By ANDY ORAM
HIMSS has opened and closed in Florida and I’m in Boston with snow up to my rectus abdominis. After several years of watching keynote pageants and scarfing up the amenities at HIMSS conferences, I decided to stay home this year.
Writing articles from earlier conferences certainly called on all my energy and talents. In 2010 I called for more open source and standards in the health care field. In 2012 I decried short-term thinking and lack of interest in real health transformation. In 2013 I highlighted how far providers and vendors were from effective patient engagement.
In general, I’ve found that my attendance at HIMSS leads moaning and carping about the state of health IT. So this year I figured I could sit in my office while moaning and carping about the state of health IT.
In particular, my theme this year is how health IT is outrunning the institutions that need it, and what will happen to those left behind.
The scissors crisis: more IT expenditures and decreasing revenues
Although the trade and mainstream press discuss various funding challenges faced by hospitals and other health providers, I haven’t seen anyone put it all together and lay out the dismal prospects these institutions have for fiscal health. Essentially, everything they need to do in information technology will require a lot more money, and all the income trends are declining.
Certainly the long-term payoff for the investment in information technology could be cost reductions–but only after many years, and only if it’s done right. And certainly, some institutions are flush with cash and are even buying up others. What we’re seeing in health care is a microcosm of the income gap seen throughout the world. To cite Billie Holliday: them that’s got shall get; them that’s not shall lose.
Here are the trends in IT:
Meaningful Use requires the purchase of electronic health records, which run into the hundreds of thousands of dollars just for licensing fees. Training, maintenance, storage, security, and other costs add even more. The incentive payments from the federal government come nowhere near covering the costs. EHR providers who offer their record systems on the Web (Software as a Service) tend to be cheaper than the older wave of EHRs. Open source solutions also cost much less than proprietary ones, but have made little headway in the US.
Hot on the heals of Meaningful Use is ICD-10 compliance, a major upgrade to the diagnostic codes assigned to patient conditions. Training costs (and the inevitable loss of productivity caused by transitions) could be staggering. Some 80% of providers may miss the government’s deadline. The American Medical Association, citing estimated prices for a small practice of $56,639 to $226,105 (p. 2), recently urged the government to back off on requiring ICD-10. Their point of view seems to be that ICD-10 might have benefits, but far less than other things the providers need money for. Having already put off its deadline, the Department refuses to bend further.
Continue reading “HIMSS Unplugged”
Filed Under: Tech
Tagged: analytics, Beyond Core, bundled payments, Health Fidelty, HIMSS 2014, ICD-10
Mar 10, 2014
Karen DeSalvo started as the new National Coordinator for Healthcare Information Technology on January 13, 2014. After my brief discussion with her last week, I can already tell she’s a good listener, aware of the issues, and is passionate about using healthcare IT as a tool to improve population health.
She is a cheerleader for IT, not an informatics expert. She’ll rely on others to help with the IT details, and that’s appropriate.
What advice would I give her, given the current state of healthcare IT stakeholders?
1. Rethink the Certification Program - With a new National Coordinator, we have an opportunity to redesign certification. As I’ve written about previously some of the 2014 Certification test procedures have negatively impacted the healthcare IT industry by being overly prescriptive and by requiring functionality/workflows that are unlikely to be used in the real world.
One of the most negative aspects of 2014 certification is the concept of “certification only”. No actual clinical use or attestation is required but software must be engineered to incorporate standards/processes which are not yet mature. An example is the “transmit” portion of the view/download/transmit patient/family engagement requirements.
There is not yet an ecosystem for patients to ‘transmit’ using CCDA and Direct, yet vendors are required to implement complex functionality that few will use. Another example is the use of QRDA I and QRDA III for quality reporting.
CMS cannot yet receive such files but EHRs must send them in order to be certified. The result of this certification burden is a delay in 2014 certified product availability.
Continue reading “A Little Advice for Karen DeSalvo”
Filed Under: Tech, THCB
Tagged: CMS, HIPAA Omnibus Rule, HIT, ICD-10, John Halamka, Karen DeSalvo, MU Stage 2, ONC, The ACA
Jan 22, 2014
Let me concede from the outset that, in this blog post, I lean toward the negative—dire predictions, worst-case scenarios, a bit of doom and gloom, etc.
But I ask you, oh gentle, patient reader, how could I not?
Let’s go to the satellite. You can see warm air from a low-pressure system (Meaningful Use Stage 2, not changed dramatically by the one-year extension) collide with cool, dry air from a high-pressure area (the turmoil of Obamacare) and tropical hurricane moisture (ICD-10). Tell me you don’t see the Perfect Storm yourself.
And here we sit in our little fishing boat, waiting for the mighty ocean to consume us.
Overly dramatic? Certainly, but still not wholly inappropriate, I will argue.
Consider a recent report on the HIMSS/WEDI ICD-10 National Pilot Program collaborative that was created to, “…minimize the guess work related to ICD-10 testing and to learn best practices from early adopter organizations.”
Designed to ascertain the realities of the entire healthcare system adopting and using ICD-10, this pilot included an education and adoption program for all participants, followed by a set of “waves” in which diagnoses for the 100-200 most common medical conditions were actually coded and submitted using ICD-10.
The end-to-end testing approach …
…would encompass a number of medical test cases that mirror actual processing, including situations with multiple “hops” or “steps” between providers, clearinghouses, and health plans; the identification of high-risk medical test cases to help prioritize testing; the identification of available testing partners; and key reporting and sharing of test results. The test environment must mirror production.
And how did this pilot testing go? (Cue dark, foreboding music here …)
The average accuracy was in the 60 percent range with low scores around 30 percent. Yes, some medical scenarios had nearly 100 percent accuracy, which is great. But very low accuracy accompanied a number of very common conditions. Not so great.
Continue reading “Does ICD-10 Pilot Forecast a Perfect Storm for Healthcare?”
Filed Under: Tech, THCB
Tagged: Edmund Billings, HIT, ICD-10, Meaningful Use Stage 2
Dec 17, 2013
I’ve recently written about healthcare.gov and the lesson that going live too soon creates a very unpleasant memory.
As I work with healthcare leaders in Boston, in New England, and throughout the country, I’m seeing signs that well resourced medical centers will struggle with Meaningful Use stage 2 attestation, ICD-10 go live, HIPAA Omnibus Rule readiness, and Accountable Care Act implementation, all of which have 2013-2014 deadlines.
People are working hard. Priority setting is appropriate. Funding is available.
The problem is that the scope is too big and the timeline is too short.
What are the risks?
Continue reading “Fine Tuning the National Health IT Timeline”
Filed Under: Uncategorized
Tagged: Accountable Care Act, HIPAA Omnibus Rule, HIT, ICD-10, John Halamka, Meaningful Use Stage 2, National Health IT Timeline
Nov 20, 2013
Remember the Ford Pinto and the AMC Pacer, aka the Pregnant Pinto?
Both serve as reminders of an in era in which the American auto industry lost its way and assumed drivers would buy whatever they put on the lot. Foreign competition, primarily from Japan, filled the void created by American apathy for quality and design, and the industry has never been the same.
Admittedly, the comparison of cars and EHRs is less than apt, but health IT also assumes healthcare will buy what we’re selling because the feds are paying them to. And, like the Pinto, what we’re selling inspires something less than awe. In short, we are failing our clinical users.
Why? Because we’re cramming for the exam, not trying to actually learn anything.
Myopic efforts to meet certification and compliance requirements have added functionality and effort tangential to the care of the patient. Clinicians feel like they are working for the system instead of it working for them. The best EHRs are focused on helping physicians take care of patients, with Meaningful Use and ICD-10 derivative of patient care and documentation.
I recently had dinner with a medical school colleague who gave me insight into what it’s like to practice in the new healthcare era. A urologist in a very busy Massachusetts private practice, he is privileged to use what most consider “the best EHR.”
Arriving from his office for a 7 PM dinner, he looked exhausted, explaining that he changed EHRs last year and it’s killing him. His day starts at 7 AM and he’s in surgery till noon. Often double or triple booked, he sees 24 patients in the afternoon, scribbling notes on paper throughout as he has no time for the EHR. After dinner he spends 1.5 to 2 hours going over patient charts, dictating and entering charges. What used to take 1 hour now requires much more with the need to enter Meaningful Use data and ICD coding into the EHR. He says he is “on a treadmill,” that it should be called “Meaningless Use,” and he can’t imagine what it will be like “when ICD-10 hits.”
My friend’s experience is representative, not anecdotal. A recent survey by the American College of Physicians and American EHR Partners provides insight into perceptions of Meaningful Use among clinicians.
According to the survey, between 2010 and 2012, general user satisfaction fell 12 percent and very dissatisfied users increased by 10 percent.
Continue reading “Darwinian Health IT: Only Well-Designed EHRs Will Survive”
Filed Under: Tech
Tagged: Design, Edmund Billings, EHR, HIT, ICD-10, Meaningful Use
Oct 23, 2013
Over the next few months, Jacob Reider will serve as the interim National Coordinator for Healthcare IT while the search continues for Farzad Mostashari’s permanent replacement.
What advice would I give to the next national coordinator?
David Blumenthal led ONC during a period of remarkable regulatory change and expanding budgets. He was the right person for the “regulatory era.”
Farzad Mostashari led ONC during a period of implementation when resources peaked, grants were spent, and the industry ran marathons every day to keep up with the pace of change. He was the right person for the “implementation era”
The next coordinator will preside over the “consolidate our gains” era. Grants largely run out in January 2014. Budgets are likely to shrink because of sequestration and the impact of fiscal pressures (when the Federal government starts operating again). Many regulatory deadlines converge in the next coordinator’s term.
The right person for this next phase must listen to stakeholder challenges, adjust timelines, polish existing regulations, ensure the combined burden of regulations from many agencies in HHS do not break the camel’s back, and keep Congress informed every step of the way. I did not include parting the Red Sea, so maybe there is a mere human who could do this.
What tools does the coordinator have in an era of shrinking budgets?
At present, Meaningful Use Stage 2, ICD-10, the Affordable Care Act, HIPAA Omnibus Rule, and numerous CMS imperatives have overlapping timelines, making it nearly impossible for provider organizations to maintain operations while complying with all the new requirements.
Can resources be expanded?
Continue reading “A Little Advice for the Next National Coordinator”
Filed Under: Tech, THCB
Tagged: CMS, Farzad Mostashari, HIPAA Omnibus Rule, HIT, ICD-10, John Halamka, MU Stage 2, ONC, The ACA
Oct 9, 2013
Now that Labor Day has come and gone, I’ve thought about the months ahead and the major challenges I’ll face.
1. Mergers and Acquisitions
Healthcare in the US is not a system of care, it’s a disconnected collection of hospitals, clinics, pharmacies, labs, and imaging centers. As the Affordable Care Act rolls out, many accountable care organizations are realizing that the only way to survive is to create “systemness” through mergers, acquisitions, and affiliations. The workflow to support systemness may require different IT approaches than we’ve used in the past. We’ve been successful to date by leaving existing applications in place and building bidirectional clinical sharing interfaces via ”magic button” viewing and state HIE summary exchange. Interfacing is great for many purposes. Integration is better for others, such as enterprise appointment scheduling and care management. Requirements for systemness have not yet been defined, but there could be significant future work ahead to replace existing systems with a single integrated application.
2. Regulatory uncertainty
Will ICD10 proceed on the October 1, 2014 timeline? All indications in Washington are that deadlines will not be changed. Yet, I’m concerned that payers, providers and government will not be ready to support the workflow changes required for successful ICD10 implementation. Will all aspects of the new HIPAA Omnibus rule be enforced including the “self pay” provision which restricts information flow to payers? Hospitals nationwide are not sure how to comply with the new requirements. Will Meaningful Use Stage 2 proceed on the current aggressive timeline? Products to support MU2 are still being certified yet hospitals are expected to begin attestation reporting periods as early as October 1. With Farzad Mostashari’s departure from ONC, the new national coordinator will have to address these challenging implementation questions against a backdrop of a Congress which wants to see the national HIT program move faster.
3. Meaningful Use Stage 2 challenges
Although attestation criteria are very clear (and achievable), certification is quite complex, especially for a small self development shop like mine. One of my colleagues at a healthcare institution in another state noted that 50 developers and 4 full analysts are hard at work at certification for their self built systems. I have 25 developers and a part time analyst available for the task. I’ve read every script and there are numerous areas in certification which go beyond the functionality needed for attestation. Many EHR vendors have described their certification burden to me. I am hopeful that ONC re-examines the certification process and does two things – removes those sections that add unnecessary complexity and makes certification clinically relevant by using scenarios that demonstrate a real world workflow supporting the functionality needed for attestation.
Continue reading “What Keeps Me Up At Night – 2013 Edition”
Filed Under: Tech, THCB
Tagged: BIDMC, EHR, HIPAA Omnibus Rule, HIT, ICD-10, John Halamka, Meaningful Use, The ACA
Sep 5, 2013
In 2013, I’m focused on five major work streams:
· Meaningful Use Stage 2, including Electronic Medication Administration Records
· ICD10, including clinical documentation improvement and computer assisted coding
· Replacement of all Laboratory Information Systems
· Compliance/Regulatory priorities, including security program maturity
·Supporting the IT needs of our evolving Accountable Care Organization including analytics for care management
I’ve written about some of these themes in previous posts and each has their uncharted territory.
One component that crosses several of my goals is how electronic documentation should support structured data capture for ICD10 and ACO quality metrics.
How are most inpatient progress notes documented in hospitals today? The intern writes a note that is often copied by the resident which is often copied by the attending which informs the consultants who may not agree with content. The chart is a largely unreadable and sometimes questionably useful document created via individual contributions and not by the consensus of the care team. The content is sometimes typed, sometimes dictated, sometimes templated, and sometimes cut/pasted. There must be a better way.
Continue reading “Brainstorming About the Future of Clinical Documentation”
Filed Under: Uncategorized
Tagged: ACO, Clinical Documentation, CMS, Geisinger, ICD-10, John Halamka, Kaiser, Mayo, Meaningful Use Stage 2, Physicians, quality metrics, SNOMED-CT
Dec 18, 2012
Oh, that clever Center for Public Integrity. Look what they’ve gone and done now! My, oh my. According to the article, doctors are much of the the problem, billing “billions” of Medicare upcharges according to the center.
But what if the medical coding game itself is flawed? Stop for a moment and imagine what it would look like if lawyers billed like doctors. Suddenly, we see how bizarre the world of government billing codes and chart-completion mandates has become.
Not long ago I asked readers what my time is worth on a per-hour basis. Collectively and independently, they settled on a number of about $500/hr (see the comments). Now look for a moment at what Medicare pays, even at its highest level of billing for a physician’s time for evlauation and management of a medical problem: for 40 minutes of a physician’s time, it’s $140 (or $210/hr) before taxes. Again, we see another disconnect as to how doctors are valued in our current system.
Doctors are working long hours to collect these fairly low fees from Medicare while jumping more hoops than ever to do so. They have become pseudo-experts at the coding game, trying to get as much money for their extra efforts as legally possible. But these fees paid by Medicare do not cover payments for time spent on phone calls, e-mails, and working insurance denials. These services are still considered by our system as gratis. To partially counteract this coding problem, doctors realized (and the government insisted) that doctors use electronic medical records.
But when independent doctors set out to implement these records they quickly discovered that the expense and long-term maintenance costs of local office-based EMRs could not compete with more sophisticated systems already in use by their neighboring large health care systems. Because of ever-increasing cost-of-living and overhead costs, not to mention the threats of large fee cuts, doctors have migrated to large health systems faster than ever. With the fancier electronic record at those systems (streamlined for billing, collections, and marketing) fields required for higher billing codes (but not always material to the problem at hand) are completed in less time. So are doctors really the problem?
Continue reading “Kill the Codes”
Filed Under: Physicians, THCB
Tagged: Billing Codes, Center for Public Integrity, Dr. Wes, ICD-10, Medicare, Medicare, Reimbursement
Sep 23, 2012
At HIMSS, I met with many healthcare CIOs as a part of CHIME focus groups to discuss their readiness for ICD-10. One area we explored was the impact of the delay. Most were a bit frustrated by the delay because they had committed the resources and money to an ICD-10 transition plan which was well underway. In some instances CIOs estimated they had expended at least 50 percent of the effort required to meet the compliance deadline. In fact, in one of the focus groups, 10 out of 12 participating CIOs said the delay will be more harmful than helpful. I heard two main reasons for this position:
1. Cost: Hospitals have already committed the resources and budget to transition to ICD-10, and now they will have to continue that effort for a longer period of time.
2. Engagement: It’s harder to engage staff around the importance of clinical documentation and coder education when the media is saying “delay, delay, delay” – it makes it difficult for leaders to convince providers and other stakeholders that it’s a critical priority.
A survey conducted by Edifecs validates this sentiment – 90 percent of healthcare professionals believe that the deadline should not be moved more than a year. Fifty-six percent said that a two-year delay would be “potentially catastrophic.”
However, for smaller physician practices, the delay likely has the opposite impact – more help than harm. Many of these practices were struggling to understand the impact of ICD-10 and find the resources to prepare for the October 2013 deadline. A delay gives them more time to put a plan in place, improve clinical documentation, and ensure they can get reimbursed for services.
Continue reading “Beyond Coding: Will the ICD-10 Deadline Delay Help or Harm?”
Filed Under: THCB
Tagged: Edifecs, HIMSS 2011, ICD 11, ICD-10
Mar 22, 2012