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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The Pros and Cons of Switching EHRs 

The Pros and Cons of Switching EHRs  | EHR and Health IT Consulting | Scoop.it

If you're not happy with your EHR system, making a change is not easier said than done. Take some time to weigh the pros and cons before a making this big decision.

 

"The advantage of keeping a sub-par EHR is that you don't have to go through the arduous process of changing EHRs," says Wanda is also president of the American Academy of Family Physicians. "However, one of the biggest disadvantages of keeping an EHR you don't like is that it tells the staff that they're not worth the investment in a better solution. Don't avoid making a switch because of the effort involved or the money you've already spent."

 

The advantage of making a change is that you'll hopefully pick a system that's more compatible with your needs. "Because you have the experience of what doesn't work in your current system, you can look for one that works better for your needs,” says John Meigs, Jr., a family physician at Bibb Medical Associates in Centreville, Ala., who is president-elect of the AAFP.

 

Filer's organization ultimately decided to change EHRs because, "the software was an unmitigated disaster. It was an incredibly expensive and time-intensive project to undertake, but I'm absolutely glad we switched EHRs."

 

Meigs, who has supported the use of EHRs for more than 20 years, hasn't liked any of the EHRs he's used. "Our current system takes too many clicks to do basic things, and the data isn't displayed in a way that is useful for patient care," he says. "The advantage to sticking with the devil you know is just that — you know what issues, challenges, and hassles you have to face."

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AAFP: Health IT Industry Should be Closer to EHR Interoperability

AAFP: Health IT Industry Should be Closer to EHR Interoperability | EHR and Health IT Consulting | Scoop.it

Although the Office of the National Coordinator for Health IT (ONC) recently released itsInteroperability Roadmap, the American Academy of Family Physicians (AAFP) does not believe that is enough to achieve nationwide EHR interoperability in a timely manner.

In a recent letter addressed to National Coordinator Karen DeSalvo, MD, MPH, MSc, AAFP’s Board Chair Robert Wergin, MD, FAAFP expressed his and the organization’s dismay at the slow progress of nationwide interoperability.


“Our members and the AAFP are very concerned with the very slow progress toward achieving truly interoperable systems. Furthermore, we strongly believe there is need for increased accountability on industry and decreased accountability on those who are using their inadequate products,” wrote Wergin.


According to Wergin, care coordination, patient engagement, and population health management all need greater support through increased interoperability. However, at the rate the healthcare industry is moving with regard to interoperability, those goals are not expected to be achieved soon. To change this course, Wergin says the industry needs more action rather than more planning. Additionally, providers and organizations that are playing their parts in increasing interoperability need more support.


“We need more than a roadmap; we need action. First, it is our belief that without significant changes in the way health care delivery is valued (e.g. paid) then it will not matter how many standards are created, how many implementation guides are written, how many controlled vocabularies are fortified, or how many reports are created; we will still struggle to achieve interoperability. Any roadmap for interoperability needs to ensure payment reform toward value based payment, in addition to the technical work. This aligns the health care business drivers to the achievement of true interoperability.”


Wergin argued that certified EHR systems are a contributing factor for this slow growth toward nationwide interoperability. In 2007, he said, the AAFP was responsible for creating a set of standards for healthcare summary exchange. However, despite the adequacy of those standards, Wergin reported that practitioners still experienced difficulty in exchanging information due to incompetencies of EHR systems. Because the EHR systems cannot interpret the data that is being exchanged between systems, physicians are finding themselves manually inputting data from one system to another.

“Instead, physicians must view the documents on the screen, just as they would a fax, to find the important information. Then they must re-key that information into their EHR if they want to incorporate some of the summary information into the patient’s record,” Wergin explained.

Wergin described an urgent need to transform interoperability. If practices are expected to achievemeaningful use and other incentive-based models, interoperability needs to be a high priority for the health IT industry.

“Everyone including technology vendors, hospitals, health systems, pharmacies, local health and social service centers and physicians, must come together as a nation to achieve the interoperability levels laid out in this roadmap at a more rapid pace,” Wergin wrote.


Comparing the push for interoperability to President Kennedy’s push to get to the moon, Wergin states that the health IT industry should be able to achieve its goals in the same 10-year timeframe that Kennedy did. By 2019, Wergin stated, the entire healthcare industry should be using completely interoperable systems.


“We should be much closer to our goal and it should be accomplished within ten years (2019),” Wergin wrote. “The AAFP is dedicated to continue our work to achieve interoperability which is fundamental to continuity of care, care coordination, and the achievement of effective health IT solutions.”

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Innovative Ways for Small Practices to Invest in Tech

Innovative Ways for Small Practices to Invest in Tech | EHR and Health IT Consulting | Scoop.it

At a time when American providers are offering some of the best care in the world, even the smallest medical practices cannot slip. They must offer top-tier services, while meeting and maintaining compliance with government regulations. This is no small order, and it's made increasingly difficult considering the price tag that comes with integrating cutting-edge technology — in particular, EHRs — into an office, especially for solo practitioners or practices with just a handful of doctors.


While the incentive to invest is greater than ever with the ongoing meaningful use program, the cost of implementation is still pricey. Physicians working in the smallest practices have to get creative when trimming technology expenses.


KEEPING COSTS IN CHECK


"Maintaining an electronic health record system is our largest expense," says pediatrician R. Frerichs of North Raleigh Pediatric Group. His practice isn't an isolated case. According to a survey in Medical Economics from February 2014, 45 percent of physicians spent more than $100,000 on EHR systems including service, hardware, software, training, and consulting. However, there are ways to shrink that number considerably.


It is easy to feel overwhelmed by options available in the marketplace. Practices on the hunt for tech investments must be mindful of what is specifically needed. "There is a want to measure everything without knowing why or what to do with the measurements," says Kyle Wailes, senior vice president of physician services at the Ft. Lauderdale, Fla.-based technology solutions provider, Intermedix. "A smart and focused practice can avoid much of this by determining must-haves ahead of time and knowing exactly what is needed when purchasing technology."


In addition to searching for the product that best matches a practice's needs and work flow, there is value in adopting open source products. Dozens of open source software programs have been developed for the medical industry with data security and usability at the forefront, says Greg Scott, owner and operator of Infrasupport Corporation, an IT consulting firm in Eagan, Minn. With open source software, physicians don't have to become IT experts, since someone else developed the software and the additional features. They do have to be willing to explore technology built using an open source model by accepting patches, new features, and other support built by an interested community. Any potential inconvenience is likely to be offset with the cost savings, which can be as much as 80 percent compared to proprietary competition, Scott says.


Similarly, practices should seek out "disruptive vendors" — those working on the innovative edge of mainstream technology — because they typically have lower gross margins, smaller target markets, and simpler products, experts say. Though the products and services may not appear as attractive as existing solutions when compared against traditional companies, the cost is often cheaper, says Austin Kirkland, principal and founder of healthcare management services consultancy Outperform, LLC, based in Falls Church, Va. "Many businesses have developed software tailored to suit specific specialties or to operate with less robust features, lower development costs, and reduced operating overhead," he says. "As a result, they are able to offer their products at a better price point to specific buyers than their larger competitors, so shopping for the right solution can save money."


Once practices have made the initial investment for EHR and practice management systems, there are ways to manage the ongoing costs associated with overseeing them. The unfortunate truth is that technology requires constant upgrading to remain efficient and compliant, which of course, comes at a cost. Instead of hosting technology infrastructure onsite at a practice, medical offices should consider migrating most (if not all) technology services to a cloud services provider or third-party data center. Doing so requires an initial upfront cost, but service fees are generally paid monthly at a predictable, scalable rate. Additionally, this frees medical practices from worrying about hardware failures or updating software because managing those responsibilities falls to a third-party vendor.


SHRINKING PAYMENTS IN A SMALL PRACTICE


Despite doing due diligence to select the best and most cost-effective products and maintenance options for a small practice, the fact is that someone still has to pay the bill for technology.


One of the best things practices can do is find support within a larger group of physicians. Frerichs says his participation in a practice management group called Raleigh Durham Medical Group (RDMG) has been a critical factor in his ability to manage costs for his practice. "The power in numbers allows us to negotiate deals for pricing that I would not be able to attain alone," he says. For example, he adds, collaboration through RDMG allowed them to obtain optimal pricing for purchasing an EHR. Furthermore, when the need to replace or update equipment arises, the group provides flexible financing options.


Flexible financing also allows physicians to relieve some of the weight that comes with buying technology outright. For practices that don't have credit available to take term loans — or those that simply choose not to — leasing options are available. This ensures practices have cash on hand to pay for consumables, payroll, fees and taxes, and other necessities, says Jim Phelps, CEO of Beaverton, Ore.-based equipment financier, Capital Equipment Leasing, and it keeps a line of credit open for other needs. Leasing also removes the permanence that comes with an outright product purchase, allowing companies to upgrade or change technology with minimal cost. "Software and hardware can be leased on a turn-key basis, allowing the practice flexibility as needed to move at the end of a lease and to avoid upfront capital needs," Kirkland says.


Though hardware and software can be leased, other products can as well. Phelps' company has leased digital X-ray, sonogram, and MRI machines, and exam tables. "We can lease any equipment that is not 'body invasive,'" he says.


Investing in technology, whether hardware and software, diagnostic equipment, or other necessary products and services, is a given in the medical industry. Small practices must be innovative to keep on top of advances in the industry, because the ultimate bottom line is providing the very best care to each and every patient.

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Why More Physicians Will Adopt Electronic Health Records

Why More Physicians Will Adopt Electronic Health Records | EHR and Health IT Consulting | Scoop.it

When President George W. Bush issued an executive order in April 2004 to establish the Office of the National Coordinator for Health IT, he had a clear vision in mind: to create a secure, nationwide interoperable network that allows authorized users to access medical records of anyone at anytime and anywhere in the U.S. President Barack Obama knew very well that his plan for providing health insurance to all Americans would not be successful unless it was paired with a plan for controlling the quality and cost of health care services.


Ironically, Bush’s health IT network was (and remains) the instrumental element that guarantees the financial sustainability of Obamacare. It was no surprise that the economic stimulus package of 2009 allocated $25.9 billion for promoting the adoption and use of electronic health records systems among American physicians and hospitals. But a decade and $30 billion later, only half of the U.S. office-based physicians have adopted a basic electronic health records system and a mere 20 percent of them use such software, according to the latest statistics byRobert Wood Johnson Foundation.


Now that the government funds for promoting adoption and use of such records are dried up, what will happen to the rest of doctors who have not ditched their old-school paper charts yet and still keep their patients’ records in a filing cabinet? In the following, I discuss three drivers which together will lead the other half of physicians to adopt electronic health records systems in the near future.


Marketing efforts by vendors


To increase their profit margins, electronic health record vendors prefer to target customers who will either make a large purchase (large health care organizations with multiple users) or are close by and thus do not require expensive marketing efforts. That is part of the reason why many of the physicians who have adopted such systems are affiliated with larger hospitals or are located in populated urban locations. Now that the low-hanging fruits are all harvested, vendors will focus their marketing efforts on small, office-based practices and will ultimately increase adoption rates.


Mergers and acquisitions in the health care sector


With the march toward value-based payment models, new forms of health care organizations will continue to emerge. Some of the individually owned physician offices will become a part of an accountable care organization or will be acquired by a larger health care organization. When these smaller practices join larger ones, they will have to adopt the technologies that are already being used by the larger organization. While electronic health records may not create substantial value for an independent practice, they will be an unavoidable necessity when small practices join larger organizations. Without them, it will be impossible for a large health care organization to coordinate patient care, manage population risks and efficiently submit insurance claims.


Data analytics tools


With a basic electronic health record, a physician can record patient demographics, medications and problems, as well as type in his clinical notes and prescriptions. (No, he cannot electronically send the prescription to the pharmacy.) A physician can also view laboratory and imaging results (only if the record system is interoperable with that of a laboratory or imaging center). That’s it; nothing more. Almost all of the definedfunctionalities of a basic electronic health records system could be achieved by an elaborate Excel spreadsheet. That is why many doctors are still not willing to use them, even for free. Electronic health records by themselves are just cranky databases that only archive data.


However, with the advances in artificial intelligence and decision support systems, the data that was onerously collected by frustrated doctors can now be used to create something meaningful that make doctors’ lives a little easier. The health care industry is gradually getting out of the data collection era and is now entering into the data analysis era. When doctors see tangible benefits of analytics tools such as Isabel and Watson that are based on their electronic health record data, they will flock to such systems powered by analytics tools.

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Wearables Data May Prevent Health Plan Denials

Wearables Data May Prevent Health Plan Denials | EHR and Health IT Consulting | Scoop.it

This story begins, as many do, with a real-world experience. Our health plan just refused to pay for a sleep study for my husband, who suffers from severe sleep apnea, despite his being quite symptomatic. We’re following up with the Virginia Department of Insurance and fully expect to win the day, though we remain baffled as to how they could make such a decision. While beginning the complaint process, a thought occurred to me.


What if wearables were able to detect wakefulness and sleepiness, and my husband was being tracked 24 hours a day?  If so, assuming he was wearing one, wouldn’t it be harder for a health plan to deny him the test he needed? After all, it wouldn’t be the word of one doctor versus the word of another, it would be a raft of data plus his sleep doctor’s opinion going up against the health plan’s physician reviewer.

Now, I realize this is a big leap in several ways.


For one thing, today doctors are very skeptical about the value generated by patient-controlled smartphone apps and wearables. According to a recent survey by market research firm MedPanel, in fact, only 15% of doctors surveyed see wearables of health apps as tools patients can use to get better. Until more physicians get on board, it seems unlikely that device makers will take this market seriously and nudge it into full clinical respectability.


Also, data generated by apps and wearables is seldom organized in a form that can be accessed easily by clinicians, much less uploaded to EMRs or shared with health insurers. Tools like Apple HealthKit, which can move such data into EMRs, should address this issue over time, but at present a lack of wearable/app data interoperability is a major stumbling block to leveraging that data.


And then there’s the tech issues. In the world I’m envisioning, wearables and health apps would merge with remote monitoring technologies, with the data they generate becoming as important to doctors as it is to patients. But neither smartphone apps nor wearables are equipped for this task as things stand.


And finally, even if you have what passes for proof, sometimes health plans don’t care how right you are. (That, of course, is a story for another day!)


Ultimately, though, new data generates new ways of doing business. I believe that when doctors fully adapt to using wearable and app data in clinical practice, it will change the dynamics of their relationship with health plans. While sleep tracking may not be available in the near future, other types of sophisticated sensor-based monitoring are just about to emerge, and their impact could be explosive.


True, there’s no guarantee that health insurers will change their ways. But my guess is that if doctors have more data to back up their requests, health plans won’t be able to tune it out completely, even if their tactics issuing denials aren’t transformed. Moreover, as wearables and apps get FDA approval, they’ll have an even harder time ignoring the data they generate.


With any luck, a greater use of up-to-the-minute patient monitoring data will benefit every stakeholder in the healthcare system, including insurers. After all, not to be cliched about it, but knowledge is power. I choose to believe that if wearables and apps data are put into play, that power will be put to good use.

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18% of Large Providers Planning EHR Replacement by 2016

18% of Large Providers Planning EHR Replacement by 2016 | EHR and Health IT Consulting | Scoop.it

Pundits may have designated 2013 as the original “Year of EHR Replacement,” but the accolade may have been a little premature as providers continue to make the difficult decision to rip out and replace existing EHR infrastructure at record rates.  Just under 20 percent of large practices and clinics intend to undergo an EHR replacement by the end of 2016, says a new survey by Black Book Rankings, or have already started the process.

The annual ambulatory user satisfaction poll strikes a surprisingly positive tone, considering recent grumblings from physicians about poor usability, non-existent interoperability, and torturous workflows that disrupt patient care.  In contract to a recent AMA and AmericanEHR Partners survey that put EHR satisfaction at an all-time low of just 34 percent, the Black Book poll indicates a sharp upward trend in the way users view the efforts of their vendors.

In 2013, 92 percent of multispecialty groups expressed displeasure with their EHR products and vendors, the survey says, but that number has flipped in 2015.  Seventy-one percent of physicians polled this year believe that their vendor is “meeting or exceeding” their expectations for EHR optimization.  Eighty-two percent of administrative staff also believe they have seen improvements in the operational or financial capabilities of their practice management and EHR software.

Black Books notes that the four highest-ranked vendors - Allscripts, Greenway, McKesson, and athenahealth - have all made significant investments in user experience and client satisfaction over the past year, securing their places at the top of the EHR “most wanted” list.  Sixty percent of providers who use products from these four companies agree that they have seen clinical workflow enhancements, while a third say that their vendors have adequately invested in population health management features that will aid the ongoing transition to value-based care.

Ninety percent of providers said that their vendors have solicited user feedback to improve the EHR experience.  However, more than a quarter of users say their vendors have failed to make similar efforts to improve the implementation and training process.  Eighty-five percent reported a negative opinion on the ability to receive adequate customer service.

Even though providers are becoming more likely to commend their vendors for improvement efforts, that isn’t stopping customers from jumping ship.  Seventy-one percent of providers who implemented an EHR prior to the end of 2012 reported high levels of dissatisfaction with what might accurately be termed “legacy systems,” even just three years later.

Numerous mandates and healthcare reform initiatives are leading providers to demand more from their technology, and vendors are still lagging behind their customers’ needs for health information exchange, patient engagement, and productivity boosters.

"Meaningful use deadlines, total integration and reliable delivery may have influenced large group practice buyers to purchase initial EHRs from 2010 through 2013, but replacement buyers sought better EHR tools in 2014 that include patient engagement, true interoperability, enhanced usability and productivity gains," said Doug Brown, Managing Partner of Black Book. "There was also a measurable shift in loyalty to vendors that offered a robust, core EHR to accommodate evolving reforms."  

"EHR firms with a wide offering of products including health information exchange, population health tools, revenue cycle management services, patient portals, dashboards and analytics are emerging as the next wave of healthcare technology leaders," added Brown. "These leading vendors are assisting their clients in assessing current practice operations to meet the demands of ICD-10, payment reform, connectivity beyond closed networks, revenue cycle management gaps, and population health tools, and recommending effective options within the same vendor suite."

Thirty-eight percent of primary care and specialty providers practicing in large groups have failed to return to pre-EHR productivity levels, the poll found, while only 53 percent of surgical specialists reported any productivity enhancements over 2014 levels.

Allscripts took the top spot in user satisfaction among ambulatory providers with more than 26 practitioners, squeezing past Epic Systems, eClinicalworks, and QSI NextGen.  This is the second year in a row that Allscripts has been ranked number one among provider groups with 100-plus practitioners.

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NYC Hospitals Face Massive Problems With Epic Install

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

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


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


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


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


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


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


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


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


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


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


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

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

EHR vendors uneasy about meaningful use certification | EHR and Health IT Consulting | Scoop.it

This past spring, the Office of the National Coordinator for Health IT announced the 2015 Edition Health IT Certification Criteria proposed rule, along with the proposed rule for Stage 3 of the EHR incentive program.


Vendors immediately began weeding their way through those hundreds of pages to prepare official comments and to understand the potential implications for product development.


According to ONC, the 2015 Edition seeks to "enable a more flexible certification program that supports developer innovation" and "incorporates changes to foster innovation, open new market opportunities, and provide more choices to the care community when it comes to electronic health information exchange."

Despite ONC's lofty objectives, many EHR vendors are concerned that the scope of the proposed rule is too broad with too many requirements, including certain standards that have yet to be fully vetted by the industry. One consistent criticism is that the proposed rule includes a considerable number of criteria that are not specifically tied to the meaningful use program – nor to other HHS programs.


"In all previous rules, the ONC certification requirements were tied to a meaningful use objective," explained Stephanie Zaremba, senior manager of government and regulatory affairs for athenahealth. "The rules have now been decoupled and about half of what is in the ONC rule are requirements for functionalities that are not necessary to succeed inmeaningful use."


Joe Wall, supervisor of federal initiatives for MEDITECH, shared similar concerns: "We really wanted to see ONC focus on the meaningful use regulatory aspect," said Wall. "The proposed certification rule included requirements that are not necessarily tied to any specific meaningful use objectives, but still place a burden on EHR vendors to develop, test, certify, and implement by the 2017 optional year."


Other vendors, including Allscripts, concur that the breadth of requirements, given the proposed timeline, presents a challenge.

"We certainly understand the thinking behind a lot of the suggestions, but believe the scope of what ultimately was presented was really too significant, particularly within the scope of time they allowed for the work to be done," said Leigh Burchell, vice president of policy and government affairs for Allscripts. "If we have to devote resources for all these requirements, we have to use resources that could be innovating elsewhere."


It is, she says, "an industry-wide drain on innovation."

Another area of concern is the inclusion of criteria based on new or immature standards which may have been conditionally piloted, but not fully tested and validated.


"As a vendor, we are concerned that before we adopt standards into our system they are mature, well-vetted, and well-tested – rather than the latest and greatest," said Wall.


Burchell theorizes that the ONC's inclusion of certain proposed standards was an attempt to give vendors more room to innovate. "What may have happened is that they went down the road of inclusion of more immature standards in order to broaden the list of available standards you can use towards certification," said Burchell.


"Unfortunately the way the standards showed up is not hitting the goal they were going for," said Burchell. "The reality is that if standards aren't ready, it isn't going to be something we are going to be confident in including in our products."


While vendors applauded the ONC's efforts to engage stakeholders, improve flexibility and usability, and support innovation, the general consensus is that overall the proposed rule mixed the mark.

"In trying to move away from their typically overly-prescriptive approach, ONC didn't hit the right balance," noted Zaremba. "They are still being pretty specific and prescriptive in what vendors need to do for some things.

"Our overall comment is that ONC should actually take a step back and let the market figure out what is needed and let vendors work with their clients to meet their demands. If they want to create an environment for innovation in health IT, 500 pages of regulation is probably not the way to do it."


Regardless of the final certification rule, the major vendors appear committed to developing whatever functionality is required. They predict, however, that some smaller organizations may struggle to comply.


"We will certainly meet all the demands for industry regulation and do what is necessary," said Wall. "But, the certification process will pose a challenge to smaller vendors because what they put in the certification rule is very large and the technology demands are immense."


Burchell agrees: "You can expect most of the larger companies to move forward with whatever is in the final rule. We have already seen some of the smaller organizations show up less in the Stage 2 attestation data, so that may be exacerbated if all these requirements to go into effect."

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How Should DoD Secure Health Records?

How Should DoD Secure Health Records? | EHR and Health IT Consulting | Scoop.it

The Department of Defense is about to move forward with its multi-billion dollar plan to overhaul its electronic health records system. But when you're an organization such as DoD, supporting 9.5 million active and retired military personnel and their beneficiaries, there are variety of important privacy and security challenges that must be prioritized and tackled, privacy and security experts caution.


In late July, the DoD awarded a $4.3 billion, 10-year contract to Leidos Partnership for Defense Health, a group of three main vendors that include EHR provider Cerner and consulting firms Accenture and Leidos Inc. The contract, which has the potential to be worth $9 billion if DoD exercises all its options over 18 years, involves the Leidos Partnership team transitioning the Pentagon's existing proprietary EHR system onto a Cerner off-the-shelf EHR at about 1,000 DoD sites worldwide, including military hospitals in the U.S., as well as health clinics in remote places such as Afghanistan.


However, as the Leidos partnership embarks on the massive overhaul, there are several critical privacy and security issues that need to be addressed to safeguard patient data throughout the plan.


Additionally, many of the challenges faced by the DoD in its EHR project are also similar - but much larger in scope - to the privacy and security concerns that healthcare organizations in the private sector face when undertaking their own EHR system migrations.


Those issues range from protecting patient data as its moved from one platform to the next, to thoroughly vetting the consultants involved with the EHR work.

Migrating Data

"Several security and privacy challenges exist as the DoD transitions from its old EHR to the new system," says Keith Fricke, principal consultant at consulting firm, tw-Security.


"Migrating from one EHR to another often involves importing historical data from the old system to the new one. The data set may be rather large," he notes. "Extracting data from the old EHR will likely result in a large interim database or data file. The database may need to be sent to the new vendor for data field mapping or importing."


Yet, it is not practical to send data extracts this large over a data connection. "Instead, it is better to send the data sets on an encrypted external hard drive, tracked via shipping provider," he says.


Data integrity issues are among the biggest challenges involved with such massive EHR undertakings, says Tom Walsh, founder of tw-Security. "Often times, the data mapping between an old system and new systems misses something. The only thing worse than no patient data is the wrong patient data."


To counter those problems, the data extraction process must include mechanisms to validate the data ultimately imported into the new EHR exactly matches the data stored in the old EHR, Fricke advises.

Another factor that needs close oversight is ensuring that role-based access controls to patient data are maintained from the old system to the new, especially where highly sensitive information, such as behavioral health data, is involved, Fricke says.


Privacy and security expert Kate Borten, founder of consulting firm The Marblehead Group, says it's equally important to ensure that the consultants working with or accessing the sensitive data are scrutinized. "I expect that many contractors will have access to PHI throughout this major project," she says. "It is very important that they be thoroughly vetted, that they be given the minimum necessary access permissions, and that they be monitored."

Long Haul

Because the DoD project will last several years, it's important to have measures in place to safeguard data during the various project stages.

"Workers should use simulated PHI rather than actual PHI as much as possible," Borten says. "Too often, PHI access is granted for development, testing, and training purposes, when simulated PHI could and should be used instead."


However, often a test environment must have real patient data in order to perform a true functional test, Walsh notes. "Security controls for test environments can often be less stringent. People using the test environment may forget that the data they are working with represents a real patient. Generic user accounts with easy to remember

passwords may be set up to help facilitate functional testing."


So, to avoid possible breaches or unauthorized access to PHI, the test environment needs to have security controls set to the same level as the production environment, Walsh recommends.


Because there will be thousands of people involved with the project - including individuals working for contractors and subcontractors - another danger is a watering down of security measures and practices that should be in place throughout the project, at all locations, for all personnel involved with the work.


"A front line worker may honestly say, 'I didn't know,' and it is a true statement," Walsh says. "Privacy and security education must be conducted for everyone involved."


As for securing data during project stages, Fricke recommends that data be stored on servers located in a secure data center and accessed via virtual desktops. "Doing so significantly reduces the likelihood that data is being stored on contractors' laptops or hard drives of workstations," he says.


"If storing data locally on laptops and desktops is required, these devices must be usingencryption."

User Access

In addition, Fricke suggests that two-factor authentication be used for any remote access to the data being worked on for the migration. "We've seen news stories in the past year about foreign countries targeting US government systems for hacking and exfiltration of data," he says. "The vendors involved in this EHR migration must ensure that all systems involved in the process have proper security patching levels, well-maintained malware protection, and 24x7 audit log monitoring."


Also, if any of the individuals working on this project had their information compromised in the Office of Personnel Management breach, extra care must be exercised to avoid becoming a victim of a spear-phishing attacks.


Because the DoD EHR systems contain healthcare data for U.S. military personnel, then the information potentially could be a hot target of the most devious cyberattackers, Walsh notes.


"The data in these systems are not just any patient. This is the patient data of the men and women who willing chose to serve our country," he says. "Our military personnel are prime targets for domestic and foreign terrorists. Workforce clearance will have to be strongly enforced for anyone involved, but especially far more rigid for any person with elevated privileges, such as system administrator, super user, etc."


Finally, because the DoD project will last at least a decade, maybe two, it's vital that all project work is thoroughly documented, Fricke says.

"It is important that from a project management perspective, the project managers ensure all project documentation is kept very current," he says. "There is always staffing turnover of project managers and contractors in a project this large and with the long timelines expected. Gaps in documentation will cause potential delays, potential rework and possible lapses in security practices as turnover occurs."

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Technical Barriers Limiting Health Information Exchange

Technical Barriers Limiting Health Information Exchange | EHR and Health IT Consulting | Scoop.it

Less than a quarter of hospitals have the capability to find, send, receive, and use data, according to data compiled by the Office of the National Coordinator for Health Information Technology (ONC) and American Hospital Association (AHA).


During yesterday's monthly meeting of the Health IT Policy Committee, ONC Senior Advisor Vaishali Patel, PhD, MPH, provided a data update on the health information exchange and interoperability capabilities of hospitals.


According to the latest update, a vast majority of hospitals have the health IT infrastructure necessary for exchange, with 75.5 percent reporting having a basic EHR system and 96.9 percent of them having a certified EHR technology (CEHRT) in 2014. Those figures are up from, respectively, 59.4 percent and 94.0 percent in 2013 and 44.4 percent and 85.2 percent in 2012.


Concomitant with the increased hospital EHR adoption is increase HIE with outside ambulatory care providers and hospitals over that same period of time. More than three-quarters of hospitals (76%) surveyed by the ONC and AHA exchange with these providers externally, up from 62 percent and 58 percent in 2013 and 2012, respectively.

What remains elusive for many hospitals, however, is the capacity for finding, sending, receiving, and using data electronically all at the same time:


"Find" is only interoperable exchange activity not specific to summary of care records. Find refers to query. "Send" and "Receive" include routine exchange using secure messaging using an EHR, using a provider portal, OR via health information exchange organization or other third party. "Use" requires that the records are integrated into the hospital’s EHR system without the need for manual entry.


Only 23 percent conduct all four interoperable exchange activities. Taken individually, the send functionality is most common to hospitals, with 78 percent having the capability. This is followed by receive (56%), find (48%), and use (40%).


ONC observes in the findings that hospitals engaging in more interoperable exchange activity end up have higher levels of information available to them from external data sources above the national average of 41 percent.


The findings include three types of barriers to exchange health data — technical, operational, and financial — with most belonging to the first type.


Leading the list of barriers were the technical barriers of ability of exchange partners' EHR or other systems of exchange partners to receive data (59%) and the capability of EHR systems themselves to receive data (58%). Difficulties associated with finding a provider's address (45%) was the third most-common barrier, which also was technical in nature. The leading operational and financial barriers were workflow challenges to send data from the EHR system (30 percent) and the additional costs for exchanging with external providers (25%), respectively.


As ONC concludes, solutions to increasing interoperable exchange must by and large address technical rather than operational and financial barriers.

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When EHRs Are Not Enoug

When EHRs Are Not Enoug | EHR and Health IT Consulting | Scoop.it

Thanks to some technology incentives from the government over the past several years, electronic health records (EHRs) have permeated the U.S. healthcare industry very quickly. Fewer than two out of 10 physicians used EHR systems in 2001. Just a decade later that jumped to six out of 10. Studies and surveys vary, but most find 75 to 80 percent of physicians are using them today. And, although there are varying opinions, most of the studies I’ve read find EHRs to be useful and beneficial to patient safety and care quality.


However, EHRs are not, by design, communication tools. They’re a treasure trove of information, but they’re rooted in documentation and not purpose-built for workflow communication.


I see the EHR as the documentation or tracking system, and complementary communication tools as how the interactions are actually accomplished. For example, if you’re in IT, your documentation system may be your project management or agile development software. But when it comes down to actually communicating with your colleagues to execute the work on these outlined projects, you connect with them via communication tools like instant messaging, email, or web conferencing.


The EHR is similar in that it is the center of information, but it needs to be complemented by communication tools to manage the minute-to-minute, or even second-to-second, aspects of care delivery. Let’s say a physician wants to order a series of labs. She enters them into the CPOE. Communication occurs so the desired samples are taken from the patient. Tests are run on the samples, and the results are entered into the EHR, right back where they’re supposed to be. Yet, the results still need to be communicated. And it can take a lot of time for phone tag, pages, and so on to finally close the loop on this workflow. Information needs to be communicated quickly to the right people for the most optimized workflows. Technology can move this asynchronous communication to effortless electronic alerts and messaging.

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For Many, ICD-10 Readiness Testing is on the Back Burner

For Many, ICD-10 Readiness Testing is on the Back Burner | EHR and Health IT Consulting | Scoop.it

Last summer when CMS announced yet another delay in implementation of the ICD-10 system, putting it off from October 2014 to October 2015, practices breathed a collective sigh of relief. At the time, a few apt experts predicted that the delay would give a dangerously false sense of security to those who were nowhere near ready. That seems to have been exactly what happened. According to survey results released this week by WEDI (Workgroup for Electronic Data Interchange), only 20 percent of physician providers have completed external testing.


When asked why so few practices had tested, Ken Bradley, vice president of strategic planning and regulatory compliance at Duluth, Ga.-based medical claims clearinghouse, Navicure said that it's not so much not wanting to test, as it’s the inability to do so According to a Navicure survey, fewer than half of practices surveyed have even completed installment of their EHR systems.


This may not be due to old-fashioned procrastination. "Many practices wanted to wait until it was clear that ICD-10 really was going to happen," said Bradley, adding that it’s perhaps understandable.

Preparation for ICD-10 has been a huge challenge for smaller practices. "I think practice administrators and physicians are on total overload," said Elizabeth Woodcock, president of Woodcock and Associates, a Fredericksburg, Va.-based physician practice consulting firm. "Think about it —the physician quality reporting system, meaningful use, EHR implementations, value-based payment modifier, let alone all of the commercial payers' initiatives. It's almost too much." Bradley adds that, "Putting time and money into things they know for sure are going to happen—such as meaningful use—seemed to many practices the only sensible way to allocate resources."


There may also be a tiny bit of the Pollyanna out there. "Y2K, 5010, etc., all caused hysteria in the industry, yet it all went without a hitch," said Woodcock. "I think this is what practices think about ICD-10—that it will be okay."


But is that confidence well-founded? Maybe. Even though many smaller practices haven't tested, the big payers have and for the most part, things went smoothly. Indications are that the electronic systems are going to work just fine (as long as providers have them installed and ready to go), but Bradley points out that ICD-10 is not just a tech update. "The biggest concern is getting the coding staff trained and ready," he said. On the other hand, CMS has agreed to give leeway for coding errors during the transition period, but if your systems just don't work, you're out of luck.


The testing question may be moot anyway. Many of the big payers have done enough testing and are not available for more testing with tardy practices. "Some practices may have to just do without testing," Bradley said.

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A Billion Here..And the New DOD EHR Contract

A Billion Here..And the New DOD EHR Contract | EHR and Health IT Consulting | Scoop.it

Everett Dirkson, the Illinois Senator, did not actually say “A billion here, a billion there, pretty soon, you’re talking real money”, although he did say he wished he had. The billions, or $4.3 billion to be exact, that I have been thinking about is the Department of Defense two year contract with Cerner, Accenture Federal and Leidos to provide an EHR to 8 hospitals in the first year and eventually 55 hospitals and 600 clinics. This is the first phase of a $9 billion 10 year deal. I was comforted to learn that this is a 20% savings compared to the previously estimated $11 billion. The also-rans for this award were Epic and Allscripts, and their respective partners.


The $9 billion for seems to me to be a good deal of money. That’s $13.7 million per unit including the hospitals and clinics for the same EHR system for the same customer, but it does include training. This is seemingly not a high number for a hospital EHR, but it probably is for clinics although real costs are elusive. Beyond the cost there are two other aspects of the deal that caught my attention.


One was the announcement that this was going to be off-the-shelf version of Cerner’s existing product. A good quote relative to this from Undersecretary of Defense for Acquisition, Technology and Logistics Frank Kendall is “The trick … in getting a business system fielded isn’t about the product you’re buying, it’s about the training, the preparation of your people, it’s about minimizing the changes to the software that you’re buying” In other words, forget about usability and other issues with the software and instead try to force the users into compliance with the needs of the product. Maybe the high cost per unit takes into account the amount of training that is going to be needed to help people overcome their dislike for the system.


This take-the-software-as-is approach might be viewed in the context of recent news that 20% of community hospitals want to change their EHR vendor. This report also included that 54 percent of respondents were unhappy with the usability of their system and 53 percent said their system lacked functionality. One wonders if these hospitals will shop any more carefully when they seek to change vendors, and if they will like the new product any better than the old. The DOD approach also is in sharp contrast with recommendations from a recent AHRQ webinar on “Using Health IT to Support Improvements in Clinical Workflow”. Note that the title was not “Changing Clinical Workflow to Accommodate Health IT”. One such recommendation was to actually understand clinical workflow before you try to improve it and to use this understanding to design the IT component. This seemingly obvious recommendation is unfortunately an intellectual breakthrough.


Another interesting thing about the Cerner award is that Cerner was included in assertions that the major EHR vendors have not only failed to enable interoperability but have worked against it in support of their proprietary interests. National Coordinator for Health IT Karen DeSalvo was asked about this during a May Senate hearing. Her answers were basically that it was a solvable problem, which of course is different from a problem that will be solved.


It will take a few years until we find out of the $4.3 billion, or the $9 billion has been well spent, and if the DOD’s EHR will be able to talk to either the VA’s system or the private sector.

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AHA Explains Industry Challenges for EHR Interoperability

AHA Explains Industry Challenges for EHR Interoperability | EHR and Health IT Consulting | Scoop.it

EHR use presents many healthcare benefits, including coordination of care and increased patient engagement. However, , the lack of EHR and health IT interoperability is posing a serious threat to other healthcare initiatives, according to a recent report published by the American Hospital Association.

The report, entitled Why Interoperability Matters, discusses the various aspects of the healthcare industry and care delivery that are negatively impacted by a lack of interoperability. Among those aspects include care coordination, patient engagement, and public health and quality measures reporting.


Care coordination


The exchange of health information is critical for the coordination of care, according to AHA. When patients receive care from multiple different providers, physicians should be able to securely send relevant patient information to the practicing physician. However, that tends not to be the case because EHR systems are not interoperable and cannot exchange information.


Furthermore, care coordination and successful interoperability are vital for provider finances. As accountable care organizations and bundled payments continue to grow more prevalent, the AHA maintains that interoperability and the ability to see all of the care a patient in receiving is crucial in preventing unnecessary treatment.


Patient Engagement


Patient engagement and the shared decision-making between providers and patients is critical in achieving the aims of the healthcare industry, the authors of AHA report maintain. Further, patient engagement is a central part of federal regulations on using an EHR. However, the agency states that many patients are unable to access their electronic health information, hindering the practice of patient engagement.


“The real problem is that the vast majority of patients cannot access their health information in a holistic, meaningful way. Instead, they must go to each of their providers’ patient portals and download unintegrated data. Making sense of this, particularly for patients with multiple chronic conditions who frequently have many health encounters a year, is difficult,” the report states.


Public Health and Quality Measures Reporting


EHR use also provides the opportunity for enhanced public health reporting. Because patient data is aggregated on one, electronic system, healthcare professionals can track healthcare trends and analyze information about population health. But without adequately interoperable systems, that process is significantly hampered.

“Hospitals are happy to report this data to improve public health but must contend with a wide variety of reporting formats and transmission technologies to do so, including faxing, mailing, e-mailing, web forms and secure file transfer protocols,” report reads.


This cumbersome process results in wasted time and resources. Similarly, practices face issues with quality measure reporting. Quality measures reporting is another federally mandated practice for EHR use, however without properly interoperable systems, health systems face challenges.


Interfaces and HIEs as solutions


Healthcare providers have created a few solutions to this interoperability problem, including interfaces and health information exchanges.


Interfaces are programs that allow a facility’s EHR to pass along information from one system to another, yet practices face challenges when using interfaces for more than one provider.


“...in health care, each interface currently is like a snowflake: it must be built to meet the unique requirements between two providers and cannot be reused,” the authors explain.


Because practices would need to adopt multiple interfaces, they are not always a financially stable solution to interoperability.


Like interfaces, health information exchanges (HIEs) have presented themselves as potential solutions to interoperability problems. Although HIEs can be successful in securely transmitting health information between providers, they too are quite costly. Furthermore, AHA explains that many HIEs are installed via federal grants, and that when the grants run out, many practices are unable to maintain their HIEs.


Health IT standards need more specificity


Although there are a set of standards identified for the use of EHRs and other health IT, they are not specific enough to be effective, the authors note. Creating uniformity in how data is collected and stored on an EHR, however, would be a drastic step forward for interoperability, the report states. Increased health IT standards would cause data to be input in the same way across the healthcare delivery spectrum, making information sharing more feasible.


Although the authors acknowledges the potential that health IT standards have in increasing interoperability, the agency maintains that much work in defining those standards and developing other platforms needs to be done before the industry can achieve nationwide interoperability.

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A Coding Tool that Supports the Needs of Providers

A Coding Tool that Supports the Needs of Providers | EHR and Health IT Consulting | Scoop.it

It happened. The switch flipped and on Oct. 1, our healthcare system went from around 14,000 diagnostic codes to 68,000 codes with the final implementation of ICD-10. No “Y2K”-style catastrophe. No computer system meltdowns.


We will now be watching for the long-term effects of this change. Will the processing of payments for healthcare services in the United States be adversely affected by this transition? We won't know the answer to this for some time.


As the EHR guru for my private practice, I have been responsible for the transition on the local level. This means making sure that our software is up to date and ready, and our various billing documents and their associated procedures are ready to communicate ICD- 10 information to our billers.


Additionally, as an EHR "superuser" on the medical staff of my community hospital, I watched transition issues and steps very closely in preparation for the transition. I have to say that I have been pleasantly surprised with both the administration of the hospital, as well as with the IT folks and on-site EHR vendor staff, in making this transition as painless as possible.


I have written before about how, in this phase of EHR development, the EHR has focused on the needs of the system (i.e. meaningful use, billing, etc.) and not the needs of the providers in making the process of documenting our care as smooth and easy as possible. In the most recent major upgrade to the industrial strength EHR system, significant strides forward were achieved in making the providers’ lives easier.


The first was to make customizable specialty view landing pages that facilitated EHR use to document patient encounters in a very linear and intuitive process. I have been documenting patient care with the EHR for more than three years now, and this one change was a huge step forward in using my time efficiently on rounding in the hospital.

The second major change in the hospital's EHR was simplifying the coding tool. From within the landing page, you just click on diagnosis, and start with a simple search term like "breast neoplasm." This immediately presents you with vertical lists in columns, from left to right. As you make choices in the columns (e.g., disease specifics, anatomical location, laterality, etc.) the choices rapidly narrow, and the coder lets you know through visual clues when there is sufficient information for a complete ICD-10 code. Whoever designed this deserves a medal.


I have worked with physicians and showed them how to use the landing page, as well as the diagnosis tool, and early and late adopters have both been able to adjust their way around the software quickly - indicating a sign of intelligent, user-friendly design.


I have been told by the vendor support staff that the new focus on supporting the needs of the providers will bring tablets and tools to the floor of the hospital, which will make the end user experience much better, time efficient, and useful. This has not happened just yet – one step at a time - but I remain bullish on the promise of the EHR.

I'm hopeful that the world of the EHR is moving to a new phase; a phase that focuses more on making the processes of documenting patient care easier, faster and more intuitive. Good data flows uphill, and makes the other outputs of the EHR more cohesive. The coming weeks, months, and years will ultimately tell the tale of this transition to ICD- 10, but I’m hopeful that it will ultimately give us the information and data we need to make a difference in the healthcare system and in the lives of our patients. 

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Senator Gives 5 Reasons to Delay Stage 3 Meaningful Use

Senator Gives 5 Reasons to Delay Stage 3 Meaningful Use | EHR and Health IT Consulting | Scoop.it

Joining the group of critics of Stage 3 Meaningful Use, Senate Chairman of the Committee on Health, Education, Labor, and Pensions (HELP) Lamar Alexander (R-TN) urged the administration not to move forward with the rule in a statement before administration officials, according to a press release.

Alexander advocated against implementing Stage 3 Meaningful Use rules, stating that doing so would be a detriment to the administration’s goals of providing better and more coordinated care for patients. Using that logic, Alexander stated that there was no downside to taking their time in developing an effective and manageable rule, while giving providers adequate time to achieve Stage 1 and Stage 2 Meaningful Use.


Alexander continued by underscoring the importance of the meaningful use programs in achieving broader goals within the healthcare industry, such as goals for precision medicine and transitioning Medicare payments to value-based payments. Because of the high-stakes surrounding meaningful use, Alexander argues that it needs to be developed carefully in order for it to be effective and successful.

In his testimony, Alexander listed five reasons why the administration should delay the Stage 3 rule:


Stage 2 Has Not Yet Been Successful


First, Alexander explained how Stage 2 Meaningful Use has not yet been successful, citing the statistics that a mere 12 percent of physicians and 40 percent of hospitals have managed to achieve Stage 2 success. It would make more sense, Alexander argues, to pause Stage 3 implementation and allow providers more time to comply to Stage 2.


Medicare Payment Issues Meaningful Use Penalties


In Medicare’s transition from fee-for-service payments to value-based payments, the program has put a priority on providers meeting meaningful use standards. Because of this, providers will face harsh penalties if standards are not met. To that end, Alexander explains, it is important that providers be given ample time to properly meet these standards.


Industry Leaders Also Recommend a Stage 3 Delay


Alexander states that the general consensus that he has gathered amongst prominent providers is an overall fear of Stage 3 rules.

“Physicians and hospitals have said to me that they are literally ‘terrified’ of stage 3, because of the complexity and because of the fines that will be levied,” he explains.


Stage 3 Requirements May Actually Hinder Interoperability

A leading goal for the administration includes the interoperability between EHR systems. However, a recent GAO report which Alexander commissioned stated that many industry stakeholders find thatmeaningful use rules hamper interoperability. This is because they concentrate on achieving program requirements rather than on effectively achieving interoperability.

The Final Rule Should Match the Legislation’s Primary Goals

When developing the meaningful use programs, the administration identified seven goals for the program. Alexander argues that meaningful use rules should match and enhance these goals. The seven goals include:


  1. Decreasing unnecessary physician documentation;

  2. Enabling patients to have easier access to their own health records;

  3. Making electronic health records more accessible to the entire health care team, such as nurses;

  4. Stopping information blocking

    1. This could be described as intentionally interfering with access to my personal health information;

  5. Ensuring the government’s certification of a records system means what it says it does;

  6. Improving standards; and

  7. Ensuring the security and privacy of patient records.


Alexander suggests a timeline that would begin with phasing in Stage 2 Meaningful Use modifications, aiding providers in achieving that step of the overall program. From there, Alexander suggests the administration phase in subsequent stages “at a rate that reflects how successfully the program is being implemented.”


Alexander has advocated for delaying Stage 3 Meaningful Use before. Recently, he and Senator John Thune cosigned a letter to HHS Secretary Sylvia Matthews Burwell. In the letter, the two request that the final rule for meaningful use not be implemented until January 1, 2017 at the earliest. This letter, along with Alexander’s testimony before the administration, are just two examples of congressional resistance to the final rule.

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EHR Integration Target of DoD EHR Modernization Subcontract

EHR Integration Target of DoD EHR Modernization Subcontract | EHR and Health IT Consulting | Scoop.it

The Leidos-led team that won the Department of Defense Healthcare Management System Modernization (DHMSM) award — that is, the DoD EHR modernization project — has made another addition to its squad for the purposes of health IT integration and health information exchange.


The Leidos Partnership for Defense Health now includes Orion Health as a subcontractor, the health IT company announced Monday.


"Orion Health is proud to be part of the Leidos Partnership for Defense Health, the team that has been selected as the best value solution for the DHMSM contract," President Paul Viskovich said in a public statement.


"Together, our qualified and experienced team is working with the Department of Defense to deliver a world class interoperable electronic health records solution for our nation’s armed forces, their families and beneficiaries," he continued. "We look forward to the work ahead and are committed to improving access to comprehensive healthcare data in order to facilitate improved clinical outcomes for our deserving men and women in uniform."


According to the statement, the partnership is looking to take advantage of the company's health IT integration engine to facilitate the exchange of health data between the DoD Cerner EHR and the health IT systems of non-military healthcare organizations and providers.


Last month, the Leidos Partnership for Defense Health added Clinovations Government + Health to spearhead the team's training of "clinicians, nurses, clinical advisors and clinically-trained technical personnel to help the delivery team ensure the resulting solution is finely tuned for the military’s medical environment."


The focus now appears to be shifting to the technical nuts and bolts of ensuring that health data flows inside and outside the Military Health System, a decisive factor in the Leidos bid winning the DHMSM contract.


"Cerner’s demonstration of wide-ranging provider interoperability on multiple, different platforms were the huge differentiator over Epic’s garden-walled methodology to system user data sharing," Black Book Managing Partner Doug Brown told EHRIntelligence.com when the contract was awarded.


As part of the Leidos-led bid, Cerner beat out rivals Epic Systems and Allscripts for the project that could approach $10 billion when all is said and one.


According to research published by IDC Health Insights, financials also proved to be a key differentiator between the Cerner- and Epic-backed bids.


"The DoD's requirements are unique, which makes comparisons difficult, but pricing was surely a critical factor in the DoD decision," the research organization stated. "IDC Health Insights views the pricing of the winning bid as having come in quite low when compared with commercial EHR contracts in recent years. This gives the DoD the potential to realize higher ROI from its EHR investment than is likely possible at many private health systems."


The company will be hosting its annual user conference next week and new details about the DoD EHR modernization project are likely to emerge.

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Are Physicians Really Dissatisfied With EHRs? Should We Be Concerned?

Are Physicians Really Dissatisfied With EHRs? Should We Be Concerned? | EHR and Health IT Consulting | Scoop.it

Microsoft Office was first introduced by Bill Gates at COMDEX, Las Vegas, in August, 1988.


Here we are almost exactly 27 years later, and if you plug the words ‘hate,’ ‘Microsoft’ and ‘Office’ into Google, you’ll get more than 4 million results. Remove ‘Office’ and Google returns more than 33 million results.


Clearly, some people don’t feel like Microsoft has perfected products to their satisfaction.


The perpetual unhappiness with a monolith like Office comes to mind as I read reports on the most recent surveys of physician satisfaction with electronic health records (EHRs). Let’s sum up, for those unfamiliar with the reports


First, reporting on survey data from last year, the American Medical Association (AMA) and American EHR, a division of the American College of Physicians (ACP), recently published “Physician Use of EHR Systems 2014.” Among other findings, the reports includes these nuggets:


  • 42 percent thought their EHR’s ability to improve efficiency was difficult or very difficult.
  • 72 percent thought their EHR’s ability to decrease workload was difficult or very difficult.
  • 54 percent found their EHR increased their total operating costs.
  • 43 percent said they had yet to overcome the productivity challenges related to their EHR.


Contrast those figures and levels of satisfaction with a survey of large physician practices released last week by market research firm Black Book that shows significant increases in physician EHR satisfaction. In particular, physician experience satisfaction has risen from 8 percent to 67 percent in the last three years. Physician documentation satisfaction went from 10 percent to 63 percent over the same time period, while practice productivity enhancement satisfaction has gone from 7 percent to 68 percent.


Worth nothing is that, with the AMA/ACP surveys, “Each society was allowed to select the population of their members to receive the survey. Information about EHR use by individual society members was not available. Therefore, the survey went to both users and non-users of EHRs.”


Also important: A similar ACP survey from five years ago showed significantly higher levels of satisfaction among the physicians surveyed.


The cognitive dissonance over EHRs continues, giving rise to theories on the Interwebs about the actual source of this disconnect.


At Healthcare IT News, contributing writer Jack McCarthy wonders if the constraints of Meaningful Use are antagonizing doctors, or if increased expectations and more sophisticated technology that fails to improve the daily challenge of patient care (in effect, a mashup of the two ideas) is creating dissatisfaction.


“Now, however, we have a lot more users who were forced to adopt EHRs meaning their tolerance for poor performance or usability will be lower,” notes health IT expert Shahid Shah in the article’s very interesting comments section. “I think it’s pretty easy to see why clinicians are less satisfied — if it was their choice they would be more tolerant. Since it’s not their choice in many cases, they’re less tolerant.”

Adds O’Reilly Media editor Andy Oram: “They [doctors] could be more familiar with the advantages computers offer in other areas of life … In short, having seen what a good interface can do, doctors become more demanding of the sub-par interfaces on EHRs.”


Expanding on the ‘why’ question, Michelle Ronan Noteboom (formerly ‘Inga’ of HIStalk fame) offers similar theories—MU forces doctors to use EHRs a certain way, compared to Facebook and Amazon most EHRs are clunkers, EHRs don’t deliver the ROI they promised—for the ACP survey results and asks if we should care whether or not physicians are happy.


“I’m of the opinion that physician satisfaction matters, but not nearly as much as improving the quality of patient care,” she writes at Healthcare IT News. “Patient care will be enhanced when all providers have access to thorough and accurate documentation. Ideally the patient records from one provider will integrate with records from other providers to create a single longitudinal record that is easy to decipher and provides a full picture of the patient’s health history.”


That sounds like a worthwhile goal. And Noteboom also has an explanation for the ACP survey results, pointing out “a direct correlation between physician satisfaction and the number of years a physician used his/her EHR. For example, among physicians on their system for three years or less, only 25 percent reported any level of satisfaction; satisfaction jumped to 50 percent among physicians that had used their EHR for five or more years.”


Sure, the differences between the two cited surveys could be attributed to methodology. But we know too much about how EHRs are influencing clinical culture to leave it at that. Physicians are human and subject to the same impulses—resentment when forced to do something; envy and confusion when seeing technology function well in other contexts; fear and consternation when learning something new—we probably faced when Microsoft started to become a rather sizeable part of our lives.


And, let’s recall, we’re really not that far into the ongoing transformation of American health care. Only now are we on the leading edge of value-based care as a replacement for fee for service. As EHRs evolve to improve quality, increase revenue, ensure patient safety, etc., instead of just meeting the contrived requirements of Meaningful Use, they will become the essential tools we envisioned at the beginning of this long and complex dance.


So it’s encouraging when both surveys show that physicians who’ve had their system for a while are happier with it. Indeed, while we continue to ask the specific question, “Are you happy with your EHR?”, maybe we don’t consider often enough the general frustration of digitizing processes that were once manual.


Also, it appears that plenty of hospital and health system administrators didn’t get the memo about creating buy-in before selecting and implementing an EHR. As David Whiles, former CIO at Midland Memorial Hospital said of their EHR journey, “Implementing an EHR is definitely an organizational project, not an IT project.”


And even though we are dealing with computers, this isn’t a binary choice of EHRs OR physician satisfaction. No one thinks computers are going anywhere, even if the Meaningful Use program ends. And physician satisfaction, to a reasonable extent, must be a high-level consideration for all clinical organizations. Over time, EHRs will improve and doctors will become more satisfied with them, perhaps will even depend on them, as essential clinical tools.


In the meantime, plug ‘hate’ and ‘EHRs’ into Google from time to time and see what you get. When we get over 30 million results, we’ll know we finally achieved Microsoft-ian levels of influence.

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EHR Satisfaction Growing Among Large Physician Practices

EHR Satisfaction Growing Among Large Physician Practices | EHR and Health IT Consulting | Scoop.it

There appears to be a shift upward in physician experience across the large practice and clinic sector when it comes to electronic health record (EHR) satisfaction, according to an annual survey by Black Book Market Research.


Black Book first began measuring EHR satisfaction among providers six years ago. In 2013, 92 percent of multispecialty groups using electronic records were “very dissatisfied” with the ability of their systems to improve clinical workload, documentation and user functionalities.  In 2015, comparably, 71 percent of all large practice clinicians stated their optimization expectations of top ranked Black Book EHR vendors were being met or exceeded according to physician and clinician experience. Eighty-two percent of administrative and support staff declared upgraded operational and financial developments, as well. For this survey, more than 27,000 EHR users participated in the 2015 polls of client experience in a sweeping five month study.


Interestingly enough, a recent physician-based survey from online resource organization AmericanEHR Partners and the American Medical Association (AMA) found that compared to five years ago, more physicians are reporting being dissatisfied or very dissatisfied with their EHR system.


What’s more, the Black Book survey found that Allscripts, Greenway, McKesson and athenahealth recorded the largest increases in client satisfaction over the past year among the large group practice sector of medical care delivery. According to the survey results of 1,304 large practices, overall satisfaction improved as follows:


  • Physician experience satisfaction, from 8 percent (2013), to 31 percent (2014) to 67 percent in Q2 2015.
  • Physician documentation improvements, from 10 percent (2013), to 28 percent (2014) to 63 percent in Q2 2015.
  • Practice productivity enhancements, from 7 percent (2013), to 17 percent (2014) to 68 percent in Q2 2015.


Users of the top four ranked EHR systems agreed that vendor investments in 2014 and 2015 have attributed update and releases (34 percent), practice assessments (44 percent), clinical workflow enhancements (60 percent), revenue cycle management and analytics value adds (89 percent), population health capabilities (33 percent) and solicited physician feedback (90 percent) have contributed the most to their rise in overall system satisfaction.


Significant decreases in satisfaction were also noted by users of several clinic-oriented EHR users that failed in regional connectivity attempts (76 percent), implementation and training (77 percent), and customer support (85 percent).


“Meaningful use deadlines, total integration and reliable delivery may have influenced large group practice buyers to purchase initial EHRs from 2010 through 2013, but replacement buyers sought better EHR tools in 2014 that include patient engagement, true interoperability, enhanced usability and productivity gains,” Doug Brown, managing partner of Black Book, said in a statement. “There was also a measureable shift in loyalty to vendors that offered a robust, core EHR to accommodate evolving reforms.”   


Among those surveyed, Black Book revealed just 18 percent of implemented large practices and clinics are in the discussion or execution stages of replacing their original EHR by 2016 year end. Opportunities for product penetration among current client bases of the top ranked EHR vendors were also recorded in the 2015 survey. 

According to large practice executives and physicians, the primary reasons for top vendors succeeding in product penetration into their current client bases in the second half of 2015 include: client education (42 percent); product bundling (31 percent) and marketing (26 percent).


“EHR firms with a wide offering of products including health information exchange, population health tools, revenue cycle management services, patient portals, dashboards and analytics are emerging as the next wave of healthcare technology leaders,” said Brown. “These leading vendors are assisting their clients in assessing current practice operations to meet the demands of ICD-10, payment reform, connectivity beyond closed networks, revenue cycle management gaps, and population health tools, and recommending effective options within the same vendor suite.”

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Begin With the End in Mind: Common EHR Activation Risks and How to Mitigate Them

Begin With the End in Mind: Common EHR Activation Risks and How to Mitigate Them | EHR and Health IT Consulting | Scoop.it

No matter the size or scope, thorough electronic health record (EHR) implementation planning should begin with determining your desired end-state, what is needed to reach it, and the potential hurdles you may encounter along the way. Identifying potential activation risks before implementation allows for time to proactively and appropriately plan, budget, and communicate resource needs and expectations. You can alleviate surprises that may negatively affect clinician satisfaction and limit the full benefit of your new EHR.


What follows are several common activation risks and how you can address them upfront.


  1. Ambulatory Acquisition Scope Creep

Risk: As more physician groups are added to the potential user base through acquisition, affiliation agreements or EHR extension initiatives, the temptation is often to accommodate these additional providers in the original activation timeline. This increases resource needs for build, testing, and go-live support and introduces additional risk to the timeline.


Solution: Develop an implementation strategy for ongoing acquisitions, affiliations and private practices to minimize the impact on activation budget and plans. This will also set expectations with the newly acquired and affiliated groups as to how they fit into the implementation strategy. For example, create a schedule to add new providers to the beginning of the last clinic group’s testing cycle. Determine how many clinics the implementation team can handle to determine when to create the next grouping – whether the current strategy is “big bang” or phased. This requires reviewing the existing team resources to ensure the right number of resources are available to support ongoing implementations and clinics that are live on the system.


  1. Scheduling Reduction Trickledown

Risk: To provide physicians with time to adapt to a new system and workflows as they gain expertise with the new EHR, many organizations allow for a scheduling reduction in operating cases, office visits or scheduled procedures. Physicians who receive RVU-based compensation could see a reduction in their compensation. Scheduling reductions may also trigger revenue loss for ancillary departments such as radiology, laboratory and surgical services due to fewer referrals – a common trickledown effect from schedule reductions.


Solution: If you choose to reduce scheduling, you need to determine how or if you will bridge the gap in compensation or bring in external clinical staff with EHR experience to maintain existing schedule loads. It is also a good idea to provide insight about potential budget impacts (e.g., up staffing, vacation planning and schedule reduction) to the finance department as soon as they are identified to help them plan for the impact. By proactively communicating the trickledown impact of revenue loss for ancillary departments to executive leadership and governance bodies, the reduction in revenue will be anticipated and planned for accordingly.


  1.  Conversions

Risk: Clinicians and staff will be required to participate in manual conversion activities before activation for inpatient chart conversion, scheduling and registration of appointments, schedule template build, surgical case block and case creation, pre-op order entry, etc. Manual conversions will result in overtime due to after hours and weekend work, as well as hospitality costs, which are often overlooked.


           Solution:  A hybrid approach to converting appointments is possible by using an electronic format for simple appointments and manual conversion for more complex appointments to save time. Staff will be needed to validate electronic conversion results as well as participate in backfilling for those participating in manual conversion activities – either with internal or external resources. Early communication with clinical and business departments about the need to participate in these activities will help them better manage their staff scheduling. Prepare for additional staffing and their needs in the budget.


  1. Command Center Planning

Risk:  Allocating adequate space for command centers can be challenging, especially for large scope activations. Dedicated space is necessary to accommodate large groups of people (120+ for a “big bang”) before and after activation. It may be necessary to reserve space well ahead of time to ensure it will be available. For ambulatory activations, there are challenges with where to locate the command center to best meet the needs of the end users. Command center space must be equipped with network access, telephony and hardware. Additionally, there are physical security considerations, increased parking needs and workspace considerations, such as tables and chairs, and hospitality costs for the command center which are typically an afterthought and under-budgeted.


Solution:  For large scope activations, identify and reserve a command center area one year before go-live to ensure you have the necessary space. Approximately four months before go-live, identify all of the resources needed to equip the command center to plan and monitor logistics and communications. Adjust budget line items with the actual costs being incurred. Depending on the current configuration of the space being used, it may require relocating existing users or running wiring and cable. Consider HVAC requirements for afterhours work as well. The complexity of the command center preparations may require that the work begins several weeks before the space is needed. Getting this space set up prior to activation will also allow it to be used for manual conversion work efforts to better facilitate communication, training and support. Define in advance what hospitality (e.g., food and beverages) will be offered and for how long including manual conversion activities and post activation needs.


  1. Outsourcing for Coding and Legacy Accounts Receivable

Risk:  Billing and coding staff will be focused on learning the new system and work queues, as well as new workflows for accounts receivable management. This will affect their ability to continue accounts receivable work and coding in the legacy systems.


Solution:  By outsourcing the legacy accounts receivable tasks, billing staff will have time to focus on adjusting to the new system. Additionally, outsourcing coding for four to eight weeks post go-live gives coding staff time to learn the new system and workflows.


  1. Go-live Support Resource Planning

Risk:  Large numbers of staff are needed to provide support for go-lives – whether they are internal super users or external resources brought in to assist with support of staff and physicians. Both types of resources are expensive. Internal super users have been pulled away from their regular responsibilities and must be backfilled. While, competing implementations in your area could increase competition for external resources driving up costs.  


Solution:  Carefully estimate the resources and budget needed to provide support for staff learning the new system being careful not to underestimate what is needed. Assume that super users will need to be backfilled for two to four weeks post go-live and that you will be using external resources for the same timeframe. Continue to monitor the numbers of super users that will be available to provide support in order to more accurately determine how many external resources will be needed. Understanding what competing priorities may exist for external resources in your area will allow for proactive contracting of these resources. Finally, don’t forget logistics and the ability to manage all of these resources.


When done in a thorough and thoughtful manner it is possible to determine your activation needs upfront during EHR implementation planning and reduce risks at activation. It alleviates unexpected budget overruns and prevents organizational frustration with the activation process. Additionally, it minimizes negative perceptions by clinicians that can impact early adoption of the EHR and realizing its full value potential.

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Meaningful use didn't spark EHR uptake

Meaningful use didn't spark EHR uptake | EHR and Health IT Consulting | Scoop.it

There will be government officials and health IT experts who refute these findings. Others, meanwhile, are likely to argue that it just confirms what they've been saying all along.


Here goes: There is little or no actual hard evidence to prove that theMeaningful Use program triggered an uptake in electronic health records adoption. That's  according to a new study published in the Journal of the American Medical Informatics Association.

The authors of "Impact of the HITECH act on physicians' adoption of electronic health records" examined the extent to which meaningful use and some $30 billion in incentives behind it influenced the EHR adoption curve that existed prior to the Healthcare Information Technology for Economic and Clinical Health Act of 2009, that being the legislation funding the meaningful use program.


"The authors find weak evidence of the impact of the MU program on EHR uptake," JAMIA explained. "This is consistent with reports that many current EHR systems reduce physician productivity, lack data sharing capabilities, and need to incorporate other key interoperability features (e.g., application program interfaces)."

It's a curious piece of research, particularly given that the Office of the National Coordinator for Health IT, on the public dashboard it maintains and elsewhere, has said that 95 percent of eligible and critical access hospitals have "demonstrated meaningful use of certified health IT. Through participation in the Centers for Medicare & MedicaidServices EHR Incentive Programs."


What happened, then? EHR adoption has indeed risen since meaningful use began, yet JAMIA determined that the federal reimbursement incentives are not the reason.


"The models suggest that adoption was largely driven by 'imitation' effects as physicians mimic their peers' technology use or respond to mandates," JAMIA authors contend. "Small and often insignificant 'innovation' effects are found suggesting little enthusiasm by physicians who are leaders in technology adoption."


Do you buy that? Is what we have here a simple case of correlation and not causation? Or much more complicated?

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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 | Scoop.it

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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Groups Call for Final Changes to Meaningful Use Requirements

Groups Call for Final Changes to Meaningful Use Requirements | EHR and Health IT Consulting | Scoop.it

A group of eight hospital associations have joined voices to ask the Department of Health & Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS) to move forward with finalizing proposed changes to meaningful use requirements made earlier this year.


"As organizations representing hospitals and health systems across the country, we are writing to urge the Department of Health and Human Services (HHS) to release, in the immediate future, a final rule making modifications to the meaningful use requirements under the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs for fiscal years (FY) 2015 to 2017," they state in a letter to HHS Secretary Sylvia Mathews Burwell.


CMS first indicated that it was considering reducing meaningful use requirements between 2015 and 2017 earlier this year. In January, Deputy Administrator for Innovation & Quality and Chief Medical Officer Patrick Conway, MD, authored a blog post revealing that the federal agency "intended to be responsive to provider concerns about software implementation, information exchange readiness, and other related concerns in 2015."


CMS did not release the proposed rule in question until April and the proposal has made little progress since then which has drawn consideration from multiple industry associations. Just last week, the College of Healthcare Information Management Executives (CHIME)called on the HHS Secretary to finalize the rule.


Now it is the case that the following eight hospital associations have come together to make a similar request:


  • America’s Essential Hospitals
  • American Hospital Association
  • Association of American Medical Colleges
  • Catholic Health Association of the United States
  • Children’s Hospital Association
  • Federation of American Hospitals
  • Premier healthcare alliance
  • VHA Inc.


According to these organization, the finalized rule is long overdue:

The rule is past due, given that it will affect the current program year for meaningful use. Indeed, under current rules, meaningful use applies to fiscal year performance for hospitals. FY 2015 ends on Sept. 30 — fewer than 60 days from now. We recognize that the Centers for Medicare & Medicaid Services (CMS) also proposed to change meaningful use reporting for hospitals from a fiscal to a calendar year. Under that policy, the last possible reporting period would begin on Oct. 3. However, the proposed rule also allowed other reporting periods for earlier dates in FY 2015. Even if reporting is moved to a calendar year, hospitals need the certainty of a final rule now to determine the best reporting period to choose and begin the process of reviewing performance and ensuring they have met all of the revised requirements.

That is not to say that these hospital groups are content with the provisions of the proposed rule as is:

Other proposed changes, such as making e-prescribing of discharge medications mandatory or adding new public health reporting measures, however, would make meeting Stage 2 more difficult. And, given the delay in the release of a final rule, they would be virtually impossible for hospitals to accommodate. Hospitals simply will not have sufficient time to understand the new requirements, work with their vendors to purchase and implement new or revised technology that would accommodate them, and invest in the training and work flow changes necessary to meet the new requirements.

With the closing of the fiscal year coming for eligible hospitals at the end of September, the hospital groups are concerned that the delayed release of the final rule would impose burdens on these providers and have far-reaching consequences.


"Widespread failure to meet meaningful use due to unrealistic regulatory requirements and insufficient technology will undermine hospitals’ ability to use EHRs to improve care and involve patients in their care. It will also result in significant financial penalties for the hospital field. Therefore, we urge HHS to release a final rule as quickly as possible," they add.

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Adopting Physicians

Adopting Physicians | EHR and Health IT Consulting | Scoop.it

I have been going to my family practitioner for years. During these visits I have been able to witness the devolution of the EMR. One thing I really enjoyed about him when we first met was how excited he was about his home grown EMR. He navigated quickly through it and dictated his notes. Then a few years later his affiliated hospital decided to standardize on an EMR. He had to give up his system and adopt to a new one. It was not ideal, and he would tell me all about his challenges, but he was able to use dictation and he completed his notes efficiently. Over time I noticed that his office fell into a nice routine and he could retrieve all the information he needed and dictate notes and orders quickly.  


It had been a year since I had seen him and I called for an appointment. I had to provide all my information and none of my insurance information was in the system. You guessed it, they updated their practice management system and EMR. My patient experience went downhill from there. My previous clinical history was archived and not incorporated into the new EMR. So no trending, no real history. Years of electronic, discrete data now converted to a static view only. It is like having your EMR converted to paper, then scanned.


My provider was frazzled, I could tell the way he focused on my encounter and then had to “hunt and pick” his way around the new EMR. No microphone, no dictation, and no customized templates. He confided to me how the hospital system decided to migrate all their physicians to this new ASP platform and they all had to use the same templates. There was no dictation and even if he could, his old profiles were gone, meaning that he would have to retrain the system to recognize special words and speech patterns. Something that he had spent years investing in. Here he was working for a large healthcare organization and they would not use time proven physician adoption strategies. Instead they adopted physicians into whatever their leadership felt was needed.   


My scenario is being played out through many healthcare organizations. EMR’s are being replaced because of vendor problems, healthcare acquisitions or just because they have outgrown the capabilities of the existing systems. So why are CIO’s allowing their organizations to use a “slash and burn” technique for system replacement? An even more alarming question is; why are CMIO’s not making a stand against it?   


During the sales process EHR vendors focus on their ability to quickly install and train employees on the new system. Organizational leadership views this as an opportunity to get this “information technology” project out of the way so they can move on to the next thing. They might even have this labeled as a Strategic Initiative, tied to bonuses for on time completion.


 The thought of having to deal with all the physician requirements and pay for the process of converting all the old data into the new system, is too daunting. Especially when you have software vendors telling them how difficult and costly it will be. Keep in mind that they have a vested interest in getting the system installed as quickly as possible.

I am certainly not going to talk about physician adoption. This has been the topic of just about every HIMSS conference. It also has been at the core of every EMR adoption strategy. So why are we having to visit this again? Because:


  • Organizations are focused on project life cycles and fail to factor impact to productivity.
  • Hospital leaders often do not understand ambulatory practice operations.
  • Leadership incentives are designed to accomplish quick wins.
  • CEO’s still do not understand the value of discrete data.


As my family physician entered information into my problem list, medication history (which I had to bring with me from Walgreens for my visit) and reviewed my labs (toggling back and forth trying to find scanned images of my previous lab values) I started to get annoyed. Not at him, but at the hospital leadership that placed more importance on their performance appraisals and ignored the impact they would have on thousands of patients. My data which my healthcare provider and I built for years was now relegated to view only files which could now be printed like a pdf. I am sure on a macro level they could trend on the population as a whole, but I have to rebuild my record, history and trends all over again.   


Hospitals focus on episodes of care. Billing is all about the bed stay and the admission timeframe. For ambulatory care it is a longitudinal record. It is all about establishing that long term relationship with the patient. Providers can go months or years without seeing a patient, but are expected to jump into the exam room with a smile, a look of recognition, and an understanding of the patient’s history without having to ask all the same questions all over again.


As an industry we need to do a better job at safeguarding our patient’s records in a way that will allow them to have seamless transitions from one system to the next. Converting data to static views is not only counterproductive, but borderline irresponsible. My personal physician was an EMR champion that loved the technology because of what he could do for his patients. At the end of the day, that’s how it should be for all of us.

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Three Common EHR Missteps

Three Common EHR Missteps | EHR and Health IT Consulting | Scoop.it

Family physician Saroj Misra is an educator, and thinks that physicians are at the low end of the learning curve when it comes to EHRs.

"Despite the fact that we've had EHRs in some form or another for the last 15 to 20 years … we are surprisingly behind the times in terms of how they work; what they do, and, most importantly from a physician's perspective, how they help in the delivery of healthcare," says Misra.


That is probably a perspective that many physicians would share. In the 2015 Physicians Practice Technology Survey, Sponsored by Kareo, only 53 percent of 1,181 respondents said they had a fully implemented EHR system. And, despite seeing an improvement in documentation (66 percent), 68 percent said they did not see a return on their investment in EHR. Respondents said one of their top information technology problems was "a drop in productivity due to our EHR," indicating a significant disconnect between the intent of EHR and its reality.


If you are wondering what EHR trip-ups other physicians are struggling with, our experts tell us these areas are the worst offenders.


INADEQUATE TRAINING


Inadequate training on EHR systems for both physicians and clinical staff can be a significant source of frustration. Yet there are many other demands for a physician's time and money. It is a paradox that devils many practices: If a practice doesn't go "off line" and dedicate enough time to initial training on the EHR, implementation and subsequent productivity will suffer. But few practices can afford to take a full week or more away from patient care.


Tom Giannulli, chief medical information officer for EHR vendor Kareo, counsels physicians to avoid learning a new system while they are seeing patients. "EHRs have learning curves, for some they may be steep, and if you do not ascend the curve in a productive learning environment, you will be paying for it with wasted time and frustration," he says.


Misra, who directs the development and implementation of curriculum at Michigan State University's College of Osteopathic Medicine, incorporates technology use in his teaching. He says in order to have true success with understanding and efficiently using the EHR, physicians need to "commit time each week to relearning [the system]." He gives the example of a "power-user" who goes beyond learning basic system functionality and commits time each week to really learn what the system can do. Understandably, that might sound like a pipe dream, given the lack of excess time in a busy practice. But there are ways around that limitation. Misra recommends carving out one to three hours each week for a single physician or staff member to learn the functionality of the practice's EHR. "Then, that person becomes a liaison or a de facto liaison to the EHR vendor," he says, "but also a person who can educate and provide ongoing education for the physicians and the office staff."


ACTION STEPS:


• Training should be timely, and repeated for both new staff and current users.


• Training should focus on specific tasks that staff/providers will use daily.


• Identify a practice "super-user" who will be a clinic resource/trainer/ IT support person.


INADEQUATE IMPLEMENTATION


Marissa Rogers is program director for a large family medicine residency at Genesys Regional Medical Center in Burton, Mich., and a practicing member of a 46-provider faculty practice. She says her providers often struggle with spending too much time on documenting the patient encounter in the EHR. She encourages her residents to chart on the computer when the patient is in the exam room, to "get the meat of what the patient is telling them," but admits it is not always an easy task. "It's very difficult for physicians to do because we are used to wanting to talk and listen [to our patients]," she says, "… But in the new world that we are living in, we now have to get used to having a computer in front of us."


Rogers says completing the patient note while the patient is present in the exam room is a necessary component of providing a summary of care for the patient to bring home — a meaningful use requirement. So for physicians who are not ace typists, being required to enter the patient note during the encounter can slow down their day and reduce overall productivity.


Another productivity drag? Misra says physicians commonly fail to make use of time-saving EHR features like shortcuts, templates, built-in coding, and voice recognition software to dictate the patient note. And, when he visits other clinics, he often sees them using out-of-the-box templates provided by the vendor, which he believes slows down physician work flows. Knowing your practice's work flows and how they are affected by the EHR can allow your practice to create customized templates that will speed up documenting the patient encounter.


"Many EHRs have the ability, with time and effort, and that's the problem, to make some modification to these [templates]. But most physicians find those barriers too high, in terms of time and effort. But if they did [modify the templates]… that would speed things up immensely for them," says Misra.


Elizabeth Woodcock, principal of Woodcock & Associates, a practice management consulting firm, says that in some cases, it is not possible to customize EHR documentation to fit practice needs, especially in the case of a unique specialty practice like a fertility clinic. But even when customization is not possible, Woodcock says that correctly configuring the EHR during implementation is crucial. Small things like incorrectly setting up the dictionary can cause a physician to hate his EHR and negatively affect "the whole course for the EHR for years and years to come," she says.


ACTION STEPS:


• Integrate the EHR into clinical work flows, and revisit work flows after implementation.


• Develop templates/customization that work for the specific practice.


• Ask the vendor for system enhancements to facilitate improved work flows, where possible.


INADEQUATE TECH SUPPORT


Many practices have vendor-provided tech support onsite for the first week of EHR implementation, and after that they are essentially on their own. Obviously that can be a huge detriment to a practice. Woodcock advises administrators to have tech support return within 90 days after the initial implementation, for one or two days, to answer questions that have cropped up at the practice.


Misra advises practices to communicate with the vendor on a regular basis. He suggests that the appointed EHR "super-user" should also be the practice's vendor liaison. "That person should not only be communicating back to the vendor what they need and what's working, but they should be communicating back to the office what updates are coming out for the software."


Large health systems typically have their own onsite tech support, which is a definite plus for busy practices. But that doesn't always mean your practice can get the personal attention it deserves. Woodcock says a new trend that she sees beginning to take hold in health systems is the use of an EHR optimization team. "Their goal is to make that system work better for you." She says these professionals tend to have EHR vendor experience and approach their work from a "lean-thinking" perspective.


ACTION STEPS:


• Build in adequate tech support in the initial vendor contract, with a return visit within 90 days.


• Develop a practice work group (physicians and staff) that will initiate and support EHR implementation/use.


• Task the EHR super-user to act as a vendor liaison.


SOAP NOTE SLOWDOWN


According to a member survey of the American College of Physicians, most of whom were experienced EHR users, 89 percent of respondents said they experienced slower data management; 63.9 percent said the SOAP (subjective, objective, assessment, and plan) note documentation took longer; 33.9 percent said it took longer to review medical data; and 32.2 percent said it took longer to read another clinician's note using EHRs.

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