Getting your practice head, Volume 4: Medical Data Backup Essentials for Physicians. Know more about Data Backup and HIPAA Compliant Data Backup here
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Despite the massive growth in demand for virtual medical services, major EMR vendors are still proving slow to support such options, seemingly ceding the market to more agile telemedicine startups.
Independent telemedicine vendors targeting consumers are growing like weeds. Players like Doctor on Demand, NowClinic, American Well and HealthTap are becoming household names, touted not only in healthcare blogs but on morning TV talk shows. These services, which typically hire physicians as consultants, offer little continuity of care but provide a level of easy access unheard of in other settings.
Part of what’s fueling this growth is that health insurers are finally starting to pay for virtual medical visits. For example, Medicare and nearly every state Medicaid plan also cover at least some telemedicine services. Meanwhile, 29 states require that private payers cover telehealth the same as in-person services.
Hospitals and health systems are also getting on board the telemedicine train. For example, Stanford Healthcare recently rolled out a mobile health app, connected to Apple HealthKit and its Epic EMR, which allows patients toparticipate in virtual medical appointments through its ClickWell Care clinic. Given how popular virtual doctor visits have become, I’m betting that most next-gen apps created by large providers will offer this option.
EMR vendors, for their part, are adding telemedicine support to their platforms, but they’re not doing much to publicize it. Take Epic, whose EpicCare Ambulatory EMR can be hooked up to a telemedicine module. The EpicCare page on its site mentions that telemedicine functionality is available, but certainly does little to convince buyers to select it. In fact, Epic has offered such options for years, but I never knew that, and lately I spend more time tracking telemedicine than I do any other HIT trend.
As I noted in my latest broadcast on Periscope (follow @ziegerhealth), EMR vendors are arguably the best-positioned tech vendors to offer telemedicine services. After all, EMRs are already integrated into a hospital or clinic’s infrastructure and workflow. And this would make storage and clinical classification of the consults easier, making the content of the videos more valuable. (Admittedly, developing a classification scheme — much less standards — probably isn’t trivial, but that’s a subject for another article.)
What’s more, rather than relying on the rudimentary information supplied by patient self-reports, clinicians could rely on full-bodied medical data stored in that EMR. I could even see next-gen video visit technology which exposes medical data to patients and allows patients to discuss it live with doctors.
But that’s not how things are evolving. Instead, it seems that providers are largely outsourcing telemedicine services, a respectable but far less robust way to get things done. I don’t know if this will end up being the default way they deliver virtual visits, but unless EMR vendors step up, they’ll certainly have to work harder to get a toehold in this market.
I don’t know why so few EMR companies are rolling out their own virtual visit options. To me, it seems like a no-brainer, particularly for smaller ambulatory vendors which still need to differentiate themselves. But if I were an investor in a lagging EMR venture, you can bet your bottom dollar I’d want to know the answer.
In order for patient engagement to be effective, providers need to learn how to integrate patients as partners in care, the Senior Director of Clinical Applications at Inland Northwest Health Services (INHS) added.
However, efforts to do so are impeded by struggles to provide patients with adequate methods of accessing information. Patient portals, which are often included on a hospital’s EHR, seem to be the most prevalent method by which patients may engage with their health information, but as Cheadle pointed out, patient portals present considerable hurdles in increasing patient engagement.
“Consumers said that a provider’s website needs improvement,” Cheadle said. “That we could not find the portal easily on the website, and if we did find the portal, they’re not easy to use, and they did not have an ability to find the information -- either it wasn’t there or wasn’t the relevant information that the patient was looking for.”
Throughout the webcast, Cheadle provided strategies on how providers can increase patient engagement via the patient portal, as well as on where the healthcare industry is today in implementing that patient engagement.
A huge economic industry expected to reach $9 million by 2017, patient portals on EHRs are major drivers of measuring patient engagement. Cheadle explained how patient portals have been used by the federal government to measure meaningful use success, and to subsequently reward outstanding providers or providers who are not up to par.
However, as Cheadle pointed out, most patients don’t visit with their physicians often, making the current model for EHRs and patient portals ineffective. Although patient behavioral and social data have an underscored importance, much provider technology doesn’t align itself with these goals, making it hard to implement truly meaningful patient engagement.
A critical aspect of patient engagement is patient access to medical information. That patient data sharing is the primary job of the patient portal, but as Cheadle explained, these portals don’t seem to be performing that job adequately.
She stated that portals have been fairly well implemented amongst many providers, but there are still no widespread positive results.
“Despite the success of the implementation of portals across the United States, our readmission rates into our hospitals is remaining relatively consistent,” she said. “We have not reduced the high cost of readmissions into the healthcare setting.”
Cheadle continued the rest of the webcast by explaining different strategies providers can implement to make best use of their patient portals to increase patient engagement.
What can we do?
Cheadle explained that it is important to use the overall structure of patient portals and change the way in which providers use them to engage with the patient. The means using a patient-by-patient, individualistic approach to patient engagement.
By using pre-existing parameters for the healthcare provider’s business model, physicians can alter their engagement strategies to integrate the needs of the patient and to incorporate the patient as a part of his or her own care team.
Creating patient partnerships
Cheadle suggested creating a balance and a feasibility in improving patient engagement by selecting top priorities and implementing them with excellence. Incorporating the patient as a part of the care team should be among those priorities.
“By having more patient involvement, that activation of the patients in their care journey, their longitudinal healthcare journey, we’re really looking to leave behind that unilateral decision-making, that white coat paralysis that happens to all of us when go in to see the doctor,” Cheadle said.
An important aspect of integrating patient portals into patient lives is to do so at a basic level. Cheadle suggested using this kind of technology for patients to do simple tasks such as update insurance information or medication and allergy information in the waiting room.
Determine consumer preference
Ultimately, Cheadle asserted, making patient portals more consumer-centric will make patients more likely to utilize them. This means establishing what a specific patient may want out of their portal.
Cheadle suggested engaging with patients’ health histories-- gathering information about what they already know about their health conditions and feedback regarding the kinds of care they have received in the past. This will help providers to shape what kinds of information patients would like to receive from their portals.
Two components of patient portals, convenient reminders and photos, are really helping patients to engage. Convenient reminders can offer scheduling assistance or allow patients to remember to get a routine screening. Photos allow patients to see what is going on in their bodies-- the progressing growth of a baby, or the healing of a broken bone, for example.
It is simply not enough to emphasize portal use, Cheadle said. Providers need to explain to consumers what to do with them as well. This means explaining how often they should use it, when to use it, and for what purposes.
This process may replace printouts used to outline patient self-care which often get discarded upon leaving the physician’s office.
“What if instead I said to the patient as they leave the emergency room in my discharge process, ‘hey, let me show you where your information is on your portal.’ What would that look like?” Cheadle said.
Taking a moment like the one Cheadle described is an opportunity not only to show patients the structure of the portal and how to access it, but to explain to them for what purposes they should be utilizing it.
Optimization of care
How do we use these strategies to optimize patient care? Cheadle said by providing patients with the skills and the resources to provide more health information during their next visit. By helping patients engage with their health information on the portal, as well as with any data collected via wearable technologies, patients can increase their own health knowledge and help their physicians increase the quality of their treatment.
Cheadle also emphasized the importance of opening dialogue over all points of care in order to foster an environment in which patients feel comfortable expressing health concerns.
“From an overall perspective just as a healthcare provider, really encouraging me as a healthcare provider to talk differently, to engage differently, maybe to take off my coat when I meet with the patient,” Cheadle said.
Keys to success
These patient engagement strategies are just a piece of the puzzle in terms of healthcare industry shifts, Cheadle said.
“In the big picture, we are in a huge healthcare shift, a huge change,” she said. “What we have not identified is that we are at a point where we have patient reform where we can engage and activate that curiosity by patients about their health and wellness, where we can begin to leverage that to improve overall their desired clinical outcomes.”
Through integrating these strategies to increase and optimize patient engagement, Cheadle said overall quality of care can flourish.
“I truly believe it is through these engagement strategies, these key strategies, that we can ultimately impact overall care.”
In preparation for the October 1 ICD-10 implementation deadline, the Centers for Medicare & Medicaid Services (CMS) have completed their third Medicare fee-for-service end-to-end testing with great success, according to a recent CMS report. This is the third successful CMS ICD-10 testing to occur in 2015.
The testing week, which occurred between July 20 and 24, included healthcare providers, clearinghouses, and billing agencies. These entities utilized the help of Medicare Administrative Contractors (MACs) and the Durable Medical Equipment (DME) MAC Common Electronic Data Interchange (CEDI) to file their claims. Participants from previous tests were invited to partake in the July tests, thus bringing a considerable amount of returners to this session.
The July test was a success, according to CMS, with an 87 percent acceptance rate of the 29,286 claims received. The rejection rate for ICD-10 errors was 1.8 percent, and the rejection rate for ICD-9 errors was 2.6 percent. However, majority of rejected claims were not ICD-10 related. Among others, these included invalid NPIs, claims outside of the covered date range, and invalid place of service. CMS confirms that many of these same errors occurred in previous test sessions.
Additionally, CMS states that many rejected claims may have been submitted with errors on purpose. This practice, referred to as “negative testing,” is intended to ensure that CMS’ rejection processes are functioning properly and will indeed reject a provider’s invalid claim.
CMS reports a larger cross-section of volunteers this test session, with about 1,200 organizations selected to participate in the test. There were 493 organizations returning for previous tests. Additionally, 1,400 National Provider Identifiers (NPIs) participated in the test, and approximately 12 percent of those were repeats from prior tests.
This test brought about similar results to previous tests performed in January and April. In January, CMS reported an 81 percent approval rating between January 26 and February 3. This test included 661 volunteers. Just like this most recent test, the January test boasts a high success rate, with a majority of rejected claims resulting from non-ICD-10 related errors.
Tests performed in April were likewise successful. With 875 participants, CMS reported an 88 percent acceptance rate, which is consistent with the July tests. The number of rejections due to ICD-10 and ICD-9 errors are also consistent with the July tests, with a majority of rejections being due to other provider-related issues.
As providers and payers alike continue to prepare for the impending October 1 ICD-10 deadline, these test results bring promise to CMS. Not only have CMS’ systems shown a proven capability for accuracy, but they have shown consistent accuracy, with only a seven percent difference between the best and worst test performances. Provided these positive results, CMS has shown that it is ready for this new coding system.
Pundits may have designated 2013 as the original “Year of EHR Replacement,” but the accolade may have been a little premature as providers continue to make the difficult decision to rip out and replace existing EHR infrastructure at record rates. Just under 20 percent of large practices and clinics intend to undergo an EHR replacement by the end of 2016, says a new survey by Black Book Rankings, or have already started the process.
There appears to be a shift upward in physician experience across the large practice and clinic sector when it comes to electronic health record (EHR) satisfaction, according to an annual survey by Black Book Market Research.
Black Book first began measuring EHR satisfaction among providers six years ago. In 2013, 92 percent of multispecialty groups using electronic records were “very dissatisfied” with the ability of their systems to improve clinical workload, documentation and user functionalities. In 2015, comparably, 71 percent of all large practice clinicians stated their optimization expectations of top ranked Black Book EHR vendors were being met or exceeded according to physician and clinician experience. Eighty-two percent of administrative and support staff declared upgraded operational and financial developments, as well. For this survey, more than 27,000 EHR users participated in the 2015 polls of client experience in a sweeping five month study.
Interestingly enough, a recent physician-based survey from online resource organization AmericanEHR Partners and the American Medical Association (AMA) found that compared to five years ago, more physicians are reporting being dissatisfied or very dissatisfied with their EHR system.
What’s more, the Black Book survey found that Allscripts, Greenway, McKesson and athenahealth recorded the largest increases in client satisfaction over the past year among the large group practice sector of medical care delivery. According to the survey results of 1,304 large practices, overall satisfaction improved as follows:
Users of the top four ranked EHR systems agreed that vendor investments in 2014 and 2015 have attributed update and releases (34 percent), practice assessments (44 percent), clinical workflow enhancements (60 percent), revenue cycle management and analytics value adds (89 percent), population health capabilities (33 percent) and solicited physician feedback (90 percent) have contributed the most to their rise in overall system satisfaction.
Significant decreases in satisfaction were also noted by users of several clinic-oriented EHR users that failed in regional connectivity attempts (76 percent), implementation and training (77 percent), and customer support (85 percent).
“Meaningful use deadlines, total integration and reliable delivery may have influenced large group practice buyers to purchase initial EHRs from 2010 through 2013, but replacement buyers sought better EHR tools in 2014 that include patient engagement, true interoperability, enhanced usability and productivity gains,” Doug Brown, managing partner of Black Book, said in a statement. “There was also a measureable shift in loyalty to vendors that offered a robust, core EHR to accommodate evolving reforms.”
Among those surveyed, Black Book revealed just 18 percent of implemented large practices and clinics are in the discussion or execution stages of replacing their original EHR by 2016 year end. Opportunities for product penetration among current client bases of the top ranked EHR vendors were also recorded in the 2015 survey.
According to large practice executives and physicians, the primary reasons for top vendors succeeding in product penetration into their current client bases in the second half of 2015 include: client education (42 percent); product bundling (31 percent) and marketing (26 percent).
“EHR firms with a wide offering of products including health information exchange, population health tools, revenue cycle management services, patient portals, dashboards and analytics are emerging as the next wave of healthcare technology leaders,” said Brown. “These leading vendors are assisting their clients in assessing current practice operations to meet the demands of ICD-10, payment reform, connectivity beyond closed networks, revenue cycle management gaps, and population health tools, and recommending effective options within the same vendor suite.”
A municipal hospital system’s Epic EMR install has gone dramatically south over the past two years, with four top officials being forced out and a budget which has more than doubled.
In early 2013, New York City-based Health and Hospitals Corp. announced that it had signed a $302 million EMR contract with Epic. The system said that it planned to implement the Epic EMR at 11 HHC hospitals, four long term care facilities, six diagnostic treatment centers and more than 70 community-based clinics.
The 15-year contract, which was set to be covered by federal funding, was supposed to cover everything from soup to nuts, including software and database licenses, professional services, testing and technical training, software maintenance, and database support and upgrades.
Fast forward to the present, and the project has plunged into crisis. The budget has expanded to $764 million, and HHC’s CTO, CIO, the CIO’s interim deputy and the project’s head of training have been given the axe amidst charges of improper billing. Seven consultants — earning between $150 and $185 an hour — have also been kicked off of the payroll.
With HHC missing so many top leaders, the system has brought in a consulting firm to stabilize the Epic effort. Washington, DC-based Clinovations, which brought in an interim CMIO, CIO and other top managers to HHC, now has a $4 million, 15-month contract to provide project management.
The Epic launch date for the first two hospitals in the network was originally set for November 2014 but has been moved up to April 2016, according to the New York Post. HHC leaders say that the full Epic launch should take place in 2018 if all now goes as planned. The final price tag for the system could end up being as high as $1.4 billion, the newspaper reports.
So how did the massive Epic install effort go astray? According to an audit by the city’s Technology Development Corp., the project has been horribly mismanaged. “At one point, there were 14 project managers — but there was no leadership,” the audit report said.
The HHC consultants didn’t help much either, according to an employee who spoke to the Post. The employee said that the consultants racked up travel, hotels and other expenses to train their own employees before they began training HHC staff.
HHC is now telling the public that things will be much better going forward. Spokeswoman Ana Marengo said that the chain has adopted a new oversight and governance structure that will prevent the implementation from falling apart again.”We terminated consultants, appointed new leadership, and adopted new timekeeping tools that will help strengthen the management of this project,” Marengo told the newspaper.
What I’d like to know is just what items in the budget expanded so much that a $300-odd million all-in contract turned into a $1B+ debacle. While nobody in the Post articles has suggested that Epic is at fault in any of this, it seems to me that it’s worth investigating whether the vendor managed to jack up its fees beyond the scope of the initial agreement. For example, if HHC was forced to pay for more Epic support than it had originally expected it wouldn’t come cheap. Then again, maybe the extra costs mostly come from paying for people with Epic experience. Epic has driven up the price of these people by not opening up the Epic certification opportunities.
On the surface, though, this appears to be a high-profile example of a very challenging IT project that went bad in a hurry. And the fact that city politics are part of the mix can’t have been helpful. What happened to HHC could conceivably happen to private health systems, but the massive budget overrun and billing questions have government stamped all over them. Regardless, for New York City patients’ sake I hope HHC gets the implementation right from here on in.
The way in which physicians interact with data as it pertains to patient care has clearly identified the EHR as a critical tool. The statistics speak for themselves — approximately 78 percent of all office-based physicians had an EHR in place as of 2013, according to a 2014 study in Health Affairs. However, this doesn't mean that physicians are satisfied with the EHRs they have; recent studies, including a 2014 report in JAMA Internal Medicine, have shown that even experienced EHR users find significant decreases in productivity, losing on average, 48 minutes of productivity every workday. It becomes critical, then, to find ways to maximize the use of existing EHRs in an effort to improve efficacy for patient care and reduce end-user frustration.
The biggest problem with an EHR system is not the product itself — it is the way we learn to use it and how we communicate with those who make and update it. These five strategies might help to reduce both the frustration level and inefficiency that many doctors feel come with their EHRs.
1. Train and train again. Most EHR training occurs prior to "going live" and is often not tailored to individual "teams" within the office (medical assistants, front-desk staff, physicians, billers). In addition, once the initial training is done, most offices rarely do any further training. The reality is that "relearning" your EHR is critical to maximizing its advantages. Consider appointing one individual in your office (or one from each stakeholder group) to set aside time each week or month to "retrain" on the EHR. The focus should be on capabilities (what can it do) and needs (what do we need it to do).
2. Check your "flow." Work flows in your office need to be looked at before and after an EHR is implemented. Have your office manager and/or you (the physician) spend a day watching how a patient moves through the process of being seen — from check-in to check-out. When you identify choke points (be they people or processes), work on how to fix and redirect those tasks.
3. Use shortcuts. Most EHRs have huge amounts of customizability that physicians often forget to take advantage of. Learn how to use encounter templates and order sets to speed the process of getting data into the system. Don't forget about dictation and transcription capabilities as well.
4. Engage the portal. Using the patient portal to allow patients to manage common tasks and requests can dramatically reduce the amount of work your staff needs to do. Recent CMS guideline changes allow for reimbursement of "non-face-to-face" visits for chronic diseases — using the patient portal as a tool for this type of patient interaction is an optimal strategy.
5. Communicate with the vendor regularly. It's important to remember that you are a client when it comes to the EHR and that you are paying for services as well as product. Don't hesitate to ask for further training or retraining if needed. Make sure the EHR vendor has regular meetings with your office staff designee to keep you updated on changes to the EHR system.
Strategies such as the ones above will help your practice get the most out of the EHR it has, while waiting for the day when healthcare has an EHR physicians actually want.
The National Defense Authorization Act (NDAA) for Fiscal Year 2014mandated that the Defense and Veterans Affairs departments "certify that all healthcare data in their systems complied with national standards and were computable in real time," by Oct.1, 2014.
What with DoD's 9.5 million patients and the VA's 8.3 million that's a terrifically ambitious goal, to be certain, and not one that can be rushed.
"Both departments stated they intend to do so later in calendar year 2015," the Government Accountability Office wrote in a report published on Thursday. "Further, the departments' system modernization plans identify a number of key activities to be implemented beyond December 31, 2016 -- the deadline established in the NDAA for the two departments to deploy modernized electronic health record software to support clinicians while ensuring full standards-based interoperability."
Indeed, DoD's modernization plans took a step forward at July's end when officials revealed the agency awarded its EHR contract to the team of Leidos, Cerner and Accenture – at which point DoD also said it intends to deploy the new EHR at eight sites in the Pacific Northwest by the close of 2016, with plans to have it installed at more than 1,000 sites around the globe by 2022. VA, for its part, is sticking with its proprietary VistA EHR and will modernize it incrementally toward a full installment at VA locations in 2018.
"These plans – if implemented as currently described – indicate deployment of the new systems with interoperabilitycapabilities will not be completed across the departments until after 2018," GAO states in its report.
This is not to say that VA and DoD don't share records already. They do. DoD officials asserted that "there is not a big interoperability problem with VA," and, instead, the agencies "share more information than any two large institutions today," to the tune of approximately 1 million pieces of information every day.
What the DoD and VA currently lack, GAO continued, are "outcomes-oriented metrics and goals for defining and measuring interoperability progress."
That's where the report paints a messy picture.
The joint Interagency Program Office, which essentially sits between the VA and DoD, told GAO it assigned a team to work with VA, DoD and the Office of the National Coordinator for Health IT to identify better metrics, such as user experience and improved outcomes. But that team had yet to commit to a delivery date when those would be incorporated into their guidance, at least as of late May, GAO noted.
"Officials of the departments and the IPO explained that defining appropriate outcome metrics for interoperability is not just a DoD and VA issue; rather, it is a national challenge to identify how to measure interoperability and what data are needed," GAO reported.
Fair enough. It's safe to say that at this point in history health information interoperability is a problem that the DoD and VA cannot – and should not – solve by themselves.
But it does raise the question of whether they can move as far forward as they need without private healthcare organizations and technology vendors measuring interoperability progress in lockstep.
"Until they establish a time frame, complete steps to define outcome metrics and goals, and incorporate these into IPO guidance," GAO contended, "the departments and the IPO risk not knowing the status of program operations and areas that need improvement, and ensuring accountability for end results."
All of which makes even GAO's estimate of 2018 look perhaps overly optimistic, doesn't it?
Go-live tends to garner the most attention for an EHR implementation, especially in the event that it does not go well. But many more activities go into a successful EHR implementation that precede and post-date the production launch.
Earlier this month, Emory Healthcare CMIO Julie Hollberg, MD, highlighted the value of at-the-elbow support to a successful EHR implementation. For Hollberg, a key to her organization's EHR implementation was the deployment of physician support services as different departments and sites went live as part of the EHR optimization project.
"I have been the CMIO for four years and the physician champion when we went live with CPOE in the inpatient setting. When we went live, we had bodies everywhere. I jokingly say physicians want help in the exact moment when they want it, not ten minutes before or after," she toldEHRIntelligence.com.
The question was put to readers: Is spending more on implementation services the key to EHR adoption success? As the responses show, much more goes into a successful EHR implementation than the resources and activities dedicated to Day 0.
For one reader, EHR implementation hinges on due diligence being done well in advance of go-live:
For another, the success of an EHR implementation is gauged with what follows the initial go-live event:
Still another set the value of the EHR implementation to its integration with other hospital systems:
Not only is an EHR implementation an expensive process, but it is also an extensive one in terms of what goes into determining its success.
The Department of Defense is about to move forward with its multi-billion dollar plan to overhaul its electronic health records system. But when you're an organization such as DoD, supporting 9.5 million active and retired military personnel and their beneficiaries, there are variety of important privacy and security challenges that must be prioritized and tackled, privacy and security experts caution.
In late July, the DoD awarded a $4.3 billion, 10-year contract to Leidos Partnership for Defense Health, a group of three main vendors that include EHR provider Cerner and consulting firms Accenture and Leidos Inc. The contract, which has the potential to be worth $9 billion if DoD exercises all its options over 18 years, involves the Leidos Partnership team transitioning the Pentagon's existing proprietary EHR system onto a Cerner off-the-shelf EHR at about 1,000 DoD sites worldwide, including military hospitals in the U.S., as well as health clinics in remote places such as Afghanistan.
However, as the Leidos partnership embarks on the massive overhaul, there are several critical privacy and security issues that need to be addressed to safeguard patient data throughout the plan.
Additionally, many of the challenges faced by the DoD in its EHR project are also similar - but much larger in scope - to the privacy and security concerns that healthcare organizations in the private sector face when undertaking their own EHR system migrations.
Those issues range from protecting patient data as its moved from one platform to the next, to thoroughly vetting the consultants involved with the EHR work.Migrating Data
"Several security and privacy challenges exist as the DoD transitions from its old EHR to the new system," says Keith Fricke, principal consultant at consulting firm, tw-Security.
"Migrating from one EHR to another often involves importing historical data from the old system to the new one. The data set may be rather large," he notes. "Extracting data from the old EHR will likely result in a large interim database or data file. The database may need to be sent to the new vendor for data field mapping or importing."
Yet, it is not practical to send data extracts this large over a data connection. "Instead, it is better to send the data sets on an encrypted external hard drive, tracked via shipping provider," he says.
Data integrity issues are among the biggest challenges involved with such massive EHR undertakings, says Tom Walsh, founder of tw-Security. "Often times, the data mapping between an old system and new systems misses something. The only thing worse than no patient data is the wrong patient data."
To counter those problems, the data extraction process must include mechanisms to validate the data ultimately imported into the new EHR exactly matches the data stored in the old EHR, Fricke advises.
Another factor that needs close oversight is ensuring that role-based access controls to patient data are maintained from the old system to the new, especially where highly sensitive information, such as behavioral health data, is involved, Fricke says.
Privacy and security expert Kate Borten, founder of consulting firm The Marblehead Group, says it's equally important to ensure that the consultants working with or accessing the sensitive data are scrutinized. "I expect that many contractors will have access to PHI throughout this major project," she says. "It is very important that they be thoroughly vetted, that they be given the minimum necessary access permissions, and that they be monitored."Long Haul
Because the DoD project will last several years, it's important to have measures in place to safeguard data during the various project stages.
"Workers should use simulated PHI rather than actual PHI as much as possible," Borten says. "Too often, PHI access is granted for development, testing, and training purposes, when simulated PHI could and should be used instead."
However, often a test environment must have real patient data in order to perform a true functional test, Walsh notes. "Security controls for test environments can often be less stringent. People using the test environment may forget that the data they are working with represents a real patient. Generic user accounts with easy to remember
passwords may be set up to help facilitate functional testing."
So, to avoid possible breaches or unauthorized access to PHI, the test environment needs to have security controls set to the same level as the production environment, Walsh recommends.
Because there will be thousands of people involved with the project - including individuals working for contractors and subcontractors - another danger is a watering down of security measures and practices that should be in place throughout the project, at all locations, for all personnel involved with the work.
"A front line worker may honestly say, 'I didn't know,' and it is a true statement," Walsh says. "Privacy and security education must be conducted for everyone involved."
As for securing data during project stages, Fricke recommends that data be stored on servers located in a secure data center and accessed via virtual desktops. "Doing so significantly reduces the likelihood that data is being stored on contractors' laptops or hard drives of workstations," he says.
"If storing data locally on laptops and desktops is required, these devices must be usingencryption."User Access
In addition, Fricke suggests that two-factor authentication be used for any remote access to the data being worked on for the migration. "We've seen news stories in the past year about foreign countries targeting US government systems for hacking and exfiltration of data," he says. "The vendors involved in this EHR migration must ensure that all systems involved in the process have proper security patching levels, well-maintained malware protection, and 24x7 audit log monitoring."
Also, if any of the individuals working on this project had their information compromised in the Office of Personnel Management breach, extra care must be exercised to avoid becoming a victim of a spear-phishing attacks.
Because the DoD EHR systems contain healthcare data for U.S. military personnel, then the information potentially could be a hot target of the most devious cyberattackers, Walsh notes.
"The data in these systems are not just any patient. This is the patient data of the men and women who willing chose to serve our country," he says. "Our military personnel are prime targets for domestic and foreign terrorists. Workforce clearance will have to be strongly enforced for anyone involved, but especially far more rigid for any person with elevated privileges, such as system administrator, super user, etc."
Finally, because the DoD project will last at least a decade, maybe two, it's vital that all project work is thoroughly documented, Fricke says.
"It is important that from a project management perspective, the project managers ensure all project documentation is kept very current," he says. "There is always staffing turnover of project managers and contractors in a project this large and with the long timelines expected. Gaps in documentation will cause potential delays, potential rework and possible lapses in security practices as turnover occurs."
Are you considering migrating from an older EHR to a newer EHR or are you in the process of that conversion? If so, you are well aware of the complexity of this process. There are a lot of reasons that drive the EHR conversion decision, but the primary reason that organizations undertake EHR conversion is simply to improve patient care and safety by providing clinicians and caregivers with the right information at the right time.
It’s easy to think that this is all about the technology. EHR conversion is far more than an IT project. It is a central business issue that needs to be strategically sponsored and backed by upper level management. In our previous post, we addressed the issue of aligning integration goals for business and technology. In a project of this magnitude, aligning business and technology goals becomes critical. Implementation takes hard work, time, and is very expensive. Effectively dealing with scope, budget & time creep, and change management matched to the stated business goals is the key to success. The complex planning needed is just one part of the story but the actual execution can be extremely problematic.
Since the primary reason for undertaking EHR conversion is to improve patient care and safety, clinical workflow is top-of-mind and coupled to data exchange and flow through your systems. On the IT side, your analysts define the project requirements and your developers build the interfaces based on those requirements. But the team that plays the most critical role is your quality team. Think of them as your project’s glue.
QA has layers of responsibilities. They are the ones that hold the requirements as the project blueprint and make sure that those requirements, driven by the pre-identified business needs, are being met. They also make sure that all defined processes are being followed. Where processes are not followed, QA defines the resulting risks that must be accommodated for in the system. A subset of responsibility for QA is in the final gate-keeping of a project, the testing and validation processes that address the functionality and metrics of a project.
Analysts work to build the interfaces and provide QA with expected workflows. If those workflows are not correctly defined, QA steps in to clarify them and the expected data exchange, and builds test cases to best represent that evolving knowledge. Identifying workflow is often done blindly with little or no existing information. Once the interface is built, those test cases become the basis for testing. QA also plays an important role in maintenance and in contributing to the library of artifacts that contribute to guaranteeing interoperability over time.
Though it is difficult to estimate the actual costs of interfacing due to the variance implicit in such projects, functional and integrated testing is often up to 3x more time consuming than development. It’s important to note that this most likely represents defects in the process. Normally, in traditional software development those numbers are inversed with QA taking about 1/3 of development time. It’s quite common that requirements are not complete by the time the project lands in QA’s lap. New requirements are continually discovered during testing. These are usually considered to be bugs but should have been identified before the development phase started. Another major reason for the lengthy time needed is that all testing is commonly done manually. A 25 minute fix may require hours of testing when done manually.
In technology projects, risk is always present. QA teams continuously work to confine and evaluate risk based on a predefined process and to report those issues. The question continually being asked is: what are the odds that X will be a problem? And how important is that impact if there is a problem? Here the devil is in the details. QA is constantly dancing with that devil. Risk is not an all or nothing kind of thing. If one were to try and eliminate all risk, projects would never be completed. QA adds order and definition to projects but there are always blind alleyways and unknown consequences that cannot be anticipated even with the most well defined requirements. Dealing with the unknown unknowns is a constant for QA teams. The question becomes how much risk can be tolerated to create the cleanest and most efficient exchange of date on an ongoing basis.
If QA is your glue, what are you doing to increase the quality of that glue, to turn that into super glue?What you can do is provide tools that offset the challenges your QA team faces. At the same time, these tools help contain project scope, time & budget creep, and maintain continual alignment with business goals. The right tools should help in the identification of requirements prior to interface development and throughout that process, identify the necessary workflows, and help in the QA process of building test cases. De-identification of PHI should be included so that production data can be used in testing. Tools should automate the testing and validation process and include the capability of running tests repetitively. In addition, these tools should provide easily shared traceability of the entire QA process by providing a central depository for all assets and documentation to provide continuity for the interoperability goals defined for the entire ecosystem.
While physician EHR use has benefits for healthcare delivery, it poses various legal challenges different from paper records, according to two members of the Healthcare Group at Sands Anderson PC.
"On the one hand, EHR have given health-care providers, and those who sue them and those of us who defend them, access to more information than was available with the traditional paper record,"write Matthew Curtis and Michelle Warden. "But on the other hand, EHR have raised a host of new questions and challenges, and as the systems evolve they promise to highlight more conflicts between good clinical care and effective legal representation."
The two legal experts point to several areas of conflict that EHR technology currently present and which could prove more difficult as the technology matures — who accesses the chart, how is data in the chart managed, and what types of information comprise the chart.
"As EHR systems evolve, more and more conflicts likely will arise between what is good for the doctor and his patient and what is good for the attorney and her client," add Curtis and Warden.
A handful of examples demonstrate where confusion can arise. For one, there is the uncertainty resulting from prepopulated fields, such as for indicating "within normal limits" for the neurological system:
A patient chart, meanwhile, is much clearer in indicating whether the physician has indeed marked a field.
Electronically populated fields – that is, data coming from connected monitors and integrated directly into the EHR — raise similar doubts. Unless reviewed by the physician, the information may flow into the electronic record without his knowledge. Other uncertainties could include whether the clinician was in fact the one to enter vital signs.
As another example, audit trails may not sufficiently indicate when a physician interacted with the EHR system depending on how time is recorded in that system.
The final example presented by Curtis and Warden centers of differences between the electronic chart and the printed record because of the fact that the latter "rarely looks the same as what they would have seen on a computer screen at the time they were caring for their patient."
That is problematic, they argue. "This potential discrepancy may give the health-care provider — and subsequently the medical malpractice attorney—difficulty in deciphering the options that were even available for the health-care provider to select while caring for a patient," claim Curtis and Warden.
While the legal experts do not offer solutions to any these examples, they draw attention to an obvious for changes in how EHR technology is presented in legal proceedings to ensure that all parties are on the same page, albeit electronic.
Only time will tell whether the endorsement by the American Academy of Family Physicians (AAFP) of a particular EHR technology will translate into increased EHR adoption among these providers.
Late last week, AAFP struck an agreement with EHR company, HealthFusion, to promote its MediTouch EHR technology among its members.
"MediTouch offers the specifications AAFP members need," HealthFusion Chairman Sol Lizerbram, RPH, DO, said in a public statement. "The system was founded and created by family physicians with the goal of enhancing the practice of medicine and improving provider workflows. The quality of the system has been recognized by numerous organizations and health systems. We are honored that we now have the opportunity to associate with AAFP and its membership."
According to the EHR vendor, its EHR technology is a means for family physicians to keep pace with federal regulation and industry standards for health IT use:
For its part, AAFP has said little about the agreement. Its website includes details about HealthFusion/MediTouch EHR and practice management technology as part of discounts and services to members, with the following preface: "Help lower everyday practice costs and save time doing it. AAFP has done the research for you and negotiated the deal."
As for EHR adoption and use, AAFP has remained largely supportive of the EHR Incentive Programs, most recently in welcoming changes to meaningful use requirements proposed by the Centers for Medicare & Medicaid Services (CMS) earlier this year (although still awaiting finalization).
"Family physicians are among the earliest adopters of certified electronic health record technology and remain committed to the promise of delivering better health care with interoperable electronic health records," the organization said in February. "As health providers across the United States build out the EHR infrastructure over the coming years, family medicine will continue to play a central role, and CMS's announcement demonstrates that it is listening to our concerns. We’re gratified to see that our collective voice has been heard and needed change is coming."
As for billing and claims management, AAFP joined its voice with those of other provider associations in supporting additional ICD-10 flexibilities following the ICD-10 compliance deadline set for October 1.
The agreement between AAFP and HealthFusion is no guarantee of increased EHR adoption of a particular technology, but it does steer family physicians in an obvious direction when considering a specific health IT platform.
This story begins, as many do, with a real-world experience. Our health plan just refused to pay for a sleep study for my husband, who suffers from severe sleep apnea, despite his being quite symptomatic. We’re following up with the Virginia Department of Insurance and fully expect to win the day, though we remain baffled as to how they could make such a decision. While beginning the complaint process, a thought occurred to me.
What if wearables were able to detect wakefulness and sleepiness, and my husband was being tracked 24 hours a day? If so, assuming he was wearing one, wouldn’t it be harder for a health plan to deny him the test he needed? After all, it wouldn’t be the word of one doctor versus the word of another, it would be a raft of data plus his sleep doctor’s opinion going up against the health plan’s physician reviewer.
Now, I realize this is a big leap in several ways.
For one thing, today doctors are very skeptical about the value generated by patient-controlled smartphone apps and wearables. According to a recent survey by market research firm MedPanel, in fact, only 15% of doctors surveyed see wearables of health apps as tools patients can use to get better. Until more physicians get on board, it seems unlikely that device makers will take this market seriously and nudge it into full clinical respectability.
Also, data generated by apps and wearables is seldom organized in a form that can be accessed easily by clinicians, much less uploaded to EMRs or shared with health insurers. Tools like Apple HealthKit, which can move such data into EMRs, should address this issue over time, but at present a lack of wearable/app data interoperability is a major stumbling block to leveraging that data.
And then there’s the tech issues. In the world I’m envisioning, wearables and health apps would merge with remote monitoring technologies, with the data they generate becoming as important to doctors as it is to patients. But neither smartphone apps nor wearables are equipped for this task as things stand.
And finally, even if you have what passes for proof, sometimes health plans don’t care how right you are. (That, of course, is a story for another day!)
Ultimately, though, new data generates new ways of doing business. I believe that when doctors fully adapt to using wearable and app data in clinical practice, it will change the dynamics of their relationship with health plans. While sleep tracking may not be available in the near future, other types of sophisticated sensor-based monitoring are just about to emerge, and their impact could be explosive.
True, there’s no guarantee that health insurers will change their ways. But my guess is that if doctors have more data to back up their requests, health plans won’t be able to tune it out completely, even if their tactics issuing denials aren’t transformed. Moreover, as wearables and apps get FDA approval, they’ll have an even harder time ignoring the data they generate.
With any luck, a greater use of up-to-the-minute patient monitoring data will benefit every stakeholder in the healthcare system, including insurers. After all, not to be cliched about it, but knowledge is power. I choose to believe that if wearables and apps data are put into play, that power will be put to good use.
Microsoft Office was first introduced by Bill Gates at COMDEX, Las Vegas, in August, 1988.
Here we are almost exactly 27 years later, and if you plug the words ‘hate,’ ‘Microsoft’ and ‘Office’ into Google, you’ll get more than 4 million results. Remove ‘Office’ and Google returns more than 33 million results.
Clearly, some people don’t feel like Microsoft has perfected products to their satisfaction.
The perpetual unhappiness with a monolith like Office comes to mind as I read reports on the most recent surveys of physician satisfaction with electronic health records (EHRs). Let’s sum up, for those unfamiliar with the reports
First, reporting on survey data from last year, the American Medical Association (AMA) and American EHR, a division of the American College of Physicians (ACP), recently published “Physician Use of EHR Systems 2014.” Among other findings, the reports includes these nuggets:
Contrast those figures and levels of satisfaction with a survey of large physician practices released last week by market research firm Black Book that shows significant increases in physician EHR satisfaction. In particular, physician experience satisfaction has risen from 8 percent to 67 percent in the last three years. Physician documentation satisfaction went from 10 percent to 63 percent over the same time period, while practice productivity enhancement satisfaction has gone from 7 percent to 68 percent.
Worth nothing is that, with the AMA/ACP surveys, “Each society was allowed to select the population of their members to receive the survey. Information about EHR use by individual society members was not available. Therefore, the survey went to both users and non-users of EHRs.”
Also important: A similar ACP survey from five years ago showed significantly higher levels of satisfaction among the physicians surveyed.
The cognitive dissonance over EHRs continues, giving rise to theories on the Interwebs about the actual source of this disconnect.
At Healthcare IT News, contributing writer Jack McCarthy wonders if the constraints of Meaningful Use are antagonizing doctors, or if increased expectations and more sophisticated technology that fails to improve the daily challenge of patient care (in effect, a mashup of the two ideas) is creating dissatisfaction.
“Now, however, we have a lot more users who were forced to adopt EHRs meaning their tolerance for poor performance or usability will be lower,” notes health IT expert Shahid Shah in the article’s very interesting comments section. “I think it’s pretty easy to see why clinicians are less satisfied — if it was their choice they would be more tolerant. Since it’s not their choice in many cases, they’re less tolerant.”
Adds O’Reilly Media editor Andy Oram: “They [doctors] could be more familiar with the advantages computers offer in other areas of life … In short, having seen what a good interface can do, doctors become more demanding of the sub-par interfaces on EHRs.”
Expanding on the ‘why’ question, Michelle Ronan Noteboom (formerly ‘Inga’ of HIStalk fame) offers similar theories—MU forces doctors to use EHRs a certain way, compared to Facebook and Amazon most EHRs are clunkers, EHRs don’t deliver the ROI they promised—for the ACP survey results and asks if we should care whether or not physicians are happy.
“I’m of the opinion that physician satisfaction matters, but not nearly as much as improving the quality of patient care,” she writes at Healthcare IT News. “Patient care will be enhanced when all providers have access to thorough and accurate documentation. Ideally the patient records from one provider will integrate with records from other providers to create a single longitudinal record that is easy to decipher and provides a full picture of the patient’s health history.”
That sounds like a worthwhile goal. And Noteboom also has an explanation for the ACP survey results, pointing out “a direct correlation between physician satisfaction and the number of years a physician used his/her EHR. For example, among physicians on their system for three years or less, only 25 percent reported any level of satisfaction; satisfaction jumped to 50 percent among physicians that had used their EHR for five or more years.”
Sure, the differences between the two cited surveys could be attributed to methodology. But we know too much about how EHRs are influencing clinical culture to leave it at that. Physicians are human and subject to the same impulses—resentment when forced to do something; envy and confusion when seeing technology function well in other contexts; fear and consternation when learning something new—we probably faced when Microsoft started to become a rather sizeable part of our lives.
And, let’s recall, we’re really not that far into the ongoing transformation of American health care. Only now are we on the leading edge of value-based care as a replacement for fee for service. As EHRs evolve to improve quality, increase revenue, ensure patient safety, etc., instead of just meeting the contrived requirements of Meaningful Use, they will become the essential tools we envisioned at the beginning of this long and complex dance.
So it’s encouraging when both surveys show that physicians who’ve had their system for a while are happier with it. Indeed, while we continue to ask the specific question, “Are you happy with your EHR?”, maybe we don’t consider often enough the general frustration of digitizing processes that were once manual.
Also, it appears that plenty of hospital and health system administrators didn’t get the memo about creating buy-in before selecting and implementing an EHR. As David Whiles, former CIO at Midland Memorial Hospital said of their EHR journey, “Implementing an EHR is definitely an organizational project, not an IT project.”
And even though we are dealing with computers, this isn’t a binary choice of EHRs OR physician satisfaction. No one thinks computers are going anywhere, even if the Meaningful Use program ends. And physician satisfaction, to a reasonable extent, must be a high-level consideration for all clinical organizations. Over time, EHRs will improve and doctors will become more satisfied with them, perhaps will even depend on them, as essential clinical tools.
In the meantime, plug ‘hate’ and ‘EHRs’ into Google from time to time and see what you get. When we get over 30 million results, we’ll know we finally achieved Microsoft-ian levels of influence.
EHR use has been on the rise since the 2009 passing of the Health Information Technology for Economic and Clinical Health (HITECH) Act provided financial incentives for EHR implementation. However, do the gains of EHR adoption outweigh the substantial costs?
A recent study written by Tara O’Neill of the American Action Forum takes a look at these questions and states that although there are considerable benefits to EHR adoption, these come with costs that can only be resolved with changes in healthcare policy.
Since the passing of the HITECH Act, EHR adoption has risen to 76 percent, and over 468,000 Medicare and Medicaid providers have received some sort of subsidy from the Centers for Medicare & Medicaid (CMS) for reaching certain meaningful use standards. That totals to approximately $30.4 billion in subsidies, or $65,000 per provider.
Those subsidies are paid for a good reason-- according to O’Neill, the total cost for an individual provider to adopt an EHR is $163,765, and for five providers $233,298. Unfortunately, many adopters have yet to see the payoff for this investment, O’Neill writes. However, O’Neill cites a study by David Dranove, et al, which states that providers with a strong IT system may see larger payoffs come into effect in as soon as three years following the EHR adoption process.
“...in IT-intensive areas, hospitals with basic EMR systems saw cost decreases of 3.4 percent three years after adoption,” she writes. “As the number of workers in IT-related jobs continues to increase and EMR technology is adapted and improved, all areas may begin to see cost decreases.”
O’Neill also states that the lack of interoperability is hindering the productivity rates of EHRs. Because many systems do not do well with exchanging information between different hospitals, EHRs are being primarily used as tools within a specific healthcare facility. However, meaningful use standards are aiming to change this and to increase interoperability and health information exchange (HIE).
And while some of this lack of data exchange may be a result of the high cost of EHR adoption, O’Neill suggests that this may also be intentional “data blocking.” This is because providers and payers are reluctant to share with other providers important patient information that would help the other providers treat the patient.
“Essentially, under the current payment models, one person’s revenue gain is another person’s revenue loss,” she writes. “Thus, it will likely require a complicated policy solution in order to bring all of the players together for the benefit of society as a whole.”
As more healthcare organizations begin to adopt EHRs, patients are seeing more electronic files being created on their behalf. This poses as serious security risk, O’Neill says, one that can be very costly.
“The average cost of data breaches in the health care industry has been more volatile and has increased sharply in the last two years,” O’Neill writes. “The average cost of a data breach in the U.S. in 2014 was $217 per compromised record, compared to $398 in the health care industry.”
Additionally, data breaches are becoming increasingly expansive. Compared to 2014, the total number of records compromised per breach increased by 160 percent in 2015. This means that although there have been fewer breaches to date in 2015 than in 2014, the overall costs of data breaches is significantly higher.
O’Neill states that this may be an effect on the increased overall number of EHRs.
“With the growing number of electronic records and increased sharing among providers, the number of records potentially accessed in a single incident is growing exponentially,” she writes.
O’Neill recognizes the benefits EHRs could have on the healthcare industry, citing improvements in population health management and care coordination. However, she states that in order to see those gains, policymakers and healthcare professionals alike will have to cooperate and rework legislation to make EHR use more effective.
“As EMR adoption continues to increase along with the type of information gathered, policymakers should work with experts and the public to ensure that the appropriate balance is struck between sharing information to allow advancements and providing necessary privacy protections,” she writes.
Why is it that patients are slow to take charge of their health records? Some articles suggest that management of health information should be a patient-driven initiative and the points that are used to propagate this idea are not without merit. However, the primary reason is a lack of a collaborative effort among patients and providers. It is the responsibility of healthcare professionals – who bear more accountability than ever – to make a concerted effort to drive this change. And, since the technology is available to support this effort, the first step for providers is to embrace their influential role in educating patients on the importance of managing life-long health and wellness.
A Culture of Connectivity:
Dr. Kvedar confirmed how, in the new network-based model of healthcare, connectivity is critical to providing the highest level of care, by saying “the ideal way to keep you focused on improving your health is through connectivity and in-the-moment, contextual messaging – messages directed at your specific health needs at the moment you need them.” The result of greater connectivity is higher engagement, but providers must actively pursue initiatives centered around leveraging filtered, personal health data from patients. Health providers need to have an influential role in closing the loop of contextual messages by responding on priority, as demanded by the condition at hand.
A Culture of Convenience:
New breakthroughs in technology have helped overcome the traditional challenges of interoperability, making diagnosis and ongoing care more convenient than ever. Portable devices and clingy fitness trackers have contributed to having health vitals available at your fingertips; data that has now become easy to upload and analyze on any platform for possible conditions. And, as a recent article in The Economist states, “…computing power is now being applied successfully in countless small ways, using smartphone and other diminutive devices, to make a big difference to the effectiveness of treatments,” (“Bedside Manners”).
A Culture of Change:
Taking it one step further, healthy lifestyles within various segments of the population can be promoted by developing and implementing community wide initiatives that leverage vital data monitoring. These efforts can impact greater health issues such as diabetes, blood pressure, early child birth, obesity and other conditions. By adopting a consistent and motivating approach toward shared data exchange processes, providers will be able to better manage and motivate patients, while driving positive, ongoing change at the fraction of the cost of live interactions.
In healthcare, proper use of medical data is critical to optimizing outcomes and lowering costs, but the absence of a truly collaborative effort among patients and providers remains as a barrier to success.
Drivers of Change
is the fact that no simple solution is available and no national initiative – legislative or otherwise – exists to helps fill this engagement void in healthcare. Just as providers are responsible for patient care and satisfaction, so too should they serve as facilitators of patient engagement. By taking this approach, new age health initiatives will reshape the culture of healthcare and lead the industry to a truly preventative system.
Just 10 percent of Texas physicians are confident that their practice is prepared to transition to ICD-10 on Oct. 1, according to a new survey from the Texas Medical Association (TMA).
In July of 2015, Texas physicians were surveyed regarding their practice’s readiness to transition to ICD-10. Approximately 37,000 Texas Medical Association members and non-members with email addresses in the TMA database were emailed a link to the survey. The results are based on 936 responses. According to TMA, 97 percent of respondents currently treat patients in active medical practice. Among physicians who quit treating patients in active medical practice, 48 percent quit due to regulatory and/or administrative burdens and 22 percent quit due to ICD-10.
Nearly two-thirds (65 percent) of all physicians responding have little or no confidence that their practice is prepared to transition to ICD-10 by the deadline, even though the new coding system is supposed to enable doctors’ offices to collect and report more detailed patient data. “It’s horrible,” TMA President Tom Garcia, M.D., said in a statement. “The United States is the only country that couples the ICD coding with payment. The implications are that the doctor/patient relationship is going to be stressed.”
The survey found that few physicians have begun transitioning to ICD-10 extensively (7 percent). Physicians employed in hospitals are least likely to feel their practice has begun to transition to ICD- 10 extensively (3 percent). Even among physicians who feel very confident their practice is prepared to transition to ICD-10, only 42 percent report their practice has begun transitioning extensively.
Regarding training, 53 percent of physicians report the staff, and 46 percent report the physicians in their practice have taken ICD-10 preparation courses or training. Physicians in partnerships (34 percent) and the staff of solo practices (39 percent) are least likely to have taken preparation courses or training in ICD-10.
What’s more, older physicians are more likely to close or sell a practice and/or retire early in response to delayed or denied claims payments as a result of ICD-10. Physicians in the youngest age group (40 years and younger) are more likely to terminate or renegotiate plan contracts (34 percent).
Regarding electronic health record (EHR) status, 74 percent of physician respondents said that their practice currently uses an EHR. Among EHR users: 65 percent report their EHR is currently capable of handling ICD-10 codes; 29 percent of physicians whose EHR is not currently capable of handling ICD-10 codes are expecting an update; 15 percent of physicians report their will be a median cost of $10,000 associated with this update; and 1 percent of physicians report their software will need to be replaced.
The survey found that physicians fear the massive switch to the new coding system will disrupt patient care, and delay payment. In fact 83 percent of the doctors anticipate delayed or denied claims because of the transition, regardless of specialty. More than one-third of the physicians expect disruption so bad they will have to draw from personal funds to keep their practice open (36 percent) and almost one-third (30 percent) might retire early over anticipated cash-flow problems. (Almost half of the doctors age 61 or older might retire early.) Nearly a third (32 percent) might cut employees or reduce employee work hours or benefits.
Responding to the industry’s pleading, Medicare has said it will not deny doctors’ claims for one year whose ICD-10 codes are not specific enough, as long as the doctor submits an ICD-10 code from the correct family of codes. And if the doctor submits claims in the correct code family but are not specific enough, Medicare also will not audit those. Dr. Garcia said, “I asked for two years’ grace period but they only gave us a one year grace. I think it is going to take at least three years before this thing is finally settled down.”
No matter the size or scope, thorough electronic health record (EHR) implementation planning should begin with determining your desired end-state, what is needed to reach it, and the potential hurdles you may encounter along the way. Identifying potential activation risks before implementation allows for time to proactively and appropriately plan, budget, and communicate resource needs and expectations. You can alleviate surprises that may negatively affect clinician satisfaction and limit the full benefit of your new EHR.
What follows are several common activation risks and how you can address them upfront.
Risk: As more physician groups are added to the potential user base through acquisition, affiliation agreements or EHR extension initiatives, the temptation is often to accommodate these additional providers in the original activation timeline. This increases resource needs for build, testing, and go-live support and introduces additional risk to the timeline.
Solution: Develop an implementation strategy for ongoing acquisitions, affiliations and private practices to minimize the impact on activation budget and plans. This will also set expectations with the newly acquired and affiliated groups as to how they fit into the implementation strategy. For example, create a schedule to add new providers to the beginning of the last clinic group’s testing cycle. Determine how many clinics the implementation team can handle to determine when to create the next grouping – whether the current strategy is “big bang” or phased. This requires reviewing the existing team resources to ensure the right number of resources are available to support ongoing implementations and clinics that are live on the system.
Risk: To provide physicians with time to adapt to a new system and workflows as they gain expertise with the new EHR, many organizations allow for a scheduling reduction in operating cases, office visits or scheduled procedures. Physicians who receive RVU-based compensation could see a reduction in their compensation. Scheduling reductions may also trigger revenue loss for ancillary departments such as radiology, laboratory and surgical services due to fewer referrals – a common trickledown effect from schedule reductions.
Solution: If you choose to reduce scheduling, you need to determine how or if you will bridge the gap in compensation or bring in external clinical staff with EHR experience to maintain existing schedule loads. It is also a good idea to provide insight about potential budget impacts (e.g., up staffing, vacation planning and schedule reduction) to the finance department as soon as they are identified to help them plan for the impact. By proactively communicating the trickledown impact of revenue loss for ancillary departments to executive leadership and governance bodies, the reduction in revenue will be anticipated and planned for accordingly.
Risk: Clinicians and staff will be required to participate in manual conversion activities before activation for inpatient chart conversion, scheduling and registration of appointments, schedule template build, surgical case block and case creation, pre-op order entry, etc. Manual conversions will result in overtime due to after hours and weekend work, as well as hospitality costs, which are often overlooked.
Solution: A hybrid approach to converting appointments is possible by using an electronic format for simple appointments and manual conversion for more complex appointments to save time. Staff will be needed to validate electronic conversion results as well as participate in backfilling for those participating in manual conversion activities – either with internal or external resources. Early communication with clinical and business departments about the need to participate in these activities will help them better manage their staff scheduling. Prepare for additional staffing and their needs in the budget.
Risk: Allocating adequate space for command centers can be challenging, especially for large scope activations. Dedicated space is necessary to accommodate large groups of people (120+ for a “big bang”) before and after activation. It may be necessary to reserve space well ahead of time to ensure it will be available. For ambulatory activations, there are challenges with where to locate the command center to best meet the needs of the end users. Command center space must be equipped with network access, telephony and hardware. Additionally, there are physical security considerations, increased parking needs and workspace considerations, such as tables and chairs, and hospitality costs for the command center which are typically an afterthought and under-budgeted.
Solution: For large scope activations, identify and reserve a command center area one year before go-live to ensure you have the necessary space. Approximately four months before go-live, identify all of the resources needed to equip the command center to plan and monitor logistics and communications. Adjust budget line items with the actual costs being incurred. Depending on the current configuration of the space being used, it may require relocating existing users or running wiring and cable. Consider HVAC requirements for afterhours work as well. The complexity of the command center preparations may require that the work begins several weeks before the space is needed. Getting this space set up prior to activation will also allow it to be used for manual conversion work efforts to better facilitate communication, training and support. Define in advance what hospitality (e.g., food and beverages) will be offered and for how long including manual conversion activities and post activation needs.
Risk: Billing and coding staff will be focused on learning the new system and work queues, as well as new workflows for accounts receivable management. This will affect their ability to continue accounts receivable work and coding in the legacy systems.
Solution: By outsourcing the legacy accounts receivable tasks, billing staff will have time to focus on adjusting to the new system. Additionally, outsourcing coding for four to eight weeks post go-live gives coding staff time to learn the new system and workflows.
Risk: Large numbers of staff are needed to provide support for go-lives – whether they are internal super users or external resources brought in to assist with support of staff and physicians. Both types of resources are expensive. Internal super users have been pulled away from their regular responsibilities and must be backfilled. While, competing implementations in your area could increase competition for external resources driving up costs.
Solution: Carefully estimate the resources and budget needed to provide support for staff learning the new system being careful not to underestimate what is needed. Assume that super users will need to be backfilled for two to four weeks post go-live and that you will be using external resources for the same timeframe. Continue to monitor the numbers of super users that will be available to provide support in order to more accurately determine how many external resources will be needed. Understanding what competing priorities may exist for external resources in your area will allow for proactive contracting of these resources. Finally, don’t forget logistics and the ability to manage all of these resources.
When done in a thorough and thoughtful manner it is possible to determine your activation needs upfront during EHR implementation planning and reduce risks at activation. It alleviates unexpected budget overruns and prevents organizational frustration with the activation process. Additionally, it minimizes negative perceptions by clinicians that can impact early adoption of the EHR and realizing its full value potential.
This past spring, the Office of the National Coordinator for Health IT announced the 2015 Edition Health IT Certification Criteria proposed rule, along with the proposed rule for Stage 3 of the EHR incentive program.
Vendors immediately began weeding their way through those hundreds of pages to prepare official comments and to understand the potential implications for product development.
According to ONC, the 2015 Edition seeks to "enable a more flexible certification program that supports developer innovation" and "incorporates changes to foster innovation, open new market opportunities, and provide more choices to the care community when it comes to electronic health information exchange."
Despite ONC's lofty objectives, many EHR vendors are concerned that the scope of the proposed rule is too broad with too many requirements, including certain standards that have yet to be fully vetted by the industry. One consistent criticism is that the proposed rule includes a considerable number of criteria that are not specifically tied to the meaningful use program – nor to other HHS programs.
"In all previous rules, the ONC certification requirements were tied to a meaningful use objective," explained Stephanie Zaremba, senior manager of government and regulatory affairs for athenahealth. "The rules have now been decoupled and about half of what is in the ONC rule are requirements for functionalities that are not necessary to succeed inmeaningful use."
Joe Wall, supervisor of federal initiatives for MEDITECH, shared similar concerns: "We really wanted to see ONC focus on the meaningful use regulatory aspect," said Wall. "The proposed certification rule included requirements that are not necessarily tied to any specific meaningful use objectives, but still place a burden on EHR vendors to develop, test, certify, and implement by the 2017 optional year."
Other vendors, including Allscripts, concur that the breadth of requirements, given the proposed timeline, presents a challenge.
"We certainly understand the thinking behind a lot of the suggestions, but believe the scope of what ultimately was presented was really too significant, particularly within the scope of time they allowed for the work to be done," said Leigh Burchell, vice president of policy and government affairs for Allscripts. "If we have to devote resources for all these requirements, we have to use resources that could be innovating elsewhere."
It is, she says, "an industry-wide drain on innovation."
Another area of concern is the inclusion of criteria based on new or immature standards which may have been conditionally piloted, but not fully tested and validated.
"As a vendor, we are concerned that before we adopt standards into our system they are mature, well-vetted, and well-tested – rather than the latest and greatest," said Wall.
Burchell theorizes that the ONC's inclusion of certain proposed standards was an attempt to give vendors more room to innovate. "What may have happened is that they went down the road of inclusion of more immature standards in order to broaden the list of available standards you can use towards certification," said Burchell.
"Unfortunately the way the standards showed up is not hitting the goal they were going for," said Burchell. "The reality is that if standards aren't ready, it isn't going to be something we are going to be confident in including in our products."
While vendors applauded the ONC's efforts to engage stakeholders, improve flexibility and usability, and support innovation, the general consensus is that overall the proposed rule mixed the mark.
"In trying to move away from their typically overly-prescriptive approach, ONC didn't hit the right balance," noted Zaremba. "They are still being pretty specific and prescriptive in what vendors need to do for some things.
"Our overall comment is that ONC should actually take a step back and let the market figure out what is needed and let vendors work with their clients to meet their demands. If they want to create an environment for innovation in health IT, 500 pages of regulation is probably not the way to do it."
Regardless of the final certification rule, the major vendors appear committed to developing whatever functionality is required. They predict, however, that some smaller organizations may struggle to comply.
"We will certainly meet all the demands for industry regulation and do what is necessary," said Wall. "But, the certification process will pose a challenge to smaller vendors because what they put in the certification rule is very large and the technology demands are immense."
Burchell agrees: "You can expect most of the larger companies to move forward with whatever is in the final rule. We have already seen some of the smaller organizations show up less in the Stage 2 attestation data, so that may be exacerbated if all these requirements to go into effect."
There will be government officials and health IT experts who refute these findings. Others, meanwhile, are likely to argue that it just confirms what they've been saying all along.
Here goes: There is little or no actual hard evidence to prove that theMeaningful Use program triggered an uptake in electronic health records adoption. That's according to a new study published in the Journal of the American Medical Informatics Association.
The authors of "Impact of the HITECH act on physicians' adoption of electronic health records" examined the extent to which meaningful use and some $30 billion in incentives behind it influenced the EHR adoption curve that existed prior to the Healthcare Information Technology for Economic and Clinical Health Act of 2009, that being the legislation funding the meaningful use program.
"The authors find weak evidence of the impact of the MU program on EHR uptake," JAMIA explained. "This is consistent with reports that many current EHR systems reduce physician productivity, lack data sharing capabilities, and need to incorporate other key interoperability features (e.g., application program interfaces)."
It's a curious piece of research, particularly given that the Office of the National Coordinator for Health IT, on the public dashboard it maintains and elsewhere, has said that 95 percent of eligible and critical access hospitals have "demonstrated meaningful use of certified health IT. Through participation in the Centers for Medicare & MedicaidServices EHR Incentive Programs."
What happened, then? EHR adoption has indeed risen since meaningful use began, yet JAMIA determined that the federal reimbursement incentives are not the reason.
"The models suggest that adoption was largely driven by 'imitation' effects as physicians mimic their peers' technology use or respond to mandates," JAMIA authors contend. "Small and often insignificant 'innovation' effects are found suggesting little enthusiasm by physicians who are leaders in technology adoption."
Do you buy that? Is what we have here a simple case of correlation and not causation? Or much more complicated?
Multiple motivations are driving EHR adoption in the healthcare industry from the EHR Incentive Programs to the promise of increased healthcare efficiency. Yet in a recent survey by AmericanEHR Partners and the American Medical Association (AMA), researchers found that physician satisfaction is on the decline.
The report finds that in 2010 a total of 61 percent of respondents were satisfied or very satisfied with their EHR systems. In 2014, after the total number of EHR users has increased, a mere 34 percent of respondents are satisfied.
Additionally, nearly half of respondents reported that EHRs actually decreased efficiency, with 42 percent saying EHR technology made it difficult to improve efficiency, 72 percent stating it was difficult for EHRs to decrease physician workloads, 54 percent saying EHRs increased total operating costs, and 43 percent saying their practices have not yet overcome these challenges.
The report notes that other findings in the survey heavily depended upon whether respondents were satisfied or dissatisfied with their EHR system. This means that there was polarized variation in responses depending upon how respondents felt about their EHR systems. Naturally, respondents who were satisfied responded positively to the survey questions, while those who were dissatisfied did not.
For example, when responding to questions regarding staff time spent processing and refilling prescriptions, 42 percent of all respondents said they were satisfied with their EHR. However, of those who were dissatisfied with their overall EHR use, only 25 percent were satisfied in the processing and refilling prescriptions category. Of those who were satisfied with their overall EHR use, nearly 69 percent were satisfied with the process and refilling prescriptions category.
However, there were some questions all respondents were generally able to agree upon. Merely nine percent of respondents — or 19 percent of those who were satisfied with their EHR — reported that adopting an EHR system decreased their practices’ overall costs. Likewise, only 13 percent of respondents — or 21 percent of those pleased with their EHRs — reported that their EHR technology made a positive impact on a number of their employees.
The report also indicates that primary care physicians tend to be more satisfied with EHR systems than specialists. This is because primary care physicians on average have worked with EHR systems for longer than specialists have, and therefore have figured out the best and most efficient ways to use them. The report also indicated that it took an average of three years for physicians to get used to working with an EHR and to resolve the initial challenges the systems presented.
Shari Erickson, MPH, Vice President of the American College of Physicians Division of Governmental Affairs and Medical Practice, contends that as EHRs continue to be integrated into physician practice, satisfaction ratings will increase.
“Perhaps we are getting over the curve in EHR adoption,” she said. “It may be that as we see more practices that have been using these systems longer we will see satisfaction begin to rise.”
The Centers for Medicare & Medicaid Services (CMS) continues gearing up for the October 1 ICD-10 compliance deadline with Acting Administrator Andy Slavitt scheduled to address the ICD-10 transition during a national provider call later this month.
On August 27, Slavitt will provide a national implementation update as the nation reaches the five-week countdown to October 1. Also scheduled to speak are American Health Information Management Association (AHIMA) Senior Director of Coding Policy and Compliance Sue Bowman and American Hospital Association (AHA) Director of Coding and Classification Nelly Leon-Chisen.
Two recent surveys show industry-wide progress toward a successful ICD-10 transition in October. In July, the 2015 ICD-10 Readiness reportpublished by AHIMA and the eHealth Initiative stated that half of respondents had completed test transactions with payers or claims clearinghouses.
Despite these positive findings, the report also revealed that ICD-10 preparation gaps still remain for many providers in the area of testing and revenue impact assessments. Only 17 percent indicated that they had completed all external testing. Similarly, only a minority of respondents (23%) have contingency plans related to ICD-10 go-live.
More recently, latest ICD-10 readiness survey from the Workgroup for Electronic Data Interchange (WEDI) showed physician practices to be lagging behind their counterparts.
As compared to seven-eighths of hospitals and health systems ready for October 1, less than a half of physician practices indicated they would be ready. This disparity was also evident in the area of provider impact assessments. Only one-sixth of physician practices had undertaken the assessment versus three-fifths of hospitals and health systems. "This lack of progress is cause for concern as it will leave little time for remediation and testing," WEDI reported.
In a letter to Department of Health & Human Services Secretary Sylvia Mathews Burwell, WEDI cautioned that without a concerted effort the ICD-10 transition could lead to negative consequences for the healthcare industry.
"We assert that if the industry, and in particular physician practices, do not make a dedicated and aggressive effort to complete their implementation activities in the time remaining, there is likely to be disruption to industry claims processing on Oct 1, 2015," the organization stated.
Around the same time, CMS provided clarification about ICD-10 flexibilities it make available to providers following a joint statement with the American Medical Association (AMA) in June. The major ICD-10 flexibility is the federal agency's decision not to reject claims coded incorrectly in ICD-10.
"Medicare claims with a date of service on or after October 1, 2015, will be rejected if they do not contain a valid ICD-10 code," the federal agency stated. "The Medicare claims processing systems do not have the capability to accept ICD-9 codes for dates of service after September 30, 2015 or accept claims that contain both ICD-9 and ICD-10 codes for any dates of service. Submitters should follow existing procedures for correcting and resubmitting rejected claims."
Here's a quick look at the agenda for the MLN Connects Call:
As the entire healthcare industry counts down to October 1, CMS appears ready to ramp up its activities.
There is no shortage of complaints about the usability of Electronic Health Record systems (EHRs). More and more evidence is emerging regarding the lack of EHR usability. Speaking at the 2013 Healthcare Information and Management Systems Society (HIMSS) Conference & Exhibition, Michael S. Barr, MD, MBA, FACP, of the National Committee for Quality Assurance (NCQA) warned that:
“Satisfaction and usability ratings for certified electronic health records (EHRs) have decreased since 2010 among clinicians across a range of indicators.”
Barr’s presentation at HIMSS focused on “ the need for the Meaningful Use program and EHR manufacturers to focus on improving EHR features and usability.”
The healthcare industry in the United States is facing a crisis as medical facilities have spent hundreds of billions of dollars implementing electronic health record (EHR) systems, yet many patients and the physicians and nurses that care for them are seeing few benefits.
In a recent article published in the The Journal of the Human Factors and Ergonomics Society examined 50 studies with the keywords: electronic medical records and electronic health records combined with interface design, usability, safety, and errors published after 2000. Their review of EMR and EHR usability studies revealed nine major types of problems:
Given that these nine types of usability issues persist across many Electronic Health Systems, it is the responsibility of all EHR vendors to reach out to specialists in Healthcare Usability, and solve them. Usability in healthcare is unique in that the creation of more usable systems not only can save these companies money—with reduced development, training, support, and documentation costs—it can save lives!
Less than a quarter of hospitals have the capability to find, send, receive, and use data, according to data compiled by the Office of the National Coordinator for Health Information Technology (ONC) and American Hospital Association (AHA).
During yesterday's monthly meeting of the Health IT Policy Committee, ONC Senior Advisor Vaishali Patel, PhD, MPH, provided a data update on the health information exchange and interoperability capabilities of hospitals.
According to the latest update, a vast majority of hospitals have the health IT infrastructure necessary for exchange, with 75.5 percent reporting having a basic EHR system and 96.9 percent of them having a certified EHR technology (CEHRT) in 2014. Those figures are up from, respectively, 59.4 percent and 94.0 percent in 2013 and 44.4 percent and 85.2 percent in 2012.
Concomitant with the increased hospital EHR adoption is increase HIE with outside ambulatory care providers and hospitals over that same period of time. More than three-quarters of hospitals (76%) surveyed by the ONC and AHA exchange with these providers externally, up from 62 percent and 58 percent in 2013 and 2012, respectively.
What remains elusive for many hospitals, however, is the capacity for finding, sending, receiving, and using data electronically all at the same time:
Only 23 percent conduct all four interoperable exchange activities. Taken individually, the send functionality is most common to hospitals, with 78 percent having the capability. This is followed by receive (56%), find (48%), and use (40%).
ONC observes in the findings that hospitals engaging in more interoperable exchange activity end up have higher levels of information available to them from external data sources above the national average of 41 percent.
The findings include three types of barriers to exchange health data — technical, operational, and financial — with most belonging to the first type.
Leading the list of barriers were the technical barriers of ability of exchange partners' EHR or other systems of exchange partners to receive data (59%) and the capability of EHR systems themselves to receive data (58%). Difficulties associated with finding a provider's address (45%) was the third most-common barrier, which also was technical in nature. The leading operational and financial barriers were workflow challenges to send data from the EHR system (30 percent) and the additional costs for exchanging with external providers (25%), respectively.
As ONC concludes, solutions to increasing interoperable exchange must by and large address technical rather than operational and financial barriers.