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Technical Doctor's insights and information collated from various sources on EHR selection, EHR implementation, EMR relevance for providers and decision makers
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Will Altering EHR Incentive Programs Raise EHR Implementation?

Will Altering EHR Incentive Programs Raise EHR Implementation? | EHR and Health IT Consulting | Scoop.it

While the HITECH Act and meaningful use requirements under the Medicare and Medicaid EHR Incentive Programs have truly increased the number of healthcare providers implementing and utilizing EHR systems, new research suggests that these federal regulations may have also led to specific disparities in patient care. A study stemming from Weill Cornell Medical College found “systematic differences” between doctors who were avid participants in the EHR Incentive Programs versus those who did not invest as much time and resources into meeting meaningful use requirements.


The study was published in the June edition of Health Affairs and analyzed more than 26,000 doctors across the state of New York. Additionally, the researchers looked at payment data from the Centers for Medicare & Medicaid Services (CMS) and the state Department of Health.


The payment data analyzed in the study stemmed from the years 2011 to 2012. The results show that participation in the Medicaid EHR Incentive Program increased by 2.4 percent during those two years. However, participation in the Medicare EHR Incentive Program rose much more quickly, showing a 15.8 percent increase in the number of providers taking part in the program and implementing certified EHR technology.


The results show that early and consistent provider participants in the EHR Incentive Programs have more financial capacity, better organization and resources for supporting EHR implementation, and previous experience using health information technology.

While meaningful use requirements pushed EHR adoption forward, the process of using the systems on a constant basis had a new set of challenges that some providers were unable to attain, the researchers said. However, the differing rates of participation in the EHR Incentive Programs is leading to higher quality care at some physician offices while others are lacking and administering lower quality healthcare services.


“The expectation is that physicians and hospitals should be electronic,” senior author Dr. Joshua Vest, an Assistant Professor of Healthcare Policy and Research at Weill Cornell Medical College, said in a public statement. “How would everybody feel if only half of the banks were electronic nowadays? Without additional support to move forward there is the potential to stall out among those who don’t have the resources or capability to adopt EHRs.”


The researchers explained that there is a “digital divide” among different healthcare providers due to the participation in the EHR Incentive Programs. These results may play a role in the future of healthcare policy. Since there are certain providers who dropped out of the Medicaid EHR Incentive Program, it may behoove federal agencies to make some significant changes to the objectives within this particular program in order to keep providers participating.


“Electronic health records are vital not only because of their ability to efficiently provide physicians with a comprehensive portrait of and decision support for their patients, but also to drive new healthcare delivery models that can improve the value and quality of clinical care,” Dr. Rainu Kaushal, Chair of the Department of Healthcare Policy and Research and the Frances and John L. Loeb Professor of Medical Informatics at Weill Cornell, said in a public statement.

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The Blocking of Health Information Undermines Interoperability and Delivery Reform

The Blocking of Health Information Undermines Interoperability and Delivery Reform | EHR and Health IT Consulting | Scoop.it

The secure, appropriate, and efficient sharing of electronic health information is the foundation of an interoperable learning health system—one that uses information and technology to deliver better care, spend health dollars more wisely, and advance the health of everyone.


Today we delivered a new Report to Congress on Health Information Blocking that examines allegations that some health care providers and health IT developers are engaging in “information blocking”—a practice that frustrates this national information sharing goal.


Health information blocking occurs when persons or entities knowingly and unreasonably interfere with the exchange or use of electronic health information. Our report examines the known extent of information blocking, provides criteria for identifying and distinguishing it from other barriers to interoperability, and describes steps the federal government and the private sector can take to deter this conduct.

This report is important and comes at a crucial time in the evolution of our nation’s health IT infrastructure. We recently released the Federal Health IT Strategic Plan 2015 – 2020 and the Draft Shared Nationwide Interoperability Roadmap. These documents describe challenges to achieving an interoperable learning health system and chart a course towards unlocking electronic health information so that it flows where and when it matters most for individual consumers, health care providers, and the public health community.


While most people support these goals, some individual participants in the health care and health IT industries have strong incentives to exercise control over electronic health information in ways that unreasonably interfere with its exchange and use, including for patient care.


Over the last year, ONC has received many complaints of information blocking. We are becoming increasingly concerned about these practices, which devalue taxpayer investments in health IT and are fundamentally incompatible with efforts to transform the nation’s health system.


The full extent of the information blocking problem is difficult to assess, primarily because health IT developers impose contractual restrictions that prohibit customers from reporting or even discussing costs, restrictions, and other relevant details. Still, from the evidence available, it is readily apparent that some providers and developers are engaging in information blocking. And for reasons discussed in our report, this behavior may become more prevalent as technology and the need to exchange electronic health information continue to evolve and mature.


There are several actions ONC and other federal agencies can take to address certain aspects of the information blocking problem. These actions are outlined in our report and include:

  • Proposing new certification requirements that strengthen surveillance of certified health IT capabilities “in the field.”
  • Proposing new transparency obligations for certified health IT developers that require disclosure of restrictions, limitations, and additional types of costs associated with certified health IT capabilities.
  • Specifying a nationwide governance framework for health information exchange that establishes clear principles about business, technical, and organizational practices related to interoperability and information sharing.
  • Working with the Centers for Medicare & Medicaid Services to coordinate health care payment incentives and leverage other market drivers to reward interoperability and exchange and discourage information blocking.
  • Helping federal and state law enforcement agencies identify and effectively investigate information blocking in cases where such conduct may violate existing federal or state laws.
  • Working in concert with the HHS Office for Civil Rights to improve stakeholder understanding of the HIPAA Privacy and Security standards related to information sharing.


While these actions are important, they do not provide a comprehensive solution to the information blocking problem. Indeed, the most definitive finding of our report is that most information blocking is beyond the current reach of ONC or any other federal agency to effectively detect, investigate, and address. Moreover, the ability of innovators and the private sector to overcome this problem is limited by a lack of transparency and other distortions in current health IT markets.


For these and other reasons discussed in our report, addressing information blocking in a comprehensive manner will require overcoming significant gaps in current knowledge, programs, and authorities. We believe that in addition to the actions above, there are several avenues open to Congress to address information blocking and ensure continued progress towards the nation’s health IT and health care goals.


Information blocking is certainly not the only impediment to an interoperable learning health system. But based on the findings in our report, it is a serious problem—and one that is not being effectively addressed. ONC looks forward to working with Congress, industry, and the health IT community to properly address this problem and ensure continued progress towards achieving the goals of an interoperable learning health system.


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ProModel Analytics Solutions's curator insight, April 17, 2015 11:37 AM

Karen DeSalvo-Leads the Office of the National Coordinator for HIT

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HITECH Stage 3 Security Rules

HITECH Stage 3 Security Rules | EHR and Health IT Consulting | Scoop.it

Some security experts are concerned that narrower risk assessment requirements in a proposed rule for Stage 3 of the HITECH Act "meaningful use" electronic health records incentive program could confuse healthcare organizations about the importance of conducting a broader risk assessment as required under HIPAA.

On March 20, the Department of Health and Human Services' Centers for Medicare and Medicaid Services issued a notice of proposed rulemaking for Stage 3 of the Medicare and Medicaid EHR incentive program, and HHS' Office of the National Coordinator for Health IT issued the notice of proposed rulemaking for EHR software that qualifies for the incentive program: 2015 Edition Health Information Technology Certification Criteria.


The rules are slated to be published in the Federal Register on March 30, with HHS accepting public comment for 60 days. Regulators are expected to issue final rules after reviewing the comments, which could take months.

Under Stage 3 of the HITECH Act incentive program, eligible hospitals and healthcare professionals can qualify to receive additional incentives by "meaningfully" using certified EHR software to accomplish a list of objectives, including sending secure messages to patients and conducting a security risk assessment of EHR data.

Currently, depending upon when they began participating in the HITECH program, which launched in 2011, eligible hospitals and healthcare professionals are participating in Stage 1 or Stage 2 of program.

Under the HITECH Act, penalties for not using a certified EHR system will kick in beginning in January 2018. Hospitals and physicians participating in the Medicare program must meet a list of Stage 3 objectives and measurements to avoid reduced Medicare payments, a CMS spokesman explains. Those participating in Medicaid have through 2021 to qualify for financial incentives under the HITECH program, and are not subject to financial penalties for failing to meet the objectives.

Meaningful Use Proposals

One of the most significant proposed changes for Stage 3 requirements deals with risk assessments.

While healthcare providers are still expected to conduct broader HIPAA security risk analysis as part of their HIPAA compliance, the Stage 3 proposals state that healthcare providers must conduct annually an assessment that specifically looks at technical, administrative and physical risks and vulnerabilities to electronic protected health information created or maintained by the certified EHR technology.

The proposal addresses "the relationship" between this EHR-related measure and the HIPAA Security Rule risk assessments. "We explain that the requirement of this proposed measure is narrower than what is required to satisfy the security risk analysis requirement under [HIPAA]," the proposal says.

"The requirement of this proposed measure is limited to annually conducting or reviewing a security risk analysis to assess whether the technical, administrative and physical safeguards and risk management strategies are sufficient to reduce the potential risks and vulnerabilities to the confidentiality, availability and integrity of ePHI created by or maintained in [the certified EHR technology]," says the proposal.

"In contrast, the security risk analysis requirement under [HIPAA] must assess the potential risks and vulnerabilities to the confidentiality, availability, and integrity of all ePHI that an organization creates, receives, maintains or transmits. This includes ePHI in all forms of electronic media, such as hard drives, floppy disks, CDs, DVDs, smart cards or other storage devices, personal digital assistants, transmission media or portable electronic media."

Seeking Clarity

Security expert Tom Walsh, founder of consulting firm tw-Security, says the proposed rule offers some clarity of what's expected of healthcare providers.

"With the new MU Stage 3 there was clarification that this was the original intent" to assess the security risk of EHR data, he says.

However, the focus on the annual security risk analysis of EHR data may inadvertently water down the importance of conducting broader HIPAA risk analysis, he says.

"Some organizations, especially smaller organizations that do not have a dedicated information security professional on staff, think that the only risk analysis they need to conduct is just for the certified EHR," Walsh says. "The HIPAA Security Rule requires that all applications and systems that store or transmit ePHI need to have a risk analysis conducted."

John Halamka, CIO at Beth Israel Deaconess Medical Center in Boston, expressed disappointment with the risk assessment language in the proposed meaningful use rule. "The MU3 security requirements are less than HIPAA requirements in that they focus only on the EHR and not all information flows. Since security is an end-to-end process, it is not clear to me why the security focus of MU should be less than HIPAA."

Halamka suggests that "maybe a balanced approach is to require a HIPAA Security analysis - NIST 800-66 for example - once every three years, then ask for yearly progress on the plan, rather than yearly re-audits."

Secure Messaging

Another security issue spotlighted in the meaningful use requirements proposed for Stage 3 is secure messaging.

The proposal call for healthcare providers ramping up patient communication using secure messaging, especially after patients are discharged from a hospital or emergency room. For instance, the proposal says that providers should electronically send secure messages to more than 35 percent of all patients seen by a provider or discharged from a hospital during the EHR reporting period. The secure message should be sent "using the electronic messaging function of the certified EHR technology to the patient - or the patient's authorized representatives - or in response to a secure message sent by the patient or the patient's authorized representative."


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How Medical Practices Can Stay Ahead of EHR Adoption

How Medical Practices Can Stay Ahead of EHR Adoption | EHR and Health IT Consulting | Scoop.it

Physicians Practice has been asking physicians and practice administrators about their use of technology for over a decade. Now, many practices are on a second or third EHR system, and an increasing number use a cloud-storage solution for patient data.

Technology expert Derek Kosiorek, a consultant with the Medical Group Management Association, says "We see, especially [in] the healthcare sector, certain timeframes when there is a wave of technology adoption. … The big upgrade [for practices] was moving to the EHR." Chances are, your practice is somewhere in the process of implementing a new EHR, upgrading old systems, or adding new technology like a patient portal. If you are wondering where your peers are on the EHR adoption continuum, here's what we found out.


Data systems


Hands down, EHRs are the largest piece of technology that medical practices purchase. Whether your practice is part of a large integrated delivery system or a small independent "shop," EHR is the scaffolding that supports all other technology use. According to our 2014 Technology Survey, Sponsored by Kareo, which asked over 1,400 physicians and practice administrators how they are using technology in their practices, 53 percent of respondents say they have a "fully implemented EHR," and another 17 percent use a system provided by a hospital or corporate parent.  Only 20 percent of respondents say they do not currently have an EHR. When compared to past years, the trend is a slow but steady adoption of EHR: In 2010 (the year meaningful use became effective) 48 percent of responding practices had implemented an EHR, in 2014 that number was 70 percent.

*Check out the complete data from our 2014 Technology Survey to see how your peers are navigating the tech curve.

John Squire, president and chief operating officer of Amazing Charts, says his EHR company, which caters to small primary-care practices (one to five docs), sees similar adoption patterns. Approximately "half of the practices we contact are coming from paper. We get about 30 percent of our business from 'switchers,' somebody who has adopted another EHR system or is getting off of it," says Squire. He notes that many non-adopters are finally deciding to purchase technology, a concept he calls "the last mile," because their attitudes on technology are changing and with the extended deadline for meeting meaningful-use targets, physicians can still take advantage of the financial incentives.


Even if practices decide to opt out of government programs like meaningful use, an EHR can support many practice operations like keeping clinical records and generating patient billing statements. Squire says his company also sees an increase in interest in patient portals for similar reasons. For those practices that are preparing to attest to the Stage 2 rules of meaningful use, it is a necessity to have a portal, but for those that don't the benefits to patients and practice alike are still very real — for instance, removing the burden of "call-backs" to answer routine patient questions.


Patient portals also give a competitive advantage to your practice. Kosiorek notes that patients have come to expect online access to services like banking. He predicts that, soon, practices won't really have a choice. "I think it is going to be a competition thing. Your competition down the street across town has that portal, so any patients are going to start migrating toward that, especially newer patients," he says.


According to our survey, attitudes about the challenges of technology adoption are also shifting. Three years ago, our survey indicated that "cost" was the primary concern for technology adopters. This year, that has changed: EHR adoption and implementation concerns came in first and cost slipped to third place. That dynamic is slightly different if the numbers are sorted by independent and hospital-owned practices. But not as much as one might think: Adoption and implementation of EHR is the primary concern for both groups, with interoperability and cost in a near tie for second place for independent physicians. For hospital-owned practices cost is much less of a worry.

Hospital-owned advantages


When planning on acquiring an EHR, one way practices can address the twin issues of cost and technical support is by becoming part of a hospital or integrated delivery system; especially in rural areas that have fewer resources and large numbers of uninsured patients. Once abhorred by independent physicians, for some, the financials are proving hard to resist. Our survey indicates that 64 percent of respondents are in independent practice, while 36 percent are owned by a hospital. A slight majority of independent docs, 42 percent, say they are in solo practice and 33 percent practice with two to five physicians. That differs significantly when compared to the hospital-employed physicians, where there is a greater spread in practice size. On one end of the spectrum, 32 percent of respondents say they practice with two to five physicians, and on the other, 20 percent practice in a group with over 50 physicians.


Jo Orquia runs a small family medicine practice — located in a suburb of Atlanta — that consists of himself, a new physician partner, and a nurse practitioner. However, because his practice belongs to a large integrated delivery system, he's actually part of a multi-specialty group that has over 700 providers and is spread out over many locations. He's been in practice for over 20 years, and during that time he's vetted and partially implemented three different EHR systems, all with the help of his hospital network. Orquia firmly believes that his practice has benefitted from having access to hospital resources and IT support. He says that had he been in independent practice, he would have been pressured to pick a much less expensive EHR system.

Even though Orquia started his quest to adopt EHR in 2002, he's presently only a month into implementation of the hospital system's new EHR. While he says it has slowed down productivity, from prior experience he knows work flow will improve when he masters the learning curve.


However, he's less than pleased with the bureaucratic processes associated with his new system. "The frustration that I have now is simply, it takes so much time to do the things [EHR] requires me to do," he says, referring to his health system's requirement that as the physician, he must personally order tests and studies that previously he relied on his NP to order, with his supervision.

Forty-seven percent of respondents to our survey indicated that implementation of an EHR made their practice work flow more efficient; while 32 percent said they had not benefitted from new work flows. However, as Orquia notes, it takes time to fully implement and train staff members on a new system. Seventy percent of responding practices said that they had a fully implemented EHR (software/ hardware installed, and all providers and staff trained and using the system as needed) within one year of acquisition.


Independent practice concerns


Brandon Peters' solo practice, Northeastern Family Medicine, has been providing care to the citizens of Elizabeth City, N.C., since 1872. It is truly a family practice: before Peters, his father ran the practice, and before him, his grandfather and great uncle did. Elizabeth City is a small town about 50 miles south of Norfolk, Va., where 28 percent of the population lives below the poverty line. For Peters, that means a negative impact on his practice revenue.

"Unfortunately, some folks that make the commute up to the tidal area to have service have insurance, but we have a large uninsured population," Peters explains. That was part of the impetus for him to abandon his standalone practice management system two years ago and to adopt a new EHR system. He feels strongly that newer reimbursement models will depend heavily on reporting quality patient-care measures.

Squire sees the same trend in terms of practices adopting and using data systems that will not only document patient visits and facilitate automated billing tasks, but are also integrated with regional healthcare delivery networks. "[Primary-care physicians] see a little bit of everything," says Squire, "… they are basically the triage for the healthcare system. And they've got to interact with all these delivery systems; hospitals and larger [integrated delivery networks] and ACOs … and want the data portability and the ability to fit into all those systems."


Even for those physicians who are not wholly connected to data networks, Squire says the majority of physicians he talks to are embracing technology like e-prescribing and automating lab orders. "There's a clear payback there. If you look at one screen and see all your lab results come in, it's very convenient vs. a pile of faxes."

Another benefit to practices that adopt EHR will come through better transitions of care; for instance being notified when a patient is discharged from the hospital. Squire says that process is not as smooth as it should be, but CMS is working to automate it — and provide for greater provider reimbursement. New procedural codes for transitions of care will "allow the physician to basically make more money [for] follow-up care," Squire notes.

Peters does believe there is value in collecting and reporting patient data, but he's not convinced that translates into better patient care or improved work flow. He's even changed the structure of the questions he asks his patients during the office visit, so that he can better enter the data into the EHR. He fears that change will tarnish the patient-physician relationship. He likens the EHR-directed patient visit to driving 70 mph on the interstate, where changing direction is not an easy maneuver.

Peters also says he struggles with completing patient notes and often stays late at night trying to finish up. In that regard he is not alone. A third of respondents to our survey said EHR made their work flows more difficult. Peters says he cannot afford to hire someone to help him enter patient data. "I know some people have scribes … so you are not trying to collect [data] in real time while the patient is right there in the office. But the value, the charge for each one of our visits is so low … we're only getting $35, $40 per patient," he explains.

Using a medical scribe may be a concept before its time: Only 21 percent of our survey respondents indicated that they used a scribe to help enter patient data.

Since his practice consists only of himself, a receptionist, and a nurse, Peters must wear multiple hats — which make further drains on his time and pulls him away from patient care. "If we had somebody in-house to run the system, to customize the system, to keep it running, to do the updates, to make sure the printers worked, to make sure everything ran together [it would be better]."


New tech tools


If you contrast the hospital-owned group versus the independent practice contingent, it is clear that goals like implementation, access to new technologies, and IT support are more easily attained with the help of an integrated delivery system.

Robert Goldszer is chief medical officer at Mt. Sinai Medical Center in Miami Beach, Fla. Mt. Sinai is a 600-bed teaching hospital that also has five multi-specialty satellite clinics located within a 10-mile radius from the main campus.

The hospital uses an EHR that is accessible to providers on inpatient, outpatient, and teaching services. It can also be accessed remotely through laptop, tablet, smartphone, or whatever device is convenient. Goldszer says that physicians who treat patients at satellite clinics carry no patient charts. "I [the provider] just drive there, I log in to the desktop or my iPad, and I can do all the computing and look at every chart, write my notes, and see all the results I need," he explains.

Goldszer notes that Mt. Sinai has implemented several of the newest healthcare technologies: a HIPAA-compliant texting application; a heart-rhythm monitoring and reviewing application that uses telemetry; a diagnostic imaging application that can be viewed on mobile devices; and a patient portal.

The hospital also supports its residents' technology use by giving them an education allowance — which many use to buy an iPad.

"In this hospital on … teaching rounds, there's an attending, two interns, and three of the people have their iPad out. One of them is reading something from UpToDate or technology that they have online; the other person is looking at the X-ray; and the other person is writing the orders," says Goldszer.


In summary


While most practices have adopted an EHR, concerns about implementation are still front and center.  Here are some ways to make technology work for your practice:

• Use hospital/laboratory data networks to share/transmit patient records electronically;

• Write and transmit prescriptions electronically;

• Avoid printing and faxing reports, lab results, and prescriptions;

• Select EHR systems that allow remote access to patient data on mobile devices; and

• Use a cloud solution to store patient data — reducing expenses for upgrades, maintenance, and support.

Erica Sprey is an associate editor at Physicians Practice. She can be reached at erica.sprey@ubm.com


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Solving Problems that Arise Due to EHR Use

Solving Problems that Arise Due to EHR Use | EHR and Health IT Consulting | Scoop.it

In plastic surgery, we live by the maxim that to correct a problem in one area is to create (or expose) a problem in another area. That is what I see happening with the transition to EHRs. The use of EHRs has rapidly increased and expanded over the past five years. The HITECH Act and the onset of meaningful use have provided significant incentives to assist practices and providers to implement EHRs in their practices.

Many initiatives to improve care delivery and patient handoffs have also expanded the emphasis on EHRs, leading to expanded use in both emergency departments as well as outpatient settings. According to the National Center for Health Statistics, the use of EHRs in the emergency department nearly doubled from 46 percent to 84 percent in the five years preceding 2011. The growth on the outpatient side was even more significant with a change of 29 percent in 2006 to 73 percent in 2011.

EHRs allow us to leverage the power of computers to provide a better quality of service to the patients who rely on us for their care. They provide great benefits to care delivery, including automated evaluation of drug interactions, preventative healthcare suggestions, persistent patient problem lists, and electronic prescribing, among other components.

While there has been fantastic progress made toward the goal of successfully implementing EHRs at all levels of the U.S. healthcare system, we still have work to do to ensure the process works smoothly for patients and providers.

Problems are arising as they are being solved.

Providers have expressed concerns about needing to refine the EHR process to enhance productivity, not decrease it, as well concerns about perceived reduction in patient satisfaction and attentiveness to patients.

Another issue is the very real problem with fraudulent documentation. The EHR was created to assist providers and hospitals for properly documenting the care that is delivered in support of appropriate, higher level coding. However, a small but significant level of falsification of records is occurring, facilitated by the utility of the EHR, that is driving up healthcare costs. To combat this, insurance carriers and CMS are employing increasingly sophisticated tools to detect fraud in the EHR, and going after providers and facilities to recover fraudulent reimbursement, among other penalties.

I still believe in the promise of the EHR. I’m confident that the EHR will fulfill its potential to become one of the more valuable tools that we have in modern medicine to improve the care we give to patients.

How can we combat some of these problems that are arising due to EHRs? Here’s my prescription:

• Provide more and continuous training resources for providers in the use and utility of EHRs.
• Clearly define and explain how EHRs can contribute to and result in fraudulent and nefarious practices. It is also the responsibility of the provider to understand this issue, as ignorance of the laws and regulations is no defense.
• Provide more tools to make it easier for providers to focus on patient care, and not the process of charting and ordering in EHRs. Examples include biometric log on to systems and enterprise level medical dictation to cut down on the time drain that EHRs represent in the current deployment.
• Be patient. A transition is a change from one paradigm to a new one. It takes time, money and resources to change something as significant as the way in which we document the care that we provide.

I discover additional utility in the two EHRs that I use daily by being inquisitive, and working with IT and the representatives of the software providers. It can seems like a daunting task due to the time pressures under which we all operate in our respective clinical environments, however, the benefits will be far worth it in the long run. With the proper training, and support, we can reach our potential and get the focus back where it belongs — on patient care.


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Keep Calm and Interoperate On

Keep Calm and Interoperate On | EHR and Health IT Consulting | Scoop.it

Following the recession, the Obama administration sought shovel-ready projects.


One unlikely shovel wielding aggregate demand was health information technology. The Health Information Technology for Economic and Clinical Health (HITECH) Act passed in 2009 directed 5 % of the stimulus towards digitizing medical records.


Computerization of medical records doesn’t induce the images of public works as building freeways during the Great Depression does, but the freeway is a metaphor for exchange of information between electronic health records with the implication that such an exchange is a public good and so government intervention is justified.


Robert Wachter, voted the most influential physician by Modern Healthcare, sums the optimism and frustration with the electronic health record (EHR) in Digital Doctor – which stands to be a classic.

It was Bush Jr., not Obama, who started the digitization. Seeking bipartisanship after the war in Iraq, Bush was inspired by his closest ally, Tony Blair, who was wiring the National Health Service (NHS) – a $16 billion initiative which has since failed, spectacularly.


Bush founded the Office of National Coordinator of Health Information Technology (ONC) and appointed David Brailer – a physician, quant and entrepreneur – as head. Brailer wanted interoperability so that hospitals shared information. It is because of interoperability that we can use our debit cards in New York and Singapore. The market must agree on a common language, such as the TCP/ IP for the internet, to achieve interoperability.


Patients suffer when systems can’t talk. Were patients, not a third party, bearing the full costs of care – a free market – they might have forced hospital information systems to talk. Rightly or not, healthcare is not a free market and hospitals have little motivation in making cross-talking simpler.


Brailer wanted the ONC to be an enabler not dictator of common standards. Fearing that market innovation would be ruined by regulatory over reach, he drew a fine line. A budget of $42 million suited his libertarian ethos. Following the HITECH Act, the budget for ONC increased to $30 billion and Brailer’s line was wiped.


With unabashed Keynesianism, the government subsidized the purchase of EHRs by physician practices from certified vendors. The logic was sound. Expecting practices to digitize voluntarily is like expecting people to buy roads to make Interstate-95. The cost of digitization is high, yet all will, one day, benefit from the wiring, not just practices which choose to be wired.


The reformers wanted a Goldilocks system in which doctors delivered neither too much nor too little care. To pay doctors for doing the right thing, not just for doing, an electronic repository was necessary, so that payers knew which doctors followed guidelines, encouraged prevention and practiced high value care.


If only payers could measure doctors they could reward the good and punish the bad. EHRs would be the treasure trove of that information. If mandating health insurance was crucial to reforming insurance, the EHR was essential to reforming physician payment. Thus, the EHR transmogrified into an electronic version of Bentham’s panopticon.

The government could not subsidize physicians unconditionally. The conditions were named, with unintended irony, “Meaningful Use.” Regulators no longer were concerned just with interoperability but how the technology was being used. It was like Steve Jobs and Bill Gates selling computers only if used for activities they both approved.

In a dialectic not odd in healthcare, HITECH is a success and disaster. The adoption of EHR, which increased from 10 % to 70 % of practices, would not have happened so quickly without the subsidies. The Blitzkrieg has consequences – many physicians loathe EHRs, viscerally.


The paradox of automation is at once diminution and magnification – fewer but more catastrophic errors. Wachter narrates how a young male received an obscenely high dose of an antibiotic because of a user-unfriendly prescription interface. The bad tool might blame the workman. Whether the tool or the workman is at fault is a distinction without a difference.


Why are doctors deskilled by EHRs when they use I-pads, power point and Yelp? EHR is like a library which throws all books all at once at you when all you wish to read are books by Herman Melville. The information overload fatigues.


EHRs serve many masters including administrators, payers, risk managers and researchers. EHRs must also capture the nuances of a doctor-patient interaction. By bloviating the EHR with information rather than trimming the interface with context, the vendors have pledged their servitude to the comptroller not the foot soldier; which would be fine but it is the foot soldier who uses the EHR predominantly.


Wachter is no Luddite. He speaks in measured tones with subtle angst and his sharp analysis will please Luddites as well as Futurists. He occasionally invites the reader to disagree. Wachter believes EHRs, though flawed, have improved healthcare delivery. I might argue with that. The loss of clinical context is tangible. But would I return to paper records? Truthfully, probably not.


Computerization of records was inevitable. Had it emerged organically, through dispersed agents and trial and error, the way advised by Friederich Hayek in his landmark essay “Use of Knowledge in Society”, arguably we might have interoperability. The precocious adoption of EHR may have stunted its growth.


Imagine if the government had subsidized the purchase of cars in 1896. Perhaps all Americans would have owned cars before the twentieth century, and horse buggies would have disappeared sooner. But would Henry Ford have innovated beyond the Quadricycle?

Mr. Ford might have envied the EHR-vendors. I do. They enjoy a rare carapace which shields them from unhappy customers. Disgruntled doctors are summarily dismissed as change-phobic dinosaurs. Hospital administrators don’t admit that they have misjudged costly technology. Some contracts forbid doctors from shaming vendors openly, even as taxpayer’s money flows to the vendors. Free market advocates will protest that this is not capitalism. To be fair, neither is this socialism. Whatever this innominate political economy will be named, it seems quite unique to US healthcare.


John Maynard Keynes famously said that in a recession there was value even in the government burying bottles with bank notes and luring private enterprise in to retrieving them. HITECH didn’t exactly bury the bottles but handed them out, with $30 billion in them. In return for the bottles we have strategic plans, shared goals, pages and pages of rules but no interoperability. Instead, the ONC is remonstrating with hospitals not to block information. Might the stimulus have been better spent on tinkerers? Brailer believes so.


To quote Seneca: to be everywhere is to be nowhere. The reformers may have asked too much, too soon of electronic health records, which may deliver too little, too late. Time will tell, of course, and in twenty years either the tinkerer or the central planner will have the satisfaction of “I told you so.” But both will applaud Wachter’s tome.


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ONC Slams EHR Vendors, Health Providers for 'Information Blocking'

ONC Slams EHR Vendors, Health Providers for 'Information Blocking' | EHR and Health IT Consulting | Scoop.it

Some health IT vendors and health care providers are intentionally blocking the sharing of patient information, impeding progress toward a national data sharing goal, according to a report by the Office of the National Coordinator for Health IT, the Wall Street Journal reports.

Background

Under the 2009 economic stimulus package, health care providers who demonstrate meaningful use of certified electronic health records can qualify for Medicaid and Medicare incentive payments. According to the Journal, the incentive payments have helped nearly 80% of eligible professionals and 60% of eligible hospitals convert from paper files to EHRs. However, just 20% to 30% of providers are able to share EHRs with outside providers, according to the Journal.

Report Details

The report was written in response to a December 2014 request from Congress

For the report, ONC examined allegations that some health IT developers and providers have engaged in "information blocking," which ONC describes as a practice in which "persons or entities knowingly and unreasonably interfere with the exchange or use of electronic health information".

Report Findings

In the report, ONC listed several complaints that it has received, including that vendors have:

  • Charged high fees to establish connections and share patient records;
  • Required customers to use proprietary platforms; and
  • Made it prohibitively costly to change EHR systems.

Further, the report found that many hospital systems complicate the transfer of patient records to rival providers to control referrals and enhance market dominance.

The report noted that ONC does not have the authority to regulate prices and that many of the actions in question do not violate laws. The agency wrote that it could decertify EHR systems that intentionally block data sharing but warned that doing so would wrongly penalize customers.

ONC wrote, "While many stakeholders are committed to achieving this vision, current economic and market conditions create business incentives for some persons and entities to exercise control over electronic health information in ways that unreasonably limit its availability and use." It added, "These concerns likely will become more pronounced as both expectations and the technological capabilities for electronic health information exchange continue to evolve and mature".

Recommendations

ONC outlined several actions that can be taken to address information blocking, including:

  • Assisting federal and state law enforcement agencies in identifying information blocking cases that violate current laws;
  • Bolstering oversight of certified health IT capabilities "in the field" through new requirements;
  • Creating a nationwide health information exchange governance framework;
  • Requiring certified health IT developers to disclose additional costs, limitations and restrictions associated with their products;
  • Working with CMS to create incentive payments that reward interoperability and health data sharing; and
  • Working with HHS' Office for Civil Rights to educate stakeholders on how HIPAA privacy and security standards apply to information sharing.
Reaction

The Electronic Health Record Association, a trade organization, said that its members aim to share patient records but that it requires time and money to build connections used by several different stakeholders.

Meanwhile, some vendors have said they do not depend on connection fees. For example, vendors in the CommonWell Health Alliance -- which comprises about 70% of the acute care market and 24% of the ambulatory care market -- say they seek to create a network with low-cost connections that make it easy for physicians to find patient records throughout the system.


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Finding the Right EHR for Meaningful Use Attestation

Finding the Right EHR for Meaningful Use Attestation | EHR and Health IT Consulting | Scoop.it

Starting with a new EHR system or switching vendors requires hours of training — something many physicians are reluctant to do. However, switching EHRs is sometimes a necessary step to successfully attesting to meaningful use.

Understandably, physicians get frustrated about having to learn a whole new EHR system, so practice managers and administrators have to approach training delicately.

"I think that some physicians have felt over the years that they may not have gotten everything that they needed from their vendor from a partnership standpoint and may not have gotten it in a timely enough manner," said Trenor Williams, managing partner at The Advisory Board's consulting and management division.

Williams added that integrated technology solutions are, "one of the things that clinicians, administrators, and their operators are thinking about and, to me, that's one of the major drivers that we're seeing outside of meaningful use to get physicians to think about changing their electronic health records."

According to a 2014 survey by Medical Economics, 67 percent of physicians are dissatisfied with their EHR's functionality. However, recent research from the American Academy of Family Physicians showed physicians who did switch their EHR vendors were not necessarily happier about their new purchase. Out of 305 physicians who changed EHRs, 43 percent said they were happy with their new software and only 39 percent were pleased with the new system as a whole.


EHR TRAINING 2.0


Whether implementing a new EHR system due to an acquisition or another scenario, according to Bill Fera, principal in the Advisory Health Care practice of Ernst & Young, it's best to tread lightly when training on a new system is required.

"As with any implementation, the approach should be tailored to the persona of the physician," Fera said. "Physicians who had trouble adapting to an EHR the first time around, will probably have trouble again and will probably exhibit a greater level of frustration. They will need more time and attention for training."

Mary Griskewicz, senior director of healthcare information systems for the Health Information and Management Systems Society, said the initial training on an EHR takes about two days. "Then reinforcement of about two weeks to three weeks of using it over and over again is what is typically needed," Griskewicz said. "Having an expert user on hand is best as well as peer-to-peer training, when possible, to train the staff."

Another factor causing practices to change EHR vendors is the need for enterprise-wide functionality, Fera said.

"Practices who were ahead in selecting EHRs often chose ambulatory-specific products that may not be easily integrated into an enterprise strategy," said Fera. "As the industry emphasizes hand-offs and seamless transitions for patients from one care venue to another in the context of re-emerging risk based payment models, the consistent flow of information through an enterprise related to all aspects of a patient's care become paramount. In these cases, physician practices are often being switched to an enterprise product for ambulatory care."

Griskewicz said some of the resistance to training by physicians is because they don't want to take time away from seeing patients.

"Sometimes what [practices] will do is shut down for a couple of days or do appointments in the mornings and then do training in the afternoons where they'll shadow either with the super user or another physician," she said. "Giving clinicians time to learn the system is really important. There's no way around that."


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Go Beyond Using Your EHR; Practice Heads Up Medicine

When providers and their staff don’t have the time or tools to effectively communicate with patients, a slew of issues can result: from physicians missing important cues and misdiagnosing patients to preventable hospital readmissions and poor outcomes because patients didn’t understand or follow care guidelines.

The problem has become endemic. According to one study, 80% of what doctors tell patients is forgotten as soon as they leave the office. Beyond that, 50% of what the patient did recall is incorrect. In addition to impact communication and follow up have on care and outcomes, patients are expecting a different experience than they once had. Nearly two thirds of patients now say they would consider switching to a physician who offers access to medical information through a secure Internet connection.

Just having the technology isn’t really enough. It is just as much about how you use it. Using an EHR, providing access to a secure patient portal, and other features are great but if you don’t take advantage of all they have to offer, you aren’t likely to change the physician patient dynamic.

That is where heads up medicine comes in because it is a process that engages patients with and in spite-of technology. It enables a variety of actions to be accomplished by a simple gesture, finger swipe, or tap rather than diverting your attention with complex navigation, keystrokes, spelling, or editing. As a result, you can focus your attention on your patient, instead of your technology.

The use of a truly mobile EHR can allow providers to practice heads up medicine by:

Enabling physicians to maintain eye contact with patients.
Allowing providers to have meaningful conversations with patients, share images, and educational materials, drug interactions, and more on the device.
Offering care recommendations to improve both preventive care and chronic disease management.
Assist the provider in capturing accurate information efficiently, yet without distraction.
Providing visit summaries and educational materials for review with patients before they leave the office.
Extending patient care beyond the boundaries of the office/office hours.

What all this requires from providers, aside from having the technology, is the commitment to using it completely. Many physicians want a truly mobile EHR but only a handful use one. My impression is that fear of learning and using new technology stands in the way. So here are my suggestions for getting comfortable with your mobile device so you can better engage with patients, improve outcomes, and increase satisfaction.

The use of a truly mobile EHR can allow providers to practice heads up medicine by:

Enabling physicians to maintain eye contact with patients.
Allowing providers to have meaningful conversations with patients, share images, and educational materials, drug interactions, and more on the device.
Offering care recommendations to improve both preventive care and chronic disease management.
Assist the provider in capturing accurate information efficiently, yet without distraction.
Providing visit summaries and educational materials for review with patients before they leave the office.
Extending patient care beyond the boundaries of the office/office hours.

What all this requires from providers, aside from having the technology, is the commitment to using it completely. Many physicians want a truly mobile EHR but only a handful use one. My impression is that fear of learning and using new technology stands in the way. So here are my suggestions for getting comfortable with your mobile device so you can better engage with patients, improve outcomes, and increase satisfaction.

Don’t skip the how-to: When you get new device, sit down for an afternoon and go through any and all tutorials on how to use your hardware and software. No one can do this part for you.
Use your device every day. Use it for everything from the beginning, not just documenting visits. Read books, do email, play games. The more you use it, the more familiar you’ll get with how to use it.
Tweak your templates. You’ll have preloaded templates in your EHR but you can customize them to fit better with your patterns. The more familiar the sequencing, the faster and easier you’ll be able to run through the template and document while talking to the patient.
Practice makes perfect. Do several test runs with staff or family before real patients to get your flow down. You want to get to the place where you can mostly tap and swipe without having to look at the device too much.

When it comes to choosing an EHR, take your time to get it right because the software and device are important. But if you want to practice a heads-up medicine approach, a big part of your success will also depend on getting comfortable with the device so you can focus more on the patient and less on the technology.

To discover more strategies to fully engage patients, download 10 Powerful Ways to Engage Patients.
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ProModel Analytics Solutions's curator insight, March 26, 2015 11:49 AM

Using tech and still looking your patient in the eye!

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Mobile EHRs forge a patient journey platform

Mobile EHRs forge a patient journey platform | EHR and Health IT Consulting | Scoop.it

As last year wound down, Practice Fusion optimized its electronic health record service for Apple and Android tablets — and, in so doing, joined the growing number of vendors making mobile EHRs.

In addition to the obvious benefits of cutting the proverbial cord and arming clinicians with software tuned to specific devices, mobile-optimized EHRs lay a foundation for providers.

On tap for 2015? Patient check-in.

“Very soon the front office staff will no longer have to get out paper forms,” Practice Fusion CEO Ryan Howard says, stressing that this upcoming Practice Fusion feature would finally cover “every step of the patient journey.” 

Indeed, Practice Fusion revealed online check-in earlier this month and explained that patients will be able to submit insurance information, prescription status, and the reason for their upcoming visit before they even set foot in the doctor’s office. 

The company claimed that its new service will eliminate a quarter-billion pieces of paper this year by replacing the average 3-7 page forms patients complete at the doctor’s office.

Beyond check-in, Practice Fusion will also be looking to gear its cloud-based offering toward medical specialists.

“We’re pretty focused on flow sheets this year and really delivering a lot of functionality for subspecialties,” Howard revealed. 

As far as legislation and regulation go, ICD-10 and telemedicine mandates will be huge in 2015 and key at HIMSS15, Howard says. Meaningful Use Stage 3 will also be entering the fold this year, a fact the industry is hard-pressed to heed given the difficulties currently unfurling with Stage 2.

And EHRs optimized for mobile use will be underlying all of the above, Howard explains.

That’s because patients want mobility as much as doctors do.


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