premiums regulated. "The industry talks a good game about marching for reform side by side with all healthcare stakeholders — patients, drug manufacturers, doctors and hospitals. Ignagni says her members will ‘come to the table with real proposals and solutions’ rather than ‘the old-fashioned playbook of ads and 30,000-feet campaigns.’ Veterans of earlier healthcare battles justly wonder if the industry is merely trying to get in front of the parade, the better to lead it into a dead end. "

Many groups and individuals have been calling for CCHIT to evaluate more than interoperability, having it rate functionality and usability in addition to what it does now (sometimes straying far off the interoperability track and getting into those areas anyway). Should the government be in the business of rating and comparing commercial products at more than a pass-fail level of granularity? And if so, should CCHIT (and its previous HIMSS connections) be the one doing it?

Would an EMR have helped here? The Iowa Board of Medicine cites a physician for failing to maintain "timely, accurate, and complete" medical records. She agrees to pay a $1,000 fine and stop practicing medicine while she attempts to get her records current. 

An EMR would probably have impacted the outcome of this case. A Kansas cardiologist and his practice agree to pay $1.3 million to settle Medicare fraud claims. The Justice Department contends the physician submitted claims for services not rendered or without proper documentation. The attorney claims the issue was all Medicare’s interpretation of the documentation rules, which required that certain portions of the records to be in the doctor’s own hand, rather than dictated by the doctor or written by a nurse. Which, frankly makes no sense at all because many, many doctors use scribes and/or dictate the whole chart. This happens to be the doctor’s second Medicare settlement. The first was for $1.5 million in 2000 after the doctor was charged with over-billing Medicare.

E-mail Inga.
E-mail Mr. HIStalk.

Mark Anderson 3/7/09

Beware, the ICE Age Is Coming

The EHR industry has been claiming great implementation successes for the past five years. When you ask the various vendors, “How many successful EHR implementations have you done?" the answer would amaze even the most skeptical person– however, in the wrong way.

Based on data obtained in the 2008 AC Group survey, the top 100 EHR vendors claim they have more than 300,000 physicians using an EHR today. This is almost too good to believe — and for good reason. According to a New England Journal of Medicine article dated July 3, 2008[1], “only 4% of physicians reported having an extensive, fully functional electronic records system, and 13% reported having a basic system”.

This means that after 20 years of EHR adoption, less than 30,000 providers are using the full capability of an EHR, and an additional 90,000 are using partial EHR. So what does this mean for the entire medical community?

Basically, the EHR industry has FAILED miserably. The main question everyone should be asking is, “Why after 20+ years do we only have 4% of physicians using fully operational EHRs?” The answer is usually, “Cost is a factor”.

However, we do not believe cost is really the factor for low adoption. In fact, some EHR products are provided free of charge or at a highly subsidized rate. Even these products have not been implemented in masses.

So what is the real problem with EHR adoption? The main reason we hear is that EHRs slow the physician down. One reason: there is no information in the product when it goes live.

To help resolve this issue, AC Group has coined a new term, Integrated Community EHRs (ICE). ICE products are designed for community systems, including hospitals, MSOs, and IPAs where there is a desire to create a community-integrated patient record no matter where the patient is treated. These products may have full EHR or EMR-Lite functionality.

A true ICE product must provide and maintain a community health record via a community clinical and demographic data exchange.  Advanced functionality includes reporting and tracking of orders, results, e-Rx, allergies, and problem lists, among others. The product must provide a community master patient index based on numerous inputs, including hospitals, health plans, and numerous physician practice management systems.

ICE products have the abilitye  into interface with multiple EHR vendors following the national CDA standard. With changes in the Stark laws, hospitals and other community initiatives are interested in viewing ICE applications.

Under a community model, ICE product allows multiple practices to share information regarding the patient, even though the practices may have different EHR products. To insure an effective community EHR, the product of choice must have the following capabilities:

• Community master patient index (MPI) for retrieving patient and insurance demographics.
• One interface between all third-party companies (LabCorp, Quest, PACS, hospitals) while allowing the sharing of interface costs between all practices.
• Patient demographics information where an address change can update each practice’s database.
• Patient insurance information shared between all practice’s databases.
• Patient family, social and medical history can be updated by one provider or by the patient. The information can be updated as discrete data into a practice’s EHR with one click.
• Potential for centralized billing and accounts receivable with multiple tax IDs.
• Reporting as individual databases and the ability to report clinical data over the entire community.
• Referral tracking between multiple tax IDs.
• Community patient portal, community physician portal, and community registry reporting.
• Allows practice to leave the community and remove their database without adversely affecting the community EHR repository.

Benefits of an ICE Age strategy:

• Data is entered once and can populate multiple databases.
• The patient has complete control over disseminating data following HIPAA rules.
• Duplicate data entry is reduced by 92%.
• Overall data entry time is reduced by 74%.
• Clinical testing is reduced by 19%.
• Referral tracking activities are reduced by 32%.
• Uncompensated ER costs are reduced by as much as $500,000 for every 20,000 emergency room visits. A study conducted by AC Group on 3,120 ER visits determined that if clinical data was available to the ER physician at the time of treatment, the ED physician could properly treat the patient faster and with fewer tests. Patient time in the ED was decreased by 26%. Test costs were reduced by 31%.

In summary, to enhance EHR adoption, we need to move to a new model where clinical data is shared between physicians who are treating the same patient. With community governance and security rules and regulations, an Integrated Community EHR can enhance the use of EHRs and finally drive true ROI.

[1] – N Engl J Med 2008:349:50-60

Mark Anderson is CEO and healthcare IT futurist with AC Group, Inc.