Trendspotter: Computer-Assisted Coding Is Coming

By Ken Terry


Are you ready for computer-assisted coding (CAC)? So far, it’s being used mainly in hospital outpatient departments, emergency rooms, imaging centers, and ambulatory surgery centers. But it’s starting to move into inpatient settings and ambulatory-care clinics, as well. So you might soon be receiving solicitations from CAC vendors such as CodeRyte, A-Life Medical, AMI and 3M Healthcare Solutions. Whether or not your practice can benefit may depend on such factors as EHR adoption, the types of work you and your colleagues do, and whether you employ professional coders.

There are at least two different forms of CAC. One is similar to the E&M code checkers found in many EHRs. Products from companies like IMO are integrated with EHRs and map the medical terms used in those records to diagnosis and procedure codes. So if you use drop-downs and pick lists for most of your documentation, the program can identify many of the codes you should be using, based on the discrete data in the EHR.
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A more common approach to CAC uses what is known as “natural language processing” to identify relevant terms in electronic text and analyze them in the context of coding logic. By using this kind of software, some radiology departments have been able to code up to 60 percent of their claims automatically and send them directly to the billing system. Radiology and a few other specialties are especially suited to CAC because they have so many repetitive cases. Because these are easy to code, CAC is fairly accurate in these areas.

In more complex care settings, CAC helps increase productivity by doing some of the basic coding work, while allowing human coders to make the final decisions. These programs reduce the amount of time that coders have to spend searching through documents to find relevant information. CAC software does not work with paper or scanned documents; it’s designed for electronic text, such as transcribed notes or reports. But since that’s all that the majority of practices have online right now, CAC might be useful to some groups in which physicians don’t code their own claims.CodeRyte, which has been around for a decade, claims that it “automates medical coding for leading multi-specialty clinics around the country.” It also automates coding for about 70 single-specialty, hospital-based practices. Most of them are radiology, pathology and ER groups, but their customers also include some cardiology practices. CodeRyte avers that its product can increase coder productivity by up to 200-300 percent.

A-Life Medical, another CAC leader, also says that it improves coder productivity and integrates with hundreds of billing, hospital and document management systems. According to the company, it assists coding operations for more than 40,000 physicians.

There are a few reasons why CAC is likely to become more prevalent. First, experienced coders are in short supply, which means that practices need to maximize the productivity of those who are available. Second, hospitals are using these products, and more and more physicians are working for hospitals. And third, the industry is on the verge of moving to ICD-10 diagnostic coding. When that happens, there will be a big expansion of codes, with an accompanying rise in the complexity of coding. Some observers believe that computer-assisted coding can help physicians and hospitals cope with this challenge.

One thing is for certain: physicians and their staffs spend far too much time on administrative tasks that take time away from patient care. If CAC can remove some of that burden, while helping practices code more appropriately, it will be welcomed in physician groups of all kinds.

Don McDaniel: RECs to the rescue

Many of the readers of Practice Notes are members of or affiliated with small physician practices — physician organizations of 10 physicians or less. As you are now undoubtedly aware, the U.S. government is making a significant investment, as a major component of the American Recovery and Reinvestment Act, to support the adoption of electronic health records.

EHR adoption is still very low in the United States, especially among smaller practices. Therefore, to facilitate the adoption and the achievement of meaningful use of these EHRs among small practices, the Office of National Coordination for Health Information Technology (ONC) has now designated some 60 Regional Extension Centers (REC).
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The mission of the RECs are to help primary-care physicians, small practices, and safety-net providers such as community health centers, rural health centers, and critical-access hospitals, through the provision of consultative support and advisory services to enable successful development of EHR systems, and ultimately achievement of meaningful use.

The REC program funding will create technical extension centers throughout the U.S., and each REC will target approximately 1,000 to 2,000 physicians. They are chartered to be vendor agnostic and to provide unbiased guidance — that is to say that they will not promote any specific application over others — with a goal of helping the smallest of practices manage the work flow and business process challenges of achieving meaningful use.

In total, the federal goal is to assist 100,000 physicians nationally by the end of 2012. Each REC will have access to a newly created, federally funded health IT research center — meant to act as a knowledge management hub and disseminator of best practices to the individual RECs and its clients, the physicians. The RECS will be moving to full operating status within the next six months and a list of each REC, as well as information about the REC program, can be accessed at HHS’ Web site. I encourage all practices to reach out to their assigned REC to ascertain how it can help you on your health IT journey.

Melissa Young, MD: How my EMR stacks up

In previous posts, I wrote about my journey towards finding an EMR. I did lots of research. I read multiple articles online and in print. I looked at the surveys. I asked the experts. I had demos, online and live. I did site visits. And eventually, I made my choice.

But despite this somewhat obsessive search for the perfect EMR (this was probably the most important decision I had to make at the time), I have still found imperfections. This part doesn’t work as smoothly as I had hoped. This needs tweaking. This part is inconvenient. This part is just nonfunctional. And since the grass is always greener on the other side of the fence, I have from time to time wondered if, perhaps, there could have been a better choice.

Now don’t get me wrong. Most of the time, the EMR works (nearly) flawlessly. It performs all the major functions that I need it to. It makes my life and the life of my staff infinitely easier than it would have been had we had paper charts. The schedule, chart, and billing information are at our fingertips. Everything gets documented without a six-inch stack of paper.
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Patients who come with their previous records of the last 10 years can leave with their epic saga in their hands because we don’t need to keep the hard copies. When a patient calls because he needs a refill, I can say, “No you don’t. I gave you 90 days and two refills on December 12. ABC Pharmacy on Main Street has your scrip.” Since I can copy their last visit, I can ask (as if from memory), “So has that ache in your left leg gotten better?” or “Has your daughter had the baby?”

But I was most reassured earlier this week when I attended an EMR seminar. I almost didn’t go. After all, I’m not in the market for a new one. But part of the lecture was going to be on getting the Medicare incentive for that all-too-nebulous “meaningful use,” and I figured it would be a good networking event, so I went.

The first third of the seminar was how to choose an EMR and how to implement it. The second was “the top 10 questions EMR vendors don’t want you to ask.” Although I didn’t “need” that information, it did make me feel good about my choice. And that’s because I knew from experience what the answers were. Questions about backing-up data, customer support, ease of implementation, work flow, etc.

Listening to the questions and the things to look for in an EMR, I knew that if someone asked me if I would choose my EMR again, I would have to say that based on what I had to compare it with, and knowing what I know about it now, I definitely would.

Don McDaniel: The eligible provider that stimulus forgot

I visited recently with a group of providers in southern California that are preparing to implement a new EHR system. The group is a large multispecialty practice with more than 150 physicians — all eligible professionals in Stimulus-speak — and derives a significant portion of its work and hence a lot of its revenue from treating Medicare patients.

The CIO of the group asked me what they should expect in terms of incentive payments pursuant to the HITECH Act of 2009’s ARRA — and I immediately said, “Well of course your physicians will all be eligible, and likely for the maximum incentive payment of $44,000 per eligible professional over five years.”

He looked at me like I had two heads, and commented that almost all of its Medicare revenue comes from treating Medicare Advantage (MA) participants. Then it hit me: Does HITECH treat MA providers differently than providers that participate with the original Medicare program?
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I had to research this — and found to my utter disbelief that the answer is yes. The process to qualify for incentives as a provider to Medicare recipients under several MA contracts is much more stringent than what we’ve come to learn about Medicare eligibility.

You see, if a provider doesn’t generate enough Medicare Allowable Charges (MAC) (from seeing “original” Medicare patients) to garner incentives because of the size and scope of their MA practice, they have to pass the 80-80-20 rule with one MA organization — essentially a commercial insurer that provides covered services to Medicare recipients under a contract with CMS.

In other words, they have to be nearly exclusive with one organization that pays 80 percent of their overall MA payments, perform at least 80 percent of their overall Medicare business with MA patients, and practice in a clinical setting at least 20 hours per week.

So, the MA portion of the incentive really only applies to treating essentially exclusively one MA Organization’s (MAOs) patients. For example, a payer-organization like Kaiser Permanente comes to mind. Never mind that many physicians with MA practices have contracts with multiple MAOs.

One question is why was the bill written this way? Could have been that it was an oversight, so in the rush to get the bill released in February 2009, details were missed or left out. A conspiracy theorist might contend that since the current administration has made no secret of its disdain for the MA program, this slight is just a manifestation of a policy desire.

Nonetheless, it stands that a number of hardworking physicians will be affected by this hole. So what can you do if you’re affected by this? You need to mobilize all available advocacy resources at your disposal to make a collective voice heard that CMS has to develop a methodology that recognizes your standing as a Medicare provider, regardless of the source of your revenue from that program. May the force be with you!

Trendspotter: Physicians Remain Leery of EHRs, Despite Government Incentives

By Ken Terry

The results of recent surveys suggest that a majority of physicians intend to buy electronic health record systems within the next few years. But software vendors interviewed at a recent annual meeting of health IT professionals aren’t yet seeing any stampede of doctors to acquire EHRs. And the Medical Group Management Association (MGMA) has expressed reservations about the ability of physician groups to meet the “meaningful use” criteria for government financial incentives. That casts some doubt on the eagerness of doctors to adopt EHRs.

A study by consulting firm Accenture shows that 58 percent of physicians in groups of 10 or fewer doctors who don’t have an EHR plan to get one in the next two years. Four of five non-EHR-using doctors under the age of 55 are gearing up to go digital, according to the survey. Three quarters of the non-users say they’d buy an EHR through a hospital if the facility subsidized it, and the average amount of subsidy these doctors expect is about half of the EHR’s cost.

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Another survey, by EHR vendor athenahealth and physician social network Sermo, finds that 80 percent of Sermo’s online users have a favorable opinion of EHRs and believe that these systems can improve patient care. Seventy-three percent say that the patient benefits of an EHR justify the financial costs. But most respondents agree that EHRs are expensive to purchase and maintain; 54 percent agree with the statement that EHRs slow physicians down; and barely more than 50 percent believe that EHRs have been designed with physicians in mind.

I’m somewhat skeptical of the latter survey, since it was co-sponsored by an EHR vendor. Also, physicians who participate in Sermo’s online network are not necessarily representative of doctors as a whole. I’d guess that a far smaller percentage of physicians view EHRs favorably than this survey indicates. As for the Accenture study, I’m struck by the fact that 61 percent of the non-EHR-users want to adopt because of the threat of Medicare/Medicaid penalties down the line, and only 51 percent are motivated by the federal subsidies for EHR adoption. What that tells me is that physicians are being reluctantly dragged into this deal.

One reason for their reluctance and their skepticism about government incentives is the difficulty of achieving meaningful use. In an MGMA survey, member practices said that the hardest requirements to meet were providing electronic copies of medical records to 80 percent of patients requesting them within 48 hours and providing electronic copies to all requesting patients within 96 hours. The majority of respondents also foresaw problems in using clinical decision support and submitting quality data. More than two-thirds of the respondents said that the use of EHRs would reduce productivity. Thirty-one percent said that productivity would drop more than 10 percent.

The latter MGMA findings and the similar one from the Sermo/athenahealth survey show that physicians remain apprehensive about the financial impact of EHRs on their practices. This impact is related not only to cost, but also to productivity. Dr. Daniel Palestrant, CEO of Sermo, commented, “It is clear from the survey that current EHR solutions are imperfect, with cost, resource allocation, and ease of use being areas that could stand great improvement. Discussion amongst the Sermo physician community supports the survey’s findings of ‘holes’ in current offerings and, more broadly, the notion that EHRs have a long way to go towards delivering on the promise of cost savings, freed resources, and better medicine.”

Nothing exhibited at last week’s conference in Atlanta of the Health Information Management and Systems Society (HIMSS) really represented a breakthrough in EHR design. Some vendors were offering components of EHRs that stressed connectivity more than documentation. That’s important, because the ability of EHRs to exchange data with other information systems remains poor. Also, many physicians find it difficult to document visits in EHRs. There have been some advances in “natural language processing,” which enables computers to parse the meaning of text and sort medical terms into EHR fields. When that’s ready for prime time, many more physicians will be enthusiastic about EHRs, because they won’t be required to enter data. But that’s probably at least 10 years away, and the government incentives for EHRs will be available only from 2011 to 2015.

In the meantime, doctors will have to adjust to the realities of current EHRs if they want to win federal subsidies and avoid later penalties. Let’s hope that as the market expands, EHR vendors will reinvest some of their profits in developing products that are easier to use and that help physicians improve quality and efficiency more than those now on the market.

Trendspotter: AMA To Give Small Practices a Helping Hand in Launching EHRs

By Ken Terry

Small physician practices are less likely than big groups to have electronic medical records—and there’s a reason that goes beyond cost. They lack the resources and the technical knowledge to implement these complex systems. The support and training that vendors offer is frequently inadequate, especially for physicians who aren’t especially computer-savvy. And the vendors freely admit that they don’t have sufficient staff to cope with the expected influx of new EHR buyers who want to show meaningful use by 2011, when the government incentives start flowing.

Under the HITECH provisions of the American Recovery and Reinvestment Act (ARRA), the government is required to create health IT regional extension centers (HITRECs) across the country to help up to 100,000 primary-care physicians install EHRs in their practices. The Office of the National Coordinator for Health IT has allocated nearly $600 million for this purpose, and 60 HITREC grants will be handed out by the end of March.
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Some healthcare systems are taking advantage of the Stark exception to subsidize EHR purchases by non-employed staff physicians, and far more are trying to get their employed practices online. But in either case, the demands of working with a multitude of small practices to implement EHRs exceeds the capacities of most hospital IT staffs. Moreover, the hospital IT people have expertise in inpatient systems but know little about ambulatory-care EHRs.

The AMA is trying to help fill the gap by creating a new web portal that will “provide physicians access to information, products, services, and resources to help facilitate medical practice and ease adoption of health information technology.” While the AMA will give doctors access to e-prescribing and lab ordering applications via the portal, now in beta test mode, AMA’s partner, Dell Perot Health Care Systems, will help physicians implement their EHRs. According to Dell Perot, the AMA will initially offer its member an Allscripts EHR, and it appears that other products will be made available later.

No pricing was available at press time. But, since Dell Perot will host the EHRs on a remote server, upfront and maintenance costs will be lower than they would be if the program and the patient data were hosted on an in-office server.

The big question is how effective Dell Perot can be in working with small physician practices. Both companies have extensive experience in helping hospitals set up and integrate their systems, and Perot—which merged with Dell last year—has also done a lot of outsourcing work for hospitals. The company has also been helping some big healthcare systems, such as Memorial Hermann in Dallas and Tufts Medical Center in Boston, ramp up EHRs in the offices of affiliated physicians. But small independent practices outside the orbit of a healthcare system present a different set of challenges.

In an interview with Physicians Practice, Jamie Coffin, vice president of Dell Healthcare and Life Sciences, pointed out that Dell has helped computerize lots of small businesses in non-medical fields. Of course, that doesn’t mean too much, because EHRs and healthcare are much more complex than, say, a bookkeeping system in a restaurant chain.

Part of the small-practice solution, Coffin indicates, is to use remote training and support tools. Dell Perot will install the hardware, do a “brief touch” in the practice to get the software running, and then follow up online. This does not leave much room for change management or handholding, and practices that cannot figure out how to use the software quickly might drop it, as many have before. But based on Dell Perot’s success to date in working with healthcare systems, they’re hopeful that this approach will also click in private practices.

In any case, Coffin points out, the AMA-Dell venture will fill a need as physicians scramble to show meaningful use. “The real question is whether EHR vendors can scale to the number of installations they have to do over the next 36 months,” he says. “It’s not a cost question for them, it’s an issue of whether they can scale to the demand. They’re going from 1,000 implementations a year to 10,000-20,000 or more. That’s one reason why they’re looking at companies like Dell and Perot.”

A call for relaxing meaningful use critiera

Quite a few groups have criticized the draft meaningful use requirements as being too complex and nearly impossible to comply with. Now, the Health IT Policy Committee has called for relaxation of the standards that providers must meet to receive EHR incentive funding.

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As it stands, providers would have to perform 25 different measures in the areas of care coordination, privacy, quality and safety, etc. But in their recommendation submitted to David Blumenthal, the national coordinator for health IT, the group asked that the government abandon an “all or nothing” approach and allow providers to defer up to five measures from 2011 to 2013.

However, the group said certain measures should remain mandatory, such as e-prescribing and computerized order entry.
(CMS is accepting public comment on the meaningful use rules through mid-March and is expected to publish its final rule in late spring.)

What do you think? Is the criteria currently far too complex?

Don McDaniel: What's eHealth all about?

I’ve spent the past few weeks attending a number of healthcare information technology meetings focused on achieving interoperability in healthcare — so-called eHealth. You see, we have a major trading partner issue in healthcare — even if we gave every physician and hospital in America an EHR, all we would achieve are a group of discrete applications that don’t share information by and between them.

In other words they won’t be able to communicate with each other. This is a real problem — a real practical problem because unfortunately, because consumers, of course, attend care givers widely and without attention to what information system they use!

So, there’s been a lot of discussion about how to facilitate all these disparate systems to connect, communicate, and make the amalgam (the integrated data) information that is actionable.
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The Institute of Medicine (IOM) reports that about 1.5 million patients are injured each year because of adverse-drug events; events that presumably could be eradicated if we have true mission-critical healthcare information sharing.

While at the mHealth Conference, I saw a number of applications built and positioned for mobile devices — and this makes perfect sense in a world which is quickly becoming hardware- and even appliance-agnostic. These applications include a number of mobile phone applications to enhance disease management services and even review images remotely. We should be prepared for the integration of mobile systems.

At the eHealth Initiative’s annual meeting in DC, I learned about a number of functioning local information exchanges, mostly led by large Integrated Delivery Networks. For example, Boston HealthNet with it anchor tenant Boston Medical Center, has developed a health exchange that includes the BMC hospitals and eight to 10 discrete community health centers (FQHCs), allowing clinicians access to real time medication history for any patient seen throughout the system. This is one of what is today a limited group of operating health information exchanges; what I’ve described at BMC is really still an isolated HIE, but the promise is evident and I think the train has left the station.

I encourage you to do your homework, and seriously evaluate opportunities to pursue and engage a health information exchange. By the way, if you are a provider, and even if you plan to purchase an EHR, you will not be able to achieve meaningful use in the later adoption years without a relationship with a health information exchange. Food for thought.

Trendspotter: Apple iPad is already attracting physician attention

By Ken Terry


The new Apple iPad is causing a stir in the medical world, even though no electronic medical record software has yet been designed specifically for it. One indication of this interest comes from a physician survey by Epocrates, a leading vendor of software for mobile devices. Of the respondents to this poll, conducted just before the iPad’s launch, nine percent said they would buy one immediately. Another 13 percent said they would get an iPad within a year, and 38 percent said they were interested in the product but needed more information to make a decision.

One reason for physicians’ curiosity about the iPad is that it uses the same operating system and has the same finger-activated pressure screen as the iPhone and the iPod Touch. According to Epocrates, which has just announced its compatibility with the iPad, more than one of five physicians is using its applications on either of those devices. The fact that the iPad’s screen size is almost as big as a full-size tablet’s doesn’t hurt, nor does its svelte weight (just 1.5 pounds).

Moreover, the basic features of the iPad—web access, e-mail, photos, video and music playback, electronic books, and access to 140,000 applications—probably appeal to tech-savvy docs. But many physicians are also intrigued by the idea that the iPad might someday be used for EMRs and various modes of inpatient documentation and ordering.

According to Satish Misra at iMedicalApps:

“Rumors abound that Apple is already pitching the iPad in LA-area hospitals as the replacement for the old physician clipboard. For outpatient practices already running a Mac-based EMR, MacPractice has already announced development plans for an iPad interface. According to their press release, they plan to develop apps that will allow patients to fill out registration, medical history, and other forms on the iPad. For physicians, it will integrate with the MacPractice EMR to manage schedules, view patient records, and even enter clinical notes.”
Read moreHowever, Misra notes, most EMRs run on the Windows operating system; while there’s already a Citrix application that allows an iPad to use Windows as a dumb terminal, that would eliminate the cool interface that is the iPad’s biggest selling point. Also, the iPad has no digital handwriting capability. And its handwriting recognition probably has to be better than that of the “digital ink” in tablet PCs, which some physicians find too slow and clunky, Misra says.

I’d also point that there’s a problem with the iPad’s lack of a keyboard. Although many physicians like pressure screens and the ability to scroll or select with their fingers, a certain amount of typing (or, alternatively, dictation with voice recognition software) is inevitable when documenting visits in an EMR. The iPad features an onscreen keyboard, but physicians have found such keyboards to be only marginally usable in other computer tablets. You can also tap on an external keyboard when the iPad is in its docking station, but that is not a portable feature.

A few other drawbacks should also be mentioned: While the iPad contains a rechargeable battery, it cannot be removed and exchanged with a fresh battery. If you believe that the iPad battery will go 10 hours without a charge, as Apple claims, that’s probably sufficient for daily use with an EMR. But some observers are skeptical about that. And a survey of physicians conducted by Software Advice about the features physicians desire in a tablet shows that the iPad falls short in several areas:

“It lacks a large number of features that healthcare professionals deemed important, such as resistance to dust and hospital fluids and disinfectants (the iPad does not have sealed ports); fingerprint access to the system (HIPAA compliance); barcode scanning (patient safety); and an integrated camera (documenting diagnosis). In fact, you could argue that the iPad’s difficulty in being disinfected or kept clean of hospital fluids is a deal breaker for healthcare workers.”

Of course, conventional tablets also have problems, including the fact that most are heavier and have a shorter battery life than the iPad does. But many physicians like tablets and have had success in using them with their EMRs. Whether or not the iPad becomes a major competitor in the EMR space will probably depend on whether Apple adds some new physician-friendly features and on the willingness of EMR vendors to write applications for the Apple operating system.

Melissa Young, MD: More on the patient portal

So just when I was about to give up on the whole patient portal thing (see last week’s blog entry), a patient decides he wants to sign up.

You know that foreign language class you took in high school, after which you could sort of carry on a slowly spoken grammatically incorrect conversation? You know how you can now recognize certain words in that language but can’t put two words together?

Well, that’s how it was for us the first time a patient actually decided to plunk down his portal registration fee and sign the authorization form. Heck, our training was three months ago! We got as far as scanning in the form. Uh, now what? Some e-mail is supposed to be automatically generated, right? And then…?
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Before we could completely figure that out, two more patients signed up. We thought we had followed all the necessary steps, but something seemed to be missing. We called a patient to find out if she received an e-mail with her username and password. No. Hmmm.

We broke out the user manual. We went through the steps again. Ah-hah! We had missed a step, a click of the mouse. We rescanned the authorizations forms and clicked away. Ah-hah (again)! Now we got a window with the patient’s username and password. We must be in business now.

I checked the administrator’s account on the portal. Yup. There were three patients on there. I sent one a message. I didn’t hear back. I sent another. Still no answer. I have no way of knowing whether the messages went through. I have not received a “read receipt.” I’m a little embarrassed to call and say, “Hey, you know that thing you paid $25 for? Is it working?”

I like having an electronic medical record. I really do. I like having minimal amounts of paper sitting around the office. I am also one who enjoys e-communication in general. I e-mail, text, IM, Facebook, chat, and (obviously) blog. I would love a secure way to communicate with my patients. And apparently, some of my patients want to e-communicate with me. I just wish there was some way to verify what goes on in the ethereality that is the Internet.

Melissa Young, MD: The patient portal

A patient portal has been touted as a time saver, an efficient and secure way for patients to communicate with the office. It’s supposed to save money and effort, too, by decreasing time spent by the staff and the physician on the phone.

I cross my fingers. Quite honestly, two weeks ago, I considered ditching the whole thing.

First of all, it took more effort than I envisioned to get it going. It doesn’t help that you are required to develop a “portal authorization form,” something for the patients to fill out saying that they understand the purpose of the portal and what their responsibilities are, etc, etc. But the vendor can’t give you a template for this form. They can’t give you an example. I didn’t really understand the explanation for why they can’t. Ah, but Google is a wonderful thing, and I found one.
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Then there are the various disclaimers you have to post (that the vendor can’t help you with either). You know the disclaimers like, “we try to keep your information private, but well, stuff happens and we can’t be held responsible if someone hacks into the site,” and “if you received this in error, please tell us, otherwise you will be in big trouble.”

And let’s talk about the cost. It seemed like a minimal expense compared to everything else at first. But now that there are a million other things to pay for, and I’m looking around to find the least expensive toilet paper, I realize that there is no such thing as a minimal expense. I had planned to offer the service for free, but I was advised to at least charge an administrative fee. I chose to have a one-time fee, as opposed to a yearly one.
And I figured that two to three patients a month would cover the annual fee I pay.

Well, perhaps I over-estimated the number of patients who would be interested. After having the portal up and running for almost three months, we had people express interest in using it, but nobody who had actually signed up.

Until two weeks ago. And that just gave me fodder for next week’s blog entry.

Don McDaniel: Why certify EHRs?

I was recently at the eHealth Initiative’s annual meeting in Washington, DC. eHealth Initiative is the organization focused on building bridges in healthcare by and between all of the disparate information systems in healthcare — in short, they are promoting the development of a truly interoperable information ecosystem in healthcare.

The promise of this concept is significant to many stakeholders in healthcare for many reasons, not the least of which is the significant benefit that might be offered to patients that won’t be victimized by the various and sundry errors prevalent in our dysfunctional domestic healthcare system. It’s been well chronicled that tens of thousands of patients per year are harmed or even killed as a result of something as innocuous as an adverse drug reaction.

Anyway, at lunch I struck up a conversation with an especially bright CIO from an integrated delivery system in Eastern North Carolina. We were discussing the recent pronouncements of CMS and ONC on the topic of meaningful use and I mentioned certification of vendors. He quickly replied that there’s no reason to certify vendors of electronic health records because the market will take care of that. I was simultaneously impressed and upset that I didn’t suggest the very same thoughts; I am, after all the free enterprise guy!
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My new acquaintance was right. Meaningful use is a process/outcome achievement scheme. Providers will not be incentivized to simply implement electronic health records, but rather to achieve a (nirvana-like) “state of meaningful use” – which will require appropriate data collection, fidelity to certain clinical treatment protocols, monitoring of patient status and intervention when necessary, and finally, reporting that one has mastered all of the above.

If someone is stupid enough to buy an appliance that doesn’t support their achievement of these goals, shame on them. Is their protection really worth all the money that will be spent — and passed onto purchasers in the form of higher prices — to achieve and maintain certification status? As with every market transaction – caveat emptor – buyers need to educated and ask the right questions.

For instance, I can’t imagine advising one of my clients to purchase clinical decision support technology from a vendor that won’t guarantee that their product will be completely meaningful use-compatible. But do we need a regulator to ensure our protection?

Then again maybe if we were all much better, more demanding consumers of healthcare services, we wouldn’t need the government to carrot and stick our way through meaningful use!

Melissa Young, MD: The day the network went down

I don’t know why I didn’t immediately write about this on the day it happened. I must have blocked the painful memories, but somehow they resurfaced today.

It was an ordinary day. I saw patients in the office in the morning. Everything was running smoothly. I entered all my notes in the EMR. We had Internet. Nothing extraordinary.

I went to do rounds at the hospital at around 2 p.m. At 3 p.m., I get a text from my receptionist: “The computers are down.” Down? What does she mean “down?” They were fine an hour ago. And computers? Plural? Oh, no, no. This can’t be good.

So I texted her back (I do love texting): “Just the EMR or Internet, too?”
“EVERYTHING”
Good mother of all that is good and pure, what happened?!
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I ran back to the office. Sure enough, the computers were on, but none of them could connect to the network. Therefore, none of them had an Internet connection, none of them could run the EMR. And there in the waiting room was my next patient. I tried rebooting each computer. Nothing. I checked the server. That was on, had Internet, and could run the EMR. Now if I could see my patient in the computer closet that it was in, I would have been fine.

I called my IT company. They couldn’t “see” my computers. I was offline. Oh, sweet baby James, I was this close to having a stroke. OK, they said, unplug the switch, then plug it back in. Unplug the modem and plug it back in. I really hate that unplugging and replugging things just seems to be the way to fix things. Still nothing. My IT guy says he’ll send someone out immediately. Nothing could have been immediate enough for me at that point.

Meantime, I remember the patient in the waiting room. She fortunately had a good sense of humor and was rather amused at my agita. I took a step back. She’s a new patient, so it’s not like there was really anything in the EMR that I needed that second. I’ve seen patients for years without templates, and I’ve written notes on paper before. So, I forged ahead.

Funny, after only three months, it seemed almost foreign, but I went forth. And it was fine until I asked her if she had had recent labs. She said yes, and her doctor had faxed them to me. I slapped myself in the forehead. Of course, she had. But I couldn’t look at them, because all that would be in the EMR. She looked bemused again, “You don’t keep a hard copy?”

“We don’t get a hard copy. All faxes go directly into the computer.” So I go out to tell my staff to call the patient’s PCP to have them re-fax the labs, this time to our “old-fashioned” fax machine.

While they do this, I get a call from IT, “Turn off the server, then turn it back on.” Really, seriously? Fine. Now, a regular computer takes but a minute or two to reboot. “A server has a lot more going on” I’m told as I stand there impatiently. Then after what seemed like an eternity, it was back on. And, lo and behold! One by one the other computers on the network came alive. Hallelujah! We were back in business.

This happened about a week or two ago. It has not happened again. I have no explanation for what happened. Just the new-found wisdom that if it happens again to reboot the server. And a bill from IT for “minimum service – 2 hours” plus tax.

EHR stimulus update

Do you have meaningful use on the brain? In a follow up to the primer on EHR stimulus incentives, Ken Terry's EHR Incentives Update in the February journal digs deeper into the meaningful use criteria.

There's a good chance you've got some confusion or anxiety about acquiring and learning to use an EHR. But if you want to get the maximum federal dollars, you can't really hesitate. Ken's article will help clear up some confusions and get you on the right path for the EHR incentives.

I also welcome your comments here about what you're doing to acquire and meaningfully use an EHR.

Trendspotter: EHR vendors peg financing deals to incentives

By Ken Terry


The deals from EHR vendors are getting better.

Among the latest offers to be announced is Ingenix’s for its Care Tracker EHR. Ingenix is offering an interest-free loan through OptumHealth Bank, a fellow UnitedHealth subsidiary, to cover implementation and subscription costs until Nov. 30, 2015. Qualifying physicians can repay the loans with annual government payments for meaningful use, which can total up to $44,000 over five years if they’re from Medicare, more if from Medicaid. Physicians who buy a Care Tracker EHR this year would pay nothing out of pocket for use of the remotely served, Web-based software. They’d have to repay the first installment of the loan after they received their government check next year; for the rest of 2011 and part of 2012, they’d pay nothing until they got their next government payment.

Like many other vendors, Ingenix is offering a meaningful use guarantee: If a practice doesn’t qualify for the annual government incentive, it doesn’t have to pay back the previous year’s loan.

Allscripts is offering practices deferred payments for the first six months on loans that are available through “preferred banks.” After that, they have to pay back the loans over 54 months. At the end of that term, they own the software. “Unlike some of the subscription models in the market, where you continue to pay on an annual basis even after that 60-month period, our solution is rent to own,” says Allscripts President Lee Shapiro. “And the loan payments are very competitive with any subscription services in the marketplace.”
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Allscripts offers its MyWay software on a subscription basis, too, and many small practices prefer that arrangement. But Shapiro notes that if a practice wants to purchase the Web-based EHR and have Allscripts remotely host and manage it, that is also an option. Allscripts guarantees that its software will meet HHS’ EHR certification criteria. If it doesn’t, it will wave up to 12 months of a client’s monthly support fees.

NextGen is offering three options. Along with a six-month deferred payment option, it is also allowing doctors to defer payments for four months, followed by incrementally increasing payments (four months at half payments, eight at three-quarter payments, and 44 months at full payments). The third possibility, available only to practices of three physicians or more, is a no-money-down purchase with 12 months of deferred payments, followed by a standard five-year loan.

Mark Anderson, a health IT consultant based in Montgomery, Texas, points out that most leading vendors are offering zero-interest or deferred-payment arrangements in expectation of the government incentives. “In reality, the cost ends up being the same,” he says. “If your payments are deferred, then the interest rate is higher later. If they’re zero interest, the practice ends up paying more for the solution.”

Shapiro, however, says that Allscripts is offering “very attractive programs” through its banking partners. The vendor is using its buying power, he says, to obtain loans at better rates than most practices could get on their own.

The other thing to bear in mind is that the software cost is only part of the total cost of ownership, which also includes outlays for hardware, training, and implementation. Steven Tolle, senior vice president of Ingenix’s Physician Solutions Group, says that, especially in the small-practice space, vendors must minimize these expenses to get physicians onboard.

Still, the five-year cost of subscribing to Care Tracker is $7,000 per physician, and Ingenix estimates that the total five-year cost for the EHR system is $23,500. That is less than the $44,000 maximum payment from Medicare, but a significant portion of that amount must be laid out upfront, despite the zero-interest software financing.

Ingenix and other vendors are aiming their new offers squarely at small-practice physicians who have notoriously resistant to EHRs. To what degree the software vendors will succeed is uncertain. Certainly, many physicians remain hesitant to buy, even with the government incentives. Some doctors fear they will lose productivity, and some have heard horror stories about failed EHR implementations. On the other hand, Allscripts just reported a 30 percent hike in revenues for the quarter ended Nov. 30, 2009.

The real deal lies somewhere between these viewpoints. Many physicians will adopt EHRs and show meaningful use in 2011, but some will need help that goes beyond what their vendors can provide to do that. What could make a big difference are the government’s plans to launch 70 health IT regional extension centers and have community colleges train thousands of EHR technicians. The sooner that happens, the better for everyone.

Ken Terry is a New Jersey-based freelance writer and the author of the book "Rx for Health Care Reform." In his weekly Trendspotter column, Ken is looking out for trends and changes that may affect your practice.

New Tip of the Week

For the latest Tip of the Week, endocrinologist Medhavi Jogi advises practices to not accept the one-time training from their EHR vendor.

How did your EHR training stack up? Do you have ongoing support?

Trendspotter: Meaningful use criteria may not suffice for care coordination

By Ken Terry
The Department of Health and Human Services (HHS) has released draft regulations on the “meaningful use” of electronic health records that will be required to qualify for government incentives in 2011. The good news is that physicians will not have to enter visit notes electronically to show meaningful use. But you will have to use some other EHR features out of the box, including electronic prescribing and decision support tools such as drug interaction alerts.

Patient demographics, vital signs, and smoking status must be recorded in the EHR, and at least 50 percent of lab results will have to go into the EHR as structured data. That means you will need interfaces with your major labs. In addition, you will have to give patients access to key data from their medical records, and you will have to transfer clinical summaries as part of referrals. In addition, you must either submit quality data based on PQRI measures and other metrics endorsed by the National Quality Forum, or attest that you can do so. In 2012, you will have to send in the data electronically.

All of this, of course, is designed to prove that physicians who apply for up to $44,000 in Medicare incentives ($64,000 for Medicaid) are using their EHRs in a way that will improve the quality, safety, and efficiency of patient care. A key part of that quality improvement is enhanced coordination of care — a major goal not only of the HITECH Act, but also of the public and private medical home pilots that are underway.
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But a new study from the Center for Studying Health System Change casts doubt on whether current EHRs, even if they meet meaningful use criteria, are up to the task of improving care coordination in today’s environment.

Based on their interviews with users of EHRs (which they call EMRs) in 12 markets, the CSHSC researchers conclude:

“There is a gap between policy-makers’ expectation of current EMRs’ role in the coordination of care and clinicians’ real-world experience with them. We found that commercial ambulatory care EMRs facilitate care coordination within a practice by making data available at the point of care, but they are less helpful for exchanging information between practices and settings. EMRs may also have unintended consequences for coordination, such as creating an information overload that complicates providers’ efforts to discern key clinical information.”

There are some non-technological reasons for these shortfalls, including physician culture and a lack of reimbursement for care coordination. But the researchers also delineate some deficiencies that affect some or all EHRs. Among them are these:

• A lack of interoperability between systems used by various physician practices, hospitals, diagnostic testing facilities, and other providers. This results in practices scanning paper documents into the EHR as non-searchable PDF files.
• Problems with problem lists. Few EHRs link specific problems to portions of past notes that address them. Also, the lists often include redundant diagnoses generated by test results.
• Inability to capture the planning component of medical-decision making. EHRs typically do not remind physicians of things that need to be done for patients until the doctor opens that patient’s chart for the next visit.
• Lack of registries or other mechanisms that would facilitate population health management, ensuring that patients with particular conditions receive the preventive and chronic care they need when they need it.
• Inability to track referrals within the EHR.
• Tendency to generate too much information in referral notes, making it difficult for physicians to find the important points about a patient’s care.

The CSHSC researchers suggest that HHS use its meaningful use and EHR certification regulations to prompt vendors to correct these and other deficiencies in their products. The 2011 meaningful use criteria indirectly address some of these issues, such as interoperability, referrals, and population health management. But they are not specific about the technology tools that are needed. Neither are the accompanying standards and EHR certification criteria, which are designed to support the meaningful use requirements.

One reason why the rules are not more specific is that HHS and its advisory committees wanted to avoid requiring certain types of functionality, fearing that that would limit innovation and favor established vendors. In addition, it is clear that the government does not want to require EHRs that might prove too complex for the majority of physicians. In fact, doctors are even allowed to combine several components from different vendors if those enable them to show meaningful use.

This might be an acceptable starting point if the only goal were to persuade the bulk of physicians to adopt some kind of EHR. However, the implementation of any kind of EHR — other than a basic electronic chart — requires a big investment in time and money. If physicians are going to go to all this trouble, the least that the vendors can do is provide them with the tools they need to meet the government’s goals.

Ken Terry is a New Jersey-based freelance writer and the author of the book "Rx for Health Care Reform." In his weekly Trendspotter column, Ken is looking out for trends and changes that may affect your practice.

Meaningful use reactions

The reactions so far to the meaningful use requirements out late last week are mixed.

Among those who are not so pleased is the MGMA, which in a statement called the requirements “overly burdensome” and that practices will “confront significant challenges trying to meet the program requirements.”
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Among the barriers MGMA sites are:
- Unreasonable thresholds for some of the criteria (such as electronic claim submission and electronic insurance eligibility verification
- Potentially difficult meaningful use attestation after the first year
- A requirement that physician offices provide patients with electronic copies of their health records

The American Hospital Association also had some concerns, according to Modern Healthcare.

CMS and the Office of the National Coordinator for Health IT released two highly-anticipated regulations defining the meaningful use of EHRs and setting the criteria for how to receive federal incentives for EHR use.

The requirements will be phased in over three stages between now and 2013, and the first stage focuses on collecting and sharing electronic health data, reporting quality measures, and using EHR data to track conditions and coordinate care. Providers will also be required to provide patients with electronic copies of their medical records.

Our own Trendspotter, Ken Terry, will be writing about this in his column this week, so stay tuned for more.

Trendspotter: Health information exchange raises new liability issues

By Ken Terry


When physicians are asked how an EHR might affect their malpractice risk, they usually think about their own documentation and orders. More comprehensive records, better access to those records, and automatic alerts might help them avoid an error that could result in a suit, they say. System crashes, diversion of their attention from the patient, and “charting by exception” could increase the possibilities for liability.

But what you do with your own EHR is not the only source of potential difficulties. As EHRs become increasingly interlinked with outside information systems, including those of other practices, hospitals, labs, pharmacies, and health information exchanges, the greater availability of data from these other sources could also raise malpractice risks, say some experts.
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In a recent Dr. Kevin blog post, attorney Robert J. Mintz points out that, as access to data on patient treatment outside your practice grows, you might also be held accountable for a higher standard of care. “Even as quality increases, the legal standard of care will keep rising too, so that rather than fewer mistakes and fewer lawsuits, there are more of each since the information you ‘should have known’ is now right at your fingertips,” Mintz writes.

Mintz cites a case involving a pharmacist who was sued after a patient to whom he dispensed a painkilling drug caused a fatal car accident. Because the pharmacist had access to records showing that this patient had gotten prescriptions for a large number of similar drugs before, the plaintiff alleged that he should have known the patient was abusing these medications. Mintz believes that similar suits could be brought against physicians who have access to the records of other physicians, as well as to community medication histories.

Other observers are concerned about the unintended effects of the information revolution on physician liability. Gerald “Jud” DeLoss, a healthcare and malpractice defense attorney in Fairmont, Minn., notes that when one physician’s EHR is interlinked with those of other doctors, “faulty information that may have been inputted into the system by a physician or staff member outside their facility could result in some type of incorrect treatment or an allergic reaction that could injure the patient.”

Steve Waldren, a family physician who is director of the AAFP’s Center for Health Information Technology, is concerned that if a physician has access to lab results in a colleague’s EHR and doesn’t integrate those results into his own record, he might be held liable.

And Washington, D.C., internist Peter Basch, a leading health IT expert, says that if you even open a colleague’s e-mail that contains information about a patient and don’t file it in your EHR, you could be held accountable because the audit trail would show that you had opened the e-mail.

Electronic prescribing is another can of liability worms. First, as mentioned earlier, physicians who prescribe online to pharmacies, either through an EHR or a standalone e-prescribing system, have access to Surescripts’ community medication history, based on claims data from pharmacy benefit managers and health plans. In some areas, prescribers may also be able to access a point-of-sale database that shows all of the medications, both prescription and OTC, that a patient has purchased in participating pharmacies.

What this means is that the e-prescribing physician either knows or should know what other medications a patient is taking when he prescribes a drug that might have an adverse interaction with one of those other pills. If everybody looked up this information, it would be a great leap forward for patient safety. But Surescripts says that in 2008, only 16 million prescription histories were routed to physicians who ordered 68 million prescriptions online. So doctors were checking their prescriptions against community records less than a quarter of the time.

The other liability risk associated with e-prescribing comes from the new ability to find out whether a patient has filled his prescription. (Surescripts includes the fill status as part of the medication history.) If a physician does not check on whether a patient has filled his prescription, is he liable if the patient doesn’t get the medication and has an adverse event as a result? If the doctor does know that the patient isn’t taking or refilling his meds, should he follow up immediately or wait until the next visit, and what responsibility does that entail?

The list of possibilities is endless. But, perhaps because legal experience in this area is sketchy, relatively little attention has been paid to the liability implications of health information exchange. That is likely to change, however, as more physicians acquire EHRs and as HIEs emerge across the country.

Ken Terry is a New Jersey-based freelance writer and the author of the book "Rx for Health Care Reform." In his weekly Trendspotter column, Ken is looking out for trends and changes that may affect your practice.

Trendspotter: Will EHRs save money?

And if not, what does that mean for physicians’ “meaningful use” payments?

By Ken Terry


The Obama Administration’s push for widespread adoption of EHRs is based on the premise that it will lead to a reduction in healthcare costs.

During the presidential election campaign, then-candidates Barack Obama and Hillary Clinton both cited a RAND Corp. study that predicted savings of nearly $80 billion a year. But some observers assailed that conclusion after the RAND study was released, and recent research has clouded the issue further.

A new study published in the American Journal of Medicine’s online edition found that, while U.S. hospitals increased their use of health IT between 2003 and 2007, the technology was not correlated with lower clinical or administrative costs in the institutions that adopted it. In fact, the hospitals that computerized most rapidly had the biggest increases in administrative outlays, the researchers said.
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It should be borne in mind that two of the three Harvard professors who conducted this study, David Himmelstein, MD, and Steffie Woolhandler, MD, are single-payer supporters who oppose the Democratic approach to healthcare reform. Showing that health IT will not help save our system is part of their agenda.

Still, their study has statistical power. The researchers linked a HIMSS survey of computerization at 4,000 hospitals with administrative cost data from Medicare Cost Reports and cost and quality data from the 2008 Dartmouth Health Atlas. The impact of health IT on quality, they found, was mixed. “Higher overall computerization scores correlated weakly with better quality scores for acute myocardial infarction…but not for heart failure, pneumonia, or the three conditions combined,” they concluded.

On the other side of the coin, a study by Ashish Jha, David Bates, and other experts found that adverse events in hospitals and redundant tests ordered by multiple physicians—both of which could be mitigated through the use of health IT—contribute significantly to hospital costs. In 2004, they calculated, preventing adverse events could have reduced hospital spending by $16.6 billion, or 5.5 percent of inpatient costs. Prevention of redundant testing would have cut costs by an additional $8 billion, or 2.7 percent. Of course, the use of health IT, even if it were ubiquitous, would eliminate only part of this waste.

There’s also evidence that it takes a long time for the use of EHRs to improve the quality of care or reduce costs significantly. In a recent survey of 200 large physician groups by the American Medical Group Association (AMGA), 63 percent said they’d had EHRs for two years, and 25 percent had had them for five years. Yet only half were using their systems to drive clinical protocols, 27 percent were using them for population health management, and a quarter were using the EHRs to improve clinical cost effectiveness.

In a commentary on the KevinMD blog, Glen Laffel, MD, Ph.D., points out that some other studies have shown that EHRs can improve the quality of care delivered. But it’s still unclear whether they will save money at a societal level.

This issue, Laffel notes, has implications for the government incentives for meaningful use of EHRs under the HITECH Act. Originally, it was reported that the legislation had allocated $19 billion to help physicians and hospitals acquire EHRs. The CBO estimated that the total cost would be $30 billion and that health IT-related savings would save about $12 billion from 2011 to 2019. Recently, the Office of the National Coordinator of Health IT (ONC) has been floating a figure of $47 billion for the total cost, although that may change, according to an ONC spokesman. As the late Senator Everett Dirksen memorably quipped, “A billion here, a billion there, pretty soon it adds up to real money.”

The real savings from EHRs will come from networking them together so that clinicians know what everyone else is doing for a patient and so they can work together across care settings to produce the best outcomes. We are still in the early stage of building such networks and getting EHRs from different vendors to communicate with one another. But when those goals are achieved, and when we create the right incentives for physicians to collaborate, the resultant increase in quality and efficiency could have a major impact on the sustainability of healthcare.

Ken Terry is a New Jersey-based freelance writer and the author of the book "Rx for Health Care Reform." In his weekly Trendspotter column, Ken is looking out for trends and changes that may affect your practice.