Tag: EHR

The Penguin Problem

Nov 22, 2010• 11

By VINCE KURAITIS, JD

Remember the penguin problem described by economists?

No one moves unless everyone moves, so no one moves.

Overcoming the penguin problem has a lot to do with creating expectations. A recent writing by Dr. James O’Connor in Physician Practice expresses a voice from the physician community that I’ve never heard before. His essay is entitled “Meaningful Use — Doctors Have No Choice”.

Physicians Have No Choice Other Than to Adopt EHRs?

Dr. O’Connor argues that physicians are effectively being forced into adopting EHRs. He cites facts and reaches a powerful conclusion:

1. CMS penalties begin in 2015.
2. What if you won’t or don’t accept Medicare/Medicaid patients (13 percent of practices in 2009, up from 6 percent in 2004? In August, four major insurers (Aetna, Highmark, United Health Group, and Wellpoint) announced that, at a minimum, they will link their pay-for-performance programs to federal meaningful use criteria. Other insurers are likely to follow.
3. Do you run one of the increasing number of “boutique” or VIP practices that work on a cash-only basis? The American Board of Medical Specialties (ABMS) released a statement in August saying that they intend to link meaningful use of health information technology into the ABMS Maintenance of Certification© program.
4. You don’t care about being board certified? (Sound of crickets chirping.) The Final Rule gives states the authority to impose additional requirements that promote compliance with meaningful use. As reported in Physicians Practice, the state of Massachusetts may take away your license to practice medicine in 2015 unless you demonstrate meaningful use of an EHR system. In Maryland, private insurers will be required to build incentives for acquisition of EHRs and penalties for not adopting them into their payment structure.

OK, so technically, we do have a choice. We could stop taking Medicare and Medicaid patients, accept cash only, give up our board certification (and thus usually hospital privileges), and move to a state (or country) that doesn’t impose EHR requirements. But is that really a choice? No.

Meaningful Meaningful Use

Nov 19, 2010• 14

By ROB LAMBERTS, MD

Quiz:

What does the term “meaningful use” mean?

a. Using something in a way that gives life purpose and leads to carefree days of glee.
b. It depends on your definition of the word “term.”
c. It is not mean. It is really nice.
d. A large number of rules created by the government to assess a practice’s use of electronic medical records so that they can spur adoption, give criteria for incentive rewards, and have physicians in a place where care can be measured.
e. Job security for those making money off of health IT.

The answer, of course is d and e.

Meaningful Use, in the eyes of many is seen as curse words, especially doctors.Continue reading…

EHRs in Surgical Practices

Nov 16, 2010

By JOHN HALAMKA, MD

I was recently asked to offer advice about implementing EHRs in surgical practices. Here are the lessons learned from our Massachusetts EHR rollout experts.

1) . Surgical practices are challenging in general because they frequently use dictation and the most obvious benefits of EHRs do not apply to them. They do not have substantial amounts of structured data to enter and they do not have a high fraction of recurring patients so a large fraction of records are “new” records. The highest benefit areas for them require interoperability, which takes time to accomplish. A significant fraction of the information they need for documentation comes from hospital operative notes, referrals/consults are the biggest element of workflow, and they rely on electronic lab and imaging test results.

2) . The most successful workflow change approach requires shifting more responsibility to mid-levels so that basic structured data entry (like vitals, history, etc) and billing related entry do not fall on surgeons who can be resistant to doing that type of documentation. Unfortunately shifting practice roles/responsibilities is not easy.

3) . Working with the practice to build structured procedure templates in advance of go-live and setting up voice-recognition to allow surgeons to continue to dictate are key workflow/adoption steps.

4). Some EHRs such as eClinicalWorks have templates for Operative Notes as well as SOAP notes, which are key to EHR adoption.

5). Interoperability should be implemented as quickly as possible: diagnostic results delivery (especially imaging results) and hospital document push (operative notes, discharge summaries) should be integrated into workflow during implementation.

Unhealthy Skepticism

Nov 15, 2010• 5

By JOHN MOORE

There remains an unhealthy level of skepticism in the market as to whether or not consumers will use a personal health record (PHR). While a certain level of skepticism is healthy in any market, the level to which it is laid towards PHRs is unwarranted and likely more a function of ignorance then malicious intent. Following is a brief PHR case study that provides validity to the mantra that a patient who is provided access to their personal health information (PHI) via a PHR can become a more engaged patient in self-managing their health. What is particularly striking about this story is that it is does not take place in middle-class America, where many have targeted their PHR initiatives, but rather among the urban poor.

Last week, I met with Dr. Nunlee-Bland, Director of Howard University Hospital’s (HUH) Diabetes Treatment Center, who graciously provided the context and content for this remarkable story.

Empowering the Urban Poor to Self-Manage Their Diabetes:

In 2008, HUH received a grant from the Dept of Health, DC to launch a diabetes treatment program primarily targeting urban poor. As part of this grant, HUH launched a PHR initiative creating a patient portal using NoMoreClipboard (NMC), linking NMC to their clinical diabetes EHR, CliniPro from NuMedics. The PHR provides patients with access to their problem list, vitals (height, weight, blood pressure, BMI), medication lists, basic lab results, A1C results (can be charted for track and trend) and basic demographic information. While Dr. Nunlee-Bland stated that HUH has no reason not to provide patients with full access to all PHI, they have purposely kept the PHR simple and focused on the treatment of diabetes.

HIT Trends Summary for October 2010

Nov 10, 2010• 2

By MICHAEL LAKE

This is a summary of the HIT Trends Report for October 2010. You can get the current issue or subscribe here.

The evolving health information exchange market. The HIE segment was center-stage this month with a game-changing announcement by Surescripts. It will combine its national physician directory and EMR connectivity with apps from its strategic investment in Kryptiq to offer physician-to-physician clinical messaging beginning in December, extending its dominant market position. As first to market with these functions, it will likely cement its standing as the country’s premiere neutral national network. It also enables a platform for additional web services from collaborating partners in the future. We are also reminded this month in Healthcare IT News of the relative dominance of Epic in the IDN and large practice market with the startling statistic that 75% of Wisconsin residents are in the databases of its state user group. Using Epic tools and with patient consent physicians in the state can see patient information across institutions. And there’s a story this month that Verizon is expanding its vision as an HIE by adding clinical lab and imaging results to its networking services with leading transcription companies. These three lenses: (1) Surescripts as the leading national network; (2) Epic as the leading national EMR; and (3) Verizon as the leading national telecom, exemplify the rapidly changing dynamics in this segment.

EHRs and HIT have become central to transformation of clinical practice. One large driver is the announcement by the insurance commission of the inclusion of HIT as well as wellness and care management as medical expenses for insurers under PPACA. In the past these areas were generally allocated to the administrative budget of health plans which limited participation. This will increase payer investment. A CMS exec, Anthony Rogers, reported to Healthcare IT News on early results of CMS accountable care organization (ACO) pilots. He noted that practices with EMRs were getting most of the $36M in incentives and said, “If that’s not a business case [for EHRs], I don’t know what is.” The Patient-Centered Primary Care Collaborative, the organization driving medical homes released two reports this month also highlighting HIT’s role in transformation. One report looks at best practices to engage patients in a medical home project using HIT. It’s a compendium of 15 essays by a diverse set of experts on different perspectives about using health IT to engage patients, plus snapshots of two dozen case examples. The other report focuses on five ways to implement HIT effectively to enable clinical decision support. And CSC released a roadmap for HIT in ACOs with an elegant six factor model: member engagement; medical management; clinical information exchange; quality reporting; business intelligence; and risk and revenue management.

The EMR Cage Match Results

Nov 4, 2010

By JONATHAN BUSH

It turns out, there was no cage at the experimental debate earlier in October between me and Girish Kumar Navani of eClinicalWorks. And Girish was wearing a shirt…and no mask.

These, plus other anticlimaxes, sent our PR guy John Hallock into a deep, week-long depression.

“He could have gone for the jugular! Why didn’t he go for the jugular?!?”

This was all he said for days.

The truth is that it’s hard to get too snippy with a guy who has built such an awesome company—WITHOUT VENTURE CAPITAL! It’s just an incredible accomplishment. That, combined with his incredible intuition around software design, made him a guy I really wanted to hear from…rather than jump on.

Also though, I heard Girish start to say words that for most plain ol’ software company leaders are “un-sayable.” He said he wanted to host for his clients. He said he wanted to maintain their data for them. As a private company, I think Girish is in the best place to go the rest of the way. Why not insist that all ECW clients get on a shared instance? Why not start to take on some of the functions that cause so much frustration (34% of new athenaClinicals clients are actually frustrated software-based EMR clients!) These acts would destroy ECWs profits for a few years but they would emerge a genuine candidate for national HIT backbone, along with athenahealth.

We need that…a lot more than we need more versions of software.

Jonathan Bush co-founded athenahealth, a leading provider of internet-based business services to physicians since 1997. Prior to joining athenahealth, he served as an EMT for the City of New Orleans, was trained as a medic in the U.S. Army, and worked as a management consultant with Booz Allen & Hamilton. He obtained a Bachelor of Arts in the College of Social Studies from Wesleyan University and an M.B.A. from Harvard Business School.

Dismantling the Cottage Industry

Nov 2, 2010• 33

By MARGALIT GUR-ARIE

Last week I went to see a doctor about an EHR. Dr. Greene (not his real name) is a typical solo primary care physician in a typical small town in the typical middle of nowhere. Four hours from the closest airport and miles and miles of winding roads, cow pastures and corn fields away from medical centers of excellence. Dr. Greene is in his late fifties and has been practicing medicine for over thirty years in the same location. He works six days per week and missed “two and a half” days of work since he hung his shingle up and never missed a Rotary Club luncheon. Dr. Greene is planning on practicing for ten more years and now, he wants to go electronic.

Dr. Greene’s practice is located in a small and spotless one-story building with large windows and an open floor plan. We sat down at a white laminate round table in the kitchen during his lunch break. His wife of many years is his office manager and the only other employee is a nurse who doubles as front office receptionist. His shortest appointment is for 30 minutes and new patients, who are scheduled for 1 hour, come at the end of the day just in case it takes longer than planned. His notes, written on special gold colored paper in nicely rounded cursive font, are concise and neatly organized by visit date. Like most doctors who use paper charts, he doesn’t code his visits. He checks diagnoses and procedures on a sparse super-bill devoid of any numbers. His wife and office manager takes it from there and all his claims go out electronically every day.

Privacy Paradigms: From Consent to Reciprocal Transparency

Nov 1, 2010• 2

By FRANK PASQUALE, JD

Computational innovation may improve health care by creating stores of data vastly superior to those used by traditional medical research. But before patients and providers “buy in,” they need to know that medical privacy will be respected. We’re a long way from assuring that, but new ideas about the proper distribution and control of data might help build confidence in the system.

William Pewen’s post “Breach Notice: The Struggle for Medical Records Security Continues” is an excellent rundown of recent controversies in the field of electronic medical records (EMR) and health information technology (HIT). As he notes,

Many in Washington have the view that the Health Insurance Portability and Accountability Act (HIPAA) functions as a protective regulatory mechanism in medicine, yet its implementation actually opened the door to compromising the principle of research consent, and in fact codified the use of personal medical data in a wide range of business practices under the guise of permitted “health care operations.” Many patients are not presented with a HIPAA notice but instead are asked to sign a combined notice and waiver that adds consents for a variety of business activities designed to benefit the provider, not the patient. In this climate, patients have been outraged to receive solicitations for purchases ranging from drugs to burial plots, while at the same time receiving care which is too often uncoordinated and unsafe. It is no wonder that many Americans take a circumspect view of health IT.

Privacy law’s consent paradigm means that, generally speaking, data dissemination is not deemed an invasion of privacy if it is consented to. The consent paradigm requires individuals to decide whether or not, at any given time, they wish to protect their privacy. Some of the brightest minds in cyberlaw have focused on innovation designed to enable such self-protection. For instance, interdisciplinary research groups have proposed “personal data vaults” to manage the emanations of sensor networks. Jonathan Zittrain’s article on “privication” proposed that the same technologies used by copyright holders to monitor or stop dissemination of works could be adopted by patients concerned about the unauthorized spread of health information.Continue reading…

Healthy Eats For Data-Hungry Doctors

Oct 10, 2010• 5

By DAVID C. KIBBE, MD, and BRIAN KLEPPER, PhD

Imagine that an innovative health plan – aware that half or more of health care cost is waste and that physician costs to obtain the identical outcome can vary by as much as eight fold – hopes to sweep market share by producing better quality health care for a dramatically lower cost. So it begins to evaluate its vast data stores. It’s goal is to identify the specialists, outpatient services and hospitals within each market that, for episodes of specific high-frequency or high value conditions, consistently produce the best outcomes at the lowest cost. Imagine that, because higher quality is typically produced at lower costs – there are generally fewer complications and lower incidences of revisiting treatment – the health plan will pay high performers more than low performers. Just as importantly, it will limit the network, steering more patients to high performers and away from low performers.

Suddenly, it will become very important for physicians and other providers to understand, in detail, how they compare to their peers within specialty, and how to provide the best care possible. And if they find the results aren’t so positive, they may want to figure out where their deficiencies lie, and how they can improve.

Now imagine that clinicians could easily view data about their patients and themselves.

Basic demographics: e.g. age, gender, length of time since last visit.
A problem list based on diagnoses within the past year.
A list of medications prescribed, including ordering physician, dates and fulfillment information.
A list of lab tests ordered, by physician and date.
A list of immunizations.

Suppose the clinician could review, revise or copy this information to create a lasting “patient profile,” saving it online and retrieving it for use at each subsequent visit as appropriate.