The health care crowd is abuzz with The New York Times revelation that Medicare billing rates seem to have increased by billions of dollars in parallel with increased adoption of EHR technologies for both hospitals and ambulatory services. The culprit for this unexpected increase is the measly E&M code. Evaluation and Management (E&M) is the portion of a medical visit where the doctor listens to your description of the problem, takes a history of previous medical issues, inquires about relatives that suffered from various ailments, asks about social habits and circumstances, lets you describe your symptoms as they affect your various body parts, examines your persona and proceeds with diagnosing and treating the condition that brought you to his/her office or hospital.
The more thorough this evaluation and management activity was, and the more complicated your problem is, and the more diagnostic tests are reviewed, and the more counseling the doctor gives you, the more money Medicare and all other insurers will pay your doctor. Makes perfect sense, doesn’t it?Continue reading…
The wrong question always produces an irrelevant answer, no matter how well-crafted that answer might be. Unfortunately the debate on health information technology seems to be increasingly focused on the wrong question. An Op-Ed in the Wall Street Journal argues that we have had a “Major Glitch” in the use of electronic health records (EHRs). This follows on a series of recent studies that have asked the question “do EHRs save money?” Or “do EHRs improve quality?” with mixed results.
While the detractors point to the systematic review from McMaster, boosters point to the comprehensive review published in Health Affairs that found that 92% of Health IT studies showed some clinical or financial benefit. The debate, and the lack of a clear answer, have led some to argue that the federal investment of nearly $30 billion for health IT isn’t worth it. The problem is that the WSJ piece, and the studies it points to, are asking the wrong question. The right question is: How do we ensure that EHRs help improve quality and reduce healthcare costs?
The fundamental issue is that our healthcare system is broken – our costs are too high and the quality is variable and often inadequate. Paper-based records are part of the problem, creating a system where prescriptions are illegible, the system offers no guidance or feedback to clinicians, and there is little ability to avoid duplication of tests because the results from prior tests are never available. Even more importantly, the paper-based world hampers improvement because it makes it hard to create a learning environment. I have met lots of skeptics of today’s health information technology systems but I have not yet met many physicians who say they prefer practicing using paper-based records.
The problem is that some Health IT boosters over-hyped EHRs. They argued that simply installing EHRs will transform healthcare, improve quality, save money, solve the national debt crisis, and bring about world peace. We are shocked to discover it hasn’t happened – and it won’t in the current healthcare system.
Under the Health Information Technology for Economic and Clinical Health Act of 2009, healthcare providers are now offered incentives to use electronic health records (EHRs).
A recent analysis from the Centers for Disease Control and Prevention (CDC) found that by 2011, 55 percent of physicians reported they had adopted EHRs, indicating that EHR adoption is finally on the rise. Moreover, three in four adopters said their system met the Act’s criteria for meaningful use.
Healthcare providers deserve recognition for adopting EHR systems. Their journey to date has not been easy, with challenges ranging from unexpected expenses to the logistics of incorporating technology smoothly into their interactions with patients.
Adoption of an EHR in and of itself does not improve care. Having electronic access to data is just the first step. Quality is only improved when providers interpret data to connect the dots between diagnoses and treatment options.
This July will mark the 16th anniversary of the installation of our electronic medical record.
Yup. I am that weird.
Over the first 10-14 years of my run as doctor uber-nerd, I believed that widespread adoption of EHR would be one of main things to drive efficiency in health care. I told anyone I could corner about our drive to improve the quality of our care, while keeping our cash-flow out of the red. I preached the fact that it is possible for a small, privately owned practice to successfully adopt EHR while increasing revenue. I heard people say it was only possible within a large hospital system, but saw many of those installations decrease office efficiency and quality of care. I heard people say primary care doctors couldn’t afford EHR, while we had not only done well with our installation, but did so with one of the more expensive products at the time. To me, it was just a matter of time before everyone finally saw that I was right.
The passage of the EHR incentive program (aka “meaningful use” criteria) was a huge validation for me: EHR was so good that the government would pay doctors to adopt it. I figured that once docs finally could implement an EHR without threatening their financial solvency, they would all become believers like me.
But something funny happened on the way to meaningful use: I changed my mind. No, I didn’t stop thinking that EHR was a very powerful tool that could transform care. I didn’t pine for the days of paper charts (whatever they are). I certainly didn’t mind it when I got the check from the government for doing something I had already done without any incentive. What changed was my belief that government incentives could make things better. They haven’t. In fact, they’ve made things much worse.
In March of 2005, I staffed an interview between Todd Park and Steve Lohr of The New York Times in the cafeteria of the old New York offices of the “Grey Lady.” At the time, Park was heading a very small web-based start-up company that was trying to convince medical groups – and on that day, a leading national technology business reporter – that web-based “cloud” technologies would become mainstream in the healthcare IT industry and were the only logical means to get the hundreds of thousands of independent U.S. doctors and their small offices to go digital.
At the time, Lohr, one of the foremost technology reporters in the country covering IT giants like Microsoft, IBM and Intel, had just started covering Health IT upon the appointment of Dr. David Brailer as the nation’s first National Health Information Coordinator (or, as many called him back then, the “Health Information Czar”). In fact, Lohr had just gotten back from attending the annual HIMSS Conference in Dallas where he met with CEOs of “legacy” healthcare IT behemoths like IDX (now GE), Siemens, Cerner, Allscripts, McKesson and Epic.
In his first article addressing Health IT adoption in the U.S., Lohr touched on what he felt was the core challenge to achieving widespread EHR adoption: getting small medical practices to adopt and actually use these systems – something that had eluded the industry and those legacy IT vendors for many years. On the topic of getting small practices to adopt EHRs and the potential harm to the industry and the Bush Administration’s efforts if they didn’t, Dr. Brailer told Lohr, “The elephant in the living room in what we’re trying to do is the small physician practices. That’s the hardest problem, and it will bring this effort to its knees if we fail.”
Last week President Obama appointed Todd Park as the new Assistant to the President and U.S. Chief Technology Officer, with the responsibility to ensure the adoption of innovative technologies to support the Administration’s priorities including affordable health care. This got me to thinking.
Since taking office, President Obama has made some strong moves to champion the adoption of EHRs through the passing of the HITECH Act. This act, combined with the existing relaxation to the existing Stark anti-kickback laws, has actually enabled a spike in adoption of EHRs due to medical groups’ efforts to qualify for Meaningful Use dollars. But it has also had some unintended consequences that Mr. Park may now find himself in a unique position to rectify if he stays true to his support of cloud computing.Continue reading…
Every year I write about the projects and trends which keep me up at night. Here’s my list for FY12:
1. Workforce recruitment/retention – $27 billion in stimulus funds from HITECH have increased demand for experienced IT staff to implement and support electronic health records. In many ways, it’s a mini “dot com” boom for healthcare IT experts. This makes recruiting and retaining qualified staff even harder. Tomorrow, I’m meeting with a consulting team to formulate an FY12 workforce strategy.
2. 5010/ICD10 – 5010 describes a set of X12 standards used for administrative transactions (benefits/authorization. referral authorization, claims). Payers and providers must support 5010 by January 1, 2012 or risk disruption of the revenue cycle. BIDMC completed all its 5010 work and is now in final testing with every payer. Most payer and provider stakeholders will meet the deadline, but significant resources have been pulled from other projects. ICD-10 implementation is required by October 1, 2013 and I’ve written about those challenges. Billions will be spent, many healthcare IT projects will be deferred for the next 2 years, and the end result will be no cost savings (coding costs are likely to increase 50%), no quality improvement, no increased safety, and no efficiency gains. If we complete the ICD-10 project on time, no one will notice, but customers will all be angry at the IT department (and the CIO) for the work on other projects that was deferred.
3. Vendor Product Quality – over the past year, I’ve had several bad experiences with infrastructure and application vendors which delivered products that did not have the reliability, security, or performance promised. Why?
* the pace of innovation is so fast, that time for quality assurance is diminished
* the economy has stressed companies and they are focused on making as many sales as fast as they can while controlling development and support costs
What doctors are most likely to use patients’ personal electronic health records? Fewer than 1 in 2 are willing to. Those who most likely would include Hispanic physicians, doctors who practice in rural areas, those employed in hospitals, and surgeons.
As part of the HITECH Act included in the American Recovery and Reinvestment Act (ARRA) 0f 2009, U.S. physicians have the opportunity to receive a portion of the $20.8 billion carved out as incentive payments to those who adopt and “meaningfully use” electronic health records (EHRs).
Many EHRs include portals which allow patients to access a slice of their personal health information. Some patients create their own personal health records that might be as simple as an Excel spreadsheet or as robust as Kaiser Permanente’s My Health Manager or the VA’s MyHealtheVet.
The bottom line is that physicians’ willingness to connect with patients’ PHRs varies by the doctor’s gender, clinical specialty, race, geographic location, size of the practice, and whether they are already using an EHR. The chart details these findings by physician characteristic.
The physicians who would least likely embrace patients’ would most likely practice in suburban geographies, in solo or duo practices, be female, and be in primary care or pediatrics. And those who don’t use an EHR currently are much less likely to be unwilling to use a patient PHR.Continue reading…
I’m keynoting this year’s Intersystems Global Conference on the topic of “Freeing the Data” from the transactional systems we use today such as Enterprise Resource Planning (ERP), Customer Relationship Management (CRM), Electronic Health Records (EHR), etc. As I’ve prepared my speech, I’ve given a lot of thought to the evolving data needs we have in our enterprises.
In healthcare and in many other industries, it’s increasingly common for users to ask IT for tools and resources to look beyond the data we enter during the course of our daily work. For one patient, I know the diagnosis, but what treatments were given to the last 1000 similar patients. I know the sales today, but how do they vary over the week, the month, and the year? Can I predict future resource needs before they happen?
In the past, such analysis typically relied on structured data, exported from transactional systems into data marts using Extract/Transform/Load (ETL) utilities, followed by analysis with Online Analytical Processing (OLAP) or Business Intelligence (BI) tools.
In a world filled with highly scalable web search engines, increasingly capable natural language processing technologies, and practical examples of artificial intelligence/pattern recognition (think of IBM’s Jeopardy-savvy Watson as a sophisticated data mining tool), there are novel approaches to freeing the data that go beyond a single database with pre-defined hypercube rollups. Here are my top 10 trends to watch as we increasingly free data from transactional systems.Continue reading…
We’ve known for years that health information technology can improve health care. But until recently, the implementation rate among providers has been low, except for a few early adopters.
In the last two years, however, there has been a significant upward inflection in the adoption rate. For primary care providers, adoption of a basic EHR increased by half from 19.8 percent in 2008 to 29.6 percent in 2010.
And with HITECH Act programs now in full swing, it looks clear that adoption and use of health information technology will go into high gear. Already, 81 percent of hospitals and 41 percent of office physicians are saying they intend to achieve meaningful use of EHRs and qualify for Medicare and Medicaid incentive payments.
The 2009 Health Information Technology for Economic and Clinical Health Act (HITECH) authorized incentive payments, potentially totaling some $27 billion over ten years, to clinicians and hospitals when they implement electronic health records in such a way as to achieve “meaningful use,” in terms of advances in health care processes and outcomes.
But, are EHRs really “meaningfully useful” or are they more likely to be costly and ineffective?
The latter seems to be one possible interpretation of a recent RAND study of EHR adoption in US hospitals.
The RAND study statistics are impressive: five study authors tallied 17 “quality measures” for three medical conditions against three possible levels of EHR capability (no EHR, basic EHR, advanced EHR) for more than two thousand hospitals for each of 2003 and 2007. They then related changes in quality over the four year timeframe against changes in EHR status (for example, from no EHR to an advanced EHR).
The reported results were disappointing to EHR proponents. Among the hospitals whose EHR capability remained unchanged over the four years, there was no statistically measurable difference in quality improvement between hospitals with EHR capability and those without. For hospitals which upgraded their EHR capability, the performance improvement was generally less than for those who didn’t change, including those with no EHR at all.
So, should we forget about EHRs? Maybe defund HITECH?