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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HITPC Claims Interoperability Progress Not Fast Enough

HITPC Claims Interoperability Progress Not Fast Enough | EHR and Health IT Consulting |
Four general policies and developments could help speed up the interoperability initiative.

As a part of a federal mandate to improve EHR use, interoperability, and connected care, the Health IT Policy Committee (HITPC) has submitted its December report to Congress explaining barriers and policy suggestions with regard to interoperability.

Develop Health Information Exchange (HIE) Measures

The first policy suggestion the HITPC explained to Congress was the establishment of HIE-sensitive measures which would not only measure the amount of information providers were exchanging amongst one another, but the meaningfulness and impactfulness of that information. In order for providers to receive high scores on these measures, the information exchanged would need to be used meaningfully, as to reflect an important use of the information.

“In order to enhance the strength of incentives that drive interoperability, a set of specific measures should be developed that focus on the delivery of coordinated care, facilitated by shared information across the entire health team (including the individuals and families) and throughout the continuum of care settings,” the HITPC explained. “An example of an HIE-sensitive measure would look at medically unnecessary duplicate testing.”

This new policy could be effective in strengthening incentives by first allowing payers to incorporate these measures into their payment methods, and second by integrating these measures into public reporting that would in turn reveal which providers give the highest level of coordinated care.

Develop Vendor HIE Measures for Certification

Just as providers should be tested against certain HIE-sensitive measures, as should vendors. Such measures could potentially serve as a direct catalyst to improve vendor developments and performances.

Specifically, HITPC is looking for these measures to occur in practical use -- not in a lab -- and to take into account needs that go beyond certification measures for the EHR Incentive Programs.

“Today, purchasers of EHR systems lack such measures to inform purchasing decisions or to use as a lever to put pressure on vendors to improve,” HITPC confirmed. “Although vendors have strong incentives to pass the interoperability requirements for EHR certification, this process is “one-time” and occurs in a lab. It has not been shown to translate into interoperability that is affordable or easy to implement in the field.”

HITPC also listed a few specific measures that could record vendor HIE performance:

  • Number of data exchanges from external sources, which could include other providers, community social-service organizations, consumers, payers, etc. (denominator that measures ability to exchange data with another electronic system such as an EHR, HIE or consumer application (app));

  • Percentage of external data elements viewed (numerator that measures perceived value of the external data);

  • Percentage of external data elements incorporated/reconciled with internal records (represents meaningful data); and

  • Percentage of time viewing of external data changed current activity (e.g., appeared in clinical decision support, led to change in order being written), which demonstrates impact of external data.

Accelerate Incentive Payments for Interoperability

HITPC maintained that in order for providers and vendors to make interoperability progress, they must have adequate incentive payments. Not providing incentive payments encourages providers to deal with internal needs rather than prioritize interoperability.

Today, the lack of palpable financial incentives for interoperability favors the status quo. Pressing internal priorities compete for attention and resources are needed to achieve interoperability, especially when specific actions to enact interoperability are complex and time-consuming. This results in slow progress. Moving interoperability up the priority list will likely take financial incentives that are more targeted than a broad shift from fee-for-service to pay-for- 17 value. To have the desired effect, the incentives must be strong and specific, with clearly defined measures and a deliberate implementation timeline and effective dates.

Initiate Sustained Multi-Stakeholder Action

In order for the above-mentioned goals to be met, HITPC explained that multiple stakeholder groups will need to take action in the overall interoperability efforts. Several of the policy suggestions, such as creating HIE-sensitive provider measures, require multiple voices for development, and multiple interpretations of the ONC Interoperability Roadmap.

Thus, HITPC suggested creating an interoperability Summit of various industry stakeholders in order to collaborate on interoperability efforts.

The output of the Summit would be an action plan with milestones and assigned accountabilities for achieving the milestones in the context of this larger interoperability initiative. We expect the compelling call-to-action would engage the stakeholders to continue their activities after the Summit as a way of meeting the payer-driven incentives that reward HIE-sensitive measures of coordinated care.

Earlier this year, Congress requested a report from the Office of the National Coordinator for Health IT (ONC) which detailed the issues surrounding information blocking. In the report, the ONC both defined information blocking as a practice, and provided examples.

Specifically, ONC defined information blocking as using criteria of interference, knowledge, and lack of justification for refusing to share information.

The information provided in this most recent report from HITPC could potentially put an end to those negative information blocking practices by providing incentives for fostering HIE and interoperability. Between monetary incentives and a clear prescription of HIE measures, both providers and vendors could ideally implement more effective interoperability strategies.

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The Guide for Physicians to Stay Independent

The Guide for Physicians to Stay Independent | EHR and Health IT Consulting |

I am contacted fairly frequently by physicians in private practice who ask me whether I know of a hospital or other similar entity that may be interested in acquiring their practice.  Sometimes a physician is nearing retirement, but more often the physician has simply determined that remaining in private practice is a hopeless endeavor. 

Although independent physicians often opine that the independent practice is no longer sustainable, recent data from the AMA shows that more than 60 percent of physicians continue to work in practices with ten physicians or fewer and their practice size did not really change all that much between 2012 and 2014.  In the study, evidence seems to show that although more physicians are becoming employed by hospitals and health systems, they may not be doing so at the rate or speed previously thought.

According to the AMA study, the percentage of physicians working for hospitals or in practices that had some hospital ownership increased from 29 percent in 2012 to 32.8 percent in 2014 and physicians, as practice owners, decreased from 53.2 percent to 50.8 percent in that same time period.  Solo practitioners decreased from 18.4 percent to 17.1 percent and physicians directly employed by hospitals increased from 5.6 percent to 7.2 percent.  Certainly the trend towards increased physician employment and decreased physician practice ownership is clear, but it’s hardly the wave of change that was predicted. Could it be a trend that is showing signs of slowing? Is it a movement that

physicians can halt?

There is no doubt that independent and small practices are still an important part of the healthcare delivery system. Many are continuing to thrive despite the reforms in healthcare going on in this country.  How can physicians continuing in the private practice of medicine hold on to traditional healthcare?  The practices I’ve spoken with which seem most successful are engaged in some of the following strategies:

a. Expansion into multispecialty groups and new areas of ancillary healthcare;

b. Involvement in clinical integration, accountable care organizations (ACOs), and other strategies that focus on reducing unnecessary utilization and costs for which practices are not compensated in traditional fee-for-service contracts;

c. Supergroup models in which independent practices share in the expense of compliance and technology, share resources, and gain the benefit of group market power;

d. Strategic models that use high numbers of mid-levels and lower overhead and other costs of traditional medical practices.  These groups are often expanding into home visitation and other untapped areas of physician services.

Other practices I work with are also looking more often to concierge models in order to limit patient volume and defray costs by charging patients for extras the physicians are willing to provide. However, the uncertainty with concierge models that still rely primarily on insurance is whether there will continue to be non-covered services for which such physicians will be able to bill.   For example, many concierge physicians spend extended time with patients talking about end-of-life planning, family issues, and even assisting patients with advance-care planning.  These physicians may find they can no longer charge for this service to Medicare as the CY 2016 Proposed Physician Fee Schedule (published in the Federal Register on July 15, 2015) contains a proposal to include separate reimbursement for advance -care planning, including discussion of advance directives by physicians or other qualified health professionals.  While it is certainly a positive trend when payers pay for services physicians were forced to provide for free in the past, the coverage of new services may cause challenges for some concierge physicians. 

While remaining in independent practice may be a challenge for many, independent practitioners are among the most clever and entrepreneurial clients that I work with.  I am hopeful they will continue to flourish and certainly continue to help by exploring all viable models that may be workable for the independent practice.

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Take Control of Your Data Ownership

Take Control of Your Data Ownership | EHR and Health IT Consulting |

A recently published report by the Annenberg School for Communication at the University of Pennsylvania describes the "Tradeoff Fallacy." Companies interpret your willingness to give them, or allow them to use, your information as a sign that you feel you are getting fair value in exchange. When you become a customer or client of a company that offers a one-of-a-kind product or service, they interpret your action as a sign that you are pleased with their policies and with the value you are getting. Only companies that have a monopoly can get away with this. A company doesn't have to be big and predatory to have a monopoly.  

Amazon, Netflix, iTunes, Facebook, LinkedIn, Twitter, your e-mail provider (if your address is me@, your EHR, the bank where your direct deposits are sent, etc., each have a monopoly as far as an individual user/customer is concerned.

Does a business' estimate of the value you're getting jibe with yours? According to the study it doesn't. The "Tradeoff Fallacy" concentrates on personal information but the concept actually extends to any business that has you locked in, such as when your EHR vendor asks (forces) you to pay for an upgrade. It happens when any product that you use changes their terms and conditions and takes your continued use as evidence that you agree with them.

The reason the authors say it's a fallacy is that what the business believes about the value of their stuff is generally different from how people see things. People don't like being asked to reveal themselves, but they do it. They feel powerless to do anything else. There is generally no way to negotiate other terms and conditions, something that might be possible in a face-to-face interaction, so most people have simply resigned themselves to being ordered around that they no longer even look at the fine print.

There are a couple of things you can do to avoid being sucked in these vortices. One is to "just say no" to services that play fast and loose with your information, such as selling it without your knowledge. These services can be addictive so if you can't escape your dependence completely, perhaps you can cut the number way down and avoid the urge to sign up for more.

Another strategy to avoid getting locked in by monopolistic products and services is to use commodities, freeware, and products that are "open source" and eschew DRM (which prevents downloading your Kindle eBook so you could continue to use it if Amazon goes bust. Here's more about DRM). Commodities are interchangeable. Fundamentally a lettuce is a lettuce and a car is a car. It's hard to get locked into a commodity item.

Freeware can be obtained and used anonymously. If you like it, and use it a lot, you can pay for it anonymously, which is a good idea if you would like it to be around in the future. Some freeware alternatives to proprietary products that I find useful are:

• LibreOffice, a pretty good — and getting better — replacement for Microsoft Office.

• Calibre, an absolutely wonderful program for managing and reading eBooks, especially the ones that are free, open source, and DRMless. It will even convert free eBooks to Kindle format and transfer them to the device.

• VLC, a media player with most of the function found in iTunes and the Microsoft media player.

• GIMP, is a freely distributed app for such tasks as photo retouching, image composition, and image authoring. It's no Photoshop, but it's free.

• Firefox Web Browser has many useful features that are not found in the browsers that come from the monopolizers. Occasionally webpages don't render or function correctly but it's still my go-to browser.

• Thunderbird E-mail Client is less vulnerable to attack than Microsoft Outlook. I've tried Outlook and Apple Mail and neither of them have the flexibility and usability of this one.

All of these run on Windows, Mac, and Linux minimizing lock-in.

A big question remains: Are the companies that use lock-in as the means of getting your information right or are the authors of "Tradeoff Fallacy" right? Do you value information about yourself highly or not very much? If the answer is "not very much" then maybe you are getting fair value in exchange for handing it over. If the answer is "a lot" then, unfortunately, you're being taken advantage of and it's going to take some work to develop a strategy for keeping as much of it private as possible.

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Staff Training Crucial in ICD-10 Conversion Preparations

Staff Training Crucial in ICD-10 Conversion Preparations | EHR and Health IT Consulting |

Healthcare providers who are behind in their ICD-10 conversion preparations may benefit from following the ICD-10 Quick Start Guide provided by the Centers for Medicare & Medicaid Services (CMS).

The five steps that providers will need to take when it comes to their ICD-10 conversion preparations are the following: (1) developing a plan, (2) training the healthcare staff, (3) updating system processes, (4) working with vendors and health insurers, and (5) testing workflow processes and systems.

When it comes to training the clinical staff (including nurses, doctors, and medical assistants) and moving forward with ICD-10 conversion preparations, it’s vital to focus on new clinical concepts and documentation obtained through ICD-10 codes. When training coding and administrative staff including coders, billers, and practice management employees, the focus should be on ICD-10 fundamentals.

CMS provides a variety of resources including webinars, national provider calls and presentations, the Road to 10 website, and email updates. Physician groups, healthcare organizations, hospitals, payers, and vendors also offer a variety of resources for medical providers who are still behind with some common ICD-10 conversion preparations.

The very first step to take is to identify the top 25 most common ICD-9 codes used in one’s medical facility. Common diagnosis codes are also available on the Road to 10 website and other resources.

Teach your healthcare and coding staff how to code the most common cases using the ICD-10 coding set. Using reports via one’s practice management software and billing documents, providers can better identify the most commonly used ICD-9 codes.

Once the top 25 codes are gathered and there is still time before the ICD-10 implementationdeadline, providers are encouraged to expand ICD-10 coding of typical cases past an additional 50 or more codes. This would ensure the majority of a provider’s cases are managed effectively under ICD-10.

Even though the ICD-10 coding set has expanded to more than 68,000 codes, providers will only need to use a small section of the set. Along with training staff, updating system processes is vital for one’s ICD-10 conversion preparations. All hardcopy and electronic forms need to be updated while information gaps should be resolved before the October 1 deadline.

Clinical documentation will need to include laterality, the number of encounters (initial or subsequent), kinds of fractures, and other information about related complications. It is useful to put together a documentation checklist detailing new concepts that should be captured with ICD-10 codes. Once systems are in place, ICD-10 end-to-end testing is crucial to ensure a healthcare facility is prepared for the October 1 deadline.

“With four months remaining to correct issues discovered during testing, the high rate of successful submission of ICD-10 codes is especially encouraging for physician offices since half the claims submitted for end-to-testing were professional claims,” the Coalition for ICD-10 commented on CMS’ latest ICD-10 end-to-end testing results. “These results indicate that significant progress has been made since the January end-to-end testing with the overall rejection rate dropping from 19 to 12 percent and ICD-10 rejections dropping from 3 to 2 percent.”

Direct Reimbursement Solutions's curator insight, July 1, 2015 10:10 AM

Excellent advice for ICD-10 preparedness.!

10 Reasons to Outsource Medical Billing

10 Reasons to Outsource Medical Billing | EHR and Health IT Consulting |

Several years ago, based upon a thorough review of the facts, I recommended a client outsource his practice's billing. It was a peculiar conversation:

Me: You could successfully address a number of issues by outsourcing your billing.

Client: I learned in medical school that it is important to keep billing in-house.

Me: That may have been true at the time. Your current situation is different. Let's talk about it.

Client: I learned in medical school that it is important to keep billing in-house.

That old advice, based on who knows what set of facts, was as universal and unchanging for that physician as "Do no harm" or "When you hear hoof beats, think horses not zebras." Unquestioning loyalty to that premise cost him a lot of money.

Here are some of the benefits that can be achieved with outsourcing billing:

1. Free up office space

If the billing is outsourced, the biller does not need a place to sit and the billing records are somewhere else.

2. Make some employee turnover irrelevant

Make employee turnover in the billing department someone else's problem. Unless your practice is big enough to justify a billing department, with a set of employees with varying skills and levels of sophistication, high turnover is almost inevitable. Some billing work can be mind-numbingly dull and some requires sophisticated skills in analysis, synthesis, and communication. Very few people capable of these higher-level requirements will be satisfied for long with dull routine work.

3. Cut down on incoming phone calls

Office staff is relieved of calls that go directly to the billing service. The biggest benefit, however, is the calls that are never made because billing and claims errors are more often avoided in the first place.

4. Turn a fixed expense into a variable one

Staff and office space are fixed expenses. They cannot go below a certain level no matter how low the volume of billing is. When they go up, they go up in stair steps. If the practice is paying a percentage of collections for the billing service, there is a perfect correlation between collections and cost.

Another benefit is that the interests of the practice and the billing service are aligned. If the billing service increases collections and their rate is anything less than 100 percent of collections, the practice is money ahead.

5. Know what is going on in the marketplace

Access a broader perspective of what's going on in the healthcare marketplace. This is one of the most valuable intangibles. An in-house biller cannot know what other practices in the same specialty are doing and what their outcomes are.

6. Anticipate payer rule changes

Avoid being caught flat-footed when payers' rules change. A good billing service is always aware of proposed and pending changes that can have an impact on the revenue cycle, especially technical changes that seldom hit the radar of a medical practice until reimbursements are impacted.

7. Access solid data analytics

A billing service can help your practice identify what the practice is doing well and poorly, in terms of maximizing legitimate reimbursements. The service will identify bottlenecks in the flow of billing documentation and be able to teach providers and staff how to avoid errors that negatively impact claims.  A really good billing service will also share information about alternative ways to code that result in more favorable reimbursements.

8. Know your accounts receivables

Enjoy the benefit of knowing exactly where you stand in terms of receivables. Any service worth its salt will be able to tell you, at least monthly, the percentage of claims that are paid from the initial submission, how many are 30 days, 60 days, and 90 days outstanding, and which payers are most important to the practice. It's valuable information that an internal billing person almost never has the time to provide.

9. Have a resource at payer offices

The biller in an individual practice deals with all the payers, and is essentially anonymous to all of them. A biller at a billing service typically deals with a subset of payers, and often with a single payer. That allows him to develop personal relationships that expedite problem resolution.

10. Be prepared for a payer audit

You will have an expert advocate in case of a payer's audit. A payer's audit is in the ordinary course of business for a billing service. They know the process and the vocabulary, and they have all the documentation at hand.

In general, it makes good business sense to outsource the billing for most medical practices. That said, the outsourcing must be done to a competent billing service and the relationship must still be managed by the medical practice.

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Why EHR Systems Use Should be Part of Medical School Education

Why EHR Systems Use Should be Part of Medical School Education | EHR and Health IT Consulting |

With the wide range of healthcare reforms, new health IT implementations, mobile health growth, and ongoing federal policy changes, the medical sphere can be daunting when entering the field as a young physician or nurse. Today, there is much more to learn before a student enters the workforce and the American Medical Association (AMA) is currently supporting the need for medical students to learn how to utilize EHR systems while still in school.

According to an AMA press release, the organization is looking to ensure all medical students are properly trained and ready to join the constantly evolving healthcare sector upon graduating. The AMA has adopted a policy that encourages medical students to obtain much-needed experience utilizing certified EHR systems.

“There is a clear need for medical students today to have access to and learn how to properly use electronic health records well before they enter practice,” AMA Board Member Jesse M. Ehrenfeld, M.D., said in the press release. “For our future physicians to successfully navigate the 21st century health care system, we must close the gaps that currently exist between how medical students are educated and how healthcare is delivered now and in the future.”

The policy initiated by the AMA will lead the organization to work with accrediting bodies among medical schools and further urge schools, residencies, and fellowship programs to train students in using EHR systems and medical devices while interacting with patients in the exam room or at the hospital bedside.

Ensuring that medical students are truly ready for utilizing innovative technologies within the healthcare setting is expected to improve patient care and the accuracy of communications, the AMA explains.

Some typical hands-on experience that medical students would benefit from include entering patient encounter data and clinical orders into relevant EHR systems. The AMA is looking to completely revamp medical school education across the country through its Accelerating Change in Medical Education initiative.

Currently, the organization along with with 11 leading medical schools across the nation are addressing the need for EHR training as part of new undergraduate medical education models. The innovative policy also asks to define specific “characteristics of an ideal software system” to be used at medical schools.

Some other steps that the AMA is taking to address medical education is emphasizing the need for inter-professional education, which will lead them to better manage team-based care. New workshops and programs are being created to give medical students the opportunity to work with pharmacy, social work, public health, and nursing students.

Additionally, it is important for future doctors to become skilled learners and master adaptive learning, as the healthcare industry may continue evolving and changing over the coming decades to address the many challenges of complex patient care.

Most importantly, it is necessary to train medical students how to properly use technologies like mobile health applications, EHR systems, data analytics software, medical devices, and remote monitoring tools, as the health IT sector continues to grow and impact patient care delivery.

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How Certified EHR Technology Affects Population Health Outcomes

How Certified EHR Technology Affects Population Health Outcomes | EHR and Health IT Consulting |

Population health management is a vital aspect of enhancing patient outcomes across the medical industry and ensuring a healthier community of people in the majority of regions across the country.Certified EHR technology can be used alongside patient care processes to better manage population health and public health reporting, according to the Office of the National Coordinator for Health IT (ONC).

In fact, certified EHR technology is also expected to boost population health outcomes through data collection and reporting across multiple medical care facilities. The collected data can be analyzed to determine prevention strategies and quality improvement goals.

There are several key opportunities for utilizing certified EHR technology toward the aim of improving population health management and these include electronic laboratory reporting, surveillance data repositories, and public immunization registries.

As the amount of data available through certified EHR technology continues to grow, providers and public health officials can better utilize the information to monitor and prevent disease. For example, public health alerts can be sent directly to physicians in effort to manage a potential epidemic or other medical condition. Meaningful use requirements have played a role in boosting population health management through the utilization of health IT systems and EHR platforms.

One example of utilizing certified EHR technology to assist with improving population health management comes from cloud-based EHR vendor Practice Fusion who has partnered with the American Urological Association to develop an Overactive Bladder (OAB) population health management (PHM) program, according to a company press release.

Healthcare staff who uses Practice Fusion’s certified EHR platform may be able to treat as many as 1.5 million OAB patients by accessing their data through the cloud-based system. With OAB affecting up to 46 million Americans, this new initiative should prove fruitful for enhancing population health management strategies.

“We believe this new initiative may help the millions of Americans living with OAB,” Deborah Lightner, MD, chair of the AUA Practice Guidelines Committee, stated in the release. “The Population Health Management program is particularly helpful with patient diagnosis and treatment for this common condition as patients often don’t feel comfortable discussing their symptoms.”

Specific guidelines in the new version of the EHR platform will show whether a provider needs to conduct an overactive bladder assessment for a particular patient. Additionally, there will be information on a provider’s patient load as well as the ability to compare OAB patient populations among other Practice Fusion physicians. The technology will allow providers to better track and enumerate any clinical decision making regarding OAB patient care.

“With this clinically challenging treatment condition affecting 46 million Americans, Practice Fusion is helping to improve physician-patient communication through the use of this unique collaboration,” Ryan Howard, founder and CEO of Practice Fusion, said in a public statement.  “On a national scale, Practice Fusion is helping to arm healthcare professionals and patients with simple, effective management tools that follow trusted AUA guidelines while helping support meaningful use of EHR technology by providers.”

Clearly, certified EHR technology can make an impact on improving population health management initiatives across the country. As more providers strive to meet meaningful use requirements in the coming years, EHR systems will continue to affect population health outcomes.

Laurie Bolick Wolf's curator insight, June 19, 2015 1:15 PM

Using EHR/EMR technology can help improve the health of the overall population.  Through data entry into the EMR, statistical data analysis is much easier and accessible to follow overall trends and guide changes in recommendations of care.!

First Apple Watch health IT apps bring important messages to the wrist

First Apple Watch health IT apps bring important messages to the wrist | EHR and Health IT Consulting |

Many of the first Apple Watch health IT apps will give doctors faster access to critical information and ease communication between health care providers, while other apps will attempt to get patients more engaged with their health.

Don’t expect doctors to glance at their wrists to view X-rays or a patient’s chart, though. Given the Apple Watch’s screen size, functions that involve text messages work best on the device.

 “Doctors get that the watch is a tool to help them deal with information overload,” said Michael Nusimow, CEO of drchrono, which makes EHR (electronic health record) software.

Like many other companies in the health space, drchrono announced its app this week at a large health IT conference put on by the Healthcare Information and Management Systems Society, a nonprofit that looks to use IT to improve medical care. About a dozen companies in the health care industry announced their Apple Watch apps this week.

EHRs can overwhelm a physician with troves of data on a patient, Nusimow said.

With drchrono’s Apple Watch app, doctors can receive relevant and important information, such as when a patient arrives at the office. The app can also provide them with the patient’s vital statistics and pictures.

The watch is better suited for tasks like getting text notifications, while the iPad and iPhone, which drchrono also has apps for, can handle functions that require bigger screens, like reviewing charts, Nusimow said.

Watches are more socially acceptable than smartphones, making them ideal to handle messages and notifications, said Vik Kheterpal, principal at CareEvolution, which develops the technology behind health information exchanges.

CareEvolution worked with health insurance provider Anthem to develop its Apple Watch app, which was announced this week. The app, called cFHR, is designed to provide Anthem customers with timely health information. The app, for example, will remind patients to check their blood pressure or alert them about possible medication interactions.

While the iPhone can complete the same tasks as the Apple Watch, there’s a nuanced difference between the devices, Kheterpal said.

People depend on smartphones to instantly convey information. But as the devices have become larger, people may find them a bit cumbersome to constantly remove from their bag or pocket. Plus, some aspects of smartphones, like the devices inopportunely ringing, are social taboos, he said.

The Apple Watch, by comparison, is an extension of the phone, always on a person’s wrist and reliably delivers notifications, Kheterpal said.

The Apple Watch won’t replace the iPhone, said Nate Gross, co-founder of Doximity, a startup that operates a social network for U.S. physicians.

With its app, Doximity was looking to offload some functions to the watch, but save a majority of the tasks for the iPhone.

“We focused on messaging because in the clinical setting, there are a number of times when you just don’t want to take out your phone to start texting,” said Gross.

In some situations, doctors may find that speaking is a better option that typing, he said. For instance, they may prefer to dictate patient notes instead of type them into an iPhone.

While an iPhone app can receive messages, doctors may not hear the phone or feel it vibrate if they place the device in their pocket or lab coat, said Gross.

Doximity’s app, which was announced last week, allows physicians to view messages sent to them from other doctors who use the company’s social network and also to receive alerts when a fax arrives.

In health care, “time is tissue” and delivering alerts to a person’s wrist may help a doctor view an urgent message more quickly, he said.

Some physicians who work long hours may need to extend the Apple Watch’s 18-hour battery life to the get the most from their health IT apps, Gross added. Emergency room doctors and medical residents can work 24-hour shifts.

Some may purchase third-party watch bands equipped with batteries while others will charge the device during their shifts, he said.

“We will see friction occur on battery life for very specific doctors rather than doctors as a whole,” said Gross. Physicians aren’t accustomed to owning watches that require nightly charging, he added.!

Five Mobile Health Tools for Practices to Consider

Five Mobile Health Tools for Practices to Consider | EHR and Health IT Consulting |

As technology evolves and medical practices attempt to get more patients actively involved and engaged in their healthcare, many practices are exploring how mobile devices might help them along that journey.

But with so many mobile device options available and with so little long-term evidence to show which tools are most effective and in what circumstances, it can be difficult to determine what mobile health solution is right for your practice.

Chanin Wendling, the director of the division of applied research and clinical Informatics at Geisinger Health System, is involved in determining what mobile and portal technologies drive digital patient engagement and facilitate the provider's ability to deliver quality patient care.

During her presentation, "Active Patient Engagement: mHealth as a Tool for Interaction," at the Healthcare Information and Management Systems Society (HIMSS) conference in Chicago, Wendling discussed some of the most notable mobile health options available to practices today. She also shared some of her feedback regarding which of these tools practices might want to consider and why.

1. Patient portals (that can be accessed via a mobile app or on a mobile device). Patient portals are a fundamental platform in helping patients become more informed about their healthcare, said Wendling. They also may be a great tool to help patient visits go more smoothly.

Wendling noted that Geisinger recently introduced a new pre-visit center patient portal feature to see if it helps streamline patient visits and help patients come to appointments more informed. Two weeks prior to appointments, patients receive a message that they should log on to the portal to fill out go pre-visit paperwork, review notes from previous visits, and so on.

2. Mobile apps. While mobile apps are generating a lot of buzz, practices may want to proceed cautiously before rushing to implement them. Wendling said that since there are so many options, and since many of them are "young," it can difficult to determine which are going to be valuable to your patients and healthcare system.

So what's a good place to start with mobile apps? If your healthcare system is using desktop-based applications and your vendor offers a fairly inexpensive mobile app, it's probably worthwhile to deploy that, said Wendling.

3. Text messages. Text messages have been an "underrated" mHealth tool, said Wendling. Since patients are already interested in and familiar with text messages, a text message program is cheap to deploy, and such a program can be implemented quickly, it's a great mHealth option for many health systems, said Wendling.

Examples of how Geisinger is using text messages include text message appointment reminders and text messages sent to diabetic patients hoping to lose weight that include motivational language and tips.

4. Activity trackers. Wendling was bit more cautious about mobile devices that track activity and health information that can then be shared with providers. "... I think the big issue there is, do you want the data?" she said, noting that it may add to physicians' workload.

While this type of mHealth has promise, carefully consider whether the approach you are considering is necessary and of clinical value to your patients. 

5. A multi-faceted tablet approach. Another mHealth tool that Wendling touched on is a variety of ways tablets might be used in patient care.

Geisinger, for instance, is embarking on a pilot program to test whether tablets distributed to in-house patients can entertain and serve as a positive distraction for pediatric patients, connect patients to medical information, enable patients to provide feedback to providers (such as their pain level), and so on.

No comment yet.!

Shift the focus from patient satisfaction to employee satisfaction

Shift the focus from patient satisfaction to employee satisfaction | EHR and Health IT Consulting |

By now, everyone in health care is accustomed to the idea of patient satisfaction data and the multi-million dollar industry ($61 million in annual revenue for Press Ganey alone) which exists thanks to the health care leaders and policy makers who embrace it.  Most physicians believe it is absurd to use it as a marker of quality care, but have accepted it anyway.  We will “play the game” in order to get paid for our work.  Although high patient satisfaction scores have been proven to be a poor indicator of quality care, and in some studies have been proven to increase morbidity and mortality, they are already so entrenched in U.S. health care that it will prove difficult to impossible  to uproot the established practice of satisfaction data collection.  The absurdity of using patient satisfaction data as a clinically helpful metric has been exposed in numerous well done studies and articles.  “Why Rating Your Doctor Is Bad For Your Health” is a fantastic example.

It doesn’t matter that this data is clinically useless.  The fact that it is easily obtained and tabulated has led our policymakers, politicians, and health care administrators to assign it great value.  It would be very difficult to painstakingly comb through individual patient charts and determine true quality, while it is quite easy to send out lots of surveys and make a spreadsheet.  Without a tectonic shift in policy, it will determine reimbursement and compensation levels for years to come.  When it comes to the assumption that satisfaction data is clinically important, we as physicians cannot seem to change perception by shouting that the emperor isn’t wearing any clothes.

Perhaps a shift in our approach is in order.  I was intrigued by a recent article I read about the management  strategy of Southwest Airlines, and I would encourage all of those in health care (especially administrators) to read it.  It is the most elegantly simple, yet effective strategy for high customer satisfaction I have come across.

The bottom line is that Southwest values its employees as its greatest asset.  Employees are provided with a work environment in which they feel safe, supported, comfortable, and respected.  Southwest realizes that a small percentage of their customers will simply never be satisfied.  These bad apples will always complain about something.  Many are surely trying to get something for free, some are just dysthymic, like Eeyore of Winnie the Pooh.  Southwest sides with its employees in these cases.   The customer is not always right.

The same should be true in health care.  Doctors, nurses, ACPs, and other health care staff come to work to help people and make them healthier and happier whenever they can.  Most of the time, the relationship between hospital staff and patient (or family) is a mutually respectful one.  When it is not, morale and employee satisfaction suffer if administration adopts a “customer is always right” approach.  This simply isn’t true, and it leads to resentful and anxious employees.

In the emergency department where I work, there is a crisis of nurse attrition.  I believe it to be due to the work environment, which each day brings increased patient loads and acuity, yet is not met with commensurate increases in support.  This trend is making our department less safe for patients, creating a more toxic work environment, increasing wait times, and defacing the holy grail of patient satisfaction.  It would make the most sense to work toward retention of talented nurses by spending the money to staff up and improve morale by providing a more supportive environment.  If administrators can do that, just sit back and watch as the patient satisfaction scores climb.  Don’t tell us that you don’t have the money — we all see the hospital profits and administrator salaries in the news.

Hans Batzke's curator insight, April 30, 2015 8:44 PM

The medical profession in the US are beginning to experience a paradigm shift from a customer based focus where the customer is always right to a more employee satisfaction paradigm is clear indication that employee satisfaction does have a positive contribution on customer/client service. Parallels  form of behavioural psychology theory where positive view/appreciation of employee (stimulus) leads to a better, qualitative service/diagnosis from happier, satisfied staff and doctors (response) where client returns/referrals are improved (reinforcement).  A positive view of localised, labour staff by giving better pay incentives to stay on with their jobs will result in more experienced staff employed longer. The presence of more experienced staff will in turn lower the frequency in accident and safety breaches by the transient, short-term backpacker workforce at Pinata Mareeba.!

Epic Systems’ Open Platform Will Bring U.S. Health Care Delivery Into the 21st Century | The Health Care Blog

Epic Systems’ Open Platform Will Bring U.S. Health Care Delivery Into the 21st Century | The Health Care Blog | EHR and Health IT Consulting |

Epic Systems, the market leader in electronic health record software (EHR), recently made a quiet but potentially transformative announcement that may finally shake the healthcare industry out of its technological doldrums.

Epic said it is prepared to support the creation of a more open interoperability platform for integration with other diversified healthcare applications. This will attract substantial investment to create software that operates, hopefully seamlessly, within the Epic EHR infrastructure.  Expect Epic’s competitors to follow suit, eventually opening up the marketplace of installed EHRs to third-party software developers and the efficiencies of modern, post-EHR technology ecosystem.

Epic’s critics have often denounced the company for selling a mostly closed technology, dampening hopes for the creation of an ecosystem of best-of-breed applications that work together with the EHR to automate much of the care delivery infrastructure beyond patient intake and billing.  The value of such an infrastructure is extremely compelling and so the company is under enormous pressure from its customers to become more open.

An open-architecture environment, with published Application Programming Interfaces (APIs) and open standards, will improve the functionality of EHRs in myriad ways.  Consider innovations such as full-service, secure, HIPAA compliant mobile care networks within and around hospitals, integrated delivery systems and ambulatory care providers. These networks would facilitate powerful point-of-care mobile automation, such as the delivery of interactive care checklists to doctors, nurses and patients; the sharing of patient medical histories to create a comprehensive care record; and automating the patient hospital discharge process with care plans developed digitally by physicians and nurses for their individual patients.  These networks integrated to the data available through the EHR will also enable advanced workflow applications.  Imagine providers interacting with one another and their patients in real-time, independent of care settings when care considerations and treatments get logged as part of a living patient record and, ultimately, when real-time software and cognitive analytics can aid in the development of patient care options.

The move toward open-standards, cloud-based, mobile-enabled EHR applications will be the biggest development in the healthcare software industry in many years.  The passage in 2009 of the Health Information Technology for Economic and Clinical Health Act (HITECH Act) stimulated the adoption of EHRs, but these systems were largely built on older technology and struggle to incorporate the benefits of internet-based architectures, enabling cloud and mobile computing, and as such, today the EHR value proposition still remains uncertain.  However, open standards for interoperability is the key to opening up the EHR infrastructure to all facets of the provider value chain.

One of Psilos’ investments, PatientSafe Solutions, developer of a smart point-of-care mobile communications network, is already working on adapting their product for to Epic’s open source standards.  As the CEO of PatientSafe Solutions, Joe Condurso, recently mentioned, “All of our customers are now seeking to optimize their EHR investments through interoperability in order to liberate and activate data with mobile tools for clinicians and patients. It’s an important part of our operations today. Being able to leverage OpenEpic to interoperate and connect with the Epic allows us to deliver more capabilities for our customers to prepare for quality and value-based reimbursement.”

Open architecture EHR as the standard, rather than the exception, should set the stage for a much brighter future for participants at all levels in the healthcare arena. Let’s hope it meets its promise and makes the delivery of U.S. healthcare — not just our medical technology — the envy of the world.

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The Fastest Path to a Secure Cloud

The Fastest Path to a Secure Cloud | EHR and Health IT Consulting |

Personal Health Information (PHI) records and electronic PHIs (ePHIs) comprise our most confidential data, including demographic information, medical history, test and laboratory results and insurance information. Health care professionals utilize the PHI to identify the patient and determine appropriate care and treatment; insurers input financial data, and patients can access this information by request. Due to this highly sensitive combination of medical and financial data, these records have become a favorite target for hackers, as shown by the recent Premera and Anthem breaches.

As hackers become more sophisticated in their attacks, organizations must become increasingly vigilant in implementing HIPAA compliant standards to secure their data. Healthcare organizations currently use both on premise and cloud deployments to house their information. In fact, a recent survey of healthcare provider organizations indicates that 83% of IT executives report that they are currently using cloud services. The areas with the most uptake include lab systems and email services; electronic health record and information exchanges (CHIs, EMRs, Telehealth, etc.), and Shadow IT – which is enlisting cloud-based services, but not via their IT departments.

While the advantages in moving to the cloud include improved access, powerful processing capabilities, higher availability and significant savings with on-demand hosting, healthcare organizations are still wary that the cloud may deliver a less secure option. They are reluctant to transfer mission-critical and sensitive information to a seemingly anonymous IT admin in an unidentified location. Other organizations may be concerned that their IT teams may not have the requisite skills and processes to manage the migration and maintenance of the cloud deployment.

In the Public Cloud environment, responsibility for IT security is shared between the health care organization and the Cloud Service Provider (CSP), with a clearly defined demarcation. The CSP is in charge of securing access to the physical servers and the virtualization layer, while the health care organization is responsible for securing the hosted Operating Systems, the applications and the data itself. CSPs differ in the ‘native’ security features they offer, but those always fall short of best-practice security requirements. Therefore, organizations using public clouds are required to supplement the CSP offering to ensure a HIPAA compliant cloud deployment.

As part of a cloud migration process, ePHIs may be ‘exported’ to the cloud, to share with other healthcare organizations, clinicians and insurers, or for cloud-based storage and processing.  In such cases encryption of the data in transit and at rest is critical. Firewall policies to control data transfer and access are also required. Since many healthcare organizations have only migrated a portion of their resources to the cloud, the encryption and firewall policies must encompass the hybrid, private and enterprise cloud environments.

When ePHI or other clinical or sensitive data is stored in the cloud, the issue of remote access must also be addressed. Health care professionals and IT staff as well as others need to access cloud resources from remote offices and via mobile devices. Although remote access provides flexibility it is also a significant security caveat. Almost half of the healthcare security incidents last year were the result of loss or theft of devices such as laptops, phones or portable drives. Internal threats are especially worrisome, as 15% of the security incidents in healthcare in 2014 have been attributed to unapproved or malicious use of organizational resources.

The answer to these threats are strong integration with identity controls as well as access management. To protect their resources, organizations must implement a strong two factor or multi-factor authentication systems. Identity-based access management policies assure that employees are not able to access unauthorized data, and multi-factor authentication ensures that those who steal or find lost devices will not be able to reach internal resources.

Another important step in securing healthcare information involves implementing monitoring and logging capabilities. This is emphasized in a cloud environment where the infrastructure is owned by a third party and is shared among several organizations (i.e. multi-tenant). Although logs are important, unless they are regularly monitored in an accurate manner, important or suspicious events will not be noted. Therefore, visibility and automated alerts are critical in early detection of security incidents.

The cloud is becoming the default choice for healthcare CIOs. The fastest path to a secure, compliant healthcare deployment in the cloud requires careful planning and implementation. Key to a viable security solution are encryption, access management and firewall policies, combined with event monitoring capabilities and alerts. Solutions that provide this set of security elements for the public and hybrid cloud are now becoming available in the marketplace, evidence that cloud technologies for healthcare are coming of age.

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How Physicians, Managers Should Handle 'Too Much to Do'

How Physicians, Managers Should Handle 'Too Much to Do' | EHR and Health IT Consulting |

The paradox of today's medical practice environment is that the more you can do, the more that's expected of you. Expectations about what you can accomplish arise immediately with the introduction of tools that facilitate accomplishments.

This explains why you frequently feel like a modern Lucille Ball: You're working on an assembly line that you can't keep pace with, but yours is digital, byte-sized, ethereal, and cyber-driven.

What should you do if you find yourself with too many responsibilities but you are being asked to take more on? Here are some questions that can help you determine if you can safely take on more responsibilities:

• Is the task aligned with your priorities and goals?
• Are you likely to be as prone to saying yes to such a request tomorrow or next week?
• What else could you do that would be more rewarding?
• What other pressing tasks and responsibilities are you likely to face?
• Does the other party have other options besides you? Will he/she be crushed?
• Do you like him/her?

What about when you are asked to take on more in the midst of already grappling with a full plate? 

The fastest way to convey your current level of tasks is to show the other party your assignment roster or calendar. When others have a visual depiction of your workload for say, the coming week, they will be less inclined to randomly pile on more.

When faced with “too much to do” recognize that unless you make the right decisions regarding what to do, you might meander and end up working less productively than otherwise.

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What’s the Glue Holding EHR Migration and Conversion Projects Together?

What’s the Glue Holding EHR Migration and Conversion Projects Together? | EHR and Health IT Consulting |

Are you considering migrating from an older EHR to a newer EHR or are you in the process of that conversion? If so, you are well aware of the complexity of this process. There are a lot of reasons that drive the EHR conversion decision, but the primary reason that organizations undertake EHR conversion is simply to improve patient care and safety by providing clinicians and caregivers with the right information at the right time.

It’s easy to think that this is all about the technology. EHR conversion is far more than an IT project. It is a central business issue that needs to be strategically sponsored and backed by upper level management. In our previous post, we addressed the issue of aligning integration goals for business and technology.  In a project of this magnitude, aligning business and technology goals becomes critical. Implementation takes hard work, time, and is very expensive. Effectively dealing with scope, budget & time creep, and change management matched to the stated business goals is the key to success. The complex planning needed is just one part of the story but the actual execution can be extremely problematic.

Since the primary reason for undertaking EHR conversion is to improve patient care and safety, clinical workflow is top-of-mind and coupled to data exchange and flow through your systems. On the IT side, your analysts define the project requirements and your developers build the interfaces based on those requirements. But the team that plays the most critical role is your quality team. Think of them as your project’s glue.

QA has layers of responsibilities. They are the ones that hold the requirements as the project blueprint and make sure that those requirements, driven by the pre-identified business needs, are being met. They also make sure that all defined processes are being followed. Where processes are not followed, QA defines the resulting risks that must be accommodated for in the system. A subset of responsibility for QA is in the final gate-keeping of a project, the testing and validation processes that address the functionality and metrics of a project.

Analysts work to build the interfaces and provide QA with expected workflows. If those workflows are not correctly defined, QA steps in to clarify them and the expected data exchange, and builds test cases to best represent that evolving knowledge. Identifying workflow is often done blindly with little or no existing information. Once the interface is built, those test cases become the basis for testing. QA also plays an important role in maintenance and in contributing to the library of artifacts that contribute to guaranteeing interoperability over time.

Though it is difficult to estimate the actual costs of interfacing due to the variance implicit in such projects, functional and integrated testing is often up to 3x more time consuming than development. It’s important to note that this most likely represents defects in the process. Normally, in traditional software development those numbers are inversed with QA taking about 1/3 of development time. It’s quite common that requirements are not complete by the time the project lands in QA’s lap. New requirements are continually discovered during testing. These are usually considered to be bugs but should have been identified before the development phase started. Another major reason for the lengthy time needed is that all testing is commonly done manually. A 25 minute fix may require hours of testing when done manually.

In technology projects, risk is always present. QA teams continuously work to confine and evaluate risk based on a predefined process and to report those issues. The question continually being asked is: what are the odds that X will be a problem? And how important is that impact if there is a problem? Here the devil is in the details. QA is constantly dancing with that devil. Risk is not an all or nothing kind of thing. If one were to try and eliminate all risk, projects would never be completed. QA adds order and definition to projects but there are always blind alleyways and unknown consequences that cannot be anticipated even with the most well defined requirements. Dealing with the unknown unknowns is a constant for QA teams. The question becomes how much risk can be tolerated to create the cleanest and most efficient exchange of date on an ongoing basis.

If QA is your glue, what are you doing to increase the quality of that glue, to turn that into super glue?What you can do is provide tools that offset the challenges your QA team faces. At the same time, these tools help contain project scope, time & budget creep, and maintain continual alignment with business goals. The right tools should help in the identification of requirements prior to interface development and throughout that process, identify the necessary workflows, and help in the QA process of building test cases. De-identification of PHI should be included so that production data can be used in testing. Tools should automate the testing and validation process and include the capability of running tests repetitively. In addition, these tools should provide easily shared traceability of the entire QA process by providing a central depository for all assets and documentation to provide continuity for the interoperability goals defined for the entire ecosystem.

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Windows Server 2003: Mitigating Risks

Windows Server 2003: Mitigating Risks | EHR and Health IT Consulting |

With Microsoft ceasing support for Windows Server 2003 as of July 14, security experts are warning organizations to migrate to a new operating system as quickly as possible and, in the meantime, lock down any servers that continue to use the aging operating system.

Beginning in August, Microsoft will begin releasing Windows updates that attackers can potentially reverse-engineer to design exploits that will compromise every Windows Server 2003 system that remains in use.

"After July 14, Microsoft will no longer issue security updates for any version of Windows Server 2003," according to a Microsoft announcement. "If you are still running Windows Server 2003 in your data center, you need to take steps now to plan and execute a migration strategy to protect your infrastructure."

The company recommends current users upgrade to Windows Server 2012 R2, as well as Microsoft Azure and Office 365 where applicable.

"Computers running the Windows Server 2003 operating system will continue to work after support ends," US-CERT warned in a November 2014 alert. "However, using unsupported software may increase the risks of viruses and other security threats. Negative consequences could include loss of confidentiality, integrity and/or availability of data, system resources and business assets."

To mitigate those risks, organizations that continue to use Windows Server 2003 can pay Microsoft for an extended support contract for the operating system.

Microsoft declined to comment on how much it charges for Windows 2003 extended support contracts, but by some accounts, base pricing starts at $600 per server, per year, with the price doubling every year.

"If you have deep pockets, you could easily follow up with Microsoft and pay for that extended support, though it's not indefinite," says Karl Sigler, threat intelligence manager at security firm Trustwave, tells Information Security Media Group. "Frankly, depending on your architecture, it would probably be far more inexpensive and beneficial to [simply] upgrade."

Still, paying for extended support was the route chosen by some organizations after Microsoft ceased support for Windows XP. Microsoft stopped supporting that operating system in January 2014, although it did subsequently release a security update for a zero-day flaw. Microsoft's Malware Protection Center also promised to continue releasing new signatures and updates for XP's built-in anti-virus software engine until July 14.

Even so, market researcher NetMarketShare reports that Windows XP still accounts for 12 percent of all laptop and desktop operating systems. The U.S. Navy reportedly signed a $9.1 million contract with Microsoft in June to continue support for 100,000 Windows XP devices.

12 Million Servers

Official usage statistics for Windows Server 2003 are difficult to come by, although US-CERT reports that as of July 2014, "there were 12 million physical servers worldwide still running Windows Server 2003."

According to a survey of 1,400 IT professionals released in March by IT firm Spiceworks, 15 percent of firms that used Windows 2003 reported that they had fully migrated away from it, while half of all firms had partially migrated, 28 percent said they were planning to migrate, and 8 percent said they had no plans to migrate.

Sigler says that numerous organizations that are still using Windows Server 2003 are likewise running older versions of SharePoint, the Internet Information Services platform, or Exchange. "Organizations - especially IT - tend to be change-averse," he says. "They're basically under the premise that if it's still working, it isn't broken, so why fix it?"

Some organizations remain stuck on Windows Server 2003 and older software due to tight IT budgets in recent years, says information security expert Brian Honan, who heads Dublin-based BH Consulting and also serves as a cybersecurity adviser to Europol, the European law enforcement agency. "I am aware of a number of organizations that are still running Windows Server 2003 and indeed will be for the foreseeable future," Honan tells ISMG. "This is due, in part, to a lack of investment in IT infrastructure over the past number of years - due to the recession - resulting in systems and hardware not being capable of or suitable to run modern operating systems."

Honan says beyond the cost of the new hardware, organizations are also faced with the cost of new software and training, as well as the challenge of having to test and potentially re-engineer numerous applications and processes that currently work on Windows Server 2003 devices. "Some legacy applications may not yet be tested - or indeed supported - on more modern platforms, therefore forcing organizations to remain on outdated platforms," he says.

Gambling with Critical Flaws

But the dangers of continuing to use unsupported operating systems have been well documented. Since Microsoft ceased supporting Windows XP, for example, the operating system has been vulnerable - and remains vulnerable - to numerous flaws that have been patched via updates to more modern Windows operating systems. And every time Microsoft patches a more modern version of Windows with a flaw that also affected Windows XP, it gives attackers the option of reverse-engineering the fix, and then creating malware that can target the flaw to exploit XP systems en masse.

The same goes for Microsoft's server software, Honan warns. "Organizations that will remain on Windows Server 2003 ... should look at additional security controls to reduce their attack profile, such as employing anti-virus software, change monitoring and file integrity monitoring software; ensuring firewalls and [intrusion prevention] systems are updated and operating as expected; restricting traffic to those [servers] by users or by certain IP addresses; implementing additional security monitoring of these systems and also of associated network traffic; and finally ensuring that their incident response plans are up to date," he says.

Trustwave's Sigler says the security risks facing organizations might not be immediately severe once Microsoft stops releasing patches for Windows Server 2003 and starts releasing updates for only more modern versions of its server software. "If it's a public server facing the Internet, then it's going to be a higher risk than if it's a server just facing a small internal team," he says.

Still, the security risks will only increase, going forward. "How risky it's going to be is really dependent on what happens in August, and the months following that," he says.

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Some Methods For Improving EMR Alerts

Some Methods For Improving EMR Alerts | EHR and Health IT Consulting |

A new study appearing in the Journal of the American Medical Informatics Association has made some points that may turn out to be helpful in designing those pesky but helpful alerts for clinicians.

Making alerts useful and appropriate is no small matter. As we reported on a couple of years ago, even then EMR alert fatigue has become a major source of possible medical errors. In fact, a Pediatrics study published around that time found that clinicians were ignoring or overriding many alerts in an effort to stay focused.

Despite warnings from researchers and important industry voices like The Joint Commission, little has changed since then. But the issue can’t be ignored forever, as it’s a car crash waiting to happen.

The JAMIA study may offer some help, however. While it focuses on making drug-drug interaction warnings more usable, the principles it offers can serve as a model for designing other alerts as well.

For what it’s worth, the strategies I’m about to present came from a DDI Clinical Decision Support conference attended by experts from ONC, health IT vendors, academia and healthcare organizations.

While the experts offered several recommendations applying specifically to DDI alerts, their suggestions for presenting such alerts seem to apply to a wide range of notifications available across virtually all EMRs. These suggestions include:

  • Consistent use of color and visual cues: Like road signs, alerts should come in a limited and predictable variety of colors and styles, and use only color and symbols for which the meaning is clear to all clinicians.
  • Consistent use of terminology and brevity: Alerts should be consistently phrased and use the same terms across platforms. They should also be presented concisely, with minimal text, allowing for larger font sizes to improve readability.
  • Avoid interruptions wherever possible:  Rather than freezing clinician workflow over actions already taken, save interruptive alerts that require action to proceed for the most serious situation. The system should proactively guide decisions to safer alernatives, taking away the need for interruption.

The research also offers input on where and when to display alerts.

Where to display alert information:  The most critical information should be displayed on the alert’s top-level screen, with links to evidence — rather than long text — to back up the alert justification.

When to display alerts: The group concluded that alerts should be displayed at the point when a decision is being made, rather than jumping on the physician later.

The paper offers a great deal of additional information, and if you’re at all involved in addressing alerting issues or designing the alerts I strongly suggest you review the entire paper.

But even the excerpts above offer a lot to consider. If most alerts met these usability and presentation standards, they might offer more value to clinicians and greater safety to patients.

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Four Medical Practice Embezzlement Red Flags

Four Medical Practice Embezzlement Red Flags | EHR and Health IT Consulting |

Keep an eye out for these red flags for possible embezzlement at your medical practice:

• Carl Frost, founder of Frost & Co., a healthcare consulting and accounting firm, advises physicians to keep an eye on the office manager who writes all the checks and makes all the deposits, in addition to other factors. "Collections aren't on an automated billing system. The same manager [who] handles all payroll functions and has a home computer for doing work from home," is a recipe for trouble, he says. "I've never had a client practice that had all those things going on and not been the victim of embezzlement."

• If your billing staffer refuses to take a vacation, be aware that this is a common trait among employees who embezzle, experts say. Insist on a vacation, and use the time to check over the employee's work.

• Watch and listen to your employees on a daily basis. Pay attention to sudden displays of wealth or, conversely, admissions about major financial setbacks, such as a spouse losing a job.

• Staffers who recommend friends or family for jobs in the practice. Though some companies actually encourage staff referrals, many practice experts say it's a bad idea because the pair could work together to embezzle, or because one relative might be reluctant to turn in another.

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Usability of Certified EHR Technology Lacking Among Vendors

Usability of Certified EHR Technology Lacking Among Vendors | EHR and Health IT Consulting |

When the HITECH Act was passed and meaningful use regulations were established under the Medicare and Medicaid EHR Incentive Programs, the steep rise of EHR adoption and implementation brought hope for patient care advocates. After more providers increased their use of certified EHR technology, questions still remained as to whether the quality of patient care had actually changed. Many physicians still find issues with utilizing EHR systems and the lack of EHR interoperability is causing problems for effective healthcare data exchange across multiple medical facilities.

Providers continually find the usability of certified EHR technology unsatisfactory, which led researchers from the Georgetown University School of Medicine to analyze 11 different EHR vendors and study their user-centered design process, according to a paper published in the Journal of the American Medical Informatics Association (JAMIA).

A survey conducted by the American College of Physicians in 2012 showed that nearly two out of five physicians were dissatisfied with their use of certified EHR technology. Essentially, EHR systems have lacked easy-to-read interfaces and an overall user-friendly platform.

The researchers from Georgetown University assessed the challenges vendors had to overcome when they attempted to incorporate user-centered design (UCD) in their certified EHR technology. The researchers uncovered that vendors either have well-developed UCD, basic UCD, or completely misunderstand how to incorporate UCD into their EHR development.

Those with well-developed UCD still lacked “contextually rich studies of workflow” among a variety of specialized healthcare providers. Those found to include basic UCD processes did not have the resources or knowledge for leveraging their ideas and insight of user-centered EHR development. Vendors who have misconceptions on UCD will need greater education on the importance of safety and usability of their EHR products.

The researchers essentially conducted interviews with vendor staff to better understand some of the difficulties they’re having with EHR design. Some of the problems surrounding integrating UCD and ensuring physician EHR use is satisfactory include lacking leadership support throughout a vendor establishment, missing strong studies of clinical workflow, and difficulties with recruiting subjects for these kind of usability studies.

Usability, however, is critical to ongoing EHR adoption and patient safety within a clinic or hospital. The Office of the National Coordinator for Health IT (ONC) even included “Safety Enhanced Design” in last year’s certification criteria stipulations, which include usability process requirements.

“There are increasing pressures on health IT vendors to improve the usability of EHRs and other health IT systems,” the researchers wrote in their report. “The ONC has UCD certification requirements in place to promote improved usability. Although the health IT vendors themselves are the end users of these regulations, no data are available to describe the current usability processes of health IT vendors.”

“Our results reveal variability in the UCD practices of EHR vendors, despite the ONC’s certification requirements that all EHR vendors attest to employing a UCD process in order to certify their EHR product. Given that UCD is an important factor that contributes to the usability and safety of the EHR, the variability in UCD practices may partially account for the poor usability of some vendors’ EHR products.”

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Patient Engagement Underscored with Decision Making Tools

Patient Engagement Underscored with Decision Making Tools | EHR and Health IT Consulting |

Healthcare providers remain dedicated to improving patient engagement throughout the medical field despite the fact that the latest proposed modifications to Stage 2 Meaningful Use requirements have changed the percentage of patients required to download, view, and transmit their health information to just one patient. Nonetheless, the current proposed Stage 3 Meaningful Use requirement mandates providers have a total of 25 percent of their patients view and download their medical data via a portal.

The ongoing rulings toward patient engagement keeps the goal at the forefront of providers’ minds. The network PatientsLikeMe has recently taken part in boosting patient engagement by assisting Partners HealthCare in offering patients tools and data on clinical decision support with their medical providers, according to a company press release. These tools are expected to improve patient health outcomes as well.

PatientsLikeMe Executive Vice President of Marketing and Patient Advocacy Michael Evers stated that the website tools will be available through a patient portal, which is the first agreement that will provide this access.

“We’re excited to work with such an esteemed health system to help patients and their care teams have a more complete understanding of patients’ whole health experience, and to support shared decision making about next steps,”  Evers said in the press release.

Partners Population Health Management Associate Medical Director Adam Licurse also explained that the partnership between the two organizations will lead to patients becoming more aligned with their health and wellness as well as “better involving patients in their care.”

“We know that as patients become more engaged in their care, they have better care experiences, make more informed decisions based on their goals, and in some cases can actually receive higher value care at the end of the day,” Population Health Management Associate Medical Director Adam Licurse said in a public statement. “Peer mentorship, patient self-management, and patient education are all critical pieces to that puzzle. We believe PatientsLikeMe’s online patient community provides a meaningful solution to help meet these needs.”

Partners Patient Gateway is one online tool that provides an effective communication and messaging platform between doctors and patients as well as offers more medical condition information to consumers. Additionally, the partnership will bring about a “PatientsLikeMe 101” training series for both doctors, caregivers and patients to learn more about the offered tools and support network.

Also, there will be a multitude of projects developed by Partners HealthCare to better understand patient engagement, patient empowerment, satisfaction levels, and care coordination. Clinicians will learn how to use patient-generated information during a medical visit and determine how this data can be used to reveal patient health outcomes.

The multitude of technologies that can be used to engage patients with their health and wellness goes beyond patient portals, as mobile health applications and devices can also bring greater awareness of one’s medical care. Whether it’s through remote monitoring tools, fitness trackers, or the standard patient portal, healthcare providers are gaining more momentum in enhancing patient engagement across the nation.

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ICD-10 End-to-End Testing Week Shows Few Coding Errors

ICD-10 End-to-End Testing Week Shows Few Coding Errors | EHR and Health IT Consulting |

The Centers for Medicare & Medicaid Services (CMS) has released the results of its second effective Medicare FFS ICD-10 end-to-end testing week, which took place at the end of April.

Starting on April 27 and ending on May 1, clearinghouses, payers, billing agencies, and Medicare Fee-For-Service healthcare providers participated in CMS’ second successful ICD-10 end-to-end testing week.  Medicare Administrative Contractors (MACs) and the Durable Medical Equipment (DME) MAC Common Electronic Data Interchange (CEDI) contractor assisted the individual entities during this end-to-end testing.

CMS was able to work with a wide range of providers, submitters, and claim types, as it served the majority of volunteers. The second ICD-10 end-to-end testing week shows that the federal agency will be able to successfully accept claims when the ICD-10 implementation deadline rolls around.

With 875 participants in the ICD-10 end-to-end testing period, more than 23,000 test claims were submitted at the end of April. To see the results, click here. For the most part, participants were able to send their ICD-10 claims effectively and these were processed by Medicare billing systems without any major issues, CMS reports.

In fact, the results show that the acceptance rate was higher in April than the prior ICD-10 end-to-end testing rate from January. There were less errors related to diagnosis codes on the latest batch of end-to-end testing claims.

Out of any errors that did occur, the majority were unrelated to ICD-9 or ICD-10 diagnosis codes, CMS states. Providers who are still looking to participate in ICD-10 testing with the federal agency are encouraged to take part in acknowledgement testing, which can be performed at any time until the October 1 deadline.

The last ICD-10 end-to-end testing week with CMS will take place on July 20 to July 24, 2015. The ability to volunteer for this testing week has already ended. However, any participants from January or April are welcome to participate in the July ICD-10 end-to-end testing session again and are automatically eligible to test their systems an additional time.

It is vital to continue preparing for the ICD-10 transition over the coming months. Starting on October 1, any Medicare claims that do not use an ICD-10 diagnosis code will be invalid. The Medicare claims processing systems will be unable to accept ICD-9 codes after the deadline. The last day providers can submit ICD-9 codes to CMS is September 30, 2015. Dual coding will also not be accepted after this deadline.

While there is only four months left to prepare for the ICD-10 transition, providers can still take advantage of the many resources offered by the federal agency. The Road to 10 website, for instance, is a very useful tool in preparing for the ICD-10 implementation. CMS offers a variety of solutions for providers that are struggling to meet the ICD-10 transition deadline.

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Florida governor fights Obama administration over healthcare funding

Florida governor fights Obama administration over healthcare funding | EHR and Health IT Consulting |

Florida Governor Rick Scott said on Thursday he will sue to stop U.S. health leaders from ending more than $1 billion in federal funding for low-income patients, arguing it stems from the state's refusal to expand Obamacare for the working poor.

Scott pledged to take legal action, but provided no details, amid an escalating fight between Florida's Republican leaders and President Barack Obama's administration.

The dispute has become entangled in Florida's rejection, so far, of about $51 billion in federal dollars available over 10 years to expand Medicaid coverage to some 1 million Floridians under the Affordable Care Act, known as Obamacare.

Scott singled out a letter this week in which federal officials acknowledged a connection between Medicaid expansion and ongoing negotiations with Florida officials over the state's "Low Income Pool." Florida stands to lose about $1 billion in federal funding to pay hospitals for treating needy patients.

He contends the Democratic president is "crossing the line into a coercion tactic" in violation of a 2012 Supreme Court ruling allowing each state to decide whether to accept the expansion.

"It is appalling that President Obama would cut off federal healthcare dollars to Florida in an effort to force our state further into Obamacare," he said in a statement.

Debate over expanding Medicaid has deadlocked Florida's GOP-controlled legislature. State senators want to take the money, but their counterparts in the more conservative House of Representatives remain staunchly opposed.

Florida's low-income pool, launched in 2006, had been designed to support safety-net hospitals for a limited time, U.S. health officials said. Expanding Medicaid would reduce the financial burden of uncompensated care in Florida, they noted.

Medicaid expansion and low-income pool funding "are linked in considering a solution for Florida's low income citizens, safety net providers, and taxpayers," Vikki Wachino, an acting director for the U.S. Centers for Medicare and Medicaid Services, said this week in the letter to state officials.

Following a one-year extension, the federal funding is now due to expire in June.

Scott, once a tepid supporter of expansion, recently backpedaled. He said he no longer trusts the federal government to honor its funding commitment amid the dispute over the low-income funding for hospitals, which has stalemated negotiations over the state's more than $80 billion budget.

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‘Action First’ Vital in Health Information Exchange

‘Action First’ Vital in Health Information Exchange | EHR and Health IT Consulting |

The conversation within the health IT industry and federal agencies is geared toward health information exchange (HIE) and improving data sharing through EHR systems. More healthcare providers and EHR vendors are joining forces to fully implement the exchange of data between hospitals, laboratories, physician practices, pharmacies, public health agencies, and other entities.

CommonWell Health Alliance, an organization dedicated to developing a vendor-neutral platform for effective health data exchange, recently announced the addition of five new members to its team. Jitin Asnaani, Executive Director of CommonWell Health Alliance, recently spoke with about the organization’s mission of making significant inroads with HIE development.

“The addition of five members who joined CommonWell will improve healthcare data exchange for everybody. Specifically, it raises our ability to connect into acute care settings, ambulatory care settings, and opening the doors to connecting to other care settings,” Asnaani said. “One of the fundamental principles behind CommonWell is that all healthcare data should be focused around the person.”

The inclusion of these additional members will expand data exchange in radiology, eye care, cardiology, post-acute care and more. The movement toward nationwide healthcare exchange is growing, as more healthcare systems and EHR vendors have begun showing interest in information exchange, according to Asnaani.

“We’ve seen a surge of interest [in HIE] over the last couple of years since we formed,” stated Asnaani. “The promise of value-based reimbursement models and greater quality of care to the patient, the healthcare industry is realizing that being able to hoard data and create your own unique view of the patient dependent on the storage of data [is no longer beneficial]. I think we’re seeing that this is eroding. We’re looking towards being able to unlock the data, create a new view of the patient, and do so affordably across the US.”

One new member of CommonWell Health Alliance, PointClickCare, joins as another vendor of cloud-based software. The Executive Director mentioned the advantages of both premise-based and cloud-based EHR technology.

“From my perspective, there are advantages to both cloud-based and premise-based technology models. I think one of the advantages of cloud-based business models is that it is easier to deploy software and functionalities to your customers because of more direct control of the environment in which the software is deployed,” said Asnaani. “Premise-based can have its own set of advantages such as the ability to more easily customize the software to align with the goals of the customer.”

Asnaani also spoke about the major benefits of effective healthcare data exchange and how discussions have centered around HIE development over the last several years. However, while interest in data exchange is high, not enough activities are taking place to advance EHR interoperability.

“Health information exchange and interoperability are concepts that have been discussed for a long time,” Asnaani explains. “They have been a topical focus for the last several years. What some people don’t realize is that there is much more discussion around those topics than there is actual action.”

“CommonWell’s distinguishing factor is that we started and have continued to go down the path of action first and discussion as a complement,” he continued. “We have built real software and services that are serving real clients in the real world for real information exchange.”

HIE development has many key advantages particularly with regard to patient care. The ability to access data in real time enables providers to improve quality of care, reduce medical errors, and account for drug allergies or other key health issues.

“Health information exchange fundamentally enables better care of patients,” said Asnaani. “When a provider needs information that will make a difference in the diagnosis or create a solution for the best care possible, they are often lacking of the data that they need. Health information exchange and real-world interoperability enables that provider to get the data they need to take the best care they can of their patients.”

CommonWell also supports patient-centered care through effective health information exchange and feels that it will lead to greater confidence in providers and ease for patients. With patient engagement initiatives playing a key role in meaningful use requirements, HIE development could be an important part of improving the patient experience.

“It’s not about where the data is. It’s about who the data corresponds to. Our aim is that every person enrolled in CommonWell has data that can be accessed by whoever is taking care of that person no matter where [the data] resides,” Asnaani stated.

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Allscripts: Above the EHR

Allscripts: Above the EHR | EHR and Health IT Consulting |

Allscripts not only boasts a large presence at HIMSS15, along with its "Power Wall" and client involvement at the booth, it also promises a substantive message, especially concerning its products.

The Power Wall zeroes in on Allscripts solutions: the core clinical and financial products and also the many others for population health, patient engagement, analytics and referrals.

Allscripts will actually have two booths – across the aisle from one another, in fact. The main booth, at 6,300 square feet, is designed to be open, inviting and easy to navigate, much like what clients are used to seeing at Allscripts' annual user conference, or ACE for Allscripts Client Experience.

The spot is also decked with a new palette, away from the lime green to go with green accents complemented by grays and whites.

"It's very clean, very crisp imaging,” said Russ Cobb, Allscripts vice president, marketing and communications.

The booth includes an interactive area with a large screen. The company is planning some TED-talk type activities, Cobb said. There will be plenty of subject matter experts to both speak and mingle with visitors to answer questions they might have about products or topics such as population health, patient engagement and technology.

The booth will have a couple of lounges, a total of eight meeting rooms and 14 to 16 product demo areas.

Across the aisle will be a separate Allscripts booth spotlighting "Above the EHR Platform."

"These are all the products and solutions that we have that can work with the Allscripts EHR core solutions, or they can work with the likes of Cerner, Epic, McKesson, Siemens – any other vendor or ambulatory or acute marketplace, Cobb said. "Those deal with transitions of care. They deal with population health. They deal with referral patterns."

As Cobb sees it, the industry is moving beyond the EHR and looking for ancillary tools.

"This will allow clients to take advantage of their core needs from an EHR perspective, but then also be able to leverage all the data and intelligence that is part of the clinical data repository that those EHRs create," he said.

At the booth, Allscripts will have plenty of clients on hand.

"We would prefer not to talk about what you do," Cobb said. "We prefer to tell the story through the clients. We will pair end users with our demonstration team."

There's plenty to talk about: the EHR, and also population health, patient engagement, referral tracking, readmissions, all part of the Allscripts offerings and all noteworthy.

But Cobb is especially focused on what he calls the differentiator: an open platform.

"We will give you access to your data at any point in time. We continuously open up our APIs to third-party applications or to other EHR vendor applications so they can share data from point to point," he said. "The open platform, for us, is kind of the key to our connectivity and one of the true differentiators of the Allscripts portfolio vs. everybody else."

Attendees can find Allscripts at booth 3521 and 4225 in Hall A of the South Building.

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How Does ONC Plan to Expand Health Information Exchange?

How Does ONC Plan to Expand Health Information Exchange? | EHR and Health IT Consulting |

With the vast amounts of data collected in the healthcare industry, providers, vendors, and other stakeholders are putting more focus into developing health information exchange (HIE) and greater EHR interoperability. The Office of the National Coordinator for Health IT (ONC) released a report to Congress – Update on the Adoption of Health Information Technology and Related Efforts to Facilitate the Electronic Use and Exchange of Health Information – to offer policy guidance on the best ways for optimizing health IT systems and supporting HIEs.

Ever since the federal government passed the Health Information Technology for Economic and Clinical Health (HITECH) Act, the number of hospitals and physician practices adopting EHR systems has grown substantially. Currently, more than half of hospitals have at least a basic EHR system in place while, in 2013, 48 percent of physicians had EHRs at their practice.

Additionally, eligible professionals and eligible hospitals across the country are participating in the Medicare and Medicaid EHR Incentive Programs. While there has been significant progress in implementing health IT, there are still barriers that are halting widespread health information exchange across healthcare organizations and vendor products.

For example, if an individual from Maine takes a vacation in Florida and experiences a patient encounter, their primary care provider from Maine would likely not be informed nor would be able to access the patient’s emergency care data.

The report states that some of the common barriers to EHR adoption and thereby challenges for expanding health information exchange include the cost of purchasing a system, loss of productivity, training difficulties, the costs of annual maintenance, and obstacles related to finding an EHR system that supports practice needs. Nonetheless, in 2013, eight in ten physicians were using an EHR system or planning to adopt one, according to an ONC data brief.

ONC explains in its report that some of the reasons health information exchange is lacking is due to inconsistent structure, format, and even medical vocabulary used across different EHR systems and vendor products. ONC outlines key actions the Department of Health and Human Services (HHS) will need to take to improve nationwide EHR interoperability. These actions include:

  1. Creating new standards that are integral to the development of a connected healthcare system
  2. Requiring more staff in the health IT workforce to support the implementation of electronic records
  3. Improving the sharing of data among providers and public health agencies
  4. Collaborating, advising, and sharing studies with states, communities, and providers to stimulate IT solutions in the healthcare field
  5. Driving patient engagement with their health information

ONC hopes that Stage 2 Meaningful Use requirements will also catalyze a widespread data exchange network within the healthcare sector. By using these five strategies, HHS plans to further advance health information exchange and invest in health IT usability throughout the nation.

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Retail-Based Clinics vs. Private Medical Practices

Retail-Based Clinics vs. Private Medical Practices | EHR and Health IT Consulting |

Over the past few years, Terence R. McAllister has watched more and more retail-based clinics set up shop near his practice."I think four or five years ago there was one nearby; now, there's four or five, as well as some urgent-care clinics," says the Plymouth, Mass.-based pediatrician. "There definitely are more of them out there."

McAllister is not the only physician noticing this trend. Over the past few years, retail-based clinics, often referred to as "RBCs," have surfaced inside thousands of pharmacies, supermarkets, and "big box" retailers across the country, and analysts predict that their growth will continue. A June 2013 report from Accenture, a management consulting, technology services, and outsourcing company, projected that the number of retail clinics would grow 25 percent to 30 percent annually between 2012 and 2015. Overall, the report concluded, the number of retail clinics in the U.S. could reach more than 2,800. The authors of the report, "Healthcare Reform and Retail Medical Clinics: From Foe to Friend," recently confirmed to Physicians Practice that those projections are on pace with the current numbers.

For physicians who are concerned about their new retail clinic neighbors, there may be more troubling news: It appears that more patients are using them. A consumer survey by PwC's Health Research Institute, conducted in December 2013, showed that 35 percent of respondents had visited a retail clinic in the last 12 months, up from 9.7 percent in 2007.

So what does all this growth and increasing utilization mean for practices? To provide some answers, we asked several experts to weigh in. Here, they discuss some of the biggest challenges practices may face due to competition from retail clinics, and how practices can minimize any negative effects.  


While the quality of care patients receive in retail clinics is a common concern among physicians and physician organizations, many are also expressing reservations regarding the effect a patient's visit to an RBC could have on a patient's continuity of care. For instance, could the patient's visit to a retail clinic lead to a disconnect between the patient and his primary-care physician down the line? Or, could the RBC provider miss out on something relating to the patient's condition that the patient's long-term physician would not?

As initiatives that prioritize highly coordinated, team-based approaches to patient care, such as Patient-Centered Medical Homes, gain momentum, the continuity-of-care concerns associated with retail clinics may be increasing.

The American Academy of Pediatrics (AAP) published a policy statement in the March 2014 issue of Pediatrics that stated RBCs are an inappropriate source of primary care for children because they "fragment" healthcare and do not support the medical home. "The AAP recognizes that convenience and access to care will continue to be important drivers of how healthcare is delivered," lead author, pediatrician James Laughlin said in a statement. "However, the expertise of the pediatrician and the medical home should continue to be recognized as the standard for care of children, and we encourage all AAP members to provide accessible hours and locations as part of a medical home." To view the full policy statement, visit

Brandon Betancourt, a practice administrator at Salud Pediatrics, a three-physician practice in Algonquin, Ill., agrees that the potential "disruption of care," and "disruption of the medical home" that comes from using retail-based clinics is a big concern from a pediatric perspective. "... If a patient goes to a retail-based clinic and then they're prescribed an antibiotic or something like that, the primary-care physician is not aware," says Betancourt. "Or, if they're going to a wellness visit to receive immunizations, then that's not part of the medical record, and so it creates further fragmentation as opposed to the medical home."


Despite concerns that retail clinics could have a negative effect on a patient's continuity of care, some physicians report positive experiences with them. McAllister says RBCs have been fairly good about letting him know when one of his patients has visited their clinic, usually mailing him notes on the care they provided within two weeks.

According to the Convenient Care Association (CCA), the national trade association for companies that provide healthcare in retail-based locations, this practice of sending information back to the primary-care physician should be standard at all of its members' clinics. "All CCA members build collegial relationships with the traditional healthcare system and its providers to share patient information as appropriate and ensure continuity of care," the CCA website states. "All patients are given the option of sharing their healthcare record with other providers."

Physicians Practice reached out to the CCA for an interview, but it could not be reached directly for comment.

If you feel like you aren't receiving enough information about your patients receiving care at outside clinics, communicate with the RBCs about your desire to be better informed, suggests internal medicine physician Simon Samaha, principal in PwC's health industries practice. "... I don't think it would hurt for them to reach out to the retail clinic and see if there's anything they can do to assure the continuity of care." He also suggests starting a dialogue with patients regarding their retail clinic use. Encourage patients to tell any RBC they visit that you are their established primary-care provider, and ask them to give the RBC permission to share information about the care they received with you, says Samaha. "Since the retail clinic is a separate entity from the physician office, [it] cannot release protected health information without the consent of the patient," he says. "So unless there is a formal relationship between the retail [clinic] and physician office, the retail [clinic] cannot just share such information with them. However, the patient can request that their info is released to their physician office."

To prevent information from slipping through the cracks, also encourage your patients to tell you when they visit a retail clinic. This is something McAllister does in his practice. "I want the patients to come back to me and tell me what happened," he says. "... It can take a couple weeks before I get those notes from [the RBC] so I like for the families or the patients to call us the next day to let us know that they were there."

To further encourage that transparency from patients, McAllister's practice website identifies retail clinics as an alternative option for care if his practice is closed. "If we pretend that they don't exist or don't address them, then parents [of patients] might feel reluctant to tell us they went there, that they are somehow going behind our backs to do something, and then we lose out on that communication," he says.


In addition to concerns about patient care, retail clinics raise business-related concerns for some physicians. After all, they are new competitors in your local area, and they promise something that patients highly value: easy access and convenience.

But Alan Nalle, senior manager at Accenture and co-author of its retail clinic report, says RBCs may not be as harmful to patient volume as some physicians fear. Most patients, he says, use them as an "after-hours option," primarily for non-emergent sick visits or, occasionally, non-sick visits such as physicals or flu shots. " ... I think for a primary-care office, [an RBC] is a lower complexity visit, that's a less frequent visit," says Nalle. "I don't see that as a particularly huge amount of overlap in disturbing that primary-care physician's relationship with their patients."

Still, for practices that are already struggling to stay afloat, RBCs could begin to take a toll, especially if growing numbers of patients begin using them for services that your practice traditionally provided.

There is another negative effect that practices, particularly independent practices, may want to keep in mind, says Samaha. When patients who visit retail clinics require referrals, the clinics typically refer them back to their primary-care physicians. Still, about 50 percent of patients who visit RBCs don't have established doctors, so when these patients visit RBCs and require referrals, the clinics tend to refer them to healthcare systems with which they are connected, he says. Since many RBCs form relationships or connections with large integrated networks, independent practices could miss out on these referrals. "The patient is going to be exposed to options, and I wouldn't be surprised if the options take them more [often] into an integrated delivery network if they need follow up," says Samaha.


There are several different strategies practices can use to counteract the potential negative economic effects posed by RBCs. Here are three to consider:

1. Play their game. Most patients who visit RBCs are drawn to them because of the convenience, price transparency, and open access they provide, says Drew Boston, a manager at Accenture, who co-authored the RBC report. If you want to compete with retail clinics, determine how you can offer similar features. For instance, evening appointments one day per week might be appealing to busy professionals; and urgent-care hours one day per week might be a draw to patients who would otherwise go to the retail clinic. Another feature to consider? E-visits, says Samaha, noting that when it comes to providing access and convenience, nothing can beat e-visits.

2. Differentiate your practice. Since RBCs are "really good at what they do," going head-to-head with them, as in the above scenarios, may not always be the best move. Instead, some practices might benefit from exploring what they can offer that retail clinics cannot, says Betancourt. For instance, your practice might provide more of a personal touch, better continuity of care, a more comprehensive wellness visit, and so on. Once you determine what sets your practice apart, cultivate that and market it to patients, he says.

Also, consider other features and amenities that might appeal to patients. For instance, Betancourt's practice has a partnership with a behavioral health psychologist that many of his patients' parents appreciate. "We don't attract people that would normally go to a retail-based clinic because of the effort that we have put into creating a culture that would appeal to a certain group of people," he says. "... Everybody is welcome, but not everybody appreciates the same things or is willing to pay money for them."

3. Use RBCs to your advantage. Practices that are at full patient capacity with high patient demand might be able to use retail clinics to their benefit, says Nalle. Think of retail clinics as a "low-acuity triage channel," he says. "In other words, you could start to think about how you can incorporate or occasionally refer some of your members or patients [to the RBC], or educate them about how and when to use a retail clinic for some of those lower-acuity, lower-complexity, lower-reimbursement type of items. It's good for the overall health system but it also could be good for practices as they start to manage the complexity for some of their patients, which may impact reimbursement."

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