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Tag: Meaningful Use

Is the Electronic Health Record Defunct?

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By JEROME CARTER , MD

flying cadeuciiWhen building software, requirements are everything.

And although good requirements do not necessarily lead to good software, poor requirements never do.   So how does this apply to electronic health records?   Electronic health records are defined primarily as repositories or archives of patient data. However, in the era of meaningful use, patient-centered medical homes, and accountable care organizations, patient data repositories are not sufficient to meet the complex care support needs of clinical professionals.   The requirements that gave birth to modern EHR systems are for building electronic patient data stores, not complex clinical care support systems–we are using the wrong requirements.

Two years ago, as I was progressing in my exploration of workflow management, it became clear that current EHR system designs are data-centric and not care or process-centric. I bemoaned this fact in the post From Data to Data + Processes: A Different Way of Thinking about EHR Software Design.   Here is an excerpt.

Do perceptions of what constitutes an electronic health record affect software design?  Until recently, I hadn’t given much thought to this question.   However, as I have spent more time considering implementation issues and their relationship to software architecture and design, I have come to see this as an important, even fundamental, question.

The Computer-based Patient Record: An Essential Technology for Health Care, the landmark report published in 1991 (revised 1998) by the Institute of Medicine, offers this definition of the patient record:

A patient record is the repository of information about a single patient.  This information is generated by health care professionals as a direct result of interaction with the patient or with individuals who have personal knowledge of the patient (or with both).

Note specifically that the record is defined as a repository (i.e., a collection of data).   There is no mention of the medium of storage (paper or otherwise), only what is stored.   The definition of patient health record taken from the ASTM E1384-99 document, Standard Guide for Content and Structure of the Electronic Health Record, offers a similar view—affirming the patient record as a collection of data. Finally, let’s look at the definition of EHR as it appears in the 2009 ARRA bill that contains the HITECH Act:

ELECTRONIC HEALTH RECORD —The term ‘‘electronic health record’’ means an electronic record of health-related information on an individual that is created, gathered, managed, and consulted by authorized health care clinicians and staff.  (123 STAT. 259)

Even here, 10 years later, the record/archive/repository idea persists.  Now, back to the issue at hand: How has the conceptualization of the electronic health record as primarily a collection of data affected the design of software systems that are intended to access, manage, and otherwise manipulate said data?

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2014 Black Book Survey Says Majority of Medical Practices Want Updated Software

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By TOM GIANNULLI, MD

Screen Shot 2014-06-26 at 2.07.25 PMThe new mantra for the medical practice is upgrade, integrate, and outsource according to the results of the Black Book Rankings™ 2014 Survey. Each year, Black Book gathers over 400,000 viewpoints on information technology through an interactive online survey and telephone discussions. The result is an annual barometer of HIT satisfaction and experiences.

This year, three clear trends emerged for practices looking to stay independent in a changing and challenging time in healthcare. While each trend holds its own unique benefits, it is clear from the survey that many practices are looking to implement all three—upgrade technology, implement integrated solutions, and outsource business functions like revenue cycle management.

According to the survey, nearly 90% of physician practices agree their billing and collections systems need upgrading. Over 65% of those practices are considering a combination of new software and outsourcing services. Here are the trends:

Move to Upgrade Outdated Software

Even with recent changes in the CMS EHR Incentive program, delaying the required use of a 2014 Edition CEHRT, many practices do not currently have an EHR that will enable them to attest for meaningful use. In addition, 91% of business managers fear that the ramifications of their outdated and/or auto-piloted revenue cycle management (RCM) systems, particularly those not integrated to EHRs, will force their physician to sell.

As a result of these challenges and other impending changes like ICD-10, 21% of practices are considering an upgrade of their RCM software within the next six to twelve months, and 90% of those are only considering an EHR centric module.

Practices considering upgrades to cloud-based solutions can see other benefits including reduced costs, seamless upgrades, more flexible access, and reduced concerns around storage and security.Continue reading…

Penalizing Hospitals For Being Unsafe

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By ASHISH JHA, MD

Ashish JhaAdverse events – when bad things happen to patients because of what we as medical professionals do – are a leading cause of suffering and death in the U.S. and globally.  Indeed, as I have written before, patient safety is a major issue in American healthcare, and one that has gotten far too little attention. Tens of thousands of Americans die needlessly because of preventable infections, medication errors, surgical mishaps, and so forth.  As I wrote previously, according to Office of Inspector General (OIG), when an older American walks into a hospital, he or she has about a 1 in 4 chance of suffering some sort of injury during their stay.  Many of these are debilitating, life-threatening, or even fatal.  Things are not much better for younger Americans.

Given the magnitude of the problem, many of us have decried the surprising lack of attention and focus on this issue from policymakers.  Well, things are changing – and while some of that change is good, some of it worries me.  Congress, as part of the Affordable Care Act, required Centers for Medicare and Medicaid Services (CMS) to penalize hospitals that had high rates of “HACs” – Hospital Acquired Conditions.  CMS has done the best it can, putting together a combination of infections (as identified through clinical surveillance and reported to the CDC) and other complications (as identified through the Patient Safety Indicators, or PSIs).  PSIs are useful – they use algorithms to identify complications coded in the billing data that hospitals send to CMS.  However, there are three potential problems with PSIs:  hospitals vary in how hard they look for complications, they vary in how diligently they code complications, and finally, although PSIs are risk-adjusted, their risk-adjustment is not very good — and sicker patients generally have more complications.

So, HACs are imperfect – but the bottom line is, every metric is imperfect.  Are HACs particularly imperfect?  Are the problems with HACs worse than with other measures?  I think we have some reason to be concerned.

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Be Prepared: Beyond the Alphabet Soup of Value-Based Care

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By JOSH SEIDMAN

Screen Shot 2014-06-19 at 11.04.40 AMACO, MSSP, BPCI, HIE, CQM, P4P, PCMH, yadda, yadda, yadda … The litany of acronyms describing changing P&D (excuse me, payment and delivery) models can sometimes numb the senses. But it would be unwise to allow the latest healthcare jargon to lull you into an AIC—an acronym-induced coma, for which I believe there is a new ICD-10 code—because the world might look a lot different when you snap out of it.

Little debate exists that the U.S. healthcare system needs to transition from turnstile medicine to value-based care, from a predominantly fee-for-service payment model to one that emphasizes accountability for population health. This, of course, is not a novel concept, so the biggest challenges relate to how we get there. As many skeptics have argued, the same dynamics have existed before – unsustainable healthcare costs and too little value for our money – so the Talmudic question arises: Why is this era different from all other eras?

  1. EHRs have changed the playing field completely
  2. Reporting of comparative performance is now embedded into the delivery system
  3. We understand the centrality of patient engagement
  4. Today’s incentives reward greater accountability and value

There are some fundamental differences compared to, for example, the environment that existed in the 1990s when some experts believed managed care would change the underlying cost structure of the health care system. A majority of providers now have implemented electronic health records (EHRs) and an increasing number are – or soon will be as a result of Stage 2 “Meaningful Use” – able to exchange clinical data across network and vendor boundaries. The expectation that quality measurement will be used for holding providers accountable has taken root and most health care organizations regularly submit standardized performance data to public and private payers, purchasers and independent accrediting bodies. Providers increasingly recognize that their success in population health management relates to their ability to effectively engage with their patients in collaborative relationships.

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Should Health Consumers Be Paid for Performance Too?

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By MICHELLE SNYDER

flying cadeuciiMeaningful Use and Pay for Performance – two of the most talked about programs in healthcare IT over the past several years. They are both based on the premise that if you want to drive behavior change among providers and improve quality of care, you need to offer financial rewards to get results.

But what about the consumer? We have now entered a new era in healthcare where the consumer is rightfully front and center – AHIP is even calling 2014 the “Year of the Consumer.” Payers, and other population health managers, who until recently viewed consumers as claims, now want to “engage,” “motivate” and “delight” them.

The challenge, however, is that we are giving consumers more responsibility, but not making them accountable for the quality of care they provide for themselves.

As a country we have spent tens of billions of dollars on Meaningful Use incentives and Pay for Performance programs for clinicians. Providers need to demonstrate they are making the best choices for patients, being efficient and coordinating care.

They need to educate patients and give them access to information based on the belief that if patients are informed, they will take responsibility and action. Unfortunately, this seems like a “Field of Dreams” spinoff – “If we say it, they will act.”

However, that movie has a different ending. The intentions are good, but the flaw is that consumers don’t simply need more information. They need personalized guidance and support, and they need to feel like they have a financial stake in the game.

So the big question is – why aren’t we spending more time thinking about how the concepts behind “meaningful use” and “pay for performance” could be used as a way to get consumers engaged in their health? Yes, clinicians are important as they direct approximately 80 percent of the healthcare spend in our “sick-care” health system.

However, what most people do not realize is that 75 percent of healthcare costs are driven by preventable conditions like heart disease and type-2 diabetes. And while some consumers may throw up their hands and blame genetics for the majority of their health issues, it’s a fact that 50 percent of what makes us healthy is under our control – as opposed to 20 percent for genetics.

So what if we made wearable technologies such as FitBit more “meaningful” for the consumer?  Instead of just tracking steps, what if consumers were financially rewarded for taking steps to improve their health (pun intended) through health premium reductions, copay waivers or even gift cards?

Consider a scenario where an individual who was identified as being pre-diabetic and then took action to prevent the onset of diabetes. What if we required that proactive person to pay less in premiums than someone who was not taking any initiative to improve their health? That would clearly be very motivating.

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Survey Says: EHR Incentive Program Is on Track

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By Karen DeSalvo, MD

We continue to see progress in improving the nation’s health care system, and a key tool to helping achieve that goal is the increased use of electronic health records by the nation’s doctors, hospitals, and other health care providers. These electronic tools serve as the infrastructure to implementing reforms that improve care – many of which are part of the Affordable Care Act.

Doctors and hospitals are using these tools to reduce mistakes and hospital readmissions, provide patients with more information that enable them to stay healthy, and allow for rewarding health care providers for delivering quality, not quantity, of care.

The adoption of those tools is reflected today in a release from the Centers for Disease Control and Prevention’s National Center for Health Statistics which provides a view of the Medicare and Medicaid EHR Incentive Program and indicates the program is healthy and growing steadily.

The 2013 data from the annual National Ambulatory Medical Care Survey are encouraging:

  • Nearly 80% of office-based physicians used some type of electronic health record system, an increase of 60 percentage points since 2001 and nearly double the percent in 2008 (42%), the year before the Health Information Technology and Economic and Clinical Health Act passed as part of the Recovery Act in 2009.
  • About half of office-based physicians surveyed said they use a system that qualifies as a “basic system,” up from just 11% in 2006.
  • Almost 70% of office-based physicians noted their intent to participate in the EHR incentive program.

Figure 1. Percentage of office-based physicians with EHR systems: United States, 2001-2013

The report also noted that 13% of physicians who responded said they both intended to participate in the incentive program and had a system that could support 14 of the Meaningful Use Stage 2 “core set of objectives,” ahead of target dates. This survey was performed in early 2013 – before 2014 certified products were even available.

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Quality Measurement 2.0

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By John Halamka, MD

I’ve written several posts about the frustrating aspects of Meaningful Use Stage 2 Certification.   The Clinical Quality Measures (CQMs) are certainly one of problem spots, using standards that are not yet mature, and requiring computing of numerators and denominators that are not based on data collected as part of clinical care workflow.

There is a chasm between quality measurement expectations and EHR workflow realities causing pain to all the stakeholders – providers, government, and payers.   Quality measures are often based on data that can only be gathered via manual chart abstraction or prompting clinicians for esoteric data elements by interrupting documentation.

How do we fix CQMs?

1.  Realign quality measurement entity expectations by limiting calculations (call it the CQM developers palette) to data which are likely to exist in EHRs.   Recently, Yale created a consensus document, identifying data elements that are consistently populated and of sufficient reliability to serve in measure computations.   This is a good start.

2.  Add data elements to the EHRs over time and ensure that structured data input fields use value sets from the Value Set Authority Center (VSAC) at NLM.    The National Library of Medicine keeps a Meaningful Use data element catalog that is likely to expand in future stages of Meaningful Use.

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Darwinian Health IT: Only Well-Designed EHRs Will Survive

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By Edmund Billings, MD

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.

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What Keeps Me Up At Night – 2013 Edition

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By John Halamka, MD

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.

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Replacing Farzad

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By Anonymous HIT Insider

In the wake of the National Coordinator’s announcement that he is departing, there has been a flurry of tweets, blog posts, impromptu online polls, and conjecture about the most likely successor.  To date, none of these conversations has resulted in a thoughtful assessment of the set of characteristics that would represent the ideal candidate, nor has there been any thorough review of the most likely candidates in the context of these attributes.  The need for a rapid transition to a successor is well understood by all – yet there has been no indication that the Obama administration is in a hurry.  Let’s hope that we can evolve them toward a greater sense of urgency. The fragility of ONC – and the importance of its health – can’t be overlooked.

Let’s consider some history:

The first two National Coordinators, David Brailer and Rob Kolodner, were appointed before ARRA.  The agency was small, focused largely on certification (through CCHIT), standards (through HITSP) and policy.  When ARRA arrived, David Blumenthal, a thoughtful, deliberate, policy-savvy internal medicine physician from Boston was brought in to lead the rapid expansion of health IT that was facilitated by the HITECH Act.

ONC expanded under Blumenthal from a team of ~ 30 people to a team of >100 in the two years that he was at the helm, and the agency published the 2011 certification criteria regulations, and collaborated with CMS to publish the regulations that defined stage 1 of the Meaningful Use incentive program.  The policy foundation was that the three-stage program – to be implemented over six years – would evolve the nation’s care delivery system by causing adoption of EHR technology (stage 1) and then exchange of clinical information electronically (stage 2) and finally improved clinical outcomes (stage 3).

Farzad Mostashari, who joined Blumenthal as the Deputy National Coordinator early in Dr Blumenthal’s tenure, was quickly named as Blumenthal’s successor when Blumenthal announced his resignation in the Spring of 2011.  Both Mostashari and Blumenthal pushed hard for Mostashari’s appointment – so that the consistency, focus and forward momentum of the organization could be maintained.

And so it was.  Under ARRA, adoption of EHRs has skyrocketed.  The CMS MU Stage 2 regulations and the ONC 2014 certification regulations were published, and the size of the agency has doubled to over 150 people.  Recognizing the need for experienced partners to assist him in leading a larger agency – and growing national reliance on health IT and an essential component of the care delivery ecosystem – Mostashari hired David Muntz as the “Principal Deputy” (essentially the COO of the agency), Jacob Reider as Chief Medical Officer (leading a team of clinicians focused on quality and safety) and Judy Murphy as the Deputy National Coordinator for Programs and Policy (adding internal coordination support for ONC programs).

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