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I once wrote about the communication difficulties caused by electronic medical records systems. The response on Twitter ranged from sentiments including everything from “right on, sister” to “greedy doctors are only complaining about EMRs because of their price tag.” The disconnect between policy wonk’s (and EMR vendor’s) belief in the transformative power of EMRs and exasperated clinician users of these products is jaw-dropping. Physicians are often labeled as obstinate dinosaurs, blocking progress, while policy wonks are considered by physicians to be living in an alternate reality where a mobile phone app could fix all that is wrong with the health care system.
Being on the dinosaur side, I thought I’d try a quick experiment/analogy to demonstrate that EMR dissatisfaction is not a mere cost artifact. To show what happens when a digital intermediary runs medical information through a translator, I selected a random paragraph about the epidemiology of aphasias from an article in Medscape. I copied and pasted it into Google translator and then ran it backwards and forwards a few times in different languages. In the end, the original paragraph (exhibit A) became the second paragraph (exhibit B):
“Not enough data are available to evaluate differences in the incidence and clinical features of aphasia in men and women. Some studies suggest a lower incidence of aphasia in women because they may have more bilaterality of language function. Differences may also exist in aphasia type, with more women than men developing Wernicke aphasia.”
“Prevalence and characteristics of men and women are expected to afasia is not enough information available. If afasia some studies, women work more, not less, because they show that the spoken language. There may be differences in the type of OST, women and men to develop more of a vernikke afasia, more.”
Although the B paragraph bears some resemblance to A, it is nearly impossible to determine its original meaning. This is similar to what happens to medical notes in most current EMRs (except the paragraph would be broken up with lab values and vital signs from the past week or two). If your job were to read hundreds of pages of B-type paragraphs all day, what do you think would happen? Would you enthusiastically adopt this new technology? Or would you give up reading the notes completely? Would you need to spend hours of your day finding “work-arounds” to correct the paragraphs?
And what would you say if the government mandated that you use this new technology or face decreased reimbursement for treating patients? What if you needed to demonstrate meaningful use or dependency and integration of the translator into your daily workflow in order to keep your business afloat? What if the scope of the technology were continually expanded to include more and more written information so that everything from lab orders to medication lists to hospital discharges, nursing summaries, and physical therapy notes, etc. were legally required to go through the translator first? And if you pointed out that this was not improving communication but rather introducing new errors, harming patients, and stealing countless hours from direct clinical care, you would be called “change resistant” or “lazy.”
And what if 68,000 new medical codes were added to the translator, so that you couldn’t advance from paragraph to paragraph without selecting the correct code for a disease (such as gout) without reviewing 150 sub-type versions of the code. And then what if you were denied payment for treating a patient with gout because you did not select the correct code within the 150 subtypes? And then multiply that problem by every condition of every patient you ever see.
Clearly, the cost of the EMR is the main reason why physicians are not willing to adopt them without complaint. Good riddance to the 50 percent of doctors who say they’re going to quit, retire, or reduce their work hours within the next three years. Without physicians to slow down the process of EMR adoption, we could really solve this health care crisis. Just add on a few mobile health apps and presto: We will finally have the quality, affordable, health care that Americans deserve.
In my previous scanning post we discussed the important role scanning documents plays in a successful EHR implementation. Moving from paper to electronic medical records takes a plan to know what you want to migrate from your files to your computer. But what about after your implementation and now in your daily workflow? Does scanning have a new role? Practices and hospitals alike find that while going digital helps to lessen the paper flow it still doesn’t eliminate it. There will always be something that might be acquired on paper. And when that happens, it is important to scan the document and be sure it gets included in a patients record.
Having scanning stations that are available and easily accessible for use will help integrate scanning needs into your workflow. If the scanner is off in a workroom or administrative office, it is more likely the task will be overlooked or put off in a to-do pile. Consider more than one scanner depending on your physical layout and system workstations. Here are some areas where you might continue to see documents for patients in paper form and should be included in a patient’s electronic record. Where is this paper being collected and how can it get scanned into your system most efficiently?
Practices should also remember their overall business and consider digitizing all areas not just patient records. Human Resources is a big paper department with employee records and files. There are a lot of forms that start on paper for the simple fact of collecting signatures. Are you still keeping all this information in file cabinets? Consider digital employee files and scan the documents for electronic retrieval and storage.
Is your practice still using paper log sheets for medication dispensing and inventory reconciliation? Are you still using a paper sign-in sheet for patients when they arrive? Are you still receiving paper faxes for business or patients? Evaluate all the paper processes and consider a solution to convert to electronic or continue and store by scanning the documents. Benefits to electronic documents range from ease of ability to retrieve and share to simply eliminating the physical storage needs of paper documents.
Massachusetts will allow physicians to demonstrate EHR proficiency in multiple ways to retain their medical licenses.
Physicians in Massachusetts will be able to choose from several options to demonstrate their EHR proficiency in order to renew their licenses in 2015, according to final regulations provided by the state’s Board of Registration. The controversial provision that initially required providers to attest to meaningful use in order to retain their ability to practice medicine has been modified to allow for flexibility and certain exemptions.
The rule prompted outrage and disappointment among Massachusetts providers, and the Massachusetts Medical Society (MMS) has lobbied heavily against the restrictive requirements of the original language. Opponents of the EHR proficiency provision decried the mandate as an unwanted intrusion into the practice of medicine.
“Collectively, these requirements increase administrative demands, add costs to the practice of medicine, and to the health care system as a whole,” said former Massachusetts Medical Society President Ronald Dunlap. “They will take time away from direct patient care and drive small to midsize practices to seek alignment with larger entities that have the capacity to fulfill the requirements, potentially causing further consolidations in the healthcare market.”
Starting on January 2, 2015, Massachusetts providers looking to renew their licenses will need to meet one of several methods of proving that they can adequately use an EHR system to provide quality care. Participating as an eligible professional (EP) in the EHR Incentive Programs, or being employed by an eligible hospital (EH) that has attested to meaningful use, can both satisfy the provision.
But providers who are not eligible for meaningful use participation can still prove their competency by completing at least three hours of accredited CME courses on EHR use or becoming an authorized user of the Massachusetts Health Information Highway, which is the state’s designated health information exchange.
All physicians renewing their licenses before March 31, 2015 will be provided with a one-time waiver from the requirements, while physicians with renewal dates within 60 days of the end of March could submit their application early and qualify for the automatic exemption. Additional exemptions are available for providers who are applying for limited licenses as an intern or medical resident, those who are applying for licenses but are not actively practicing medicine, or providers on active duty in the National Guard who are called up during a national emergency or crisis. Physicians may also apply for a 90-day “undue hardship” exemption under certain circumstances.
“The Massachusetts Medical Society believes that electronic health records have enormous potential for patient care, and the Society’s extensive policy on EMRs declares support for them and a desire to work toward improving them,” said MMS President Richard Pieters, MD. “We are grateful that the Board of Registration in Medicine has taken a reasonable approach on this issue, exhibiting utmost concerns for patient safety and access to care.”
A recent study led by the Regenstrief Institute raises interesting questions about patient health data: who controls it, who sees it in the electronic health record and how it should be shared across the care continuum.
For more than a decade, electronic medical records (EMRs) have been called a critical step forward in modern medicine. The idea was that transitioning from paper to electronic records would increase efficiency, safety and savings in health care. The potential for EMRs to make patient records more accessible, reduce medical errors, allow medical institutions to communicate more seamlessly and save the health care industry billions of dollars each year was too tempting to pass up.
Despite this, the reality of EMRs seems not to have lived up to the hype. EMR systems have been costly to implement and are often laborious and confusing to learn. There is no universal system that all physicians can use; instead, medical professionals are faced with more than 100 systems, all competing for users and many of which cannot communicate with one another. But perhaps most notably, these systems do not appear to improve patient care, as promised, and in some cases may make care worse.
Nevertheless, the use of EMRs has ballooned in the past 10 years. In 2005, fewer than 25% of physicians’ offices and hospitals had adopted an EMR system, but today more than 80% use one. Despite the rapid spread, the central concerns about EMR systems remain the same: high cost, lack of standardization and interoperability, privacy issues and inferior patient care (Health Aff 2005;24:1103-1117).
But even before this spike in usage, many medical professionals were already well aware of the issues. In a 2004 report, researchers who had conducted 90 interviews with EMR managers and physicians found that “most physicians using EMRs spent more time per patient for a period of months or even years after EMR implementation. The increase resulted in longer workdays or fewer patients seen, or both, during that initial period …. Most respondents or their colleagues considered even highly regarded, industry-leading EMRs to be challenging to use because of the multiplicity of screens, options and navigational aids” (Health Aff 2004;23:116-126).
In a 2013 survey conducted by RAND Health, and sponsored by the American Medical Association, physicians echoed many of the same sentiments. In fact, physicians rated EMRs as a main reason for their job dissatisfaction. Summing up the results of the report, the RAND researchers wrote: “Despite recognizing the value of EHRs [electronic health records] in concept, many physicians are struggling to use their EHRs, which they describe as negatively impacting patient care in several important ways and undermining their professional satisfaction.”
In the study, the authors interviewed 24 practices about EHRs, 22 of whom were currently using a system. On the plus side, about one-third of the physicians reported that the EHR improved their job satisfaction and 61% said it improved quality of care. These physicians noted that their EHR system enhanced their abilities to access patient data at work and at home, provided guideline-based care and tracked patients’ disease.
In contrast, many physicians also expressed concerns over their EHRs, with about 20% saying they would prefer to return to paper charts. The central issues boiled down to inferior patient interactions, an inability to exchange information between different systems and a labor-intensive and time-consuming learning curve and data entry.
“Just because something is more expensive doesn’t mean it’s better,” said Peter Kim, MD, associate professor of surgery, Albert Einstein College of Medicine of Yeshiva University, New York City, who was not involved in the study. “For instance, the EMR giant Epic received $302 million from New York City, in 2013, for use in about 11 New York City public hospitals. But even within the same system, not all Epic EMRs are alike. An EMR’s functionality depends on who is programming it as well as the local needs of the institution. The same system may end up working well in one hospital, but poorly in another.”
Although people often assume that technology will reduce errors, that also is not the case. “In our hospital, administrators try to make our EMR sound perfect, but in reality, we have encountered huge errors and have had no audits of the system,” said Guy Voeller, MD, FACS, professor of surgery at the University of Tennessee Health Science Center, Memphis.
Along these lines, Dr. Kim recalled an incident when a toxic drug dose was written for the wrong patient, which missed all of the EMR system’s checks and balances. “Although that error could have happened with the old system, it wasn’t prevented by the EMR as it should have been,” Dr. Kim said. “We still need that human element in care, where a person is checking and verifying orders.”
Regarding patient interactions, physicians in the RAND study who complained that EHRs interfered with in-person patient care found that they were forced either to divide their attention between the patient and the computer or to give patients their attention but then spend hours inputting data afterward.
“With EHRs, physicians and nurses are looking at a computer screen and have their backs to the patient,” said Dr. Voeller. “Physicians and nurses are forced to devote time to their computer, not their patient.”
Another report revealed similar results. A team at Medscape surveyed 18,575 physicians in 25 different specialties from April 9, 2014, to June 3, 2014, about their EMR use. Of those, 4%, or 743 participants, were general surgeons.
The report found that about one-third of respondents felt their EHR systems worsened clinical operations and patient services, although about the same percentage reported the opposite. In terms of patient interactions, 70% of respondents said their system decreased their face-to-face time with patients and 57% said it lessened their ability to see patients, while about one-third felt their system enhanced their ability to respond to patients and effectively manage treatment plans.
Patient privacy was another major worry for physicians, approximately half of whom expressed concern about losing patient information because of a technological malfunction or about their lack of control over who can access patient data. About 40% of participants were also concerned about HIPAA compliance and hackers getting to data.
Similarly, of physicians who opted not to purchase an EHR system, the top reason was that the technology would interfere with the doctor–patient relationship (40% of responses). The other most frequent complaints were that EHR systems are too expensive (37%), and that the incentives and penalties from the Centers for Medicare & Medicaid Services are not worth the hassle of adopting a system (32%). Other reasons were that EHRs hurt patient privacy (22%) and were too complicated to learn (16%).
The financial burden of EMRs appeared to be increasing as well. According to the Medscape survey, in 2014, 23% of respondents said their EHR system cost $50,000 or more per physician to purchase and install, whereas in 2012, only 7% of respondents said their EHR system cost that much. Another report that evaluated the cost of EHRs, using survey data from 49 community practices in a large EHR pilot project, found that “the average physician would lose $43,743 over five years; just 27% of practices would have achieved a positive return on investment; and only an additional 14% of practices would have come out ahead had they received the $44,000 federal meaningful-use incentive” (Health Aff 2013;32:562-570).
Currently, Dr. Kim said, the federal government is forcing institutions to have an EMR system, which is driving many physicians out of business and into a hospital on a salary or into retirement.
“Besides the cost of implementation, evidence already is accumulating that doctors order more—not fewer—imaging studies when [an] EMR is used,” wrote David Cossman, MD, a vascular surgeon in Los Angeles, in a 2012 piece in General Surgery News (May 2012, page 1).
As for billing, Dr. Voeller noted, “the way we bill through EMRs lends itself to fraud because physicians can document more complex visits that come with a higher price tag and reimbursement.”
Amid the confusion and ambivalence, some surgeons are holding out hope that as companies iron out the kinks in the current systems, EMRs may eventually live up to the early hype. Others remain skeptical that there is a magic bullet that will vastly simplify and improve EMRs.
Reflecting on the current state of the technology, Dr. Cossman wrote: “The big problem is that HAL [the sinister computer in Stanley Kubrick’s film “2001: A Space Odyssey”] is once again stalking us with the sweet siren song of untold efficiencies, cost containment and protection from human fallibility if we only move over to the passenger seat and let it drive. Don’t believe a word of it. Medicine cannot be practiced on autopilot. We will crash and burn without the human touch at the controls.”
The latest results from CMS ICD-10 acknowledgement show no flaws in Medicare FFS claims systems although acceptance rates are lower than March’s ICD-10 testing numbers.
The most recent run of ICD-10 acknowledgement testing by the Centers for Medicare & Medicaid Services (CMS) revealed no problems with the Medicare Fee-for-service (FFS) claims systems but did show a lower rate nationally of accepted test claims as compared to previous testing in March.
“Acceptance rates improved throughout the week with Friday’s acceptance rate for test claims at 87 percent,” the federal agency said in Medicare Learning Network (MLN) Connects update on Monday. “Nationally, CMS accepted 76 percent of total test claims. Testing did not identify any issues with the Medicare FFS claims systems.”
The ICD-10 acknowledgement testing week running the week of November 17 included more than 500 providers, suppliers, billing companies, and clearinghouses and close to 13,700 claims.
“To ensure a smooth transition to ICD-10, CMS verified all test claims had a valid diagnosis code that matched the date of service, a National Provider Identifier (NPI) that was valid for the submitter ID used for testing, and an ICD-10 companion qualifier code to allow for processing of claims,” CMS stated. “In many cases, testers intentionally included errors in their claims to make sure that the claim would be rejected, a process often referred to as ‘negative testing.’”
According to CMS, most rejected professional claims were the result of an invalid NPI while others contained future dates which the acknowledgement testing does not accept.” Additionally, claims using ICD-10 must have an ICD-10 companion qualifier code. Claims that did not meet these requirements were rejected,” the federal agency added.
These most recent results are from the first of a three-part ICD-10 acknowledgement testing series. The next two week-long sessions take place the weeks of March 2 and June 1.
Earlier this year, CMS celebrated the results of a March 2014 ICD-10 acknowledgement testing week, which saw the average of accept test claims nationally reach 89 percent with some parts of the country reporting acceptance rates to close to 99 percent. Acceptance rates for Medicare FFS claims averaged between 95 and 98 percent. Similarly, testing did not reveal any problems with the Medicare FFS claims systems. The March ICD-10 acknowledgement testing week involved an estimated 2,600 participating providers, suppliers, billing companies and clearinghouses and more than 127,000 test claims.
Unlike ICD-10 acknowledgement testing from earlier this year, CMS has provided fewer details about last month’s testing week such as how the acceptance rates of FFS Medicare claims compared to total acceptance rates or other regional comparisons. And beyond highlighting the use of negative testing practices, the federal agency does not include specifics about purposefully erroneous claims and their effects on acceptance rates overall.
The next scheduled ICD-10 testing activities led by CMS take place in January and focus on ICD-10 end-to-end testing.
The number one topic of debate on this blog has definitely been Client Server EHR versus SaaS EHR. There are staunch parties on both sides of this aisle. No doubt both sides have a case to make and we’ll see both in healthcare for a long time to come. Although, I think that long term the SaaS EHR will win out.
As I was thinking about this recently, I realized that while client server EHR can do everything a SaaS EHR can do, it definitely makes a lot of things much harder to accomplish.
It’s much harder to create an API that connects to 2000 client server EHR installs.
It’s much harder to make 2000 client server EHR installs interoperable.
It’s much harder to evaluate data across 2000 client server EHR installs.
I’m sure I could keep going with this list, but you get the point. Even though something is possible, it doesn’t mean that they’re actually going to do it. In fact, if it’s hard to do, then it takes extreme pressure for them to do it.
All of this has me begging the question of whether client server installs are holding back the EHR industry. Up until now, many of the things I mention above haven’t been that important. Going forward I think that all three of the things I mention above are going to be very important.
The good thing is that I see many client server EHR moving to some kind of hosted EHR solution. That solves some of the problems mentioned above. At least if it’s a hosted EHR solution, they can control the environment and more easily implement things like API access and interoperability. That’s much harder in the client server world where if you have 2000 EHR installs, you have 2000 unique setups.
Of course, as soon as a large SaaS EHR has a massive breach, healthcare will go running after the client server EHR. The battle lines are drawn and each side knows each other very well. Although, I think the SaaS EHR have the high ground right now. We’ll see how that continues over time. Client server EHR have done an amazing job battling.
I recently did a tally. Since starting my locums adventure last year, and going to full-time locums in January, I’ve worked in a grand total of 11 emergency departments. Let me qualify that for the occasional visitor to my blog. I decided to do this for purposes of flexibility, finances and a much needed change of scenery. Not because I’m a problem physician, or unable to do the work in a “real” job. I say that to emphasize the fact that at 21 years into my career, I am a keen and qualified observer of life in emergency medicine; in fact, of life in medicine in general. It’s one of the things I write about most. And I do so because there are so many regular physicians out there with grave concerns and real problems, for whom there is no voice at all. I try to be that voice.
And one of the things the doctors are crying out over is electronic medical records, or EMR. These are systems that hospitals impose upon physicians in order to capture extra federal dollars via meaningful use. Or in order to mine the data so that they can squeeze every more blood from the turnip of paying patients and insurers. Or, they are used to track every motion, every action so that administrators can have sufficient flow charts, spread sheets and other data with which to send “bad boy” letters to clinicians reminding them to work faster or better. (And which allow various mid-level managers something to do all day without having to actually care for patients or provide intrinsic value to the hospital.)
Mind you, EMRs were already on their way, but now the administrative pressure is high. Sadly, the systems are very, very bad indeed. It is said that use of an EMR, versus paper charts or dictation, typically reduces physician productivity by about 30% right out of the box. It is also noted that now, young physicians in training spend more and more time at keyboards and less and less time looking at that pesky throwback to ancient times, the human patient. (How dare they not be pixelated!)
The sound of medicine these days is the sound of the keyboard. It is so prevalent at times that it nearly causes me to have a headache and nausea. Tap, tap, tap, day and night. We dash to the patient and we come back and spend the lion’s share of our time using the one class of all our classes that mattered most; typing or keyboarding.
This is not because it generates a good chart. In fact, most systems generate terrible charts. Charts full of clipped sentences and check box histories and exams that read worse than the worst prose. A patient encounter can generally be summarized in well composed paragraph. It’s just harder to mine the data from said writing. So modern EMR charts are inundated with time-stamps and worthless information, much of it put in the chart by nurses also forced to document everything from the patient’s pain scale to when they last fluffed his pillow or inquired as to his general state of happiness. All too often, the reason for the visit is buried in nutritional assessments and statements about whether or not they feel safe at home, or the bed-rails are up. (I have actually witnessed charts on patients with a laceration in which the laceration or its location were nowhere described.)
The whole thing is demoralizing. It is my experience that physicians and nurses routinely stay an hour or two later than their shift time, just to complete charting that they couldn’t do while trying to see human beings in a timely and competent manner. In the process, they develop repetitive stress injuries like carpal tunnel syndrome. I have had right shoulder pain on several occasions after prolonged charting. Of course, this extra time does not in any way result in extra hourly compensation. It is a requirement added on the already too many requirements of life in modern emergency departments, imposed by those whose jobs end at 3 or 5 and who do not spend their days logging in, logging out and trying to click all the right boxes while around them, people may well be dying. But I digress.
Having used a number of EMR systems, I can say that some are horrendous. These are the systems that require at least four to eight introductory hours of classroom time. These are the systems that ultimately take users weeks to fully comprehend and employ. These leave users frustrated and angry; sometimes tearful as they simply can’t be used in a manner commensurate with the pace of the actual medicine being practiced.
Why are cumbersome systems used? Many reasons, no doubt. Perhaps because the hospital or hospital system has been heavily courted by a large company that convinced them that it was an “industry standard,” that “everyone who is anyone is using it.” Certainly not, in general, because the end-user (physicians and nurses) found it simple and effective; that metric seems almost laughable these days. Doctors and nurses are commoditized quantities who will do as they’re told or else. Period.
The cumbersome systems are also, often, connected with the large corporations that run health care. They own or are affiliated with EMRs and those systems, with their built in data capture and billing systems, are forced upon the system’s providers to maximize reimbursement. ( One more reason, in my estimation, that a simple laceration costs $1,000 in most emergency departments.)
I am not naming bad systems; not yet. But I am going to name two systems that are excellent. I am not an owner, shareholder or employee of either. I simply want to illustrate the difference. I have used systems that required an IT nurse educator to sit by my side for at least an entire 8 or 10 hour shift; and still I wasn’t clear. And by way of disclaimer, I realize that even the systems I’m naming are businesses, dedicated to both documentation and generating revenue.
Having said that, I repeat that I have used systems that I understood and could use competently in 30 minutes. Why aren’t these more popular? Because if we want physicians to use EMR, and we want those physicians to do their jobs effectively and quickly, we need to simplify and streamline.
Which ones, you ask? First of all, EPOWERdoc. I have used this at two facilities and found it to be delightfully simple, with a very gentle learning curve. I learned, and used it, within about 15 minutes. The doctor leaving night shift showed it to me and I used it seamlessly for the next 12 hours and from then on at that, and another, facility.
Second, T system. I have used paper T-sheets and they’re nice and simple. Personally, given my bad penmanship, I prefer the electronic version. When I first used it in June of this year, I was met by an IT educator as I walked into the shift. In 20 minutes, I understood it and smiled as I enjoyed its intuitive design for the next 10 hours.
I suspect that if physicians had any control of this situation, the majority would use the simplest system possible. As it stands, however, we don’t.
Pity, because the demands on emergency departments grow more intense every day. The stresses are high and the resources are stretched. The last thing anyone needs is a complicated, time-intensive, soul-sucking computer program.
What we need is simplicity and compassion for providers.
Is that too much to ask?
Patient portals are becoming important tools for engagement and population health, but patients are largely unaware of the technology.
While patients are generally enthusiastic about viewing their EHR data and engaging with their providers online, a concerning number of patients are unaware of the possibilities of using a patient portal, finds a new survey from Xerox. Among the 64 percent of patients who are not portal users, 35 percent did not know a portal was available to them, and 31 percent stated that their providers had never mentioned the technology to them. Despite the widespread lack of knowledge, 57 percent of non-users said they would be more engaged and more proactive in their own healthcare if they had access to their data online.
“With providers facing regulatory changes, mounting costs, and patients who increasingly seek access to more information, our survey points to an opportunity to address issues by simply opening dialogue with patients about patient portals,” said Tamara St. Claire, Chief Innovation Officer of Commercial Healthcare for Xerox. “Educating patients will empower them to participate more fully in their own care while helping providers demonstrate that electronic health records are being used in a meaningful way.”
The survey indicates a generation gap when it comes to how patients use online tools. While baby boomers are more likely to view patient portals as a utilitarian feature by making appointments online (70 percent), refilling prescriptions (58 percent), and communicating through emails with their physicians (60 percent), millennials view portals as an informational hub. Younger patients want to see personalized information (44 percent), tailored care plans, details about related services from their providers (44 percent), and industry news that might relate to their issues and concerns (23 percent).
Perhaps surprisingly, baby boomers, aged 55 to 64, were among the most frequent users of patient portals. Eighty-three percent of this age group indicated that they already do or would be very interested in communicating with their healthcare providers through a portal. Millennials were more likely to want mobile access to online tools, with 43 percent stating their preference for smartphone and tablet interfaces.
Providers can help to shape patient engagement – and help themselves to meet the 5 percent patient engagement threshold included in Stage 2 meaningful use – by taking the time to educate patients about their options and opportunities. Reinforcing the idea of signing up for a patient portal account at multiple points along the patients’ journey through the office, from check-in to follow-up, can help to secure a patient’s interest. And physicians themselves should take the lead, St. Claire asserts.
“Physicians just aren’t having that dialogue,” she said to HealthITAnalytics. “When we look at some of the best practices out there, we see that having that conversation multiple times along the patient’s path through the office is most effective. And we think having that conversation directly with their physician is going to be most important. People really want to hear it from their physician, because they’re that trusted source. Even as medicine is changing, having that talk with the physician is probably going to have the most impact.”
With the deadline for physicians, providers, suppliers, clearinghouses, and billing agencies to apply to take part in the next wave of ICD-10 end-to-end testing, the Centers for Medicare & Medicaid Services (CMS) is providing a closer look at these ICD-10 preparation activities.
The application deadline for volunteer testers to participate in ICD-10 end-to-end testing between April 26 and May 1 is scheduled for January 9. Those who are already slated to participate in ICD-10 end-to-end testing next month do not need to re-apply.
“Approximately 850 volunteer submitters will be selected to participate in the April end-to-end testing,” the federal agency announced earlier this week. “This nationwide sample will yield meaningful results, since CMS intends to select volunteers representing a broad cross-section of provider, claim, and submitter types, including claims clearinghouses that submit claims for large numbers of providers.”
After April’s testing week, physicians, providers, suppliers, clearinghouses, and billing agencies will have one final end-to-end testing week to be a part of between July 20 and 24.
In a list of frequently asked questions (FAQs) released alongside this call for ICD-10 end-to-end testing volunteer applications, CMS details components of the testing activities ranging from differences between types of testing as well as the data used during the testing process. Here’s a sampling:
Last month, American Health Information Management Association (AHIMA) and eHealth Initiative found that some healthcare providers still lacked ICD-10 testing plans as well as assessments of the impact ICD-10 implementation would have on their facilities. According to their findings, ten percent of organizations did not have a plan in place for conducting end-to-end testing, with 17% having no clear understanding of when their organization will be ready to begin ICD-10 testing processes.
The AHIMA-eHealth Initiative survey gives credence to claims from Workgroup for Electronic Data Interchange (WEDI) that the most recent ICD-10 delay will cause many providers to postpone their ICD-10 testing activities until 2015 with potentially costly effects.
“Delaying compliance efforts reduces the time available for adequate testing, increasing the chances of unanticipated impacts to production. We urge the industry to accelerate implementation efforts in order to avoid disruption on Oct. 1, 2015,” WEDI Chairman and ICD-10 Workgroup Co-chair, said in September.
Physicians, providers, suppliers, clearinghouses, and billing agencies applying to be part of April’s testing week will receive word from their Medicare Administrative Contractors (MACs) and the Common Electronic Data Interchange (CEDI) contractors in late January.
In 2012, ARcare undertook a fast-paced transition to a next-generation electronic health record system. Less than two years later, ARcare was nationally recognized, receiving HIMSS Analytics' Stage 7 Ambulatory Award, the highest HIMSS honor for EHR adoption.
In 2012, ARcare undertook a fast-paced transition to a next-generation electronic health record system. Less than two years later, ARcare was nationally recognized, receiving HIMSS Analytics' Stage 7 Ambulatory Award, the highest HIMSS honor for EHR adoption.
ARcare, a private, non-profit corporation providing primary care in rural Arkansas and Kentucky through a network of clinics, pharmacies and wellness centers, is the first Federally Qualified Health Center – and was one of only two ambulatory practices not connected with a hospital – to receive a Stage 7 ambulatory award.
On the way to a successful implementation, ARcare learned a great deal about the relationship between ongoing physician involvement and final clinical training – information that may help our peers who are moving forward with similarly ambitious systems replacements.Managing change during the transition
ARcare’s system replacement involved moving from comparatively basic EHR use to a more comprehensive system with clinical event functionality that would enable us to better manage patient conditions across multiple care venues. A primary goal was to have the system drive orders and events rather than merely document clinical activity.
Migrating to next-generation technology across an enterprise requires significant IT resources, training, management support and workflow changes. Our strategy was to tie these elements together with a carefully constructed change-management plan, in which a highly experienced, multi-disciplinary team with C-level support facilitated all aspects of system adoption. The change-management team was tasked with creating a continuum of sustained change with a primary focus on improved patient care, stripping away governance of information silos. In this spirit of change management, each identified issue was relevant to the team – rather than individual roles – without regard to reporting structures.The importance of keeping physicians in the change-management loop
Although ARcare achieved significant success in the arena of change management from an IT perspective, and within an aggressive timeframe, we also found in hindsight that keeping physicians in the loop throughout the transition can simplify clinical training during the final stages of implementation.
While ARcare actively sought input and buy-in from physicians on the front end of the transition, our sensitivity to the demands on physicians’ available time led us to remove most of them from the actual transition process, preserving involvement to a select few clinical staff members as physician representatives. While physicians remained involved to provide input to the new standardized workflows required by the new system, most of them had minimal exposure to the new system prior to clinical training.
The scheduled training sessions involved the clinical staff who were part of the change-management team performing training duty: nurse practitioners training other nurse practitioners and physicians training other physicians. We had anticipated this to be one of the easier tasks of implementation, and hadn’t fully accounted for the learning needs of clinical staff.
Although our physician leadership group requested they be the trainers, it soon became apparent that many healthcare professionals are simply uncomfortable voicing the need for additional help, especially to their peers. We also learned that having select clinical staff involved in the overall process didn’t necessarily translate directly to building teaching skills; the ability to understand complex technology and to teach its use are quite different. We decided to revisit training with the assistance of our own KMS – knowledge management systems – education team.Getting clinical training back on track
Together with the KMS education team and led by four top instructors, we created a new, three-day program that integrated training for physicians, nurses and physician assistants.
Working in small groups, clinical staff participated in the training program, which was rolled out across facilities in series. Feedback gathered at the end of each training session helped to improve each subsequent session. Satisfaction increased quickly and steadily, and ARcare has continued to provide training updates on a regular basis to ensure continued optimal performance.Well worth the effort
Five months after going live with our new system, ARcare became the first ambulatory practice that was not part of a hospital to achieve Stage 6 on the HIMSS Analytics EMR Adoption Model. One year later, we became the first FQHC to achieve the highest level of EHR usage, Stage 7.
The overall experience helped the organization recognize and develop an appreciation for the fact that change can and should be a positive experience. ARcare has developed a level of confidence across the organization where employees are less reluctant or fearful of change, and where learning from failure produced valuable outcome – not just in successful training, but in the successful adoption of a new Greenway Health EHR that brought with it substantial benefits, including:
During the transition to the new system, ARcare successfully converted more than 17.2 million records, including clinical notes, images and test results. Now, when ARcare identifies and secures a new clinic site, the new site can be completely operational from an IT perspective in 30 days or less thanks to advanced system capabilities for scalability and extremely fast implementations. As of today, the system provides paperless charting and order entry for 37 ARcare clinics.
In all, it’s been a very satisfying transition in which the gains were well worth the pain – pain that can be avoided by following the lessons learned in ARcare’s approach and re-working of clinical training. In short: It’s all about identifying an effective training team.
Patients should have the right to control their own healthcare and their own EHR data regardless of a provider’s opinions or disagreements, state David Blumenthal, MD, MPP and David Squires, MA in a commentary published in the Journal of General Internal Medicine. Even though some patients withhold critical information from their physicians or refuse to comply with treatments, clinicians are nothing more than “guests” in a patient’s life and must act with respect and understanding, the authors say.
The question of whether patients should be able to control the information in their electronic health records (EHR) provokes strong opinions, says Blumenthal, a former National Coordinator for Health IT and current President of the Commonwealth Fund. “Some argue that the information rightfully belongs to patients, and they should be able to decide what is recorded and who can access it. Some clinicians, however, argue that because they have a duty to provide their patients with the best possible care, doctors should have unfettered or nearly unfettered access to any information needed to meet that obligation.”
Blumenthal and Squires, a senior researcher at The Commonwealth Fund, come down on the side of the patient’s rights to make their own choices about the quantity and completeness of the data they share with their clinicians, as well as the access, use, and transmission of information stored in their EHRs.
As privacy and security concerns continue to affect the way patients view the use of EHRs, patients must be properly educated about data security, health information exchange, and the benefits of providing complete and accurate data to their physicians. Providing this education is a “considerable challenge,” the authors note, as many patients do not understand the details of how data is exchanged between providers or even what privacy protections are built into HIPAA.
While patients may have the right to withhold information based on these concerns, incomplete or incorrect data can have significant impacts on a patient’s health and wellbeing in unanticipated ways. “A patient’s decision to withhold data about a sensitive medication—such as a psychotropic or HIV-related drug—may have later consequences that neither patients nor clinicians could have anticipated,” Blumenthal and Squires write. “Beyond this, when evaluating a patient, experienced clinicians often rely on an array of data, including information not obviously related to the current problem, to raise and evaluate hypotheses about diagnosis and treatment.”
EHR developers are still working to refine and implement technologies that deal with patient consent for the sharing of specific pieces of information, such as HIV status, sexual orientation, or mental health diagnoses. Even when these capacities are more mature, the authors point out, there will always be instances when clinicians feel they must override a patient’s wishes in order to provide proper care or protect other patients from communicable or infectious disease.
However, Squires and Blumenthal caution providers who wish to assert their unrestricted rights to a patient’s health information that “if patients do not trust the health system to protect them, their relationships with their clinicians will suffer, they will withhold information, and the value of the health information contained in the EHR will be undermined. In the long run, clinicians as well as patients will benefit from a health information system that patients feel they can depend on to protect their privacy.”
As EHR adoption reaches the majority of healthcare providers and the tension over issues of consent, data exchange, and data usage become more complex, these questions will continue to prompt discussion among healthcare professionals on both sides of the argument. “Continued research on how to inform patients, support their choices, and understand the consequences for their care is essential,” the article concludes. “And while caution cannot be thrown to the wind, our prejudice should be to give patients a chance to express their views, and then abide by those as best we can.”
Moving to the cloud is a smart business move for many medical providers these days. The security, convenience, and scalability are attractive attributes for busy practices that don’t want the hassle of attempting to handle all their IT needs in-house. Plus the mandated move to electronic health records (EHR) is causing many enterprises to rethink their entire IT strategy.
While there are many benefits to moving to the cloud, reaping the rewards takes some serious preparation. Following best practices for pre-migration planning is key to ensuring the success of cloud operations. Sure, planning the move sounds simple, but it’s so simple that many firms fail to do it. The result of inadequate preparation is often lost data.
Check the Paper Trail
First, it’s important for medical practices to look closely at the service-level agreements (SLAs) they have with existing vendors. And then look at them again.
Practice groups should make sure the answers to the following questions are clear:
Have an Itinerary
It’s important for practitioners to know where data will “live” during the entire process. There should also be a plan spelling out who is responsible for maintaining the data during the migration. For businesses that can’t afford a lot of downtime, it might be a smart option to replicate data rather than doing a straight transfer.
Then, it’s critical to consider every operation the data touches and how those systems will communicate after the move.
Obviously, testing security is key in any case. But when migrating to the cloud it’s important to test it twice. Security should be checked both before porting the data and again after it resides in the cloud. Keep in mind that some aspects of security may need to be reconsidered after the data is refactored for cloud optimization.
Practice groups should also work with their service providers to formulate a porting plan so they can ensure they have a plan for retrieving data.
The upshot: Working with an IT partner that can understand the critical needs of practices’ data integrity and business continuity is key to ensuring a smooth transfer with minimal interruption.
This week, I visited a hospital which belonged to a health system going with Epic. This hospital, one of the smaller facilities in the chain, was running Picis in the ED and (I think) Cerner throughout, but the decision had been made to convert everything to Epic sometime soon, a tech told me.
I can’t say the news was surprising, but it was disappointing nonetheless. The community hospital in question has given me excellent service, and my guess is that when Epic barrels in, it will lose its way — at least for a while — frazzling the staff and decreasing the quality of their interaction with me.
However, I ‘d better get used to this trend. As Healthcare Technology Online editor in chief Ken Congdon notes in an excellent editorial, the pendulum is definitely swinging toward enterprise-wide EMR implementations, a direction encouraged by the standardized demands imposed nationwide by Meaningful Use.
If interoperability was easier to pull off, things might be different. But with HL7 and other integration standards and languages still not quite up to the job, one can see the sense of going with an enterprise option.
Here’s the story one CIO told Congdon as to why he’s deploying Siemens Soarian solution:
Michael Mistretta, CIO of MedCentral Health System [said:] “Vendor management was a key consideration in our decision to use a single vendor approach to EMR implementation,” says Mistretta. “With a single vendor, I only have one finger to point at. It simplifies my environment because I don’t have Siemens telling me it’s McKesson’s problem and vice versa. Also, the built-in interoperability is key. There is a trade-off in the fact that the system does not provide prime functionality to certain departments or specialties within our health system, but at this point in time, it’s much more beneficial for our organization to have the ability to share data across the continuum of care quickly and easily.”
CIOs of large hospitals also told Congdon that enterprise system replacements were much cheaper than going through a long-term, highly-complex integration effort.
In an interesting twist, however, hospital IT leaders from mid-sized to smaller hospitals have reached the opposite conclusion, Congdon reports. They’ve been telling him that buying an enterprise system would be much more expensive than sticking with what they had and making it interoperate.
I see a market opening here. If enterprise EMR vendors can get their pricing in line for smaller hospitals, they may have a lot more wins coming their way than they expected. Interesting stuff.
A physicians network in the Mid-Atlantic has been awarded the highest level of electronic medical record adoption, joining the only 6 percent of all ambulatory clinics that have achieved this status. Lancaster General Health Physicians, an ambulatory clinic composed of more than 300 family physicians and specialists, last week was awarded the HIMSS Analytics Stage 7 Ambulatory Award, which represents the highest level of EMR adoption. To achieve this status, an ambulatory provider must go beyond implementation of patient portals, CPOE and clinical decision support. It must also be HIE capable, able to exchange data between the EMR and a community-based EHR, in addition to utilizing business and clinical intelligence. "This award represents the dedication and teamwork of our physicians and employees to transform healthcare," said Thomas E. Beeman, president and CEO of LG Health, in a Dec. 18 statement. "We believe that the successful transition to electronic records in our hospitals and practices sets the foundation for population health. Stage 7 affirms our strong commitment to patient safety, quality of care, process improvements and technologies enabling us to accomplish these goals." Lancaster General Hospital achieved Stage 7 status for hospitals just last year. The IT department at LGH system, which includes Lancaster General Hospital, Women & Babies Hospital and the ambulatory network, is led by Chief Information Officer Gary Davidson. The health system uses a single, integrated Epic electronic medical record, a $100 million initiative that hospital officials started in 2010. Their IT success stories include clinically integrating all IV pumps with the EMR, as well as full barcoding for pharmacy inventory. Earlier this year, the health system also announced it was moving forward with a big data and analytics initiative, after deploying a SaaS-based population health platform. Lancaster General Health Physicians joins the other 75 ambulatory clinics in Pennsylvania and the 1,590 nationwide that have achieved Stage 7 on HIMSS Analytics EMRAM scale. Earlier this month, HIMSS also awarded the Cleveland Clinic Health system with a Stage 7 award.
Different healthcare specialties have different electronic health record (EHR) requirements as there is significant variation in care processes, clinical content and decision support across care settings. For example, a primary care facility’s EHR “must-haves” are dramatically different from those of outpatient surgery center. While the primary care provider sees many patients for a variety of reasons, the surgery center delivers more focused, predictable and short-term care with unique workflow requirements. In the same vein, an ophthalmology practice requires technology to capture data from a number of instruments—often more than many other specialties. Likewise, a dermatology provider often completes numerous procedures in one visit, and an inpatient behavioral health setting with group counseling demands yet another approach to capturing and collecting patient care information.
Despite their diverse EHR needs, there is a commonality among these and other medical specialties: each requires a robust EHR that enables providers to easily gather data, completely and accurately document care, smoothly share information and facilitate good communication to achieve the best patient outcomes. To select the right EHR, specialty practices must fully appreciate how the technology addresses their particular needs and requirements.
Five considerations for selecting a specialty-focused EHR
Verifying that an EHR has the features clinicians need to provide care and manage patients is critical to its success. The following five considerations can guide a practice when evaluating an EHR to ensure the technology meets the organization’s clinical and business specifications, strengthening care delivery while safeguarding the practice’s future.
1. The right content. The first step—and probably the most important—is to look at the depth and breadth of content the solution provides and make sure it fully aligns with the specialty’s requirements. This becomes more complex for a subspecialty. For example, an EHR with strong cardiology features may not meet the distinct needs of a pediatric cardiologist. In these cases, it is also important to select an EHR that can be supplemented with additional subspecialty information to better meet their needs.
2. Configuration flexibility. When specialty practices can easily configure their EHR to reflect workflow nuances, they can optimize data capture, streamline care and improve outcomes. The EHR should allow physicians to easily configure their own templates, yet provide consistency to maintain a high standard of care. For instance, an OBGYN facility needs EHR flexibility for visits ranging from prenatal care and reproductive endocrinology to annual wellness exams. Physicians should be able to customize these forms to match workflow, yet maintain alignment with ACOG (American Congress of Obstetricians and Gynecologists) standards.
3. Smooth integration with current technology. Specialty practices often have more diagnostic equipment feeding data into the EHR than primary care practices. For example, an ophthalmology group may have as many as 12 different devices capturing and sending data to the EHR. Because of this, a practice should closely review how well a potential solution interfaces with the practice’s current technology, particularly focusing on how the EHR incorporates the disparate data into workflow. Specialties linked to a hospital or health system should also assess how seamlessly the proposed EHR share key information with the larger organization. Ideally this is bi-directional!
4. Facilitates the patient experience. Patients can be nervous when they see a specialist, and this can be exacerbated if the physician is more focused on navigating technology rather than talking with the patient. By choosing software that enables patients, medical assistants, nurses and others to capture as much data as possible in the EHR before the doctor enters the room, a practice can allow the physician to focus on the patient’s particular care needs instead of looking at a computer screen to input routine data. Remember, a good EHR gives physicians the right information at the right time to come to the right conclusion while they are in front of the patient. In other words, it keeps the patient at the center of the experience.
5. Strong, Forward-thinking vendor. Not all vendors are equal, and spending time comparing the various options is a valuable exercise. As part of the vetting process, practices should gauge a vendor’s commitment to their specific clinical specialty and learn about plans for future technology development. In addition, consider the vendor’s organizational and financial strength to sustain the cost of supporting the specialty into the future and keeping up with regulatory compliance.
Although specialty practices have historically avoided jumping feet first into EHR technology, this is no longer an option for organizations that want to sustain and build referral volumes. In fact, by selecting and implementing a tool that consistently captures and shares specialty-focused data, providers can position themselves as the expert of choice for both peers and patients.
Have you ever thought about just how many moving parts there are in an ICD-10 implementation? The whole process can seem overwhelming to a practice and as a Practice Management/EHR vendor who needs to understand all of these different pieces, we’ve found that the best way to approach this is by breaking down the implementation into three main ingredients: People, Processes & Technology. So what do these mean, what’s your role and how do you formulate a plan for ICD-10 success?
People – Because a successful ICD-10 implementation affects all departments in your practice, awareness, preparation, testing and training should already be well underway. Medical coders and physicians aren’t the only people who require high ICD-10 competency. The key to preparing your entire staff for ICD-10 readiness is identifying what training is required by role, who conducts the training, budgeting for training costs and downtime, timing and finally, ensuring staff is adequately prepared and capable. ICD-10 readiness should include regular communications with management, IT staff and clinical staff about new procedures and new or updated software such as Practice Management and EHR systems. Staff also needs to be able to handle new requirements and forms, such as paper superbills, as part of the new billing, claims and documentation procedures.
Processes – The impact of ICD-10 on practices can vary depending on specialty, patient mix, top diagnoses and payer mix. Solo and other small practices will typically have greater risk and deeper impacts due to fewer resources and available funds. Moving to ICD-10 will require tremendous effort and process coordination of nearly every workflow. Processes to manage 120,000 new codes in a way that allows simple, accurate look-up and application of codes requires collaboration across the practice – including your IT systems and people. Productivity standards may have to be redefined, requiring additional coding staff, existing staff may need to be retrained, and providers may need to change how they document with more detailed diagnosis information.
Technology – This is the backbone of a successful ICD-10 implementation and gives your practice, people and processes a foundation to guide your operations and improve coordination of benefits and care. When properly configured to an ICD-10 environment, technology can help ensure critical processes are performed – such as documentation, coding, billing and bi-directional data transmission – all while ensuring third-party integrations can do the same. As the ICD-10 crossover date approaches, the risk of having non-compliant IT systems grows exponentially. By paying close attention to your existing IT environment and examining it against changes required to accommodate new data, new workflows and potentially new people prior to implementation, you can greatly increase your ICD-10 readiness.
As you can see, we all have a responsibility to understand the ingredients that make up an ICD-10 implementation, which will increase our knowledge in these areas and in turn, reduce risk. Look for opportunities for training, industry webinars and vendor testing. Some vendors are even offering ICD-10 Risk Assessments to assist practices in understanding the impact of ICD-10 and providing recommended actions based on the assessment results. All of these opportunities will support the success of the People in your practice performing Processes that are supported by your Technology. When these three ingredients are understood, planned for and in sync, we’ll be able to achieve ICD-10 success together!
How possible or impossible is the idea of having a universal electronic health record in the US? Our readers highlight the health IT obstacles in the way.
In concept, a universal electronic health record would eliminate many of the obstacles in the patient’s path along the care continuum. Such an idea, however, is not reality.
In searching for a solution to fragmented healthcare, the authors of a recent Harvard Business Review article pointed to the lack of a universal EHR as one factor in the way of integrated healthcare in the United States.
“The lack of a single health record for each patient that clinicians from all specialties can access in both inpatient and outpatient settings is an obstacle to integrating care. In addition, patient privacy protections inhibit the sharing of health information, creating both perceived and real hurdles,” wrote Institute for Healthcare Improvement and Weill Cornell Medical College’s Kedar S. Mate, MD, and the Permanente Federation’s Amy L. Compton-Phillips, MD.
The following question about universal EHRs was put to our audience: How possible or impossible is the idea of having a universal electronic health record in the US?
Three of our readers offered their insight into answering that question and their feedback providers more detail about the factors contributing to fragmented health data, highlighting how health data and privacy make the concept of a universal EHR highly unlikely.
The first set of comments comes from the head of a health IT privacy and security consultancy who recalls the work of the Nationwide Health Information Network and its inability to resolve interoperability after ten years of work:
These comments were echoed by another health IT privacy and security consultant who highlighted the potential of local health information exchanges to make up for the lack of a national HIE infrastructure:
The last set of reader comments placed the concept of a universal EHR in the context of federal and state health IT regulations and policies (i.e., the requirements on covered entities and business associates under HIPAA) that continue to place limits on HIE, intentionally and unintentionally. These comments come from a regional health IT director with experience working with state HIEs:
Integrated is the focus of most current attempts at healthcare reform, but up to this point regulation and infrastructure have yet been able to work well together. As the comments from our readers clearly suggest, the resolution to interoperability is unlikely to come from those incapable of seeing the barriers in its path.
You may have noticed aviation-inspired terms, illustrations, and ideas on the High-Usability EncounterPRO EMR Workflow System:
What if I told you that EHR/EMR workflow systems:
It would be true, but I would be paraphrasing page 176 of the Handbook of Aviation Human Factors in which it says that designers of cockpit automation hope to:
I’ve seen many EMRs over the years, some designed by physicians, some designed by programmers, and many designed by both. However, a physician, a programmer, *and* a pilot designed EncounterPRO—and it shows.
Aviation human factors techniques and ideas about individual and team performance have been used to improve patient safety (for example), but less so for sheer high-performance effective and efficient EMR data and order entry. Since World War II, the aviation industry has spent millions (perhaps billions) of dollars on aviation human factors research on the design of high-usability, high-performance robust avionics and cockpit management systems. Many aspects of traditional EMR design contradict this accumulated knowledge and experience.
As a result, an EMR Workflow System looks and works differently from any other EMR of which I am aware. While I wouldn’t want to fly a plane using EncounterPRO as cockpit management software, of the hundreds of EMRs out there it would the most suited to the task. In fact, after one presentation, representatives from an aviation software company approached us to ask if we would consider adapting EncounterPRO to serve as a cockpit management program. Given EncounterPRO’s roots we were flattered and intrigued, even if we eventually decided to continue to concentrate solely on ambulatory EMR workflow automation.
My own MS in Industrial Engineering at the University of Illinois, Champaign-Urbana involved a year in both the aviation human factors and health systems engineering programs. (This was by accident. There was a research assistantship available to work on an aviation human factors research project.) Aviation and aerospace medicine intrigued me for a while, but I decided that health care workflow was an even more target rich environment. Ironically, several years later I wrote natural language processing grammars for the Pilot’s Associate project (where I faced the truth of a popular linguistic proverb: All grammars leak.)
I had the enjoyable experience of hanging out with a sizable community of aviation human factors graduate students (both from IE and from other graduate departments such as psychology). That’s where I learned about the Fitts and Hicks laws that I discussed in the Cognitive Psychology of Pediatric EMR Usability and Workflow. I also bumped into an idea that has stuck with me since.
For each of the effects of the normal aging process–
–there are a set of design principles and assistive technologies that address environmental challenges causing similar decreases in skilled performance.
Centers for Medicare and Medicaid Services announced that around 257,000 U.S physicians and health professionals’ payment will be deducted as they are not utilizing electronic health records (EMR) in their practices.
EMR is a process through which data is accumulated in the office of provider. It offers complete medical and treatment history of the patient. It permits clinician to find which patient is left for preventative screening. The main aim of EMR is to make the entire procedure of record keeping of patient much accurate, easier and comprehensive.
CMS informs that the chief goal of the government health agency is to improve the health care quality. Therefore, this action may compel doctors to make use of the electronic health records.
Additionally 200 hospitals would lose 1 percent of their Medicare payments in 2015 for not adequately using EMR. Thus Far, notifications has been sent to almost 257,000 medical care providers.
This is not the first time when the government cut the salary of the health workers. Earlier, President Obama passed a Health law which state that $20 would be given to Medicare providers for this particular purpose. The providers are requested to give incentives to health professionals who adequately make use of EMR.
Up till now, around 400,000 providers got the bonus Medicare payments as they properly installed EMR system. Unfortunately, the number of incentives given are relatively low when compare to the payment cut of physicians.
Members of Congress and CHIME respond to reports of meaningful use penalties and participation figures.
In the span of one week, the Centers for Medicare & Medicaid Services (CMS) released two telling pieces of information regarding the Medicare EHR Incentive Program — meaningful use penalties and Stage 2 Meaningful Use attestation — both being used by a cohort of Congress members and one industry association as proof of the need for immediate changes to 2015 meaningful use requirements.
As part of this month’s the Health IT Policy Committee meeting, CMS reported that 1,681 eligible hospitals (EHs) had successfully attested to Stage 2 Meaningful Use as of December 1, doubling the last month’s figure 840 EHs successfully attesting as of November 1.
This revelation motivated 30 members of Congress (28 Republicans and 2 Democrats) to call on the Department of Health & Human Services to reduce the 2015 meaningful use reporting from a full year to a 90-day quarter.
“We recognize that the Meaningful Use Program has been a catalyst in the widespread adoption of health information technology across the country,” the letter from the group led by Representatives Renee Ellmers (R-NC) and Jim Matheson (D-UT) states. “However, we remain convinced that program success hinges on addressing the 2015 reporting period requirements.”
Ellmers and Matheson are co-sponsors of the Flexibility in Health IT Reporting (Flex-IT) Act of 2014, which they introduced in the House of Representative in September and currently sits with the House Energy & Commerce and Ways & Means Committees.
According to the most recent letter to HHS Secretary Sylvia M. Burwell, the subscribers contend that a failure to reduce “will complicate the forward trajectory of Meaningful Use and jeopardize the $25 billion in federal investment made to date.” Moreover, the group claims that feedback to the flexibility rule published by HHS and CMS in the Federal Register in September calling for a reduced 2015 meaningful use reporting period were “disregarded.”
The more recent news that more than 257,000 providers eligible for the Medicare EHR Incentive Program will receive notice that they will be subject to Medicare payment adjustments beginning in 2015 in the coming weeks has another supporter of the Flex-IT Act urging CMS to move quickly to address 2015 meaningful use reporting requirements.
That supporter is the College of Healthcare Information Management Executives (CHIME), which released a statement Thursday:
Despite calls from Congress and industry associations, neither HHS nor CMS has hinted at the possibility of modifying the EHR Incentive Programs in 2015.
Stage 2 meaningful use attestations have shown big improvements recently, but many providers are still struggling. With her Flex-IT Act gaining traction in the House, Rep. Renee Ellmers, R-N.C., along with 28 fellow members of Congress, have called on HHS Secretary Sylvia Burwell to offer relief in the form of a shorter 90-day reporting period.
In my previous post I talked about the benefits of using social media in a medical practiceand I said that the next post in the series would take a look at the tools, techniques, and social media platforms you should use to help you realize the benefits of social media. This will not be an exhaustive look at social media platforms or the way to get the most out of them. However, it will be a good place for you to start and will offer some techniques that those who’ve started might not have heard about.
First, a word of warning. When starting to work with social media, be sure to pace yourself appropriately. As you start working with a specific social media platform, you might want to start “sprinting” and dive really deep into the product. That’s a great way to develop a deep understanding of the platform, but it’s not sustainable. After doing a deep dive into a social media platform, find a sustainable rhythm that your practice can sustain long term.
Social media is a marathon, not a sprint.
Facebook – With nearly 800 million active users, it’s hard to ignore the power of Facebook. Given these numbers, the majority of patients are on Facebook and they’re likely talking with their friends about their doctors. Unlike many other social media platforms, most people are connected to their real life friends on Facebook. That means the focus of your work on Facebook should be to help your most satisfied patients be able to remember to share this with their friends as the need arises.
On Facebook this usually takes the form of a practice Facebook page that your patients can “like.” Invite your patients to like your Facebook page when they’re in your office or through your patient portal. You can even test some Facebook advertising using your internal email list to get your patients to like your page. However, the most important thing you can do is to make sure you regularly update your Facebook page with quality content. That way, they will want to like your page when they find it.
When it comes to content, put yourself in the shoes of your patients and think about what content you would find useful as a patient. Don’t be afraid to post things that represent the values of your practice, but may not be specific to your practice. In most cases, what you’re sharing on Facebook is more about helping that patient remember your practice as opposed to trying to sell them something. For example, it’s more effective to post something entertaining that your patients will like and comment on than it is to post some dry sales piece that they’ll ignore.
Twitter – Similar to Facebook, you want to create a two step process with Twitter. First, think about content you can post to your Twitter feed that would be useful to your patients and prospective patients. No matter what marketing methods you employ to increase Twitter followers, if your Twitter account isn’t posting interesting, useful, funny, entertaining, or informative content, then no one will follow you.
Second, find and engage with people in your area that could be interested in the services you offer. Finding them is pretty easy thanks to the advanced Twitter search. When you first start on Twitter you’re going to want to spend a bit of time on that search page as you figure out what search terms (including location) are going to be most valuable to your clinic. Sometimes you’ll have to be creative. For example, if you’re an ortho doctor, you might want to check out search terms and followers of a local youth rec league.
Once you find potential patients on Twitter, follow them from your account and engage with those you find interesting. Just to be clear, a tweet saying “Come visit our office: [LINK]” is not engagement. Offering them answers to their questions or links to appropriate resources (possibly on your website, blog, or Facebook page) is a great form of engagement. You’ll be amazed how consistently following and engaging with potential patients over time will build your Twitter profile. Once they’ve followed your account, you have created a long term connection with that person.
As I suggested in my previous post, Twitter can be a great way to find patients, but it can also be a great way for your practice to connect and learn from peers and colleagues. I’d suggest using different accounts for each effort. The tweets you create for each will likely be quite different so don’t mix the two. However, the same search and engagement suggestions apply whether you’re connecting with patients or colleagues. The search terms will just be quite different.
Physician Review/Rating Websites
Discovering which one is most popular in your region is pretty easy. Many of your patients will have told you that they found your practice through these sites. However, you can also do a search on each of these services and see which ones are most active. A Google search for your specialty and city is another way for you to know which services are likely popular in your area.
Many of these sites will let you claim your profile and be able to respond to any reviews. Do it (although, don’t pay for it). Responding to reviews is a powerful way to engage your patients. If they post a bad review, keep calm and show compassion, understanding, and a willingness to help and that bad review will become good. Plus, that negative review could be an opportunity for you to improve your practice. If they post a good review, show gratitude for them trusting you as their doctor.
Once you’ve discovered which website is most valuable in your region, encourage your satisfied patients to go on that site and post a review of your practice. In some cases that might be handing the patient a reminder to rate you as they leave. In other cases, you might send them an email after their visit asking for them to review you on one of these sites. With mobile phones being nearly ubiquitous, a sign in the office can encourage a review as well.
I think we could broaden the question even more and ask if any EHR vendor has really fostered healthcare innovation. I’m sorry to say that I can’t think of any real major innovation from any of the top hospital EHR companies. They all seem very incremental in their process and focused on replicating previous processes in the digital world.
Considering the balance sheets of these companies, that seems to have been a really smart business decision. However, I think it’s missing out on the real opportunity of what technology can do to help healthcare.
I’ve said before that I think that the current EHR crop was possibly the baseline that would be needed to really innovate healthcare. I hope that’s right. Although, I’m scared that these closed EHR systems are going to try and lock in the status quo as opposed to enabling the future healthcare innovation.
Of course, I’ll also round out this conversation with a mention of meaningful use. The past 3-5 years meaningful use has defined the development roadmap for EHR companies. Show me the last press release from an EHR company about some innovation they achieved. Unfortunately, I haven’t found any and that’s because all of the press releases have been about EHR certification and meaningful use. Meaningful use has sucked the innovation opportunity out of EHR software. We’ll see if that changes in a post-meaningful use era.