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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Analyzing the Alleged Death of Meaningful Use

Analyzing the Alleged Death of Meaningful Use | EHR and Health IT Consulting |

Earlier this week, Andy Slavitt, Acting Administrator for CMS, told a group of attendees at the J.P. Morgan Annual Health Care Conference that meaningful use is on its way out.

“Now that we effectively have technology into virtually every place care is provided, we are now in the process of ending meaningful use and moving to a new regime culminating with the [Medicare Access and CHIP Reauthorization Act of 2015] (MACRA) implementation,” Slavitt told attendees. “The meaningful use program as it has existed, will now be effectively over and replaced with something better.”

The idea that meaningful use, a program which began in 2011 and aimed to incentivize or penalize physicians for adopting an EHR system, would be over, naturally caused many physicians to celebrate. Melissa Young, an endocrinologist in Freehold, N.J., and a member of the Physicians Practice Editorial Board, e-mailed a three word reaction to the news: “Hooray! ‘Nuff said.”

The AMA had a more formal way of celebrating this news. Of Slavitt, AMA President and CEO, Steven Stack, an emergency physician, told Beckers Hospitals Review in a statement: "He listened to working physicians who said the meaningful use program made them choose between following Byzantine technological requirements and spending more time with their patients. This is a win for patients, physicians and common sense."

In his speech, Slavitt talked about winning the “hearts and minds” of physicians back. Getting rid of meaningful use would undoubtedly help the federal agency achieve that goal, as evidenced by the rising number of docs who opted out of the program due to its stringent requirements.  “The concept of meaningful use was always doomed to failure and it has been proven that there is no improvement in the quality of our healthcare delivery system and it has not reduced the costs of the provision of medical care,” Jeffrey Blank, a podiatric physician in Loxahatchee, Fla., and a member of the Physicians Practice Editorial Board, said via email.

Hold that Thought

Despite the excitement, Robert Tennant, health information technology policy director for the Medical Group Management Association (MGMA), says physicians should keep the champagne on ice. For one thing, they will still be judged on EHR and technical capability.

At the conference, Slavitt talked about MACRA, which authorized the creation of the Merit-Based Incentive Payment System (MIPS). MIPS will measure and compensate physicians on quality, practice improvement, cost, and use of technology. Within MIPS will be elements of meaningful use. Rather than rewarding physicians for using technology, MIPS will aim to pay them on using it towards improving their outcomes.

While Tennant says a reworked meaningful use is “potentially very positive,” the guidelines for MIPS are supposed to be released and finalized this year, which he notes could be a problem for physicians. “Payment under MIPS is supposed to take effect in 2019. If the traditional approach of using a two-year look back [to make those adjustments] is in place, it would mean reporting would begin in 2017,” he says. “If you look at the timing from a regulatory process, we’re concerned with how this would be accomplished.”

In essence, vendors would have to redevelop software around the guidelines, train customers, and practices would have to go live within the space of a year. Moreover, Tennant says if MIPS regulations are finalized in December of this year, they’d likely overlap with a new presidential administration.

“Any new administration, the first thing they do is typically put all pending regulations on hold and review them before they approve,” he says.  Tennant also notes practices still have to be concerned over meaningful use regulations for 2016, including a full-year reporting period and the fact that Stage 3 of meaningful use is technically supposed to be mandatory in 2018.

“We don’t know what we are moving ahead to,” Tennant says. For practices, he advises to select software that fits their clinical needs and to not worry about “arbitrary and potentially changing” regulations. “Don’t focus on 2017 or beyond. We don’t know. The vendor doesn’t know.”

Even still, he is “cautiously optimistic” about Slavitt’s remarks. “We’re hoping CMS takes this opportunity to leverage MACRA to develop a program that is achievable and clinically relevant,” he says.

Blank is interested to see what lies ahead with government regulations, but is not as optimistic as Tennant. “I'm sure that many interest groups and the insurance industry will profit and doctors like me will continue to struggle,” he says.

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NIST Ties Limited EHR Usability to Patient Safety Risks

NIST Ties Limited EHR Usability to Patient Safety Risks | EHR and Health IT Consulting |

The National Institute of Standards and Technology (NIST) has issued new guidance for ensuring patient safety by improving EHR usability.

The results from a technical evaluation, testing, and validation of EHR usability list three "major critical risk areas: the EHR data identification, EHR data consistency, and EHR data integrity.

"Ultimately, the data from this study demonstrate that during safety-critical tasks and times, patient safety is negatively affected, in part because mistakes and critical use errors occur more frequently and because users are highly frustrated, and thus more likely to employ workarounds, such as relying upon supplemental artifacts, e.g., paper ‘shadow charts’ or whiteboards," the authors conclude.

The NIST report identifies a handful of ways EHR problem areas contribute to inadequate patient care:

  • clinically relevant information being unavailable at the point of care
  • lack of adequate EHR clinical documentation
  • inaccurate information present in the clinical record
  • inability to retrieve clinical data

Based on empirical analysis of inpatient and ambulatory EHR use, the NIST document proposes three EHR usability enhancements that EHR technology incorporate to eliminate or reduce risks to patient safety.

The first centers of how critical patient identification data is presented. According to NIST, this information should be presented in a reserved area. The authors of the report recommended reserving the upper left-hand corner of all screens or windows and remain persistent regardless of scrolling or navigation throughout the EHR. Additionally, they hold that a patient's name appear with last name first, followed by first and middle names, modifiers, data of birth, age, gender, and medical record number (MRN) number. For EHR mobile technology, the NIST guidance allows for the presentation of this information horizontally to maximize screen space.

The second enhancement calls for the use of visual cues to "reduce risks of entering information and writing orders in the wrong patient's chart." The enhancement would prevent EHR users from entering information into multiple charts simultaneously as well as visually different between read-only and editable charts. Under this guidance, EHR users would have to deliberately enable the software to move between charts and maintain unrestricted access and provide clear cues when an EHR user moves between charts.

The third and final enhance places an emphasis on supporting the effective identification of "inaccurate, outdate, or inappropriate items in lists of group information by having information presented simply in a well-organized manner." The NIST document contains several examples:

3.1 Lists of patients assigned to a particular clinician user should be presented in consistent, predictable locations within and across displays and print-outs and the content should not vary based on display location.

3.2 The status of a note and order as draft as compared to final shall be clearly indicated on appropriate displays.

3.3 Clearly indicate the method by which the system saves information, whether auto-save or requiring deliberate action to save, or combinations thereof.

3.4 Inputted information should be automatically saved when a user transitions from one chart to another.

3.5 The language used should be task-oriented and familiar to users, including being consistent with expectations based upon clinical training.

3.6 Enable a user to easily order medications that have a high likelihood of being the appropriate medication, dose, and route. The likelihood is increased when displays are tailored to specialty-specific user requirements, comply with national evidence-based recommendations, are in accordance with system, organizational, unit, or individual provider preferences specified in advance, or are similar to orders made by the same physician on similar patients, on the same patient in the past, or providers with similar characteristics.

3.7 Support assessing relationships of displayed information and allowing users with appropriate permissions to modify locations and relationships for inaccurately placed information, including laboratory results, imaging results, pathology results, consult notes, and progress notes. This includes information within a single patient’s chart as well as information placed in the wrong patient’s chart. The information about the time and person that made the change should be viewable on demand.

On top of these recommendations, the guidance provides two use cases to illustrate the components of EHR usability testing in identifying and mitigating potential patient safety risks in both inpatient and outpatient settings. 

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Meaningful Use Audits: An Update

Meaningful Use Audits: An Update | EHR and Health IT Consulting |

The lion’s share of the CMS EHR incentives have been paid out, especially for those who participated on the Medicare side of the incentive program. The Meaningful Use (MU) incentives are winding down but it is prudent to keep an eye on the rear view mirror and make sure you are up to date on past MU documentation. One of the more common questions we are asked at Meaningful Use Audits has to do with how long after attestation can a CMS Meaningful Use audit take place. What is the look back period? How long does an Eligible Professional (EP) or Eligible Hospital (EH) need to keep their “book of evidence” in a handy place? When it is OK to breathe easy?

Our friends at CMS tell us: “Eligible professionals (EPs), eligible hospitals (EHs), and critical access hospitals (CAHs) should retain ALL relevant supporting documentation (in either paper or electronic format) used in the completion of the Attestation Module responses. Documentation to support attestation data for meaningful use objectives and clinical quality measures should be retained for six years post-attestation.”

So six years post-attestation is the period in which an incentive recipient needs to be prepared to respond to an audit. What are the chances you might be audited for an early attestation, say back in 2011 or 2012? I’m not a gambler and have never been too good at calculating odds but I was recently contacted by an EP who had received an audit engagement letter from the gang over at Figliozzi & Company. That EP had never been audited before and received the letter just a few week ago in early September 2015. The audit was for a 2011 attestation. That’s right, the audit was going all the way back to the 2011 attestation. There was scant guidance and clarification from CMS in those early days of MU and I imagine an EH or EPs “book of evidence” could be a bit on the slim side.

I don’t need to tell you what the lesson is here. An occasional glance in the rearview mirror to make sure documentation is intact would not be a bad thing to do.

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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 |

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.

AACS Atlanta's comment, October 18, 2019 2:29 AM
If you have been charged with a DUI, or if the DUI charge was reduced to reckless driving, the state of Georgia will most likely require you to attend a 20-hour Risk Reduction Program. For detail for directions!

Windows Server 2003: Mitigating Risks

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

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

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

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

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

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

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

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

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

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

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

12 Million Servers

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

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

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

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

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

Gambling with Critical Flaws

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

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

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

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

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A Strive Towards “Meaningful” Data Exchange in the Midwest

A Strive Towards “Meaningful” Data Exchange in the Midwest | EHR and Health IT Consulting |

Although the successful exchange of health data has been a struggle in most U.S. regions, a commitment to the free flowing of information on a patient’s history—regardless of what local healthcare facility they have been at—has helped spur health information exchange (HIE) in the Midwest.

Indeed, the Lewis and Clark Information Exchange (LACIE) is one of the first fully operational, multiple-state HIEs in the country, providing patient information to healthcare systems and providers in Kansas and Missouri. Getting the HIE up and running to a point where it could successfully exchange data required a few key elements, starting with getting hospitals on board that were willing to share data. To this end, in the last 18 months, LACIE announced two major connections: first with the Kansas Health Information Network (KHIN), another major HIE in Kansas. This was a significant moment for data exchange in the Midwest, as in the past, the two organizations had failed to reach an agreement on sharing data.

A few months after that, LACIE announced that patients' electronic medical records (EMRs) were being securely shared with Tiger Institute Health Alliance (TIHA) in Columbia, Mo. In total, LACIE is now connected to 17 hospitals in two states in addition to three accountable care organizations (ACOs), the two aforementioned regional HIEs, multiple private HIEs, and the Kansas City Metropolitan Physician Association (KCMPA), a large independent physician group with 80 clinics and 350 providers. The 24 different EMRs those organizations use have been connected via a hub that has been put in place from Cerner, says Mike Dittemore, the executive director for LACIE. Dittemore says that LACIE connects to that hub so it doesn’t have to do all of the independent connections, leading to greater efficiencies and cost savings.

However, getting different provider organizations on board has not been easy, Dittemore admits. “There are always challenges with provider participation, and one of reasons we had the strategy to work with hospitals and get them on first is that we felt if we did a good job with them, that would spur participation from others. The best marketing out there as far as HIEs go is word of mouth by providers who actually use it,” he says. What’s more, LACIE’s board of directors consists of several physicians, including multiple CMIOs of organizations in the Kansas City area. “That’s really helped us, having these physicians have conversations with other providers or their clinics and talk to them about why it’s important to share this information and participate,” says Dittemore. “They can show other [providers] the value by being able to not tie up so much staff in administrative time in tracking information down that already exists in the HIE.”

Still, there are additional challenges for independent providers who have all kinds of mandates and rules they are struggling with, in addition to low reimbursement rates, Dittemore notes. “So we try to have a price point that works for them, and we also have found some grant funds through the Office of the National Coordinator for Health Information Technology (ONC). In Kansas, we used some of those funds to help folks to connect, but it’s always an uphill climb to get individual providers on board. We do think that if we can get in and meet with clinic managers, maybe not the providers themselves, but a trusted person they go to, and show them the value, getting these smaller providers on board might not be as hard,” he says.

One of these physicians on LACIE’s board is board chair, Gregory Ator, M.D. CMIO and practicing physician at the University of Kansas Hospital. Ator says that as of late, LACIE has become much more focused in getting smaller practices on board. “It’s been a great experience, it’s very refreshing to see all of these large organizations that are not competing around the ‘this is my data and you can’t have it’ concept, but rather the ‘let’s compete around quality of care and let information freely flow’ concept. That’s been quite refreshing, and moving forward we’re looking at the next tier of smaller physician practices,” Ator says.

LACIE further attempts to make the exchange process more doable by not charging organizations a fee to connect. “We have always believed in connecting to other HIEs, be it community, regional, or state. But we don’t pay other organizations to connect nor do we charge others to connect to us,” Dittemore says. “LACIE is a public type of entity. We think that’s why it’s here, for the spirit of moving information regardless of where they reside. We have been adamant about that, but not all facilities feel the same way. So that’s been a barrier,” Dittemore notes.

Making HIE Valuable

Currently, LACIE is consistently seeing 100,000 queries per month going through the HIE, and according to Dittemore, one of the things that really helps provide value to its providers is getting robust information trading rather than just checking a box. “If checking a box is what you want, our HIE won’t be for you. We’re about the meaningful trading of information,” he says.

To this end, all of LACIE’s connected providers are encouraged to share radiology reports, discharge reports, clinic visits, and any summaries, Dittemore adds. “What we have found is that when you have that type of information above and beyond the continuity of care document (CCD) or consolidated-clinical document architecture (C-CDA), it really provides a great platform for providers to go in and look at the information and find out what is really going on with patients in those last visits,” he says. “We want to try to get rid of the fax machine, or reduce its use by as much as possible. Having this robust information available does help providers to move onto other duties like taking care of patients. They become valuators rather than investigators,” says Dittemore.”

Expanding on the notion of meaningful data exchange, Ator notes that fax machines are how providers are doing HIE right now, and what’s more is that Direct also has issues with people’s addresses as well as its own technological problems. “I am an Epic customer at KU, so we have a number of Cerner operations in town as well as Epic operations, and when you log into Epic for instance, we can go out to the HIE and search for a patient, at which point a very robust matching algorithm kicks in and we get textual documents presented in reverse chronological order. Operative notes, progress notes and discharge summaries are all within Epic without a separate log-in,” Ator explains. “Our providers don’t have to dig through exchange formats such as CCDs and CCDAs to see it in a meaningful manner. And that’s Cerner shop looking at Epic and vice versa,” he says.

Value to providers is further seen in the form of impacting patient outcomes. According to Ator, the strongest use case now is in the ER. “The patients here in a big city circulate around the EDs, and it’s fabulous to have the notes as it was was signed from an organization right down the street that a person might have checked into,” he says. “So we have seen improved outcomes around the ED, and the literature backs that up. I think that it is clear there is benefit in ED world, but rest is bit too soon to call,” Ator says.

Dittemore also says that value has been seen on the care

management side. Kansas City has multiple medical facilities and acute care facilities, but even more non-acute facilities, he says. Just because a patient happens to go to a provider or an urgent care clinic that they have affiliation with, they might not go there for all care, and that’s something that needs to be seen in the HIE, he says. Also with specialists, making sure to ensure patients have done the appropriate follow up and have been to specialists allows care managers to see if that has happened and if not, find out why, Dittemore says. “Was it a transportation problem, an illness or what? It gives them something to go off of when they reach back out to the patient. Care managers have seen great value in this to manage that care between multiple facilities that might not be financially related to one other. That’s been rewarding,” he says.

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drchrono preps EHR, PHR for Apple Watch

drchrono preps EHR, PHR for Apple Watch | EHR and Health IT Consulting |

The first developer to make an EHR exclusively for the iPad is now aiming to be the first choice for physicians and patients looking to make the most of their new Apple Watches.

When the Apple Watch first becomes available from select retailers April 24,  Mountain View, Calif.-based ambulatory EHR developer drchrono will be ready – just as is it was five years ago, when a newfangled contraption called the iPad first hit stores.

At HIMSS15 in Chicago this past week, Daniel Kivatinos, drchrono's co-founder and chief operating officer, demonstrated new software for the Apple Watch that had been in the works for months – since Apple first put out the software development kit for the device.

"The moment they release the SDK, we can build a simulator app, even though we don't actually have the physical hardware," said Kivatinos. "We did the same thing with the iPad: When we heard about the iPad in 2010, we downloaded the SDK prior to the actual hardware being released.

"The moment the physical hardware came out for the iPad, we released the app in the app store," he added. "Same situation here: The moment the physical hardware comes out, our app will be available."

Kivatinos says drchono plans to be among the first to offer an integrated EHR as soon as Apple Watch becomes available. He's excited about the device's potential to transform the office experience for doc early adopters, offering a new twist on real-time communication between physicians and their patients.

"We've thought about this a lot: What is our company, what do we do?" said Kivatinos. "Over the past several years we've realized we're creating wearable health records for doctors and patients."

With close to 70,000 physicians and more than 4 million patients registered on the drchrono platform, he said, both groups are poised to enjoy the benefits of this unique way of interaction.

"This is a completely new experience," he said. "For the first time, doctors are going to have information given to them with their hands free: A doctor could be administering a shot, picking up a child, moving an elderly person – looking at the information while doing whatever it is they need to do."

Likewise, said Kivatinos, patients should be drawn to experiencing their personal health records through a device on their wrists, using drchrono's app to schedule appointments, get medication reminders and manage their chronic diseases: "Apple creates a very nice experience for patients. It's not just about usability, it's about enjoyment."

The app will enable docs to view a patient information at a glance, respond to messages via quick text and see eRx refill requests – offering a wearable extension of the drchrono iPhone and iPad apps, according to drchrono.

"Doctors are incredibly busy; drchrono on Apple Watch gives them insights about their practice and patients just by checking their wrist," said CEO Michael Nusimow in a press statement. "Its simply amazing to have a hands-free way to gather quick insights about a patient."

Plenty of other vendors have already readied software for the Apple Watch's release, of course, and many of them were showcasing it at HIMSS15. Epic, Cerner, athenahealth, Vocera, Mayo Clinic and more all announced apps – or plans for apps – at the show.

Kivatinos said he's confident drchrono's early leadership among curious early adopters of Apple technology will keep them well-positioned among physician practices.

"If you look at the early days in 2010, we put our (iPad) app out the first week and had thousands and thousands of docs download it," he said. "It took some of our competitors years to get to that point."

Physicians "want innovation, but they want it to work," said Kivatinos. "We had one doctor who bought a $100,000 EHR, and came to us a week later and said, 'This doesn't work. What do you guys have?' He literally just junked it. If it doesn't work, they're just going to walk away."

The critical questions? "Is it usable, is it designed well, can I just put information into it and walk away quickly? Can I just do my rounds? I don't want this thing in my way."

The company touts different "modes" for the Apple Watch app, depending who's using it and how. "Glance" offers a quick view, giving docs a snapshot of their patient schedule for the day. "Short Look Notifications" can display brief messages generated from the EHR app. "Long Look Notifications" offer a doctor a view of the app itself.

Kivatinos says he's "100 percent" certain the Apple Watch is going to catch on in a big way among consumers – and his customers.

I wonder aloud whether the embrace might be more tepid – something akin to a new form factor such as Google Glass, which found limited acceptance among the general public, but is still enjoying innovative clinical use cases.

Kivatinos says he's convinced it's an Apple to oranges comparison. Glass, with its temple tapping and head nodding, necessitated a new and sometimes questionable type of social etiquette, he said. The "experience was a little different: harder to set things up and install," he said – to say nothing of the cost.

"I bought a Google Glass. It cost $2,000 with prescription lenses," he said. "$2,000 and $350 is a drastic difference. Price point is so critical."

Whether it's docs looking for easy access to vital signs, staff messaging, e-prescriptions and labs; or patients looking for an attractive and convenient interaction to manage their meds or schedule appointments, he's convinced the Apple Watch will find favor among folks and physicians alike.

"The interest is amazingly high," he said.

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Without Obamacare, Jobs Report Might've Been Worse

Without Obamacare, Jobs Report Might've Been Worse | EHR and Health IT Consulting |

The Affordable Care Act, which is infusing millions of new paying customers into the economy who previously couldn’t afford medical care services, continues to boost jobs growth as the health industry emphasizes outpatient care and value-based medicine.

The health care industry added 22,000 jobs last month, which was about on par with February totals for health services jobs, according to the jobs report issued Friday by the U.S. Department of Labor’s Bureau of Labor Statistics.

In the past year alone, 363,000 jobs have been added in the health sector. The entire U.S. economy added 126,000 jobs in March though such totals ended a string of 12 consecutive months when 200,000 jobs or more were added to employment rolls.

The growth in health care continues to come in the ambulatory care sector which is key to the shift away from fee-for-service medicine to value-based care models that emphasize outreach to patients, encouraging them to take their medications and see a primary care provider, typically in a less costly outpatient care setting.

The labor department said there were 19,000 jobs added in the ambulatory care sector. By comparison, hospitals added just 8,000 jobs. And the nursing home sector actually contracted by losing 6,000 jobs.

As an example of the shift going on in health care, technology firms are benefiting as well as hospitals and other traditional medical care providers look to cloud-based platforms to help them manage populations of patients. Value-based care emphasizes health outcomes.

On Friday, Chicago Mayor Rahm Emanuel said health technology company ZirMed, which helps hospitals manage populations of patients in part with predictive analytics and help with claims management, is openings its first Chicago office and would add 200 or more jobs, including “advanced healthcare technologists” to what it calls a “Healthcare Analytics Center of Excellence.”

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How Primary Care Health IT Use Spurs Quality Improvements

How Primary Care Health IT Use Spurs Quality Improvements | EHR and Health IT Consulting |

Strengthening workflow, treatment, and billing processes in primary care is critical to healthcare reform initiatives taking place around the nation. EHR technologies and other health IT systems play significant roles in supporting quality improvements in primary care practices.

The Agency for Healthcare Research and Quality (AHRQ) released a white paperUsing Health Information Technology to Support Quality Improvement in Primary Care –that discusses some key best practices for supporting enhanced quality of care.

The report outlines various health IT tools that can lead to quality improvements in the primary care setting as well as ways to stimulate greater use of health IT among primary care physicians. The key health IT tools primary care physicians will need in their practice include EHR systems, registries, decision support systems, and health information exchange (HIE). Several case studies are also presented to illustrate ways that providers can incorporate health IT in quality improvements.

Over the last six years, the Health Information Technology for Economic and Clinical Health (HITECH) Act has pushed forward the adoption of EHRs, e-prescribing systems, and other health IT tools.

Through the Medicare and Medicaid EHR Incentive Programs, the majority of healthcare providers have adopted health IT systems and are working toward quality improvement within their practice. The Patient Protection and Affordable Care Act also spurred healthcare reforms such as the integration of Accountable Care Organizations (ACOs).

AHRQ spoke with a panel of eight health IT experts to establish ways of incorporating health IT tools and advancing the development of quality improvements in the primary care setting. The organization also spoke with clinicians from an independent primary care practice, a large academic primary care facility, and a health information exchange that supports primary care establishments.

The researchers from AHRQ uncovered four factors that lead to the effective use of health IT tools in pursuit of improving the quality of primary care. These four factors are:

  1. A practice culture committed to health IT
  2. High-functioning health IT tools capable of tracking
  3. Knowledgeable staff with experience in health IT and quality improvement
  4. Workflows and practice processes that incorporate health IT

Both financial incentives and training assistance from health IT experts are key to garnering these four factors for a primary care practice. The Centers for Medicare & Medicaid Services (CMS) has already been utilizing this finding by offering meaningful use incentives and ICD-10 testing to ensure providers are on track with federal health initiatives.

One example of how health IT can be used for quality improvements in the primary care setting comes from Foresight Family Physicians, which has been operating for 25 years in western Colorado. The facility began transitioning to electronic records starting in 2004 and adopted a full-scale EHR system in 2007.

“Foresight currently uses health IT for quality improvement in several interrelated ways. First, the practice has a standing QI team, which includes four people who meet every two weeks for 1.5 hours,” the AHRQ report states. “To identify gaps in care and needed preventive health screening, the front office staff runs approximately 15 daily registry reports for all patients with appointments that day. This process generates reminders for patients who require screenings for depression, are due for a colonoscopy or mammography, have a body mass index over 30, and other concerns.”

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Survey Reveals Patients' Perspectives on EHRs

Survey Reveals Patients' Perspectives on EHRs | EHR and Health IT Consulting |

I spend a lot of time studying and understanding EHRs. I am a “superuser” within both the inpatient facility in which I have medical staff privileges, and in the private outpatient practice. I made the leap to EHRs more than two years ago, and haven’t looked back.

I can honestly say that the two EHRs I use have improved patient care, documentation, accuracy, and quality of life for me. I realize that systems vary, but I feel fortunate that I have good tools for accessing and using the EHR.

We seem to always talk about the EHR from the perspectives of the provider, facility, and the system. But what about the patient? That seems to be an afterthought in this process. How can we leverage the data that we are collecting and storing to make the patient's experience more inclusive and meaningful to improve the health or our communities?

The National Partnership for Women and Families just published a survey that demonstrates that patients also value the EHR, and are eager for more access and features in better understanding their healthcare and options.

Here are some of the key findings from the survey of 2,045 U.S. adults:

• Eighty-five percent to 96 percent of all respondents found EHRs useful in various aspects of care delivery, while only 57 percent to 68 percent saw paper records as useful.

• Patients’ online access to EHRs has nearly doubled, surging from 26 percent in 2011 to 50 percent in 2014.

• Patients want even more robust functionality and features of online access than are available today, including the ability to e-mail providers (56 percent); review treatment plans (56 percent), review of doctors’ notes (58 percent), and and review of test results (75 percent). They also want the ability to schedule appointments (64 percent), and submit medication refill requests (59 percent).

• Patients’ trust in the privacy and security of EHRs has increased since 2011, and patients with online access to their health information have a much higher level of trust in their doctor and medical staff (77 percent) than those with EHRs that don’t include online access (67 percent).

• Different populations prefer and use different health IT functionalities. For instance, Hispanic adults were significantly more likely than non-Hispanic Whites (78 percent vs. 55 percent) to say that having online access to their EHR increases their desire to do something about their health; and African American adults were among the most likely to say that EHRs are helpful in finding and correcting medical errors and keeping up with medications. Specialized strategies may be necessary to improve health outcomes and reduce disparities in underserved populations.

In many ways, the survey findings really surprised me, as this is the first time that I have seen substantial survey data about how patients see the whole process of the EHR. Their understanding of the utility of the EHR was refreshing.

Some findings raise concerns, however. Patients' desire to have more electronic access may be problematic. Think of the increased workload in responding to a new access point, and the potential for misunderstandings and conflict in care plans if diagnostic data and records can be viewed unfiltered and without the assistance of the care provider.

On the other hand, the EHR seems to provide at least some of the tools that a provider needs to improve health outcomes and reduce healthcare disparities among diverse populations. It was good to see that the EHR was seen by some ethnic populations as a way to motivate them to be healthier and to take more responsibility and control of their healthcare.

Much has yet to be learned and uncovered in the wake of the push to automate and digitalize the health record in the United States. Sometimes the law of unintended consequences can work in the favor of the healthcare system.

One fact remains for all providers, learning to survive in the post-EHR world, and acquiring the skills needed to become efficient in the use of the EHR, have never been more important. There is no going back to the paper record.

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Is This the Year the "Doc Fix" Becomes Reality?

Is This the Year the "Doc Fix" Becomes Reality? | EHR and Health IT Consulting |

The Medicare Sustainable Growth Rate (SGR) is a method currently used by CMS to control spending by Medicare on physician services. Generally, the SGR is a method to ensure that the yearly increase in the expense per Medicare beneficiary does not exceed the growth in GDP. CMS sends a report to the Medicare Payment Advisory Commission (MEDPAC), which advises Congress on the previous year's total expenditures and the target expenditures. The report contains a conversion factor that will change the payments for physician services for the next year in order to match the target SGR. If the spending for the previous year exceeds target spending, then the conversion factor will decrease payments for the next year. If spending is lower than expected, the conversion factor will increase physician payments for the next year.

Maybe this is all coming to an end. According to a March 11 report by The Wall Street Journal, Congressional leaders are discussing ways permanently to end the recurring scramble to avoid mandatory cuts in Medicare payments to physicians set to go into effect March 31.

The elimination of the SGR (referred to in Washington, D.C., as the "Doc Fix") would be a huge step forward. SGR is a cruelly ironic, and frankly absurd misnomer. The term SGR" actually is a business term, loosely meaning the "maximum amount of growth a business can experience without borrowing money to finance growth. In the case of Medicare, the joke lies in the idea that there is any SGR Medicare can sustain before resorting to borrowing — that ship sailed years ago.  

According to the Wall Street Journal, many agree the Doc Fix is needed (meaning "politically popular.") No one is sure how to pay for it. Lawmakers would need to agree on a way to offset the cost of eliminating SGR cuts — estimated $175 billion over 10 years.

This time, however, the idea may actually grab traction. The Journal quoted Sen. Ron Wyden (D-Ore.) , the top Democrat on the Senate Finance Committee,  as saying, "I've been in Congress long enough to be skeptical of rumors, but what we are hearing from the House suggests there is real movement to fully repeal and replace the flawed formula for paying Medicare providers known as SGR."

Time will tell.

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When Your EHR Goes Down…And It Will | Hospital EMR and EHR

When Your EHR Goes Down…And It Will | Hospital EMR and EHR | EHR and Health IT Consulting |

Erin McCann at Healthcare IT News wrote a recent report on a McKesson EHR outage at Rideout Health after an HVAC unit burned out. In the article she also talks about the $1 billion (I love that she added the price tag) Epic EHR outage that occurred in August 2013 at Sutter Health and lasted an entire day. Plus, she mentions the IT network failure at Martin Health System in January 2014 and had their Epic EHR down for 2 days. I’m sure there are many more that were shorter or just weren’t reported by news outlets.

When I think about EHR downtime I’m reminded of the Titanic. You can invest all you want in the “unsinkable” EHR implementation and unexpected downtime will still occur. Yes, much like the Titanic that everyone thought was totally unsinkable, it now lies at the bottom of the ocean as a testament to nature’s ability to sink anything. That includes causing your EHR to go down.

Let’s say your EHR is able to have 99.9% uptime. That would feel pretty good wouldn’t it. Well, that turns out to be 8 hours 45 minutes and 57 seconds over the year. That’s still a full working day of downtime. If you expand to 99.99% downtime, that’s still 52.56 minutes of downtime. At 99.999 (Five Nines as they say in the industry) of downtime is 5.39 minutes of downtime.

The challenge is that with every 9 you add to your reliability and uptime requirements the costs increase exponentially. They don’t increase linearly, but exponentially. Try getting that exponential cost curve approved by your hospital. It’s not going to happen.

Another way to look at this is to consider tech powerhouses like Google. They have some of the highest quality engineers in the world and pay them a lot more than you’re paying your hospital tech staff. Even with all of that investment and expertise, they still go down. So, why would we think that our hospital EHR could do better than Google?

One way many organizations try to get a Google like uptime in their organizations is to use an outside data center. Many of these data centers are able to implement and invest in a lot of areas a hospital could never afford to invest in. Of course, these data centers only provide a few layers of the technology stack. So, they can minimize downtime for some things, but not all.

The real solution is to make sure your organization has a plan for when downtime occurs. Yes, this basically means you assume that your EHR will go down and what will you do? This was my first hand experience. At one point the EHR that I implemented went down. The initial reaction was fear and shock as people asked the question, “What do we do?” However, thanks to a strong leader, she pulled out our previously created plan for when the EHR went down. Having that plan and a strong leader who reminded people of the plan calmed everyone down completely. It still wasn’t fun to have the EMR down, but it was definitely manageable.

What have you done to prepare for EHR downtime? Do you have a plan in place? Have you had the experience of having your EHR down? What was it like? Are you afraid of what will happen in your hospital when your EHR goes down?

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Physician outcry on EHR functionality, cost will shake the health information technology sector

Physician outcry on EHR functionality, cost will shake the health information technology sector | EHR and Health IT Consulting |

Despite the government’s bribe of nearly $27 billion to digitize patient records, nearly 70% of physicians say electronic health record (EHR) systems have not been worth it. It’s a sobering statistic backed by newly released data from marketing and research firm MPI Group and Medical Economics that suggest nearly two-thirds of doctors would not purchase their current EHR system again because of poor functionality and high costs.

In a surprise finding, nearly 45% of physicians from the national survey report spending more than $100,000 on an EHR. About 77% of the largest practices spent nearly $200,000 on their systems. 

While physicians can receive $44,000 through the Medicare EHR Meaningful Use (MU) incentive program, and $63,750 through Medicaid’s MU program, some physicians say it’s not nearly enough to cover the increasing costs of implementation, training, annual licensing fees, hardware and associated services. But the most dramatic unanticipated costs were associated with the need to increase staff, coupled with a loss in physician productivity.

“We used to see 32 patients a day with one tech, and now we struggle to see 24 patients a day with four techs. And we provide worse care,” said one survey respondent.

While some physicians cited benefits of accessing patient data, availability of practice metrics, and e-prescribing conveniences for patients, most physicians do not believe these systems come close to creating new efficiencies or sharing data with multiple providers or improving patient care.

In fact, when doctors were asked if their EHR investment was worth the effort, resources and cost, “no” was the reply given by nearly 79% of respondents in practices with more than 10 physicians.

Medical Economics’ survey results, based on responses from nearly 1,000 physicians, were corroborated by the findings of a January 2013 RAND Corp. study, detailed in Health Affairs, The New York Times, USA Today, and other national media organizations, criticizing the usability and interconnectedness of current EHR systems.

“The failure of health information technology to quickly deliver on its promise is not caused by its lack of potential, but rather because of the shortcomings in the design of the IT systems that are currently in place,” says  Art Kellermann, MD, MPH, the study’s senior author and the Paul O’Neill Alcoa Chair in Policy Analysis at RAND.

Another 2013 RAND report, titled “Physician Professional Satisfaction and their Implications for Patient Care,” concludes that frustrations related to EHRs are negatively influencing physician attitudes about their careers. 

“Poor EHR usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information between EHR products, and degradation of clinical documentation were prominent sources of professional dissatisfaction,” the report says.


The most recent data from MPI Group and Medical Economics not only corroborates these physician sentiments related to EHRs, but calls on software developers to build solutions that help physicians improve
patient care, not obstruct it.

Closer look at the results

Here are other key findings from the national survey:

  • 73% of the largest practices would not purchase their current EHR system. The data show that 66% of internal medicine specialists would not purchase their current system. About 60% of respondents in family medicine would also make another EHR choice.
  • 67% of physicians dislike the functionality of their EHR systems.
  • Nearly half of physicians believe the cost of these systems is too high.
  • 45% of respondents say patient care is worse since implementing an EHR. Nearly 23% of internists say patient care is significantly worse.
  • 65% of respondents say their EHR systems result in financial losses for the practice. About 43% of internists and other specialists/subspecialists outside of primary care characterized the losses as significant.
  • About 69% of respondents said that coordination of care with hospitals has not improved.
  • Nearly 38% of respondents doubt their system will be viable in five years. 
  • 74% of respondents believe their vendors will be in business over the next 5 years. 

Major Disconnect

The Medical Economics survey was conducted to gauge physician attitudes about EHRs and benchmark data gathered during a separate and novel 2-year EHR Best Practices Study of 29 U.S. physicians in independent practices (nearly all were in solo practice). 

While this 2-year study concluded at the end of 2013, some of the same physician attitudes and frustrations related to the implementation and use of EHRs were documented in the national survey. Common frustrations cited by physicians in both projects included a decrease in patient visits, reports of efficiency declines, and unanticipated costs associated with implementing and using EHR systems.

The national survey underscores the major disconnect between the current state of EHR software and the needs of physicians.

Kenneth Stuart Christie's curator insight, March 27, 2015 1:04 AM

This journal article states that many health professionals in the US are dissatisfied with electronic health record (EHR) systems. The article uses statistics to support this view. There is no doubt that EHR's will remain in the health system. 

The challenge is to implement an efficient system that health professionals will trust and be willing to use. There is a realistic likelihood that an efficient, user-friendly system is available, however a senior administrator has not been willing to invest in it for budgetary reasons. Healthcare may need to borrow money from the military IT budget.!

What's Best Way to Boost Health Information Exchange?

What's Best Way to Boost Health Information Exchange? | EHR and Health IT Consulting |

A new report to Congress recommends steps to ease the secure sharing of patient information, paving the way for better coordination of care and improved patient outcomes. For example, the report recommends the creation of incentives to help overcome the "blocking" of data exchange or reluctance to participate.

Although the federal government has spent $31 billion so far on HITECH Act incentives for hospitals and physicians to "meaningfully use" electronic health records systems, Congress has been scrutinizing whether the investment has paid off in enabling the sharing of health information.

Some security and privacy experts say that while the report spotlights some of the key barriers to secure health information exchange, some of the concerns may be overstated.

For instance, Micky Tripathi, CEO of the Massachusetts eHealth Collaborative, says intentional information blocking among healthcare providers is generally not a widespread problem.

"There are bad apples in every group of humans, and healthcare providers are no exception," he says. "In my experience, malicious information blocking for competitive purposes is very, very rare, and is certainly not a big factor or even a major factor impeding health information exchange. The biggest impediment to information exchange up until now has been lack of demand. That has changed, and now that we have strong demand, we're seeing the market respond and I expect interoperability to grow dramatically over the next couple of years."

Report Findings

The Health IT Policy Committee, which advises the Office of the National Coordinator of Health IT, recently submitted its Report to Congress: Challenges and Barriers to Interoperabilityas mandated by Congress.

The report delves into the various technical, operational and financial challenges that the healthcare sector faces in achieving health information exchange. Among the issues related to privacy and security listed in the report are:

  • Misunderstanding about HIPAA and other privacy laws has led some to refrain from sharing information.
  • Applying privacy laws that were originally designed to address paper-based processes to today's electronic transactions has been problematic.
  • Designing electronic systems and rules to accommodate varying state privacy and security laws has been challenging.

The advisory panel makes four key recommendations to accelerate health information exchange:

  • Develop and enhance incentives that drive interoperability and data exchange, such as by focusing on delivery of coordinated care. For example, payers could decline to reimburse for medically unnecessary duplicate testing that could have been avoided if information was shared.
  • Develop and implement health information exchange vendor performance measures for certification and public reporting;
  • Set payment incentives to encourage health information exchange. Include specific performance measurement criteria and create a timeline for implementation.
  • Convene a summit of major stakeholders co-led by the federal government and the private sector to act on ONC's recently unveiled 10-year interoperability roadmap.

Information Blocking

Drilling down on the report's recommendations pertaining to payment incentives to help accelerate interoperability, the HIT Policy Committee specifically addresses the problem of information blocking, which involves healthcare providers refusing to share of clinical information.

Sometimes information blocking is related to misinterpretations and misunderstandings about HIPAA and other privacy laws, the report notes.

"There are many examples where misinterpretations of complex privacy laws inhibit providers from exchanging information that is permitted under HIPAA," the report notes. "Also, many providers do not fully appreciate that the HITECH Act gives patients the right of electronic access to their EHR-stored information. As the Centers for Medicare and Medicaid Services defines new payment incentives ... it should incorporate mechanisms that identify and discourage information blocking activities that interfere with providers who rely on information exchange to deliver high-quality, coordinated care."

Other Recommendations

The document also outlines some previous recommendations made by the HIT Policy Committee to ONC, including:

  • Explore regulatory options and other mechanisms to encourage appropriate sharing of certain sensitive information, including substance abuse and mental health data;
  • Provide guidance about best practices on the privacy considerations associated with sharing of individuals' data among HIPAA covered entities and other community organizations;
  • Guide efforts to establish "dependable rules of the road" and to ensure their enforceability in order to build trust in the use of healthcare big data.
Overcoming Privacy Hurdles

David Whitlinger, executive director of the Statewide Health Information Network of New York - the state's health information exchange - says privacy and security issues clearly represent some of the biggest hurdles to overcome before achieving nationwide data exchange.

"Privacy and security regulations vary across different states, and those difficulties are exacerbated even more in sharing sensitive health data, such as mental health, substance abuse, HIV, reproductive health, and information about minors," he says. EHR platforms don't easily support compliance with varying laws when data is exchanged, he notes.

But he points out that industry players are discussing the use of various technologies that "tag" sensitive information so that patients have more control over what part of their health records can be shared among healthcare providers. Also under discussion are policy issues such as "giving patients complete control over their data, so that they ultimately make the decisions about what subsets of data they'll share," he notes.

Tripathi says the biggest barrier to health information exchange, from a privacy and security perspective, "is the heterogeneity of privacy rules that any particular provider faces, which has a paralyzing effect on electronic information exchange."

For instance, in Massachusetts, HIV and genetic test results require consent from patients for each disclosure, he notes. "So even though a Direct [secure email] transaction doesn't require any special consent, certain types of payloads may trigger other consent requirements. So ... as a healthcare provider ... I will hesitate to send out anything until I understand which laws pertain and whether that data my EHR sends triggers any of those other laws."

What's Next?

Members of Congress now must decide whether to act on the HIT Policy Committee's various recommendations.

An aide to Sen. Lamar Alexander, R-Tenn., chair of the Senate Committee on Health, Education, Labor and Pensions, says in a statement provided to Information Security Media Group: "Sen. Alexander is focused on making electronic health records something that physicians and hospitals look forward to instead of something they endure, and he looks forward to hearing what recommendations [the HIT Policy Committee] outlined in [the] report."

While the report notes that steps could be taken to begin implementing various recommendations within the next six months, some healthcare IT experts say it could take years for comprehensive health information to be securely and readily exchanged among healthcare providers by using health information exchange organizations and EHR systems.

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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 |

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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Methods for Improving Patient Access to Health Information

Methods for Improving Patient Access to Health Information | EHR and Health IT Consulting |

The latest hearing held by the Senate Committee on Health, Education, Labor & Pensions (HELP) resulted in more than the call to delay Stage 3 Meaningful Use. It also provided numerous methods that federal legislators and healthcare organizations can take to improve patient access to health information.

Each of the three witnesses offered insight into the barriers preventing patients from having timely access to their health information in a highly useable electronic form.

First up was Raj Ratwani, PhD, who serves as Scientific Director at National Center for Human Factors in Healthcare at MedStar Health and Assistant Professor of Emergency Medicine at Georgetown University School of Medicine.

For Ratwani, the major issue surrounding patient access to health information is usability.

"Patients must have easy access to their health information to improve health outcomes, facilitate patient and family engagement in care, and to reduce safety risks. Critically, this information must be presented in a manner that is both understandable and useful," he stated in his opening remarks.

In comments specific to the critical nature of patient use of health IT, Ratwani identified three critical factors: access, functionality, and information quality.

Of the first, he noted that patients "should be able to easily access all of their health information, securely, and in one place" and that "interoperability is crucial to patient access."

Of the second, he emphasized the need for user-centered design when presenting health information to patients and making patient engagement a part of the clinician's workflow.

"The information and capabilities of the system must be useful for the patient," he stated. "The design of system capabilities, such as patient-provider communication, should be intelligently integrated with the workflow processes of the clinician so that the clinicians are able to support the patient in a timely manner."

Lastly, Ratwani tied to quality of information to its usefulness to patients. "Information must be accurate and meaningful to the patient, presented in a manner that can be easily understood, and that will help them gain insights," he added.

According to a second witness, Kathy Giusti, MBA, Founder and Executive Chairman of the Multiple Myeloma Research Foundation, the potential of patient health IT to improve health outcomes hinges of EHR integration, aggregation, and sharing of data.

For Giusti, patient engagement begins with education to ensure that patients are aware of the tools available to them to help manage their own care. "Physicians, hospitals, advocacy organizations, and the government must ensure that patients are educated on how best to use the technology," shenoted.

EHR integration plays an important picture in enabling providers to have a complete picture of a patient's health at the point of care rather than having to access disparate sources of clinical data.

"The greatest efficiency will come from our ability to integrate EHRs across the vast number of specialized doctors and centers that patients now see," she maintained. "That data must be integrated into a centralized portal that we as patients feel like we own, share, update, and provide."

Giusti's final observation on patient access to health information centered on the importance of analyzing large stores of health information for research purposes, such as in her organization's work on cancer.

"The ability to understand, integrate, aggregate and analyze EHRs is on the critical path to improving outcomes and accelerating cures. We have shown the impact of data sharing in one uncommon, fatal disease," she closed.

The hearing's third witness shifted the focus of patient access to information to Congressional intervention. In his opening remarks, Intel Felllow and General Manager for Health and Life Sciences at Intel Corporation Eric Dishman called on Congress to do four things:

  • Advance health IT standards and current interoperability initiatives
  • Remove legal and financial obstacles to health data sharing and access
  • Continue shift to value-based care models
  • Eliminate social and economic barriers to health data access

Altogether, the testimony of three witnesses highlight the many moving pieces involved in ensuring patient access to health information.

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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 |

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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CHIME Highlights Need to Improve Certified EHR Technology

CHIME Highlights Need to Improve Certified EHR Technology | EHR and Health IT Consulting |

The College of Healthcare Information Management Executives (CHIME) has shared a handful of recommendations with the Senate Committee on Health, Education, Labor and Pensions with the purpose of realizing the potential of certified EHR technology to improve patient care.

The organization's letter to the Senate HELP Health IT Working Group outlines challenges and solutions for five use cases, the first centering on improving care quality and patient safety.

According to CHIME, the "most significant challenge" is the lack of a unique patient identifier:

"As our healthcare system begins to realize the innately transformational capabilities of health IT, moving toward nationwide health information exchange, this essential core functionality – consistency in patient identity matching – must be addressed," the letter states. "As data exchange increases among providers, patient data matching errors and mismatches will become exponentially more problematic and dangerous."

The organization is asking Congress to remove a prohibition preventing federal funds from going toward the development of a unique patient identifier. "Robust information exchange and nationwide interoperability can flourish only once we can confidently identify a patient across providers, locations and vendors," claim CHIME President & CEO Russell P. Branzell and Board Chair Charles E. Christian.

CHIME is also calling on Congress to help simplify quality reporting for healthcare organizations and providers, especially holding off on a requirement to the electronic submission of clinical quality measures (CQMs) until the Centers for Medicare & Medicaid Services (CMS) have conducted sufficient testing of the accuracy and completeness of submitted data.

As for the use case of health data exchange and interoperability, the organization emphasizes the need for Congress to drive standards identification and adoption in nine areas:

1. Patient identifiers

2. Standards for resource locators (e.g. provider directories)

3. Standard terminologies

4. Detailed clinical models

5. Standard clinical data query language based on the models and terminology

6. Standards for security (standard roles and standards for naming types of protected data)

7. Standard Application Program Interfaces (APIs)

8. Standard transport protocols

9. Standards for expressing clinical decision support algorithms

Additionally, CHIME calls into question the ability of the health IT certification program administered by Office of the National Coordinator for Health Information Technology (ONC) to ensure interoperability between certified EHR technology (CEHRT).

The organization maintains that Congress should require the ONC to change its approach to testing, enhance ONC's ability to enforce adherence to the certification program, and enable greater transparency into the interoperability of CEHRT.

The CHIME letter also include recommendations related to patient engagement and IT resources to improve patient safety. For the former, the organization makes the case for CMS to consider alternatives to the patient portal for providers to more effectively engage their patients. "Congress should consider the discrepancy between HHS’ priorities for patient engagement, and patients’ self-indicated priorities," argue Branzell and Christian.

For the latter, CHIME reiterates the dangers presented by limited EHR interoperability and again calls for a patient identification strategy to avoid errors.

Patient privacy is the last of the five use cases covered by CHIME. " CHIME calls on Congress to lead an open dialogue to help states align privacy and consent policies that enable cross border exchange of health information in a secure manner. This should include reexamining certain provisions of the Health Insurance Portability and Accountability Act (HIPAA)," the letter states.

The letter concludes with one additional caveat — changes to meaningful use requirements. These recommendations for the EHR Incentive Programs include a delay for Stage 3 Meaningful Use and a revised approach to measuring quality among others.

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Senate panel to look into EHR usability

Senate panel to look into EHR usability | EHR and Health IT Consulting |

Unhappy with the state of electronic health records across the country two U.S. Senators have decided to take the matter into their own hands.

Lamar Alexander, a Republican from Tennessee and chair of the Senate Committee on Health, Education, Labor and Pension, or HELP, and Ranking Member Patty Murray, a Democrat from Washington State, announced Wednesday they would form a bipartisan, full health committee working group to identify ways to improve electronic health records.

"After $28 billion in taxpayer dollars spent subsidizing electronic health records, ‎doctors don't like these electronic medical record systems and say they disrupt workflow, interrupt the doctor-patient relationship and haven't been worth the effort," said Alexander in a news statement. "The goal of this working group is to identify the five or six things we can do to help make the failed promise of electronic health records something that physicians and providers look forward to instead of something they endure."

"As we focus on making our healthcare system work better for families, electronic health records could not be more important," Murray added. "Having more and better information can make all the difference for patients."

The goals of the committee's working group, as stated by Alexander and Murray, are to help identify ways Congress and the administration can work together to:

  • Help doctors and hospitals improve quality of care and patient safety;
  • Facilitate information exchange between different electronic record vendors and different health professionals, or interoperability;
  • Empower patients to engage in their own healthcare through convenient, user-friendly access to their personal health information;
  • Leverage health information technology capabilities to improve patient safety; and
  • Protect patient privacy and security of health information.

The bipartisan staff meetings will involve participation from health professionals, health information technology developers, relevant government agencies and other experts specializing in health information technology, Alexander said. Participation is open to all members of the Senate's health committee.

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75% of Hospitals Had a Basic EHR System in 2014, ONC Data Show

75% of Hospitals Had a Basic EHR System in 2014, ONC Data Show | EHR and Health IT Consulting |

The percentage of hospitals with electronic health record systems increased eightfold between 2008 and 2014, according a data brief from the Office of the National Coordinator for Health IT, FierceHealthIT reports.

The report was based on an American Hospital Association survey of non-federal acute-care hospitals.


Overall, the data show 97% of hospitals in 2014 had certified EHR technology, an increase of 35% since 2011


Meanwhile, 75.5% of hospitals in 2014 had a basic EHR system, up from 59.4% in 2013 and 9.4% in 2008.

The report showed that in every state at least half of hospitals had adopted a basic EHR in 2014.

The states with the highest adoption rates of basic EHR systems included:

  • Delaware, with 100% of hospitals;
  • South Dakota, with 95.1% of hospitals; and
  • Virginia, with 93.2% of hospitals.

Those with the lowest adoption rates included:

  • West Virginia, with 49.6% of hospitals;
  • Hawaii, with 54.8% of hospitals; and
  • Kansas, with 60% of hospitals.

Meanwhile, 34.4% of hospitals in 2014 had adopted comprehensive EHR systems.

In a blog post, Matthew Swain -- a program analyst in ONC's Office of Planning, Evaluation and Analysis -- and ONC Interoperability and Exchange Portfolio Manager Erica Galvez wrote that that about 60% of hospitals in 2014 exchanged data electronically, marking a 55% increase from 2013.

However, Swain and Galvez said, "While these survey results are promising, there is plenty of room for progress." They added, "These results capture exchange activity among hospitals; however, these results do not assess exchange volume, whether the exchange is interoperable, and if information is available to providers at the point of care".

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Strategies for Dealing with Value-Based Modifiers

Strategies for Dealing with Value-Based Modifiers | EHR and Health IT Consulting |

As we know many payers are implementing various approaches to pay-for-performance reimbursement or value-based reimbursement programs. Medicare has announced significant goals in modifying payment models; rolling out value-based payment modifiers (VBPM) this year. Patient care activity in 2015 will impact every Medicare payment in 2017. Physician groups of 100 or more will have payments affected this year, groups of 10 or more in 2016, and all groups in 2017. Medicare will determine the amount of payment incentive or adjustment based on the information noted below. The range is from - 4 percent to + 4 percent of Medicare payments.

Below are some thoughts on how you can respond to VBPMs and optimize the care provided patients and maintain or gain financial viability.

1. Continue to participate in PQRS which is the basis for the Medicare Value-Based Payment Modifier program. Understand how your profile fits within the six domains (check meaningful use): clinical process/effectiveness; patient and family engagement; population/public health; patient safety; care coordination; and efficient use of healthcare resources.

2. Access your practice Quality and Resource Use Report, QRUR, by obtaining an IACS number from CMS. This report was published by CMS last fall and compares your practice to peers on both quality and cost measures. This can be downloaded in both PDF and excel formats. It's complex but worth spending time on to both understand and identify your practice profile.

3. Monitor your entire provider panel in key measures:


a. Preventable hospital admissions:

• Patients with acute episodes of dehydration, UTI, and bacterial pneumonia

• Chronic patients with heart failure, COPD, and diabetes

b. All cause hospital readmissions

Cost — your practice status:

a. All Part A and Part B payments (Part D excluded)

b. For disease categories: COPD, heart failure, coronary artery disease, and diabetes

c. Medicare Spend Per Beneficiary, MSPB, for three days prior to and 30 days post discharge

d. Total Medicare Allowable per applicable CPT code

4. Report monthly on what is occurring.

a. Your practice will not know the Medicare ranking until the end of period.

b. Rankings are determined by the eligible provider (EP) who has a "plurality" of primary-care codes assigned and the Medicare allowable charge amount assigned. Primary-care providers will be considered first, but any specialist may qualify.

c. A minimum of 20 episodes per measure (see quality above) hence the need to monitor your practice. If insufficient numbers are there, you may not see either the incentive or adjustment.

5. Regular review and reporting will help lead the practice toward a more "quality" impact and focus. When all staff, not just providers, work together, the cumbersome nature of reporting will become easier and part of everyday practice life — since in many cases the impact is not significant this year. It will however become more impactful in the years to come, as not only VBPM programs come into play, but overall payment model reforms are implemented. There will be an eventual culture change!

Long term outcomes for practices should be improved patient care, compliance with the new paradigm, and an improved financial picture. How you approach it now may determine the long-term success and viability of your practice in the future.

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Why Can’t Release of Records Be Automated Through A Patient Portal?

Why Can’t Release of Records Be Automated Through A Patient Portal? | EHR and Health IT Consulting |
I was in a recent discussion with one of the leading providers of release of information services, HealthPort about EHR’s impact on the release of health records. In our discussion, I asked why the release of health records can’t be completely automated through a patient portal. In my mind, meaningful use is requiring that healthcare organizations put a patient’s record up on a patient portal, so shouldn’t that mean that the release and disclosure of patient records would become obsolete?

Of course, I was applying a limited view to what’s required when a disclosure happens and who is making the records request. In most cases, it’s not the patient requesting the record and these third parties don’t have access to the patient’s portal. Plus, the release and disclosure of patient records often requires accessing multiple systems along with assessing which information is appropriately included in the disclosure. The former is a challenge that can be solved, but the later is a complex beast that’s full of nuance.

In order to clarify some of these challenges and explain why a patient portal won’t replace all records requests, here’s a short interview with Jan McDavid, Esq., General Counsel at HealthPort.

Q: What are HIPAA requirements around “charging” for copies of records, and what are considered “reasonable” costs?

A: HIPAA is very clear that its pricing applies only to copies provided to “individuals,, which HIPAA defines as the person who receives treatment—the patient. HIPAA guidance pertains only to patient requests for medical records, approximately seven percent of all requests received by healthcare providers.

The majority of records are requested by physicians for continuing care, governments for entitlement benefits, insurers, and inquiries from attorneys, according to internal data from HealthPort’s 2014 record release activity nationwide.

Within the realm of patient requests, providers can charge patients no more than their labor costs to produce the record, plus supplies and shipping. No upfront fee to search or retrieve records may be charged to patients.

Q: Why shouldn’t records just be free now that they are electronic?

While many believe the cost to produce records should be negated once information is digital, there are misperceptions and logistics that must be understood. The process of disclosure management (release of information) involves many steps that still require human intelligence and intervention—especially on the front end of the process (receiving, validating and approving the request). Here are three examples:

The authorization must be adhered to strictly, which often requires contacting the requester and explaining that some of the records they requested may not be available, or may require very specific patient authorization.

Information is commonly pulled together from multiple sources and systems (paper and electronic) to fulfill a request. While providers are working toward completely electronic environments, almost all still have a combination of paper and electronic. Depending on who makes the request, every single page of a record may require review.

Staff releasing records must be trained on HIPAA, HITECH, the Omnibus Rule, state and federal subpoena requirements, and specific state and federal laws for drug, alcohol, HIV/AIDS, mental health, cancer, genetics, minors, pregnancy, etc.

Q: If the EHR is in the portal, what other records aren’t in the EHR that HIM staff has been aggregating in a records request?

A: Not all patient information is automatically included within the patient portal view, nor should it be. Each provider organization determines what EHR information is posted to the portal and what patients can do within the portal (e.g. requesting refills, scheduling appointments, viewing lab results, etc.). HIM experts are key in these decisions.
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Three Small Layout Adjustments to Improve EHR Use

Three Small Layout Adjustments to Improve EHR Use | EHR and Health IT Consulting |

If you have implemented an EHR but physicians and staff are having trouble adjusting, you might want to consider modifying your office's physical layout to better accommodate the new technology.

According to Rosemarie Nelson of the Medical Group Management Association Health Care Consulting Group, low-cost adjustments can lead to big improvements in EHR use.

Here are three of her suggestions:

1. Get mobile.

If your staff and physicians use laptops or tablets to access the EHR, consider purchasing a couple of desk carts that can be wheeled in and out of exam rooms, says Nelson. "That eliminates a common complaint, which is having to go into the exam room and sign-on [to the system] every single time they go into another room," she says, adding that a couple of seconds saved here and there add up. "They don't have to buy those big expensive carts that are used in hospitals with battery back-up power and this and that, they could use a common everyday kind of desk cart."

If your practice wants to go the more high-end route, consider investing in carts that can be raised or lowered to seating or standing level (such as through a hydraulic lift), says Nelson. That way physicians and staff can have the option of sitting or standing while in the exam room with patients.

Carts also make it easier for each of your physicians to situate the EHR in the exam room according to their unique preferences (for instance, some may like to face the computer and cart away from the patient; others might like the patient to view the EHR with them as they work through the visit).

2. Invest in wall-mounted workstations.

A dropdown shelf that can be mounted on the wall just outside the exam room is another modification to consider, says Nelson. "You can actually mount a laptop in it and it can close right up, so it's less than 3 inches outstanding from the wall," she says. "You pull it down, it opens up the laptop automatically, and you get a chance to take a quick glance at that patient's record as you are going in so you don't feel like you are going in blind. You don't have to say, 'Ah, just give me a minute to look at your chart.'" The reverse is also true, says Nelson. "You can escape the room and get your documentation done right at that [dropdown shelf] and not feel like you are in the room and the patient's going to keep talking your ear off."

3. Adjust your exam rooms.

Also, look for smaller ways to tweak exam rooms that might help physicians better merge their EHR use with the patient visit. "You might not be able to shift the cabinet but you can shift [the exam table]," says Nelson. "You might be able to use a stool so that you can wheel and twist."

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Selecting Staff Benefits for Your Medical Practice Team

Selecting Staff Benefits for Your Medical Practice Team | EHR and Health IT Consulting |

Studies show that losing an employee and subsequently conducting a search and rehiring for that position can cost an organization one-fifth of that person's annual salary, according to The Center for American Progress. You owe it to your practice to invest just as much work and care in retaining quality staff members, as you do hiring new ones. One way to do that is to offer a competitive benefits package. Many practices can't offer significant raises or bonuses. And most can't compete with the local hospital system. But what you can do is find out what is meaningful to your staff members and then make it happen.

Maybe that will be a dedicated parking spot for those cold, wintry days in Northern Wisconsin. Maybe a flex schedule for new moms? It's up to you to find out. We talked to a number of staffing and practice management experts to identify that magic mix of benefits that will warm your staff members' hearts. Here's what they recommended.


In Physicians Practice's 2014 Staff Salary Survey, 87 percent of respondents said they offered their staff paid vacation and sick leave, nearly three-quarters said they offered health insurance, and half offered a retirement plan with an employer match. Dental insurance and short-term disability insurance rounded out the top five benefits that practices said they offer their staff. If the other practices in your community are offering a close facsimile of this type of benefit package and yours doesn't, it will put your hiring manager at a distinct disadvantage.

Joe Capko, a principle with Capko & Morgan, a San Francisco-based consulting firm, says that benefits should be viewed as a significant part of the practice's culture. "We like to think of the benefit package that is offered to employees as one of the components to building, really, a culture of appreciation among the management and the staff," he says.

Here are some other reasons to offer a high-quality benefits package:

• Staff loyalty and retention. Apart from salary and robust benefits, practices can engender staff loyalty by offering small, extra perks that may not cost a lot of money. Even a heartfelt thank you can go a long way to creating happy, loyal staff members. Happy people like to stay where they are, and they also work hard for a practice that appreciates them. If your staff takes ownership of their roles and their commitment to patients, then everyone benefits.

• Strong competitor. Like many other professions, regional healthcare can be a small, intimate community. Everyone pretty much knows everyone else. Sometimes the grass can look greener in the next pasture, especially if your employee is feeling overworked and underappreciated. Offering great benefits, or individually tailored ones, can make your practice a competitive employer that attracts the best employees.

Carol Stryker, principal at Symbiotic Solutions, a Houston-based consulting firm, says it's the "absence" of benefits that will take your practice out of the running for a top-notch employee. "I'm never sure that benefits, with the exception of health benefits, ever attract an employee. … The lack of them can eliminate your practice for consideration," she says.

• Well-qualified staff. The best staff members have their choice of employers, and they will look first at salary and benefits as major determinants in selecting one practice over another. A good compensation package will also help keep the best employees in your camp. Capko says that smaller practices have an advantage over larger ones because, "It's easier for the management to know all of the employees, allowing management to tailor a benefit package that offers the biggest staff benefit per dollar."


Just as highly productive, well-oiled practices tend to staff at higher ratios, those that are willing to spend a bit more on their staff benefits tend to retain top employees. Yes, that means greater expense, but there are ways to find economies of scale. Sometimes you may even be able to join up with a professional association to get more bang for your buck.  

Capko says his firm advises administrators to network with other practice administrators, "So, for example, you can very easily find yourself reinventing the wheel. Someone may have already found out, 'Hey, this is great coverage through this professional association,'" he notes.

Stryker says, "Continuing education benefits are huge for people," but she cautions talking to staff first. She adds there's nothing wrong with being transparent and telling your staff that you only have a certain amount of money to spend. Ask them what they want. Spending money on a benefit that's not wanted is a waste, and won't endear you to staff either.


What are some of the perks that great practices offer? And what are the perks that you should slip off your radar? It depends: on your community, your staff, your schedule; even your specialty.

Daniel Bernick, a principal at The Health Care Group, a practice-management consulting firm based in Plymouth Meeting, Pa., says, "The most popular benefits are vacation, sick days, personal days, paid days off — PTO [paid time off] in one form or another is very popular and expected by staff."

Bernick notes that benefits are an important part of any compensation plan, because of the value they bring. "It is a tax-advantaged way of compensating employees," he says.

Aside from paid days off, health benefits are an essential component in most benefit packages. While Capko notes that many practices are spending less on the type of health insurance plan they offer to employees because of financial pressures (like choosing a plan with a greater deductible, or more cost sharing), there are other ways to make it up to employees — for example, offering flex schedules to young parents.

If a practice wants to offer full-time employees a basic benefits package, Bernick says it should include paid vacation time, sick days, personal days, a 401K plan, and health insurance with a cost share. However, he notes that a practice can use discretion in determining how much of a benefit they wish to offer.

"You could offer a larger amount or a smaller amount. Simply because you are offering vacation doesn't mean that you offer six weeks of vacation. You don't necessarily offer a lot of benefits, but at least you provide something in these categories. It is meaningful and people really appreciate it," Bernick says.

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Is your medical practice ready for dual coding?

Is your medical practice ready for dual coding? | EHR and Health IT Consulting |

Although medical practices cannot submit medical claims with ICD-10 codes until Oct. 1, there are a few good reasons to start using them sooner.

Those reasons support dual coding — when healthcare organizations assign ICD-10 and ICD-9 codes simultaneously to medical records.

The advantages include:

  • Medical coders can practice their ICD-10 knowledge
  • Clinical documentation deficiencies are exposed
  • Extensive internal and external testing can be done

This won't be cheap. Systems need to be designed for dual coding. And no matter what your vendor promises, dual coding is extra work. That means there will be a productivity loss. Maybe computer assisted coding (CAC) will help. Costs would be associated with:

  • Added time
  • Maintaining data collection
  • Analyzing data

Medical practices likely will need to assign extra coding resources. Extra medical coders can be hired to cover the dual coders. Healthcare providers need to do a cost-benefit analysis to determine if it's better to hire personnel or accept longer reimbursement cycles.

To get dual coding started, the Centers for Medicare and Medicaid Services (CMS) recommends answering the following questions:

  • Can the practice management system (PMS) or electronic health record (EHR) can capture ICD-9 codes and ICD-10 codes in the same patient encounter?
  • How much dual coding will be done?
    • How often?
    • How many encounters will be processed?
    • Are all diagnoses or just the top X percent of diagnoses are represented?
  • Will the ICD-10 codes be captured in the PMS or EHR system or on paper?

Before dual coding can start, a medical practice should:

  • Upgrade systems so they are ICD-10 compliant.
  • Make sure clinical documentation can support ICD-10 coding.
  • Start ICD-10 training and education.
  • Test with healthcare vendors or payers.

Then start practicing ICD-10 coding on real cases in the medical practice. Chances are that all this time and money will be investments that payoff after Oct. 1.

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