News 3/26/09

From:  Dr. Deborah Peel: "Re: health care information technology vendors’ ‘Hold Harmless’ Clause. Unlike most of what is written about HIT, this article reports on the reality that HIT creates new problems and risks for patients and new liabilities for clinicians. Congress’ and the public’s magical thinking that HIT is a silver bullet for everything wrong with the healthcare system can only be cured with factual information–in large doses. Ross Koppel examines the fact that HIT software inevitably has defects. The most severe defects can result in patient harms/deaths, but currently all software defects are being concealed."  Unfortunately you have to be a JAMA subscriber to view the whole article, but Dr. Peel included an interesting quote by Koppel. "Vendors shifted liability to users and inserted other contractual language that effectively concealed from users the fuller knowledge of serious faults in their HIT systems. Those steps are both counterproductive and unethical. Reducing incentives for getting software right is neither a prescription for HIT health nor for lessened patient harm. Whether the industry is obliged to accept traditional liability, regulatory oversight, or both, restricting the hold harmless/learned intermediary clauses should help to speed the repair of faulty HIT."

The Madoff Ponzi scheme weaves its way into a radiology clinic as federal investigators attempt to return funds to investors. Five years ago, Madoff’s wife bought a 21% share of Hoboken Radiology (NJ) and the practice administrator now expects the federal government to seize Ruth Madoff’s portion.

The 50 radiologists at Northern Ohio Medical Specialists deploy eRAD’s RIS/PACS for its outpatient radiology center. eRAD replaced Evolved Digital Imaging’s discontinued solution.

KLAS is offering an EMR Toolkit to help providers make informed choices regarding stimulus-related technology decisions. The Toolkit includes ratings and analysis of the top EMR vendors for the inpatient and outpatient market. The kit is free to providers and available for a fee to the rest of us.

You can tell which vendors are hot by Googling them to check how many text ads display. eClinicalWorks seems to be the frontrunner with six, one of them, curiously, Microsoft.

A neurosurgeon in Naples, Italy has a heart attack while performing a brain operation. Claudio Vitale insisted on finishing the procedure, them immediately became a patient and underwent angioplasty surgery.  Both the surgeon and his patient are recovering.

Sounds like a better outcome than a Beth Israel patient’s whose doctor fell asleep during surgery. The patient suffered complications following surgery for liposuction and a scar repair. The doctor, who has since been fired and has temporarily lost his state license, claims he had been up all night working on a book.

We’ve gotten several positive comments on the HITECH vendor executive series. It’s a fun read in a compelling, head-to-head format. We appreciate the participation of the executives involved. We have a final installment left to run on Friday.

iMedical and Imagetek team up to provide a scanning solution that allows users to automatically scan and store documents within iMedica’s PM/EMR application.

The visits and e-mail signups for HIStalk Practice have picked up nicely. Put your e-mail address in the Get Instant Updates box to your upper right and click Subscribe and you will know instantly when we’ve written something new. Thanks, too, to our sponsors.

Sage adds three more FQHCs to its client base, as the community health centers purchase Sage’s Community Health System management and EHR systems.

A new article in tomorrow’s NEJM concludes that putting more money into existing HIT may be the wrong approach for delivering long-term benefits. Instead, the authors recommend that HHS mandate development of a new platform that will support a variety of individual applications, making the data "liquid" and providing an easy way for providers to change systems. Good authors: Kenneth Mandl and Isaac Kohane, both MD/PhDs from Children’s Hospital Boston’s informatics programs. Sorry, no link yet since the press release just came out.

The former chief of staff of Anaheim Memorial Medical Center is sued by the MGM Grand over $2.9 million worth of unpaid gambling markers extended to him at the casino.

Three Tuscon cardiologists agree to pay the federal government $355,000 to settle Stark violations. Apparently the physicians were not aware of they were violating any laws until several months after they opened a nuclear imaging practice, to which they referred patients. Once the doctors realized the problem, they reported themselves to the federal government. The doctors say that before opening the practice, they consulted a lawyer. Apparently the lawyer needs some CLEs on healthcare.

After the sudden closure of a county-run nonprofit clinic in California, patients are left scrambling for alternative medical providers, as well as for their medical records. Last week, Coastside Family Medical Center went bankrupt and closed its doors. Many of the clinic’s uninsured and Medicare patients are having difficulty finding new doctors.  Meanwhile, the bankruptcy trustee is taking custody of medical records and not releasing them until requested by a new physician. In other words, patients appear to be unable to take custody of their own records. So, who exactly owns a patient’s medical record?

Speaking of, faculty members from Wake Forest and Duke University collaborate on a commentary that stresses the need to clarify the legal ownership of patient records. In order to make use of potentially valuable clinical data for medical research or improving patient outcomes, regulators must create a new system of patient-initiated control of health records.

One in five American workers are uninsured, according to a new study, a big jump from the one-in-seven number of the mid-1990s. Also, insurance costs have increased 61%, while wages are up only 10%.

Earlier this week we asked if physicians really have time to use all these cool new smart-device applications being introduced. This article suggests that these products have potential  to "overhaul the way physicians and hospitals dispense health care." Perhaps, but we tend to agree with John Q Seriously who pointed out that desktops are today pervasive in both hospitals and clinics and offer a much more efficient workflow than even the fastest iPhone.

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EMR Vendors on HITECH – Part Four of a Series

We asked several vendor executives a series of five questions related to the economic stimulus as it impacts electronic health records.

Much of the EHR-related compensation will come in the form of payment for improved outcomes. How do you expect that to be defined and what product capabilities will it require?


Allscripts – Glen Tullman, CEO

The government has aspired for some time to be able to implement comparative effectiveness analytics programs related to diagnosis and treatment protocols. The anticipation of a rapid EHR adoption curve over the next few years means there will be an exponentially larger pool of raw data available for these efforts, along with broad availability of the technology capable of collecting and transmitting that information. Chronic diseases such as diabetes, chronic obstructive pulmonary disease, hypertension, and others will likely continue to be a focus of this type of research. President Obama’s own personal interest in curing cancer will also likely lead to various manifestations of that disease being a focus of study.

Regarding product capabilities, improved outcomes will require that EHR products incorporate analytics functionality already available through Allscripts, with only the need to adjust the data pulled to match what CMS requires within the reporting process. We have for many years been looking past the point of mass EHR adoption towards a healthcare landscape in which quality care measures can be easily tracked and acted upon with the aid of our solutions. The government’s new focus on comparative effectiveness will only accelerate the timing of the transformation that we have long anticipated.

athenahealth – Jonathan Bush, CEO, President, and Chairman 

We define it as it is currently spelled out in the legislation that was signed – which we also believe will be expanded over time. We are aware of a HIT Policy Committee being formed to put more context to that and we welcome any new criteria that they will want prior to the start of the program and the subsequent years following. Again, anytime more data or the need to report complex data is required it further supports our network-based model. To think over the five year program that CMS won’t want the number of measures and other data sets captured and reported on increased is short sighted. They will and the vendors that are able to keep pace with that beyond just some software upgrade will be the best positioned to assist providers.

eClinicalWorks – Girish Kumar Navani, President

We think that it is fair to require that providers be compensated for use of the system and not merely for purchasing one. eClinicalWorks is already participating in projects like the Primary Care Information Project (PCIP) in New York where eClinicalWorks is used as a tool for quality improvement, and we are paid once physicians demonstrate use and report on outcomes. We have spent the better part of two years improving our solution for clinical decision support for chronic and preventative care. EMRs should be judged by how they automate the office without reliance on paper and as a tool for better patient outcomes.

Eclipsys – Tom Cooke, VP and GM of Eclipsys Practice Solutions

Eclipsys believes there is a large body of valuable outcomes-based measurement tools in use today that should be used to help identify appropriate levels of EHR-related compensation including:

• JCAHO core measures
• Never events
• Pay-for-Performance / PQRI
• Functional status surveys
• Healthcare Effectiveness Data and Information Set (HEDIS)
• RDRGs, APR-DRGs etc.

We also believe there needs to be new measures developed that track outcomes of chronically ill patients across multiple episodes of care.  Additionally, there should be statistically relevant ways at looking at health status of populations as well as individuals. Eclipsys continues to invest in software, content, monitoring tools, professional services methodologies and our client research to further these outcomes measurement tools.

eMDs – Michael Stearns MD, President and CEO

Pay-for-performance and care coordination programs like PQRI and the Patient Centered Medical Home will likely be modified to make better economic sense in both directions. Hopefully as these programs mature they will reward physicians who adhere to guidelines supported by evidence-based medicine. Regarding product capabilities, EHRs need to be able to capture information during documentation as “discreet” data that can be used for reporting. The systems also need clinical decision support tools that remind physicians of actions needed to be compliant with best practices. A mechanism that supports the automated updating of guideline information will also be central to the success of outcomes based compensation.

Greenway – Wyche “Tee” Green, President 

We see this following the lines of the Physicians Quality Reporting Initiative (PQRI) and outcomes criteria that has yet to be defined by the Secretary. I hope it will be in collaboration with entities such as the Agency for Healthcare Research & Quality (AHRQ) and the National Quality Foundation (NQF). As far as what the EHRs will have to do; it will be around the capabilities of reporting/exchanging information efficiently. Many will have to build central data exchanges to accomplish this on a mass scale. Fortunately for us, we have a platform in place called PrimeExchange that enables this data exchange.

MED3OOO – Jay Anders, M.D., Chief Medical Information Officer 

The greatest share of the incentive, in the beginning, will be paid for getting a system installed and fully operational. PQRI incentives based on demonstrated outcomes will start out as a smaller portion of the overall incentive and then grow. The government is moving very quickly to a population health management model with this administration. As CMS gathers more and more information about the ways physicians and hospitals deliver care, they will start to direct care to those physicians and hospitals that can demonstrate high quality through improved outcomes.

With healthcare costs consuming an ever-great portion of our GDP, CMS and other payers will move more and more towards a system in which costs are transparent and quality is rewarded. Payors, led by the government, will likely continue the trend toward “bundled” payments that reward providers for managing the total cost of an episode of care, and also facilitate the comparison of costs between providers.

The Congressional Budget Office predicts a $60 billion savings in healthcare costs by fully adopting EHR technology in the physician and hospital base. EHR product capabilities will be directed through the certification process to provide reporting data to support the quality improvement initiatives of CMS in high cost disease states such as diabetes. Ultimately, they will be a necessary part of data-driven pay-for-performance and pay-for-quality reimbursement systems.

Medsphere – Mike Doyle, CEO 

 
Again, Medsphere would hold up Midland Memorial Hospital as a prime example of improved outcomes. We’ve already mentioned three key areas (patient mortality, infection, unreconciled medications) where improved outcomes make a difference in patient lives, but there are numerous others. Almost all physicians at Midland are using OpenVista for CPOE, which ensures closed-loop medication administration and a much safer process. So, in noting that CPOE is part of Stage 4 in the HIMSS Analytics EMR Adoption Model, perhaps Stage 4 and the use of CPOE by a certain percentage of physicians would be a good standard. The elimination of never events, since government has already started down that path, is also a minimal standard to incorporate.

NextGen – Patrick Cline, President 

This also is a question that will likely be decided for us. But improved outcomes imply implementation of specific clinical processes, entry of patients and their data into the designed process, compliance tracking, and outcomes reporting. This will require a system to be robust enough, yet flexible enough, to configure required protocols, quality and outcomes measurements, and reporting tools without vendor-provided customizations. NextGen, by the way, already has many practices across the country that are tracking and reporting outcomes. In fact, many consider us to be on the forefront of providing the functionality that allows practices to receive significant incentive payments under such programs as the Physicians Quality Reporting Initiative (PQRI).

QuadraMed – Keith Hagen, President and CEO 

We expect improved outcomes to be largely based on the reporting mechanisms that exist today with The Joint Commission and CMS. It is important that reimbursement will be tied to these outcomes, not just quality reporting. We’ve seen this pay-for-performance regime coming for a while now and the ARRA will only accelerate it. We are well positioned to help QuadraMed clients both achieve and demonstrate improved outcomes. We have a strong solution set in place today that our clients can take advantage of: We are developing evidence-based order sets and advanced clinical decision support within QCPR. We have a market leading HIM solution set, including coding, compliance and abstracting. (This is an area most of our competition is relatively weak on and will become increasingly important in a pay for performance world.) Finally we have a web-based Joint Commission reporting and benchmarking tool (COPE – clinical outcomes practice evaluator) that clients are using today for quality reporting purposes.

Sage – Lindy Benton, Chief Operating Officer 

A significant part of this legislation is the ability to prove efficacy of different treatment options. Adhering to, learning from and contributing to evidence-based medicine and protocols is one of the main benefits of having a structured-documentation, single-database practice management and electronic health record system. Sage Intergy EHR uses MEDCIN structured nomenclature to create codified data during the encounter. The Sage Intergy EHR product, combined with the Sage Practice Analytics ad hoc reporting system to extract data from the system, perfectly positions Sage to comply with and provide employers, payers, CMS, NCQF and all other entities the required information. The physician also has analytical capabilities at their fingertips so they can repurpose information into knowledge for practice efficiency and improved quality of care.

SRSsoft – Evan Steele, CEO 

The incentives are intended to help bring about better outcomes. That won’t be accomplished by merely purchasing an EMR, regardless of who pays for it. Not only must the product be functionally competent, it must be a tool that is “usable” by physicians and other providers without impacting their productivity or getting in the way of providing care.

“Government” EMRs force physicians to input and collect data across the board. In contrast, hybrid EMRs identify the measures of interest up-front and limit the data collection appropriately, sparing physicians an overwhelming and distracting task. Once the government identifies the quality measures linked to the outcomes they want to evaluate, it should be up to EMR vendors to determine the most efficient way to collect this data. Why put the cart before the horse?

Improved outcomes are dependent upon several capabilities. First, ePrescribing will prevent medical errors due to drug-to-drug interactions, allergic reactions, duplicate prescribing, and illegibility of prescriptions, and it will help identify drug seekers. The data collected through ePrescribing will facilitate the measurement of the comparative effectiveness of drug treatments. The SRS hybrid EMR already includes a fully integrated, robust ePrescribing module.

“Government” EMRs typically require the building of structured “templates” as the means to collect exam data. This is time-consuming, costly, and inflexible for practices to do. SRS has developed a variety of options to facilitate efficient data collection to allow physicians to document exams the way they prefer. That is the advantage of the hybrid EMR. We also have the ability to incorporate whatever standards may emerge because of our Open Path™ architecture and user functions like “PowerTabs” and “Plug-Ins” that easily incorporate other external products and modules. We anticipate being able to respond quickly to the quality-measurement standards when they are published, as we have done with PQRI.

“Improved outcomes” will result from assisting the doctor in following pre-defined, evidenced-based treatment plans and protocols. We believe an EMR should be more than a repetitive, inflexible set of exam templates. It should be an adaptable tool set that helps busy physicians operate more efficiently and effectively. That means things like generating reminders and alerts. For example, the hybrid EMR can do the calculations and analysis on each patient and provide recommendations (e.g., prescribe beta blockers to all patients over 18 with history of CAD and MI).

News 3/24/09

CCHIT announces that it will speed up the process for its advanced technology certification programs, including clinical decision support, interoperability, quality, and security. Vendors will need to complete all these options for the 2009-2010 development cycle. The advanced clinical decision support and security components were not scheduled for completion until 2011. The new certification options will be finished by the time the HIT Policy and Standards Committees of HHS meet later this year, thus supporting ARRA’s certification requirements.

Speaking of CCHIT, new ambulatory certifications this month include iSuite Version 4 by MedAppz, SILK 4.2, and UroChart EMR by Intuitive Medical.

Physicians can now access the interactive online community QuantiaMD via their iPhones. QuantiaMD is already available for BlackBerry and Windows Mobile devices users. Question: when, exactly, does a physician access an online community? Most likely not while in the midst of seeing patients. Will clinicians really use a smartphone (instead of a PC) to review a clinical presentation or complete CME activities? What type of applications really make sense for clinician use on an iPhone or BlackBerry?

West Virginia’s optometrists and ophthalmologists are at odds over current legislation that would allow optometrists more authority to prescribe medications and perform minor surgeries. Ophthalmologists claim the legislation would put patients’ health at risk because optometrists are non-physicians with less training. Optometrists claim the current laws are antiquated and stand in the way of lower costs.

HIT leaders caution that providers must be educated on the new HITECH legislation incentives and potential penalties to avoid being hurt financially. Surely there are plenty of vendors and consultants begging for a chance to "educate."

Google will change its in-house employee clinic EHR to WebChart Enterprise EHR from Medical Informatics Engineering. The "minimally invasive EHR" will integrate with Google Health.

The program director for the Office of National Coordinator (ONCHIT) sees problems ahead for the Nationwide Health Information Network. Government systems follow a security standard called FISMA, while practice and hospital EMRs are designed to comply with HIPAA. The problem arises when patient information from the VA or DoD is sent to non-government hospitals and doctors. CCHIT is considering additional vendor certification for FISMA.

Former Missouri Congressman Richard Gephardt, now on the board of advisors of PHR vendor MyMedicalRecords (along fellow "formers" astronaut Buzz Aldrin and boxer Sugar Ray Leonard), will pitch the company’s products and try to get stimulus money to subsidize its PHR cost. He’ll be working the company’s booth at the HIMSS conference next Sunday.

This is a KLAS report, not a novel: The Rise of eClinicalWorks: Separating Fact from Fiction, which apparently lauds the company’s user product satisfaction and price-performance, but frets over growth-strapped implementation and support capabilities. You have to buy the report to learn more.

Consultants encourage physicians to use text-messaging to save staff time for such tasks as appointment reminders, lab calls, and follow-ups. Most web-based text applications can be free to set-up with average costs of $200 per month. Between estimated staff time savings of 50 minutes per day per provider, and the potential for increased revenue, texting could add $100,000 a year to the bottom line. Sounds a bit high, but then Mr. H and Inga aren’t big on text messages.

A Las Vegas internal medicine practice is charged with performing an estimated 15,000 unnecessary cholesterol tests on its patients over a three-year period. US attorney’s office claims the physicians overcharged Medicare by $130,000 for tests that were no more useful than performing a "mathematical calculation."  But, everyone knows that drawing blood is more fun that doing math.

In North Carolina, the number of doctors e-prescribing has doubled in the last quarter to over 2,000, according to BCBS of NC. The carrier offers a one-time $1,000 incentive to physicians who agree to submit e-Rxs to at least 20 patients. The state still has a ways to go to cover its 29,000 licensed practitioners.

Several SE Missouri physicians admit that the transition to electronic medical records was difficult, but worth it. A doctor in a three-physician family practice group says the EMR cost $100,000 three years ago, but saved $80,000 in overhead in the first year.

The government’s EHR initiatives appear to be boosting the stock performance of several HIT vendors. NextGen’s parent company Quality Systems, athenahealth, Cerner, and Allscripts-Misys have all outperformed the general market since President Obama was elected.

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EMR Vendors on HITECH – Part Three of a Series

We asked several vendor executives a series of five questions related to the economic stimulus as it impacts electronic health records.

How is your company defining "meaningful use" of an EHR and how will ensure your customers can reach that level?

Allscripts – Glen Tullman, CEO

It is not our direct role to define “meaningful use” for the government. While the law has given us a sneak peek at what may be required, the new Secretary of HHS will further define the details. Accordingly, we are guiding our clients to understand that in order to collect the HITECH incentives, they will need to demonstrate that they are using a certified, ePrescribing-capable EHR that is connected for the exchange of relevant and appropriate personal health information (PHI) to the systems of other healthcare providers. Additionally, while we will not know for some time – likely not before 2010 – what the requirements will be for reporting on quality care measures (the third component of meaningful use), Allscripts is committed to ensuring that our products make it as simple as possible for our clients to comply with any directive that comes out of HHS at that point. Again, our best advice is for physicians to ensure that they are currently using or about to purchase a CCHIT-Certified Electronic Health Record and that the company they buy it from has the resources to invest in the future and is going to be around for years to come.

athenahealth – Jonathan Bush, CEO, President, and Chairman 

We define it as it is currently spelled out in the legislation that was signed – which we also believe will be expanded over time. We are aware of a HIT Policy Committee being formed to put more context to that and we welcome any new criteria that they will want prior to the start of the program and the subsequent years following. Again, anytime more data or the need to report complex data is required it further supports our network-based model.  To think over the five year program that CMS won’t want the number of measures and other data sets captured and reported on increased is short sighted. They will and the vendors that are able to keep pace with that beyond just some software upgrade will be the best positioned to assist providers.

eClinicalWorks – Girish Kumar Navani, President 

eClinicalWorks believes that “meaningful use” of an EMR involves making every aspect of the patient encounter electronic, which includes visit documentation, lab orders, e-prescribing and clinical decision support for preventative and chronic care. Meaningful use should enable physicians to eliminate reliance on paper charts and provide pertinent information at the point of care. Clinical decision support features help elevate the role of an EMR from passively collecting information to actively helping providers make informed decisions.

We have always invested heavily in our customers’ on-going training, providing around 20 free Webinars a week and multi-media educational materials. There is also an online users’ forum.

Eclipsys – Tom Cooke, VP and GM of Eclipsys Practice Solutions 

In our judgment, “meaningful use” can only be measured by how the software improves outcomes, whether these are clinical outcomes, satisfaction outcomes, efficiency outcomes, or financial outcomes. Today, the HCIT community has the opportunity to work together to develop industry guidelines for achieving “meaningful use,” which will then contribute to improved healthcare delivery and care.

We believe that one of the key guidelines should be proven interoperability between systems to enable clinicians to access complete patient information at any point throughout the healthcare continuum. Interoperability also will enable providers to quickly and cost-effectively deploy HIT solutions without ripping out legacy systems – an aspect that has become even more important in this economic downturn.

The “meaningful use” guidelines also should include support for a) the inclusion of evidence-based medicine and b) the sharing and implementation of industry best practices.

Eclipsys brings a wide variety of tools to our clients to help ensure “meaningful use” including:

• Demonstrated best practice rules and alerts
• Speed-to-value implementations
• Outcomes toolkits
• Evidenced-based order sets and documentation templates
• Social networking tools to allow client-to-client sharing of best practices, documentation templates, etc.

eMDs – Michael Stearns MD, President and CEO

The basic criteria outlined in HITECH include e-prescribing, interoperability and clinical reporting. We are hopeful this will be expanded to include clinical decision support and orders tracking. Fortunately our current level of functionality markedly exceeds these basic requirements. However, making sure our providers attain the meaningful use status, once it is defined by DHHS, will be a priority for our organization. We will be launching an extensive educational program for our clients. e-MDs currently offers practice optimization services and these will be modified to include meaningful use “certification.”

Greenway – Wyche "Tee" Green, President 

We are defining, just as the legislation states, that certified EHRs must have e-prescribing and interoperability capabilities, as well as outcomes and quality reporting. We feel that any company that has the most current CCHIT Certified products and is committed to advancing their platform along the CCHIT 09 plan is well-positioned to ensure their customers are afforded a solution that can be “meaningfully used.” Every company must stay nimble, flexible and adaptive to change in order to be successful in this area.

MED3OOO – Jay Anders, M.D., Chief Medical Information Officer 

This is a tough area to address specifically, as ONCHIT has great latitude in setting this standard. I believe that physicians and groups will be required to demonstrate meaningful use, either by reporting PQRI from the EHR or by applying a yet-to-be-determined code that their visits were documented within the system when they are sent to CMS for processing. Practices will also need to demonstrate that they are using EHR for the great majority, if not all, of their patients—75% use in this area has been alluded to in other parts of the law and will probably be adopted in the regulations. Given the latitude here, we are working with all our clients to fully adopt all the functionality of the EHR so that they will meet whatever criteria the regulations require.

Looking beyond the specifics of the HITECH Act into the motivations behind it, the “take home” point here is that EHRs are expected to do much more than automate current physician practices. Meaningful use of EHRs will enhance the quality of patient care, promote the portability of health care, create efficiencies in the delivery of healthcare services, and ultimately lower the aggregate cost of care. These are the higher standards which we’re helping our clients achieve.

Medsphere – Mike Doyle, CEO 

Medsphere defines “meaningful use” of an EHR as Clinical Transformation. Is the EHR being used to improve care in statistically measureable ways? OpenVista was used to do exactly that at Midland Memorial Hospital, reducing patient mortality, infection rates, and unreconciled medications. An EHR needs to provide real-time physician access to relevant patient information from various points of care. It also must improve clinical outcomes, as OpenVista has.

NextGen – Patrick Cline, President 

Again, a vendor perhaps should not be providing such a definition as it would be hard to do so without it being seen as self-serving. Let’s just say that whatever the definition is, we feel comfortable that practices that have installed or will install NextGen under this program will be able to meet the requirements – both in terms of functionality and reporting – that will be instituted to verify "meaningful use." We do know that a portion of the requirement for meaningful use will be e-prescribing, connection to a health data exchange and submission of clinical quality data. Our current clients and those considering NextGen can take comfort in the fact that all three capabilities have been practically demonstrated in client sites, using the currently available NextGen 2008 CCHIT certified solutions.

QuadraMed – Keith Hagen, President and CEO

 
According to the HIMSS Analytics ‘EMR Adoption Model’ there is a major drop-off between Stage 3 (basically nursing documentation) and Stage 4 (CPOE with embedded clinical decision support). According to the 2008 survey, 36% of hospitals have attained Stage 3 but only 2.5% have attained Stage 4. Most of QuadraMed’s clients have achieved Stage 5 (closed loop medication administration), which is an area of strength for our QCPR product. Given this drop off we think the incentives being put into place today should be aimed at moving hospitals from Stage 3 to Stages 4 and 5. We will be focusing on moving our clients to QCPR with its integrated medication management functionality. We are confident that by implementing QCPR our clients will attain ‘meaningful use’. 

Sage – Lindy Benton, Chief Operating Officer 

While we wouldn’t be so presumptuous as to define the term, there are probably some assumptions that can be made. E-prescribing, the capture of discrete data during the encounter, and some level of interoperability will likely be required. Additionally, to meet the goals for comparative effectiveness research, some level of outcomes reporting will be involved.

One of the goals of our new services organization is to help customers – existing and those to come – meet the “meaningful use” standard once it is defined.

SRSsoft – Evan Steele, CEO 

We define “meaningful use” from the physicians’ perspective. “Meaningful use” of an EMR is achieved when that EMR successfully enables a physician to accomplish his/her goals for quality of care, cost-effectiveness, and outcomes measurement—and it is more likely to be achieved by technology that does not compromise productivity or practice style.

The government’s “meaningful use” requirements pose a significant hurdle to physicians who are tempted by the $44,000 incentives. How can physicians become meaningful users of systems that have been shown to reduce their productivity? Even the government, through the Congressional Budget Office, has said that EMRs may cause “financial harm” to office-based physicians.

There are 4 landmark studies that have demonstrated that “government” EMRs (traditional, CCHIT-style EMRs) impose hardship on physicians (http://www.srssoft.com/landmarkstudies.php). Not a single landmark study exists that concludes otherwise. If you can find one, please post it as a comment at the bottom of this interview.

With this backdrop, it’s easy to compare the stimulus plan to the government offering $44,000 of credits over a 5 year period to purchase a “government designed” car that has a maximum speed of 48 miles per hour. To get the incentives, the driver must first pay for the entire car up-front and then the driver must prove “meaningful use” of the car to a government agency via various reporting mechanisms. If he stops using the government car in a meaningful manner because he is always running late or he finds that 48 mph doesn’t suit the way he drives, he is stuck with the entire cost of the car. If it were known that over 50% of the time, drivers who purchase government cars abandon those cars and lose the entire investment, who in their right mind would buy a government car?

The same problem exists with government EMR. Everyone wants the EMR incentives, but the realities of a fast-paced, busy medical practice will cause physicians to abandon the EMR systems just as they have been doing en masse without the incentives. The incentives will only accelerate the demise of traditional point-and-click EMR systems as physicians with less IT proficiency and a lower level of IT support attempt to use the very same systems that have failed among the deep-pocketed, more technically savvy early adopters.

Thankfully for doctors, government EMR adoption is 100% voluntary and, over the next 9 years, the incentives are relatively small as a percentage of their total income. Therefore, doctors are free to purchase the digital solution that best meets their practices needs—one that incorporates the voice of the physician rather than the voice of government.

If an EMR can be built according to government specifications that we feel physicians can “meaningfully use” without being slowed down, SRS will develop such a product. If sometime late in the next decade CMS requires the use of an EMR, then SRS stands ready to provide its clients with the software they need. In the meantime, we keep listening to what our clients want and to provide a hybrid EMR that works wonders for their practices.

EMR Vendors on HITECH – Part Two of a Series

We asked several vendor executives a series of five questions related to the economic stimulus as it impacts electronic health records.

Providers will be required to implement “certified” software to participate. Who should perform the certification and what criteria should they use?

Allscripts – Glen Tullman, CEO

We believe the Certification Commission for Healthcare Information Technology (CCHIT) is very well positioned to perform the certification of EHRs. Allscripts has been a strong supporter of CCHIT – one of the industry’s primary product certification bodies – since its inception.  We are pleased that Congress appears to recognize the good work CCHIT has done through its certification process and that HHS will likely base many of its go-forward standards on that work. Today, all of the products in our EHR portfolio have current CCHIT certification, and we intend to ensure that every one of our clients is in a position to participate in the new Stimulus incentives that will become available starting in 2011.

Regarding criteria, we believe CCHIT is on the right track with its Roadmap for Expansion of Health IT Certification. We support CCHIT’s plans to include advanced interoperability, advanced quality, advanced security and advanced clinical decision support in their 2010 and 2011 certification programs. Doing so will contribute to ensuring that the widespread adoption of Electronic Health Records envisioned by President Obama results in true transformation of our healthcare system. It’s critical that physicians use EHRs that reach beyond their own practices in an interoperable fashion rather than becoming simply another “software silo.” To get there, we need to ensure that physicians and patients alike feel confident that their information will be secure. We need to ensure that certified EHRs are capable of capturing and analyzing information needed for participation in pay-for-quality programs. And we need to ensure that physicians receive real-time, accurate clinical decision support to harness the power of information.

With a certification process that measures all four of these areas – interoperability, security, quality and advanced decision support – we have a real chance to truly improve the quality and lower the cost of providing patient care in the US today.

athenahealth – Jonathan Bush, CEO, President, and Chairman 

As we all know CCHIT handles this process, and we are currently in the midst of certifying for 2008 and will look to certify athenaClinicals for every single year moving forward. I am sure more and more standards and privacy entities will appear in years to come and athenahealth will incorporate whatever measures they require into our national network just the same as we do today . There will be no cumbersome version “whatever” launch and subsequent failure for athenahealth as we see with traditional software players. We release 6-8 major new versions of athenaNet a year across our entire national base over night. We also update athenaNet daily with new payor and clinical rules, security, and privacy measure etc. Today we have over 40 million various scenarios that require our proprietary rules engine in athenaNet to fire in order to guide providers away from making billing or clinical documentation errors that would lead to a poor outcome – unpaid claim or incomplete patient record. To this end, we have a website http://www.athenahealth.com/campaign/hitech/index.php , as do most HCIT vendors on the HITECH Act and issues around certified systems. However, we tried to communicate the realities of this program and attempt to give providers a moment of pause before they select the very same stagnant software systems that have proven not be adopted and utilized for many years. Certification of certain software functionally does not directly correlate with ROI or adoption. We believe providers are getting savvier to the fact they need much more flexible clinical systems that will be able to change with an evolving healthcare system and not wait hat in hand for the latest and great upgrade. I think we even saw some interesting research from Avalere Health researchers on this issue that indicated a solo or small group physician practice will spend an estimated $124,000 over the five year period of 2011-2015 to adopt and maintain a traditional EHR, and could receive up to $44,000 in federal incentive payments.  The resulting financial deficit would be $70,000, or an average of $14,000 a year. The value has to come from both vendor and the incentive – software functionality is only a small part of this.

eClinicalWorks – Girish Kumar Navani, President 

Interoperability is a key objective for eClinicalWorks. Standards should focus on sharing patient records in a way that is private and secure. It is also important that technology promotes patient care, preventative measures and disease management. We would like to see standards in place that support these aspects. Whatever standards the government decides on, we are confident that we will meet them.

Eclipsys has been, and remains, a supporter of CCHIT as the proverbial Underwriters Laboratory (UL) for HCIT. We believe it is in everyone’s interest for the industry to police itself through this independent “Good Housekeeping Seal of Approval” process. Eclipsys believes that the roadmap for functionality and interoperability being laid out by CCHIT is reasonable and appropriate to create standards of certification.

eMDs – Michael Stearns MD, President and CEO

Our EHR has been certified by CCHIT in 2006, 2007 and 2008, including the child health and cardiovascular specialty certifications offered in 2008. Regardless of what direction the DHHS secretary and national coordinator decide to take, we fully commit to being compliant with any and all EHR certification requirements.

To date, CCHIT has provided the most effective and thorough certification process. The industry as a whole has invested millions into certification, interoperability, privacy and security with tremendous achievements in the last three years. Products that are currently certified with 08 CCHIT criteria have a high level of functionality that deliver long-term and interoperable solutions. CCHIT is currently the only recognized certification body (RCB) by the Secretary and by starting over; we will take considerable steps back.

The bill has language that puts the oversight of the certification process in the hands of ONCHIT. The logical assumption is that CCHIT will continue as the organization that will recommend criteria to the office of the National Coordinator, with input from the new national HIT policy and standards committees. Overall, CCHIT has done a good job in setting criteria that advance EHR functionality. I believe they should continue in this role, with oversight from ONCHIT.

We can’t say exactly who should perform the certification, and we don’t really want to. That may not be much of an issue. What the certification focuses on and requires is more relevant. Now, might the requirements demand that government oversee or take some roll in the process? Yes, they might.

The assumption seems to be that CCHIT will be the certifying body, though the organization isn’t mentioned in the legislation. Historically, CCHIT certification has not incorporated considerations such as interoperability, transparency, or affordability, which were alluded to by Congress. Maybe the requirements that come out in April will. Medsphere thinks certification must incorporate these elements. Perhaps government oversight will be required to ensure they are addressed.

What criteria should they use?

• Proven (evidence-based) to improve clinical outcomes: Medsphere’s OpenVista EHR is built on VistA, the proven and popular VA EMR system field-tested by the U.S. Department of Veterans Affairs (VA) for two decades in more than 1,300 sites of care, including 160 medical centers and 850 clinics. VistA was designed specifically for the outcomes-oriented management of patients with chronic disease, which sets it apart from most health information systems. The changes resulting from VistA at the VA are considered the largest case study ever of objectively improving care. Peer-reviewed research has documented the VA’s higher compliance with performance standards, unparalleled patient safety improvements, and better overall health outcomes than private-sector organizations resulting from its use of VistA.
• Affordable / Cost-effective: Medsphere’s OpenVista EHR leverages the multi-billion dollar public investment in the comprehensive and highly-acclaimed VistA EHR. In commercializing an already valuable tool, Medsphere has transformed VistA into OpenVista, a feature-rich EHR designed to meet the needs of acute, ambulatory, and long-term care environments as well as multi-facility, multi-specialty healthcare organizations.
• An innovative pay-as-you-go subscription pricing model enabled by open source technology incorporates no mandatory upfront implementation costs, a departure from traditional “vendor lock” solutions. Medsphere creates ongoing value via product upgrades and application support included in every subscription, helping customers get the most from their solution now and for years to come. Plus, the most a hospital is eligible for under the federal legislation is $11 million, which will easily cover OpenVista implementation. Ask Cerner or Epic if they want to do an implementation for that price.
• Interoperable: OpenVista works with existing hardware and software, thus preserving legacy IT investments. When deployed across the enterprise, the integrated platform delivers superior time-to-value and time-to-benefit. The interoperability incorporated into OpenVista also enables health information (HIE) exchange and broader coordination of patient data where other solutions simply don’t. We clearly seem to moving toward more information flowing to hospitals and clinics around the county. How is that possible if patient records are locked up in proprietary systems that won’t play nice?
• Fosters collaboration: How would healthcare progress if advances in medicine were retained by individual hospitals or research facilities? The same question is relevant with health IT. When a hospital or university develops an effective application or template, there is something unconscionable about not sharing it with other healthcare providers, particularly if it can directly and positively impact patient care. As an Open Source solution, OpenVista and our Healthcare Open Source Ecosystem encourage people to get under the hood and create. There are a hundred ways to approach a task, and only through a diversity of opinion unfettered by corporate orthodoxy can we find the best one.

As a vendor, it may not be appropriate for us to comment on who should perform the certification. But let me be clear that we support the need for the body to be well respected by all participants – including physicians. As far as the criteria needed, it probably makes sense to look towards the CCHIT 2008/2009 criteria, at least as a starting point. Various stakeholders can certainly be included in the process to make sure that all sectors are represented. It is likely that their additions, expansions, or even deletions and corrections to the CCHIT criteria should help the process gain widespread acceptance.

It makes sense that CCHIT will be the certifying body. The group has done a good job of establishing “harmony,” credibility and legitimacy among vendors, payers, providers and other 3rd parties. Additionally, there is synergy with the CMS demonstration programs since the new incentive program leveraged the CCHIT certification criteria.

However, the legislation leaves specifics unfulfilled. We will be closely monitoring developments to ensure we meet all certification requirements.

Certification requirements should be determined by a group led by the end users—that is, the busy, practicing physicians who will be using the software. The software they would structure would be easy to use, increase their productivity rather than ask them to be data entry clerks, generate reports based on the outcome measures they identify, and streamline practice workflows.

In contrast, the starting point for government EMR standards under the Stimulus Plan will likely be CCHIT. It is unfortunate that the 21-member CCHIT commission lacks significant representation by front-line, private-practice physicians. There is nothing in the certification criteria that requires that features be usable and convenient for the doctor. Of the 477 feature-focused CCHIT certification criteria for 2008, not one addresses usability. For example, it can take a doctor 20 productivity-sapping clicks to accomplish a task with a certified feature, but as long as it produces the desired result, that feature will pass certification with flying colors.

Compounding the frustration, the HITECH legislation creates a newly formed HIT Policy Committee charged with setting overall policy and overseeing the distribution of the Stimulus Plan funds. Unfortunately for front-line physicians, the committee will consist of a group of 20 politically appointed individuals with only one physician representative. This does not bode well for the development of usability-based criteria that physicians will find adoptable.

Instead of focusing on features alone, EMR developers should focus their energy and R&D budgets on producing elegant, streamlined, and efficient products that are highly usable. This has always been, and remains, the focus at SRS. Alternatives to CCHIT-type EMRs, such as hybrid EMRs, should be evaluated for their ability to boost the EMR-adoption rate.