Mike Gleason 3/5/09

Moving Toward Specialty-Specific EMRs

I’ve noticed a trend over the past few years in EMR/EHRs. I’m seeing a lot of EMR to EMR conversions where the practice is not happy with their all-in-one EMR. The existing EMR is often their first one and they are looking to convert over to a more specialty-specific EMR/EHR. More often, practices are converting to their third EMR. One wonders how these practices, many containing 10 doctors or more, can continue to make costly EMR replacements.

Common reasons for the switch? In speaking with the practice administrators, consultants, and providers, I hear some pretty consistent thoughts. The practice needs better specialty content, relevant workflow, faster documentation speed, and a system designed or tailored to their specialty. A growing trend in healthcare practices over the past few years has been mergers between large, specialty-specific practices. These practices have tough decisions over which PM and EMR they should keep. Usually one group is forced to adopt the EMR and PM of the majority (often kicking and screaming).

I thought it might be interesting to bring this up to readers and see if they are experiencing this as well.

Content

It seems that many of the generic, all-in-one, or multi-specialty (take your pick of labels) EMRs are not able to provide rich enough content for a specialist. The specialties I see most often struggling with customization of content in a generic EMR are urology, gastroenterology, neurosurgery, ENT, dermatology, general surgery, and plastic surgery.

These are just some of the specialties getting the short end of the stick in terms of standard templates and content in many of the all-in-one EHRs. The content in these EHRs heavily emphasize family medicine, internal medicine, pediatrics, and gynecology.

Most EMR/EHR vendors are in a mad dash to provide a wealth of content to prevent client attrition as well as add new customers to their client pool. The mistake that vendors often make is that they forget to run this content past the physicians, nurse practitioners and physician’s assistants using the software 40 hours a week or more. This content dash may be for naught if the providers are not included in the design and QA process.

There is a fine art to creating great content. It often involves a lot of tweaking and refining and testing. Content testing is most effective when done in an actual clinic setting, where users experience off-the-wall combinations of issues and can provide instant feedback on speed and effectiveness.

During the implementation process, a practice is asked what their top 10, 20, or 50 diagnosis codes may be. However, the list they provide rarely matches the mix of actual patient chief complaints during go-live. That’s why testing the customization on live charts prior to go-live is so critical. If the implementation process can focus on the 80% of the content they see daily, the other 20% can get created post go-live. After the go-live, physicians usually have a better idea of what additional customization is needed.

In order to get content to the level that specialists require, vendors have historically placed the burden of content creation on the practice. The creation work often falls on physicians, who have little time to learn customization, much less do the actual customization work. In other words, vendors measure the success of their software based on how successfully THEIR CLIENTS can learn how to customize THEIR software.

I’m reminded of a struggling physician who had completed three days of customization training. He relayed his frustrations to me this way. “I feel like I bought a Bentley, the nicest Bentley on the market. Unfortunately it has come with complete assembly required and the instructions are all in Chinese. I wonder if I’ll ever get to drive it?”

How can we let the success of our product depend on how well a physician can learn to customize it? Often, practices will not customize or improve their systems much beyond what they had at their initial go-live. They find a way to get by, which often includes scanning handwritten notes or dictation. Many vendors now offer customization for the client, but these services are billable to the practice.

I think practices can benefit from narrowing the field during their EMR search and focus on EMRs that cater to their specialty. Content delivered by specialty-specific EMR vendors can allow for faster adoption because the workflows make better sense and are more familiar to the clinical staff.

Workflow

“This EMR workflow does not fit our office.”

“Our office has to adjust to the EMR workflow.”

“We don’t schedule like a family practice. We see patients every 10 minutes and may see 50 patients in a day, two or three days a week.”

These are common complaints that can be heard from specialists trying to cram a generic EMR in their office. If you deal with urine dips all day long, you need a fast way to enter results. If you have specific lab devices, you need an efficient interface with your EMR. If both the doctor and nurse work on the same patient encounter at the same time, they need to have dual entry capabilities in the EMR.

Many specialists have to fax letters and H&P reports to multiple providers for one patient. They need easy to use tools to indicate which items (the office note, the lab data, imaging reports, etc.) need to go to the primary care provider and which need to go to other treating providers. If an EMR can only generate one H&P or referral letter at a time and can only fax to one office or provider at once, you are not going to make the grade in a specialist’s office.

A specialist’s office may follow unique workflows that can’t be duplicated in some EMRs. For example, some EMRs do not allow a nurse to order labs on behalf of the physician, or allow lab results to forward automatically to the nurse. Often the nurse is the one monitoring the lab and e-prescribing process, then forwarding the record to the physician for sign-off.

Specialists often do not follow a typical SOAP-type flow in the patient encounter. You may need to order and result a lab prior to the physician seeing the patient. Office procedures such as EKGs or breathing treatments may need to be completed prior to the physician seeing the patient for the first time.

Specialty offices also need a greater focus on their specific body system in physical exam. A generic EMR often can’t provide that detail without massive and complex customization. Many specialists need to include lab data as well as note what specific data review process was completed prior to completing an assessment and plan section. Generic EMRs often lack this ability.

Speed

I was shocked when I first encountered a specialty office where they see 50 patients in less than a six-hour shift. A generic EMR rarely has the capability to effectively complete more than 25 to 35 office visits in a day with a very adept family medicine provider running the keyboard. Place one of these EMRs in the hands of a specialist and you can have a recipe for disaster. If the EMR does not have the generic content turned off and the specialist’s content customized with their specific phrases, the software may get tossed back in your face.

Many EMR implementation consultants do not know how to customize their vendor’s EMR for speed and efficiency. There is a fine art to making content that is complete, quick to document, and easy enough for a beginner to comprehend and use on a daily load of patients.

Many EMRs lack the ability to share templates between practices. Specialists may need the ability to import different types of formats, such as images, pictures, and drawings. This can be a bottleneck if the EMR vendor does not work with different document formats.

Tailored for my specialty

Given enough time, you can customize great HPIs, assessment and plan order sets, physical exam templates, nurse lists, history lists, etc. Many practices never get to this higher level of customization. A specialist will never achieve success in a generic EMR because they can’t afford to put in the hours required to customize the product to suit their needs. They can’t take the hit to their revenue or reduce their patient load. Many have minimal staff and lack the support staff to work on the back loading of data, scanning, or customizing.

Specialists have a very focused data set for patient history that is often hard to understand when you are trying to use a generic history form to gather data. Most practices fail to take the opportunity to change the forms used to gather information from patients, as well as tailor the history lists to their specific needs. When the form comes back across the counter or data is entered in the kiosk or Web site by from the patient, does it make sense? Is it even usable in the specialist’s EMR?

I guess the question to ask is, “Are generic EMRs doing more harm than good when implemented in a specialists office?" I’m interested in hearing from the practices. 

Mike Gleason is a 25-year veteran of the HIT industry with expertise in sales, support, and implementation of clinical and financial systems.

News 3/5/2009

From R.W. Emerson: “Re: Massachusetts Health Care Reform. Often I read negative things about how the Massachusetts Health Care Reform demonstrates a failure in the design instead of being a model for other states to follow. People point out the large number of people still uninsured as a symptom of its failure. My response to this is that the government can’t force people to get health insurance who simply don’t want to do the very limited paperwork to have it. I recently graduated from college, having no health insurance and an unreliable part-time job. I applied for Mass Health, which took all of ten minutes, and within days had a health insurance card in my hand. I had no co-pays for visits and paid $1 or $2 for my scripts depending on whether they were generic or name brand. I now have a job and an HMO. My free Mass Health was much better and cheaper as my co-pay for scripts have gone up over 700% and now I have to fight charges.”

Will healthcare-specific credit cards be the next big trend in consumer-driven healthcare?  A consultant predicts that banks will soon offer interest-free healthcare credit cards that are linked to payroll for deductions and may even provide discounts. Perhaps it’s not a bad idea, given that more providers are requiring payment up front and patients have increasingly higher deductibles and co-pays.

Patients who could name their own doctors and whose doctors also identified them as their patient were more likely to get preventive screenings. This according to a Massachusetts General Hospital and Harvard Medical School study of more than 155,000 patients.

CoxHealth (MO) successfully implements GE’s clinical data registry system to streamline reporting from Centricity EMR/PM. GE’s Medical Quality Improvement Consortium data system gives Cox the necessary tool to participate in CMS’s PQRI program.

A Press Ganey survey of 2.4 million patients indicates that patient satisfaction is on the rise. The report concludes that increased competition and consumer empowerment are spurring improvements. Patients claim their top priorities are the sensitivity of caregivers, the cheerfulness of the practice, the overall care received, and the comfort of exam rooms. The survey also found that patients will tolerate some waiting, but delays over 10 minutes decrease satisfaction. Practices with 3-8 physicians earned the highest overall patient satisfaction scores.

A pharmacist in Lancaster, PA estimates that 65% of the local doctor offices are e-prescribing, considerably higher than the 6% national average. Numerous practices in the area have adopted the technology, including about 140 at Lancaster General  Medical Group and Physicians’ Alliance.

With the increase in physician rating Web sites, some doctors are now requiring patients waive their right to publicly post comments about the expertise and/or treatment of their providers. Some people just can’t handle criticism.

Document manager vendors SolCom and EDCO merge their businesses and unite the document management services and technology efforts. We posted an HIT Moment interview on HIStalk yesterday with Mark Addink, the Chief Innovative Officer for the combined EDCO and SolCom’s former CEO.

CCHIT announces plans to develop dermatology-specific functionality criteria this year and launch a dermatology-specific certification program in 2010. According to CCHIT, the dermatology community is overwhelmingly supportive of the move.

HIIMSS releases a statement supporting President Obama’s picks for Secretary of HHS and the Director of White House Health Reform Office. HIMSS President H. Stephen Lieber calls Governor Kathleen Sebelius and Nancy-Ann DeParle "exceptional choices".

Former Dictaphone CEO and Chairman Rob Schwager joins Amphion, a medical transcription and coding service firm.

The New Mexico state senate passes a bill that would allow patients to opt in to having their medical records be made available electronically. An interesting aspect of the bill is that patients must re-consent annually, a unique patient identifier is required, and audit logs must be made available to patients showing who has accessed their records. Patients could also choose with records to make available.

An interesting take on the stimulus bill, which the author calls a 21st Century Gold Rush for those communities and organizations that quickly put shovel-ready projects together. In addition to submitting new projects for stimulus money, the author suggests dusting off old ones or partnering with others who have projects but will need help.

The California Nurses Association says the only reasonable option for meeting President Obama’s healthcare goals is to expand Medicare to cover everyone. "To achieve the lasting and cost-effective reform the president seeks and most Americans desire, we must confront the source of the present crisis — an insurance industry that has been steadily pricing people out of access to care, or bankrupting them if they attempt to use it. Insurance company practices drive skyrocketing costs, a problem that won’t be solved by more technology, electronic medical records, or any other stopgap measures some propose."

A workforce study by Adecco  finds sobering results of the recession: 20% of employees say the economy has had a negative impact on their mental health; 28% of employees (including 44% of men aged 18-35) would do something dishonest, like blackmail, to keep their jobs; and despite layoffs, 82% say their employer isn’t paying any more attention to their job performance.

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News 3/3/09

Kansas Governor Kathleen Sebelius (at right in the picture) is picked by President Obama to be the secretary of Department of Health and Human Services. Her primary healthcare experience was an eight-year stint as her state’s insurance commissioner. If confirmed, Sebelius will oversee the Office of the National Coordinator of HIT and CMS.

President Obama also names former Clinton administration veteran Nancy-Ann DeParle (in the center of the picture) as Director of the White House Office for Health Reform, the "health czar" position conceived by Obama’s original HHS secretary nominee Tom Daschle. DeParle managed Medicare and Medicaid in the Clinton administration and ran Tennessee’s Department of Human Services from 1987 to 1989. She sits on the board of Cerner, Medco Health, and Boston Scientific, which could raise concerns about conflicts of interest. Cerner’s report indicated that she made $195,000 from the company in 2007 (cash and stock) and held around $1 million worth of its stock at today’s price.

The New York Times provides an update on NYC’s Primary Care Information Project, a $27 million endeavor started two years ago. To date, over 1,000 physicians are live on eClinicalWorks, which is now installed in two hospital outpatient clinics, 10 community health centers, 150 small group physician offices, and one women’s jail.

Navicure announces (warning: PDF) its new self-service patient kiosk solution, Navicure Check-In, which can operate stand-alone or be integrated with a practice management or HIS. The kiosk facilitates insurance verification, including real-time information on co-pay’s and deductibles.

The day before the annual meeting of the American Academy of Orthopaedic Surgeons, physicians, nurses, vendors, and other volunteers built a playground in North Las Vegas. The 6,000 square foot playground is designed to be fully accessible to children with physical disabilities.

We are proud to announce the sponsors of HIStalk Practice, all of which officially came on board March 1. Our Founding Sponsors are EHR Scope/EMRConsultant and RelayHealth. dbMotion is a Platinum Sponsor and Hayes Management Consulting is a Gold Sponsor. We’ve known all of these companies for some time through HIStalk and we cannot thank them enough for their help in bringing you HIStalk Practice (we’re amateurs working day jobs in healthcare IT, so the support of those companies means a lot to us). Please give their ads a click and check out their offerings if you are so inclined.

A retired Virginia physician recalls his early days in practice in the late 1950s, in which an office visit cost $3 and a house call $5. The average wage was $1 an hour and 80% of patients paid. Today’s average hourly wage is $18.50, but I’d venture to say the average office visit is not $55.50. 

However, for $1.99, you can now load a iPhone application that will help you diagnose your symptoms and figure out just how sick you are. Self Care Decisions just introduced SymptomMD, giving users the ability to use one device to talk on the phone, check email, and figure out the cause of that nasty rash.

Speaking of RelayHealth, we interviewed SVP Jim Bodenbender on HIStech Report.

The eight-physician Cary Orthopaedic Sports Medicine & Spine Specialists (NC) claims it has eliminated transcription costs and paper charts since implementing ChartLogic EHR in 2006. 

This may be an early warning sign of ARRA’s industry impact: KIG Healthcare Solutions (EMR reseller) and Precision Practice Management (medical billing) get a mention in the St. Louis business paper for strong growth. KIG expects to double its staff in the next 18 months. We interviewed KIG’s Scott Anderson not long ago.

An increase in newly built medical office space and the weaker economy may work to the advantage of physicians. An excess of medical office space is providing physicians with options to move into new and larger space or renegotiate rates on current leases. Or, perhaps buy your own building at a lower price if you are so inclined.

Massachusetts gets kudos for its healthcare reform and is often promoted as a model suitable for national rollout, but the Boston Globe says its program flunks all five criteria advanced by IOM: universal coverage, not tied to a job, affordable to those covered, affordable to society, and providing access to care for everyone. Its respective arguments: over 200,000 residents still don’t have coverage, insurance is still tied to jobs, even marginal coverage is expensive that starts at over $800 per month including premiums and payments, state costs have doubled to $1.3 billion, and high deductibles and co-pays prevent insured patients from seeking care.

Blue Cross Blue Shield gets $10 per claim for processing North Carolina’s state employee medical insurance claims, 18 times what the state pays for processing Medicaid claims. The extra $20 million being paid to BCBS wasn’t noticed until lawmakers met to consider bailing out the state health plan, which will go broke this month and needs $250 million to run through June. BCBS claims its margin on processing claims is 0.625%.

The business section of the New York Times features an article called How to Make Electronic Medical Records a Reality, with the answer apparently being regional health I.T. extension centers as recommended by Blackford Middleton and use in the New York City’s Primary Care Information Project. The leader of that group, an assistant city commissioner in the health department, said, "There’s no way small practices can effectively implement electronic health records on their own. This is not the iPhone."

If you’d like a house call, you may have to pay $1,500 a year, plus a per visit fee, if you are a patient of Dr. Natalie Hodge. She claims that technology has made house calls easy, saying all she carries is her iPhone, laptop, and a high-tech cooling system for medicine.

It seems like just yesterday that we launched HIStalkPractice, but actually it’s been almost two months. So far we have had over 14,000 visitors and our subscriber base grows daily. If you have not signed up for updates, you can use the handy box on the top right of the page. We appreciate feedback, so if there is anything you think we could be doing differently, send us a note.

Internal documents released Friday indicate that AstraZeneca suppressed unfavorable studies on its multi-billion dollar psychiatric drug Seroquel. An e-mail from a company official praised its project physician for minimizing negative findings, saying, "Lisa has done a great ‘smoke-and-mirrors job!" In another, the company’s publications manager indicated that three sets of drug trials had been "buried."

E-mail Inga.
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Intelligent Healthcare Information Integration 3/2/09

U.S. Healthcare Overhaul? Sure … in 5 Easy Steps!

The unfettered free market system has done about as well for Healthcare as it did for its cousin, Finance. I personally believe in capitalism, but perhaps guided capitalism is necessary when universal concerns are involved (to corral the misguided – right, Mr. Madoff?) It appears to me that without some form of nationalized healthcare supervision (the dreaded ‘socialized’ medicine monster?) it is unclear if we will ever stop digging deeper this healthcare hole. Exactly what form of federal regulation and to what extent we need it is controversial, but I do know we must address the problem, preferably with some new, creative thought.

With this in mind, my dear Mr. Obama, et al, I here offer up the …

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

…for your review and consideration.

As this is a blog spot and not my personal manifesto home page (now there’s an idea!) I will offer the steps to Healthcare Nirvana as a serial blog, limiting each rant …er, discussion …to one of the component steps.

STEP ONE

Living Your Name – What to do with HMOs, MCOs, & Inscos

Health Maintenance Organizations – HMOs, Managed Care Organizations – MCOs, and Health Insurance Companies: read the names and forget your now ingrained biases. Don’t the names themselves actually imply something pretty desirable? Isn’t the goal of U.S. healthcare overhaul as a whole, and the National Health Information Network as a subunit thereof, actually seeking to provide better healthcare maintenance and management for the every U.S. citizen, both those who can and those who cannot afford it?

Unfortunately, such organizations have evolved (devolved?) into entities less concerned with helping maintain and manage quality care services than they are about maintaining and managing profit margins and bottom lines. With constant focus on cost containment, earnings, and shareholder happiness, how can we expect them to have much room left for actual patient care concerns? (Personally, I generally avoid talking about providing healthcare to patients as all patients are people and “they is us.” Somehow, categorizing people as patients adds a degree of distancing I find distasteful).

Health insurance companies are, at least, less evasive about their agendas; they are about money, period.

It is a fact that HMOs, MCOs, and health insurance companies are a gigantic part of our current economic system, not just healthcare. When considering our currently distressed jobs and economic picture as a whole, they are important and integral considerations. The entire economic structure is in need of a major tune up and, most talking heads agree, an “overhaul” of the current U.S. healthcare quagmire is crucial to the success of our recovery. I suggest an adjustment in our thinking might provide us some helpful wrenches for the servicing we need on them all.

Problem One: Corporate profits, not people’s health, have become preeminent

As we are seeking to improve the healthcare and the efficiency of its provision for all Americans, let’s prioritize that as “Job One”. Yes, we are a capitalistic society and I, for one, have no desire to see healthcare socialized. But, to achieve the better “bang for the buck” that we all know we need here, I propose that the goal of quality care for all Americans be kept preeminently in view and all other considerations become subservient to that goal. Thus, I propose a redefining of the term “health maintenance organization,” a redirection of healthcare’s middlemen, and a retraining of their workforce to maintain (or even create) jobs and begin improving the efficiency of healthcare provision using current tools. (Not to worry; geeky techno-tools will be promoted soon!)

Answer One: Live Your Name

As both a “grunt in the trenches” solo physician and as one of the American people who has health that needs care, I would love to have the assistance of a health maintenance organization to help me manage the overwhelming information and requirements modern healthcare entails. If my health info was better organized, shared, and managed, I have no doubt I could better help both the people I treat and myself.

Current competing and conflicting procedure approvals, payment choices, formulary differences, and other issues separating the major middlemen corporations only serve to confuse, complicate and “chaotisize” healthcare…not to mention the effect upon accelerating costs.

Suppose there was one acceptable formulary structure, that quality measures could be promoted universally, that health maintenance care was paid better than (or, at least as well as) health repair, that our struggles with healthcare provision were about improving “best practices” not “best reimbursements.”

How about retraining many of those current so-called “HMO” (or other middlemen) employees – and their bosses! – to help guide and support quality healthcare decisions? If they weren’t spending their time fighting for profits, we could use them to actually help “health maintenance” such as:

1. Helping people with

a. Appointment reminders
b. Test and procedure prompts
c. Vaccinations schedules
d. Finding appropriate services

2. Helping providers with

a. Information organization
b. Credentialing
c. Group pricing and supplies tracking
d. Care plans and protocols
e. Patient compliance support

3. Helping researchers and epidemiologists with

a. Data tracking and coalescence
b. Disease monitoring
c. Large prospective studies
d. Best practices design and follow-up

With a uniform set of payment and approval guidelines, most of the people who now spend their time “delaying, denying, and defending” in order to enhance healthcare’s middlemen profits could begin to “unite, support, and assimilate” (USA!) healthcare information to enhance actual healthcare provision. We can’t afford to simply eliminate these giant middlemen of medicine, even if their amazing corporate headquarters of marble and mahogany spit in the face of their initial role to curtail healthcare costs. We need their workforce and brainpower, just redirected towards actually helping healthcare instead of sucking off its marrow.

Health maintenance organizations, managed care organizations, and health insurance providers – helping doctors provide care, not dictating care provision, and, actually living up to their names. Scandaleux, oui?

Still to come:

Step 2: Two Thirds of the NHIN by 2010

Step 3: Equalizing the Playing Field (“Open” is not a Four Letter Word)

Step 4: EHR? PHR? Phooey! How About an IHR

Step 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.

Intelligent Healthcare Information Integration 2/28/09

Chumming the Sharks

Did you happen to catch the Mythbusters episode where, off the coast of South Africa, they chummed a feeding ground for sharks at breakfast to see if a dolphin could deter these ravenous beasts from chowing on a helpless little seal? (Don’t fret, PETA people, both the seal and dolphin were man-made). The fake seal was always chomped within seconds without its mammalian mate, but whenever it was in the water nearby, the incredibly real-looking robo-dolphin was 100% effective keeping the sharks at bay.

Well, I waste your time discussing a TV show because I see an ominous analogy.

As you well know, Obama has now set his signature to the Grand Economic Stimulus Package promising over $19 billion to healthcare info tech (not to mention the 100-some billion for CMS, et al.) Even before the pen hit the paper, you could see the HIT waters churning with the frenzied maneuverings of all the “sharks” scurrying to see their version of healthcare digitization fed. Since the signing, the “seas” have been virtually bubbling with their voracious intrigues. (Imagine what’s happening behind the scenes if we can see this much commotion above the surface!)

Me? I feel like one of thousands of helpless little seals swimming along, looking for my buddy Flipper to keep my fur firmly affixed to my hide. The giants of this sea – big centers, big RHIOs, big HIEs, big insurance, big EHR/technology vendors, and big governmental groups – are all thrashing about, stirred by the perceived problem-solving chum of the Obama bucks.

Here I sit, in my little town, in our little community hospital, knowing full well that virtually all of the solutions the sharks are promoting are oriented toward the big boys in the big cities in the big centers. All the while, they ignore that nearly 70% of the NHIN will be comprised of small communities, their associated small hospitals, and their affiliated docs. We, the seals of the US healthcare information technology world, desperately need a dolphin to help us avoid becoming the aftertaste of the sharks.

Maybe Barry (did you know Barack was called ‘Barry’ in college?) and company could be our dolphin. We don’t need all the HIT bells and whistles the sharks are selling, just a little seal’s basic model. A truly end user-oriented, patient-centric, but community-driven solution — a little “HIT Mini Cooper,”  if you will — for the MAJORITY of us, instead of one of those sharky Rolls-Royce or Humvee HIE/RHIO/CHIN thingies.

I have a plan for such a system which, for a relatively small chunk of the Stimulus Stash, we could implement for some 70% of the country and …

Aw, crap…did I just sprout big teeth and a dorsal fin?

Dr. Gregg Alexander is a grunt-in-the-trenches physician and admitted geek. He runs an innovative, high-tech, rural pediatric practice in London, OH, and can be reached at doc@madisonpediatric.com.