An HIT Moment with … Jim Tate

An HIT Moment with ... is a quick interview with someone we find interesting. Jim Tate is president and eHealth consultant at EMR Advocate, LLC.

What’s the best way to use federal dollars to get physicians to use EMRs in ways that benefit patients?

The current Federal incentive program for e-prescribing that began January 1, 2009 is a good model to also encourage providers to document patient care in an electronic record. I would suggest that starting July 1, 2009 providers would be given a bonus (5%?) for every Medicare/Medicaid charge that was documented in a CCHIT-certified EMR. Reduce that bonus every year by 2% until it becomes a penalty (-5%).

The process would play out over five years and the requirement that the EHRs are CCHIT-certified would guarantee that interoperability would be a part of the adoption wave.

What tips can you offer physician practices for selecting and contracting for EMRs?

• Take your time.
• Designate one physician to become the EHR Champion and assume ownership of the process.
• Talk to peers and ask them which EHR systems they use and what has been their experience.
• Go online and see what other physicians are saying about the systems they are using.
• Consider only systems that are CCHIT certified.
• Narrow your list of vendors down to three or four before calling the companies for a demo.
• If you are not comfortable with your level of expertise, locate a consultant to help with the due diligence and contract negotiation.
• Make sure your expectations are clearly understood by the potential vendor.
• When you ask for a quote, make sure it is for a complete and inclusive system. I have seen physicians sign a contract and then be told three months later that if they want an interface to their in-house lab it will cost $20,000.
• If you are not really sure what should be in the contract find someone who can help you.
• Do not assume anything.
• Everything is negotiable until you sign the contract.
• If you have a timeline for your implementation, make that part of the contract.
• If you want the trainers to have at least one year of experience, make that part of the contract.

You really need to protect yourself and stay in the driver’s seat and do the things that will lead to a smoother implementation that will occur on your terms.

Assuming physicians buy systems that are CCHIT-certified and therefore theoretically interoperable, how will they actually interoperate for patient benefit?

Interoperability can occur to benefit patients in ways that could never have been possible with paper records. The ability to generate, receive, and display CCD (Continuity of Care Document) type files is part of CCHIT’s 2008 Ambulatory criteria. This ability to generate and receive a file composed of a patient’s demographic and clinical information is a good first step to ensure that information can be shared between physicians and different EHR systems.

Another standard of CCHIT certified systems is the requirement that the EHR must be able to receive laboratory results in a discrete format directly into the patient’s electronic medical record. The provider is notified of the presence of the lab result by the system, not by the nurse. The results can be compared, graphed and then messaged to the nurse for appropriate resolution. This leads to fewer steps in the workflow, fewer lost labs and increased efficiency in the process. 

Debate continues on whether today’s EMRs are good enough to be worth massive federal investment. Where do they fall short and what should vendors be doing?

It is apparent that Obama is preparing a massive federal program to accelerate the adoption of health information technology. Currently we are only at the early stages of interoperability and the subsequent ability to exchange and gather data. The capability to exchange and congregate this discrete data must be aggressively expanded to bring added clinical value. Also, the user interfaces of many EHRs are cluttered due to the high level of functionality. Design work needs to be done to make these systems easier for the users. 

What technologies are available today that can help physician practices, but are less expensive and easier to implement than full-blown EMRs and practice management systems?

As a project manager for numerous EMR implementations in both the US and China, I saw the great risk of trying to immediately adopt all possible functionalities in an EHR. We called it the “Big Bang”. It was good for the vendor, usually not so good for the providers.

In many clinics, the workflow has been created over years, sometime decades. To change everything at once is incredibly stressful and can lead to the failure of the EHR being embraced by the users. To implement in a modular fashion has the benefit of reducing stress and also minimizing the loss of productivity that usually takes place with the “Big Bang”.

Messaging, e-prescribing, e-faxing and receiving discrete lab results are all good examples of “first steps” that can get the provider into the electronic arena.

News 1/29/09

From Ken Kercheval: "Re: physician practice EMRs. It is going to be an interesting year. Lots of companies will go away. Like they say, ‘When the tide goes down, you find out who isn’t wearing a swimsuit.’ Indeed." We are curious to see if the final economic stimulus legislation will include a requirement that funding is only available for CCHIT-certified products. If that becomes a condition, that should shake the industry up a bit.

California ER doctors file a class-action lawsuit against the state, contending that unless emergency medicine is better funded, the state’s emergency care system risks collapse. California ranks last in EDs per capita (seven per one million people compared to the national average of 20 per million people.)

Advantage Healthcare Solutions will be the exclusive provider of physician billing and A/R management services for the employed physicians of State Island University Hospital. Advantage will provide services to more than 20 practices and over 150 physicians.

Unlike typical hospital CEO’s, the new head of Cape Cod Healthcare lacks MBA or MHA credentials. Richard F. Salluzzo is actually a physician who intends to continue practicing emergency medicine while overseeing the hospitals operations.

Tennessee expands its medical video network to allow physicians to treat pregnant women in rural counties. BCBS of Tennessee Health Foundation has provided $1.8 million in funding to allow perinatologists to view live ultrasounds remotely.

A study in the Journal of the American College of Radiology finds the biggest area of growth for imaging billings is coming from the private office setting. A review of 10 years’ worth of Medicare data concludes that imaging billings by non-radiologists in private-office settings grew by 63% between 1996 and 2006.

VirtualHealth Technologies, Inc. completes its $1.5 million financing commitment to Private Access, Inc, a developer of privacy management tools for medical information.

New Milford Orthopedic Associates (CT) selects the SRS hybrid EMR for its six-physician, four-office practice.

Transaction service provide MedAvant Healthcare Solutions appoints Troy Burns as CTO. Burns previously worked at Misys and Payerpath.

The Illinois Medical Society and athenahealth agree to extend discounted pricing to medical society members for athenahealth’s PM solution. Approximately 12,000 physicians are members of the medical society.

EMR and PM provider Purkinje is offering free training and installation services for practices signing up during February. Purkinje is a Web-based SaaS solution that costs a flat $399 per month per provider. What is it about human nature that makes us wonder what the catch is? Or why we are reminded of the expression that sometimes "free" isn’t free enough? We don’t know much about the Purkinje product, so feel free to share any insights you might have.

Biopharmaceutical company Favrille and PHR vendor MyMedicalRecords complete their merger, making MyMedicalRecords a wholly-owned subsidiary of Favrille.

Retail prices charged by doctors in 2008 increased 2.9%, compared to 4.1% in 2007, according to the US Bureau of Labor Statistics. Wholesale prices for physicians increased 1.2% last year compared to 4% the previous year.

Noteworthy Medical Systems, Inc., announces a partnership between Portneuf Medical Center, Medical Resources of Idaho, and the Idaho Association of Physicians to form a community-wide HIE for providers in southeastern Idaho.The medical center and IPA are sponsoring the program designed to provide regional physicians access to Noteworthy’s web-based EHR. Leaders anticipate 100 physicians will join the program within the next six months.

HIMSS announces its support for HIT provisions under consideration by Congress.  HIMSS cites three reasons to support HIT investment: 1) the economy will benefit as jobs are created; 2) patients will benefit because of increased safety, and, 3) doctors will benefit because it reduces the current cost barriers.

As you watch the Super Bowl Sunday, consider this (between munching on spicy wings and drinking your beverage of choice, of course):  the headbanging collisions by your favorite football players can lead to impairments in movement and thinking 30 years or more later. If a player suffers multiples concussions, he is more likely to suffer more severe emotional and behavioral problems.  Doctors also advise Super Bowl  TV viewers to be careful.  Emergency rooms are usually busy right after the game, with patients complaining of such ailments as sprains, stomach ailments, and vocal chord damage.

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An HIT Moment with … Naomi Grobstein

An HIT Moment with ... is a quick interview with someone we find interesting. Naomi Grobstein, MD owns Family Health Center of Montclair in Montclair, NJ.

You are using several of RelayHealth’s online tools to communicate with your patients. How have your patients responded to having such tools as prescription refills or webVisits?

My patients love to be able to contact me via e-mail. It removes a lot of the frustration of phone menus, inaccurate messages, lost messages, etc. As for webVisits, it hasn’t really caught on much. I’ve only had a few patients use it. Now some insurance companies are covering it, but I’m not sure that is widely known.

How do you see medical practice evolving over the next 3-5 years, given available and potential technology?

I can’t really predict the next 3-5 years. Even what we have now is beyond what I could have imagined. I do hope to get rid of all the piles of paper that still clutter the office and get away from voice phone messages as much as possible.

How would you respond to providers or patients that view these type of online tools as a privacy risk?

That sort of thing is beyond my control. We could have a hurricane, a terrorist attack, or a major privacy breach. I hope the people working at the planning/implementation of these tools considers it carefully just as they have to consider backing up data. We’re all using our credit cards to order things online and yet we know there could be a breach.

Beyond the RelayHealth tools, does your practice use other automation tools such as EMR, practice management, or on-line connections to other data sources?

We have an EMR to do patient charting and messaging around the office, and of course we do electronic billing and banking. Through Relayhealth we do electronic prescribing, and the pharmacy or patient can request refills electronically.

How has the use of technology in your practice affected patient care and satisfaction?

Somehow the expectations rise with the ability to do more. In the old days, the patients were satisfied to get an appointment within a week and they didn’t ask questions. Still, I think my practice stands out for being accessible because of these electronic tools.

News 1/27/09

From Al Stewart: "Re: Allscripts. Didn’t athenahealth’s CEO Bush do this exact interview weeks ago? Tullman and crew must be getting a little slow on the PR front, I guess. Big surprise, he wants Congress to foot the bill upfront for EHRs. Typical big box HCIT CEO speak. Of course, maybe then Allscripts will finally make their numbers …" Link. Allscripts CEO Glen Tullman suggests that federal stimulus money first be used to help buy EMRs, then give doctors (and presumably hospitals) financial incentives to use them. Each of us could argue those points (like the commenters at the bottom of the WSJ article), but I suppose the one argument that’s already lost is whether the government should be pushing commercial products in any fashion, no matter how beneficial their use might be. I’m sadly out of fashion as a free marketer. Actually, Jonathan Bush’s platform is the opposite: don’t spend taxpayer money buying products already available that doctors are passing on for one reason or another (cost, productivity, etc.) but rather spend the money giving them performance goals and let them pick the tools. Both CEOs, naturally, advocate a position that would benefit their respective companies, which is what they’re paid to do.

From Parker Lewis: "Re: government buying EMRs. I hope to God they don’t offer to buy them, or else a bunch of second-tier businesses will stick around when otherwise the market would take them out."

From Bignurse: "Re: 77% of consumers not supporting increased healthcare IT spending. The healthcare community needs to launch a public relations campaign to inform consumers about why healthcare IT is needed and how it benefits them, i.e. PHR, patient safety, better informed physician decision-making, and hopefully, reduced waiting times. Consider the successes of past public campaigns on seatbelts and Medicare Part D, for example." I like the idea, but I’m not sure even providers agree on that (and certainly have inconsistent outcomes in trying to achieve them).

From Doris DeMarco: "Re: Baylor revenue cycle management. It’s being done by MED3OOO."

Medical Records Institutes announces the finalists for the 2009 TEPR Awards. The PHR finalists are CapMed, Doctations, and myHealtheVet. In the Hot Products category, finalists are Doctations, iChart, TapChart, and three products by Private Access.  Winners will be announced at the TEPR+ Conference next week in Palm Springs. Are we the only ones who have barely heard of most of these products? The competition is free to all the exhibitors (67 are listed on TEPR’s Website, including an assortment of magazine publishers, the Social Security Administration, etc.) If you are not exhibiting, you can still participate in the TEPR Awards for a "fee." As nice as it sounds to be in Palm Springs right now, we’ll take a pass.

The so-called HITECH Act (warning: PDF), the Health Information Technology for Economic and Clinical Health Act (man, that’s one contrived acronym) from the House Ways and Means Committee, is one angle at HIT stimulus. It claims that EMR adoption would reach 90% of doctors and 70% of hospitals within the next 10 years. It’s interesting that, despite urging that the stimulus money be used on projects that are ready to go quickly, that HITECH wouldn’t provide any immediate incentives to doctors, and in fact would require them to buy EMRs and get some level of reimbursement later. Doctors would be eligible for $40,000 to $65,000 if they can demonstrate system use through improved quality measures (different from Glen Tullman’s position above, where he thinks EMRs should be bought upfront and rewarded for use with a second round of money later). And here’s the part that every vendor (and therefore HIMSS) hates: "After standards are adopted in 2009, the National Coordinator shall make available at a nominal fee an electronic health record, unless the Secretary determines that the needs and demands of providers are being substantially and adequately met by the marketplace." In other words, unless Rob Kolodner (a VA guy) believes that existing practice and hospital systems are good enough, he can make a low-cost system available. That’s not much of a bold move since the only obvious system fitting those criteria is the VA’s VistA, already free for anyone who wants to burn a CD (but not necessarily easy to install or use).

All of the federal debate begs a question: why would you buy a system now if there’s a chance that Uncle Sam will help pay for it if you wait? If I were a vendor, I would be concerned about dramatic short-term sales dropoffs while waiting for possibly beneficial legislation to pass.

As the economy worsens, doctors are seeing the health of their patients decline as well. Providers are noting increases in headaches, stomach pains, anxiety, and depression, as well as rising blood pressure and increased obesity. Doctors believe the tougher economic conditions are elevating stress levels. Patients are also cutting corners on their diet and exercise, choosing cheaper and less nutritious fast food, and skipping refills of expensive medications.

As hospitals try to remain solvent, some resort to layoffs of employed physicians.  Consultants warn that more physician layoffs and pay cuts could still be ahead.

A Pennsylvania doctor starts a concierge practice, charging 400 patients $1,750 per year ($700K gross), which covers all visits, 24-hour telephone access, e-mail access, and online medical records. Interesting: she doesn’t have hospital privileges since she doesn’t take insurance, but she still is actively involved in the care of her patients when they are hospitalized. Some folks gripe that cherry-picking cash patients just makes the precarious healthcare system worse, but let’s be fair: if it wasn’t for the hassle of dealing with insurance companies, doctors wouldn’t do it.

Robert Gumbiner, a doctor and philanthropist who created the FHP HMO because he thought fee-for-service was immoral because doctors get paid only when patients are sick, died last week at 85.

Big healthcare reform news from China: the government will spend $120 billion to build hospitals and clinics, subsidize insurance costs to get more citizens covered, and improve rural care. The official news agency said, "The health care sector is one of the weak links in China’s social welfare system. Soaring medical fees, a lack of access to affordable medical services, poor doctor-patient relations and low medical insurance coverage compelled the government to launch the new round of reforms." It should not be forgotten, however, that China is wealthy, backward, and Communist, even though their problems are similar to ours.

The current House Ways and Means Stimulus Bill includes wording that would require federally appropriated funds only be spent on CCHIT-certified products. How is that going to fly with all those uncertified EMR vendors and their users?

Sage launches Intergy version 5.5 of its EHR/PM system. Some of the new features includes cardiac device integration, predictive orders management, encounter note wizard, and enhanced e-prescribing capabilities.
 

QxMD announces another cool iPhone application. Safe OR is based on the 19-item surgical safety checklist, A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population.

A study concludes that physicians who participate in online physician communities and social networks write about 24 more prescriptions per week. Good news if you are selling online ads for the pharma companies.

CMS posts the Measure Applicability Validation process for 2009 PQRI, which will be used to determine satisfactory PQRI reporting for participants who achieve a reporting rate at or above 80% for each measure submitted.

Odd: a college student drops by a local podiatry office after seeing an ad for a free nail trim, whirlpool, and foot massage. She finishes up 20 minutes later, fills out a medical form, and heads out. Her mother found out later that her insurance was billed for over $3,200, including charges for five surgical procedures. The doctor’s receptionist told her that anytime the doctor touches a patient’s foot, it’s considered a surgery. Cigna, which paid $616, is looking into it.

The Association of Academic Health Centers calls for a revision of the HIPAA Privacy Rule, claiming the current version has a negative impact on research. The Association cites a recent study that found researchers were having difficulty recruiting participants and that HIPAA created barriers to diversity in research studies.

Doctations and Zynx Health form a strategic alliance to incorporate Zynx’s AmbulatoryCare product with Doctations EMR.  Zynx AmbulatoryCare is a suite of clinical decision support content that includes evidence=based recommendations, order sets, performance checklists, alerts, and reminders.

The owner of a Montana billing service is convicted for mail fraud and filing false income tax returns. Kathleen Hunnewell billed insurance companies and patients on behalf of her healthcare provider clients and pocketed portions of the patient and insurance reimbursements, $225,000 worth over two years. She faces 20 years in prison and a $250,000 fine.

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Joel Diamond 1/24/09

Patient Perspectives on New Technology

I remember a few years ago when one of my mentors in Family Medicine told me that the use of computers during patient encounters would destroy effective communication. "Doctors will pay more attention to the screen than their patients." 

As we strolled down the hospital hallway, I asked him to watch several doctors who were talking to patients with their noses buried in the paper chart. "What do you call that?" I asked. "Charting," he sheepishly responded. I suggested that it was just bad doctoring. 

It reminded me of watching bad surgeons wielding a laser during my training — pure carnage. So while good technology has the potential to turn surgeons into butchers, so can it reduce bedside manner to the lowest form of social ineptitude. Pardon the mixed metaphor, but new technology is always a blade that cuts both ways.

Here’s a different take on the same subject. When I first installed my EMR many years ago, I, too, struggled at times while navigating my way through new templates and would frequently apologize to patients when I forgot to maintain eye contact. Most patients would tell me not to worry — they were delighted that I had made a commitment to improving the quality of their care and were tolerant and appreciative of the obvious struggle. I soon discovered, however, that distraction can have its advantages.

We all have been there — the lovable-but-boring patient who comes in month after month with no real problems other than a need to talk. It’s uncanny how they manage to schedule their visits on the busiest, most stressful days.

During one such encounter, I started to wonder if I could perhaps multitask a bit. My new EMR had electronic messaging. Would it be possible to take care of a few refills while my patient was droning on about the amazing coincidence of her urinary incontinence treatment and her cat’s UTI?

After completing the fifth message in my inbox, I couldn’t understand why the EMR vendors didn’t use this as the main selling feature. Talk about work flow … this was awesome! I confess to only slight guilt as I encouraged my patient to tell me more about her cat’s medical issues. I was on a roll here — maybe I could review some labs as well. 

My joy ended, though, when my patient cleared her throat. It seemed like I had been caught. "Dr. Diamond", she started, "I know that I must bore you month after month, and I realize that you are a busy man with more important things to do. But you always listen to me and never act like you’re rushed, and you make me feel like someone cares about me."   

I winced as I anticipated what I thought would come next. "You know," she said, "now that you have that fancy new computer, you seem to type a lot while I have been speaking." Imagine my shock when she said appreciatively, "I want to thank you … for taking all those detailed notes on everything that I’ve been telling you!"

This seems to me to be the perfect example of technology being a double-edged sword. We have so many tasks to complete and are often conflicted about the time we would like to spend with our patients. Work flow can mean many things. Let’s just remember that maximizing both compassion and quality during the patient encounter can be an enormous incentive to doctors if carefully coupled with return on investment.

Joel Diamond, MD is chief medical officer at dbMotion, adjunct associate professor at the Department of Biomedical Informatics at the University of Pittsburgh Medical Center, and a practicing physician at UPMC.