EHR and Health IT Consulting
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EHR and Health IT Consulting
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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Changing the Culture of Healthcare

Changing the Culture of Healthcare | EHR and Health IT Consulting |

Why is it that patients are slow to take charge of their health records? Some articles suggest that management of health information should be a patient-driven initiative and the points that are used to propagate this idea are not without merit. However, the primary reason is a lack of a collaborative effort among patients and providers. It is the responsibility of healthcare professionals – who bear more accountability than ever – to make a concerted effort to drive this change. And, since the technology is available to support this effort, the first step for providers is to embrace their influential role in educating patients on the importance of managing life-long health and wellness.

A Culture of Connectivity:

The healthcare industry is becoming increasingly decentralized and engagement through health monitoring among patients and providers is more possible today than ever. In an article in the Wall Street Journal (“Staying Connected Is Crucial to Staying Healthy”), reporter Laura Landro interviewed Dr. Joseph Kvedar, vice president of Connected Health at Boston-based nonprofit health system Partners Healthcare, about the increasing decentralization of care, as well as the spread of health apps and trackers.

Dr. Kvedar confirmed how, in the new network-based model of healthcare, connectivity is critical to providing the highest level of care, by saying “the ideal way to keep you focused on improving your health is through connectivity and in-the-moment, contextual messaging – messages directed at your specific health needs at the moment you need them.” The result of greater connectivity is higher engagement, but providers must actively pursue initiatives centered around leveraging filtered, personal health data from patients. Health providers need to have an influential role in closing the loop of contextual messages by responding on priority, as demanded by the condition at hand.

A Culture of Convenience:

Platforms that monitor individual patients for ongoing prevention and large populations with multiple chronic conditions, while managing exceptions, can do so with greater coordination. This will also have a positive impact on internal operations by minimizing errors in data as it is exchanged through faster, more secure channels. In turn, this increases staff productivity, minimizes intervention and streamlines patient processing and the overall patient experience within and independent of the clinical environment.

New breakthroughs in technology have helped overcome the traditional challenges of interoperability, making diagnosis and ongoing care more convenient than ever. Portable devices and clingy fitness trackers have contributed to having health vitals available at your fingertips; data that has now become easy to upload and analyze on any platform for possible conditions. And, as a recent article in The Economist states, “…computing power is now being applied successfully in countless small ways, using smartphone and other diminutive devices, to make a big difference to the effectiveness of treatments,” (“Bedside Manners”).

A Culture of Change:

It is up to providers to facilitate this change in the culture, from one of episodic care to an ongoing healthy lifestyle with a “coaching” approach. While it is true that families should manage their own medical records and data, providers should take the lead. Combining live interactions and virtual online coaches as needed, the exchange and use of data will bring significant and actionable insights that are applicable in the daily lives of individuals everywhere.

Taking it one step further, healthy lifestyles within various segments of the population can be promoted by developing and implementing community wide initiatives that leverage vital data monitoring. These efforts can impact greater health issues such as diabetes, blood pressure, early child birth, obesity and other conditions. By adopting a consistent and motivating approach toward shared data exchange processes, providers will be able to better manage and motivate patients, while driving positive, ongoing change at the fraction of the cost of live interactions.

In healthcare, proper use of medical data is critical to optimizing outcomes and lowering costs, but the absence of a truly collaborative effort among patients and providers remains as a barrier to success.

Drivers of Change

is the fact that no simple solution is available and no national initiative – legislative or otherwise – exists to helps fill this engagement void in healthcare. Just as providers are responsible for patient care and satisfaction, so too should they serve as facilitators of patient engagement. By taking this approach, new age health initiatives will reshape the culture of healthcare and lead the industry to a truly preventative system.

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CMS Chief to Address ICD-10 Implementation in National Call

CMS Chief to Address ICD-10 Implementation in National Call | EHR and Health IT Consulting |

The Centers for Medicare & Medicaid Services (CMS) continues gearing up for the October 1 ICD-10 compliance deadline with Acting Administrator Andy Slavitt scheduled to address the ICD-10 transition during a national provider call later this month.

On August 27, Slavitt will provide a national implementation update as the nation reaches the five-week countdown to October 1. Also scheduled to speak are American Health Information Management Association (AHIMA) Senior Director of Coding Policy and Compliance Sue Bowman and American Hospital Association (AHA) Director of Coding and Classification Nelly Leon-Chisen.

Two recent surveys show industry-wide progress toward a successful ICD-10 transition in October. In July, the 2015 ICD-10 Readiness reportpublished by AHIMA and the eHealth Initiative stated that half of respondents had completed test transactions with payers or claims clearinghouses.

Despite these positive findings, the report also revealed that ICD-10 preparation gaps still remain for many providers in the area of testing and revenue impact assessments. Only 17 percent indicated that they had completed all external testing. Similarly, only a minority of respondents (23%) have contingency plans related to ICD-10 go-live.

More recently, latest ICD-10 readiness survey from the Workgroup for Electronic Data Interchange (WEDI) showed physician practices to be lagging behind their counterparts.

As compared to seven-eighths of hospitals and health systems ready for October 1, less than a half of physician practices indicated they would be ready. This disparity was also evident in the area of provider impact assessments. Only one-sixth of physician practices had undertaken the assessment versus three-fifths of hospitals and health systems. "This lack of progress is cause for concern as it will leave little time for remediation and testing," WEDI reported.

In a letter to Department of Health & Human Services Secretary Sylvia Mathews Burwell, WEDI cautioned that without a concerted effort the ICD-10 transition could lead to negative consequences for the healthcare industry.

"We assert that if the industry, and in particular physician practices, do not make a dedicated and aggressive effort to complete their implementation activities in the time remaining, there is likely to be disruption to industry claims processing on Oct 1, 2015," the organization stated.

Around the same time, CMS provided clarification about ICD-10 flexibilities it make available to providers following a joint statement with the American Medical Association (AMA) in June. The major ICD-10 flexibility is the federal agency's decision not to reject claims coded incorrectly in ICD-10.

"Medicare claims with a date of service on or after October 1, 2015, will be rejected if they do not contain a valid ICD-10 code," the federal agency stated. "The Medicare claims processing systems do not have the capability to accept ICD-9 codes for dates of service after September 30, 2015 or accept claims that contain both ICD-9 and ICD-10 codes for any dates of service. Submitters should follow existing procedures for correcting and resubmitting rejected claims."

Here's a quick look at the agenda for the MLN Connects Call:

  • National implementation update, CMS Acting Administrator Andy Slavitt
  • Coding guidance, AHA and AHIMA
  • How to get answers to coding questions
  • Claims that span the implementation date
  • Results from acknowledgement and end-to-end testing weeks
  • Provider resources

As the entire healthcare industry counts down to October 1, CMS appears ready to ramp up its activities.

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Preventing Physician Burnout

Preventing Physician Burnout | EHR and Health IT Consulting |

In a cross-sectional survey ("Predictors of physician career satisfaction, work-life balance, and burnout," Obstetrics & Gynecology) of randomly selected physicians from across the country just under half of all respondents indicated that they were satisfied with their work-life balance, and half of respondents indicated that they felt some level of emotional "resilience." It turns out that the lack of these two factors plays a significant role in the development of physician burnout; a syndrome that occurs when a person is under constant pressure, and is marked by emotional exhaustion, cynicism, feeling ineffective in one's work, and experiencing interpersonal difficulties. Burnout in physicians, which has been on the rise, has been linked to impaired job performance, poor health, marital difficulties, and alcohol or substance abuse.

The good news is that there are strategies that can be taken to significantly reduce the incidence and negative effects of burnout. Factors that are critical to combating burnout are having control over one's schedulethe number of hours worked, and emotional resilience. Unfortunately, in this current era of healthcare reform, controlling the first two factors can be quite challenging, but not impossible, if one takes a conscious and deliberate approach to managing priorities and time. Many physicians find that they spend a significant amount of time on activities that do not provide enough value — one way to think about this is to determine your "time ROI" (return on investment).

Follow these five steps to significantly improve your work-life imbalance:

1. Identify the five to eight most important aspects of your life (what you value most).

2. Now determine how much time you devote to those areas (and how much time is spent in areas not on your list).

3. If there is a disconnect between what you value and how you spend your time, this is a signal to you to make changes in your life.

4. Plan your time so that you are focused on what you value most.

5. Determine what can be delegated to others.

Preventing burnout also involves developing emotional resilience — the ability to manage stressful situations effectively and prevent stress from building up. For this we turn to some interesting research from the field of neuroscience that explores the link between stress, sleep, and positivity. These three factors have an interdependent relationship with one another — cause a change in one, and the other two are impacted.

So for example, the more stress in your life, the worse your sleep and mood. If you get too little sleep, then you will experience more stress and a lowered mood. In general, it can be difficult to derive meaningful change in the first two factors, sleep and stress, but much easier to have an impact on the latter one — positivity. If you are able to increase positivity, you will experience a significant improvement in sleep and a significant reduction in stress (negative emotional state).

Follow these simple brain-training steps to increase your positivity:

1. Practice positive "self-talk" by cultivating self-encouragement optimism, recognizing accomplishments, and appreciating good fortune.

2. Challenge your negative (typically distorted) thinking, the most common of which are:

• Catastrophic thinking. Identify a more realistic assessment of the situation. Usually, things are not as bad as we think they are. And often, our greatest learning comes from adversity.

• Black and white thinking. Challenge all-or-nothing thinking. Usually there is some gray area to work with. It is very seldom absolute.

• Jumping to conclusions. Avoid leaping to a foregone conclusion, such as thinking you know what others must be thinking. Learn to get curious, ask questions, and look for alternative explanations.

• Over generalizing. Look for a more accurate appraisal of the situation. When we look more closely at situations, we often find that negative or stressful outcomes are limited to that event, not generalizable across all situations.

• Excessive criticism. Whenever you hear yourself thinking, "should," substitute "it would be nice." This allows you to avoid excessive self-criticism or the belief that there is only one solution.

Changing thinking leads to changes in behaviors which leads to changes in results. So the easiest and most efficient method to change the results you are getting is to engage in positive and constructive thought patterns. As you transform your thoughts, you actually create an alteration in the neural connections in your brain. This in turn, leads to the development of new habits, ensuring that the changes you create are lasting ones.

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Hiring Health IT Professionals and Consultants

Hiring Health IT Professionals and Consultants | EHR and Health IT Consulting |

An ambulatory medical practice is a unique environment for information and technology. Several factors inherent in the health care community call for a specific level of competency in order to accurately install, maintain, and support technology. Where a standard small business or residential client might easily call in a local tech group or geek squad, the small to medium sized healthcare client should seek out professionals with specific knowledge of their unique needs. The following are tips to assist in hiring someone for your practice.

Five questions to ask a potential healthcare IT consultant:

Look for thoughtful and detailed answers to each of these questions. This quick evaluation will help identify which tech groups can provide knowledgeable guidance as you move your facility to a more technical infrastructure.

1) Do you have any certifications or support experience in healthcare specific technology?
2) What do you know about HIPAA compliance?
3) How familiar are you with EHR, EMR, or PM solutions?
4) Do you have any experience with or access to Medical Device connectivity?
5) What do you know about electronic vs. paper medical workflow?

Which specific Health IT skillsets do you really need to get started?

Not every practice needs the expertise of a high-level HIT consulting firm. Many agencies identifying themselves as "HIT Proficient" will provide services which exceed your immediate needs. In this case you may find that prices per hour or contract requirements are higher than expected.

To create your initial IT environment, you should seek out a group or individuals who identify themselves as providing technical expertise. Determine what areas you will need help such as:

  • Skilled IT Assessments - Assess what the practice has in place and what may be needed to be ready for an EHR.
  • Technology Consulting – Assisting in all aspects of implementation?
  • Hardware Selection – Assess what you have and what you will need to purchase or upgrade.
  • Hardware Quotes and Purchasing – Do you need help?
  • Hardware/Software Support and Systems Maintenance – Who will do this?
  • IT Installation and Upgrades – Will your new software require this? Who will do it?
  • Software User Training – Assess all users' basic skills.
  • EHR Solution and Software Selection – Review, demo, and get references on as many systems as you can.
  • Readiness and Workflow Assessments – Once a system has been purchased is you workflow aligned with the new technology?
  • Wired and Wireless Networking – Is your network HIPAA Compliant?
  • Offsite Backup and Storage – Who will do this?
  • Waiting Room/Patient Entertainment, Digital Signage and Media – Review and determine what is the right fit for the practice.
  • Remote Login Assistance and Prompt Phone Support (help desk) Line – Will you need this?

What should you expect from a good Health IT support group?

A good health information technology (HIT) group will focus on the unique needs of your medical environment. They will be tuned into your practice dynamics and look to fit the technology to your specialty, skillsets and personal goals. They should also be your partner in identifying ways to improve efficiencies – both relating to workflow and in terms of your budgeting needs. Any group encouraging you to dramatically change your flow of tasks or to spend more than are practical for your site and size should raise a red flag immediately.

In addition, you should feel that your consultant is your advocate. They should not be pressured by your EHR vendor, hospital, or manufacturers to persuade you in any on direction. Anyone receiving heavy incentives to steer you toward specific solutions, is a reseller, NOT a consultant.

Look for descriptive terms such as independent and agnostic to describe anyone you consider to give you guidance. The independent consultant can engage the services of a reseller, or many resellers, and can monitor the selection of best fit products and services knowledgeably on your behalf.

You should also expect a good consultant to oversee the entire IT infrastructure process. Making sure that all of the identified pieces fall into place at the right times for the right reasons. Ask for a clear project plan and timelines. Look for a checklist of executable goals. Steps identified and outlined with clear objectives will help you feel confident that each step is carefully planned, followed, and achievable.

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Larger Physician Groups Eye Cloud-Based EHRs

Larger Physician Groups Eye Cloud-Based EHRs | EHR and Health IT Consulting |

In January, the federal Centers for Medicare & Medicaid Services (CMS) rolled out a new fee schedule for providers taking care of patients with two or more chronic conditions. Within weeks, Privia Medical Group, a 310-provider multispecialty medical group based in Arlington, Va., had electronic health record (EHR) templates for the documentation and coding requirements as well as a 20-page tutorial with screen shots.

To Andrew Aronson, M.D., Privia’s chief medical officer, that responsiveness is one of the key reasons the group chose to work with the Watertown, Mass.-based athenahealth for its health information technology needs. “Any update or rollout of new information goes on behind the scenes and is pushed out to all our offices,” Aronson says. “It is released quickly and we are off to the races in implementing the new revenue stream. We are not driving a 4-year-old model car anymore. We are constantly driving the newest and coolest as far as technology goes.” He adds that having each physician office purchase and support its own hardware and EHR software is an “antiquated approach.”

Privia is not alone among midsize and large physician groups and independent practice associations in taking a second look at either an application service provider (ASP) remotely hosted EHR from a vendor such as eClinicalworks or a software-as-a-service (SaaS) model from vendors such as athenahealth or Practice Fusion. (The SaaS model involves a single, integrated database that is delivered as a service to multiple customers simultaneously via the Internet. In an ASP model, the EHR is delivered over a secure Internet connection but involves multiple separate instances of an application, and customers could be on different versions of the software.)

The Orem, Ut.-based KLAS Enterprises has done ambulatory EHR perception reports for almost 10 years, and has seen the pendulum gradually swing from almost no cloud adoption to much stronger interest, notes Erik Bermudez, a KLAS research director. “Ten years ago they would say if they got angry at their EHR, they felt better if they could kick a server in the basement,” he says. “They were at peace knowing it was all behind their four walls.” But that perception has gradually changed. Although many doctors may not understand the distinction between ASP and SaaS models, when KLAS has asked physicians about the umbrella term of remotely hosted EHRs, practices ranging up to 100 physicians are now open to it, he said, “although name recognition and a vendor’s size and reach continue to be important criteria for large practices. Practices with hundreds of physicians that have a CIO tend to have an interest in keeping data in-house,” he adds.

Concerns about data security might be misplaced, Kosiorek added. People tend to correlate moving records to another company as a point of fear. But security in the cloud provider’s environment is most likely better than in your own office, he says. Cloud-based systems have a vested interest in keeping things secure. If they have a breach, it will impact their reputation forever. “Small to medium-size practices have limited means to invest in security, so they are trusting their IT staff to have all the bases covered with security,” he said, “and the smaller the staff, the tougher that is to take on.”

Rodger Prong, executive director of Oakland Physician Network Services (OPNS) Inc., a 425-member Michigan independent physician organization, notes that many of its members are adopting the free (with advertising) or low-cost cloud-based Practice Fusion EHR.

“I had a lot of suspicion of this platform at first,” Prong admits. “I ignored it for two to three years. The old saying is you get what you pay for. But then I saw several positive independent surveys of doctors. What creates traction is what interferes with physicians the least,” he said. Prong said the process of migrating data to Practice Fusion from other EHRs has gone well.

The OPNS doctors using Practice Fusion have interfaces to an organization-wide registry and data warehouse. “We like the fact that they do enterprise-wide changes. It helps us not have downstream problems with interfaces,” he says.

Prong said that with some EHR vendors, interface costs are exorbitant. “If they don’t make enterprise-wide changes, then we have different versions out there and every time they change something for a doctor we wind up incurring additional cost to get the interface operational,” he says. “Practice Fusion gave us one price per interface for our entire group. We only pay them once and it works for everybody.”

You don’t see software in other industries developed in this client/server manner anymore. The mentality that the cloud is a new thing is curiously specific to healthcare. Derek Kosiorek

Some provider organizations decide to subscribe to remotely hosted EHRs to avoid costly hardware upgrades and IT personnel costs.  East Georgia HealthCare Center Inc., a federally qualified health center with nine facilities and 23 physicians, had been a customer of eClinicalWorks (eCW) for several years as part of the Georgia Primary Healthcare Association, which managed the software from an Atlanta data center. “As EHRs became more robust, and contained more information than we originally used them for, we started running out of resources,” says Herb Taylor, East Georgia’s IT director.

“Computing and processing speed started getting slow. So we could either spend a bunch of money on hardware upgrades or evaluate cloud-based options. We went with eCW in the cloud. It was a smart decision for us financially and with the IT staff we have.”

Taylor says that performance has improved dramatically.  “At the time we moved, a year ago, with 130 employees, we were averaging about 20-40 tickets a week about people experiencing slowness,” he says. “Now we get only a few tickets a month, and those are in the more rural sites and have more to do with latency with the Internet service provider.”

Taylor says the cloud offers him better disaster recovery protection than he previously had. “You as an individual provider won’t have funds to truly be redundant in a disaster situation,” he says. eCW is so big on a national scale it has sites in multiple locations, he added. The data is encrypted at rest and in transit. You gain the benefit of a larger-scale organization. He also keeps a storage-area network on site, so if there is a disruption, users could keep working and then upload data to eCW’s site later.

For Taylor, it all comes back to financial security. “You may be able to spend that $300,00 to $400,000 to get where you need to be this year, but where are you going to be in five or six years when it is time to upgrade all that hardware again? That was the big factor for me. No matter what happens, I am paying x amount of dollars to eCW. It was a no-brainer for us with 23 providers to pay the monthly fee,” he says.

Another physician group that recently signed a contract with athenahealth is Healthcare Network of Southwest Florida, which has 25 physicians and 250 staff members. In the next six months it will migrate from a GE Centricity system it has been using for the last several years.

Larry Allen, the organization’s chief information officer and vice president of information technology, was attracted by the fact that athenahealth can do 12 software upgrades a year. Like Privia’s Aronson, Allen talks about some of the advantages of the economies of scale a SaaS vendor can offer on the business side. “Let’s say an insurance carrier requires a modifier on an ICD-9 code. When they make that change, you see claims denied, and you have to go back in and reconcile and resubmit it,” he explains. “With athena, the first time any provider in their cloud has that denial, they flag it and put a business rule in the system so that the next time we code that, we would see an alert that this claim will likely be denied and a modifier code is required. And the claim gets successfully processed the first time.”

Allen said there are pros and cons to consider. “One of the advantages of having your own database is that you can make modifications to it that are unique to your group,” he says. On the other hand, with a cloud-based solution, the vendor can study EHR usability issues across all its practices and then make changes that impact all the practices at once, instead of single install of Epic, for example.

Privia’s Aronson says another advantage is that by studying keystroke click variations among Privia’s providers, athena can help its practices with work flow and train them how to become more efficient in terms of keystrokes. “We have 100 separate practices in our medical group. If they were all on disparate EHRs, we would have no idea what our benchmark was, or be able to compare one to another.”

Users also perceive a mobility benefit because they can access the EHR over the web, whether at home or working away from the office. “I can log onto athenanet anywhere I have web access, Aronson said. I don’t have to be in the office. That is huge for our providers. They want to get out of the office at the end of the day and finish their notes at home at night, and not have to go through virtual private networks,” he said.

MGMA’s Kosiorek says that one key challenge is working through contract language with the cloud service providers. “That is the biggest issue groups are going to have with cloud-based systems,” he says. “Who owns the data and what format you get it back in if the relationship ends? The contract has to be rock-solid about what happens to the data.”

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EHR Adoption Challenges Solved through Data Entry Transfer

EHR Adoption Challenges Solved through Data Entry Transfer | EHR and Health IT Consulting |

Once the HITECH Act was passed in 2009, EHR adoption and implementation of health IT systems grew tremendously over the coming years, as more providers began focusing on obtaining financial incentives from the Centers for Medicare & Medicaid Services (CMS) under the EHR Incentive Programs. While patient safety and quality of care has improved with the integration of computerized records, EHR adoption challenges have led to certain burdens among healthcare professionals.

From the potential for medical errors to a conceivably negative impact on the patient-doctor relationship, EHR adoption challenges will need to be addressed as healthcare facilities continue to implement computerized systems in order to qualify for the Medicare and Medicaid EHR Incentive Programs.

Fourteen experts from a wide background of organizations including Kaiser Permanente, Cerner Corporation, and Nextgen Healthcare put together a report to illustrate the future of EHR technology and how to overcome many common EHR adoption challenges. The report was published on behalf of the American Medical Informatics Association EHR 2020 Task Force.

Some of the “unintended clinical consequences” of EHR implementation has been the longer work hours required from the data entry around computerized patient records  and less time for physicians to communicate directly with their patients. Additionally, EHR interoperability has not grown across the medical sector as quickly as previously hoped. Health data exchange is lacking due to information blocking among providers and vendors alike.

The overall goal of the health IT industry is to develop an effective and interoperable health information exchange platform in which patients, providers, healthcare professionals, and public health agencies have ready access to key data. However, EHR adoption challenges have put up roadblocks toward meeting this goal.

The Task Force offers ten suggestions for improving on health IT systems and overcoming some common EHR adoption challenges. First, it is important to decrease the overall burden from a high amount of data entry on the physician. When it comes to diagnosis and treatment, the process of capturing data has fallen on the physician, but moving the data entry toward other members of the healthcare team or even patients themselves could prove beneficial.

“Clinicians remain uncertain regarding who can and cannot enter data into the record, placing a tremendous data entry burden on providers, the most expensive members of the care team,” the Task Force wrote in the report. “Clinician time is better spent diagnosing and treating the patient rather than charting. Regulatory guidance that stipulates that data may be populated by others on the care team including patients would reduce this burden.”

Another suggestion the Task Force offered is to include sound recording during a patient visit instead of manually entering information into the EHR system. When it comes to discussing medical history, conducting a basic physical exam, and giving patients advice, doctors would benefit from a sound recording instead of pure data entry.

By following the suggestions offered in the Task Force’s report, the healthcare sector should move forward in properly addressing some common EHR adoption challenges and paving the road toward a future of effective and interoperable health IT products.

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EMRs Should Include Telemedicine Capabilities

The volume of telemedicine visits is growing at a staggering pace, and they seem to have nowhere to go but up. In fact, a study released by Deloitte last August predicted that there would be 75 million virtual visits in 2014 and that there was room for 300 million visits a year going forward.

These telemedicine visits are generating a flood of medical data, some in familiar text formats and some in voice and video form. But since the entire encounter takes place outside of any EMR environment, huge volumes of such data are being left on the table.

Given the growing importance of telemedicine, the time has come for telemedicine providers to begin integrating virtual visit results into EMRs.  This might involve adopting specialized EMRs designed to capture video and voice, or EMR vendors might go with the times and develop ways of categorizing and integrating the full spectrum of telemedical contacts.

And as virtual visit data becomes increasingly important, providers and health plans will begin to demand that they get copies of telemedical encounter data.  It may not be clear yet how a provider or payer can effectively leverage video or voice content, which they’ve never had to do before, but if enough care is taking place in virtual environments they’ll have to figure out how to do so.

Ultimately, both enterprise and ambulatory EMRs will include technology allowing providers to search video, voice and text records from virtual consults.  These newest-gen EMRs may include software which can identify critical words spoken during a telemedical visit, such as “pain,” or “chest” which could be correlated with specific conditions.

It may be years before data gathered during virtual visits will stand on equal footing with traditional text-based EMR data and digital laboratory results.  As things stand today, telemedicine consults are used as a cheaper form of urgent care, and like an urgent care visit, the results are not usually considered a critical part of the patient’s long-term history.

But the more time patients spend getting their treatment from digital doctors on a screen, the more important the mass of medical data generated becomes. Now is the time to develop data structures and tools allowing clinicians and facilities to mine virtual visit data.  We’re entering a new era of medicine, one in which patients get better even when they can’t make it to a doctor’s office, so it’s critical that we develop the tools to learn from such encounters.

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Modifications to Meaningful Use Requirements Find Backing

Modifications to Meaningful Use Requirements Find Backing | EHR and Health IT Consulting |

Last month, the Centers for Medicare & Medicaid Services (CMS) released a new proposed rule with several key modifications to meaningful use requirements under the Medicare and Medicaid EHR Incentive Programs. The general public has until June 15 to submit comments to this particular proposed ruling.

The changes are meant to modify the EHR reporting periods from 2015 to 2017. The new reporting period was transitioned to a 90-day period that would line up with the calendar year. Additionally, patient engagement measures under the Stage 2 Meaningful Use requirements were changed.

If the ruling is passed, no longer will providers have to ensure that 5 percent of their patients download, view, and transmit their health information over the next couple of years. According to the proposed rule, only one patient will need to utilize a portal to view, download, or share their medical data.

The American Medical Association (AMA) recently announced their support of the proposed modifications to the meaningful use requirements. In a press release, the AMA stated their prior advocating of offering more flexibility under the EHR Incentive Programs so that providers and healthcare professionals may adopt and utilize health IT systems in a way that benefits their practice and workflow.

“Physicians want to use new technologies that help strengthen physician-patient relationships, improve health outcomes and make them more efficient,” AMA President-elect Steven J. Stack, MD, said in a public statement. “About 80 percent of physicians have already incorporated electronic health records (EHRs) into their practices, but they have faced significant barriers in participating in the Meaningful Use program and many are receiving penalties despite their investments in EHRs. We believe CMS’ proposal offers common sense solutions that, if finalized quickly, will help more physicians use EHRs in a truly meaningful way while supporting patient engagement.”

Within the letter sent to CMS for public comment, the AMA offered additional advice to the organization that could improve attestation to meaningful use requirements. The suggestions revolve around quality measure reporting and removing the overall “pass-fail structure” so that physicians and hospitals that attempted to meet meaningful use requirements and show positive results are not penalized.

Stack continued by discussing the importance of providing patients with secure messaging tools and patient portals and encouraging their consumers to utilize these platforms. At the same time, Stack mentioned that different physicians and healthcare providers have varying circumstances that may impact their ability to have a high percentage of patients viewing their medical information electronically.

For example, providers serving the elderly population or Medicaid-based patients in underserved areas may not have the key demographic that utilizes the Internet, smartphones, or even computers.

The AMA includes guidelines on its website for physicians looking to better engage their patients in their healthcare and the use of the patient portal. The organization is looking to work with physician groups to further patient education regarding accessing health information digitally.

Through these proposed modifications to the meaningful use requirements, CMS will be able to give providers the flexibility needed to successfully attest to the objectives and bring the healthcare industry into the 21st century.

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EHR Interoperability Stalled Due to Information Blocking

EHR Interoperability Stalled Due to Information Blocking | EHR and Health IT Consulting |

When it comes to the practice of medicine and drug discovery, the federal government plays a role in supporting these sectors and developing legislation that opens up avenues for healthcare professionals and scientific researchers. The House Committee on Energy and Commerce has gone forward with creating legislation called 21st Century Cures that delves directly into stimulating the discovery and development of new treatments and medications for patients across the nation. The legislation also impacts the expansion of EHR interoperability.

While the intentions of the 21st Century Cures legislation is beneficial for drug discovery, the American Hospital Association (AHA) finds that the enforcement strategies under the proposed rules could have negative consequences for providers, particularly in its aim to expand EHR interoperability.

AHA Executive Vice President Rick Pollack stated in a letter to the House Committee on Energy and Commerce that, which the organization appreciates the inclusion of EHR interoperability expansion, the “enforcement mechanisms” could lead to issues for healthcare providers such as putting together an ecosystem in which doctors may be significantly penalized for minor errors.

AHA does support health information exchange and EHR interoperability in pursuit of improving patient outcomes and incorporating new models of care. Nonetheless, AHA finds some issues with the enforcement related to vendors participating in information blocking problematic.

“The bill includes a number of enforcement mechanisms against those who engage in information blocking,” wrote AHA Executive Vice President Rick Pollack in the letter. “On the provider side, we believe that the use of Medicare fraud and abuse mechanisms, such as investigations by the Office of the Inspector General, imposition of civil monetary penalties or exclusion from the Medicare program, is unnecessary and inappropriate to address the concerns that the legislation seeks to remedy. We recommend that you use the existing structures of the meaningful use program to promote information sharing.”

On behalf of AHA, Pollack mentions that the organization appreciates the committee’s aim to ensure EHR vendors are responsible for creating interoperable health IT products. However, Pollack also stated that the committee should instruct the Federal Trade Commission to analyze any anti-competitive behavior among EHR vendors. In particular, Pollack finds the decertification of EHR systems among vendors that participated in information blocking objectionable, as it would affect healthcare providers and disrupt patient care.

“The language also includes decertification as a sanction for vendors that engage in information blocking. Decertification would be disruptive to hospitals and physicians that have invested in and deployed an EHR that is later decertified,” Pollack explained. “However, the inclusion of provider protections against meaningful use penalties if their EHR is decertified makes it more reasonable.”

The protections against payment penalties under the Medicare and Medicaid EHR Incentive Programs would last for more than one year, which would give providers ample time to find a new vendor, develop a suitable contract, install another EHR system, and attest to relevant meaningful use requirements.

Additionally, AHA would like the definition of information blocking to become narrower in order to avoid charges of fraud to be dealt due to standard business practices. Essentially, AHA would like to reduce some of the punitive approaches the committee set forth and develop more positive approaches to expanding health information exchange.

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Getting Started with mHealth at Your Medical Practice

Getting Started with mHealth at Your Medical Practice | EHR and Health IT Consulting |

While mHealth presents great opportunities for physicians and patients, conduct your due diligence before jumping full speed ahead into a complex mHealth venture. Here are a few important considerations:

1. Reimbursement. Incorporating mHealth into your practice takes time — time that you may not always get paid for. Before embarking on any mHealth initiative, evaluate whether it makes sense for your practice reimbursement-wise. Keep in mind that payers vary when it comes to reimbursement for care to remote patients. 

2. Legal guidelines. Prior to incorporating mHealth into your practice, consult a healthcare attorney to ensure compliance with federal and state laws, guidelines issued by your state medical association, and the HIPAA Privacy and Security Rules. For more on laws related to telemedicine, visit Also, familiarize yourself with any liability risks that the mHealth approach may raise. In fact, The Doctors Company, a medical malpractice insurer, recently highlighted some of the risks posed by remote health monitoring at

3. Take time to test the waters. Getting involved in mHealth may take a toll on physician and staff time, and it may cost a significant amount of money. For that reason, Robert Tennant, an executive consultant at healthcare management firm Beacon Partners, recommends starting out slowly with mHealth initiatives. For instance, prior to taking on a more complex mHealth initiative, such as remote health monitoring, open it to a small group of patients, such as those with a particular chronic illness. "Make sure that [you] can make it work on a small scale before going too far with it," he says. "It might be a situation where you have to evaluate a number of scenarios before you finally reach one that makes sense."

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Four Ways Vendors Should Help the ICD-10 Transition

Four Ways Vendors Should Help the ICD-10 Transition | EHR and Health IT Consulting |

ICD-10 is a lightning rod for many of the slow-to-launch initiatives promising to modernize health technology. In recent weeks, I've read wearily about 10-year interoperability roadmaps from the Office of the National Coordinator for Health IT and belabored testimony over the Medical Electronic Data Technology Enhancement for Consumers' Health (MEDTECH) Act, which, if it succeeds, would end years of regulatory uncertainty from the FDA over medical devices. So I was disheartened—though not entirely surprised—to hear that ICD-10 may be deferred yet again if powerful physician lobbies like the AMA have their way in Washington, D.C.

Policy delays are yet another variable in an already unstable landscape of rising costs, declining reimbursements, and clinical consolidation threatening the viability of many practices. As a nurse and practice manager for a small pediatric practice, ICD-10 is a policy mandate I simply can't afford to ignore. Yes, it's true that many providers are struggling with technology that isn't equipped for an Oct. 1, 2015, transition date. I feel for those providers and don't want to see them punished for the shortcomings of their laggard vendors. But rather than willfully kicking the ICD-10 can down the road, I believe that providers must prepare for the inevitable by shopping now for services that can accommodate them.

Certainly, providers have their fair share of ICD-10 preparatory work to do on their own. It's in their best interest, however, to take a long, hard look at what their vendors are offering to make the ICD-10 shift easier. Here are a few areas to think about:

Your EHR Should Know You

ICD-10 is roundly forecast to be an administrative nightmare, but it doesn't have to be. When CMS implements ICD-10, the codes which all U.S. healthcare providers use to describe diagnoses and treatment will increase overnight by from 14,000 to over 68,000. Based on your current, most commonly documented diagnoses, your EHR should know which codes you're most likely to need on come October and surface them directly into your work flow. Scrolling through a full menu of thousands of possible codes is simply untenable. EHRs which are compatible with SNOMED — a physician-friendly classification system which maps to ICD-10 — will and should provide a shorthand "crosswalk" between ICD-9 and ICD-10 codes. These product updates should be available now, so that you and your staff can begin practicing.

Your Vendor Should Curate Knowledge Just for You

Is there a resource hub full of the information you need about ICD-10? Do you have best practice configurations, which will ensure that your EHR is configured with the right clinical content based on your needs? While your vendor can't code for you, it should provide training and practice exercises to teach best practices, identify potential hot spots in your work flow, and fix problem areas before they happen.

Your EHR Should Be Prepared For a Range of Payer Compliance

Your vendor should be well underway testing payers' and clearinghouses' system flexibility and readiness to manage both ICD-9 and ICD-10 codes, given that some will linger in a bilingual ICD-9/ICD-10 environment. Vendors should have the knowledge and payer roadmap to ensure that, whatever a payer's readiness or ICD-10 compliance status is, claims are being coded in a way that will not delay payment.

Your Vendor Should Guarantee Your Success

Unlike like meaningful use certification, government mandated for all EHRs, there is no comparable test for ICD-10. It's imperative that vendors guarantee their ability to create ICD-10-compliant claims and orders to HIPAA-covered entities. If it can't, it should pledge to waive your fee. Those vendors which recommend taking out a line of credit to ease revenue cycle hiccups aren't true partners.

In the ICD-10 echo chamber, providers shouldn't be paying attention to policymakers or pundits, but to their vendors. Good technology should insulate them from the revenue cycle disruption, delayed reimbursements, incorrect documentation, and clinical work flow issues ICD-10 threatens. EHRs, practice management services, analytics tools, clinical data exchange services, clearinghouses, and payers all need to be held to account for providers' success, failure, or pain along the way.

Vendors should be taking measure, and even competing with one another, to be among the most stalwart partners for physicians as they prepare for the seismic shift about to occur in clinical documentation. ICD-10 was never meant to be the province of the provider alone. The administrative burden is potentially mammoth. Does your vendor make the cut?

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Do Health IT Systems Need Greater Interoperability?

Do Health IT Systems Need Greater Interoperability? | EHR and Health IT Consulting |

The medical sector is aimed at reaching the triple aim of healthcare by incorporating health IT systems and EHR technology. The triple aim focuses on improving patient care, lowering medical costs, and boosting population health outcomes.

In a Health Affairs Blog, National Coordinator for Health IT Karen B. DeSalvo discusses the landscape of information technology in the medical space.  DeSalvo emphasizes the need for interoperability among health IT systems and mentioned how the Office of the National Coordinator for Health IT (ONC) is developing new implementation standards. Additionally, the need for privacy and security of patient data is also asserted by DeSalvo.

The sharing of patient data through health IT systems has been a major focus for the healthcare industry over the last year. To improve EHR interoperability, ONC has listened to the health IT community to develop a roadmap for establishing strategies and opportunities to move the country toward greater health data exchange.

DeSalvo has participated in many listening sessions across the country and learned about certain issues that harm the interoperability of health IT systems and plague hospitals and providers. Rural communities in Alabama, for instance, do not have full broadband access while bordering state privacy laws in New Jersey block medical data exchange. The overall essence of DeSalvo’s discussion revolves around the importance of interoperability among health IT systems.

“I also listened to my own experiences — as a doctor, as a daughter, and as a consumer,” DeSalvo stated. “I thought of countless patients whom I have seen and those I continue to see when I am in clinic. Of visits where I did not have the information needed to make a decision that day, requiring patients to return and miss work, school, or other obligations. Of patients who want to engage and feel empowered but need not only data, but information, to help them level the playing field, to allow them to meaningfully engage.”

“Of being a caregiver for a mother dying of dementia and being frustrated at just how hard it was to get access to the information I needed to help her. And, as a public health advocate and official, needing information about my community to prioritize resources to help them address the broad determinants of health,” said DeSalvo.

Over the last six years since the Health Information Technology for Economic and Clinical Health (HITECH) Act was passed, the healthcare industry has gone forward with meeting many of the goals ONC established such as widespread implementation of EHRs and health IT systems. More and more eligible providers began meeting meaningful use requirements under the Medicare and Medicaid EHR Incentive Programs.

While these achievements are impressive, DeSalvo mentions the need to digitalize “the care experience across the entire care continuum” and gain “true interoperability.” ONC is currently working on a plan for both public and private sectors to gain interoperability. The next step for ONC and the healthcare industry is to go beyond meaningful use and EHR implementation in order to truly bring better health for patients across the country.

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As Health Apps Hop On The Apple Watch, Privacy Will Be Key

As Health Apps Hop On The Apple Watch, Privacy Will Be Key | EHR and Health IT Consulting |

One day soon, you may be waiting in line for a coffee, eyeing a pastry, when your smart watch buzzes with a warning.

Flashing on the tiny screen of your Apple Watch is a message from an app called Lark, suggesting that you lay off the carbs for today. Speak into the Apple Watch's built-in mic about your food,sleep and exercise, and the app will send helpful tips back to you.

The notion of receiving nutrition advice from artificial intelligence on your wrist may seem like science fiction. But health developers like Lark are making a bet that Apple's first wearable device, the Apple Watch, will fly off the shelves and this kind of behavior will become the norm.

Lark is just one of over a dozen health developers with new apps for the Apple Watch, which ships to consumers this week. These apps range from medication management to a button that provides instant, virtual access to a doctor.

Apple has made no secret of its health and fitness plans for the Apple Watch. And in recent months, it has recruited medical experts to work on services like ResearchKit and HealthKit, which aim to open up the flow of health data between consumers, mobile developers and medical researchers.

But is Apple doing enough to protect the privacy of your sensitive health data?

In advance of the Apple Watch's release, the company has taken some steps to put you in control of how your data is shared. You can choose to share health information with third-party apps like Lark via Apple's Health app, which comes with the device. Your health data, collected via the Apple Watch or the iPhone, is stored on Apple's HealthKit.

"Apple is leaving your HealthKit data on the device and not collecting it," said Morgan Reed, executive director at The App Association, a Washington, D.C., nonprofit that works with patient advocates and app developers.

According to Reed, this prevents third-party app developers from selling your health data without your consent.

"It also means that if an employer wants access to your health care information, they would have to demand that you give it to them," he said.

But it's still early days for the Apple Watch, and it remains to be seen whether health developers will follow Apple's privacy guidelines.

"We haven't had a developer ecosystem for a product like a smart watch," said Ben Bajarin, who specializes in consumer technology for Creative Strategies, a consulting firm. "This is [uncharted] territory."

A Message On The Wrist

Health app developers hope the Apple Watch will improve how doctors and patients communicate.

Imagine a doctor receiving a buzz on the wrist for an e-prescription request, which could be approved with a few taps. A patient could receive a similar alert when test results are available.

Developers are exploring these possibilities and more.

"We are predisposed to small changes on the skin. It was not that long ago — and is still the case in parts of the world — that mosquitoes used to kill us with a light touch," said Ron Gutman, chief executive of HealthTap, a website and mobile app for secure video calls with a doctor.

"It is so easy to turn off a notification from a website, but you can't ignore what's on your wrist," he said.

Gutman was so intrigued by Apple's smart watch that he developed three apps: one to help you manage your meds; another that connects you to a doctor with the touch of a button; and a third, which helps physicians reach new patients.

"Be prepared to take charge of your health information, and feel free to say no to sharing data with apps."

- Morgan Reed, executive director at The App Association

Managing Medications

For patients who are juggling a variety of meds — all with different dose requirements — an Apple Watch app that sends alerts to the wrist could prove useful.

WebMD, used by millions of people to check their medical symptoms, tossed around a bunch of ideas before settling on medication adherence.

"All we wanted is for the user to be reminded that it's time to take their medication, and then quickly tell us whether they plan to take it or skip it or snooze," said Ben Greenberg, who heads up WebMD's mobile products. "That interaction demands so little." The app also instructs people whether to take their medication with food, or at a certain time of day.

Other companies that are developing medication adherence apps for the Apple Watch include MangoHealth, which can also tell you how well you've managed your prescriptions over time, and pharmacy giant Walgreens.

Appealing To Doctors

Some app developers hope that doctors will flock to buy the Apple Watch to help them manage an overload of patient information.

"Doctors are finally getting amazing hardware that just works, and they're willing to pay a premium for it," said Daniel Kivatinos, cofounder of Drchrono, an electronic medical record company.

Using Drchrono's app for the watch, a doctor can receive alerts, such as when a patient has arrived at their office.

The watch could prove useful in helping doctors communicate with each other about tricky medical cases. Doximity, the Facebook for doctors, has developed a secure app that care providers can use to dictate notes, send messages and receive notifications that a fax has arrived.

But the Apple Watch's appeal may be limited to certain specialties, such as family physicians and dermatologists. Surgeons routinely remove their rings and watches before procedures, to ensure their hands stay sterile.

Moreover, doctors will need to do the work to ensure that apps they use are taking adequate steps to protect patient data. Apps may say that they are meeting privacy requirements, but most aren't properly vetted. The government has long been concerned about the proliferation of mobile health apps that make false or misleading medical claims.

Opportunities And Challenges

Privacy experts and policymakers have been worried about developers that collect and sell personal health information.

The U.S. Federal Trade Commission concluded in a recent study that developers of 12 mobile health and fitness apps were sharing user information with 76 different parties, such as advertisers.

Apple has responded to some of these fears by barring developers from selling health data that it collects via Apple devices to advertisers. After some high-profile hacks to celebrities' accounts, Apple also forbade developers to store sensitive health information in iCloud.

"Apple has clear privacy rules, but consumers should still be on guard," said Reed from the App Association. "Be prepared to take charge of your health information, and feel free to say no to sharing data with apps."

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NYC Hospitals Face Massive Problems With Epic Install

NYC Hospitals Face Massive Problems With Epic Install | EHR and Health IT Consulting |

A municipal hospital system’s Epic EMR install has gone dramatically south over the past two years, with four top officials being forced out and a budget which has more than doubled.

In early 2013, New York City-based Health and Hospitals Corp. announced that it had signed a $302 million EMR contract with Epic. The system said that it planned to implement the Epic EMR at 11 HHC hospitals, four long term care facilities, six diagnostic treatment centers and more than 70 community-based clinics.

The 15-year contract, which was set to be covered by federal funding, was supposed to cover everything from soup to nuts, including software and database licenses, professional services, testing and technical training, software maintenance, and database support and upgrades.

Fast forward to the present, and the project has plunged into crisis. The budget has expanded to $764 million, and HHC’s CTO, CIO, the CIO’s interim deputy and the project’s head of training have been given the axe amidst charges of improper billing. Seven consultants — earning between $150 and $185 an hour — have also been kicked off of the payroll.

With HHC missing so many top leaders, the system has brought in a consulting firm to stabilize the Epic effort. Washington, DC-based Clinovations, which brought in an interim CMIO, CIO and other top managers to HHC, now has a $4 million, 15-month contract to provide project management.

The Epic launch date for the first two hospitals in the network was originally set for November 2014 but has been moved up to April 2016, according to the New York PostHHC leaders say that the full Epic launch should take place in 2018 if all now goes as planned. The final price tag for the system could end up being as high as $1.4 billion, the newspaper reports.

So how did the massive Epic install effort go astray? According to an audit by the city’s Technology Development Corp., the project has been horribly mismanaged. “At one point, there were 14 project managers — but there was no leadership,” the audit report said.

The HHC consultants didn’t help much either, according to an employee who spoke to the Post. The employee said that the consultants racked up travel, hotels and other expenses to train their own employees before they began training HHC staff.

HHC is now telling the public that things will be much better going forward. Spokeswoman Ana Marengo said that the chain has adopted a new oversight and governance structure that will prevent the implementation from falling apart again.”We terminated consultants, appointed new leadership, and adopted new timekeeping tools that will help strengthen the management of this project,” Marengo told the newspaper.

What I’d like to know is just what items in the budget expanded so much that a $300-odd million all-in contract turned into a $1B+ debacle. While nobody in the Post articles has suggested that Epic is at fault in any of this, it seems to me that it’s worth investigating whether the vendor managed to jack up its fees beyond the scope of the initial agreement. For example, if HHC was forced to pay for more Epic support than it had originally expected it wouldn’t come cheap. Then again, maybe the extra costs mostly come from paying for people with Epic experience. Epic has driven up the price of these people by not opening up the Epic certification opportunities.

On the surface, though, this appears to be a high-profile example of a very challenging IT project that went bad in a hurry. And the fact that city politics are part of the mix can’t have been helpful. What happened to HHC could conceivably happen to private health systems, but the massive budget overrun and billing questions have government stamped all over them. Regardless, for New York City patients’ sake I hope HHC gets the implementation right from here on in.

Burke Autrey's curator insight, September 21, 2016 10:56 AM
Tracking companies who bring in Interim executive talent when it counts... Congratulations to Clinovations and HHC who clearly see the value of tapping into interim executives.!

OIG Found Inaccurate EHR Incentive Payments in Arkansas

OIG Found Inaccurate EHR Incentive Payments in Arkansas | EHR and Health IT Consulting |

The Medicare and Medicaid EHR Incentive Programs were established to improve the quality of care, boost population health management initiatives, and reduce overall healthcare costs, which is known as the Triple Aim of Healthcare. With these goals in mind, it is important to track the progress of meaningful use requirements and EHR incentive payments throughout the healthcare industry.

The Office of the Inspector General (OIG) found a major flaw in the EHR incentive payments completed by the Arkansas Department of Human Services. A total of 14 hospitals received incorrect EHR incentive payments, which resulted in an overpayment of $1.2 million.

An OIG report states that the organization looked at EHR incentive payments among 20 of the highest paid hospitals from November 1, 2011 to June 30, 2013. It was found that the Arkansas Department of Human Services paid 20 hospitals more than $19 million, which covered 65 percent of the total amount paid between the time period of the audit.

“The State agency did not always pay EHR incentive program payments in accordance with Federal and State requirements,” the report stated. “The State agency made incorrect EHR incentive payments to 14 hospitals. Specifically, for 13 hospitals, the State agency made incorrect payments totaling $1,225,734.”

The Arkansas Department of Human Services caused these errors because the agency had foregone following federal requirements with regard to cost report data elements concerning EHR incentive payments. Additionally, the organization failed to review supporting documentation for figures available in the reports.

The OIG recommends several measures that the Arkansas Department of Human Services will need to follow. First, it is important to refund $79,428 to the federal government. Also, the agency will need to modify the EHR incentive payments across the hospitals that received incorrectly calculated disbursement.

Additionally, it is suggested that the Arkansas Department of Human Services review all payment calculations given to hospitals that were not part of the 20 hospitals within the audit. The organization will need to determine whether payment adjustments are needed.

“The State agency did not concur with the recommendation to refund the net overpayment of $79,428 but stated that the incentive payments for 8 of the 13 hospitals had already been adjusted in accordance with our finding,” the report states. “The State agency also stated that it expected the incentive payments for the other five hospitals to be adjusted in accordance with our findings. The State agency also did not concur with our recommendation to work with the one hospital for which the total incentive amount was set aside to recalculate the incentive payment using the June 2009 cost report data.”

The Office of the Inspector General plays a major role in ensuring that various medical organizations are sticking to federal and state mandates. Hospitals and other providers attesting to meaningful use requirements under the EHR Incentive Programs will also need to ensure all information submitted to federal and state agencies are accurate in order to receive EHR incentive payments.

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Complete independence for a small practice today is unwise

Complete independence for a small practice today is unwise | EHR and Health IT Consulting |

Momentum remains in favor the flow of physicians to employed positions. Is this wisest path for physicians? That is unknown and likely depends upon the particular circumstance. Either way, independent physicians are an increasingly shrinking, yet curiously heterogeneous group. Independent practices vary in size, composition and philosophy. The impact of size (from solo to very large) and composition (primary or specialty care, single or multispecialty and physician demographics) is relatively straightforward, but the consequence of the practice philosophy may be a less obvious and more critical. Practices that wish to remain independent may need to reflect on what it means to be independent today.

Although the composition of the independent practice can cause some complexity, size may be an absolute barrier to survival. Small independent physician groups are quickly becoming an endangered species whereas larger independent practices may be better positioned to navigate the waters of health care today. Being completely independent may simply not possible for small groups (less than four physicians) and is becoming increasingly challenging for mid-size groups (4 to 8 physicians). Why is this the case? Here are a few reasons:

  • Inability to contract with managed care payors on own.
  • Inability to negotiate with vendors to keep expenses down.
  • Insufficient care management and care coordination infrastructure.
  • Inability to compete on convenience or patient experience.
  • Challenges relating to reporting and regulatory requirements.
  • High upfront and ongoing technology expenses.

Complete independence for a small practice dealing with the challenges today is at best, unwise. More strongly, one could conceivably argue that it is bordering on negligence. How can a solo practitioner for instance responsibly compete with sophisticated, well-funded, integrated systems in delivering the high quality, comprehensive patient care that is expected today? What about customer service? How loyal will their patients remain? Can the small independents stave off the convenience and access the retail clinics are offering? Single provider practices and small independents who are continuing to hold on to hope that they will survive, and health care reform will not affect them do so at their peril.

To weather the storm of health care reform and remain independent many small private practices have banded together to form independent practice associations (IPAs). Many successful IPAs have developed infrastructure for value-based contracting and have transformed into accountable care organizations (ACOs). But, what do we know about the independent practices that join these IPAs to maintain and maximize their autonomy? Will this strategy yield the outcome they seek? Are they really, truly independent? In many ways, yes.

Small independent practices may remain in charge of their own billing; they set their own compensation and benefit packages; have autonomy with human resources; flexibility around strategic practice decisions; and can more easily leave an IPA than they could an employed position. But, there are no free lunches. Independent practices that seek the shelter of an IPA must accept the movement towards value-based care. All physicians who wish to remain in practice must embrace the triple aim and endeavor to improve quality, enhance the patient experience and eliminate unnecessary cost from the system. Today physicians must grapple with reporting requirements related to quality measures, closing clinical care gaps, implementing and maintaining baseline IT connectivity for data exchange and working with other actors in the health care neighborhood in a more collaborative manner than ever before.

Physicians who believe they can opt into value-based contracts in order to realize value to their practice without a more significant, philosophical alignment with the triple aim and simply fly under the radar are sadly mistaken. This is a misconception that cannot be tolerated by a high achieving health care organization. Especially if the organization is looking to bring together disparate independent practices where an even higher bar of clinical integration is sought to satisfy the payers.

Participation in population health management through value-based contracts necessitates accountability that is shared by all stakeholders. Physicians must understand that they are accountable to the patients they serve; they are accountable the managed care payer partners, and they are accountable to each other. Poor performers, naysayers or laggards who underperform cannot be accepted if networks of independent physicians are going to be successful. Moreover, this will be counterproductive to their goal of realizing the positive returns successful performance can bring to their own practice and maintaining independence.

Networks all over the country have formed with the goal of bringing these remaining independent practices together for a shared purpose. Many of the independent networks will continue to do everything possible to educate and assist in facilitating successful behavioral and operational changes that yield positive results towards the collective best interest… but, in the end it is up to the individual physician practice to make a choice. What is more important, complete independence or survival?

Teamwork has become a common core value for successful health care organizations, and it is increasingly clear that health care is a team sport. The time has come for independent practices to embrace this, pick a partner and join a team. Many physician networks offer a great value proposition for independent practices that are realistic with their expectations. While physicians may no longer be able to achieve complete independence, as a sensible, viable path, with the right mindset there is still great opportunity in private practice if physicians can accept being almost independent.

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Examine Your Medical Billing Process for Improvement

Examine Your Medical Billing Process for Improvement | EHR and Health IT Consulting |

I met with a medical practice owner yesterday who was looking for some help and feedback on her business. She says she believes they are "doing fine," but she senses there are areas that could be improved upon. This is a great first step in making some simple changes that can yield amazing results.

Back in 2008, when I first wrote "The Lifecycle of a Single Claim," I was feeling quite overwhelmed and wondered where I should start to fix my medical billing problems. By creating this document, it allowed me to break down what appeared to be such a huge task and challenge, to a much more manageable one. The concept is simple, really. Just write down every single step that a patient's medical claim travels through at your medical practice.

When I initially performed this task, I counted 60 different steps through our billing process. Sixty may sound like a lot, but when you write down each step and carefully look at each one — and your practice's policies and procedures for that step — you will be able to identify areas of improvement. Start with the first area that needs attention, modify your process, and move to the next step. This may take several months to a year to get everything squared away, depending on how easy it is to make changes at your practice. Some people have a harder time reaching out of their comfort zone, than others.

Here are four strategies to help you tackle this challenge:

1. Include staff.

The key to making this first step a success is to include your staff members in making these changes. Ask them how they might perform a task more efficiently and get them to become part of the solution, instead of part of the problem. You will move much more easily through this process.

2. Tackle one item at a time.

Think of it as a science experiment. It is very important to make one change at a time and then give it a few weeks to see what the results are. You may end up with another task to manage, or it may result in several tasks being combined into just one step.

3. Give yourself a break.

As you move through this process of identifying areas of improvement, you may be wondering, "How the heck did I get in this mess?" Try to avoid this type of thinking, and instead look at this experience thinking, "Wow! Another area I can improve!" Your attitude is infectious and should spread through your team in a positive way.

4. Plan for the long haul.

Know this is a long-term project and plan accordingly. Areas that need improving will not be fixed overnight or even in a month. This change process should take several months if you're doing it right. By taking the time required, those big changes are introduced slowly, and by doing one at a time it's much less painful for staff to accept those changes.

Once you have managed your way through this journey, and are confident with it, know that this has become a living and breathing document. It should change as your practice grows and modifies its policies and procedures. Assign each section to the appropriate employee to manage and set some guidelines for updating. You want to make sure you or a supervisor is approving any updates and changes, and that they correlate with your overall company culture. Most importantly, have patience. This might be a little painful, but the results will surprise you, and make your practice much more manageable.

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Will Health IT Systems Improve Radiology Reporting?

Will Health IT Systems Improve Radiology Reporting? | EHR and Health IT Consulting |

Within the healthcare industry, there are a wide variety of different professionals who participate in managing patient care including treatment and diagnosis. Health IT systems and EHR technology play a role in every medical providers’ workflow, but do not always assist in streamlining healthcare services. With regard to diagnostics, radiologists have often had difficulty remaining high accuracy rates when determining disease based on test images, particularly with radiology reporting.

However, Nuance Communications has assisted the radiology field by developing the PowerScribe 360® Reporting version 3.0, which offers useful reporting information to radiologists during the clinical documentation process, according to a company press release.

Dr. Lincoln Berland, the Chair of Body Imaging Commission at the American College of Radiology, spoke with EHRIntelligence.comand shared his insights on the radiology field and the technologies including health IT systems that affect it.

When discussing the latest version of the PowerScribe 360 Reporting solution, Berland stated, “I’ve been involved with the development and refinement of this new system and what it’s designed to do is to assist the radiologist at the point of interpretation for making recommendations and describing finding. The way it works is by a radiologist dictating a report and he/she may come upon a finding – for example, an adrenal nodule that they will report. The system will recognize that it’s an adrenal nodule and highlight with a flag in the corner that there is a guidance rule for managing that.”

“A radiologist clicks on that and the algorithm list pops up. Radiologists fill in the blanks of a finding in the dialogue box,” Berland explains. “For example, it could be a two centimeter adrenal nodule that’s less than 10 field units. There may be two to five different features that you fill in. At that point, text appears that indicates how you would say it in the report and how the recommendation would appear in the report. If the radiologist finds it acceptable, he/she clicks accept and it automatically pops into the correct locations in the report.”

“This is revolutionary in the sense that nothing like this has ever been available before,” exclaimed Dr. Berland. “The reason it’s so important is that medicine has become so complex and algorithms for managing different kinds of findings – and particularly incidental findings – have become so confusing that to really make sure the right one is chosen every time, radiologists have to look it up, find an article, read through an algorithm, and follow a chart. This bypasses all of that.”

“In practical reality, the way it worked before this system, is that the radiologist most of the time doesn’t look it up. If they’re a specialist in the area, they’ll remember most of the findings and recommendations, but they won’t do it with complete accuracy. If you’re not a specialist, you may not know where to look it up or that even such a guidance rule exists and you might not get it right,” mentioned the Chair of Body Imaging Commission at the American College of Radiology. “What this provides is efficiency, accuracy, consistency, and the right recommendation every time because it’s appearing right on the screen and all of the potential recommendations have been reviewed before you get to the report.”

When asked what some common challenges in the radiology field are specifically with regard to digital technologies and health IT systems, Berland answered, “One of the main challenges that we deal with is the correlation of information. Radiology requests often have a very rudimentary amount of information that comes with it and the EHR has luminous amounts of information.”

“It’s often in a separate system and radiologists have to open that separate system to review the data, going through reams of pages to find the particular piece of information that’s relevant to the examination that you’re reporting,” he continued. “That is a tremendous challenge. Gathering the right information is one of the most difficult parts about making the correct interpretation, particularly for the increasingly complex radiology procedures that we perform.”

“Another problem is dealing with access to all of the relevant information from patients that are in multiple sites,” he explained. “Nuance now has a system called PowerShare [the Nuance PowerShare Network] so that people can share information and images from other sites very quickly. With something like PowerShare, that information can be shared through the cloud before the patient even arrives at the tertiary care center.”

As a final thought on the challenges within the radiology field, Berland stated, “Accessing the right information at the right time is very difficult. Automating that through a system at the point of interpretation is going to be a game changer in how we manage radiology reporting.”

When asked about some of the benefits and difficulties of implementing the PowerScribe 360 reporting program, Berland answered, “From the standpoint of having worked on the system to try to develop it, the challenges that we’ve had in trying to make sure that all of the answers are correct is that the logic is complex because of the algorithms that follow down multiple different paths and depend on multiple different conditions.”

“One of the advantages of the system is that using the PowerShare method, whenever  an update comes along with a newer algorithm, it can be downloaded through the cloud to all the sites used in the system so that there isn’t a significant delay between the issuance of the new guideline and everyone having access to it,” he explained.

Dr. Berland also discussed the most vital quality check tools that radiologists need to conduct their work.

“The Incidental Findings Committee has devised rules for particular organ systems where incidental findings are discovered. Now we have six papers that cover 11 organ systems. What Nuance and Mass General have done is take five of those rules and one additional guideline from another source and translated them into this computerized system. Specifically, they have a rule for managing renal, liver, adrenal and pulmonary nodules, thyroid, and ovarian cysts incidental findings,” Berland answered.

When asked whether the cloud platform is preferable for storing radiology reports, Berland explained, “I don’t think [the cloud] is a prevalent way of managing information right now. We’re a unified healthcare system with a single computerized system that goes through all of our various physical sites. We manage our data locally with backup.”

“The advantage of the cloud that we see is access to data in other health systems either in our state of Alabama or elsewhere in the region wherever a patient has been seen. The problem is that we don’t currently have standards that are well established enough – patients don’t have a single identifier – so we can’t easily have a unified system over multiple sites. There always has to be some reconciliation locally. I think the cloud will increase in utility because people are now being seen in a broader array of institutions and sites, which is going to require the interconnectivity of data,” Berland concluded.

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Tailored Physician EHR Use Necessary for Evolving Industry

Tailored Physician EHR Use Necessary for Evolving Industry | EHR and Health IT Consulting |

The healthcare industry is changing every day and new, revolutionary processes are continuing to affect patient care and population health outcomes. Whether it’s through patient-centered medical homes, accountable care organizations (ACOs), EHR adoption, or general improved care coordination, the medical sector is making some significant modifications toward better care. However, physician EHR use and implementation of health IT systems will likely depend upon the needs of each disparate medical facility.

Meaningful use requirements, for instance, will need to be flexible enough to ensure health IT platforms are useful and beneficial for differing healthcare providers. When integrating public comments into theStage 3 Meaningful Use final rules and the Stage 2 Meaningful Use modified rules, the Centers for Medicare & Medicaid Services (CMS) should consider the need for adaptable and flexible requirements that providers could customize to their interests.

The American Hospital Association’s President and CEO Rich Umbdenstock wrote in a brief the importance of removing obstacles and developing federal regulations that meet the needs of the healthcare industry. Both care coordination, reducing costs, and investing in physician EHR use are key objectives throughout the medical care market.

“It’s time for regulators to recognize the changing healthcare landscape and remove obstacles on the road to collaboration,” wrote AHA President Rick Umbdenstock. “Healthcare is changing; hospitals are changing; and regulations that block progress toward meeting patient demands and community expectations must change, too.”

Two areas within the healthcare industry that may need health IT customization are public health reporting and chronic disease management. The Department of Health and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation (ASPE) along with the National Opinion Research Center (NORC) at the University of Chicago released a report titledPublic Health IT to Support Chronic Disease Control.

In efforts to focus more attention on the triple aim of healthcare, NORC determined that chronic diseases are the major medical cost drivers and most common conditions found among patients across the country. The report went over population health interventions and physician EHR use to exchange data with public health agencies in efforts to curb the further deterioration of chronic conditions.

In particular, physician EHR use can be applied toward addressing case management, social services, behavioral health, and public health services. Incorporating EHR systems will also lead to better collaboration and communication among multiple medical facilities and public health agencies.

“The capacity to collaborate and share data across health care, public health and other partners becomes important in the context of supporting public health core functions,” the report stated. “We see great potential for using electronic data shared between health care providers, governmental public health agencies and other community partners. However, our discussion and earlier research points to important barriers to effective coordination and data sharing to promote population health. These challenges range from the limited mandate for governmental public health agencies in relation to chronic disease, limited public health IT infrastructure and historic lack of coordination between governmental public health agencies and health care providers.”

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Medical Data Exchange, Cloud Solutions Impact EHR Design

Medical Data Exchange, Cloud Solutions Impact EHR Design | EHR and Health IT Consulting |

Over the last two decades, the medical industry has changed drastically in terms of patient care and access to medical records. It was nearly impossible to obtain one’s own health record 20 years ago. Forbes reports that patients had little choice but to press legal action if they wished to access their own medical data.

In 1996, however, the Health Insurance Portability and Accountability Act (HIPAA) was passed, which did offer legal protections to patients who needed to see their health records. Nonetheless, there was still significant difficulty in accessing this information and most people never went through the challenging process.

Today, these problems are slowly disappearing, as patients have more ability to readily view their medical history and test results via patient portals and through other electronic means.

A study published earlier this year shows that after three hospital systems in separate states offered their patients the ability to view their health records and physician notes, nearly 70 percent of patients reported understanding their conditions better and taking better care of themselves including remaining vigilant about taking their medications on time. The results from the study also showed that providing patients with this ability did not majorly impact the physician workflow.

The design and evolution of certified EHR technology and health IT systems that held medical data are now changing toward a more cloud-based and mobile platform. This leads to more digitizing of medical records and providing more flexible solutions for healthcare professionals within the clinical setting.

Both mobile health and wearables are also impacting the design of certified EHR technology. The Apple watch, for instance, could potentially hold relevant medical data for physicians to view and patients to access. Additionally, mobile apps on smartphones or tablets could be used by patients to request drug refills and securely message doctors or nurse practitioners.

In a new report from market research firm IDC, Judy Hanover, Research Director at IDC, explains, “The new concept of flexible, mobile, cloud-based acute care EHR supports digitizing paper workflow and reengineering processes … There’s a huge appetite for getting better workflows into healthcare, looking at department specific and mobile apps. I would see an environment where hospitals and health systems would perhaps rip out and replace in some cases.”

According to the report, it is expected that over the next few years, providers will begin to replace their current certified EHR technology with cloud-based solutions instead. Greater investment will continue to be poured into the health IT industry as providers move onto meeting Stage 3 Meaningful Use requirements under the Medicare and Medicaid EHR Incentive Programs.

Additionally, the future of EHRs will continue to depend on EHR interoperability and the ready access of medical data across the healthcare industry. Forbes states that many within the medical sector believe EHR interoperability will be the “biggest game changer.” However, it may take longer than expected for interoperability and medical data exchange to expand across multiple healthcare settings, as this industry “moves slowly.”

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ICD-10 Implementation Vital for Value-based Care Payments

ICD-10 Implementation Vital for Value-based Care Payments | EHR and Health IT Consulting |

When the SGR bill was passed by the Senate without any ICD-10 implementation delays, the proponents of the new coding set rejoiced. Not only did passage of this bill bring about a stronger formula for Medicare reimbursements but it also meant that the ICD-10 implementation would most likely take place by the scheduled deadline of October 1, 2015.

When President Obama signed the Medicare Access and CHIP Reauthorization Act of 2015 into law on April 16, the legislation moved American physicians away from fee-for-service payments toward value-based care and accountable care delivery, according to the Healthcare Information and Management Systems Society (HIMSS).

Additionally, the new SGR bill includes innovative objectives for establishing the meaningful use of certified EHR technology. These payment models will be key for improving population health outcomes throughout the country. The volume-based payment reductions under the prior sustainable growth rate formula will now be altered with a new annual payment update of 0.5 percent through 2019.

By 2019, doctors will be able to choose their reimbursement method among two options: the Merit-Based Incentive Payment System or the Alternative Payment Model. While the Merit-Based Incentive Payment System will depend upon the performance of physicians, doctors who choose the Alternative Payment Model must utilize certified EHR technology standards and authorized quality measures as well as assume financial risk.

The overall push toward value-based care among the federal government, patient advocacy groups, and healthcare providers will require the medical industry to quickly and efficiently transition to the ICD-10 coding set. Documenting patients’ medical histories as well as accurately reporting and coding diagnoses and treatments is vital in the quest to pay for value and enhance population health outcomes across the sector.

The Coalition for ICD-10 also reports on the importance of the ICD-10 implementation in the move toward value-based care, as ICD-9 codes do not have the same capabilities as the newer coding set. While the healthcare community supports the SGR reform bill, many physician groups are still against the ICD-10 implementation and are hoping for additional delays.

However, a move toward measuring and paying for value-based care is not possible without transitioning to a modernized form of diagnostic and procedure coding. In order to accurately measure the value of a healthcare service, it is vital to have the detail available in the ICD-10 coding set, the coalition explains.

One example of the subpar quality of ICD-9 codes involves putting two patients with similar conditions but differing symptoms under the same code while ICD-10 accounts for a variety of divergence among patients. Essentially, ICD-10 codes will include key information about patients and record their medical history more accurately with additional detail.

“Despite opposition to ICD-10 by some physician groups and a few isolated state medical societies, there is general recognition in the medical community that a modern and precise coding system like ICD-10 is essential for measuring and paying for value,” the Coalition for ICD-10 stated. “ICD-9 represents medicine of a bygone era. It cannot support a move to measuring and paying for value. To meet the demands of SGR there can be no further delays in the ICD-10 implementation date.”

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Six Ways to Improve Patient Satisfaction Scores

Six Ways to Improve Patient Satisfaction Scores | EHR and Health IT Consulting |

Large physician practices and hospitals already have a portion of their payments linked to patient satisfaction. Over the next few years, it will be an integral portion of physician payment, including penalties possibly dwarfing those under meaningful use. More about this program, known as the Clinician & Group Consumer Assessment of Health Providers and Systems (CG-CAHPS) can be found on the Agency for Healthcare Research and Quality's website.

Here's the government's hypothesis in a nutshell:

• Patients who like their doctors are more likely to be compliant patients;

• Compliant patients are healthier patients;

• Healthier patients are less expensive; so

• Physicians with satisfied patients should be paid more than physicians with dissatisfied patients.

The Affordable Care Act introduced a different set of quality metrics than used by the Institute of Medicine (IOM): quality, patient satisfaction, and payment. Quality is a key element with both programs, but there's an important difference with the reform law: your patients are the arbiters of quality. Quality more or less equals patient satisfaction.

What's being measured?

CG-CAHPS measures the patient experience, an expansive proxy for quality that takes into account the following:

• Timely appointments

• Timely care (refills, callbacks, etc.)

• Your communication skills

• What your patient thinks about you

• What your patient thinks about your staff

• Your office running on schedule

I have been in enough medical practices — both as a patient and as an administrator — to know there's a method to this madness. It's less about the care and more about the caring. Here's what I suggest for improving your quality measures via these proxies.

1. Hire sunshine.

I can train anyone* to do anything in our office, but I can't train sunshine.  Look to hire positive and happy people, particularly for roles with lots of patient interaction. Your patient satisfaction — and thus, your "quality" — will improve. You'll also find a cost-saving benefit to this hiring tactic: employee turnover will shrink.

2. Start on time.

CG-CAHPS asks patients whether they were seen within 15 minutes of their appointment times; it's even underlined for emphasis. Physicians who start on time are more likely to run on time, so have your feet set before you start running.

3. Set patient expectations.

It's helpful to share with patients the FAQs about your practice so that they know what to do for refills, after-hour needs, appointment scheduling, etc. By making these answers available on your website, on your patient portal, and in your print materials, you'll better align patient expectations with patient experiences and thereby score better on quality surveys.

Some patients gauge quality by whether or not they get the antibiotic they think they need. It's helpful for primary-care physicians to include education on antibiotic overuse in their patient education materials.

Along these lines, it is important for your patient to know what to expect after their visit in terms of test results, follow-up visits, etc. I receive more complaints about the back end of our patients' experiences than anything else. Make sure you and your staff do not drop the ball as you near the goal line.

4. Listen with your eyes.

Nothing says "I don't care" like having your physician focus on a computer screen rather than on the patient. This is particularly true in the first couple of minutes of each visit, and especially important with new patients. One virtue of using medical scribes is that you can listen with your eyes a whole lot more.

5. Put your staff in their place.

Your staff has an important bearing on the patient experience. I'm a big fan of letting them know their actions influence quality. It's pretty cool, for me as a mere bureaucrat, to know that I can improve quality simply by being friendly and helpful to our patients. Make sure your staff knows that making a patient's day is a beautiful act.

6. Monkey see, monkey do.

Staff will follow your lead. If your thoughts and actions emphasize running on schedule, being kind to patients and their families, and not dropping balls, they'll be stronger teammates for you.

Patient satisfaction has always been a gauge of quality, just as patient referrals remain the lifeblood of most practices. Treat this next wave as an opportunity to show off the caring that has always been a big part of the medical care you offer your patients.

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Future of Health IT: “It’s Time to Build Something Magnificent”

Future of Health IT: “It’s Time to Build Something Magnificent” | EHR and Health IT Consulting |

When it comes to health IT policy mandates, provider organizations have long questioned what’s behind the rulemaking process, with many showing further concern regarding federal leaders’ expertise levels and their lack of willingness to change based on public opinion. At the Centers for Medicare & Medicaid Services (CMS), senior technical director of Medicaid health IT Jason McNamara pays no attention these criticisms. “Those types of comments are tied to the old 1970s and 1980s way of thinking about the government, which was slow and hard to move, which sort of like a battleship in the ocean, took time to change. That’s not part of the government I’m with now,” McNamara says.  

McNamara has a wide variety of skills and projects he works on at CMS, ranging from Medicaid electronic health record (EHR) incentive programs to meaningful use rule development to health information exchange (HIE) strategies to consulting on state health IT development under the state innovation model (SIM) grants. McNamara, who focuses on the Medicaid side at CMS, recently spoke with HCI Associate Editor Rajiv Leventhal further about the perception of the government in the health IT landscape, as well as current trends and challenges he’s seeing in the industry from a policy perspective. Below are excerpts from that interview.

Tell me about how you got involved with CMS and what your current role there is?

I work in the data systems group, and if you think about the data systems group, in the context of Medicaid, we essentially work on anything IT related as long as it touches the administration of a Medicaid program or Medicaid beneficiaries. So I like to loosely interpret that as the IT arm of Medicaid. I am a technologist by trade; I spent five years in the Marine Corps, and have trained in communications and technology. I set myself up for a public safety IT focus, which evolved into health IT over the years,  and 15 years later, here I am. I also did work as a consultant implementing EHRs, building proprietary systems for large hospital systems, eventually moving over to the Department of Defense (DoD) and Veterans Administration (VA), having worked on their clinical applications as well. I was clinical operations director for ALTA, the DoD EHR system. Then in 2012 with HITECH legislation coming down, I have been managing EHR incentive programs ever since.

What are your insider thoughts on the DoD EHR contract bid?

Well it’s needed, it’s time to modernize that infrastructure. If you look at the infrastructure that’s in place, it’s antiquated. Some of those legacy systems were developed in the 1970s and 80s. Clearly it’s time to change the way they’re deploying their clinical technologies. This proposal will give us an opportunity to modernize a much needed environment. I have to maintain vendor neutrality here, but folks know some of the largest vendors that have partnered to help develop interoperable solutions, and it’s good that they have come to the table here.

What are the biggest priorities right now for you at CMS?

We have been very focused on Affordable Care Act work; we spent a lot of time deploying that, and now we’re breathing easier and are more focused on modernizing our systems on the Medicaid side, moving them into a real-time, progressive, shared-service model across Medicaid states. We are also heavily focused on data, deploying systems both at the state and federal levels to help analyze the massive amounts of Medicaid data we have. That is huge for us over the next 12 months.  And then we are of course continuing to work on health IT an HIE, an area that has lot of area for growth both from a policy and deployment perspective.

Ideally, in a perfect world, what would be the role of the government in this industry?

It depends on the topic. If you look at the National Health Information Network (NHIN), that was an Office of the National Coordinator for Health Information Technology (ONC) program,  and they managed it 100 percent at the federal level. As time progressed, they changed that and it got run over to a non-profit, Healtheway, who has since taken it over. In that regard, the government was widely used as a kickstarter to deploy that program, which is now self-sustaining in the private market. So I think it was important to push that forward. We took a step back and let the market drive that, and it’s been successful.

 Standards are an interesting topic as to what role the government plays, and we’re still trying to figure that part out. There has been a lot of conversation around open source products, as we have been playing with this idea in the Medicaid space. But how do we administer those open source products? What is our role? We have started to dabble in that market, but how do we translate that back into the community and let them market-ize the platform?

Basically, there isn’t one answer to this question. Everyone would agree that government has an important role, and we have to figure out what that looks like in each separate scenario.

How would you respond to the criticism that federal leaders aren’t appropriately apt to make such impactful health IT policy decisions?

In our government, these are folks who are industry experts who gave up lucrative positions and high paying jobs to help do good. They come from the smartest universities such as Harvard and Johns Hopkins, they were CIOs in large hospitals, and data geeks form get go with three or four computer degrees. So I don’t see this in the world I live in. It is true that it’s difficult for policy makers to keep in touch with where the rubber meets the road. We have to understand the impacts of the policy decisions and how it translates, and we’re getting better at it. We are receptive to public reception and very perceptive into how folks see the program. I’m a technologist, I started by implementing EHRs, so when someone tells me I don’t know what I’m talking about with EHRs, it is offensive. The government is made up of people who want to do good and are here for good reasons. They are underpaid and overworked. I know colleagues that haven’t had a day off in two or three months. So I can’t really associate with those types of comments.

What did you think about the news that Karen DeSalvo is likely out at ONC, and what would you like to see from the next National Coordinator?

I think it's a logical step for her career and her success.  Karen is a dear friend and colleague and she is one who can just get things done. There's value in that mindset no matter where you are in the health system. I think the next coordinator will have to continue to push the community with health IT adoption and interoperability. More importantly, push agencies towards modernizing their various policies that have a direct or indirect impact in the use of technology.  In short, the last five years have been spent laying the foundation. It's time to build something magnificent. 

What are your biggest challenges and pain points right now at CMS?

The way we have done business in the last 30 years is significantly changing; helping become a change agent is a very sensitive thing around everything related to Medicaid. We are not your grandmother’s Medicaid program anymore—it’s a different environment and building that trust is something we’re very focused on. It will become more complicated and important as we liberate data and start to tell stories about our beneficiaries. We have begun to publish a lot of data, and then folks get access to it, analyze, and make connections. We need to make sure communications across systems is continual, that’s a big focal point for us.

With respect to EHRs, we are very mindful of providers who have never had technology in practice. They are a minority but they do exist, as a specific percent are struggling with that. So it’s a challenge considering that from a policy perspective. Also, from a federal perspective, figuring out what’s the value in what we pay for? The data systems group has a $5 billion IT portfolio across states, but what does that mean and how do we create an environment where we make taxpayers dollars most effective installing systems? That’s very complicated, especially when working with legacy systems.  

You help write the EHR certification criteria for the meaningful use program. Can you get into detail about what’s behind that?

We create an advisory group, which comes from the private sector—doctors and CIOs—not public servants.  That committee looks at the program, takes public comment, and has very intimate conversations about how it will look from a clinical and systems perspective, and how it will be deployed. So we take in recommendations, and sometimes the idea starts with a simple Word document. We’ll toss around ideas and end up with some direction. The committee acts as an objective filter for that. So once we do that, we make a notice for proposal.  

For the meaningful use program, we put that on the street and take public comment. We are required to respond back—most people don’t even know that. If there’s a policy objective or measure we use and there’s a lot of comment, we can go back, change it and finalize it. We take our process from the Hill, we interpret what we think they’re trying to achieve for regulation, and then we finalize that with our rulemaking process. Then we go forward and deploy the program. When we start to hear questions from provider groups or associations, we create a sub-regulatory guidance, which provides clarity to what we intended when people have difficulty interpreting things. And we can use riders to modify and make amendments as well.  

What has the Stage 3 feedback been like so far?

I think we are at a place where Stage 3 was an aggregate of comments that we have heard over the years. We have learned lot of lessons with Stage 1 and 2, and we are now seeing a much more simplified version. How is this connecting to other programs? It aims to simplify the administration process. Folks have been generally favorable—there have been some concerns about the details of the regulation, and we will publicize those as we start to finalize it. Stage 3 is a much needed policy change, generally speaking.

You have worked with a ton of EMR vendors in the past. How would you rate their willingness to be more open systems?

I think at the end of day, vendors are there for their customers. That means a few things: customers have to hold the vendors accountable, customers have to be knowledgeable, they have to know what they want, and they have to know what’s happening. Too often we see providers pointing fingers at vendors, but are you asking them the right questions and holding them to those standards? Chances are if you hold someone to a standard, he or she would like to perform to that standard.

I think vendors want to support their customers, do good by them, stay in business, and grow revenue, and the way to do that is to solve problems of customers. You can’t get answers to those problems unless you ask questions, though. The vendors are trying, some have built infrastructure around housing their data in an effort to move data within the context of their own systems. I think that’s okay for now. But when folks talk about restricting and closing access, that’s a problem for me. We meet with vendors regularly, people don’t realize that. If we’re hearing problems from providers over and over again we can go right to the executive leaders of those vendors to work those out.

If you had to give a message to the industry as they move forward in a challenging time, what would it be?

We have to keep asking questions and challenge the data. We have a data-saturated environment right now. There is a lot of noise around that data, but what does it all mean? A very important piece of all this, and this ties into interoperability, is the semantics of the data. Let’s keep challenging the data, keep asking questions, and if we have asked so many questions and challenged different pieces, then we have created this fog, but we could sift through that to find direction and truth. It’s not about you, me, a specific provider or vendor, it’s about the collective. What are we doing as the collective to move forward? Let’s have the conversation that way.

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CMS Releases Strategic Vision for Physician Quality Reporting Programs

CMS Releases Strategic Vision for Physician Quality Reporting Programs | EHR and Health IT Consulting |

The Centers for Medicare and Medicaid Services (CMS) has released its strategic vision for physician quality reporting programs, describing a long-term vision for CMS’ physician quality reporting programs and a future for these programs to strive toward over the next several years.

According to CMS, this vision acknowledges the constraints and requirements of existing physician quality reporting programs, as well as the role quality measurement plays in CMS’ evolving approach to provider payment, which is moving from a purely fee-for-service (FFS) payment system to payment models that reward providers based on the quality and cost of care provided.

There are five principles that the federal agency believes will ensure that quality measurement and public reporting play a critical role in improving the healthcare delivered to millions of Americans:

  • Input from patients, caregivers, and healthcare professionals will guide the programs.
  • Feedback and data drives rapid cycle quality improvement.
  • Public reporting provides meaningful, transparent, and actionable information.
  • Quality reporting programs rely on an aligned measure portfolio.
  • Quality reporting and value-based purchasing program policies are aligned.

“CMS relies heavily on quality measurement and public reporting to facilitate the delivery of high quality care,” according to a blog post from Patrick Conway, M.D., principal deputy administrator and chief medical officer at CMS. “This strategic vision articulates how we will build upon our successful physician quality reporting programs to reach a future-state where quality measurement and public reporting are optimized to help achieve the CMS quality strategy’s goals and objectives, and therefore contribute to improved healthcare quality across the nation, including better care, smarter spending, and healthier people.”

According to the blog post, the strategic vision evolved out of the agency’s desire to plan for the future in how it administers the physician quality reporting system (PQRS), physician feedback/value-based payment modifier program, and other physician quality reporting programs. With passage of legislation ending the Sustainable Growth Rate (SGR) formula, key components of these physician programs will serve as the foundation for the Merit-based Incentive Payment System, Conway added.

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How Electronic Health Records Will Be More Helpful To Doctors And Patients

How Electronic Health Records Will Be More Helpful To Doctors And Patients | EHR and Health IT Consulting |

Twenty years ago, if patients wanted to read their own medical records, they likely had to sue their healthcare provider for access. Even after the Health Insurance Portability and Accountability Act was passed in 1996, legally guaranteeing patients the right to their medical information, the process to obtain records was so arduous that few people bothered.

Today, the picture is different. Not only do patients have the right to view their records, technology is improving their ability to access them.

When three hospital systems in Massachusetts, Pennsylvania and Washington took the step of offering patients online access to their health records and physicians’ notes, more than two-thirds of the patients reported positive results: having a better understanding of their health and medical conditions, taking better care of themselves and becoming more regular with their medications. Encouragingly, this did not significantly add to physicians’ workloads: Only 3 percent spent more time answering patients’ questions outside of visits, and 11 percent spent more time writing or editing notes.

Tapping New Models

These hospitals are not alone. Several healthcare executives are experimenting with similar models and a new generation of electronic health records (EHRs) is on its way.

The legacy EHR systems, rooted in PCs tethered to server computers and built primarily to meet regulatory requirements, have become unwieldy and expensive for most healthcare organizations to support, according to the latest report from market research firm IDC. It predicts a massive structural shift to web-native technologies like cloud, allowing organizations to store and access data and programs over the Internet and pay a fee based on how much computing power is used.

“The new concept of flexible, mobile, cloud-based acute care EHR supports digitizing paper workflow and reengineering processes, ” explains IDC research director Judy Hanover. It also enables better integration with analytics, big data, mobile and social tools.

Wearable health records are knocking on doctors’ doors too. Drchrono, for instance, has made patient-facing and provider-facing Apple Watch apps to complement its iPhone and tablet versions. Using the app, a physician can view a patient’s information, respond to patient messages using quick text and assess a patient’s refill requests as well as lab results without taking out his or her iPhone or iPad.

Others in the industry seem to agree that there is demand for such seamless connectivity. The 2015 Middle Market Healthcare Outlook, conducted online by the Harris Poll on behalf of CIT, confirms that the benefits of technology are clear to most healthcare executives. According to this study, about 3 in 4 recognize the positive impact of technology in reducing costs for consumers. However, a majority of those surveyed also feel that the stakes are higher for the healthcare industry with respect to technology, and they struggle to figure out which technological advances will be most relevant.

Moving Beyond Regulation

According to Hanover, there is an acute innovation gap in EHR. Her studies indicate that doctors see fewer patients today and spend more time on documentation than they did when using paper charts in 2009. She believes that the healthcare industry has been so focused on meeting regulatory mandates like Meaningful Use — policy designed to ensure that clinicians and hospitals actually use the computers they bought through government subsidies — that there was no real push for innovative, flexible software.

But business needs are now overtaking regulatory mandates and several healthcare executives are exploring the next generation of medical records software, built on cloud as a foundation. These cloud-based systems offer lower up-front capital expenses, predictable maintenance costs and flexibility to scale up or down based on requirements. They will make it easier to access patient data from multiple endpoint devices and analytics services to understand it better.

EHRs of the Future

“There’s a huge appetite for getting better workflows into healthcare, looking at department specific and mobile apps. I would see an environment where hospitals and health systems would perhaps rip out and replace in some cases,” says Hanover. The Harris Poll study also predicts higher investments in IT. The study found that IT was the third most likely reason for healthcare executives to seek financing in 2015 after “new hires” and “new construction.”

Is it time for healthcare providers to swap their current EHR and upgrade to the new cloud-based software? Hanover expects investments to flow into this next generation of EHRs in the next one to two years. The industry will see several EHR systems move to the cloud within three to five years, she believes.

“There’s an opportunity for healthcare technology suppliers to really innovate and offer a compelling option,” she says.

Early Days for Data Sharing

The latest guidelines released by the Centers for Medicare & Medicaid Services require healthcare providers to share data with other providers and patients, without compromising on security. Many in the industry expect data sharing capability to be the biggest game changer. Will this mean a doctor can pull a new patient’s medical history — blood work, blood pressure and medication details — from another hospital? “Not so fast. Healthcare moves slowly,” warns Hanover.

It’s early days yet for opening up access to patient data, and the new generation of EHRs might begin with better workflow, improved productivity and tighter integration with analytics of patient data.

Laurie Bolick Wolf's curator insight, June 17, 2015 2:46 PM

This article specifically focuses on the changes expected in healthcare as technology improves and changes.  The expectation is that care will  improve as providers are able to access information from multiple facilities and locations easily and immediately.  While this does increase productivity and the ability to see more patients, the downside is the documentation within the EMR itself.  The shear volume of data that must be entered with EMR is much higher than when documentation was done on paper.  In the end, the time saving with technology advancements may be lost in the extra time spent on documentation.