Category: Uncategorized

Reflections on the Certification Experience

Jan 25, 2011

By JOHN HALAMKA, MD

On Friday, January 21, 2011, Beth Israel Deaconess Medical Center completed the certification of its enterprise EHR technologies via the CCHIT EHR Alternative Certification for Hospitals (EACH) program. Here's the press release. As I've written about previously, BIDMC (like many academic health centers) has a combination of built and bought technologies that collectively provide interoperability, clinical functionality, and security. We demonstrated all our Intersystems Cache-based hospital systems and our Microsoft SQL Server-based business intelligence systems.

The process was rigorous, requiring us to follow over 500 pages of scripts and implementation guides in a single 8 hour demonstration.

The staff at CCHIT were remarkable, educating us about the NIST script requirements, emphasizing the need to prepare, and clarifying aspects of the NIST scripts that were ambiguous or seemed clinically unusual.

NIST did a great job creating test scripts rapidly enough to enable vendors and hospitals to certify systems in time for meaningful use attestation. However, there are a few oddities in the scripts that are only discoverable during pilots in real hospital and eligible provider clinical settings. I strongly recommend that for all future certification, NIST pilot their scripts before they are issued for general use.

The $1000 Coding Error

Jan 24, 2011• 31

By MICHAELA DINAN

As a graduate student in the health field I often get phone calls from various family members and friends asking what I happen to know about different drugs, procedures, and devices. I was having one such conversation with my younger sister last spring. She had just completed her undergraduate education, started a new job, and was very proudly financially self-sufficient for the first time.

We were talking about birth control. Her yearly exam was coming up and she was considering the therapeutic and cost efficacy of different forms of contraceptive. I had recently attended a class where the intrauterine device had been discussed as a cheap, effective form of contraceptive that is underutilized in the United States. A few strokes of the keyboard and my sister and I were able to find that with no insurance, the hormonal IUD costs $843.60. We quickly calculated that at 20 bucks a month for the pill, after 5 years, the IUD would end up being significantly cheaper – even before taking her insurance in to account.

A few weeks later my sister excitedly told me that she had discussed the IUD with her doctor who had informed her that it would only cost around $200 with her type of insurance. She had already scheduled her appointment to have it placed.

EHR Product Management

Jan 24, 2011• 17

By MARGALIT GUR-ARIE

It has become politically incorrect to refer to EHRs as products. Instead, EHRs are now “technologies” as evident in all ONC and CMS published rules and regulations. This subtle change in terminology was intended to encourage, yes you guessed it, Innovation. It was supposed to signal an open market for alternatives to existing EHR products in the form of modular approaches, open platforms, mobile applications and web-based software-as-a-service. Naturally, the industry is obliging and all efforts now are geared towards creating stuff that runs on iPads, preferably “cloud” based and with minimal utility. The new stuff looks very cool and promises to become even cooler, so what’s the problem?

The problem is that these new things do not solve any problems. Traditional product innovation concentrated on identifying problems, designing solutions and then selecting technologies that were capable of enabling those solutions. New technologies were usually born out of the necessity to solve a burning problem and those with enough applicability to larger markets became blockbusters. Every frying-pan today sports technology first invented in the process of creating refrigerants and later used for nuclear destruction (Teflon). Every large enterprise embarking on cost cutting, new markets acquisition, or general improvements, should know all too well that selecting a “cool” technology first, and then attempting to find a good use for it, is recipe for failure.

PCAST HIT Report Becomes a Political Piñata

Jan 23, 2011• 3

By VINCE KURAITIS, JD

The PCAST Report on Health IT has become a political piñata.

Early Feedback on PCAST

Like many of my colleagues, I was taken aback by the release of the Report in early December 2010 — I didn’t know quite what to make of it. Response in the first week of release after Report was:

Limited. The first commentaries were primarily by technical and/or clinical bloggers. The mainstream HIT world had remarkably little initial reaction to the Report.
Respectful of the imprimatur of “The President’s” Report and noting some of the big names associated with the report (e.g., Google’s Eric Schmidt and Microsoft’s Craig Mundie.)
Focused on technical and/or clinical perspectives around two broad themes.
- The vision is on target: “extraordinary”, “breathtakingly innovative”.
- These guys didn’t do all their technical homework. The range varies, but the message is consistent.

Today’s POV on PCAST

What a difference a six weeks makes.

The Office of the National Coordinator for Health IT (ONC) requested comments on the Report. The comments were due by January 19 and a number of influential organizations have already made their comments public.

After having read 10 early commentaries submitted to ONC, I’ll (admittedly subjectively) divide them into 3 schools of thought:

1) PCAST is a frontal attack on mainstream clinical, technical, and economic stakeholders in existing U.S. health IT. While there are some good ideas in the report, almost all of them are already in the works. Bury PCAST ASAP.

Obtaining Meaningful Use Stimulus Payments

Jan 23, 2011• 4

By JOHN HALAMKA, MD

Many clinicians and hospitals have asked me about the exact steps to obtain stimulus payments.

On January 3, 2011, CMS began registering clinicians for participation in meaningful use programs. Every region of the United States has Regional Extension Centers which can help answer any questions. Here’s an overview of the steps you need to take.

1. Choose between Medicare and Medicaid programs. If you qualify, Medicaid offers greater incentives and does not require you to achieve meaningful use before stimulus payments begin.
a. To qualify for Medicaid, 30% of your patient encounters must be Medicaid patients. (20% for pediatricians)
b. To qualify for Medicare, keep in mind that meaningful use payments are made at 75% of Medicare allowable charges for covered professional services in the calendar year of payment, per the payment maximums below:

Year 1 $18,000
Year 2 $12,000
Year 3 $8000
Year 4 $4000
Year 5 $2000

Thus, a total of $44,000 is available at maximum, but could be less if your allowable Medicare charges are less than

Year 1 $24,000
Year 2 $16,000
Year 3 $10,667
Year 4 $5333
Year 5 $2667

The Laboratories of Democracy

Jan 23, 2011• 4

By MERRILL GOOZNER

If “Obamacare” was a federal takeover of health care, states failed to get the memo.

The House Republicans and three Democrats who voted to “repeal and replace” it with something that provides “lower health care premiums through increased competition and choice” might want to take a look at Utah. Its new internet-based insurance exchange was designed by free-market advocates.

It provides small businesses, individuals and even some large employers with access to competitive insurance plans. The state’s Republican leadership, aided by Michael Leavitt, the state’s former governor and secretary of Health and Human Services in the Bush administration, believes their exchange “could be a national model for market-based health care reform.”

Closer to where they go to work every day, the “repeal and replacers” in Washington might also want to follow onrushing events in Virginia, whose state attorney general sued to void the individual mandate in the national law. Last month, using a $1 million planning grant from the federal government, the state’s Republican secretary of health Bill Hazel, an orthopedic surgeon, issued a “Virginia Health Reform Initiative” that outlined the state’s vision of reform under the federal Affordable Care Act.

It’s centerpiece? The proposal, which was introduced in both houses of the state legislature this month with bipartisan support, calls for setting up a health care insurance exchange that will “try to promote effective competition” within the state, said Len Nichols, a professor of health policy at George Mason University, who consulted with Hazel in coming up with the proposal. Virginia desperately needs some competition since one carrier – Anthem Blue Cross Blue Shield – currently controls over 60 percent of the market, Nichols said.

Job Post: THCB Editorial

Jan 23, 2011

THCB is looking for talented interns to assist with editorial, research and web production tasks as our web site undergoes a major expansion. Perfect for a grad or med student with an interest in journalism, public policy, and/or the business of health care.

ACOs and Community Hubs of Wellness & Health

Jan 23, 2011• 18

By KENT BOTTLES, MD

Hospitals are going to change. What worked in the past will not work in the future. The passage of the federal health care reform law and the inevitable transition from fee for service to global payments is changing the rules of the hospital game. Hospitals will have to make do with less financial support from both government and private payers and at the same time deliver higher quality health care with measurably better outcomes. Hospitals will take care of fewer and fewer patients as care continues to migrate to the outpatient setting, the home, and wherever citizens live carrying their smart phones. The development of Accountable Care Organizations (ACOs) to receive and distribute these global payments will affect hospitals whether they decide to take a leadership role or a wait and see attitude. There will be winners and losers among hospitals; there will be fewer hospitals in America in ten years than there are today in 2011.

Hospitals that survive this transformation of the health care delivery and payment system will become the community hub of wellness and health (CHWH) that citizens turn to in a time of rapid and chaotic change. Becoming a CHWH will require hospitals to expand their services and expertise well beyond the traditional role of an acute care facility. It will also require hospitals to embrace social media and disruptive digital tools that are now available to help care for a defined population living in the community. Hospitals will have to forge a new culture or their ACOs will fail, no matter how sophisticated and expensive their legal structures and physician integration plans become.

Hospital leadership seems ill prepared for this transformation in mission. Robert Naldi, the CFO of Maimonides Hospital in Borough Park, Brooklyn, is not alone when he says, “I don’t spend a lot of time thinking about global issues. When I hear Medicare is being cut six billion dollars over the next ten years, Medicaid cut four billion dollars the next, that ten billion dollars doesn’t change what I do on a Thursday morning…. I don’t spend any energy forecasting the next three or four years, because I don’t think anyone can do that. We’re lucky if we forecast the next six months, things change so rapidly. I just don’t waste time on it.” (http://ow.ly/3Dlxp)

The End of the World as We Know It

Jan 23, 2011• 9

By PAUL LEVY

One aspect of religious dogma that has entered the medical world is that fee-for-service pricing of medical services is bad and should be replaced by a capitated, or global, arrangement that establishes an annual budget for care for different risk groups of patients. Like other religious beliefs, this is often offered without rigorous analytic support. Some insurance companies are particularly pleased with this approach because it shifts risk from insurers to providers and makes it easier for the insurers to create budgets and price their products.

Don’t get me wrong. This may be the right way to go, but the topic is worth more time and discussion than it has received.

It may be illustrative to think about other sectors of our economy and see which of them are characterized by global payments. Not many. Sure, there are products like cellular phone service that are sold in monthly fixed dollar amounts. But that is because it is a high fixed-cost product, where the marginal cost of additional phone calls is essentially zero. Fixed prices offer revenue stability to the vendor and a way to recover those fixed costs.

But most other goods and services in our economy are sold on a piece-work basis. Think of groceries, automobiles, electricity, gasoline, televisions, and clothing. Why is fee-for-service pricing appropriate for these? Or, in economists’ terms, why does such pricing lead to a reasonably efficient solution? The answers are pretty straightforward. Other markets are characterized by open entry and exit and by transparent information concerning quality, value, and pricing. Consumers can make more or less knowledgeable choices based on that publicly available information. New firms enter the market when they see an opportunity. Successful firms grow. Other firms fail.

A Family Physician’s EMR Experience

Jan 22, 2011• 9

By SULTAN RAHAMAN, MD

I have always looked at technology for opportunities to improve the quality of care and the efficiency of my family practice. For instance, nearly 20 years ago I started using speech recognition software to dictate all my patient notes. This eliminated the high cost of transcription and turnaround time too. However since introducing an Electronic Medical Records system (EMR) in my office about 7 months ago the quality of care and the efficiency of my practice have vastly improved. EMR immediately brings many benefits to mind. There is an obvious decrease in paper use. Even faxes such as physician correspondence and reports are now received in a digital file which can be saved to the patient’s record without printing. Prescription refill requests from pharmacies are now received, reviewed and filled electronically. Most of my patient lab test results too are now received electronically, reviewed and then saved into the patient’s record, again without printing. But perhaps one overlooked major advantage of EMR is that data is now more commonly stored on a server offsite on the internet, “the cloud” which provides tremendous advantages.

Over the years I have covered my solo family practice 24/7, essentially 12 months a year. Even when I took a brief vacation or extended weekend out of town I relied heavily on cellular phone and hospitalists for coverage. This has mostly worked well over the years except that when I returned to the office I was confronted with tall stacks of charts waiting for messages to be signed off, reports and specialist correspondence to be reviewed. In fact over the years my brief vacations have been mostly work deferred. I paid for it with extra work when I returned to the office.