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Technical Doctor's insights and information collated from various sources on EHR selection, EHR implementation, EMR relevance for providers and decision makers
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Doctors Reject Electronic Health Record Mandate

Doctors Reject Electronic Health Record Mandate | EHR and Health IT Consulting | Scoop.it

In an effort to increase the use of electronic health records by doctors, hospitals, and other health care providers, Congress passed the Health Information Technology for Economic and Clinical Health Act, more often known as the HITECH Act, in 2009. The law provided both incentives and penalties to encourage widespread adoption, but so far many hospitals and doctors have failed to comply.

On December 17, 2014, the Centers for Medicare and Medicaid Services (CMS) announced 257,000 doctors had failed to achieve what it termed “meaningful use” of electronic health records, and would have payments for Medicare services reduced by 1 percent as of January 1, 2015.

According to the American Medical Association, that is more than half of all doctors covered under the HITECH act.

Dr. Joe Bentivegna of Rocky Hill, Connecticut says electronic health records are expensive and impractical.

“Doctors struggle because the user interfaces are slow and there are too many questions,” Bentivegna said. “It works poorly with ophthalmology, my profession.”

Incentives and Penalties

Early on the HITECH act provided taxpayer funds to medical providers to help pay for the adoption of electronic health records. Those incentives will remain through 2016, but penalties have also kicked in for those who haven’t satisfied the CMS meaningful use requirement. The 1 percent reduction in 2015 will rise to 5 percent over five years, taking a significant bite out of many doctors’ revenue.

Dr. Stephen Stack, president-elect of the American Medical Association, expressed dismay over the news 257,000 doctors would be penalized in 2015.

“The Meaningful Use program was intended to increase physician use of technology to help improve care and efficiency,” Stack said in a statement. “Unfortunately, the strict set of one-size-fits-all requirements is failing physicians and their patients.”

Stack charged the meaningful use requirements “are hindering participation in the program, forcing physicians to purchase expensive electronic health records with poor usability that disrupts workflow, creates significant frustrations and interferes with patient care, and imposes an administrative burden.”

Increasing Government Control

Twila Brase, president of the Citizens’ Council for Health Freedom, sees the meaningful use requirements as a backdoor way for the government to play a heavier role in directly controlling medical care.

“So if you want to control the entire health care system, what do you need?” Brase asked rhetorically. “You need to know what the doctors are doing, you need to decide what you want them to be doing, and then you need a system to record how far they are removed from what you want them to be doing to that you can financially penalize them.”

Brase expressed concern the electronic health records created in compliance with the HITECH Act will be used to ration care, pointing to comments by controversial MIT economist Jonathan Gruber.

“Gruber says they only want people to get the right care for the right things,” Brase explained. “They’ll sometimes talk about ‘right place, right time, right patient, right care,’ as though we were all sort of widgets in the system. Their plan is to use all of our data to standardize the practice of medicine, to put those standardized treatment protocols on the electronic health system, and nothing else.”

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Decide Consulting's curator insight, February 4, 2015 7:46 PM

Should physicians be penalized for not satisfying meaningful use requirements? EHRs are meant to be customizable and helpful, but many doctors only see the burden.

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Can True EHR Customization Help Physician Practices Survive?

Can True EHR Customization Help Physician Practices Survive? | EHR and Health IT Consulting | Scoop.it
In the rapidly-evolving EHR market, one size definitely does not fit all and true EHR customization can make all the difference.

It is a commonly-held belief that the healthcare system in the United States is in need of more than a fairly steep overhaul. In fact, the once highly sought after profession of doctor has shifted to become one of the more embattled jobs nationwide.

Many healthcare professionals are now forced into the impossible situation of navigating exploitation by insurance companies and government regulations, all while grappling with the challenges of providing quality patient care, keeping their practices afloat, earning a living and paying back often-exorbitant medical school loans. If anything, in today’s world it would surprise most people to know how little doctors actually make, relative to the effort and investment in their careers they are required to put in, day in and day out.

This is a critical issue facing the US today, as tens of thousands of physicians are closing their practices every year and either retiring or becoming employees of large healthcare corporations. This is having a significant impact on accessibility and affordability of medical care. With fewer doctors available and many individuals seeking care from “corporatized” healthcare providers, not only is the personal relationship between doctor and patient lost, the cost of medical care at corporate-run medical facilities is substantially higher than ever before.

Capable and cost-effective?

So, the question becomes — how do doctors maximize their healthcare practice and record management processes, cost-efficiently and effectively? Enter the wide variety of EHR and EMR solutions that have flooded the market in recent years, each promising to streamline the process and take the guesswork out of compliance to the government’s evolving mandates that regulate healthcare record-keeping.

In addition to managing healthcare records, doctors also need a secure and HIPAA compliant scheduling system, medical devices integration, practice management system, e-prescription, lab interfaces, patient engagement, and tele-medicine. Of course, these systems must also be equipped with disaster recovery and business continuity safeguards.

And while there are many current solutions on the market which range from open source to a one-stop package that practices implement directly on their end, they miss one crucial element. Each doctor practices his/her profession in their own unique way, and this extends to all aspects of their work, from patient care to record keeping and practice management. Just as Dr. Lawrence ‘Rusty’ Hofmann in The Huffington Post, describes it, EHRs are like Model T Ford: Any Color You Want As Long As It’s Black.” The majority of these solutions hitting the market today just don’t cut the mustard when it comes to really addressing the needs of our country’s doctors and healthcare practices.

Furthermore, while the creators of many of these packaged EHR solutions claim to be “customizable,” they are actually merely “configurable.” Instead of allowing the user the autonomy and flexibility to create a system with parameters that align with their own specific practice and its operational goals, editable functions are typically limited to creating additional fields in the forms — barely paying lip service to the task of meeting the true needs of healthcare professionals in this country.

These solutions also require heavy reliance on a computer screen, which often hinders a doctor’s ability to provide the standard of care and bedside manner that comes with more face-to-face interactions inquiring into pain, ailments, and body language from patients. This seminal aspect of the healthcare field is threatened by one-size-fits-all systems that squelch the nuances between practices and the differing techniques doctors use to treat their patients. This diversity between providers is central to continued advancements in the medical field and breakthroughs in patient care and disease treatment.

Diversity and true EHR customization rule

So then, what is the answer? In my opinion, built from countless conversations with doctors on this issue, it is EHR systems that provide an easy-to-use interface that are truly customized to fit the ways in which each doctor treats patients, approaches his/her field, and manages their practice, in a cost-effective package that does not require a huge up-front investment. Additionally, everyone within the practice should have access to the system, to ensure continuity in an often-volatile EHR market that typically sees 45-50% churn annually.

In short, it is crucial that developers of these software tools accommodate doctors’ needs first, rather than create a framework that expects doctors to squeeze themselves into a pre-defined structure, often asking them to sacrifice their individuality, professional approach, and expertise.

This approach, which represents incredible opportunity in the once thought to be saturated EHR market, is the essential step to rescuing our doctors from their often embattled position, bringing them back to the esteemed position they once held, all while improving our overall patient experiences and outcomes in the process.


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Survey: Physicians See Benefits, Drawbacks in EHR System Switches

Survey: Physicians See Benefits, Drawbacks in EHR System Switches | EHR and Health IT Consulting | Scoop.it

Changing electronic health record systems could improve EHR functionality and help physicians meet meaningful use requirements, but physicians might be unhappy with the switch, according to a survey published in the journal Family Practice Management, FierceEMR reports.

Under the 2009 federal economic stimulus package, health care providers who demonstrate meaningful use of certified EHRs can qualify for Medicaid and Medicare incentive payments (Durben Hirsch, FierceEMR, 1/20).

For the survey, researchers polled 305 family physicians who had switched EHR systems in 2010 or later. The survey was conducted between July 2014 and September 2014 (Edsall/Adler, Family Practice Management, January/February 2015).

Survey Findings

The survey found that the most common reasons for changing EHR systems were:

  • Needing additional functionality;
  • Wanting to meet meaningful use requirements;
  • Desire to increase usability; and
  • Requiring improved training and support.

Researchers also found that 59% of respondents agreed or strongly agreed that their new system had better functionality, and 57% said that the change helped them to meet meaningful use requirements.

However, just 43% of respondents indicated they were happy with the switch to a different EHR system. Respondents who were part of the decision to change EHR systems were happier with the change than those who were not part of the decision-making process.

Overall, 81% said the time investment in changing EHR systems was challenging, with issues such as:

  • Productivity loss;
  • Data loss; and
  • Data migration problems.
Comments

Researchers said that physicians need to carry out a careful evaluation of their current EHR system prior to making a change. They also said that making alterations in physician workflow could result in better outcomes.

They noted that switching EHR systems might be necessary to improve functionality or achieve meaningful use but added that "if you just want to change because you don't like using your current EHR or consider it a drag on your productivity, the grass may not be greener on the other side"


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Is Physician Fear of ICD-10 Turning Them Off Preparation? | EHRintelligence.com

Is Physician Fear of ICD-10 Turning Them Off Preparation? | EHRintelligence.com | EHR and Health IT Consulting | Scoop.it

There are a lot of reasons for healthcare professionals to dislike the notion of ICD-10.  More mandates, more money, more work, and more complications that do nothing but take highly-trained physicians away from the business of patient care have been repeatedly cited as reasons why the industry should just forget the new code set all together.  But new research from AHIMA shows that frustration, empty pockets, and exhaustion may not be the only things slowing down the ICD-10 adoption process.  Many physicians in a series of focus groups expressed straight-up fear about how the new codes will impact their practices – and even more worryingly, expected their EHR vendors and billing services to do most of the heavy lifting as October 1, 2015 draws near.

“ICD-10 is scary for most people,” one physician admitted during one of the interview sessions.  The large-scale changes required to bring clinical documentation up to the appropriate level of detail and specificity are of great concern to many physicians, not only due to necessary changes in their workflow, but also because of the uncertain impact on their reimbursement.

Physicians may be jittery about the unknowns of the future, but they aren’t necessarily being proactive about addressing them.  Blaming a lack of simple educational tools, comprehensive resources, and specialty-specific guides to clinical documentation improvement (CDI), physicians in the focus groups are generally taking a wait-and-see approach to problems that may arise from documentation issues.  They will address issues as they occur and learn as they go after implementation.  They expect their EHR and billing system vendors to provide them with templates and order sets that will make documentation easier, and tend to think the biggest problems will only hit providers who perform a wide variety of procedures or see very complex patients.

“I have not done anything except read an article or two about how codes are going to increase in ICD-10,” a participant said. “I am relying on my billing service to do that. With respect to the hospital, they have not really given us any formal training for ICD-10 at all.”

“Physicians…typically don’t want to spend very much time on training for things like this,” added another. “It’s hard to engage them, so finding a set of materials that they will respond to positively would be valuable.”  Hiring an HIM or CDI professional to develop educational programs and train physicians on ICD-10 issues seemed an attractive path for some physicians, but others worried that hospitals with the resources to maintain an HIM department may only invest in significant training for inpatient coding, leaving the less lucrative outpatient coding aside.

“Hospital coding is totally depending on ICD-9 and as they convert to 10, they will do the training (for inpatient). But that is inpatient. What about outpatient? The hospital will train you as they have a vested interest. For outpatient, I don’t know,” remarked a participant.

“For surgeons, nothing came from formal groups; most of the information regarding ICD-10 preparation and training would come from the hospital side as they have the best interest in training the physicians mainly for hospital utilization and reimbursement purposes,” agreed another.

Will EHR vendors and billing partners pick up the slack?  Physicians certainly hoped so, believing that vendors would provide training and assistance if their hospitals and specialty associations didn’t give them adequate education.  The groups called ICD-10 a “new language” for them to learn, and put specialty educational materials at the top of their wish lists.  One requested “ICD-10 for dummies dumbed down by specialty,” while others asked for easy-to-understand crosswalks and a top-ten list of the most frequent reasons claims are being rejected.

The problem, many of the responses seem to indicate, is that ICD-10 isn’t meeting physicians where they are.  CDI itself is not the issue, nor is the extra burden of added time and education, even if the thought of spending a few lunch breaks or extra evenings in a specificity seminar isn’t enticing.  ICD-10 has taken on a life of its own as the big bad wolf of the healthcare industry, its shadow of trepidation growing deeper each time the new code set is delayed.  Many physicians want to view the changes as a positive development, but feel that available resources aren’t helping them do so.  “Articles on ICD-10 are fear-based,” said a participant.  “I try not to go there.”

So where will they go?  To health information management professionals, hopefully, or to CDI experts offering outsourcing services or workshop materials that will preempt the watch-and-wait attitude that may result in significant reimbursement disruptions.  It isn’t fear mongering to say that preparing in advance for ICD-10 is a wiser course of action than simply hoping that the storm will pass by without serious damage, or letting fear of the unknown preclude the search for resources that will meet a specialist’s particular needs.  ICD-10 will require effort, but the industry has been preparing for the switch for a long time, and the right training is available to those who look for it.

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Stage 3 Meaningful Use proposals at White House for final review

Stage 3 Meaningful Use proposals at White House for final review | EHR and Health IT Consulting | Scoop.it

Why do these things always seem to happen late on Friday afternoons? At least this time it’s not right before a holiday. Actually, with a bit more inspection, I see that it did happen right before a holiday.

HIMSS is reporting today that the White House’s Office of Management and Budget is “in its final stages of review” of the proposed rules for Stage 3 of the Meaningful Use EHR incentive program. OMB always goes over proposed and final regulations to measure the fiscal — and, presumably, political — impact before allowing executive-branch agencies to make public releases.

A peek at OMB’s reginfo.gov site indicates that the MU Stage 3 proposal from CMS and related ONC plan for certification of EHRs are indeed at OMB for final review.

“We are proposing the Stage 3 criteria that [eligible professionals], eligible hospitals, and [Critical Access Hospitals] must meet in order to successfully demonstrate meaningful use under the Medicare and Medicaid EHR Incentive Programs, focusing on advanced use of EHR technology to promote improved outcomes for patients. Stage 3 will also propose changes to the reporting period, timelines, and structure of the program, including providing a single definition of meaningful use. These changes will provide a flexible, yet, clearer framework to ensure future sustainability of the EHR program and reduce confusion stemming from multiple stage requirements,” CMS states in a rule summary on the OMB site.

A placeholder date (“02/00/2015 “) on the same page suggests that the proposal will be published in February. However, a placeholder date on the page for the forthcoming ONC certification standards indicates that the plan was supposed to come out in November.

And the date the two notices appeared on the reginfo.gov? Dec. 31, when pretty much everyone was already checked out for the extended New Year’s weekend.

Stage 3 is scheduled to start no earlier than Oct. 1, 2016, for hospitals and Jan. 1, 2017, for individual providers.


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IBM and Epic Prep for Multi Billion Dollar DoD EHR Contract | Hospital EMR and EHR

IBM and Epic Prep for Multi Billion Dollar DoD EHR Contract | Hospital EMR and EHR | EHR and Health IT Consulting | Scoop.it

In this recent Nextgov article, they talk about what Team IBM/Epic are doing to prepare for the massive bid:

On Wednesday, IBM and Epic raised the bar in their bidding strategy, announcing the formation of an advisory group of leading experts in large, successful EHR integrations to advise the companies on how to manage the overhaul — if they should win the contract, of course.

The advisory group’s creation was included as part of IBM and Epic’s bid package, according to Andy Maner, managing partner for IBM’s federal practice.

In a press briefing at IBM’s Washington, D.C., offices, Maner emphasized the importance of soliciting advice and insight from the group. Members of the advisory board include health care organizations, such as the American Medical Informatics Association, Duke University Health System and School of Medicine, Mercy Health, Sentara Healthcare and the Yale-New Haven Hospital.

Add this new advisory group to the report that Epic and IBM set up a DoD hardened Epic implementation environment and you can see how seriously they’re taking their bid. Here’s a short quote from that report:

Epic President Carl Dvorak explained the early move will also help test the performance of an Epic system on a data center and network that meets Defense Information Systems Agency guidelines for security. An IBM spokesperson told FCW that testing on the Epic system has been ongoing since November 2014.

As we noted in our last article, 2015’s going to be an exciting year for EHR as this $11+ billion EHR contract gets handed out. What do you think of Team IBM/Epic’s chances?



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Developing a Specialty-Specific Action Plan for ICD-10

Developing a Specialty-Specific Action Plan for ICD-10 | EHR and Health IT Consulting | Scoop.it

As the calendar turns over to the beginning of a new year, the healthcare industry begins yet another countdown towards an autumn implementation date for ICD-10.  With just under ten months left until the most recent deadline of October 1, 2015 – and that date likely to stick thanks to Congressional support and a growing chorus of healthcare stakeholders endorsing the switch – healthcare providers may not have the luxury of banking on an additional delay.  Organizations can make the most of their remaining time by using CMS resources to develop a specialty-specific action plan that will carry them through their ICD-10 prep for the rest of the year.

The Centers for Medicare and Medicaid Services has provided a number of transition resources to providers who may not be sure what is required for the ICD-10 switch or how to achieve transition benchmarks.  Among these Road to 10 tools is an interactive timeline feature which allows providers to select their practice type, size, progress, and business partners to formulate a personalized plan.

The action plan tool provides common specialties with tailored information, including the clinical documentation changes necessary for the most common ICD-10 codes and sample clinical scenarios for practice.  For cardiologists, for example, the literature reminds practitioners that a myocardial infarction is only considered acute for a period of four weeks after the incident in ICD-10 compared to 8 weeks in ICD-9.  Orthopedists are prompted to remember the specificity requires to accurately code a bone fracture, including the type of fracture, localization, healing status, displacement, and complications, while obstetricians will need to distinguish between pre-existing conditions and pregnancy-related issues when documenting complications.

For the 27% of providers who have not planned to start their ICD-10 testing as of November, and especially the 30% who admitted that a lack of understanding had them stalled, the Road to 10 timeline provides detailed steps to achieve internal and external testing of systems.  From identifying sample cases for testing to coordinating with external business partners and fixing any problems that arise from the process, the resource allows providers to review checklists and suggestions that will set them on their way towards a successful testing period.

CMS suggests that healthcare providers have their internal testing already completed by this point in the process, and is currently seeking volunteers for their end-to-end testing week scheduled for the end of April.  According to the timeline, the external testing process is likely to extend through July as organizations coordinate with their payers and clearinghouses, but the number of providers that are significantly behind these recommended timeframes means that many in the healthcare industry are likely to experience a sharp crunch up against the October deadline.

Providers that are struggling with the sheer volume of tasks associated with the ICD-10 switch may benefit from using the Road to 10 toolset and exploring CMS resources on the transition to identify common pitfalls that may strike their specialty or size of practice.


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Time for Government to Step Out of the Way of EHR and Let the Market Takeover? | Hospital EMR and EHR

Time for Government to Step Out of the Way of EHR and Let the Market Takeover? | Hospital EMR and EHR | EHR and Health IT Consulting | Scoop.it

The always interesting and insightful John Moore from Chilmark research has a post up that asks a very good question. The question is whether it’s time for the government to get out of the EHR regulation business and let the market forces back in so they can innovate. I love this section of the post which describes our current situation really well:

But as often happens with government initiatives, initial policy to foster adoption of a given technology can have unintended consequences no matter how well meaning the original intent may be.

During my stint at MIT my research focus was diffusion of technology into regulated markets. At the time I was looking at the environmental market and what both the Clean Air Act and Clean Water Act did to foster technology adoption. What my research found was that the policies instituted by these Acts led to rapid adoption of technology to meet specific guidelines and subsequently contributed to a cleaner environment. However, these policies also led to a complete stalling of innovation as the policies were too prescriptive. Innovation did not return to these markets until policies had changed allowing market forces to dictate compliance. In the case of the Clean Air Act, it was the creation of a market for trading of COx, SOx and NOx emissions.

We are beginning to see something similar play-out in the HIT market. Stage one got the adoption ball rolling for EHRs. Again, this is a great victory for federal policy and public health. But we are now at a point where federal policy needs to take a back seat to market forces. The market itself will separate the winners from the losers.

His points highlight another reason why I think that ONC should blow up meaningful use. In my plan, I basically see it as the government getting out of the EHR business. I do disagree with John Moore’s comments that the government should step away from interoperability. If they do, we just won’t have interoperability. I guess he’d make the argument that value based reimbursement will force it, but not in the same way that the rest of the EHR incentive money could force the issue.

I have learned that to really get out of this game or even do what I describe will take an act of congress. HHS can’t do this without their help. Although, they could get pretty close. Plus, maybe they could exert their influence to get congress to act, but I won’t be holding my breathe on that one.


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US Immigration Dept. Sees Advantages of New EHR Infrastructure | EHRintelligence.com

US Immigration Dept. Sees Advantages of New EHR Infrastructure | EHRintelligence.com | EHR and Health IT Consulting | Scoop.it
A centralized EHR infrastructure is promoting care quality improvements in the US Immigration and Customs Enforcement department.

The US Immigration and Customs Enforcement (ICE) system is celebrating the completion its EHR infrastructure implementation, which transformed the agency’s paper-based healthcare system into a centralized, web-based system that allows health information exchange to improve care coordination while cutting costs.  For its quick and successful implementation, the team charged with developing the EHR infrastructure has received a 2014 Director’s Award for meritorious service for outstanding performance and inspiring accomplishments advancing the mission of ICE.

As with other governmental healthcare systems, the ICE Health Service Corps (IHSC) must track and coordinate care for persons that may travel between facilities or have a history of care at private providers.  IHSC, which operates under the Department of Homeland Security, provides care to around 15,000 ICE detainees at more than 20 facilities, the department’s website says.  Patients in the system also receive care from external providers when necessary, which requires the 900-strong IHSC staff to exchange health data electronically in order to ensure continuity.

“The very nature of detainee health care requires sending medical information across different locations,” said Capt. Deanna Gephart, deputy assistant director of Operations for IHSC in a press release.  “Now that we have the capability to share data electronically, the detainee health care system is much more efficient, which translates into increased quality health care provided to detainees.”

“I couldn’t be more proud of the effort of the team who dedicated their time and effort to modernizing this system,” added Jon Krohmer, assistant director of IHSC. “In less than 15 months, they successfully acquired, installed, configured, trained and deployed the system to all 22 IHSC-staffed facilities.  In the process, ICE has realized a $2 million annual cost avoidance.”

The EHR will allow ICE to better complete public records requests, including the release of data under the Freedom of Information Act, Congressional inquiries, and routine audits.  ICE also believes the new system will contribute to a reduction in the risk of medical errors, improved standardization of care, and the ability to better measure and achieve high performance on quality metrics.

Gephart previously noted that the department’s health information management system lacked sufficient interoperability “ICE has a frequent need to send medical information across different locations, which is cumbersome when each site has its own system,” she said in September.  In 2012, ICE completed 220,000 intake screenings and 104,000 physical exams while conducting more than 13,000 emergency room or off-site referrals, highlighting the need for robust care coordination throughout the busy system.

The successful EHR implementation comes amidst massive modernization efforts by the Department of Veterans Affairs and Department of Defense (DOD), both of which operate on an even larger scale.  Interoperability and care coordination cross multiple facilities are equally critical to these projects, and are some of the major criteria for the vendor selection process as the DOD seeks to leave its legacy systems behind in favor of a newly centralized infrastructure.


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Is Your EMR Hooked Up To The World? | Hospital EMR and EHR

Is Your EMR Hooked Up To The World? | Hospital EMR and EHR | EHR and Health IT Consulting | Scoop.it

A few months ago, I was having a conversation with a vendor executive about the challenges EMR companies face.  He said that in his mind, the big differentiator won’t be interfaces or even key features, but the extent to which the vendor has hooked up with key outside services.

According to this man — whose story, to be honest, I haven’t been able to verify — it can three months or more to link up with big laboratory providers like LabCorp or Quest.  Partnering with payors is another nightmare, even for vendors that run a practice management system already handling billing issues. And what about synching up with radiology information systems

Now, don’t get me wrong:  Service providers are getting wise to this problem. LabCorp, for example, now boasts about its EDI interface and touts its connections with 300+ EMR, practice management and laboratory information service vendors. It also offers eLabCorp, a Web-based solution for test ordering and test result retrieval.

Private software vendors are also in the mix. For example, I stumbled across one vendor offering bundles that connecting physicians, payors and radiology information systems.

But most of the interface development seems to be ad-hoc, with the costs borne by the healthcare provider rather than the EMR vendor.  And it’s a costly problem.

As things stand, after all, creating flexible, functional interfaces between EMRs and key service providers is still largely a job for specialized experts, and they don’t come cheap.  (As readers know, it’s not that your crack IT team can’t build the interfaces on its own, but where will staffers find the time?)

However, my guess is that as IT users get their bearings, they’ll demand a better range of connected partners from EMR vendors.  Rating how connected vendors are to labs, payors and other transaction partners is likely to rise close to the top of RFPs and internal checklists.

Ultimately, even high-end EMR systems will begin to look similar as the hospital industry standardizes on Meaningful Use-driven features and functions. (You’d think a multi-million dollar system would have a unique footprint, but let’s face it, anything can get commoditized.)

Soon, to get hospital business, they’ll have to offer options which directly improve operations or generate profits. And it’s not a moment too soon.

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Are Best Of Breed EMRs Going Out Of Fashion? | Hospital EMR and EHR

Are Best Of Breed EMRs Going Out Of Fashion? | Hospital EMR and EHR | EHR and Health IT Consulting | Scoop.it

This week, I visited a hospital which belonged to a health system going with Epic. This hospital, one of the smaller facilities in the chain, was running Picis in the ED and (I think) Cerner throughout, but the decision had been made to convert everything to Epic sometime soon, a tech told me.

I can’t say the news was surprising, but it was disappointing nonetheless. The community hospital in question has given me excellent service, and my guess is that when Epic barrels in, it will lose its way — at least for a while — frazzling the staff and decreasing the quality of their interaction with me.

However, I ‘d better get used to this trend. As Healthcare Technology Online editor in chief Ken Congdon notes in an excellent editorial, the pendulum is definitely swinging toward enterprise-wide EMR implementations, a direction encouraged by the standardized demands imposed nationwide by Meaningful Use.

If interoperability was easier to pull off, things might be different. But with HL7 and other integration standards and languages still not quite up to the job, one can see the sense of going with an enterprise option.

Here’s the story one CIO told Congdon as to why he’s deploying Siemens Soarian solution:

Michael Mistretta, CIO of MedCentral Health System  [said:]  “Vendor management was a key consideration in our decision to use a single vendor approach to EMR implementation,” says Mistretta. “With a single vendor, I only have one finger to point at. It simplifies my environment because I don’t have Siemens telling me it’s McKesson’s problem and vice versa. Also, the built-in interoperability is key. There is a trade-off in the fact that the system does not provide prime functionality to certain departments or specialties within our health system, but at this point in time, it’s much more beneficial for our organization to have the ability to share data across the continuum of care quickly and easily.” 

CIOs of large hospitals also told Congdon that enterprise system replacements were much cheaper than going through a long-term, highly-complex integration effort.

In an interesting twist, however, hospital IT leaders from mid-sized to smaller hospitals have reached the opposite conclusion, Congdon reports. They’ve been telling him that buying an enterprise system would be much more expensive than sticking with what they had and making it interoperate.

I see a market opening here. If enterprise EMR vendors can get their pricing in line for smaller hospitals, they may have a lot more wins coming their way than they expected.  Interesting stuff.



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Ingredients to a Successful ICD-10 Implementation - HITECH AnswersHITECH Answers

Ingredients to a Successful ICD-10 Implementation - HITECH AnswersHITECH Answers | EHR and Health IT Consulting | Scoop.it

Have you ever thought about just how many moving parts there are in an ICD-10 implementation? The whole process can seem overwhelming to a practice and as a Practice Management/EHR vendor who needs to understand all of these different pieces, we’ve found that the best way to approach this is by breaking down the implementation into three main ingredients: People, Processes & Technology. So what do these mean, what’s your role and how do you formulate a plan for ICD-10 success?

People – Because a successful ICD-10 implementation affects all departments in your practice, awareness, preparation, testing and training should already be well underway. Medical coders and physicians aren’t the only people who require high ICD-10 competency. The key to preparing your entire staff for ICD-10 readiness is identifying what training is required by role, who conducts the training, budgeting for training costs and downtime, timing and finally, ensuring staff is adequately prepared and capable. ICD-10 readiness should include regular communications with management, IT staff and clinical staff about new procedures and new or updated software such as Practice Management and EHR systems. Staff also needs to be able to handle new requirements and forms, such as paper superbills, as part of the new billing, claims and documentation procedures.

Processes – The impact of ICD-10 on practices can vary depending on specialty, patient mix, top diagnoses and payer mix. Solo and other small practices will typically have greater risk and deeper impacts due to fewer resources and available funds. Moving to ICD-10 will require tremendous effort and process coordination of nearly every workflow. Processes to manage 120,000 new codes in a way that allows simple, accurate look-up and application of codes requires collaboration across the practice – including your IT systems and people. Productivity standards may have to be redefined, requiring additional coding staff, existing staff may need to be retrained, and providers may need to change how they document with more detailed diagnosis information.

Technology – This is the backbone of a successful ICD-10 implementation and gives your practice, people and processes a foundation to guide your operations and improve coordination of benefits and care. When properly configured to an ICD-10 environment, technology can help ensure critical processes are performed – such as documentation, coding, billing and bi-directional data transmission – all while ensuring third-party integrations can do the same. As the ICD-10 crossover date approaches, the risk of having non-compliant IT systems grows exponentially. By paying close attention to your existing IT environment and examining it against changes required to accommodate new data, new workflows and potentially new people prior to implementation, you can greatly increase your ICD-10 readiness.

As you can see, we all have a responsibility to understand the ingredients that make up an ICD-10 implementation, which will increase our knowledge in these areas and in turn, reduce risk. Look for opportunities for training, industry webinars and vendor testing. Some vendors are even offering ICD-10 Risk Assessments to assist practices in understanding the impact of ICD-10 and providing recommended actions based on the assessment results. All of these opportunities will support the success of the People in your practice performing Processes that are supported by your Technology. When these three ingredients are understood, planned for and in sync, we’ll be able to achieve ICD-10 success together!



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Why bad EMRs are forced on physicians

Why bad EMRs are forced on physicians | EHR and Health IT Consulting | Scoop.it

I recently did a tally.  Since starting my locums adventure last year, and going to full-time locums in January, I’ve worked in a grand total of 11 emergency departments.  Let me qualify that for the occasional visitor to my blog.  I decided to do this for purposes of flexibility, finances and a much needed change of scenery.  Not because I’m a problem physician, or unable to do the work in a “real” job.  I say that to emphasize the fact that at 21 years into my career, I am a keen and qualified observer of life in emergency medicine; in fact, of life in medicine in general. It’s one of the things I write about most.  And I do so because there are so many regular physicians out there with grave concerns and real problems, for whom there is no voice at all.  I try to be that voice.


And one of the things the doctors are crying out over is electronic medical records, or EMR.  These are systems that hospitals impose upon physicians in order to capture extra federal dollars via meaningful use. Or in order to mine the data so that they can squeeze every more blood from the turnip of paying patients and insurers.  Or, they are used to track every motion, every action so that administrators can have sufficient flow charts, spread sheets and other data with which to send “bad boy” letters to clinicians reminding them to work faster or better.  (And which allow various mid-level managers something to do all day without having to actually care for patients or provide intrinsic value to the hospital.)

Mind you, EMRs were already on their way, but now the administrative pressure is high.  Sadly, the systems are very, very bad indeed.  It is said that use of an EMR, versus paper charts or dictation, typically reduces physician productivity by about 30% right out of the box.  It is also noted that now, young physicians in training spend more and more time at keyboards and less and less time looking at that pesky throwback to ancient times, the human patient.  (How dare they not be pixelated!)

The sound of medicine these days is the sound of the keyboard. It is so prevalent at times that it nearly causes me to have a headache and nausea.  Tap, tap, tap, day and night.  We dash to the patient and we come back and spend the lion’s share of our time using the one class of all our classes that mattered most; typing or keyboarding.

This is not because it generates a good chart.  In fact, most systems generate terrible charts.  Charts full of clipped sentences and check box histories and exams that read worse than the worst prose.  A patient encounter can generally be summarized in well composed paragraph.  It’s just harder to mine the data from said writing.  So modern EMR charts are inundated with time-stamps and worthless information, much of it put in the chart by nurses also forced to document everything from the patient’s pain scale to when they last fluffed his pillow or inquired as to his general state of happiness.  All too often, the reason for the visit is buried in nutritional assessments and statements about whether or not they feel safe at home, or the bed-rails are up.  (I have actually witnessed charts on patients with a laceration in which the laceration or its location were nowhere described.)

The whole thing is demoralizing.  It is my experience that physicians and nurses routinely stay an hour or two later than their shift time, just to complete charting that they couldn’t do while trying to see human beings in a timely and competent manner.  In the process, they develop repetitive stress injuries like carpal tunnel syndrome.  I have had right shoulder pain on several occasions after prolonged charting.  Of course, this extra time does not in any way result in extra hourly compensation. It is a requirement added on the already too many requirements of life in modern emergency departments, imposed by those whose jobs end at 3 or 5 and who do not spend their days logging in, logging out and trying to click all the right boxes while around them, people may well be dying.  But I digress.

Having used a number of EMR systems, I can say that some are horrendous.  These are the systems that require at least four to eight introductory hours of classroom time.  These are the systems that ultimately take users weeks to fully comprehend and employ.  These leave users frustrated and angry; sometimes tearful as they simply can’t be used in a manner commensurate with the pace of the actual medicine being practiced.

Why are cumbersome systems used?  Many reasons, no doubt.  Perhaps because the hospital or hospital system has been heavily courted by a large company that convinced them that it was an “industry standard,”  that “everyone who is anyone is using it.” Certainly not, in general, because the end-user (physicians and nurses) found it simple and effective; that metric seems almost laughable these days. Doctors and nurses are commoditized quantities who will do as they’re told or else.  Period.

The cumbersome systems are also, often, connected with the large corporations that run health care.  They own or are affiliated with EMRs and those systems, with their built in data capture and billing systems, are forced upon the system’s providers to maximize reimbursement. ( One more reason, in my estimation, that a simple laceration costs $1,000 in most emergency departments.)

I am not naming bad systems; not yet.  But I am going to name two systems that are excellent.  I am not an owner, shareholder or employee of either.  I simply want to illustrate the difference.  I have used systems that required an IT nurse educator to sit by my side for at least an entire 8 or 10 hour shift; and still I wasn’t clear.  And by way of disclaimer, I realize that even the systems I’m naming are businesses, dedicated to both documentation and generating revenue.

Having said that, I repeat that I have used systems that I understood and could use competently in 30 minutes.  Why aren’t these more popular?  Because if we want physicians to use EMR, and we want those physicians to do their jobs effectively and quickly, we need to simplify and streamline.

Which ones, you ask?  First of all, EPOWERdoc.  I have used this at two facilities and found it to be delightfully simple, with a very gentle learning curve.  I learned, and used it, within about 15 minutes.  The doctor leaving night shift showed it to me and I used it seamlessly for the next 12 hours and from then on at that, and another, facility.

Second, T system.  I have used paper T-sheets and they’re nice and simple.  Personally, given my bad penmanship, I prefer the electronic version.  When I first used it in June of this year, I was met by an IT educator as I walked into the shift.  In 20 minutes, I understood it and smiled as I enjoyed its intuitive design for the next 10 hours.

I suspect that if physicians had any control of this situation, the majority would use the simplest system possible. As it stands, however, we don’t.

Pity, because the demands on emergency departments grow more intense every day.  The stresses are high and the resources are stretched. The last thing anyone needs is a complicated, time-intensive, soul-sucking computer program.

What we need is simplicity and compassion for providers.

Is that too much to ask?



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Updates for Meaningful Use, Interoperability, Health Reform | EHRintelligence.com

Updates for Meaningful Use, Interoperability, Health Reform | EHRintelligence.com | EHR and Health IT Consulting | Scoop.it

Developments during the last week of January will have a serious effect on the progress of meaningful use, interoperability, and health reform in the coming year.

Perhaps the most important development for health IT was a reduction in meaningful use reporting requirements in 2015. After months of feedback criticizing the meaningful use requiring for reporting in 2015, the Centers for Medicare & Medicaid Services (CMS) finally decided to opt for a 90-day reporting period rather than one requiring a full year’s worth of EHR data.

In a CMS blog post, Patrick Conway, MD, the Deputy Administrator for Innovation & Quality and CMO, highlighted three meaningful use requirements the federal agency is considering for an upcoming proposed rule.

The first would require eligible hospitals like eligible professionals to report based on the calendar year, which would give these organizations time to implement 2014 Edition certified EHR technology (CEHRT). The second would change “other aspects of the program to match long-term goals, reduce complexity, and lessen providers’ reporting burdens.” Lastly and most importantly, CMS is considering reducing the meaningful use reporting requirement from 365 days to 90 days.

As Conway noted, this proposed rule is separate from the one for Stage 3 Meaningful Use expected next month. However, the spirit of the two proposals is to reduce burdens on providers while promoting expanded use of CEHRT.

Most recently, the Office of the National Coordinator for Health Information Technology provided its earliest plans for enabling nationwide interoperability. The first draft version of the interoperability is the first iteration of the federal agency’s long-term plans for enabling a health IT ecosystem and infrastructure with the ability to exchange patient health data efficiently and securely.

“To realize better care and the vision of a learning health system, we will work together across the public and private sectors to clearly define standards, motivate their use through clear incentives, and establish trust in the health IT ecosystem through defining the rules of engagement,” National Coordinator Karen DeSalvo, MD, MPH, MSc, said in a public statement.

The lengthy draft comprises both long- and near-term goals for promoting standards-based exchange among healthcare organizations and providers. The document is current open to public comment through the beginning of April.

At a higher level, the Department of Health & Human Services (HHS) laid out its plans for shifting healthcare dramatically from volume- to value-based care. Secretary Sylvia M. Burwell has committed Medicare to making half of the program’s reimbursements based on value by 2018. Over the next two years, the department is aiming to shift 30 percent of fee-for-service payments into quality-based reimbursement paid through accountable care organizations (ACOs) or bundled payments.

The challenge for the department and the Medicare program is significant considering that accountable care comprises an estimated 20 percent of total Medicare payments. “We believe these goals can drive transformative change, help us manage and track progress, and create accountability for measurable improvement,” Burwell said.

While all these changes took place within HHS, President Barack Obama and members of Congress began revealing their plans for supporting personalized medicine. The President’s Precision Medicine Initiative is already on the table and offers $215 million to support the National Institutes of Health (NIH), the Food and Drug Administration (FDA), and ONC. Meanwhile, the House Committee on Energy & Commerce is moving forward with the discussion phase of its 21st Century Cures initiative which aims at speeding along patient-centered regulation and supporting medical researchers, clinical data sharing, clinical research, and product regulation.

All in all, the last week of the first month of 2015 may go down in history at a pivotal moment in the real transformation of healthcare in the United States.


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Questions to Ask Before Choosing an EHR

Like many managers or owners of a thriving medical practice, you have heard about the benefits of using electronic health records software and are interested in implementing an EHR in your organization. You can assume that many, if not all, of your nearby competitors are using EHR, and the more effective they are in using this software, the better they will be able to attract and keep patients.

Transitioning from the old methods of paper-based systems to the latest advances in medical software is bound to raise some questions among you and your staff. Therefore, it’s a good idea to do some research first before making the commitment and selecting your EHR. With that in mind, here are some questions to ask as you prepare to make your choice.

Is the Software Vendor Knowledgeable and Reliable?

It’s much better to go with a software vendor that has sufficient experience, knowledge, and a proven track record in developing mission-critical software like EHR. Find a firm that has been around for a while and that has excellent reviews from your peers, as well as your competitors.

A software developer for medical organizations must have a staff that keeps up with the changing nature of healthcare delivery, adjustments in industry standards, and governmental rules. This ensures that you will always have access to software this is compliant with the entities you do business with.

What Kind of Training is Available?

After assessing the skill level and knowledge of your medical organization, you will have a better idea of how much training you need. Make sure that your software provider will give your team the training and help it needs to quickly get up to speed with using EHR software.

How Does the Software Company Handle Upgrades?

Upgrades are a fact of life in any computer system. You’ll want to ask your vendor how it approaches upgrades. There will be upgrades to improve the quality of the software, to be sure, but there will also be required updates, such as the ones EHR software developers must finalize to meet the U.S. government’s required change from ICD-9 to version 10 of the International Classification of Diseases.

Does the Software Vendor Provide Good Customer Service?

The last thing you want when dealing with unfamiliar software is to contend with unanswered questions on how to use it. Check the level of customer service from your prospective provider. Otherwise, your staff may experience unexpected and unnecessary downtime, hampering office productivity and lowering your organization’s financial success.

Making the decision to move from a paper-based system for managing your medical organization will make a significant impact on your staff’s daily activities. Now that you know you want to implement an EHR, it’s crucial to resolve any unanswered questions before making your software selection.

Key Takeaway:

  • Medical practice owners and managers who are aware of electronic health record software will want to ask some questions before choosing their EHR.
  • Don’t rush into buying EHR software that you are unfamiliar with. Make sure you understand how it will integrate with your organization.
  • Check what kind of training your software provider offers to ensure your staff can quickly get up to speed with the EHR system.
  • Verify the skill level and knowledge of your software company to make sure it will be capable of handling upgrades, especially those mandated by governmental regulations.
  • Does the EHR vendor provide the type of customer service that you deem appropriate? You will want to go with a firm that has excellent communication skills and will respond in a timely manner.


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Reigniting ICD-10 Momentum in Your Organization

Reigniting ICD-10 Momentum in Your Organization | EHR and Health IT Consulting | Scoop.it

Now that Congress has rejected requests to delay ICD-10, it’s time to get on the bandwagon or risk significant financial implications. ICD-10 touches virtually every aspect of your organization’s processes and systems, and failure to prepare and comply with the mandate will have a significant impact on your reimbursements.

If your organization has lost momentum or has not started the ICD-10 journey, hiring internal resources or working with external experts will be necessary to meet the deadline. Below is a cheat sheet – based on best practices and industry guidelines – of essential questions to ask leadership and next steps:

  • Is ICD-10 a priority for your leadership team?
    Evaluate organizational awareness of ICD-10 and confirm leadership is in place to drive the transition. Successful ICD-10 planning involves defining project leadership, executive sponsorship, and reporting structures. Given the far-reaching organizational impacts of ICD-10, without defined roles and responsibilities, a critical remediation area may be missed. Identify stakeholder accountability for ICD-10 compliance and designate project managers to lead revenue cycle, coding and clinical documentation improvement (CDI), and IT system initiatives. Develop a project communication plan that sets expectations about what should be communicated to whom, the reason for the communication, frequency, and method.
  • Are your systems ready and have you evaluated the impact of ICD-10 to all system workflows?
    Assess operational readiness by taking an enterprise-wide systems and process inventory to identify where codes are used. Utilize assigned project managers to uncover all systems and processes where ICD-9 codes are sent, received, or stored. Conduct workflow analyses to ensure understanding of how systems and processes are impacted. This exercise can provide immediate benefit to an organization as workflows operating inefficiently are identified. Develop a prioritized project plan and remediation timeline for each impacted area. For example, technology and workflows need to be optimized within patient access to assure compliant orders for dates of service on or after October 1, 2015. Conduct regular reporting on initiatives and ensure stakeholders are being held accountable for designated tasks.
  • Does your staff have appropriate organizational awareness and knowledge of ICD-10?
    Understand what roles individuals play within your organization with respect to ICD-9 code usage, and employ a role-based training initiative. While coders, CDI specialists, and providers will need the majority of training, areas, such as patient access, ancillary departments, business offices, and IT should not be overlooked. Also, keep in mind the impact on your quality team. Patient populations monitored by core measures, as well as other quality metrics are determined by ICD-9 codes. When selecting a training vendor, confirm the vendor offers courses tailored by job function and provides the necessary courses for coders and specialty-specific training for providers. Track and communicate training progress and ensure training compliance is an organizational priority. As part of your strategy, attempt to incorporate training with other planned education to reduce workflow disruption.
  • Are you establishing ongoing experience with the new code set?
    Act fast to incorporate dual coding initiatives. Based on experiences with ICD-10 in other countries, research suggests that allowing coders to simultaneously code in ICD-9 and ICD-10 allows them to achieve proficiency and decrease productivity loss. Dual coding has been shown to significantly reduce the anticipated 40 to 60 percent inpatient and estimated 20 percent outpatient productivity loss. The first step is to create a project plan that identifies coders, checks systems, and determines expected coding system upgrades. Next, create a strategy for managing dual coded data to be analyzed. A coding roundtable of key stakeholders from an organization’s coding team should be developed to create accountability and drive documentation improvements during the dual coding process. As part of the learning process, coder education should initially emphasize documentation requirements for coding the most common conditions within the organization and those with the highest allowed amounts. A minimum of six months of practice is recommended.
  • Are you conducting internal and external testing of systems for ICD-10 compliance?
    Define testing goals and document a plan to test each impacted system internally and conduct external testing to the greatest extent possible. Appropriately testing impacted applications is a complex and time-consuming process and should not be seen as a last step. Many variables — including competing organizational priorities and resource availability — as well as clearinghouse, payer, and third-party tester schedules, can influence the testing timeline. Designate a well-defined team to undertake, define, and monitor the testing readiness plan for your impacted systems and software. Each impacted system should be reviewed for the type of testing that is needed. Billing systems are the most complex and must be ready to send ICD-10 coded bills to payers or payment will be denied. Testing of billing systems should include all of the workflows where codes live, (e.g., claim edits that currently contain ICD-9 codes). Use your high volume and high value codes for testing, and determine the ICD-10 workflow for each impacted application. Then, complete individual testing of applications by running the applications through the identified workflows. Once that process is complete, begin integrated testing through following the process for codes to flow to downstream applications and out to the payer. If you haven’t been selected for payer testing, then work with your clearinghouse to test claims externally through them.
  • Is your CDI program optimized and ready for ICD-10?
    Emphasize clinical documentation process improvements to realize bottom-line gains now while preparing for ICD-10. While most healthcare systems have a CDI program, many are not achieving the desired results in appropriately coding conditions to the highest level of specificity. For example, if the organization is not able to code the specific type of congestive heart failure in ICD-9, the problem will only worsen in ICD-10 with requirements for greater specificity to attain complications and co-morbidities (CCs) and major complications and co-morbidities (MCCs) for many DRGs. While revamping a CDI program is a separate goal, perfecting ICD-9 queries and introducing ICD-10 queries early will help prepare an organization for ensuring compliance with the increased specificity ICD-10 demands.
  • Have you planned for predicted delays in cash flow?
    Create a contingency plan to mitigate potential productivity and revenue losses. Hope for the best, but prepare for the worst. Based on Canada’s ICD-10 experience, coding productivity may drop by 50 percent immediately following implementation. Performance improvements may take at least 90 days to be realized. If claims are suspended, rejected, or delayed following ICD-10 implementation, have a plan available in advance to quickly respond to different scenarios. Alternatively, some providers and payers have drafted stopgap provisions in their contracts to maintain a consistent cash flow and “true up” every three months.

While changing processes, systems, technologies, and staff resources to accommodate the shift from ICD-9’s 17,000 to ICD-10’s 140,000 codes may seem overwhelming, there is still time to meet the requirements by taking a prioritized and focused approach.  Having the right mix of expertise and staffing is necessary to meet the upcoming deadline.  Contingency plans will also help mitigate losses following ICD-10 implementation. Beyond getting paid, ICD-10 also promises to improve clinical outcomes by increasing the specificity and accuracy of clinical documentation to guide patient care decision-making. It’s an investment that is worth the effort.


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EHR Technology Patent Lawsuit Deemed Abstract, Ineligible | EHRintelligence.com

EHR Technology Patent Lawsuit Deemed Abstract, Ineligible | EHRintelligence.com | EHR and Health IT Consulting | Scoop.it

MyMedicalRecords has failed in an EHR technology patent lawsuit brought against numerous competitors, according to an Electronic Frontier Foundation report.

The court’s ruling applies to a consolidation of cases with MyMedicalRecords as the plaintiff and the following as defendants:

  • Walgreen Co.
  • Quest Diagnostics, Inc.
  • WebMD Health Corp; WebMD Health Services Group Inc.,
  • Jardogs, LLC; Allscripts Healthcare Solutions, Inc.

United States District Judge Otis D. Wright, II, concludes that the MyMedicalRecords ’466 in patent ineligible on the grounds that it pertains to “long-known abstract idea.”

Following the application of a test from a related patent case (Mayo Collaborative Servs. v. Prometheus Labs., Inc.), Wright takes particular umbrage with the eighth claim of the MyMedicalRecords complaint because it lacks “inventive concepts”:

Claim 8 recites a method for providing a user with the ability to access and collect personal health records in a secure and private manner by: (1) associating access information with the user to access a server storing files; (2) providing a user interface; (3) receiving files at the server from a health care provider; (4) receiving requests through the user interface; (5) sending files; and (6) independently maintaining files on the server.  All six of these concepts are routine, conventional functions of a computer and server and therefore broadly and generically claim the use of a computer and Internet to perform the abstract purpose of the asserted claims.

According to Wright, the remaining claims similarly fail in adding anything of significance to the abstract idea of securing and sharing information.

Ultimately, the US District Court of the Central District of California sided with the defendants and their granted their motion judgment “without leave to amend.” For its part, MyMedicalRecords is still boasting a large patent portfolio that remains unaffected by the court order.

“MyMedicalRecords, Inc. will continue to pursue opportunities to monetize its 13 U.S. patents with more than 300 existing claims where appropriate in the burgeoning health information technology marketplace,” the company said in a public statement following the ruling.

As Adi Kamdar of EFF reports, the litigation being pursued by MyMedicalRecords works against meaningful use requirements that demand eligible providers perform each one of the activities listed by Wright.

“It falls in the category of threats from patent holders who decide to go after companies for abiding by new rules or regulations—doing so, they allege, infringes one or more of their patents,” he writes.

Without EHR technology certified to support, these providers would have limited options for selection EHR and health IT systems. For those opposed to “patent trolling,” the case of MyMedicalRecords raises questions about the patent application and acceptance process.


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What Gets Measured Gets Managed - HITECH AnswersHITECH Answers

What Gets Measured Gets Managed - HITECH AnswersHITECH Answers | EHR and Health IT Consulting | Scoop.it

Say what you will about the pains of implementing an EHR or meeting the requirements for Meaningful Use. I’ll grant you that there are hiccups, roadblocks, stumbling points on the path to going digital. No doubt. But, you can’t deny that data doesn’t lie and when we measure data, we can manage it.

Case in point: an 11-doctor pulmonary group was scheduled to attest to Stage 2 Meaningful Use in 2014. The group’s practice manager was new to the organization and tasked with the responsibility of managing the eligible providers’ progress. She was overwhelmed and understandably nervous that the responsibility for earning $92,000 of incentive funds and avoiding a 2% penalty in 2016 was on her shoulders.

The Stage 2 requirements were a worry. The practice had just recently updated to the 2014 Edition EHR software and the patient portal had only been implemented for a month. She wasn’t sure if they could meet the patient engagement requirements and she didn’t know where they stood with the newly introduced objectives.

She asked for support through her network and found me.

Data > Information > Knowledge

I started by getting access to her EHR and venturing to the reporting module. I found out how each provider was performing on each of the Stage 2 Meaningful Use criteria and compiled the data. In fact, you can see their starting point for yourself by looking at the left side of the below chart. (Hint: click image for better viewing)

 

I could see right away why the practice manager was concerned. You can see on the left side that as of October 5, none of the providers were meeting the criteria for Core 7 (VDT), Core 12 (Patient Reminders), Core 17 (Secure Messaging), or Menu 4 (Family Health History). Only half of the providers were capturing enough vitals information (Core 4) and clearly workflows needed to be reinforced for several others, including Core 1 (CPOE for medication orders), Core 5 (Smoking Status), Menu 2 (Electronic Notes).

They were able to exclude Core 15 (Transition of Care), which is why those rows are blank.

We had 90 days to turn this around.

Team Work

Armed with information, we came up with a plan. The practice manager would work with each doctor and their support staff to communicate the goals, state their status, and ensure that each person was enrolled in doing their part.

Meaningful Use is a team sport, after all.

The nurses were charged with increasing their vitals stats. The administrators made sure that reminders were sent out to patients with a specific diagnosis for preventive or follow-up care. The doctors were instructed to collect smoking statuses for more patients.

We found out that there were new features within the EHR to accommodate Stage 2, so with help from the EHR vendor, we found out how to trigger the numerators for electronic notes and for family health history. It took a couple tweaks in customization and then training on the new workflows.

With each week’s reports, we saw steady improvement. But it was important to keep the pressure on to strengthen the areas of weakness.

Getting Creative with the Portal

In November, we focused diligently on the portal. The practice has several locations, so they started a contest among them to see which office could sign up the most patients to the portal. Some locations struggled more than others, complaining of elderly patients not having access to the internet.

Ultimately, what worked best was incentivizing the patients. They purchased a bunch of $5 gift cards to Amazon and  gave them out to patients AFTER they had both logged in to the portal to view, download, or transmit their health record AND sent a secure message to the doctor.

They even told patients what to say:

Dear [Provider], I was able to see my health record through the portal. Now I know where I can send you messages directly if I have questions. Thanks, [Patient]

This step alone addressed the tougher patient engagement objectives and by mid-November, we started seeing drastic improvements in the VDT and Secure Messaging stats.

The First Big Win

Around the same time, we got the first provider to meet ALL of the percentage-based requirements. It took some targeted attention to improve specific workflows, but once the first doctor demonstrated that it could be done, the others followed right behind him. By the end of November, more than half the providers were hitting the marks; and by the second week of December, all of them were.

Their main focus on closing out the year was to keep up the good work.

Non-Percentage Based Objectives

Some Meaningful Use requirements are not numerator/denominator based and require a Yes/No response. For example, were clinical decision support rules in place and did at least 5 of them related to the chosen Clinical Quality measures? Did each provider generate a patient list for a specific diagnosis for the purpose of sending reminders, outreach, or research? Was a Security Risk Analysis performed and security updates implemented to correct any identified deficiencies? Yes, yes, and yes.

Lessons Learned

1. It sure helps to have engaged team members. The practice manager served as the messenger – communicating where improvements were needed. The doctors were responsive to looking at their data, comparing it with their peers, and then making concerted efforts to improve. The office staff were all willing to step up their game when they understood the mission of engaging patients. The EHR vendor was helpful with setting up the appropriate settings and customizing the EHR when needed.

2. What gets measured gets managed. Sticking our heads in the sand and hoping Meaningful Use would take care of itself simply would not have worked. We needed to know where improvements could be made and the only way to do that was to look at the data often and respond to it.


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FDA Expands EHR Data Analytics with Active Surveillance System

FDA Expands EHR Data Analytics with Active Surveillance System | EHR and Health IT Consulting | Scoop.it

The Food and Drug Administration’s Sentinel Initiative, one of the first active surveillance infrastructures focused on identifying patient safety issues related to pharmaceuticals and other medical products, will expand past its pilot phase this year, announced Janet Woodcock, MD, Director of the Center for Drug Evaluation and Research in a blog post.  As a planned continuation of the Mini-Sentinel project, the full-scale system will allow the FDA to leverage advanced EHR data analytics by scanning millions of files for adverse events linked to drugs that fall under the Administration’s purview.

“Over the past five years, the Mini-Sentinel pilot program has established secure access to the electronic healthcare data of more than 178 million patients across the country, enabling researchers to evaluate a great deal of valuable safety information,” Woodcock writes. “While protecting the identity of individual patients we can get valuable information from Mini-Sentinel that helps us better understand potential safety issues, and share with you information on how to use medicines safely. We have used Mini-Sentinel to explore many safety issues, helping FDA enhance our safety surveillance capabilities, and giving us valuable input in decision-making on drugs and vaccines.”

The Sentinel Initiative differs from previous drug safety monitoring efforts in that it allows FDA researchers to actively dive into EHR data and insurance claims to analyze potential adverse events and establish links to specific pharmaceutical products.  This allows the FDA to work more quickly to identify problems than if they continued to rely on voluntary reporting alone.  Mini-Sentinel has previously confirmed the safety of two vaccines intended to protect infants against rotavirus after the voluntary recall of a third product that raised the risk of intussusception in patients who received the immunization.

The expansion of the project will build upon successful use cases from Mini-Sentinel, Woodcock says.  The FDA will refine its EHR data analytics methodologies as it continues to grow into what the Administration hopes will be a national resource at the center of an industry-wide collaboration between researchers, pharmaceutical developers, and other healthcare stakeholders.

The success of this vision relies on cooperation from academic and research partners, all of whom will need to further develop industry data standards for the system to function effectively.  “This work will allow computer systems to better ‘talk’ to each other and, ultimately will lead to better treatment decisions as clinicians will have a more complete picture of their patients’ medical histories, including visits with other providers,” Woodcock wrote in a previous blog post touting the success of the pilot system.  “Defining standards for capturing data from clinical trials, and using standard terms for items such as ‘adverse events’ or ‘treatments’ will allow researchers to combine data from different clinical studies to learn more.”

“From the outset, the goals of the Sentinel Initiative have been large and of ground-breaking scale,” she concludes. “We knew it would be years in the making, but Mini-Sentinel’s successful completion marks important progress. We look forward to continuing and expanding our active surveillance capabilities as we now transition to the full-scale Sentinel program.”


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OMB Reviewing Proposed Stage 3 Meaningful Use Requirements | EHRintelligence.com

OMB Reviewing Proposed Stage 3 Meaningful Use Requirements | EHRintelligence.com | EHR and Health IT Consulting | Scoop.it

The Centers for Medicare & Medicaid Services is one step closer to issuing a notice of proposed rulemaking (NRPM) for the next stage of meaningful use requirements for the Medicare EHR Incentive Program.

The Office of Management and Budget (OMB) is currently reviewing the proposed rule for Stage 3 Meaningful Use that is expected to be published in February.

Few details about the requirements for Stage 3 appear in the rule submitted to the OMB by the Department of Health & Human Services as part of the Unified Agenda — that is, with the exception of the following:

In this proposed rule, CMS will implement Stage 3, another stage of the Medicare and Medicaid EHR Incentive Program as required by ARRA. We are proposing the Stage 3 criteria that EP’s, eligible hospitals, and CAHs must meet in order to successfully demonstrate meaningful use under the Medicare and Medicaid EHR Incentive Programs, focusing on advanced use of EHR technology to promote improved outcomes for patients.  Stage 3 will also propose changes to the reporting period, timelines, and structure of the program, including providing a single definition of meaningful use. These changes will provide a flexible, yet, clearer framework to ensure future sustainability of the EHR program and reduce confusion stemming from multiple stage requirements.

The rule before the OMG also indicates that CMS will coordinate with the Office of the National Coordinator for Health Information Technology to ensure that EHR certification criteria and certified EHR technology will be in place when Stage 3 goes into effect no earlier than 2017.

During a Health IT Policy Committee meeting in March, the group voted to approve 19 objectives recommended by the Meaningful Use Workgroup. Those recommendations fall into four categories of care improvements:

Improving Quality of Care and Safety
1. Clinical decision support
2. Order tracking
3. Demographics/patient information
4. Care planning — advance directive
5. Electronic notes
6. Hospital labs
7. Unique device identifiers

Engaging Patients and Families in their Care
8. View, download, transmit
9. Patient generated health data
10. Secure messaging
11. Visit Summary/clinical summary
12. Patient education

Improving Care Coordination
13. Summary of care at transitions
14. Notifications
15. Medication reconciliation

Improving Population and Public Health
16. Immunization history
17. Registries
18. Electronic lab reporting
19. Syndromic surveillance

Before any of the proposed rule’s requirements for Stage 3 Meaningful Use are enacted, the NPRM must made available for public comment which has the potential to influence the requirements of the final rule. Given the resistance CMS has faced as a result of Stage 2 Meaningful Use, the federal agency is likely to receive requests for greater flexibility and timing from healthcare organizations and industry groups.


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EHRs: It's time to start from scratch

EHRs: It's time to start from scratch | EHR and Health IT Consulting | Scoop.it

A lot has been written about how awful electronic health record (EHR) systems are. They are overwrought, overengineered, dreadfully dull baroque systems with awkward user interfaces that look like they were designed in the early 1990s. They make it too easy to cut and paste data to meet billing level requirements, documenting patient care that never happened and creating multipage mega-notes, full of words signifying exactly nothing.


They have multitudes of unnecessary meaningful use buttons that must be clicked because the government says so. They have data formats that are incompatible with other EHR systems. Doctors fumble around trying to enter orders using electronic physician order entry (POE). There is terrible user support. And so on. At the end of the day there is decreased productivity, doctors are unhappy, and patients are unhappy. Big brother in the form of the hospital and the state have more big data to look at, but certainly there doesn’t seem to be many benefits to patient care. The major benefit is to the companies that make these proprietary closed-source EHR systems. They get obscenely rich.

But surely there can be benefits to EHR systems? What about the ease of access to the patient’s chart? No more waiting for the chart to come up from medical records. In fact, no more medical records department at all! Aren’t we saving health care dollars by cutting out those jobs, as well as medical transcriptionist jobs and unit secretary jobs. Surely paper charts were worse?

Doctors should not turn away from information technology. After all, we use all sorts of sophisticated computer technology every day, from the internals of the ultrasound machine to the software running an MRI scanner, to the recording system used in electrophysiology procedures. There is a role for technology in our record keeping as well.

The problems with current EHR systems are manifold. They are hack jobs, with nightmarish interfaces that obviously were never user tested. They are overly ambitious, trying to do all things and thus doing nothing well. They are ridiculous. I mean, having doctors enter orders directly into a computer — seriously? EHR companies have no incentive to improve their user interfaces, because government mandates require that they are used no matter how awful they are. Those who don’t adopt these systems are penalized by loss of Medicare dollars.

I think it is an interesting thought experiment to consider how EHR systems would have been designed if they had been allowed to evolve naturally, without the frenzied poorly thought out incentives that exist in the real world. Imagine a world where physicians, the primary users of these systems, drove development and adoption of these systems. Imagine that there were no mandates or penalties from the government to adopt these systems. If a system was developed that improved physician workflow, it would be adopted. Nothing that slowed productivity, as the current EHR systems do, would ever be bought by a practice if the physicians made the call. Imagine EHR companies visiting practices, analyzing workflows, seeing areas that could be improved by computers, and recognizing areas that wouldn’t, at least with current technology. Imagine EHR companies testing their user interfaces using doctors from a spectrum of computer experience, as major software companies like Apple and Google do. Imagine them competing with each other not on how many modules they can provide, but on how few keystrokes or mouse clicks their system used to do the same work as another system. Imagine no government mandates for meaningful use, no dummy buttons that say “click me” but otherwise do nothing.

Think about how you would design a system. Certainly it is useful to have old records available online and we would want to keep that. The problem is how to get them there. Having physicians enter data is probably the least efficient way. Dictation and handwriting are still the fastest data entry methods. If Dragon is good enough (I’m not convinced it is) use it, or keep your transcriptionists around. They are very nice people who need jobs anyway. If handwriting recognition is good enough (I don’t think it is yet) use that, otherwise just store the written notes as pictures and be satisfied. In the ideal world, rather than force physicians to become typists and data entry specialists, we would wait until computer artificial intelligence was developed enough to allow the physicians to continue to do things the old way, with the computer processing the doctors’ notes transparently. If the technology isn’t there yet, develop it, but don’t push it on us prematurely.

Medical records primarily should exist to document important information about patients. It should not be primarily a means to ensure maximum billing of patients. If we eliminate that aspect, EHRs become much simpler. I would envision a small tablet that the MD carries everywhere with him or her. Keep the old workflow. Pull up patient records on the tablet. Write notes on the tablet in handwriting or dictate into it. The tablet transcribes the input and files it appropriately.

Need to give patient orders? Select from some templates or write them in. If the software is not good enough to transcribe written orders on a tablet, hire some unit secretaries to do this like they used to. Let them learn the intricacies of computerized order entry, and let the doctor deal with the intricacies of making diagnoses, doing procedures, and looking patients in the eye and grasping their hands when they are ailing — things that doctors do best. Minimize the interactions with the computer and maximize the interactions with the patients.

A good EHR system can simplify drug reconciliation, pull in drug data from patient pharmacies, and automatically identify patients who are being “overprescribed” pain meds. The system can look up recent relevant medical articles, can show appropriate medical guidelines, and can provide sophisticated medical calculators. There are so many good things computers can do for medicine. They’ve gotten an awfully bad rap from the current iteration of EHR systems. I think the technology exists or can exist to do all these good things, but there is no incentive if we remain satisfied with the status quo. The current systems don’t do any of these things. They just get in the way.

If we lived in an ideal world it would be time to chuck the lot and start over.


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EHR Requires You to Reconsider Your Workflow

EHR Requires You to Reconsider Your Workflow | EHR and Health IT Consulting | Scoop.it

Despite many EHR vendors best efforts to tell you otherwise, an EHR requires every organization to reconsider their workflow. Sure, many of them can be customized to match your unique clinical needs, but the reality is that implementing an EHR requires change. All of us resist change to different degrees, but I have yet to see an EHR implementation that didn’t require change.

What many people don’t like to admit is that sometimes change can be great. As humans, we seem to focus too much on the down side to change and have a hard time recognizing when things are better too. A change in workflow in your office thanks to an EHR might be the best thing that can happen to you and your organization.

One problem I’ve seen with many EHRs is that they do a one off EHR implementation and then stop there. While the EHR implementation is an important one time event, a quality EHR implementation requires you to reconsider your workflow and how you use your EHR on an ongoing basis. Sometimes this means implementing new features that came through an upgrade to an EHR. Other times, your organization is just in a new place where it’s ready to accept a change that it wasn’t ready to accept before. This ongoing evaluation of your current EHR processes and workflow will provide an opportunity for your organization to see what they can do better. We’re all so busy, it’s amazing how valuable sitting down and talking about improvement can be.

I recently was talking with someone who’d been the EHR expert for her organization. However, her organization had just decided to switch EHR software vendors. Before the switch, she was regularly visited by her colleagues to ask her questions about the EHR software. With the new EHR, she wasn’t getting those calls anymore (might say something good about the new EHR or bad about the old EHR). She then confided in me that she was a little concerned about what this would mean for her career. She’d kind of moved up in the organization on the back of her EHR expertise and now she was afraid she wouldn’t be needed in that capacity.

While this was a somewhat unique position, I assured her that there would still be plenty of need for her, but that she’d have to approach it in a little different manner. Instead of being the EHR configuration guru, she should becoming the EHR optimization guru. This would mean that instead of fighting fires, her new task would be to understand the various EHR updates that came out and then communicate how those updates were going to impact the organization.

Last night I had dinner with an EHR vendor who told me that they thought that users generally only used about 50% of the features of their EHR. That other 50% of EHR features presents an opportunity for every organization to get more value out of their EHR software. Whether you tap into these and newly added EHR features through regular EHR workflow assessments, an in house EHR expert who’s constantly evaluating things, or hiring an outside EHR consultant, every organization needs to find a way to regularly evaluate and optimize their EHR workflow.


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Scanning Medical Records and Keeping Your Practice Digital - HITECH AnswersHITECH Answers

Scanning Medical Records and Keeping Your Practice Digital - HITECH AnswersHITECH Answers | EHR and Health IT Consulting | Scoop.it

In my previous scanning post we discussed the important role scanning documents plays in a successful EHR implementation. Moving from paper to electronic medical records takes a plan to know what you want to migrate from your files to your computer. But what about after your implementation and now in your daily workflow? Does scanning have a new role? Practices and hospitals alike find that while going digital helps to lessen the paper flow it still doesn’t eliminate it. There will always be something that might be acquired on paper. And when that happens, it is important to scan the document and be sure it gets included in a patients record.

Having scanning stations that are available and easily accessible for use will help integrate scanning needs into your workflow. If the scanner is off in a workroom or administrative office, it is more likely the task will be overlooked or put off in a to-do pile. Consider more than one scanner depending on your physical layout and system workstations.  Here are some areas where you might continue to see documents for patients in paper form and should be included in a patient’s electronic record. Where is this paper being collected and how can it get scanned into your system most efficiently?

  • New patient admissions and history forms
  • Capture ID and insurance card images
  • Referrals sent from other physicians
  • Medical Orders
  • Patient submitted history records
  • Patient submitted lab or procedure results
  • Consent forms
  • Payer EOBs or denial and resubmit documentation

Practices should also remember their overall business and consider digitizing all areas not just patient records. Human Resources is a big paper department with employee records and files. There are a lot of forms that start on paper for the simple fact of collecting signatures. Are you still keeping all this information in file cabinets? Consider digital employee files and scan the documents for electronic retrieval and storage.

Is your practice still using paper log sheets for medication dispensing and inventory reconciliation? Are you still using a paper sign-in sheet for patients when they arrive? Are you still receiving paper faxes for business or patients? Evaluate all the paper processes and consider a solution to convert to electronic or continue and store by scanning the documents. Benefits to electronic documents range from ease of ability to retrieve and share to simply eliminating the physical storage needs of paper documents.



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General Surgery News - Promise of EMR Systems Yet To Be Fulfilled for Many

General Surgery News - Promise of EMR Systems Yet To Be Fulfilled for Many | EHR and Health IT Consulting | Scoop.it

For more than a decade, electronic medical records (EMRs) have been called a critical step forward in modern medicine. The idea was that transitioning from paper to electronic records would increase efficiency, safety and savings in health care. The potential for EMRs to make patient records more accessible, reduce medical errors, allow medical institutions to communicate more seamlessly and save the health care industry billions of dollars each year was too tempting to pass up.

Despite this, the reality of EMRs seems not to have lived up to the hype. EMR systems have been costly to implement and are often laborious and confusing to learn. There is no universal system that all physicians can use; instead, medical professionals are faced with more than 100 systems, all competing for users and many of which cannot communicate with one another. But perhaps most notably, these systems do not appear to improve patient care, as promised, and in some cases may make care worse.

Nevertheless, the use of EMRs has ballooned in the past 10 years. In 2005, fewer than 25% of physicians’ offices and hospitals had adopted an EMR system, but today more than 80% use one. Despite the rapid spread, the central concerns about EMR systems remain the same: high cost, lack of standardization and interoperability, privacy issues and inferior patient care (Health Aff 2005;24:1103-1117).

But even before this spike in usage, many medical professionals were already well aware of the issues. In a 2004 report, researchers who had conducted 90 interviews with EMR managers and physicians found that “most physicians using EMRs spent more time per patient for a period of months or even years after EMR implementation. The increase resulted in longer workdays or fewer patients seen, or both, during that initial period …. Most respondents or their colleagues considered even highly regarded, industry-leading EMRs to be challenging to use because of the multiplicity of screens, options and navigational aids” (Health Aff 2004;23:116-126).

In a 2013 survey conducted by RAND Health, and sponsored by the American Medical Association, physicians echoed many of the same sentiments. In fact, physicians rated EMRs as a main reason for their job dissatisfaction. Summing up the results of the report, the RAND researchers wrote: “Despite recognizing the value of EHRs [electronic health records] in concept, many physicians are struggling to use their EHRs, which they describe as negatively impacting patient care in several important ways and undermining their professional satisfaction.”

In the study, the authors interviewed 24 practices about EHRs, 22 of whom were currently using a system. On the plus side, about one-third of the physicians reported that the EHR improved their job satisfaction and 61% said it improved quality of care. These physicians noted that their EHR system enhanced their abilities to access patient data at work and at home, provided guideline-based care and tracked patients’ disease.

In contrast, many physicians also expressed concerns over their EHRs, with about 20% saying they would prefer to return to paper charts. The central issues boiled down to inferior patient interactions, an inability to exchange information between different systems and a labor-intensive and time-consuming learning curve and data entry.

“Just because something is more expensive doesn’t mean it’s better,” said Peter Kim, MD, associate professor of surgery, Albert Einstein College of Medicine of Yeshiva University, New York City, who was not involved in the study. “For instance, the EMR giant Epic received $302 million from New York City, in 2013, for use in about 11 New York City public hospitals. But even within the same system, not all Epic EMRs are alike. An EMR’s functionality depends on who is programming it as well as the local needs of the institution. The same system may end up working well in one hospital, but poorly in another.”

Although people often assume that technology will reduce errors, that also is not the case. “In our hospital, administrators try to make our EMR sound perfect, but in reality, we have encountered huge errors and have had no audits of the system,” said Guy Voeller, MD, FACS, professor of surgery at the University of Tennessee Health Science Center, Memphis.

Along these lines, Dr. Kim recalled an incident when a toxic drug dose was written for the wrong patient, which missed all of the EMR system’s checks and balances. “Although that error could have happened with the old system, it wasn’t prevented by the EMR as it should have been,” Dr. Kim said. “We still need that human element in care, where a person is checking and verifying orders.”

Regarding patient interactions, physicians in the RAND study who complained that EHRs interfered with in-person patient care found that they were forced either to divide their attention between the patient and the computer or to give patients their attention but then spend hours inputting data afterward.

“With EHRs, physicians and nurses are looking at a computer screen and have their backs to the patient,” said Dr. Voeller. “Physicians and nurses are forced to devote time to their computer, not their patient.”

Another report revealed similar results. A team at Medscape surveyed 18,575 physicians in 25 different specialties from April 9, 2014, to June 3, 2014, about their EMR use. Of those, 4%, or 743 participants, were general surgeons.

The report found that about one-third of respondents felt their EHR systems worsened clinical operations and patient services, although about the same percentage reported the opposite. In terms of patient interactions, 70% of respondents said their system decreased their face-to-face time with patients and 57% said it lessened their ability to see patients, while about one-third felt their system enhanced their ability to respond to patients and effectively manage treatment plans.

Patient privacy was another major worry for physicians, approximately half of whom expressed concern about losing patient information because of a technological malfunction or about their lack of control over who can access patient data. About 40% of participants were also concerned about HIPAA compliance and hackers getting to data.

Similarly, of physicians who opted not to purchase an EHR system, the top reason was that the technology would interfere with the doctor–patient relationship (40% of responses). The other most frequent complaints were that EHR systems are too expensive (37%), and that the incentives and penalties from the Centers for Medicare & Medicaid Services are not worth the hassle of adopting a system (32%). Other reasons were that EHRs hurt patient privacy (22%) and were too complicated to learn (16%).

The financial burden of EMRs appeared to be increasing as well. According to the Medscape survey, in 2014, 23% of respondents said their EHR system cost $50,000 or more per physician to purchase and install, whereas in 2012, only 7% of respondents said their EHR system cost that much. Another report that evaluated the cost of EHRs, using survey data from 49 community practices in a large EHR pilot project, found that “the average physician would lose $43,743 over five years; just 27% of practices would have achieved a positive return on investment; and only an additional 14% of practices would have come out ahead had they received the $44,000 federal meaningful-use incentive” (Health Aff 2013;32:562-570).

Currently, Dr. Kim said, the federal government is forcing institutions to have an EMR system, which is driving many physicians out of business and into a hospital on a salary or into retirement.

“Besides the cost of implementation, evidence already is accumulating that doctors order more—not fewer—imaging studies when [an] EMR is used,” wrote David Cossman, MD, a vascular surgeon in Los Angeles, in a 2012 piece in General Surgery News (May 2012, page 1).

As for billing, Dr. Voeller noted, “the way we bill through EMRs lends itself to fraud because physicians can document more complex visits that come with a higher price tag and reimbursement.”

Amid the confusion and ambivalence, some surgeons are holding out hope that as companies iron out the kinks in the current systems, EMRs may eventually live up to the early hype. Others remain skeptical that there is a magic bullet that will vastly simplify and improve EMRs.

Reflecting on the current state of the technology, Dr. Cossman wrote: “The big problem is that HAL [the sinister computer in Stanley Kubrick’s film “2001: A Space Odyssey”] is once again stalking us with the sweet siren song of untold efficiencies, cost containment and protection from human fallibility if we only move over to the passenger seat and let it drive. Don’t believe a word of it. Medicine cannot be practiced on autopilot. We will crash and burn without the human touch at the controls.”



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EHR/EMR Workflow System Usability–Roots in Aviation Human Factors

EHR/EMR Workflow System Usability–Roots in Aviation Human Factors | EHR and Health IT Consulting | Scoop.it

You may have noticed aviation-inspired terms, illustrations, and ideas on the High-Usability EncounterPRO EMR Workflow System:

  • A pilot helped to design EncounterPRO’s user interface (UI).
  • EMR UI design is mimicking evolution from traditional cockpits to today’s glass cockpits.
  • The phrase EMR “rollout” derives historically from “rolling out” a new aircraft from its hanger for its first public viewing.
  • EncounterPRO’s Office View is like a radar view from an aircraft control tower, from where staff can see where everyone is and how long they’ve been waiting.
  • The illustration at the top of each fat footer sitemap is an aviation concourse.
  • Aviation human factors is an important subdiscipline within Industrial Engineering (which has many other useful applications within pediatric and primary care “production systems”).
  • Then, of course, there is that cool helmet with an EncounterPRO screen projected on its wrap-around visor.

What if I told you that EHR/EMR workflow systems:

  • Reduce workload and difficulty of carrying out the phases of a patient encounter.
  • Relieve physicians of having to perform repetitive sequences that are unrewarding and for which human beings in their inconsistency can be at their best or their worst.
  • Endow physicians with the gratifying part of their jobs: decision making.

It would be true, but I would be paraphrasing page 176 of the Handbook of Aviation Human Factors in which it says that designers of cockpit automation hope to:

  • Reduce workload and difficulty of carrying out the phases of the flight.
  • Relieve pilots of having to perform repetitive sequences that are unrewarding and for which human beings in their inconsistency can be at their best or their worst.
  • Endow pilots with the gratifying part of their jobs: decision making.

I’ve seen many EMRs over the years, some designed by physicians, some designed by programmers, and many  designed by both. However, a physician, a programmer, *and* a pilot designed EncounterPRO—and it shows.

Aviation human factors techniques and ideas about individual and team performance have been used to improve patient safety (for example), but less so for sheer high-performance effective and efficient EMR data and order entry.  Since World War II, the aviation industry has spent millions (perhaps billions) of dollars on aviation human factors research on the design of high-usability, high-performance robust avionics and cockpit management systems. Many aspects of traditional EMR design contradict  this accumulated knowledge and experience.

As a result, an EMR Workflow System looks and works differently from any other EMR of which I am aware. While I wouldn’t want to fly a plane using EncounterPRO as cockpit management software, of the hundreds of EMRs out there it would the most suited to the task. In fact, after one presentation, representatives from an aviation software company approached us to ask if we would consider adapting EncounterPRO to serve as a cockpit management program. Given EncounterPRO’s roots we were flattered and intrigued, even if we eventually decided to continue to concentrate solely on ambulatory EMR workflow automation.

My own MS in Industrial Engineering at the University of Illinois, Champaign-Urbana involved a year in both the aviation human factors and health systems engineering programs. (This was by accident. There was a research assistantship available to work on an aviation human factors research project.) Aviation and aerospace medicine intrigued me for a while, but I decided that health care workflow was an even more target rich environment. Ironically, several years later I wrote natural language processing grammars for the Pilot’s Associate project (where I faced the truth of a popular linguistic proverb: All grammars leak.)

I had the enjoyable experience of hanging out with a sizable community of aviation human factors graduate students (both from IE and from other graduate departments such as psychology). That’s where I learned about the Fitts and Hicks laws that I discussed in the Cognitive Psychology of Pediatric EMR Usability and Workflow. I also bumped into an idea that has stuck with me since.

For each of the effects of the normal aging process–

  • vision decline,
  • hearing loss,
  • motor skill diminishment, and
  • cognitive decline

–there are a set of design principles and assistive technologies that address environmental challenges causing similar decreases in skilled performance.



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