By JOHN HALAMKA, MD

In a time of EHR naysayers, mean-spirited election year politics, and press misinterpretation (ONC and CMS do not intend to relax patient engagement provisions), it’s important that we all send a unified message about our progress on the national priorities we’ve developed by consensus.

1. Query-based exchange – every country in the world that I’ve advised (Japan, China, New Zealand, Scotland/UK, Norway, Sweden, Canada, and Singapore) has started with push-based exchange,replacing paper and fax machines with standards-based technology and policy. Once “push” is done and builds confidence with stakeholders, “pull” or query-response exchange is the obvious next step. Although there are gaps to be filled, we can and should make progress on this next phase of exchange. The naysayers need to realize that there is a process for advancing interoperability and we’ll all working as fast as we can. Query-based exchange will be built on top of the foundation created by Meaningful Use Stage 1 and 2.

2. Billing - although several reports have linked EHRs to billing fraud/abuse and the recent OIG survey seeks to explore the connection between EHR implementation and increased reimbursement, the real issue is that EHRs, when implemented properly, can enhance clinical documentation. The work of the next two years as we prepare for ICD-10 is to embrace emerging natural language processing technologies and structured data entry to create highly reproducible/auditable clinical documentation that supports the billing process. Meaningful Use Stage 1 and 2 have added content and vocabulary standards that will ensure future documentation is much more codified.

3. Safety – some have argued that electronic health records introduce new errors and safety concerns. Although it is true that bad software implemented badly can cause harm, the vast majority of certified EHR technology enhances workflow and reduces error. Meaningful Use Stage 1 and 2 enhance medication accuracy and create a foundation for improved decision support. The HealtheDecisions initiative will bring us guidelines/protocols that add substantial safety to today’s EHRs.
Continue reading “State of the EHR Nation”

By Al Lewis

Implementation of ICD-10s has been delayed “indefinitely.”   Rather than opine on whether that’s a good thing or a bad thing, I will note that it creates an opportunity for a simple but powerful improvement in the value of the coding.

Caveat:  I am not a coding expert (I don’t even play one on TV) so there might be something wrong with this idea.  The specific reason for the post is to find out whether there is some reason this can’t be done, given the value of doing it.  (I am so unfamiliar with coding that it is possible this is already being done and I’m the last guy to find out about it, in which case perhaps John and Matthew would be kind enough to remove it.)

Quite simply, how about adding an optional  ”R” for “rule-out” after the codes?  For instance, today if a patient gets tested for diabetes and it turns out that he HAS diabetes, he gets coded “250″ in the ICD-9s.   Whereas if it turns out the patient does NOT have diabetes, he still gets coded “250.”   My proposal would code that (in ICD-9s) 250R.

By contrast, giving two opposite diagnoses the same code creates a cascading set of problems, in outcomes measurement, risk scoring, registries, disease management, reimbursement, and predictive modeling, problems that will be exacerbated as risk shifts down to the provider level and payors move to outcomes-based reimbursement.

Continue reading “Does ICD-10 Delay Create an Easy Opportunity for Coding Improvement?”

By SCOTT SHREEVE, MD

I just received another email from another EHR Vendor pandering to physicians to implement their technology so that the physician so they can access some usability incentive to use technology that they should already be using. Here is the offending language:

By D. Brad Wright

Any ruling by the Supreme Court on the constitutionality of the Affordable Care Act’s controversial individual mandate isn’t likely for at least another several months, but it’s worth thinking about what might happen after the case is decided. The first scenario is easy: If the Court upholds the mandate, the ACA goes forward as planned to the continued objections of many conservative Americans and politicians. The second scenario is less clear: If the Court finds the mandate unconstitutional, do they find it severable from the rest of the law? If not, they’ll strike the whole ACA down. This seems like the least likely outcome. If, on the other hand, they do invoke severability, the ball is back in the White House’s court. The decision at that point would be whether or not health reform can be successful without the individual mandate.

The concern here is the death spiral first described by Nobel Prize-winning economist Joseph Stiglitz. In essence, if we don’t require everyone to buy insurance, then insurance will be disproportionately purchased by the sick, making it more expensive and leading many to discontinue coverage in a continuous cycle that drives the price higher and higher until no one can afford insurance any more and the system collapses. By contrast, getting everyone into the pool is seen as the only way to keep costs down and maintain the insurance system. So the question is: What happens if the Supreme Court strikes down the individual mandate? Does the Obama adminsitration wash its hands of health reform, proclaiming that it can’t be done without the individual mandate because costs will rise too rapidly and the insurance system will collapse, or does it forge onward and see what happens?

Continue reading “What if the Supreme Court Strikes Down the Individual Mandate?”

By RANDALL D. CEBUL, MD

Two years ago in an address to Congress, President Obama declared his commitment to invest in electronic health records (EHRs), saying he thought it was perhaps the best way to quickly improve the quality of American health care. Just two years later, that hunch is proving true in Cleveland, Ohio.

New EHR Research Findings:

This week, the New England Journal of Medicine released research authored by my colleagues and me at Better Health Greater Cleveland showing that physician practices that use electronic health records had significantly higher achievement and improvement in meeting standards of care and outcomes in diabetes than practices using paper records.

Though most of us assumed EHRs would have some effect on patient care, we were delighted by what’s proving to be the reality in greater Cleveland. Just consider:

Care is better: Nearly 51% of patients in EHR practices received care that met all of the endorsed standards.

• Only 7% of patients at paper-based practices received this same level of care– a difference of 44%.
• After accounting for differences in patient characteristics between EHR and paper-based practices, EHR patients still received 35% more of the care standards.
• Just fewer than 16% of patients at paper-based practices had comparable results.
• After accounting for patient differences, the adjusted gap remained 15% higher for EHR practices.

Continue reading “New Research Finds EHRs Improve the Quality of Diabetes Care”

By MARGALIT GUR-ARIE

According to the latest count, there are 255 Health Information Exchange (HIE) organizations across the country, which amounts to an average of 5 in each State. If you are a practicing physician and have an EHR, chances are someone already knocked on your door offering to connect your practice to the local HIE for a small fee. If you don’t have an EHR, you may have had offers to access an HIE web portal, or maybe an HIE supplied EHR Lite, allowing you to at the very least view clinical data from other sources. Perhaps for free. If you are the proud owner of one of the full-featured EHRs, you may wonder what an HIE can do for you that your EHR is not already doing, and whether that service is worth your hard earned money.

In theory, a top-shelf EHR should be able to connect your practice to multiple facilities and allow you to exchange information to the best of all participants’ abilities. Granted most EHRs are still working on some of the connections, particularly to local facilities, but all in all, an EHR should be able to eventually provide for all your connectivity needs as shown in Figure 1. Note that for some types of connections, your EHR vendor can use a clearinghouse or portal approach to simplify and reduce costs of connectivity. For example, you don’t need a separate interface for each pharmacy – you use Surescripts as the clearinghouse and let them worry about it. You also don’t need an individual connection to each patient’s home – you communicate with all of them through one portal. With the exception of Surescripts pharmacy connectivity and a small number of reference labs, each connection, or interface, is costing you a pretty penny, and the more local the connection, the longer it takes to build.

Continue reading “From EHR to HIE and Back”

By JOHN MOORE

PHRs are much like the tides, news about them ebbs and flows. Right now, with the relatively recent demise of Google Health, Dossia’s attempts at rebirth, and the significant inquiries we are receiving regarding meaningful use requirements to host a PHR (patient portal). But in and amongst all this Chilmark has heard on more than one occasion the following statement: “The problem with PHRs is that they are a technology in search of a market.”

This statement is simply wrong for the following reasons:

1) As we have said countless times before in previous posts, very few people are interested in a digital filing cabinet for their health records. Unfortunately, many PHRs in the market today are just that, digital filing cabinets. In this case it is not an issue of a technology in search of a market, it is just a bad product that really has no market.

2) Technology adoption does not occur for its own sake, it occurs when there is perceived value by the user that leads to adoption. PHRs, PHPs (personal health platforms), patient portals, etc., is certainly a technology, that when well-designed, and implemented can deliver significant value and subsequently see high adoption rates. Just look to Kaiser-Permanente’s instance of MyChart, where patient adoption is well over 40%. Up in the Pacific Northwest, the Group Health Collaborative (GHC) is seeing PHR adoption that is well over 50%. That’s a market!

Continue reading “A Technology in Search of a Market”

By MARGALIT GUR-ARIE

The post you are about to read may not be suitable for wonks. Its claims are not fact checked. Its author is not a researcher. And its opinions are not fully thought through. Reader discretion is advised.*

EHR adoption rates are picking up significantly, exceeding the most optimistic expectations. Instead of an EHR for every American by 2014, as the President commanded, we will have dozens of EHRs for each American long before that. And in health care, more is always better, not to mention the freedom of choice that comes with having a different EHR in each care setting. Not surprisingly, we are seeing a decrease in health care expenditures taking place in parallel with the uptick in EHR adoption. Following best practices in health care economics research, when two phenomena develop in parallel, the learned assumption is that there is a causality connection between the two. Deciding which phenomenon is the cause and which is the effect is discretionary and commonly based on undisclosed agendas.

It is therefore postulated here that health care expenditures are inversely proportional to EHR usage rates. The following is a rigorous analysis of the mechanisms by which EHRs are reducing health care costs, intended to inform policy makers as customary in most health care related studies, which cannot be completed, or published, without a salient recommendation of interest to policy makers.

Continue reading “Bending the Curve with EHRs”

By JANE SARASOHN-KAHN

Consider all the stakeholders with something to gain by moving from paper health records to digital electronic records. Who do you think would gain the most from EHRs, and who the least? A survey from Xerox finds that the among all the groups American adults say have the least to gain through EHRs is, the most common response is…patients.

29% of people aren’t really sure who’s to gain from moving to EHRs.

To better understand Americans’ views on electronic health records (EHRs), Xerox polled 2720 adults 18 and over in May 2011.

The topline finding is that 83% of people have concerns about digital medical records.  The most concerning issue is that “my” personal health information could be hacked, cited by two-thirds of people. The second most common concern is that  digital medical record files could be lost, damaged or corrupted (noted by 54%)  and that personal health information could be misused (52%). Another worry is that a power outage or computer problem could prevent providers from accessing health information, cited by 52% of people surveyed.

Continue reading “Most Americans Don’t Yet Perceive the Benefits of EHRs”

By MARGALIT GUR-ARIE

There are currently 386 software packages certified by an ONC approved certification body as ambulatory Complete EHRs, which means that the software should allow the user to fulfill all Meaningful Use requirements and possibly qualify the proud owner for all sorts of CMS incentives. There are 204 more software packages which are certified as ambulatory EHR Modules, and a proper combination of these packages could result in a Complete product, which if used appropriately could lead to the same fortuitous results.

There are 423 distinct manufacturers of ambulatory EHRs and EHR modules on the federal list. Most are software vendors, or wannabe software vendors, but a fair amount are facilities that developed an EHR for in-house use and had it certified. These are not really available for purchase. A very large number of listed vendors offer niche products for distinct specialties, such as optometry, oncology, behavioral health, etc. All that said, there is still an inordinate number of EHR “choices”, or so the story goes. By comparison, since we all love car analogies, there are 1,310 individual trims currently sold in the U.S., and around50 car manufacturers overall. If you ask an average citizen on the street to name their top 10 cars, chances are that you will get a Honda Accord, Toyota Camry, a Caddie, maybe a Ford truck, a Beemer, a Porsche and perhaps even a Beetle. You are not likely to hear anything about a Tesla or a Coda and rarely will anybody mention a Scion. Automotive modules are not widely sold for home assembly, so there is no parallel lesson there. One way or another, we manage to find our way when it comes to automobiles.

Continue reading “So Many EHRs. So Expensive.”