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The doctor will e-mail you now. And then see you later.

The doctor will e-mail you now. And then see you later. | EHR and Health IT Consulting |

When Ted Palen, a Kaiser Permanente researcher, started investigating what happens when doctors begin e-mailing with patients, he thought he would see the practice lighten workloads. Patients would get their questions answered remotely, with no need to turn up in person.

Palen just finished a five-year retrospective study of what happened when Kaiser Permanente in Colorado began allowing e-mail access to doctors in 2006. The outcome, as Palen notes in this week’s Journal of the American Medical Association, was “contrary to our expectations”: Online access to doctors was associated with more doctor visits, not fewer.


There was a big spike in visits and phone calls to doctors’ offices right when the new e-mail access, called MyHealthManager, came online. The graph displayed divides the Kaiser Permanente population into those who were using the online access program, and those who were not:

That initial spike did taper off with in a few months. Even a year later, however, those who utilized the online access to doctors still had higher rates of doctor visits per month


There are a few possible explanations of what is happening here. One that the researchers discuss is an issue of self-selection: Those who would sign up for the online health manager might be more inclined to take a greater role in managing their own health. “Members who are already more likely to use services may selectively sign up for online access and then use this technology to gain even more frequent access rather than view it as a substitute for contact with the health care system,” the researchers write.

Via nrip
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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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EHR adoption is the first step to an IT-enabled health care system.

EHR adoption is the first step to an IT-enabled health care system. | EHR and Health IT Consulting |
Adopting EHRs is the first step in a long and complex journey to an IT-enabled health care system in which technology is effectively leveraged to address ongoing cost and quality challenges.

This annual report produced by a team of researchers at the Robert Wood Johnson Foundation, Mathematica Policy Research, Harvard School of Public Health, and the University of Michigan tracks the progress of adoption of electronic health records (EHRs). 

In 2013, the percent of hospitals adopting at least a basic EHR quadrupled to 58.9 percent from 2010 when the EHR incentive program was implemented

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Large Illinois hospital merger to test EHR interoperability |

EHR interoperability will be put to the test in the Chicago area with the large-scale merger of Advocate Health Care and NorthShore University Health System.  The partnership will create a network of sixteen hospitals using four different EHR systems from some of the biggest vendors in the business, with more than 2000 employed physicians serving 3 million patients a year at more than 350 locations: a daunting challenge for health information exchange that raises questions about the impact of multiple EHRs in such a massive conglomerate.
The new Advocate NorthShore Health Partners, which still requires approval before the deal closes in early 2015, will shift the business paradigm in Illinois as it produces a $6.8 billion behemoth with more than 45,000 employees.  “This is a huge win for Advocate. It’s an incredible coup to lock up NorthShore. It’s a great market and it’s a great system,” said Jordan Shields, a vice president at hospital merger advisor Juniper Advisory, to the Chicago Tribune.  “[It] is going to shake people. What this does is change the gravity in the metropolitan area.”
The merger will help to secure ongoing revenues in a climate of uncertainty over the role of the inpatient setting and the long-term impact of the Affordable Care Act, which has been restructuring the way patients receive care.  While the potential for employee layoffs to reduce redundancies may have support staff and administrative workers worried, clinicians might be wondering how their EHR systems will be affected by the deal.  NorthShore University is an Epic shop with a single, unified platform across its care sites, but Advocate providers are split between Allscripts for its employed physician group, eClinicalWorks for “physician partners,” and Cerner as its inpatient EHR.
Dr. Wes Fisher, MD, FACC, a NorthShore cardiologist and Clinical Associate Professor of Medicine at the University of Chicago, explains in a blog post discussing the merger that Advocate wanted to allow their physicians to remain more independent by using multiple EHRs.  Providers who leave the Advocate Physician Partners group are allowed to take their patient data with them and set up shop elsewhere without having to worry about losing previous records.
But that admirable flexibility on the part of Advocate may prove a challenge when butting heads with a monolithic Epic partner.  “NorthShore was the metro Chicago’s first EPIC client and while its 4 hospitals are a relative minority compared to Advocate’s more geographically diverse 12-hospital system, its seamless outpatient and inpatient integration of EMR platform may threaten Cerner and Allscripts control of Advocate’s EMR solution,” Fisher writes. “While I suspect change may not come immediately, if a move to consolidate EMR systems occurs, both doctors and patients in one of the systems may see some dramatic changes going forward as a result.”
In the meantime, if the partnership is approved, all four clinical systems must find a way to work together to ensure that patient data flows appropriately across the 350 sites involved in the merger.  Cerner and Allscripts are founding members of the CommonWell Alliance, a pact between EHR vendors to improve interoperability and implement data standards, but standoffish Epic has denounced the effort as a “competitive weapon” and a “distraction” for the healthcare industry.
Will the four major competitors find a way to play nice in the new health system conglomerate, or will Epic’s unified database and proven effectiveness in the hospital setting eventually muscle its way into dominance?   Advocate’s CEO James Skogsbergh notes that the merger is an attempt at ramping up the scale of the health system to be more competitive in a fragmented market, and few EHR vendors are as accomplished at conquering large-scale projects as Epic Systems.  It will be interesting and edifying to see how the new Advocate NorthShore partnership addresses its technology challenges as it moves forward in an evolving healthcare landscape.

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Blog: Healthcare Apps and Wearables – A Gateway to Patient Engagement?

Blog: Healthcare Apps and Wearables – A Gateway to Patient Engagement? | EHR and Health IT Consulting |

Like most men my age, I could stand to lose a few pounds. It came as no surprise when my wife purchased a JawBone Up – a sophisticated pedometer and calorie tracker – for my birthday in March. I am a gadget nerd, but this device sat on my dresser for over a month before I opened it. Once I set up the device and downloaded the corresponding app, I entered the new world of data empowerment. As exciting as this may sound, the question that I keep coming back to is this: how will this data help me get healthier and shouldn’t my physician be counseling me on my self-imposed methods for self-improvement and more importantly, the results?

For hundreds of years, people have been monitoring their vital signs using stethoscopes and thermometers. It was not until the 1980s, when diabetic patients started to take digital glucose readings at home, that we saw the ability for physicians to gather solid data via patient tracking. However, the question still remains: how are we importing and maximizing use of this data?

Patient engagement is at the crux of a new paradigm within the shared-risk, Patient- Centered- Medical-Home, Meaningful-Use-Healthcare world. Further, in the self-directed Obamacare era, consumers are tasked with taking charge of their own wellness by managing their own data & health. Although EMR utilization has increased dramatically in the past decade, these silos of information largely do not tap into the devices that patients have been using for decades. With the limitations of interoperability between these silos of EMR systems, very little data is streaming from one database to the next. Patient engagement becomes limited to an individual patient portal that in most cases is clunky, hard to use, and does not give a complete picture of patient health.

A non-scientific study of 20 to early 40 year olds within my peer group showed that not one had a primary care physician they visited on an annual basis. The respondents noted that the Urgent Care setting was their only place for access to a primary care physician. This further highlights the disadvantages of patient health information being stored in multiple arenas and databases.

There is a light at the end of this gloomy tunnel. In the past couple of years, Healthcare IT Accelerators like Blueprint Health and Health 2.0 have assisted a new breed of startup. Beyond these accelerator companies, a new generation of healthcare startup is adopting a business to consumer model that can lead to business-to-business financial success. By combining premium services with convenience and social interconnection, these startups are beginning to see real market penetration.

In order for all of this to work, it must be possible for patients to be engaged passively, not actively. The information must flow without the patient having to facilitate it. Physicians must be part of the process of evaluating the engagement. With the world of wearables only in its infancy, interoperability of the network needs to define and drive how these independent silos will interact. When this networked transformation happens, the power of the system will far exceed that of the isolated patient or physician operating independently. Over time, this data will be combined with a complete health record to provide truly personalized medical updates and a comprehensive view of your health and habits, thus filling in all the gaps between medical checkups and doctor visits.

At the end of the day, when you strip away all of the technology, you are left with a patient looking to stay healthy and a physician looking to keep patients healthy. In this new exceedingly connected world, the importance of a highly-trained and technologically-adept primary care physician quarterbacking the care and interpreting data (including information from personal devices) will become more important than any time in history.

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Why final rule comes as last straw | Healthcare IT News

Why final rule comes as last straw | Healthcare IT News | EHR and Health IT Consulting |

CMS and ONC disappointed many CIOs and IT teams around the country on Aug. 29 when it issued a final rule for Stage 2 meaningful use that lacked the flexibility on reporting that so many had counted on – and perhaps expected, because what they had proposed seemed like a reasonable compromise to them.

CHIME, which represents 1,400 CIOs, fired off a statement the same day.

Russell Branzell“CHIME is deeply disappointed in the decision made by CMS and ONC to require 365-days of EHR reporting in 2015,” Russell Branzell wrote in his response to the rule. “This single provision has severely muted the positive impacts of this final rule. Further, it has all but ensured that industry struggles will continue well beyond 2014.”

[See also: MU Stage 2 offers 2014 flexibility.]

CHIME and other industry organizations had proposed reporting on Stage 2 requirements for any three-month quarter. In their view, it was a practical approach, one that made it more likely they would succeed and one that showed their continued support for the Meaningful Use Program.

Branzell further notes that nearly every stakeholder group echoed CHIME's recommendations to give providers the option of reporting any three-month quarter EHR reporting period in 2015. The recommendations he argued would "help hundreds of thousands of providers meet Stage 2 requirements in an effective and safe manner. Further, it would serve as positive incentive for those who must seek alternative paths to MU in 2014 to continue their work in 2015. Such a change would also have benefits for cross program alignment in areas of clinical quality measurement.

"This sensible recommendation, if taken, would have assuaged industry concerns over the pace and trajectory of rulemaking; it would have pushed providers to meet a higher bar, without pushing them off the cliff," he added in his statement;  "and it would have ensured the long-term vitality of the program itself. Now, the very future of Meaningful Use is in question."

As of August 25, 143 eligible hospitals and 3,152 eligible providers had attested to Stage 2. So far, the program had paid nearly $25 million in incentives.

[See also: MU Stage 2 offers 2014 flexibility.]

Marc Probst"The numbers are very low for particularly Stage 2 attestation. I mean, they’re like, what 4 percent of what should be, you know, currently going for Stage 2," Marc Probst, CIO of Intermountain Healthcare, and a member of the Health IT Policy Committee, remarked at a meeting of the federal advisory panel on September 3.

Probst was responding to CMS' Elizabeth Myers, who pointed out there was indeed flexibility in the final rule, but added there had been a lot of misunderstanding concerning reporting periods.

"I’m just wondering if we have a goal," Probst said. "I mean is it 10 percent by making these changes we should now get, 10 percent? 50 percent? I mean, there’s no way we’re going to get 50 percent, but, you know, I’m kind of going to why this set of rules, this very complex set of rules when there were some pretty obvious ones that we decided – ONC and CMS decided – not to pursue that could have had a much bigger impact."

It's a good question.

Part of the problem is that U.S. healthcare organizations everywhere have been barraged with a slew of government requirements, most of them complex and with a dizzying number of timelines. It's as if they are being told, "Do this; do that, and when you're done, make sure you dot the "i's and cross the "t's," and don't forget this other project, and the next one after that." If you don't get it all done right, there will be penalties to pay.

As if to prove our point, the day this issue was set to go to press, ONC issued yet another “final rule,” dropping its controversial 2015 edition certification criteria and instead opting for a more flexible version of the 2014 edition. The new rule is meant to “respond to stakeholder feedback,” wrote National Coordinator Karen DeSalvo, MD – but many CIOs might be forgiven for not being exactly thrilled about another 187-page document to digest.

The constant rulemaking – and revising – starts to get daunting and dizzying, even for the most detail-oriented.

Barring a change of rule, which does not seem likely – it is, after all, called a "final" rule – providers, hospitals and IT staffs are stuck with the mandate. And as trite as it may sound, the only choice is doing the best they can do, which calls for planning, maybe hiring more help and dotting one "i" and crossing one "t" at a time, or else absorbing penalties.

As for the government directives, couldn't the government at least align mandates so that deadlines do not compete with one another? Create rules that intelligent, savvy people, like Probst and his CIO colleagues can readily understand?

Sure, it's complicated. But, perhaps CMS and ONC could consider adding a large dose of simplification.

The Meaningful Use Program has garnered broad support as a way to truly transform our ailing healthcare system. It would be a shame to lose all that steam at Stage 2.

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DeSalvo praises Vermont for HIE infrastructure efforts |

National Coordinator for Health IT Dr. Karen DeSalvo applauded Vermont’s efforts to continue building a health information exchange (HIE) infrastructure that includes broadband access in rural areas of the state while speaking at the annual Vermont Information Technology Leadership (WITL) summit this week.  With very high EHR adoption rates among hospitals and physician providers and a long-term effort to bring HIE capabilities to the state’s healthcare organizations, DeSalvo held up Vermont as an example to the nation during her keynote address.
“People are willing to share their data if it will improve their care and will help others, as long as it doesn’t lead to discrimination against them,” said DeSalvo while discussing the state’s 90% patient consent rate to be involved in the VITL Access health information portal, which began rolling out to providers in August.   Ninety-three percent of the state’s hospitals and 64 percent of primary care organizations have adopted the HIE technology, the Burlington Free Press reports.
VITL also provides Direct messaging services and is working to bring admission, discharge, and transfer (ADT) notifications to providers later in the year. “This fall is really going to see nine years of work come to fruition, and the hopes and dreams of a statewide information system actually being available,” said Paul Harrington, executive director of the Vermont Medical Society.
At the end of 2013, VITL completed a successful pilot with Fletcher Allen Health Care that tested the exchange of radiology reports. “Hospitals generate volumes of clinical data that can be critically relevant for treating patients in order to enhance care, so it is invaluable for providers to have immediate access to patient health information, especially at the point of care,” said John K. Evans, CEO of VITL at the time. “What we learned through the pilot is that the development time of these interfaces can be dramatically improved by expediting decisions related to specifications and testing.”
Vermont has been at the forefront of EHR adoption and has achieved nearly universal implementation rates, with all 14 of the state’s hospitals and 97% of primary care practices now live on an EHR.  VITL also functions as the state’s regional extension center (REC) and has helped numerous providers to implement technology and achieve meaningful use.

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ONC opts against proposed voluntary 2015 EHR certification |

In light of public comments, the Office of the National Coordinator for Health Information Technology (ONC) has given up on its proposal for “Voluntary 2015 Edition” EHR certification criteria.
Instead, the federal agency revealed plans incorporate components of a revised 2014 Edition EHR certification criteria to be known as either “2014 Edition Release 2″ or “2014 Edition Release 2 EHR certification criteria” as part of a recent final rule published in the Federal Register.
“This final rule reflects ONC’s commitment to continually improve the certification program and respond to stakeholder feedback. It provides more choices for health IT developers and their customers, including new interoperable ways to securely exchange health information,” National Coordinator Karen DeSalvo, MD, MPH, MSc, said yesterday. “It also serves as a model for ONC to update its rules as technology and standards evolve to support innovation.”
The decision is motivated by the belief that a more direct naming convention will provide greater consistency and predictability across governmental programs. “Stakeholders that seek to leverage the ONC HIT Certification Program would then be able to choose which edition of certification criteria (or subset of criteria within an edition) is most relevant and appropriate for their program needs,” states the final rule.
Along with the Centers for Medicare & Medicaid Services (CMS), ONC will be hosting a webinar to discuss recent changes to meaningful use in 2014 — one for reporting flexibility for eligible providers depending on their version of certified EHR technology (CEHRT) and this most recent one changing voluntary EHR certification criteria.
The final rule for 2014 Edition Release 2 certification criteria comprises ten optional and two revised certification criteria which are included with the 2014 Edition. Additionally, the rule brings an end to one major concept — the Complete EHR.
“We have finalized our proposal to discontinue the Complete EHR definition and Complete EHR certification,” the authors of the final rule write. “To be clear, the discontinuation of the Complete EHR definition and Complete EHR certification will have no impact on current 2014 Edition Complete EHR certifications or in using a 2014 Edition Complete EHR to meet the current CEHRT definition.”
The elimination of the Complete EHR definition addresses concerns from commenters about being able to verify to which certification criteria an EHR technology was certified and avoid ambiguity that does not occur for EHR modules that must specify such details.
“Last, while we do not believe the use of the terms ‘Complete’ or ‘Comprehensive’ are appropriate for ‘labeling’ EHR technology going forward, we will consider for our next rulemaking whether any other ‘labeling’ for certified technologies could continue to make the scope of certification clearer,” the ONC concludes.
Based on the decisions of the ONC and CMS, the two agencies are listening to stakeholders. But the question remains: Are their decisions only adding to the confusion?

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HIMSS warns of full-year meaningful use reporting in 2015 |

The Healthcare Information and Management Systems Society (HIMSS) is arguing that a recent final rule with the purpose of giving eligible providers greater flexibility for meaningful use in 2014 will still lead to problems in 2015 as a result of full-year reporting requirements.
In a letter to Department of Health & Human Services (HHS) Secretary Sylvia Mathews Burwell, the association is particularly sensitive to the certified EHR technology (CEHRT) challenges facing eligible hospitals whose reporting year begins soon because it is based on the fiscal year.
“HHS’s decision to require a full-year of reporting using 2014 Edition CEHRT in 2015 puts many eligible hospitals (EHs) at risk of not meeting MU for 2015,” the letter states. “Under current regulation, EHs must use 2014 CEHRT in less than one month. If they do not, they become ineligible for incentive payments and they are subject to downward 2017 Medicare payment adjustments.”
In lieu of a full year of meaningful use reporting, HIMSS is calling on HHS to consider a quarterly approach similar to previous phases of the EHR Incentive Programs with the hope that it will ensure success for more hospitals and progress toward interoperability:
We urge the Department to revisit its position on the 2015 reporting period and CMS to change the MU reporting requirements for 2015. For providers not in their first year, CMS should allow such providers to meet MU requirements for any one quarter in 2015 rather than a full year. This approach copies CMS’s 2014 policy by allowing providers more time to implement a new 2014 solution, as well as to continue to prepare for a successful transition to Stage 2.
Many providers who were trying to meet the previous deadlines for 2014 (and as applicable, MU Stage 2 in 2014) suspended those efforts and reconfigured their systems to meet the just-finalized 2014 requirements. With the August 29 final rule, and 2015 requirements beginning for EHs on October 1, too many technology and process changes are required in too-short a period. In addition, the January 1, 2015, deadline for eligible professionals (EPs) to implement 2014 is nearly upon us. Requiring a full-year of reporting is unrealistic.
In response to concerns presented by the Centers for Medicare & Medicaid Services (CMS) in the final rule about the long-term effectiveness of meaningful use should further requirement be reduced, HIMSS foresees a much more dangerous threat to the EHR Incentive Programs emerging — an unwillingness among eligible providers to participate any longer.
“We appreciate how extending the use of a three-month reporting period beyond 2014 challenges long-held expectations for the MU program. However, if a full-year of reporting is required for 2015, we fear that large segments of the provider community will no longer participate in the MU program,” the association adds.

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FSMB announces finalized telehealth licensure model compact |

The Federation of State Medical Boards (FSMB) has finalized its model guidelines for telehealth licensure in an effort to reduce some of the most intractable legal barriers preventing physicians from engaging in telemedicine and remote care with patients in differing areas of the country.  The completed interstate licensing guidelines will speed the process of approving physicians to practice in multiple states, cutting through a tangled web of laws and regulations that has compartmentalized the telehealth industry and kept some patients from receiving the ideal level of remote care.
“With the drafting process complete, state legislatures and medical boards can now begin to consider the adoption of this model legislation establishing an interstate medical licensure compact,” said Dr. Humayun J. Chaudhry, president and CEO of FSMB. “The FSMB is pleased to have supported the state medical board community as it developed this compact to streamline licensure while maintaining patient protection as a top priority. We look forward to working with states that wish to implement this innovative new policy.”
“Today’s announcement is welcome news for physicians across the country seeking to provide and improve access to care for patients in multiple jurisdictions,” added Kevin Bohnenblust, executive director of the Wyoming State Board of Medicine. “This expedited process will let us meet our responsibility to allow capable and qualified physicians to practice medicine in a safe and accountable manner while protecting patients and expanding and improving care. The interstate compact will be a useful tool for medical boards seeking that balance.”
The compact opens up an additional pathway for expediting a physician’s accreditation with the state where the patient resides.  The newly-formed Interstate Commission will establish a database of physicians who have applied for multiple licensures, and will include voting representatives from the FSMB member state boards to give all organizations a stake in future provisions or actions related to the compact.
The announcement was also welcomed by the American Medical Association, which recently adopted new telemedicine reimbursement guidelines of its own.  “The American Medical Association has long supported reform of the state licensure process to reduce costs and expedite applications while protecting patient safety and promoting quality care,” said Robert M. Wah, MD, President of the AMA. “State-based licensure is an important tenet of accountability, ensuring that physicians are qualified through the review of their education, training, character, and professional and disciplinary histories.The interstate compact aligns with our efforts to modernize state medical licensure, allowing for an expedited licensing pathway in participating states.”

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EHRs cause physicians to lose 48 minutes per day, survey says |

As a physician, free time is a scarce enough commodity without having to factor in convoluted EHR workflows and frozen computers, but a large number of providers surveyed by the American College of Physicians (ACP) are still reporting significant productivity losses due to their EHR technology.  In a letter published in JAMA this week, participants in the poll reported an average of 48 minutes lost each day to EHR woes including sluggish record retrieval and cumbersome documentation processes.
Researchers from the ACP and National Institutes of Health surveyed more than 400 physicians and trainees from a wide variety of practice types.  The providers used 61 different EHR systems, with three-quarters of the respondents using one of nine most popular products.  Eighty-two percent had been using their EHR systems for more than a year, and 70% reported being familiar with a broad range of functionalities.
Despite the fact that most participants were experienced EHR users, their dissatisfaction with the impact of the technology on their daily workflow was clear.  Just under 90% of participants reported that at least one data management function was slower after implementing an EHR, with 63.9% stating that writing clinical notes took longer with the electronic system.  A third added that finding and reviewing data, including notes authored by other physicians, took longer with the EHR than without.
Nearly 60% of providers reported losing time to their EHRs.  Of those providers, the mean loss was 78 minutes per day, or 6.5 hours per five-day week.  The entire cohort of responding attending physicians, including those who didn’t signal that EHRs slowed them down, reported a mean loss of 48 minutes per day to EHR technology, while trainees only dedicated 18 minutes of extra time to their keyboards.  Providers who reported using the VA’s Computer Patient Record System (CPRS) experienced the least loss of free time with an average of just 20 minutes.
“The loss of free time that our respondents reported was large and pervasive and could decrease access or increase costs of care,” the letter concludes.  “Policy makers should consider these time costs in future EMR mandates.  Ambulatory practices may benefit from approaches used by high-performing practices – the use of scribes, standing orders, talking instead of email – to recapture time lost on EHR.  We can only speculate as to whether better computer skills, shorter clinic assignments with proportionally less exposure to EMR time costs, or other factors account for the trainees’’ smaller per-day time loss.”

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The Misalignment Between "Incentives" and "Purpose"

The Misalignment Between "Incentives" and "Purpose" | EHR and Health IT Consulting |

I’m often left puzzled when I read some of the tweets and blog posts out there that talk about the “purpose” of a certain product. It might be the “purpose for the EHR” or the “purpose of meaningful use” or the “purpose of HIE.” It doesn’t really matter which product, initiative or program we’re talking about. Their comment assumes a certain “purpose” is why something is being done.

I’ve always hated when people say this unless they include plenty of modifiers (which is often not possible on things like Twitter). The problem is that the purpose for something changes completely based upon who you’re talking about. Plus, even if we’re on the same page about who we’re talking about, I often ask myself the question, “Is that the purpose of that product?”

The real purpose of any business is to make more money for its shareholders. This focus doesn’t mean that a company can’t do a tremendous amount of good along the way. This focus doesn’t mean that a higher purpose for a product might make a lot of business sense as well.

My favorite is when people say things like “meaningful use is suppose to improve patient engagement.” Is it really? This might be the purpose of meaningful use for some, but I don’t know a single doctor who looks at meaningful use and thinks “Wow, that’s a great program that I want to do because it will improve patient engagement.” For most doctors, they see the purpose of meaningful use as a way to justify the distribution of billions of dollars towards EHR software. Certainly many doctors will twist this idea a lot of ways (ie. Meaningful use is a way to get more data and pay us less.). Perspective matters when we talk about purpose.

HIE is another great example. What’s the purpose of HIE? Is it to lower costs of healthcare? Is it to provide amazing continuity of care? Is it to lock in a hospital’s relationship with outside doctors? Is it a way to do population health? I could go on, but hopefully you get the point. It depends on who you’re talking to and what they’re trying to achieve. Perspective matters when talking about purpose.

Understanding people’s true motivations or purposes is important to making sure you’re providing the proper incentive. If there’s a misaligment between the incentives and people’s true purpose, then you’re not going to see the action and results that you desire.

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HHS tackles EHR, data disaster preparedness through HIE |

The Department of Health and Human Services (HHS) is ramping up its efforts to help providers safeguard their health IT systems against natural or man-made disasters with a series of pilots and new initiatives.  In a blog post on HealthITBuzz, National Coordinator Karen DeSalvo, MD, MPH, MSc and Gregg S. Margolis, PhD NREMT-P, detail the Department’s efforts to identify at-risk patients and keep providers connected to important data during emergency situations.
“The question isn’t whether or not we will have another disaster – it is just a matter of when, where and how severe it will be,” DeSalvo and Margolis write.  Citing the recent earthquake in Northern California that sent dozens of patents to the emergency room in the small hours of the morning, DeSalvo and Margolis note that the disaster “serves as a reminder that we must be prepared for the unexpected no matter where we live.”
Storms, earthquakes, or other events that cut off electricity and internet to hospitals and emergency centers can be extremely problematic for organizations that rely on electronic health records to store and access patient data.  The ONC has been working with state emergency services in California to connect the state’s patchwork of health information exchanges (HIEs) with EMS organizations to ensure widespread access to data during an emergency.
However, “we simply cannot make assumptions about how best to prepare for emergencies,” the post notes.  During a demo day hosted by the White House this summer, HHS introduced two new initiatives to help centralize data and allow local organizations to develop disaster response plans.  The first project provides a single website that aggregates real-time data from Twitter to pick out trends related to public health in an emergency situation.  The second website, still in development, will include an interactive, open data map that highlights the number of Medicare beneficiaries reliant on electricity down to the zip code level.  The map will be correlated with weather data from NOAA to warn providers of severe storms that may cut power to elderly patients dependent on home medical devices to stay alive.
“Technology and health information technology have the power to inform and help survivors, first responders, and local, state, tribal, territorial and federal governments with critical information and resources related to emergencies,” DeSalvo and Margolis conclude. “The projects outlined above are just a few examples of the many ways we are working towards the goal of better preparing and supporting communities and survivors before, during and following a disaster.”

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Personal Healthcare: Big Data Great, Small Data Better - InformationWeek

Personal Healthcare: Big Data Great, Small Data Better - InformationWeek | EHR and Health IT Consulting |

Big data is a big deal for healthcare. It will help uncover correlations that can lead to cures and treatments for disease. However, small data is important, too -- information from individuals can ultimately contribute to big data and lead to important discoveries.

The big question: Can we make personal healthcare seamless, simple, and inexpensive for each patient? If we manage to do this we'll accomplish something that no one has yet achieved.

Creating "personal" health management tools for complex consumers is not easy. A familiar term these days is "population health" -- it means coming up with solutions to manage personal health behavior in a systematic way while remaining accountable to very large groups of diverse people. The right kind of technology can certainly help do that, but only if it is flexible enough to adjust to the needs of everyone -- from healthy people to those with chronic conditions who need assistance managing their illness -- without making them feel bogged down.

[IoT holds unlimited potential -- will we use its powers wisely? Read Internet Of Things: Limitless Dumb Possibilities.]

The best case would be a tool that can manage our health in a way that is passive or that results from tasks we are already doing. An example is the population management tool platform, which assesses patient behavior through sensor data collected through an app or smartphone. It notifies your doctor if it detects behavior changes that match clinical indications of depression or other diseases, with no action required by you, the patient.

I've assembled this Personalized Medicine Model as a framework to help guide self-monitoring and care. As you will see, all four areas are interconnected:

Table 1: Personal Health Data

Genetic Lifestyle Interventional MonitoringPredispositionDietProceduresContinuous/ScheduledEffectivenessExerciseMedicationsPredictiveFamily HistoryHealth HabitsVisits/AdmissionsTrends

Genetic data is supported by both lifestyle and interventional data, and the monitoring function tracks and balances it all. For example, people with diabetes could monitor their diet and exercise programs, and that data could help them and their physicians determine whether they need different medications or new diet or exercise programs.

Tech companies recognize the potential of smartphones to boost population health and are rushing to get innovative solutions to the market. The company that can save patients and healthcare providers money while also improving patients' health will be king: Billions of dollars are at stake if we can connect the dots between the small data that can maximize an individual's personal care and the big data that can uncover solutions that can have a global impact.

A serious challenge for technology experts is how to ensure privacy as we track and quantify biometrics and other information as never before. A solution that can collect data effortlessly and provide practicable alerts for care shows promise, and it's already HIPAA-compliant.

It's not yet clear whether physicians fully understand the benefits of health platforms like Google Fit, Apple's HealthKit, and Samsung's SAMI. Many practitioners may feel that they already have enough challenges without needing to track additional datasets. Time will tell whether providers will tap the power of these tools.

But as healthcare systems across the country implement EHR systems, it makes sense to extend access to consumers and patients. These systems can help patients integrate their health information with "life-logging" devices to manage their own chronic conditions, for example, or simply to know when to schedule a colonoscopy. Physicians who have so far been unimpressed with digital health technologies may come around once they see the benefit of having EHRs connected with personal health platforms that facilitate care for all patients.

That may be the seamless, simple, and inexpensive solution we are looking for.

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Why Healthcare Professionals Should Blog | HealthWorks Collective

Why Healthcare Professionals Should Blog | HealthWorks Collective | EHR and Health IT Consulting |

A blog (a truncation of the expression web log) is a discussion or informational site published on the World Wide Web and consisting of discrete entries ("posts") typically displayed in reverse chronological order (the most recent post appears first) Wikipedia definition.

Most blogs combine text, images, and links to other blogs, Web pages, and media related to its topic. They differ from static websites because they are more interactive - allowing for real-time comments and discussion - and (ideally) are updated with fresh content on a regular basis.

Healthcare blogs vary in content and style; they range from commentary on a topical issue to patients sharing the lived experience of a disease and healthcare professionals educating patients on the management of an illness. Blogs written by doctors, nurses, health researchers, patients, and healthcare and digital marketers and innovators add much to the richness and diversity of the online healthcare conversation. Many of these blogs are widely read and shared through social media, establishing their writers as authorities and go-to experts on a particular illness.

There are several ways that healthcare professionals can benefit from creating their own blogs. Below are some of the most important.

#1. Develops Clinical Reflective Writing Skills

Reflective capacity has been described as an essential characteristic of professionally competent clinical practice. Dr Prashini Naidoo describes reflective writing as “purposeful thinking about an experience through which learning takes place”.  In addition to learning, Dr Rita Charon, Professor of Clinical Medicine and Director of the Program in Narrative Medicine at the Columbia University College of Physicians and Surgeons believes that “writing improves clinicians’ stores of empathy, reflection, and courage". 

When I asked Dr Richard Cook, a UK-based GP who blogs as Dr Moderate, his reasons for blogging, he answered: "My blog prompted me to think more deeply about the everyday things I encounter at work". And Kentucky-based cardiac electrophysiologist, Dr John Mandrola credits blogging with making him a more informed doctor: "It is astounding how much I have learned in the quest to talk smartly about medical science. Without doubt, this blog has made me a more informed doctor".

#2. Provides Patient Education

When a patient is newly diagnosed with an illness, they will inevitably have many questions.  It is most probable that many other patients have the same questions. Building a repository of information about these frequently asked questions is a valuable resource for patients and a time-saver for the physician who can easily refer patients to their blog. Dr Ronan Kavanagh, a rheumatologist based in Ireland, provides a good example of providing patient education on his blog. 

#3. Establishes Your Expertise  

Blogging can establish you as the go-to person in your field of expertise, increasing your credibility and online visibility. Dr Howard Luks, a Board-Certified Sports Medicine and Orthopedic Surgeon points to his post on whether or not a meniscus tear requires surgery  as "the most valuable question I answer on my website and the greatest driver of traffic. Since I first posted the answer to that question in March of 2011, I have had more than 80,000 views on my website for that question alone and 235 comments".

#4. Increases Your Online Visbility

According to the latest Pew Research 72% of internet users say they looked online for health information within the past year with 77% of online health seekers using a search engine. Yet the majority of Internet users don’t scroll past the first page of search results. 35% of U.S. adults say that at one time or another they have gone online specifically to try to figure out what medical condition they or someone else might have.  The most commonly-researched topics are specific diseases or conditions, treatments or procedures, and doctors or other health professionals. Google uses a variety of ranking factors in their algorithm and while some are controversial, evidence shows that good quality content with credible references and links and appropriate keywords on a regularly updated blog is a proven ranking factor.  

#5. Creates A Community Of Change 

Blogging can be a vehicle for change. Health and social care change agent, Mary Freer writes that she blogs "because I want to have a conversation with you about the way we can shape the health system. Not in some heroic way, but little by little, people joining together and determining that they will reveal who they are and what they really care about".  

#6. Provides Opportunity To Learn From Patient Blogs

Family practitioner Dr Clive Brock believes that "patients have the best stories to learn with". Increasingly you will find those stories online in patient blogs. These blogs provide a rich repository of information about the lived experience of a disease. Patient advocate, Isabel Jordan of Canada's Rare Disease Foundation believes that "healthcare professionals can hear the unfiltered truth from patient blogs".

#7. Humanizes Your Practice

While it’s important to maintain ethical and professional standards online, it is still possible to share personal anecdotes from your own experiences practicing medicine or a particular patient case study (in compliance with HIPAA guidelines).  Blogging  also allows you to show the person behind the stethoscope. Dr Brian Stork is a Michigan-based urologist with a passion for bee-keeping which he shares about on his blog alongside more traditional health related topics.  

Next Steps

If you are already a healthcare professional who blogs, I hope this article has made you reflect on your own blogging motivation.  If you haven't started a blog yet but this article has piqued your interest, I will be sharing more tips and advice on starting and promoting a healthcare blog in the coming weeks. So stay tuned.

Via Plus91
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The Important Triad Of Needs For EMR Systems

If you do business in the Healthcare industry (unless you've been absent for a few years), you undoubtedly know about the Federal Government's scheme to pay for EMR systems across the United States. It's all part of the stimulus package, of course, which means a lot of free government money will be handed out this year and next. This has resulted in a huge change in the EMR software industry, as these systems make their way into medical practices still using paper medical records.

Selecting from the wide variety of EMR software products available today on the market is no simple job. With Federal subsidies flowing fast to support the industry, every software programmer with a cell phone wants a bit of the action. Cutting down the list of electronic medical records software shops to a manageable level is the first thing you should consider in order to make choosing the right EMR system vendor. Here are some considerations when planning your purchase of an EMR software system:

1. CCHIT Certification Means Quality - In response to the huge interest in the development of electronic medical records systems, the industry created a commission known as CCHIT (or the Certification Commission for Health Information Technology) in order to create standards for EMR software. Acquiring CCHIT-certification isn't cheap or simple, which is why it's as close to a guarantee that you're dealing with a superior product and company as the industry has. Avoid all non-CCHIT certified developers from the start, and your shortlist will be far more manageable.

2. Meaningful Use, And Its Great Importance - Of all factors, having a shop with high-quality knowledge of the Government's idea of meaningful use is important when searching for your EMR vendor. As part of the Government stimulus offer, doctors must demonstrate meaningful use of electronic medical records software, which isn't as simple as it looks. As with anything Government-built, there is an ocean of small print to work through to guarantee you can qualify for the immense Medicare subsidies. Ensure you ask your potential developers for their approach to meaningful use, and ask that they provide recent references of doctors whose meaningful use claim went through easily.

3. Keep It Simple - Outside of meaningful use and CCHIT-certification, no aspect is morecrucial for your practice than your EMR system's ease of use. Keeping it simple, in this case, will save you more time and expense than you ever thought possible. The savings are all there: an easy to use EMR product is embraced quicker by your staff, learned faster, and has less potential for confusing moments once the installation has taken place and the application is operating. This can cut the cost of training your staff with the software markedly, and can save your practice countless support call dollars in the long run. Put simply, people like easy to use systems, and embrace them faster. When you look at ease of use, you don't have to be an expert: just use your gut. Once you've developed your 4-5 EMR developer shortlist, obtain all of their product demos. Install them on your computer (if there's no Windows version, you may want to move on!), get the feel for them for about an hour each, and see how you feel. Make your shortlist shorter by cutting away the more complex products.

Purchasing an electronic medical record system is not an simple task, but with the stimulus funds soon to expire, it is a timely one. Make sure your developer knows its stuff, and selecting a best of breed from the broad selection of EMR systems should be easy.

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Does EHR design limit the critical thinking of physicians? |

This week will include a fair share of praise for health information technology and its benefits for supporting efficient and effective care, but it comes on the heels of some harsh criticism by one California pediatrician who is arguing that EHR technology hinders the critical thinking of physicians.
“As a physician, I do not want my thinking to be limited in any possible way by a template that I need to fill out in order to create a note,” writes Charles McCormick, MD, FAAP. “Every patient is different, and not a single one of us fits into the same box. We are, unfortunately, dumbing down medical care providers just like we dumbed down our teachers.”
In his harangue of EHR use, the Stockton-area physician identifies two deficiencies in the current technology preventing healthcare organizations and providers from realizing the promised benefits of adopting these systems and services — a lack of interoperability and template design.
“Different record systems currently do not communicate with one another, although records can be copied and sent to another physician,” McCormick contends. “Hospital systems are substantially different from systems used in private offices and the systems used in our local hospitals are often strikingly counterintuitive and Byzantine.”
For the pediatrician and Associate Medical Director for Health Plan of San Joaquin, the EHR presents constraints for physicians looking to engage actively with their patients during encounters.
In my practice, I have been using a federally approved EMR for the past year, and I find that a significant portion of my thinking is directed toward how to record a patient visit rather than what actually happened in the visit. Previously, I had used a record-keeping system in which I recorded information in my own handwriting, and I would note those things that were important to me so that I could reference them later as I cared for my patient.
Today, I have to figure out how to get the important information into a box somewhere in the medical record. This usually means about an extra hour every day to make my notes meaningful. Mixed in with the important information is a large quantity of trivial or insignificant information that obscures what is really crucial. There is nothing concise about the modern EMR!
The not-so-subtle dig at meaningful use and certified EHR technology (CEHRT) is full of complaints about the effects of a physician adjusting his thinking to suit the electronic record rather than applying his critical thinking to providing a patient with the treatment best suited to the latter’s condition.
Apparently, the problem with current EHR templates is a lack of space for physicians to document those bits of information that do not conform nicely with check boxes and drop-down fields.
“We spend more and more time struggling to use a technology that actually limits the creative process and less time facing our patient and thinking about their problems. Applying an old cliché, we need to resume thinking out-of-the-box,” McCormick concludes.
As National Health IT Week begins, the pediatrician’s criticism is a reminder that EHR technology is not perfect and that its shortcomings need to be addressed and resolved.

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How Does a Practice Deal with All These High Deductible Plans?

How Does a Practice Deal with All These High Deductible Plans? | EHR and Health IT Consulting |

One of the biggest trends we’re seeing in healthcare today is a shift towards high deductible plans. This shift first started as more and more employers stopped offering insurance or cut the type of health insurance they offered. This started the trend towards individuals purchasing high deductible insurance plans.

While the shift to high deductible insurance plans started well before the Affordable Care Act (ACA), the government mandated health insurance and associated health insurance exchanges (HIX) have thrown gas on the already flaming fire. What most patients didn’t realize when they signed up for insurance on the government’s HIX is that a large majority of the plans were high deductible insurance plans. This has led to a huge influx in high deductible plans entering medical offices.

What does this increase in high deductible plans mean?
This change is one of the most significant changes in healthcare reimbursement we’ve seen. High deductible plans mean a major shift in who will be paying the bill. Instead of collecting most of your money from insurance companies, your clinic will need to become expert at collecting money from patients as well. Yes, that’s right. You’re still going to have to collect from the insurance companies like before, but you’re going to have to build additional expertise around collecting payments from patients too.

While it’s true that clinics have been collecting payments from patients forever, that doesn’t mean that clinics have been doing a good job of actually collecting the money. In fact, I find practice after practice who hasn’t stayed on top of their patient collections. In the end, they often send their patient collections to a collections agency which frustrates the patients and tarnishes their name or they just write off the patient pay portion completely.

Suggestions to Improve Patient Collections
The first step to improving patient collections is to really understand the details of your patient’s insurance plan. This starts with doing an insurance eligibility check and verifying your patient’s plan details. We wrote about ways to streamline your insurance eligibility checks previously. Doing it right takes time, but with the right workflow automation solutions you can make sure that those working in your practice have the right insurance information. Once they have the right payment information, you’re much more likely to collect the payment from the patient while they’re standing in front of you at the office.

While collecting the patient payment from the patient while their in your office is ideal, there are dozens of reasons why this won’t happen. Some don’t have the money on them. Some walk out before you can collect. Etc etc etc. How then do you engage the patient in the payment process once they’ve left your office? In the past, the best solution was to send out bill after bill through the US postal service or possibly call the patient directly. This is an extremely time consuming and costly process that can take 60 to 90 days to obtain results.Plus, it costs several hours of man power and postage.

In the electronic world we live in, the first thing you can do to improve your patient collection process is to implement an online patient payment portal. This online payment process increases patient collections dramatically. The next generation patient is so unfamiliar with writing checks and sending snail mail, that those payments often get delayed. However, by offering the online patient payment option, you remove this barrier to payment.

The other way to improve patient collections is to use an automated messaging and collection process. This approach uses a collection of text, secure text, email, secure email and even smart phone notifications and automated calls in order to ensure the patient knows about their bill and has the opportunity to pay the bill. Plus, these customized decision rules provide a much more seamless and consistent approach to patient collections.

This movement to the empowered patient with a high deductible insurance plan is not likely to go away. Employers are happily getting out of the health insurance business and many want patients to have more responsibility over the healthcare they receive. Being sure that you have a well thought out patient collection workflow is going to be critical to the ongoing success of any medical practice

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68% of patients would be interested in telehealth consults |

More than two-thirds of patients would be willing to give a telehealth conference a try, according to a new study in Telemedicine and E-Health, although a number of patients who tried conducting a physician visit through videoconferencing were not satisfied enough with the experience to continue online consults.  While most patients had access to broadband internet and a home computer or smartphone device, just 14% of patients believe that a telehealth consults brings them more value than meeting face-to-face with their provider.
The team of researchers from the Mayo Clinic conducted a telephone survey with 263 patients with an average age of nearly 58 years.  Eighty-four percent of patients had access to a computer or smart device, and 75% had access to broadband internet.  Just 38% felt comfortable setting up a video call on their own, but 57% believe their home technology is capable of doing so.  Perhaps unsurprisingly, the study found that patients who reported a higher level of comfort with video call technology were also more likely to accept a telehealth invitation from their providers.
Thirty-eight percent of the participants responded that they were “very likely” to engage in an online visit with their providers, while a further 28% were “somewhat likely.”  The remaining 38% indicated that they were “not at all likely” to engage.  Patients who had not participated in a video call before were much more skeptical about its benefits than those who had tried the novel method, with 86% preferring a face-to-face encounter and just 34% believing that a telehealth consult could provide the same level of care as an office visit.  However, 64% of patients who had experienced a video consult still preferred to speak to a provider in person about their health issues, indicating a questionable level of satisfaction from online meetings.
“The gap between high willingness to engage with a provider over video and the relatively little experience with the medium suggests that patients see video appointments as a feasible and desirable way to interact with their providers,” the study says. “They may be dependent, however, upon their provider to offer the service; they may not voluntarily ask for it because of a lack in fluency with related use cases.”
The researchers found three major drivers that led to higher levels of acceptance for telehealth use, including the patient’s comfort level with video technology, their age, and the distance they would have to travel to meet with a physician.  Patients who were most likely to accept a telehealth consult also reported high levels of technical ability, while those who lived a longer driving distance from their provider were more likely to try an online visit instead of making the trip.
“Those with a willingness to accept a video appointment had a mean age of 55.4 years, and the mean age was 64.1 years for those not at all likely to accept,” the team adds.  “Age also had a larger effect among those who were comfortable: increasing age was actually associated with a higher likelihood to accept an invite.”
“It is evident that patient demand for video appointments from their homes is nascent, but that there is, nevertheless, a core of patients whose interest could be leveraged to help nurture mainstream usage,” the study concludes.  “Interest in the service, once offered, is highly dependent on the patient’s willingness and confidence to co-create the experience by obtaining and setting up the components required for a video appointment on his or her end.  If the obstacles to creating and offering a reliable video appointment service can be overcome, for patients who have the interest, aptitude, and confidence, there exists an opportunity to co-create the broader experience and availability of video appointments.”

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Are Limited Networks Necessary to Reduce Health Care Costs?

Are Limited Networks Necessary to Reduce Health Care Costs? | EHR and Health IT Consulting |

Among the dirty words most hated by health care consumers–such as “capitation” and “insufficient medical necessity”–a special anxiety infuses the term “out-of-network.” Everybody harbors the fear that the world-famous specialist who can provide a miracle cure for a rare disease he or she may unexpectedly suffer from will be unavailable due to insurance limitations. So it’s worth asking whether limited networks save money, and whether they improve or degrade health care.

As I understand it, four reasons are seen for limiting the doctors covered by an insurance plan.

Increased utilization of approved facilities

This is a pure business concern, not a quality concern. If you can channel patients back into a few hospitals and clinics, you can keep your beds filled and save the money wasted when bored staff sit around posting travel photos to Instagram.

Excluding expensive facilities

Another business concern. Studies have shown no correlation between the prices charged by health care providers–including world-famous facilities and prestigious academic settings–and the quality of outcomes. So just by artificially lopping off the institutions that charge a lot, insurers can save money while still serving their recipients well.

Better coordination of care

Now we move beyond the bean-counters and enter into real issues of quality. Supposedly, institutions that know each other through frequent referrals can work more closely together, making sure that post-discharge plans are followed and patients are kept on track for improvement. There is no guarantee that such coordination will happen, but it’s a goal of health reform and underlies the Accountable Care Organization (ACO) model.

More intensive use of primary care providers

Ideally, every professional in health care would develop a holistic understanding of the patient and think long-term. In practice, the PCP is most likely to do so. (With the intensified use they’ve seen over the past several years, and consequent shortening of time spent with each patient, this valuable perspective may be less common.) If a limited network can encourage the patient to rely more on his PCP, it may keep him healthier.

I was stimulated to write this article by a recent paper by the National Bureau of Economic Research (NBER) examining the costs of health care in my state, Massachusetts. The statistical models used in this article are hard for non-specialists like me to get their heads around, but the study looks well-grounded (as one would expect from the NBER, one of the country’s leading research institutions) and the conclusions are reassuring.

People who choose limited networks pay much less, mostly because the premiums for such networks rise much more slowly than for broad networks (p. 12). The Commonwealth of Massachusetts also benefited from cost savings. Although the data provide very little on which to judge the quality of outcomes, the few statistics available on such measures as inpatient spending and emergency room visits (p. 25) indicate that quality of care for limited networks is at least as good as for broad ones.

As one might expect, the narrow plans deliberately excluded expensive health care providers (pp. 5-6).

The one variable I’m not sure the authors could control for is the possibility that healthier people were more likely to choose limited plans (p. 27), and that costs might naturally be lower for such individuals. I will have to trust that the authors took this possibility into account.

The challenge I’d like to toss into the ring is this: couldn’t a rational health care system achieve all the benefits of limited plans while allowing patients to see anyone they want? Let’s consider again the four benefits I mentioned earlier:

Increased utilization of approved facilities

A rational health care system would pay for outcome instead of utilization, encouraging hospitals and clinics to put their spending where it was needed and hold back from expensive purchases that require excess use to pay off.

Excluding expensive facilities

A rational system would collect and publicize quality measures, and place some of the financial burden on patients to encourage them to do some price-shopping. Both of these innovations are starting to be seen. Idealists among us can even hope for a standard set of fees to replace the current chaotic negotiations between provider and payers.

Better coordination of care

If patient data was stored in a standardized format–preferably by the patient herself–all providers would have access, and a fee-for-value reimbursement model would encourage them to work together for better outcomes.

More intensive use of primary care providers

A holistic approach to health–which would reach outside the individual doctor’s office to the whole community in which the patient lives–would make the PCP the natural starting point for all health issues and give PCPs the tools to maintain patient health year-round.

So even though I acknowledge the value of ACOs and other forms of limited networks so long as our current health care system is limping along, the need for that kind of trade-off could end if we lift our eyes a little higher, look farther toward the future, and make strides toward better goals.

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4.2M gain insurance under ACA, but IT glitches cost big bucks |

At least 4.2 million patients have gained health insurance coverage since the implementation of the Affordable Care Act, but states that experienced severe IT glitches with their health insurance exchanges have seen significant economic losses that average $745 per patient per year, says Amanda Kowalski in a Brookings Institute report on the early impacts of the healthcare reform package.  States that successfully launched their own insurance exchanges have fared much better on a financial basis than those that relied on the federal exchange or those that had problematic roll-outs of the new technology.
While average per-person premiums increased over 24% by the second quarter of 2014, the number of patients insured under private, individual plans jumped to at least 13.2 million, including the 4.2 million who would not have otherwise been insured, writes Kowalski, a non-resident fellow of the Brookings Institute in Economics and a faculty member at Yale University.  The marked increase in premiums stands in stark contrast to data from Massachusetts, an early pioneer of universal coverage, which saw a significant decrease in prices after implementation in 2006.
The biggest financial losses came in “direct enforcement” states that declined to set up their own insurance exchanges, instead ceding power to the federal exchange.  The difficult launch of may have contributed to the $245 per participant average losses experienced by Alabama, Missouri, Oklahoma, Texas and Wyoming.
In a lesson that will be very familiar to EHR adopters, states that experienced severe technical problems were among the biggest financial losers of 2014.  Hawaii, Maryland, Minnesota, Nevada, and Oregon are worse off by $750 per participant on an annual basis, while states that had success with their own exchanges have actually gained $420 per person.  Maine saw the greatest gains with $1500 per market participant, while Oregon came in at the bottom of the heap with an $850 annual loss.
“The impact of setting up a state exchange depends meaningfully on how well it functions,” Kowalski writes. “Although impacts within each state are likely to change over the course of 2014 as coverage, costs, and premiums evolve nationally, I expect that the differential impacts that we observe across states will persist through the rest of 2014.”


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EHRs are “a source of stress” for physicians, AMA says |

Physicians who feel like they can’t deliver quality care to patients have low levels of job satisfaction, and EHRs are the biggest obstacle to providing the best possible services, argues the American Medical Association (AMA) and the RAND Corporation in a new report.  Cumbersome workflows and confusing interfaces are a significant source of stress for providers who want to focus on their patients, contributing to high levels of disgruntlement that may serve as an early warning of deeper problems in the healthcare system.
“Many things affect physician professional satisfaction, but a common theme is that physicians describe feeling stressed and unhappy when they see barriers preventing them from providing quality care,” said Dr. Mark Friedberg, the study’s lead author and a natural scientist at RAND, a nonprofit research organization. “Physicians believe in the benefits of electronic health records, and most do not want to go back to paper charts.  But at the same time, they report that electronic systems are deeply problematic in several ways. Physicians are frustrated by systems that force them to do clerical work or distract them from paying close attention to their patients.”
Backlash against poorly designed EHR systems and complex federal mandates is not a new phenomenon.  An overall feeling of skepticism and frustration with electronic charts has been well documented since the EHR Incentive Programs brought health IT into the majority of hospitals and physician offices.  A recent survey found that physicians are losing an average of 48 minutes per day to their laptops, while a Medical Economics poll from February states that 67% of providers are unhappy with their EHR systems’ functionality, and a similar number reported financial losses after implementing the technology.
According to the AMA and RAND, providers have been coping with their frustrations in a variety of ways, including finding creative ways to complete clinical documentation or hiring extra staff members such as scribes to help them meet the demands on their time.  Physicians who have more control over their workflow and the structure of their administrative responsibilities expressed higher levels of satisfaction with their work, while a sense of fairness, equity, and communication with peers and leaders also helped to raise morale.  While physicians are generally satisfied with their income levels, they strongly desire to work to the highest level of their training without being required to perform tasks that could be relegated to lower-level members of staff, such as the copious amounts of data entry often blamed on EHRs.
“EHR usability represents a unique and vexing challenge to physician professional satisfaction,” the report says.  “Few other service industries are exposed to universal and substantial incentives to adopt such a specific, highly regulated form of technology, one that our findings suggest has not yet matured. Nearly all physicians we interviewed say the benefits of EHRs and believed in the ‘promise of EHRs.’ On the other hand, physicians cannot buy, install, and use a promise to help them deliver patient care.”
Better usability of EHR systems should be “an industrywide priority,” the report argues, and should focus on creating technology systems that reduce regulatory and administrative burdens instead of creating them.  Physicians who feel overwhelmed by their EHR systems may not be delivering optimal levels of quality care, which has a serious impact on patient safety and outcomes.  Improving the EHR user experience to keep physicians working at the best of their abilities may be a crucial factor for ensuring the long-term success of the rapidly evolving healthcare industry.

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What goes into moving an inpatient EHR into the cloud? |

On the ambulatory side, adopting EHR and other health IT cloud-based systems and services are commonplace, evidenced by the type of developers and vendors dominating the space. However, a similar move to the cloud on the inpatient side of healthcare represents a larger and more difficult undertaking.
That is not to say that healthcare organizations in the acute care space are not making use of the cloud, but plenty goes into making the transition from local to hosted EHR and health IT systems.
“First off, the transition from their data center to ours takes several months,” says Joanne Burns, Cerner Senior Vice President and Chief Strategy Officer. “It takes months because you want to make sure there is no interruption in service.”
Burns is speaking of the work that will go into bringing Georgia Regents Medical Center into its hosting environment in Kansas City as part of the Jaguar Collaborative announced last week.
“We’re standing up hardware in parallel right now to what they’ve got, so it can be a seamless transition,” she continues. “We start running the system in Kansas City in parallel so that you have all your data and everything else can cut over seamlessly. There is a lot of planning that goes into that and that is not something that just happens overnight. It really is the end-result of some well thought-out planning.”
Additionally, there is the matter of health data privacy and security. According to Georgia Regents Vice President and CIO Charles Enicks, that is where working with an established health IT company becomes especially crucial.
“Whether they like it or not, we get involved from a security perspective to look at where the data is going, who’s storing it, do we have a business associate agreement, etc.,” he maintains. “Our data is going to be in Kansas City, so we know where it is going to be, and that’s part of the contract. They understand what they’re signing up for, and we found that to be an incredibly strong part of the relationship.”
As Joe Pinotti, Interface Engineer at Children’s Hospitals and Clinics of Minnesota, mentioned in his organization’s work toward improving health IT integration, connectivity is not the same in all parts of the country, especially those trying to connect with the Cerner data centers in Missouri.
“The clinic may be next door or your lab system is right here, but you’re really connecting down to Kansas City to do all of this stuff because it’s cheaper,” he reveals. “There are tons of jumps, hops, skips, and tunnels to go through to get down to Kansas City.”
How then are all these particulars about performance and conditions about security met? It is in the wiring.
“We have dedicated lines and circuits to ensure that there is not latency in the performance,” says Burns. “You have to have that speed of data traveling back and forth. We probably have an estimated 200 to 300 clients that are currently hosted now, so we have a fair amount of dedicated bandwidth across circuits so that we’re not fighting with the same type of internet traffic a general user is. ”
So underlying all this talk of clouds is still a very much rooted in cables and physical connections. The challenge remains getting all that patient data from one server to the next and doing so without perceivable interruption.

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Epic EHR outages in force Bay Area docs on to paper records |

Providers at two John Muir Health campuses in northern California were forced to paper records as a result of intermittent outages of their Epic EHR system on Monday, according to the Contra Costa Times.
Joyce Tsai reports that the health system’s Walnut Creek and Concord locations experienced periods of downtime from the late morning through the early evening despite internal expectations of a fix within a few hours.
“What we have are downtime procedures in place,” a spokesperson for John Muir told the Contra Costa Times, “and so we have computer systems that have backed up records, so our doctors, nurses and other clinicians can access medical records, patient histories, medications and past visits.”
Paper records were used because the Epic EHR system would not allow new information to be entered and were therefore the only means of caring for the immediate needs of patients. The hospital spokesperson indicated that information from the paper records would have to be entered manually into the patients’ EHRs once full functionality was restored.
In response to the outage, the hospitals initiated a call to divert patients from the locations in Walnut Creek and Concord to other local medical facilities which lasted for either ten minutes or two hours according to differing sources — one from John Muir and another from the ambulance company American Medical Response.
The cause of the outages remains unknown. The Bay Area health system began its $300-million implementation of its Epic EHR technology in July 2012, a process led by Jane Willemsen, President and Chief Administrative Officer at Walnut Creek, according to the San Francisco Business Times. Improved integration was the impetus behind the significant investment in Epic.
Concord and Walnut Creek are both located in Contra Costa County, which has been a hotbed for EHR backlash over the past few years. The county’s decision back in 2012 to implement an Epic EHR in the its public hospitals at a cost of $45 million met with opposition from area physicians and nurses who singled out the EHR system as the cause of long waits leading many patients to be turned away.
“We were not ready for Epic and Epic was not ready for us,” pediatrician Keith White, MD, maintained in a letter to supervisors (via San Jose Mercury News). “As a result, the providers are struggling to provide safe and effective care for 100,000 citizens of the county, many of whom are very ill. We often feel that we are failing.”
The county was also the site of a near-fatal dose of medication recommended by the EHR to be administered to a patient with a known heart condition which an alert nurse was fortunately able to catch in time.
Whatever is going in in Contra Costa County is certainly not contagious but definitely worth avoiding.

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EHRs: Expecting Too Much, Too Soon? - iHealthBeat

EHRs: Expecting Too Much, Too Soon? - iHealthBeat | EHR and Health IT Consulting |

In 2014, health care record-keeping and communication are finally emerging from the Stone Age and entering the 21st century, moving away from the pen-and-paper processes abandoned by the rest of the modern world decades ago.

This revolution is driven primarily by the HITECH Act and accompanying meaningful use program. These initiatives drove greater adoption of electronic health records by doctors and hospitals in the last five years than in the previous 40. According to one estimate, EHR adoption by physician practices rose from 17% in 2008 to 48% in 2013 and hospital EHR adoption increased from 13% to 70% during the same time period. These EHRs will play a central role in the move to accountable care and population health management.

A principal HITECH objective was to improve patient care, but a number of recent publications challenge the program's success and EHRs' value -- from both the perspectives of physicians using EHRs and researchers who are decrying a high level of patient safety events across the industry. One article points out that a substantial minority of physicians are dissatisfied with the effect of the EHR on office operations; others suggest EHRs are failing to live up to their promise of reducing patient harm.

Should we be disappointed that this technological revolution hasn't yielded all the anticipated benefits? We think this would be premature. Here's why -- and who's doing it right.

Managing Expectations for the EHR

EHRs can facilitate patient care improvements through three basic mechanisms:

  • Better information capture and documentation;
  • Better sharing of information across settings; and
  • Most importantly, application of computerized clinical decision support (CDS) and data analysis.

The early literature supporting the value of CDS -- on which the meaningful use criteria were largely based -- was derived mostly from a handful of academic institutions with custom-built EHRs that they had constructed and tuned over decades.

It is unreasonable to expect that the majority of organizations that have implemented commercial EHR products in recent years will achieve the kinds of care improvements in a short period of time (two to five years, or "overnight," in health care industry terms) that took the early academic centers many years to achieve.

While in recent years we have learned more about how to design and implement effective CDS, most organizations have neither the staff expertise nor the budgets to commit to drive changes of this magnitude in a short time. Commercial EHR products are equipped with many of the ingredients needed to support clinical workflows and build robust CDS, but they bring with them their own inherent constraints.

Perhaps more importantly, we know that driving rapid technologic and workflow change in organizations is both difficult and hazardous. One way hazards can manifest is through unintended consequences of computerization. Sometimes problems arise from improperly designed or coded software containing errors; however the great majority of unintended consequences arise from the gap between vision for the system as designed and the reality of the system as used. It is virtually impossible to anticipate the full spectrum of individual human and workflow interactions with the system and the resulting manner in which the system gets used.

Implementation Challenges

Problems may manifest during implementation -- for example, during the switch from manual to automated processes. In another common scenario, designers underestimate the amount of time required by physicians to complete their documentation and ordering tasks, resulting in increased physician workload. Quality of documentation may suffer through efforts to replace narrative text with structured templates. Workflows can be disrupted in dangerous ways and new kinds of errors can be introduced.

It takes painstaking planning and rapid response during and after implementation to avoid these problems and resolve those that inevitably occur. It usually takes years for organizations to overcome these challenges and settle into the routine use of a new EHR system. Only then is it possible to truly take advantage of the system's more sophisticated tools and capabilities to affect lasting improvements in patient care processes and patient safety.

So, Who Got It Right?

While success is less newsworthy than failure, an increasing number of organizations have weathered these trials and succeeded in demonstrating genuine benefits from computerization.

Sentara Healthcare

Sentara Healthcare in Virginia reported operational and financial benefits from EHR use, such as length of stay reductions, reduced IT maintenance costs, lower medical records staffing and lower paper costs. It also reported improvements in clinical processes, including faster order execution (e.g., 80% reduction in medication delivery times), increased nursing efficiency (e.g., one hour increase in direct patient care time per nurse, per shift) and more rapid patient transfer times (e.g., 40% reduction in the time it takes to transfer a patient from one unit to another).

Most significantly, it also reported substantial outcome improvements, such as a 50% reduction in hospital mortality ratios (actual/expected deaths) and a reduction of more than 100,000 potential medication errors annually.

Texas Health Resources

Texas Health Resources in Dallas reported EHR-related improvements in its compliance with its CMS Core Indicator bundles, increasing from 65% to 90% compliance to 90% to 95% compliance for all items in the bundle. The organization also achieved a more than 50% reduction in adverse drug event incidence at several targeted hospitals within one year of EHR implementation.

They measured more than 40 minutes of net time savings per nurse, per shift in three of four studied nursing units. And the average time from order writing to computer input for non-stat orders fell from 118 minutes to zero, resulting in more rapid order execution and the more timely delivery of needed care to patients.

Geisinger Medical Center

Geisinger Medical Center in Pennsylvania reduced average hospital length of stay for coronary artery bypass cases by 16% through its evidence-based care program. Geisinger's EHR system helps ensure that 40 critical steps are followed for every patient in the program through the use of checklists, default documentation templates, health maintenance gap reminders and automated order sets; the EHR identifies gaps in care so they can be completed in a timely manner (e.g., before surgery).

Geisinger's pre- and post-implementation analysis showed that 100% of program patients received all 40 care elements included in the bundle, compared with just 59% of those in the conventional care group. Average total hospital length of stay was 5.3 days in the program group, compared with 6.3 days in the conventional care group, and hospital readmission rates were substantially lower for the program patients.

EHRs Are 'Far From Perfect,' but 'Essential'

Today's EHRs are far from perfect. Physician documentation often requires more time than it used to, at least initially. And it takes time and expertise to build out the programmatic and application structures needed to realize significant benefits in safety and quality.

But EHRs are nonetheless essential, and we should thank the federal program that's forcing health care to finally join the 21st century. We are obligated to move forward -- to use modern tools to improve medical decision making, to document legibly and to share information quickly and accurately with our colleagues, as well as our patients. We cannot return to the Neolithic era.

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Stakeholders not pleased with EHR changes in doc payment proposal

Healthcare organizations applauded several provisions of the Centers for Medicare & Medicaid Services' proposed physician fee schedule for 2015, such as reimbursement for telehealth and chronic care management, but were not enthused about the agency's' suggestions about electronic health records and the Meaningful Use program.

The American Hospital Association (AHA) was in favor of reimbursing physicians for chronic care management, but not the proposed requirement that the physicians use EHR technology certified to the most recent version of certification, and suggested that such a requirement be delayed for three years.  

"It is very likely that there are physician practices that effectively coordinate patient care but have not yet fully implemented a certified EHR; in particular, not all types of physicians have access to certified EHRs that are a good fit for their specialty practice. And as CMS well knows, many physicians are still struggling to meet meaningful use requirements,"  Linda Fishman, AHA's senior vice president of public policy analysis and development said in comments submitted to CMS.

The American Medical Association (AMA) noted that CMS' proposal that eligible professionals (EPs) would not have to recertify to the most recent version of electronic specifications for clinical quality measures (CQMs) would not be useful, since EPs needed to use CEHRT for the other Meaningful Use objectives. The AMA also recommended that measure ACO-11, which requires ACOs to have a percent of primary care physicians who successfully qualify for Meaningful Use incentive payments be dropped since it has no direct relationship to the quality of patient care.

The AMA additionally was not in favor of CMS' proposal that if an error were found in the e-CQMs, that the physician quality reporting system (PQRS) simply use the older version.

"CMS is essentially suggesting that a version of the measure that is no longer supported should be implemented which is inconsistent with program goals," AMA's CEO James Madara said in his comments. "Reverting back to an older version of a measure will requires users of the measures, including EPs and EHR vendors, to support two versions of a single standard [e.g., HQMF, QDM], thus increasing the burden on these stakeholders and creating the possibility for substantial confusion and errors."

The College of Healthcare Information Management Executives and the Association of Medical Directors of Information Systems (AMDIS) also jointly expressed concerns about CMS' proposed changes to eCQMs, as did HIMSS.

CMS has been using provider fee schedules to introduce new EHR requirements and tweak the Meaningful Use program, both for providers who are eligible to participate and for those who can't participate in the program.

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New Rules for Achieving Meaningful Use in 2014 - HITECH Answers

New Rules for Achieving Meaningful Use in 2014 - HITECH Answers | EHR and Health IT Consulting |

We’ve been waiting for it to drop since late July and it finally hit the floor just as the three-day end of summer weekend was kicking off.

The new CMS final ruling that was published on August 29, 2014 allows an end run around some of the challenges of receiving an EHR incentive in 2014. Don’t have 2014 Edition software? No problem, just use the old tattered and worn version from last year. Having trouble hitting the Stage 2 marks? No problem, just back pedal to Stage 1 and all is well. Now there are a few details in the fine print that should not be overlooked, and do not provide a poultice for every meaningful use (MU) ache and pain, but sometimes you can’t get what you want.

There are lots of folks, especially in the hospital domain, who are not reaching quite yet for the champagne. I’m learning to play the hand that is dealt so let’s take a look at the cards. First, let’s take a quick glance at the new rules for achieving MU in 2014 courtesy of CMS.


*Only providers that could not fully implement 2014 Edition CEHRT for the EHR reporting period in 2014 due to delays in 2014 Edition CEHRT availability.

Take a close look at the tiny print at the bottom of the chart. Yes, the one with the asterisk that says “Only providers that could not fully implement 2014 Edition CEHRT for the EHR reporting period in 2014 due to delays in 2014 Edition CEHRT availability.” The ability to fall back to 2011 Edition software or slide from Stage 2 to Stage1 is not solely based on choice but on availability of 2014 Edition. So, the question is, “What is meant by “2014 Edition CEHRT availability”? I have heard from many providers who are concerned that if their vendor is 2014 Edition certified they will not be able to take advantage of this option. However this is not the case. CMS in the final ruling released last week expanded on the definition of “availability” to include whether a provider is able to “fully implement” the 2014 version. “Full implementation” as described in the new Final Rule includes such items as: “staff training, system testing and workflow revisions”, “update and integration”, and “software patches or workflow changes”. To me that is a liberal, and most welcome, CMS interpretation.

Now for some of the interesting details:

  • If a Medicaid eligible professional is in the first year of the program in 2014 and needs to meet the requirements for adopting, implementing, or upgrading CEHRT, they must use 2014 CEHRT. No wiggle room here to try and breathe life into 2011 technology.
  • Eligible hospitals or professionals will not have any luck with 2011 Edition software in the 2015 MU year. That begins in less that a month for hospitals and in four months for the EPs.
  • Some providers may fall into a gap between 2011 and 2014 Edition software. They might have achieved MU in 2013 but their software has been modified to the point that the version they are now using in no longer certified and they haven’t, for whatever reason, moved to 2014 software. They appear to be out of luck.
  • Vendors will be scrambling to provide guidance to users on a case-by-case basis. Decisions will need to be made quickly to stay the course for 2014 MU or take advantage of a more appropriate option offered in the final ruling.

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