EHR Intelligence Daily
- Financial. “We were hit very hard by the recession,” she said. “We don’t want [medical] practices to go out of business” having to spend large amounts on EHR systems.
- Wide open spaces. “We have not just rural, but frontier communities,” O’Mara said. Some areas have little or no Internet connectivity. “Nevada is the most mountainous state in the U.S… Our biggest concern is not [connection] speed, but bandwidth, especially for images.” The state has significant Native American populations as well as several military bases. The bases have to contract some of the care out of state, so connectivity is essential in sending patient data.
- Physician shortage. “We have an almost statewide shortage of PCPs (primary care physicians), mental health providers, and dentists.” The shortage will only worsen, O’Mara anticipates, in the next few years as employers compete for the relatively few HIT professionals. “We hope EHR will help at least a bit,” supporting doctors by delivering ready access to data. The state is collecting data to determine whether EHR does allow greater efficiency….
- Wisconsin State Health Information Network (WISHIN), a non-profit group the state has appointed as its HIE’s governing organization that will implement the state’s HIT plan. WISHIN contracted with Medicity to develop tools that help providers connect securely to other providers and agencies.
- Wisconsin HIT Extension Center (WHITEC), a collaboration of several organizations providing technical support to providers wishing to implement EHR systems and attest to Meaningful Use incentives.
- WISHIN is working with Medicity to develop a new “community health record” application called Pulse. Pulse will assemble a compilation of a patient’s health history including all providers who have seen the patient, “regardless of health system affiliation or… EHR system,” per a WISHIN newsletter.
- WISHIN is also developing secure connectivity with such agencies as the Nationwide Health Information Network, the Social Security Administration and the Veterans Administration. Such communication can greatly speed disability determination decisions, Webb said; “the quicker they share the information for the disability determination, the quicker the services will be covered for you.” Existing protocol can take three or four months to approve services, said Webb, but using MEGAHIT (Medical Evidence Gathering HIT), “reduces the time to weeks instead of months.”
- Other future plans (too numerous to add here) include providing “de-identified” patient data for public health purposes (for example, data on disease outbreaks).
Leading a meaningful use (MU) compliance initiative to its successful conclusion requires a dedicated focus on three foundational work streams: incentive program compliance, organization performance, and electronic health record (EHR) enhancement. Each may be managed separately, but the overall initiative requires comprehensive coordination and oversight to ensure current compliance and to establish capabilities for future health reform initiatives. True MU success is the ability to manage the challenges of universal health reform. It is in this capacity that strong organizational governance can make a critical difference in an organization’s ability to achieve MU success.
Incentive program compliance
Monitoring, tracking, and managing compliance with the various and ever-changing requirements requires a concentrated focus and effort. Stage 1 program rules and regulations outline the administrative component of the incentive program. While CMS’s 2010 final rulemaking is the program’s foundation, rule updates must be monitored closely. These updates require a structure and process to respond quickly and course correct when necessary. Furthermore, each state is allowed Medicaid incentive program administration flexibility resulting in the need to closely monitor state rule differences.
CMS’s recent expansion of the Medicare RAC program to encompass audits for MU compliance further emphasizes the need to remain diligent in this area. Contracted auditing companies have already begun conducting audits under the federal waste, fraud, and abuse program. States are establishing similar Medicaid programs. Critical organization activities to manage include:
• Determining/implementing appropriate activity oversight to ensure regulatory compliance with the standards;
• Working with leadership to appoint/support internal representatives for regulatory compliance oversight and adherence to standards;
• Supporting functional areas with appropriate quality and regulatory resources;
• Monitoring the regulatory environment to ensure continued compliance;
• Maintaining working relationships with external regulatory bodies and community partners;
• Establishing a Health Reform reporting structure to the enterprise quality/performance improvement function, compliance committee, senior management, and board of directors (or similar governance bodies);
• Coordinating /directing activities for internal compliance audits;
• Managing preparation and responses to external compliance audits;
• Establishing organization expertise for all aspects of the HITECH Act to facilitate knowledge transfer to internal SMEs;
• Providing support for key strategic initiatives impacted by MU implementation.
The foundation of the MU objectives is the use of technology, primarily EHRs, to improve care quality and reduce costs. The need to enhance processes, evidence-based care practices, and organization capabilities (e.g., workforce management, patient throughput, measurement) are critical to achieving MU. High-performing organizations with flexible, efficient improvement methodologies consistently exceed minimum Stage 1 MU requirements as a sustainability strategy. As future MU stages become more complex and pay-for-performance becomes the established reimbursement model, organizational performance will be critical to sustaining and enhancing financial viability. Organizational performance activities orchestrated by the quality/improvement function might include:
• Promoting a culture of performance to sustain compliance;
• Directing the development, implementation, maintenance, and improvement of clinical, financial, and service systems to ensure compliance;
• Identifying potential areas of compliance vulnerability and risk based on analytics;
• Providing process owner guidance to develop/implement corrective plans;
• Working with education leaders to ensure effective compliance training programs that reinforce compliance or implement new regulatory requirements;
• Establishing champions/change managers for all MU-related projects across the facility;
• Facilitating workflow improvements and supporting implementation and full system adoption of certified EHR technology;
• Align MU improvement initiatives with internal current and future quality initiatives.
Comprehensive and widespread use of certified EHRs is critical to the achievement and sustainability of MU Stages 1, 2, and 3. However, having a certified EHR system and software that offer the requisite features and functions to enable MU achievement does not alone guarantee that an organization will achieve MU requirements. To ensure success, process redesign and operational improvements in conjunction with the EHR design and build phase as well as subsequent MU testing over and above standard EHR implementation approaches are required. Data capture and management are fundamental to accurate measurement of performance and mandated reporting as well as mandates for data exchange. Moreover, accurate coding coincides with ICD-10 implementation. As part of planning and implementation, changes in data capture forms, clinical processes, and reports should coordinate MU and ICD-10 redesign and training activities.
Expert oversight of a knowledgeable MU IT project manager will support enterprise initiatives in progress to demonstrate MU by:
• Working with the EHR vendor’s IT team during analysis, design and build, implementation, tracking, and reporting to monitor progress of achievements against MU targets and goals;
• Working with MU build and reporting teams to develop program-wide reporting solutions;
• Working with the performance improvement team to facilitate system-wide work flow improvements and implementation and full adoption of certified EHR technology;
• Anticipating and planning for challenges related to the ICD-9 /ICD-10 conversion, HIPAA 5010, and new federal IT security regulations;
• Working with clinical and business owners to establish MU analytics that support monitoring performance for early course correction.
The IT MU project manager manages and facilitates the documentation of changes to EHR software and processes necessary to meet requirements for MU while coordinating this effort with the MU governance bodies.
Marla Roberts, DrPH, RN, is a senior delivery manager for CTG Health Solutions.
“It’s not simple; it’s not easy. Is it doable? Absolutely,” said Nevada’s health IT coordinator is Lynn O’Mara about rising to the challenges of getting physicians to switch to electronic health records. “It takes a lot of upfront planning and the right puzzle pieces being put together right. It’s not one-dimensional, either. You must look at it from a three-dimensional perspective.”
There are an estimated 9,000 physicians in the state, including both EPs (Eligible Professionals) and non-EPs. O’Mara said the state has no statistics on the percentage of physicians with EHR, but noted that “we have non-EPs that have adopted EHR.” A 2011 Robert Wood Johnson Foundation study cited by ehrintelligence.com reported that 52.5% (national average: 57%) of the state’s doctors were using “any [EHR] system,” while about 23% (national average: about 34%) had adopted a “basic [EHR] system.” Nevada officials predict that about 75% of the state’s physicians will have adopted an EHR system by 2015.
About 10% of Nevada’s population is enrolled in Medicaid, and about 13% in Medicare, according to the HITSOP plan mentioned above. The state’s first Meaningful Use incentive payments have just recently become available (August 2012).
Long on landscape, short on resources
The Nevada State Health Information Technology Strategic and Operational Plan (HITSOP) sums up this mountainous state’s HIT challenges pretty well: “… the State‘s efforts to advance HIT/E, particularly electronic health record systems (EHRs) and HIE, are in their infancy. The State‘s economy is fragile, with little evidence that it will significantly improve over the next biennium, which may cause implementation delays.” The plan goes on to state that it will address these issues with a “commitment to implementing HITECH requirements, fulfilling the terms of the HIE Cooperative Agreement, and establishing a viable statewide HIE infrastructure.”
“We’re on the hook to make sure everything gets done,” as a grant recipient for HITECH funds, O’Mara said.
O’Mara summarized the difficulties into three categories:
Working on solutions
A basic provider web portal called NV Direct, will serve as the first phase of HIE implementation. NV DIRECT will allow provider participants to transmit encrypted patient data to other authorized participants.
DIRECT will serve as an interim HIE system until a governing entity/EHR development vendor is selected. “We want to make sure we had HIE capability first so [providers] can attest to Stage 1 [Meaningful Use],”said O’Mara.
The non-profit HealthInsight serves as the state’s Regional Extension Center.
The state has not yet installed an HIE governing entity/developer. Nevada Health Information Exchange (NHIE) will serve in this capacity, but the NHIE Board of Directors, working with Nevada’s DHHS, has just begun its process of setting up NHIE as a legal body with a set of bylaws. Once the legal entity is fully in place, NHIE will develop a robust HIE system to replace NV DIRECT. O’Mara said the system will likely store data “in the cloud” for reliable access.
Nevada is one of eight core member states of the Western States Consortium. The federally-funded cooperative body exists to resolve policy issues and develop interstate HIE standards and requirements.
What sets Nevada apart
“We’re approaching [HIE efforts] as a business,” O’Mara explained. We’re working with the office of economic development. We have a lot of moving parts and pieces… and looking at the long-term view.”
“Within the business model, each opportunity will be converted into an estimated revenue stream. Stakeholders/customers will pay into the HIE business in one of three ways: message usage, subscription, or a hybrid of usage and subscription,” said the HITSOP plan mentioned above.
“We believe it’s in the best interest of the state [to promote EHR and HIE],” O’Mara said. “It’ll improve care coordination and access to care.”
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Despite limited resources and an economy pummeled by recession, Alabama’s Health Information Exchange (HIE) Commission and the state’s Medicaid agency have won praise for their successful efforts in bringing physicians on board with EHR, and in ensuring health coverage for its most vulnerable populations, respectively.
Dr. Dan Roach, Alabama’s state HIT coordinator, attributes the HIE’s success to the high level of cooperation and collaboration among stakeholders. “Our state leaders, public and private agencies, state universities, provider groups, patient advocacy groups—we’re all at the table… everyone has a voice,” said Roach. “Everyone is part of the decision-making process. We may not all always agree, but we work it out.”
This collaboration has thrived so well that Roach has been invited to speak on a national level more than once. People ask how he and the state achieve this cooperation. “I tell them, ‘we invite them’ [to participate],” Roach laughed.
“We’re the third in the nation in bringing providers live on EHR and to Meaningful Use,” Roach said, citing the HIE’s technical assistance and training.
There are about 1300 individual provider members of the state’s Regional Extension Center, Roach said. Of these, about 91% have adopted EHR, and 31% have attested to Meaningful Use.
A 2011 Robert Wood Johnson Foundation study cited by ehrintelligence.com reported that about 47% of the state’s doctors were using “any [EHR] system,” while about 26% had adopted a “basic [EHR] system.” Updated statistics were unavailable from the Alabama officials interviewed for this article.
The greatest challenge
“It was really heavy lifting,” Roach said in describing initial efforts to get physicians on board with EHR. “There was a lot of skepticism,” particularly before any Meaningful Use (MU) funds finally reached the attesting providers.
“Getting people signed up is just a lot of hard work, [involving] a lot of human resources we may or may not have,” Roach explained. Efforts to reach smaller practices in rural Alabama were particularly taxing. The small, busy practices did not often agree to get on board over the phone. “We had a lot of windshield time,” Roach said, driving into the rural communities and offering free assistance. But now, as benefits of EHR become better known and the MU incentives are distributed, there is a lot more buy-in.
Alabama’s HIT/HIE efforts
The state’s HIE Commission is developing a secure communication system called One Health Record (OHR) as the state’s answer to the federal CMS (Centers for Medicare and Medicaid Services) Stage 1 and 2 requirements for secure patient data transfer under the Meaningful Use incentive program.
Coordinated by the Alabama Medicaid agency, OHR’s staged implementation begins with a secure portal for the state’s registered providers, who can send patient data to other registered providers as needed, such as for referrals.
Already, some unexpected benefits are emerging, said Robin Rawls, Communications Director of Alabama Medicaid. “[The portal] makes a big difference for care managers; they are very enthusiastic about it,” Rawls said. She noted that the portal is very popular even among providers who are not EPs (Eligible Professionals for Meaningful Use), such as behavioral health and durable medical equipment (DME) providers.
The next stage will allow registered providers to view updated patient records, or update them, via connectivity between certified EHR systems. While registered providers don’t have to have an EHR system to use the portal, which they can access from the OHR website, they will need certified EHR systems to access or update patient files on another provider’s EHR system.
“As providers become connected through an interface with their EHR, they will be able to access the information on the exchange through their own Electronic Health Record systems and will not need to use the portal,” said Dr. Roach. “This is the most robust type of connection because the patient clinical information will always reside on the local physician EHR and is not stored in a central repository. Therefore, the clinical information is only available if providers are connected to the exchange through their EHRs.”
“Once enrolled, providers are trained using a train-the-trainer approach,” Roach continued. “For example, an office manager could be trained who then trains the physicians and other staff at the clinic. Once the training is completed, the accounts are activated and they can begin using the system. Providers can send messages only to other providers who have been enrolled, trained, and activated in the system.”
OHR doesn’t facilitate e-prescribing, said Roach. “That is an interface between each EHR and Surescripts. However, what has been prescribed electronically will be viewable in the exchange.”
Praise for Alabama’s Medicaid agency
The agency’s ability to manage limited funds and an ever-growing Medicaid population is impressive. For space reasons and because it involves much more than EHR, we won’t discuss it here. It does make interesting reading, so click here for more information.
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The Wisconsin Department of Health Services has been working hard to help providers qualify for Meaningful Use funds. The department’s efforts are paying off: the state is considered to be within the top five performers in terms of EHR adoption rates, according to a 2011 CDC report.
Compared with a national average of 57%, Wisconsin has 75.8% of office-based physicians using some kind of EHR system, 59.9% using a basic system (compared with a national average of 33.9%). With $9.441 million in federal funding from the ARRA, the department has created agencies and some creative, innovative programs to facilitate exchange of health information.
The Wisconsin Medicaid EHR Incentive Program started accepting Stage 1 Meaningful Use attestations from eligible providers in 2012 (starting with hospitals in February, followed by professionals in May). The program has routed over $95 million in incentive payments to qualified eligible providers (more than 1700 in number) since August 2011.
Project building blocks
“We definitely have the key ingredients” in place, said Wisconsin State Health IT Coordinator Denise Webb. After careful planning, the state set up an umbrella project called WIRED for Health along with some supporting products and organizations.
The main goal of WIRED (Wisconsin Relay of Electronic Data) for Health is to help providers comply with Meaningful Use criteria by enabling secure HIE (health information exchange). Key components of the project are described below:
Phase One of WIRED for Health, Webb said, is a portal providers can log into, either from their EHR system or as an application on a smart phone or desktop. From this portal, providers can send or receive health information securely. Providers such as dentists, pharmacists, long-term care providers, “anyone who provides treatment to a patient” can use it, Webb said. “Even if you don’t have an EHR system, but you do have Internet access, you can use this portal,” she added. “For example, you could be a cardiologist and let’s say you don’t have a sophisticated EHR system. You can still use this portal” for referrals and secure data exchange.
Cool tools ready to use
Physicians who sign on as WISHIN participants have access to a somewhat slicker application. The Direct+ Referrals app allows doctors to electronically transfer patient information, receive updates automatically, and track a referral’s status as “accepted or denied.”
The specialist or other referred provider can customize his or her referral requirements with this app; for example, s/he can require certain imaging data from the referring doctor. Thus, the app makes sure there’s no missing or incomplete data.
A new segue to Direct+ Referrals is Direct+ Messaging, an app that allows communication between participating providers, providing an extra level of security for HIPAA compliance. Providers can attach documents such as care plans and test results. Upgrading will give these providers access to new features as well as to the other Direct+ apps. Designed to help providers meet Stage 1 and Stage 2 Meaningful Use requirements for HIE, the app will provide access to a directory of all other WISHIN Direct provider participants.
The Direct+ Care Coordination app helps providers form a coordinated care team for a patient. It allows the care team to communicate securely about the patient, helps track patients through various levels and types of care, and facilitates smooth transitions. To view this information, “you don’t have to have an EHR – all you need is a browser” and a qualified secure login, Webb said. To actively use the app, such as sending a discharge summary, you must be a participating provider.
Next phase—more tools, smoother HIE
“Pulse can include patient health information such as … allergies, lab results, and medications,” the newsletter continues. “Pulse can provide more information on the patient than might be found in a single provider’s EHR. This information can help providers minimize unnecessary tests, alert providers to possible drug interactions, and help minimize other services that may be harmful or costly.”
Work left to do
There are still some hurdles to clear, Webb acknowledged. The greatest challenge? “Getting more of the solo/independent/small practices on board,” Webb said. Over 70% of the large (50 or more physicians) practices already have EHR systems in place; most of those use Epic. (Webb has no current statistics on the percentage of smaller practices with EHR, but it was around 33% in 2009.)
Wisconsin offers training, as well as a tax credit for rural, small, or solo practices.
But “it’s really the regional extension center [WHITEC] that’s going to be key in helping our small practices; that’s where the focus has been,” Webb said.
WHITEC, which provides technical HIE support to providers, “will be a primary communication and outreach channel for the WIRED for Health Project for promoting statewide HIT and HIE adoption by providers.”
“The more people get on board, the more providers there are to share information with,” said Webb. “There’s a tipping point” the state is trying to reach, to make providers feel left out if they’re not connected. “We’re trying to get people to call [their colleagues], and urge them to get on board.”
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EHR vendors have followed the lead of many other software developers by using “predictive text,” a feature that furnishes words or phrases based on a few characters that the user enters. For example, based on the characters “dia,” the system might display “diabetes,” allowing the user to click on the completed word to enter it, or override it by entering other text. Predictive text in EHR systems is usually context-dependent and is sometimes added or edited by physicians themselves.
There is some debate among physicians, IT people, and other EHR users on the merits of predictive text. All agree it can save time under ideal circumstances, but some are wary of introduced and potentially serious mistakes. It’s another EHR feature that benefits greatly from customization (and sometimes requires building from scratch).
Good for repetitive tasks
“I think it all depends on the design,” said IT consultant Tim Stone of Bullet Group Consulting. “If the system gives you a quick list based on a few letters and makes it easy to pick the correct one, I think that is fine. If the system is guessing based on past choices or your specialty, I think that leads in a bad direction. There are also versions of this where whole sentences are inserted based on what you type… This also can be good or bad based on design.
“[It works well for] repetitive tasks like giving an injection. You want exactly the same thing each time [i.e. a checklist]. ‘I did this, I cleaned it this way, I prepped with this.’ But there are other times where you should accurately describe the condition instead of sticking in a canned block.” Predictive text should not be used for diagnosis or patient plans, he continued. “That can be a slippery slope.” Such documentation should be written patient by patient, said Stone.
Sure, it saves time…
“[Predictive text] can save a lot of time,” said an administrator at a mid-size Boston-area health network. “We have a retina specialist who uses certain terminology all the time. [Our IT department] developed specific… text just for her.” While some physicians in her practice complain that using electronic records is more time-consuming than paper, those who have taken advantage of such features as predictive text, as the retina specialist did, say EHR usually saves time for them.
…but still requires another step
Doctors and staff must use predictive text cautiously, warns Carolyn Hartley, president and CEO of Physicians’ EHR. When a medical office assistant (MOA) enters information into the system to assist the physician, for example, “the system starts coding for a diagnostic task… [If the MOA accepts the wrong displayed code], “the [EHR] system takes the patient record in a direction that the doctor didn’t want it to go… Now there are three players [doctor, MOA, and EHR system] where there used to be just two,” opening another avenue for errors.
Each provider or practice has to set up its own predictive text, said Hartley, who helps providers plan for and implement EHR systems. “Some vendors will imbed a library of [predictive] text, but doctors must review [the entire library].” After initial setup, “[predictive text] is a really good tool” for physicians, but they have to go back and review it every time they create or edit a record, she said. This step cancels out some of the time saved, but must not be skipped.
Overall, Hartley recommends a combination of voice recognition software and predictive text to expedite data entry, as long the physician reviews the record for accuracy. Incorrect data in patient records not only can be bad for patients, but leaves providers open to fraud or abuse lawsuits, Hartley said.
California family physician Robert Rowley agreed. Thanks to time-saving features such as predictive text and speech recognition, in addition to customizable templates, “I can now see more patients than I used to [when using paper charts],” he said. “[Predictive text] technology is coming along… but you’ve got to proofread the results.”
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A physician who developed an EHR system talks about it from both points of view
Dr. Robert Rowley, a family physician in the San Francisco Bay area and co-founder of a free EHR provider, spoke with EHRintelligence.com about the perks and pitfalls of EHR as it exists today, and speculated about its future.
Father of invention
Rowley is one of the anomalous few who are equally skilled tweaking patient health and computer code. He never planned to be an MD; he was studying information science. Some of his college buddies were pre-med; they volunteered at a free health clinic in Baja California. Because Rowley grew up bilingual (born in Mexico City), he offered his services as a translator. Volunteering at the clinic was a “life-changing” experience, prompting Rowley to switch majors and go to medical school, ultimately starting a medical practice. But he still enjoys geeking out.
Of course, Rowley started his practice using paper charts (it was 1983), but became increasingly frustrated by not having the information he needed, such as the results from a blood test from 2 days ago. “100% of my charts were 80% right” (complete), Rowley said.
So, the doctor started inventing new workflows and documents to better manage the practice. He created a succession of Word documents and organized them into a database of sorts. This became the first electronic record system he used. Later, he wrote macros that would serve as templates.
“By the mid-2000s I had an EHR that included e-prescribing, lab results, and scanned images,” Rowley said. He built it on his own, finding time whenever he could, adding features as needed.
This was the infancy of what ultimately would become Practice Fusion, an EHR Web-based software firm that gives away its product. He co-founded the company in 2005 with Ryan Howard, who helped drive their product’s focus toward independent medical practices.
Common threads between EHR and paper
Medicine is still medicine, and Rowley pointed out some ways his practice has stayed consistent over the years. “We found our staffing levels didn’t decrease when we went to EHR,” said Rowley; “they just got re-focused.” Staff workflows are pretty much the same as before EHR: for example, ‘knowing who’s in what room and who’s up next,” or following up with calls to the pharmacy if a patient calls and says the pharmacy doesn’t have his or her prescription.
Is EHR technology a time-saver?
Asked about comments from many providers that EHR actually takes longer than paper charts, giving them less time with patients, Rowley acknowledged, “That is a complaint I’ve heard. It depends on the interface design – it [sometimes] doesn’t work same way as doctors work. A doctor’s main resource is time,” and if the EHR system is poorly designed or utilized, the doctor’s time is compromised.
Some hospitals get creative in their attempts to reduce the time drain on providers. He cited Kaiser Permanente as an example, which has employed assistants with portable devices to act as scribes, taking notes and uploading them into the EHR system. Most small practices cannot afford that luxury.
But Rowley’s experience has been different. “I can now see more patients than I used to,” he says. Commonly used EHR features designed to save time, such as speech recognition and smart text, can help; “That technology is coming along… but you’ve got to proofread the results.”
But what really saves time for Rowley is his templates. Using a template that suits your practice’s needs, he says, is faster than recording all this data via paper records. “If it takes you more than five minutes to create a chart note, you’re on the wrong template” – you need to customize it to better suit your needs, or use a different EHR system with well-designed templates.
Rowley helped create a library of over 180 templates for Practice Fusion, including many for specialties such as OB/GYN. Providers choose among these templates, and if even this array is not enough to give them exactly what they need, they can download copies and modify them for their specific needs.
While some HIT professionals worry that giving doctors the ability to customize templates amounts to giving them enough rope to hang themselves (sometimes resulting in disastrous mistakes), Rowley insists on this capability. “There’s always a balance between flexibility and standardization,” he said, adding that the templates should be well-designed in the first place to minimize the need for tailoring. He also believes that because templates prompt providers for pertinent information, the templates tend to “make doctors more thorough.”
Future of EHR
Not surprisingly, Rowley sees better and better EHR systems as key to the future of medicine, and believes it can happen as long as software developers have the incentive to continue inventing and improving systems and as long as it remains a truly free market. Rowley sees Web-based data as the key that will help independent practices achieve parity with large medical groups and hospitals.
“Clinician EHR systems will likely lag behind that gathered by hospitals, because of the smaller size of those settings,” Rowley wrote on his blog. “Web-based EHRs will likely play a very large role in liberating data from these small, granular silos and allowing very useful healthcare research to take place from small-practice clinical observations.”
All throughout the Supreme Court hearings over the constitutionality of the healthcare reform law and even during the deliberation of the justices, commentators said regardless of the decision handed down, the government’s health IT initiatives would remain untouched. In the most technical sense possible this was true. The meaningful use program gets its funding through another law. Striking down the Affordable Care Act would not have affected this program. But at a more essential level this seems dishonest.
There are all kinds of provisions included in the reform law that lean heavily on IT. None of these may be so direct as the meaningful use incentive program in encouraging the adoption of EHRs or other technology, but there are pretty meaningful incentives included in the law that encourage the transition to a networked system. Health IT stakeholders should be thankful that the court ruled the way it did. Otherwise it could have set the adoption of technology in healthcare back significantly.
The most obvious example is the Medicare Shared Savings program, which rewards doctors for operating as accountable care organization and for keeping patients well in order to reduce costs. This program doesn’t necessarily require the use of EHRs, but it sure makes it hard to qualify for practices that don’t. Several of the quality measures physicians must comply with in order to qualify give extra consideration to professionals who use the technology.
And in fact, the two programs are much more intertwined than some may realize. In announcing the Stage 2 meaningful use rules, national coordinator for health IT Farzad Mostashari said that the meaningful use reporting standards will be aligned with those of the Shared Savings program, as well as other Medicare/Medicaid incentive programs.
Even if aspects of the Affordable Care Act and meaningful use were not directly linked, it would be hard to ignore the philosophical connections. Both have at their heart a desire to network physicians, encourage patient-centered care, and leverage innovation, all with the goal of making care more efficient and affordable.
The reform law seeks to accomplish these goals by organizing physicians into accountable care organizations. The meaningful use program gives physicians the tools necessary for operating in a more collaborative environment. The programs may not come from the same piece of legislation, but in a sense they are two separate legs of the same stool.
Striking down the reform law may not have eliminated the direct financial incentives for adopting EHRs, but it would have removed a more overarching motivation for using EHRs in the first place. Technology use in and of itself is not necessarily a worthwhile goal. But using technology to facilitate the free exchange of health information and delivery of truly collaborative care is. This is what the combination of the Affordable Care and HITECH Acts provide.
In the wake of the court’s ruling, the health IT industry has largely acted as if none of this were at stake. The meaningful use incentives were protected either way, and therefore the industry would have remained unaffected, for the most part.
This reaction seems a bit like people are forgetting what the meaningful use program is about in the first place. If the country is going to get healthcare costs under control and start improving outcomes, broader EHR use is a good start. But these goals will only be achievable when technology use is combined with meaningful changes to the way care is delivered and paid for. In this sense, striking down the Affordable Care Act would have delivered a major blow to health IT initiatives.
The world is going mobile. It seems nearly everyone has a smartphone or tablet and apps are everywhere. So are doctors following this trend?
A significant amount of evidence suggests they are. While physicians may have taken a long time to finally get on board with EHRs and leverage the benefits that come with greater connectivity, its seems that they are determined not to get left behind in the same way when it comes to mobile technologies. These tools are increasingly playing a major role in healthcare.
The signs of the mobile revolution are everywhere. Physicians are leading the charge. A survey conducted earlier this month by Manhattan Research showed that physician use of tablets for professional purposes nearly doubled last year, with 62 percent of doctors now using the technology.
Physicians who are looking for greater capabilities from their mobile devices are in luck, as a number of initiatives are underway to make it easier to use wireless devices in a healthcare setting. For example, the Federal Communications Commission recently voted to increase wireless spectrum capacity for use in healthcare. This will make it easier for doctors to link their various mobile devices securely to their EHRs.
Additionally, the White House just issued a directive to all executive departments, which includes the Department of Health and Human, instructing them to make more services available to mobile device users.
What does it all mean? A new report out from the Brookings Institution estimates that the use of mobile health IT products could help the healthcare industry save $197 billion over the next 25 years. These savings will come through improved self monitoring among diabetics, reduced treatment errors and other improvements, the report stated.
Clearly the healthcare industry is betting big on mobile technology. Stakeholders are moving aggressively to embrace these tools and leverage their abilities to improve communication and efficiency. So what’s behind the rapid adoption?
Improved wireless capabilities is one answer. In the last couple years, we have seen the major upgrade from 3G to 4G wireless service, which offers much faster speeds. At the same time, hardware has advanced by leaps and bounds.
It also helps that more physicians are comfortable with mobile tools. As technology advances, many have adopted devices in their personal lives. It’s a relatively small step to incorporate hardware into the their medical practice.
Furthermore, these technological advances are happening at a time when a growing number of physicians are making EHRs and other technologies a central part of their practices. The meaningful use program has prompted many doctors to implement systems. At the same time cloud computing, which pairs naturally with mobile devices, is emerging as a major factor. With mobile devices maturing at the same time that physicians are making the transition to greater technology utilization, it only makes sense to implement both simultaneously.
The situation is not without risk. Many commentators have voiced concerns about mobile devices and cloud storage systems being easier for hackers to infiltrate. If the future of healthcare is going to be mobile these concerns will need to be addressed.
However, assuming that the security question can be solved, mobile devices could unleash major benefits for the healthcare system. The technology has the potential to improve efficiency, boost communication and reduce healthcare costs like few developments that have come before. We’ve seen countless examples of how wireless devices can improve productivity in businesses. Here’s hoping the rush to leverage mobile technology in healthcare will have the same effect.
As providers and IT professionals scramble to stay one step ahead of EHR maladies, there’s a lot clinics and hospitals can do to maximize benefits and prevent trouble. Tim Stone, a Chicago-based IT consultant and contractor, shared some of his 15 years of experience (five of it in HIT) with EHRintelligence.com.
Take the data seriously
Clinics and practices “have to graduate from the cousin, friend, or kid who they rely on to take care of their computer systems. They need a professional. Practices [often hesitate to] pay someone like me more money than you have to pay a 15-year-old kid who’s been maintaining your billing system.” That might be working well, but “billing never leaves the office, while [PHI] does.”
Protect sensitive data
Everyone agrees that security of patient data is extremely important. But the biggest risk comes not from hackers, says Stone, but from careless users at clinics and hospitals.
Much of the security burden is borne by vendors; for example, when providers prescribe medications, the transaction often goes through a third party, such as Surescripts. The data is heavily encrypted.
Providers’ laptops are generally a greater security concern, says Stone.
Doctors and staff should be trained and required to use the button or keyboard shortcut that locks the laptop, requiring a password to unlock it. Some of the people who don’t lock the laptop when leaving it momentarily are probably “the same people who leave the password on a Post-It note. They think, ‘It’s no big deal.’ It is a big deal,” Stone says.
For additional protection, it’s better for providers to access data from their EHR network than to download it onto a laptop, says Stone. For example, a physician might load the necessary records onto his or her laptop before going to a hospital to check on patients. This way, if someone steals the laptop, they would have all the data for those patients. Encryption would help, but “it’s not popular,” notes Stone, “because it slows the computer down.”
Keep up with resource demands
EHR systems tend to be significant resource hogs, especially if you use voice recognition, says Stone. Most businesses tend to upgrade their computer systems about every seven or eight years, but they need to upgrade more frequently to handle the ever-increasing demands of new software. For example, when a physician prescribes a drug using EHR, the system has to be able to search through thousands of drug data in a few seconds to find drug interaction information.
Then there’s voice recognition software (VRSW) such as Dragon. Most doctors would love to have a robust, speedy, reliable voice recognition system. How well is voice recognition working out?
It depends on implementation. While some practices “buy pieces of Dragon and put them here and there” in their EHR systems, “it’s best to implement it so that it’s part of the doctor’s workflow” and include it in the planning process when installing an EHR system, Stone advises.
You also need a computer system that can handle the resource demands of voice recognition, Stone says. If you install VRSW on a four-year-old laptop, it’ll be slower and more problem-prone than if you install it on a newer laptop.
Doctors need to practice working with VRSW to get the best use out of it. “Doctors who really embrace it get really fast with it. It doesn’t want to hear you mumbling. It wants to hear you clearly enunciate,” Stone says.
Insist on good training
Considered one of the most important factors in the success of EHR, training is still surprisingly underdone in many healthcare facilities. “In reality, cost drives the level of training,” says Stone. Remote training is popular because it costs less than hiring an onsite trainer, but in order to guarantee success, clinics and hospitals “need someone to … guide them through training, help them through hurdles.”
Training must also include basic computer skills, Stone insists. Won’t this be less and less of an issue as time goes on? True, but “we’re talking about right now,” Stone emphasizes. Especially at small and mid-size practices, the senior partners are usually older and might not be great with computers; but younger staff can also lack basic skills. “If you install an EHR system and your staff is afraid of computers or doesn’t know how to use them, you’re gonna fail,” Stone says. “If a provider is going down the EHR path, they need to get their staff [good] computers and get the staff comfortable with them.”
• How providers impede their chances for smooth-running EHR systems
• When transitioning to EHRs, planning is key
• When transitioning to EHRs, planning is key
A fully networked healthcare system in which a majority of providers are using electronic health records (EHR) is supposed to save us from inefficient, redundant and disconnected healthcare, which essentially describes the HealthIT system today. But is this necessarily the case?
One expert thinks not. In a recent article published in the Journal of the American Medical Association, Julia Adler-Milstein suggested that high rates of EHR adoption will not necessarily lead to increased data exchange. CMIO reports that she doubted the future of information transfer because it raises many privacy concerns, there is a lack of interoperability, meaningful use excludes some healthcare organizations and physicians lack interest.
Adler-Milstein saw this last point as the most challenging. The fact that patients can take their health information with them to whichever provider they choose may be seen as a competitive disadvantage by some physicians. Additionally, using data from past encounters, much of which may have been collected by other doctors, to make treatment and diagnosis decisions is a new thing that some physicians may resist.
The article threw some seriously cold water in the face of proponents of EHRs and their ability to facilitate information exchange. Up until this point few commentators had anything negative to say about the prospects for data transfer in a future dominated by EHRs. The issues raised in the article certainly give the industry something to think about. So what about it? Should we believe that data transfer will be more limited than many people believe?
It may simply depend on the degree to which the industry prioritizes information exchange. It’s hard to argue with the points raised in the JAMA article. Physicians today face steep hurdles in information exchange efforts. But changes may be coming to remove some of these barriers.
For example, the new Stage 2 meaningful use rules set a higher bar for physicians to transfer patient data upon referrals. Mandates along these lines could go a long way toward encouraging physicians to loosen their grip on patient health data. Federal regulators have said in the past that they expect rules mandating information exchange to play a larger role in future meaningful use regulations. If the Stage 2 requirements go smoothly, Stage 3 could see even greater requirements for data transfer.
Furthermore, healthcare is changing and physicians are increasingly being compelled to practice in a team-based setting. Just look at Massachusetts, where state legislators recently passed a bill that would provide greater incentives for physicians who practice in patient-centered medical homes and accountable care organizations.
As physicians increasingly practice as teams there will be less of a need for individual doctors to guard their patients’ data in order to ensure that patient comes back to them. Physicians will have more reason to share information with their colleagues. In a healthcare system where doctors earn more for being a part of a team and keeping patients healthy, it simply will not matter who is the owner of information.
These developments may not completely resolve the barriers observed by Adler-Milstein, but they do point the healthcare system in the direction of data exchange. They also suggest that the nation can have the healthcare system it wants. If patients, doctors and regulators decide that information exchange is a high priority, there are ways to make it happen.
Of course, widespread EHR adoption on its own is not sufficient. But it is a necessary step along the road to information exchange.
The move from paper-based records to Electronic Health Records (EHR) marches relentlessly on and is becoming an increasingly widespread requirement.
Some EHR systems are easier to implement than others ( articles on choosing EHR systems). But even when a health facility chooses a good system that’s appropriate for the size and type of facility, sometimes EHR systems are poorly implemented and become a headache to clinic employees, patients, and even the providers themselves.
This article explores why putting an EHR system into place such that it satisfies site-specific everyday requirements can sometimes go wrong, and how to avoid these pitfalls.
When tech-savvy providers are given enough rope to hang themselves, some EHR system users observe, they can create changes that negate the good features.
Poorly planned customization can lead to inconsistency in the EHR system, and thus wasted time. Carolyn Hartley is President and CEO of Physicians EHR of North Carolina, specializing in helping providers implement EHR systems. “Techie physicians not only build templates independent of other physicians in the same practice, but build templates within templates, often making it difficult for the EP (eligible professional) and EH (eligible hospital) to extract data for Meaningful Use reporting,” Hartley says.
Not using the software well
To be blunt, some providers might have good EHR systems, but not be using them well (probably due to lack of training).
Some hospitals and clinics have reported loss of productivity since switching to EHR systems. “Doctors were able to see more patients prior to the implementation of the EHR,” writes a healthcare blogger. “The EHR, more specifically how they use the EHR, has resulted in them being able to see fewer patients.”
For example, some providers mistakenly load data incorrectly, so that it’s unusable and not readily available, says Hartley. For example, when switching historical lab results from paper to EHR, you have to make a decision: When records are, say, more than two years old – do you scan the paper lab results in as historical data? Or do you key it in as new patient data? Often the data gets loaded inconsistently on a case-by-case and doctor-by-doctor basis. Then, Hartley says, doctors have to check several places online to find the historical lab data to identify trends.
Get buy-in, and buy right
“If a doctor is going to implement any system they should start by making sure their staff is comfortable with technology before the training starts,” advises IT consultant Tim Stone on an EHR implementation list. ”Many doctors are also being force[d] into using the wrong system either because of hospital pressure or because they like a brand name. Then they are force[d] to alter their business workflows to match the system instead of the reverse…”
“Practices should look at three areas: Software, training [and] personnel… [They should] make a choice based on their real needs, not the salesman’s pitch. I see too many doctors with slow/awful workaround[s] because the software does not fit them… And they might have to look at personnel changes. It is not popular, but it might be the reality. If some of the staff is not embracing the software after six months, I would be worried.”
Because each physician often has his or her different documentation and template preferences, it can be hard to choose a system that everybody is happy with. A comment on an EHR website suggests advance testing of the EHR software you are. “Run through the templates like you’re charting on some common patients… You’ll see if the templates are overkill or below standard for your needs… Another great test is to try using multiple templates for a complex patient. How easily is that done and how well does the documentation display?”
Training? Who has time for that?
No one in a busy clinical setting wants to “lose” several workdays for system training. But learning the EHR system is essential to the success of a practice. You can’t afford to risk missing important patient history details, prescribing medications inappropriately, or other mistakes because your staff didn’t use the system right.
Focused as they should be on patient care, many physicians feel they don’t have time for the lengthy, intensive training that EHR systems require. Of course, this is especially true if the healthcare facility is newly switching over from paper records. But then, “they are surprised when productivity is low,” Hartley says.
Wendy Adams, who owns a medical transcription business, says that her physician clients aren’t familiar with the capabilities of the EHR or the data elements involved. “They want to see and care for the patient and are barely taking the time to comment in the EHR on specifics of their visit,” she wrote on an online EHR implementation discussion group.
Keep up with the upgrades
Any software needs occasional upgrades, but it’s easy to overlook or perpetually postpone this task. But when it comes to EHR systems, there’s a particularly important reason to perform upgrades: security. Your obligation to safeguard patient privacy requires you to make sure the software is as secure as possible.
Also, features that you have trouble with might be fixed or improved in a more recent version.
It’s worth it to hire an IT person who can take care of all the upgrades for you. Even if you have a small practice, hire a part-time IT specialist or consultant. Some small practices try to make do without one; some large practices have IT people, but still don’t upgrade software as much as needed.
Take ownership and plan ahead
“Generally speaking, physicians have not taken ownership of the transition to Health IT which includes EHR,” Dan Shirey of Health IT Associates is quoted on an EHR website. “The physician has limited skills for selecting an EHR system because he is not a IT expert… Also the physician has limited time to put into EHR selection and implementation… That means that a physician needs a ‘trusted partner’ with the skills and time required for EHR implementation… The trusted partner should be well qualified and experienced in IT systems selection and implementation, project management and change management…
“Physicians should begin their search now and should not proceed with EHR implementation until they have a “trusted partner” who is focused upon success.”
Everyone wants to cash in on the Medicare/Medicaid incentives for implementing EHR, but the government wants your Meaningful Use statistics to justify the payment. A few commercial tools are emerging for this purpose, but the government is offering you one for free.
The Office of the National Coordinator for Health Information Technology (ONC) contracted with Mitre Corporation to create software that could automatically create and send clinical quality measurement reports that support Stage One of the Meaningful Use initiative. This open-source software, called popHealth, sends the data to the Medicare and Medicaid Incentive Programs. Deployed to the public in 2010, popHealth automatically compiles demographic patient data and is designed for easy integration with existing EHR systems.
popHealth uses the Health Level 7′s Continuity of Care Document (CCD) standard and the Continuity of Care Record (CCR) standard to pull quality data from patient records in the EHR system. HL7 is an ANSI-accredited standards organization for health information technology. popHealth has the capability to report aggregate statistics, and can also access individual patient health records. It can launch only from within the provider’s firewall, thus protecting identifiable patient data.
EHR system developers are encouraged to incorporate popHealth into their software; the popHealth website offers guidance and source code.
An app development contest
In February 2012, the ONC and Health 2.0 invited interested stakeholders to a Healthcare Information and Management Systems Society (HIMSS) Conference in San Francisco to find out and celebrate the results of a software development contest. The popHealth Tools Development Innovation Challenge invited software developers to work with the open source software to create user-friendly applications that would help providers capture clinical quality measurements and/or identify disparities in care.
First place—and a $75,000 cash prize—went to the team that developed an application they called to Engage Your patiEnts (popEYE). This app lets providers create automated patient reminders using the cloud-based phone service Twilio and delivers the reminder message set by the provider.
Real-world beta testing
Here’s one example of a health care provider testing popHealth in its EHR system to validate the provider’s data, and working with the software developer to improve popHealth software.
“When Mitre Corporation offered to test their popHealth tool against 2 million BIDMC [Beth Israel Deaconess Medical Center] patient records to validate the Meaningful Use quality measures computed by our QDC, we jumped at the opportunity,” wrote a provider in his blog, http://geekdoctor.blogspot.com/2012/03/pophealth.html .
“Mitre ran the tool against 2 million BIDMC Continuity of Care Documents (CCDs) and compared the results to the reports generated by the QDC.
“The results were enlightening. The computations aligned well for most quality measures, justifying our early manual validation.
“However, Mitre discovered ambiguities in the CCD specification itself that led to some differences in the calculations…
“For example, the CCD does not specify an allergy vocabulary… we recognized the need to enhance the Stage 2 to include RxNorm for medication allergies…”
To download popHealth at no cost, go to http://www.projectpophealth.org/ .
One of the earliest EHR pioneers was the U.S. Department of Veterans Affairs (VA). The VA started its shift from a paper-based to computer-based records system in the 1980s (ideas for it were discussed a decade earlier). Called the Decentralized Hospital Computer Program (DHCP), the system was designed to bring consistent, standardized patient data into a locally centralized repository.
The birth of VistA
With the VA driving improvements to its EHR system, the DHCP evolved into a more robust tool dubbed VistA (Veterans Health Information Systems and Technology Architecture). One of the early major improvements was the addition in 1997 of a Computerized Patient Record System (CPRS), a graphical user interface that greatly improved ease of use. VistA’s many features included an electronic prescription module and decision support in the form of clinical guidelines.
In 2011, the VA enlisted an open-source community called OSEHRA (the Open Source Electronic Health Record Agent) to develop enhancements to VistA. This decision was part of a joint effort with the U.S. Department of Defense (DoD) to store all veterans’ and service members’ health records electronically using a single source.
The VistA system will cost about $4 billion to develop, according to Roger Baker, the assistant secretary for information and technology at the VA, as reported by healthcare.com in March 2012. This quote does not include implementation costs.
But the VA’s impact on the health of veterans is huge. According to information at http://www.va.gov, the agency had over eight million enrollees using its health services as of 2010 – resulting in over 80 million outpatient visits to its facilities. And the number of veterans with service-connected disabilities has risen by 46% since 1990 (to over 3 million), a figure likely to rise as world conflicts continue.
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Comments on VA blog
The VA’s Chief Technology Officer, Peter Levin, and Senior Advisor to the Director of the VA Innovation Initiative, Mike O’Neill, praised the VistA system in a 2011 post on VAntage Point, an official VA agency blog (http://www.blogs.va.gov/VAntage/ ).
“Our electronic health record (EHR) – VistA – is one of the reasons that VA continues to provide the best care anywhere,” wrote Levin and O’Neill. “[The] VHA under Secretary Petzel and Assistant Secretary Baker know that to keep pace with the clinical services and the rapid changes in IT, we needed to find a way to unleash the innovation inside and outside VA that made VistA one of the best–if not the best– EHRs in the world.
“The new community is designed to actively engage the best minds among the users and developers of EHR software in both the public and private sectors and will ensure that VA clinicians have the best tools possible, and that Veterans have access to the best care that we can deliver.”
While the VA’s early EHR system was not linked nationwide, today’s system stores data using cloud computing, accessible by all authorized agency offices. The Defense Information Systems Agency (DISA) administers the cloud data.
Try it out!
The VA invites the healthcare community at large to download its VistA software for free trial. Go to http://www.ehealth.va.gov/EHEALTH/CPRS_Demo.asp.
For further help with the software, go to http://www.worldvista.org/.
Toward the end of last year some encouraging data started to emerge. The Centers for Medicare and Medicaid Services said that thousands of physicians had signed up to participate in the meaningful use incentive program and the Department of Health and Human Services released statistics indicating that the number of physicians presently using EHRs had doubled since the incentive program launched in 2009.
This means we’re well on our to having a fully networked healthcare system in the, right?
Maybe not. The Medicare Payment Advisory Committee, an independent group that advises members of congress on matters relevant to Medicare, recently gave a presentation to lawmakers that throws some cold water on these overheated estimations of physician EHR use. In particular, the numbers indicate that many providers are having a hard time clearing some of the meaningful use hurdles.
According to the MedPAC presentation, 66 percent of hospitals have signed up to participate in the meaningful use program, but only 16 percent have actually received incentive payments. As for independent physicians, 25 percent have signed up with the program but only 6 percent finished qualifying for payments.
Now, it is difficult to tell from the numbers where these providers stand currently. Just because they have not yet received incentive payments doesn’t mean they are not using an EHR system for some advanced functions. It could simply be that they have not yet satisfied one or two of the program’s requirements.
However, the report does paint a much different picture than the one federal agencies have been pushing for the last few months. Far from being poised to achieve full adoption rates, the U.S. healthcare system still has a ways to go.
Figures on EHR adoption from HHS indicate that about 41,000 physicians are currently using the technology. This is a sizable percentage of the total healthcare workforce, so interest in the technology clearly remains strong. What’s less apparent is why these implementation totals are not necessarily translating into meaningful users.
The MedPAC numbers suggest that providers may simply be having a difficult time with some of the provisions of the meaningful use rules. The report does not mention how many doctors are currently using systems, only how many have signed up for the incentive program and how many have received payments.
It is understandable if some current EHR users are having a difficult time with some of the provisions of the regulations. The first stage of the meaningful use rules may impose a steep learning curve on physicians who have no experience using the technology.
However, there are plenty of resources available to doctors who are struggling with EHR implementation. Most vendors will provide a significant amount of technical assistance in getting a system up and running. The ONC has set up Regional Extension Centers across the country to provide IT help and consultation services. Even various professional groups offer tips and advice on successfully completing an IT initiative.
Taking advantage of these resources may play a key role in the ability of a practice to satisfy all of the meaningful use rules. Going it alone can be difficult. However, leveraging opportunities for help that exist may enable a technology initiative to go more smoothly.
When more physicians do take advantage of these resources the U.S. healthcare system may truthfully get on its way to becoming fully networked.
A brief list of commonly used health IT acronyms
CAH Critical Access Hospital
CDA Clinical Document Architecture
CDS Clinical Decision Support
CEHRT Certified EHR Technology
CHPL Certified HIT Products List
CMS Centers for Medicare & Medicaid Services
CQM Clinical Quality Measure
CY Calendar Year
EH Eligible Hospital
EHR Electronic Health Record
EP Eligible Professional
FY Fiscal Year
HHS Department of Health and Human Services
HIPAA Health Insurance Portability and Accountability Act of 1996
HIT Health Information Technology
HITECH Health Information Technology for Economic and Clinical Health
HITPC HIT Policy Committee
HITSC HIT Standards Committee
HL7 Health Level Seven
ICD-9-CM International Classification of Diseases, 9th Revision, Clinical Modification
ICD-10-CM International Classification of Diseases, 10th Revision, Clinical Modification
ICD-10-PCS International Classification of Diseases, 10th Revision, Procedure Coding System
LOINC Logical Observation Identifiers Names and Codes
MU Meaningful Use
ONC Office of the National Coordinator of Health Information Technology
NCPDP National Council for Prescription Drug Programs
NIST National Institute of Standards and Technology
PHSA Public Health Service Act
SNOMED-CT® Systematized Nomenclature of Medicine – Clinical Terms
Latest Trends in EHR
With the adoption rate of EHR systems running at about 55% according to the U.S. Centers for Disease Control, more and more hospitals and practices nationwide are leaving paper behind. But considering Meaningful Use incentives, and the purported practicality of electronic health records, it’s surprising that their use is not almost universal.
Or is it so surprising?
Many providers are extremely frustrated with their EHR systems. They are finding that electronic records are more time-consuming than paper. Some dissatisfaction is to be expected with any major change in systems, but most of their complaints are legitimate.
If time is money, we’re in trouble
Most EHR systems force providers to enter data using “way too many clicks,” says Carolyn Hartley, president and CEO of Physicians’ EHR. An intake specialist in the Partners HealthCare network apologized to this reporter when entering routine data for a lab sample: “With this new system… it’s supposed to save time, and it takes longer! You have to fill in something in every field, at least a period,” even when the field is not applicable.
Dr. Douglas Blayney, an oncologist, wrote about his observations of EHR use at Palo Alto Medical Foundation in California for the 2010 ASCO (American Society of Clinical Oncology) website. Blayney told of talking to a computer-generation colleague at Palo Alto Medical Foundation in California who complained that “the EHR slowed him down in the office: whereas in the paper world, his medical assistant would line up the X-rays on the view box, now he had to wait for his PACS to load the images after he signed on to the computer terminal; formerly he would have documented his findings on one page of paper, whereas now he had to point and click, dictate, and type his way through a note.”
An administrator at a mid-size Boston-area health network, generally pleased with EHR, said that the lack of well-designed templates particularly stymied specialists. “The downside [of EHR] is that it takes more time on the provider’s side of things,” she said. “Lots of specialists like paper better” because they find that, while specialized templates help, they don’t fill the bill. Better-designed customization (ideally involving the appropriate specialists) could fix the problem, the administrator said.
Wanted: well-designed, adaptable templates
In one study, flexible templates that providers can tailor to their needs definitely emerged as one of the most promising solutions to the time problem. “One-size-fits-all is not a valid approach to EHR implementation,” wrote California family physician Robert Rowley on his website.
“If it takes you five minutes to create a chart note, you’re using the wrong template,” Rowley said in an interview with EHRintelligence.com. “That’s the time deadline I give a template. If it’s too clunky, it gets in the way.” Rowley, who helped design numerous specialist templates for EHR vendor Practice Fusion, finds well-designed templates faster to use than speech recognition software.
Can’t get there from here
Often there’s no connectivity between EHR systems of different networks, a problem when providers need patient data from outside their own network.
When electronic record systems are incompatible, said Kimberly Winter, a medical litigation attorney who still has a nursing license, “you have to depend on the clinic staff to deliver the correct record to you, and to make sure it’s the complete record,” or at least every part of it you need. But harried staff often miss some portions of the needed records. “Usually the first time I get the medical record, it’s not the whole thing… the [parts of the patient record] are not even stored in one place, as physical [paper] files used to be. They’re printing from several different data banks… for example, I might see that there was a consultation, but [I receive] no report of the consultation, or no list of current medications.”
Even within an organization’s own network, connectivity is sometimes a problem. “The only advantage to paper is that it’s always available, while electronic records frequently have server or connectivity issues. Then you’re dead in the water,” said a physician in the Partners HealthCare system who wishes to remain anonymous. On their EHR system, connectivity “never gets better.”
What else should EHR systems include?
The lack of a universal standard for consistency and portability irked some providers; not all EHR systems are HL7-compliant.
“I’d like to be able to have two windows open at the same time, side by side, such as lab data and the patient record,” said the Partners physician of their in-house system. “If you’re a geek you can do it, but it’s not routine and it’s not easy.”
“An EHR system should also have e-prescribing, drug interaction lookup, lab results, and the ability to scan in faxes,” said Dr. Rowley in an interview with EHRintelligence.com.
“[Our EHR system] doesn’t have a place where you can note how a medication made a patient feel different than he did two hours before, nor a place to log new symptoms,” said John, a nurse at a Washington, D.C. hospital for the homeless, Christ House.
At a small independent practice in Massachusetts, a nurse complains that their EHR system doesn’t have a way to remind the staff about important screenings for diabetic patients.
Vendors, step up to the plate!
As the human population swells, especially graying baby-boomers with ever-increasing healthcare needs—and cost-cutting requirements become more and more stringent—pressure mounts on doctors to perform quickly and accurately. Even if some provider complaints about EHR could be ascribed to human error or avoidable factors such as inadequate training, it’s imperative that EHR systems become as streamlined as possible. They must also be accuracy-focused and offer clear, easily understood interfaces, and customizable templates. Vendors need to support these systems well, not just selling and running. Excellent IT teams and robust host systems are a must, but the product has to be ready to serve out of the box.
As a provider wrote in an EHR/EMR forum: “We (doctors) will not embrace EMR systems until they are usable and they add value! ”
To regulate or not regulate – that is the question facing policymakers as they look toward developing the Nationwide Health Information Exchange. On the one hand, groups are calling for greater direction in terms of how the system will operate in the future. On the other hand, organizations say networks need time to develop, as data transfer in healthcare is still a relatively new phenomenon. So who is right?
The question essentially breaks down to as a choice between regulatory certainty and security, and unencumbered innovation. Those on the side of regulation say only government can handle some of the most important functions that will take place through the NwHIN, while those on the other side say what’s most important at this stage is innovation.
The Certification Commission for Health Information Technology recently sent a letter to the Office of the National Coordinator in response to its request for information regarding the NwHIN. CCHIT was largely against the heavy hand of government regulation, except, that is, when it comes to several key areas.
CCHIT’s comments stated that the ONC should play an active role in establishing standards that protect patient information. Ever since the ONC released initial information about the possible shape data exchange rules might take, lots of groups have expressed concern about information security. Given that this area is so central to the ultimate success of any data exchange initiative, leaving it up to the private sector could be a mistake, the letter states.
Not so fast, said the eHealth Initiative. In its comment letter it said that the ONC should avoid excessive regulation. Most commentators have recommended that the NwHIN be governed as a private-public partnership. The ONC essentially agreed with this, but the eHealth Initiative thinks existing proposals do not go far enough. The group would place a heavier emphasis on the private section, while limiting the public arena to as small as role as can possibly be conceived of.
The HIMSS Electronic Health Record Association expressed concern in its comment letter that what is supposed to be an optional program (participation in the NwHIN) will be turned into a mandate by heavy regulation. A governance structure that stresses the importance of the role of the private sector is one way to avoid this.
The majority of comments stressed the fact that health information exchanges are just starting to get up and running. It is not at all clear yet exactly what the best policies are. More time is needed to allow networks to develop and mature.
Unfortunately, time is a luxury the healthcare industry doesn’t have when it comes to health information exchange. The Stage 2 meaningful use rules include strengthened provision mandating relatively high thresholds for data transfer, particularly in transition of care instances. There are ways information exchange can be accomplished without large-scale exchange infrastructure in place, but these options will become less viable as more and more physicians start getting involved with data transfer.
It is a positive step that the ONC requested information from industry stakeholders regarding how the rules of the road for the NwHIN should look. However, physicians who will need to start thinking soon about how to comply with the next round of meaningful use regulations will likely want to know exactly where the information exchange industry stands.
Developing consensus on firm governance standards sooner rather than later will play an important role in preparing physicians for this critical piece of the future of healthcare. Ultimately, the creation of these systems will come down to a question of whether more or less regulation is favorable.
Patients are increasingly getting involved in their healthcare through IT tools. Personal health records – the pinnacle of patient involvement – remain vastly under-utilized, but they are becoming more common. At the same time policy developments are pushing more and more patients to interact with their physicians electronically.
However, the pace at which these developments have come about has been much faster than policies guiding electronic patient-physician interactions. In order for these encounters to be truly meaningful – and most importantly, secure – the health IT community and government regulators will have to come to agreement on some basic foundational principles outlining what is appropriate, how information is shared, and what kind of control the patient has over the whole process.
The meaningful use program is one of the main drivers pushing patients into the electronic arena. The proposed Stage 2 rules mandate that physicians make electronic documents available to a certain number of patients and a certain threshold of patients must actually download their information. It remains to be seen if these regulations will hold up (there has been strong resistance to them), but if they do, it could have the effect of creating millions of e-patients.
At the same time, the majority of patient now want meaningful interactions with their physicians to happen electronically. A recent survey conducted by Accenture showed that 83 percent of patients want to view and manage their information online. Most want the flexibility to schedule appointments, refill prescriptions, and quickly check in with their doctor electronically as well.
There’s no doubt that the flexibility and engaging nature of electronic information are drawing many patients in to new ways of managing their care and connecting with their doctors. But despite the rapidly growing number of e-patients there remains little consensus on exactly what role patients should play in this new electronic world and how physicians should handle data.
The use of social media is one of the most obvious examples. There are currently no firm guidelines or widely accepted rules governing the types of online relationships physicians can have with their patients. It’s probably acceptable for a patient to send a message regarding a medical condition to a Facebook account a physician set up for his practice. But is it alright for a doctor to friend his patients using his personal account? Probably not, but there are many gray areas where propriety may be compromised.
Another important question relates to the authority patients have over their information. As more doctors adopt EHRs and start to participate in health information exchanges this question is growing more pressing.
In order for patients’ information to be traded on an HIE, the patient typically has to opt in, in other words, agree to allow various physicians to access their data. But John Halamka, the chief information officer at Beth Israel Deaconess Medical Center in Boston recently wrote a blogpost for MedCity News outlining his organization’s slightly different take on consent.
BIDMC doctors can access patient information from affiliated ambulatory centers only if it is in regards to a common patient. This essentially gives the patient greater control over who can view their records by limiting it to the doctors the individual chooses to see – a much narrower idea of opting in.
Both approaches to HIE opt-in have their pros and cons. Neither is necessarily superior. But that’s the point. As this type of exchange becomes more common there will need to be greater consensus about the superior approach.
In the grand scheme of medicine, the connected patient is a relatively new phenomenon, and it shows in the lack of agreement and standards. Overall, it is a tremendously positive thing for patients to have greater access to their providers and information, and to have their records follow them from one doctor to the next. But these benefits won’t be worth much if the healthcare community cannot come together to more precisely define the rights and responsibilities of each stakeholder.
More EHR Best Practices
Two and a half years may seem like an eternity in the world of health IT, where it sometimes feels like new technologies and government regulations come out every day. But in reality it isn’t that far off. Two and half years is roughly the amount of time physicians have left to implement EHR systems without incurring any penalties. Within this time all of the incentive money will be spent and the constantly revolving door of government regulations will have stopped spinning. So what happens after the calendar turns to 2015?
Before the meaningful use program came along EHR implementation rates were dismally low. There simply wasn’t enough incentive to get physicians to go through the process. Now that the incentives are there, EHR use is still far from universal, but the program clearly has sparked increased interest in the technology.
Still, it’s somewhat difficult to imagine that all eligible professionals will be EHR users by 2015. Take, for example, primary care doctors. The American Academy of Family Physicians estimates that slightly more than 90 percent of all primary care doctors in the U.S. accepted Medicare patients in 2011. However, most surveys indicate that only a little more than 20 percent of doctors nationwide have fully functional EHR systems in place. Will a full 70 percent of physicians implement the technology within two and a half years? That seems unlikely.
Assuming that not everyone gets on board with the program in that timeframe there could be an awful lot of doctors looking at Medicare penalties in the near future. This would leave physicians with three options: implement an EHR system, accept the penalties as the cost of doing business, or stop seeing Medicare patients entirely.
For physicians who have yet to implement EHR systems by 2015, the last scenario seems the most likely. The same AAFP numbers also indicate that participation in Medicare has dropped in recent years, in large part due to declining reimbursement rates. Add penalties on top of that and it’s hard to see that many doctors continuing to put up with the program, particularly if the nationwide shortage of physicians continues and physicians can be sure of filling up their schedules with privately insured patients who bring in more money.
But with the pace at which the healthcare industry continues to develop these kinds of considerations simply may not matter by 2015. There is already a lot of interest in coordinated care models like accountable care organizations and patient centered medical homes. If these types of systems become the standard of care, which doesn’t seem so far-fetched, EHR use may not be optional. The meaningful use program may start to seem like a quante contrivance by this time.
While there’s no way to tell what the healthcare system will look like in 2015, this is no excuse for failing to plan. Practices should look seriously at this deadline as something that will need to be dealt with sooner rather than later. Medicare payment reductions are coming one way or another. The decision of whether to implement an EHR system now or potentially sacrifice Medicare patients entirely is a big one, and physicians may have less time to make it than they think.
Because, while two and a half years may seem like a very long time in the world of health IT, it really isn’t. Workers get busy with day-to-day concerns and big-picture issues tend to fall through the cracks. Therefore, physicians need to start thinking today about what their practice will look like after the sun has set on meaningful use.
Results of a survey were released this week indicating that a majority of physicians believe that EHR systems will have no impact on or will contribute to declines in care quality. In fact the results showed that more doctors take a negative view of EHRs today than last year. As evidence mounts suggesting the opposite, that the technology actually improves care quality, it is worth considering why physicians are increasingly taking a hostile view of EHRs.
The survey was conducted by The Little Blue Book and Sharecare. It asked about 1,200 physicians from various specialties their thoughts on the impact EHRs will have on the quality of healthcare. Nearly one-third said the technology will have no effect (down from 37 percent last year), while 34 percent said EHRs would have a negative effect (up from 24 percent last year).
The findings come at an interesting stage in the development of the health IT industry. Sure, some recent studies have shown that EHRs can have somewhat of a negative impact on care quality. But overall the evidence largely supports a positive effect.
Take, for example, the recent study published in the Archives of Internal Medicine. It found that physicians who use EHRs are significantly less likely than non-technology users to be sued for malpractices. The researchers concluded that this is a sign that EHRs improve care quality, reducing the risk of errors that could expose physicians to malpractice suits.
Then there was the 2011 study published in the New England Journal of Medicine indicating that EHRs improve the management of diabetes. Neither investigation was equivocal in its findings. Both concluded strongly that EHRs can have a positive impact on care quality. So why do real world physicians – not researchers – continue to see things differently?
One explanation may be the increasing adoption rates. A significantly higher number of doctors are using EHRs today than at this time last year. Many implemented systems less than a year ago. Numbers from the Department of Health and Human Services show a major jump in adoption in January. This means that a large percentage of current EHR users are not that experienced.
Perhaps what we are seeing in physicians’ reluctance to admit the benefits of EHRs is nothing more than growing pains. Doctors who have only been using a system for a couple months may still struggle with certain aspects of it. This learning curve could be causing some to spend less time with patients, more time on administrative tasks and could even lead – at least temporarily – to an increase in medical errors.
Under these circumstances it is easy to understand why a physician would say he believes EHRs will diminish care quality. But could there be something else at work?
Ever since the meaningful use rules were announced there has been a certain segment of medical professionals who were against the proposals. These doctors may not necessarily have thought that EHRs in general were bad idea; they simply objected to the government mandating the use of the technology. Others said the meaningful use rules went too far. A government program to encourage the use of EHRs is one thing, but the requirements set the bar too high. The continued skepticism may be and expression of persisting resistance to these mandates.
Whatever the reason for this hostility toward EHRs is, it may be time to move past it. The evidence is mounting that the technology is good for healthcare. It may not be the most physician-friendly, particularly for those who have been practicing one way for several decades, but it is here to stay.
There is little that can be done at this point to stop the healthcare industry’s march toward technology use. The sooner physicians get on board with this idea, the better off everyone will be.
EHR implementation must be well thought out and suitable to its medical practice, and all staff needs to be well trained on the system. If these requirements are ignored, EHR benefits are lost, and sometimes patients would be better served by paper charts.
Paper-based success story
Dr. R’s office in a small Massachusetts town was praised by one of its insurers in 2009 as one of its best-practice primary care physicians when it comes to diabetic screenings.
The Massachusetts Department of Public Health recommends that primary care providers screen their diabetic patients for conditions and indicators such as retinopathy, LDL (low-density lipoprotein), nephropathy, and HbA1c (glycated hemoglobin). A health insurer that tracked compliance with these screenings noted that over 60% of its members received all of the above screenings from Dr. R’s practice every year as of 2009. That was about double the insurer’s overall average for these screenings.
But look who stumbled in and took over
In 2012, the well-oiled screening mechanism derailed. The practice’s nurse, who spoke on condition of anonymity, said she is not sure what percentage of their diabetic patients are still tested at timely intervals, but she’s certain that the percentage is lower than it used to be.
What has changed between 2009 and 2012? Dr. R’s office has moved from paper records to electronic, and the EHR system doesn’t have a way to remind the staff about these screenings, according to the nurse.
The nurse said that when they used paper records, the staff would flag diabetic patients’ records with sticky notes to remind them about these screenings. Although that seems preposterously old-fashioned and simple, it was very successful for them. “We all worked together” to make sure the charts were flagged and the tests performed, she said.
Now, trying to keep up with screenings is “a major problem,” said the nurse. If the doctor doesn’t order a needed test, the health insurer brings an overdue screening to the doctor’s attention. Then the staff has to call the patient in for a visit, instead of doing the screening when the patient is in for a regular checkup.
What’s wrong with this picture?
Whether this is simply a case of inadequate training, or whether the EHR system—the third different system (from different vendors) the practice has implemented in just a few years—really doesn’t have this simple capability, some patients are not receiving the screenings that could significantly impact their health. And “if it crashes, there goes everything,” the nurse said.
Overall, the nurse dislikes electronic health records. “Give me my paper charts,” she chuckled. The rapid, multiple, and radical changes in EHR systems surely compound any problems they are experiencing, including lack of buy-in by staff members such as the nurse. Due to her many years of experience with pre-EHR records, “with paper, I know what I’m doing,” she said.
Some EHR difficulties are preventable, but attitudes toward security issues are not so easily dismissed. Patient privacy and compliance with HIPAA rules make up one of the nurse’s major concerns. “Don’t tell me it’s secure” on computer networks, she fumed. “I don’t think it’s all that secure. If something got out and a patient calls and reports it, HIPAA would be all over us like white on rice.”
She goes on to chasten the U.S. government’s push for conversion to EHR. “The President says this information is secure,” she said, “but if they had to move the President’s health information from point A to point B [across computer networks], his info wouldn’t be out there in cyberspace,” because his administration wouldn’t risk compromising his privacy by transferring records across computer networks.
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It’s an old management axiom: “You can’t improve what you can’t measure.” And it’s true. How can you improve something, allocate resources effectively, compare with peers, or even know if quality is increasing or decreasing if you’re talking about something you haven’t measured?
This concept is very relevant to much of the current thinking surrounding EHRs and healthcare quality initiatives. The federal government has invested billions of dollars, private investors are shoveling cash at health IT, medical offices are running around like mad people trying to implement the right technology. But is it all worth it?
A new analysis from the RAND Corporation that was published last week in the New England Journal of Medicine suggests that we may not really know for some time because current administrative processes haven’t kept pace with developments in the delivery of care. Standard billing and coding operations simply aren’t up to the challenge of measuring the effect of technology on healthcare, and it will likely take a good deal more innovation to get the point where we can measure the effect.
The question goes to the heart of the meaningful use program. Lawmakers and taxpayers alike want to see rapid returns from their investments, which have been sizeable. However, even if care does become more efficient and productive in actuality, the gains may not be apparent when looking at numbers and study findings, which could cause a budget-conscious public to pull back the reins on health IT investment.
The authors of the report say we have seen this all before. As computers started infiltrating other industry decades ago researchers started observing what became known as the “IT productivity paradox.” Workers were able to get far more done than ever before, but if you looked at only the data it appeared that they were less productive. Why? Measures had not kept up.
We could be seeing a replay of this in healthcare. The authors point to the example of a physician who phones or emails a patient. These are incredibly efficient ways to check up on patients, but there is no place in administrative data to record these efforts. A physician can spend five minutes writing an email that could take the place of a 20-minute office visit but still come out looking less productive than before.
This is a very real problem that could have implications for the future of healthcare. Doctors are increasingly being asked to participate in pay-for-performance models where efficient, high-impact services are valued more than standard office visits. They are encouraged to use health IT tools to perform these services. Many wise people believe that this type of system is the key to solving the problems of high costs and poor outcomes in healthcare.
But if we measure the effect of these systems using standard data processes and find collaborative systems have a negative impact, support is likely to dry up very quickly.
There are few easy solutions to the problem. Ultimately the healthcare industry will need to develop completely new ways of measuring itself. In the meantime people will need to be patient, recognized that the investment has been made, and wait for it to bear fruits.
Unfortunately we do not live in a very patient society. Lawmakers and taxpayers want results immediately. When people do not see results (particularly if they were against the investment to begin with) they want to pull the plug. This could have serious consequences for the future of healthcare.
Health IT-driven collaborative systems may be among the last best hopes for developing an affordable, sustainable, effective healthcare system. Here’s hoping someone figures out how to measure the benefits of this type of approach before the naysayers pronounce its demise.
Electronic health records (EHR) have revolutionized health care in many ways. Physicians, specialists, billing specialists—even patients, in some cases—have instant access to all the important information they need: lab test results, medications, drug allergies, and so on.
Except when they don’t. If a patient needs to go to a specialist outside his or her provider network, or to an emergency room outside the network, access to the patient’s records can regress from a click of a button to a series of phone calls, faxes, and piles of paper, even when both facilities have EHR systems. That’s because there is often little consistency between such systems, and patients have to rely on a busy human being to pull all the pertinent electronic data and get it to the requesting physician in a format he or she can read: usually, paper.
But even within a provider network, if the system network connection goes down, patient records are inaccessible. Whether an EHR system has an inherent connectivity problem, or whether it’s is installed on an insufficiently robust or poorly configured computer network, this problem still plagues even some large health care networks.
What we have here is a failure to communicate
As an RN, as well as in her career as a medical litigator, Kimberley Winter grapples with non-communicating EHR systems all the time. “I find that systems are so different. This is a large overall problem – not so much the physical way of entering data,” but the way it is formatted, stored, and retrieved on different EHR systems. She often receives requested records via fax, or sometimes on a CD with the electronic record copied onto it.
The printed-out electronic paper is more difficult to read than when it’s on the computer screen it’s formatted for, Winter says. Of course, you cannot search on a text string on a paper printout.
When electronic record systems are incompatible, Winter says, you have to depend on the clinic staff to deliver the correct record to you, and to make sure it’s the complete record, or at least every part of it you need. But harried staff often miss some portions of the needed records. “Usually the first time I get the medical record, it’s not the whole thing. That’s not nefarious… the [parts of the patient record] are not even stored in one place, as physical [paper] files used to be. They’re printing from several different data banks… for example, I might see that there was a consultation, but there’s no report of the consultation; or no list of current medications.”
“It never gets better,” laments a provider in a large healthcare system about the serious connectivity problems that plague their EHR system. “If [EHR]‘s working, it’s great. If it’s not working, you have nothing.” This physician spoke candidly on the condition that her name and employer name not be used.
On her fourth visit with this physician, one patient said, “This is the fourth time I have seen you, and three out of these four times, you haven’t been able to access the records” due to lost connectivity. The patient said she wasn’t angry with the doctor, but with the facility’s computer system.
Healthcare facilities need to work with providers to make it easy for them to deliver excellent care. This includes having ready, instant, and continuous access to complete patient records – access resulting from compatible EHR systems and dependable computer networks. Standards must be set and enforced that allow compatibility across systems. A start has been made in this direction, but it needs to progress quickly yet carefully.
A recent study published in the journal Pediatrics showed that rates of diabetes and prediabetes among teens tripled during the course of the last decade. This represents one of the most pressing issues facing the healthcare industry, but more specifically, it should be viewed as a top priority for health IT vendors and users of technology.
Diabetes is a notoriously difficult condition to treat. It requires a great deal of coordination between multiple physicians and a high degree of engagement from the patient. We often hear about how EHRs lead to improvements in these areas, so it stands to reason that the technology should improve diabetes care. All that’s left is for the benefits to be proven.
There is mixed evidence regarding the use of technology in diabetes management. A frequently cited study published last year in the New England Journal of Medicine indicated that practices using EHRs delivered significantly better care to diabetics. By combining a number of different measures, the researchers determined that patients of EHR-wielding doctors experienced 35 percent better care than those not being treated with the help of technology.
However, a more recent investigation countered these claims. Researchers reported in the latest issue of the Annals of Family Medicine that there was no difference in the quality of care received by diabetics regardless of whether their doctors used EHRs.
Taken together, these findings neither indicate that EHRs are a silver bullet for improving diabetes care, nor is the technology useless in managing this chronic disease. What the collective findings should suggest to technology vendors and physicians alike is that there is a strong basis for using EHRs in diabetes care, but there is significant room for progress.
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EHR systems aren’t designed specifically for treating diabetics, but maybe they should be. The Pediatrics report indicated that one-fourth of all young people today have the metabolic condition or are at risk. It is very unlikely that those who currently have diabetes will resolve their condition as they reach adulthood, but it is likely that many of those with prediabetes will develop the full-blown condition. Therefore, we could be looking at a future in which one-third of adults are diabetic.
Given the economic cost of treating diabetes and the devastation it can cause in a person’s life, every effort should be made to help at-risk individuals avert the condition and improve the ability of those who are diabetic to manage the disease. EHRs are the prime candidate.
There is little doubt that team-based care improves treatment outcomes for diabetics. This has been demonstrated many times. EHRs can play an important role in coordinating the services of many different healthcare players.
For example, a patient’s primary care physician can administer and HbA1c test during a well visit and then make these results immediately available to the patient’s endocrinologist, who can look at the results as part of a larger trend and make recommendations as necessary. Furthermore, patients can upload daily glucose measures to their personal health records and share the results with physicians’ EHRs, which are able to monitor the readings for potential signs of worsening health.
All of this can improve blood sugar management and help individuals avoid future health complications, such as heart disease and neuropathy. These health problems are some of the main drivers of the high costs associated with treating diabetes and the poor quality of life of some diabetics.
EHRs may not be a magical cure-all for improving diabetes treatment. But the technology is well-positioned to make meaningful gains in disease management. To fulfill this potential technology vendors will have to understand what doctors need to improve diabetes care, and physicians will need to use technological tools in intelligent, targeted ways.
If this happens it may be possible to divert the approaching tidal wave of diabetes that is threatening the country.
Physicians have a great opportunity in front of them to adopt EHR systems and get paid to do so. The federal government is offering substantial incentives to those who use the technology in accordance with the meaningful use rules. These payments may help defray the cost of implementation and possibly even give doctors a little extra money for their troubles. There’s just one catch: The clock is ticking.
Physicians must complete their EHR implementation and attest to having met all the requirements of meaningful use before the end of 2012 in order to earn the full amount possible. Those who wait longer will be left with significantly diminished incentive payments, or potentially nothing at all. With all that is involved in EHR implementation, eligible professionals who have yet to start planning their technology initiative need to get going now.
The potential difference in total incentive payments is great. Those who attest to having met all the requirements of the Medicare meaningful use program in 2012 can earn up to $44,000 by the end of 2016. Those who wait until 2013 to attest will be eligible for $39,000, which is still a respectable total. However, professionals who do not get an EHR system up and running until 2014 will only have a shot at $24,000. And then, of course, there is the potential of penalties for those who still have not implemented systems after this point.
A simple two-year delay in EHR implementation will cost a physician $20,000. What doctor couldn’t use that money in his or her practice? Given the large sum of money at stake, there is no reason why a professional should wait until after 2012 to attest to meaningful use. The financial implications will never be more in the doctor’s favor.
However, physicians can’t wait until the end of the year to start thinking about EHR implementation. Getting a system in place isn’t as simple as just flipping a switch. While a professional has until the end of 2012 to complete the project, implementation can take a very long time. The clock is already running low.
First, practices need to plan out their goals, shop for a vendor, assess their readiness, begin implementation, conduct training and run tests to make sure everything is up and running. This whole process can take several months and must be completed before a physician tries to attest to meaningful use. The time it takes to get a system set up is completely dependent on the amount of resources a practice can devote to the project, but given that most smaller facilities have no IT staff, the project should be planned for several months.
And then the attestation period takes a while. In order to qualify for meaningful use a physician must report three consecutive months worth of data that describes their use of a qualifying EHR system.
With just seven months left in 2012, physicians who have yet to start planning for EHR implementation have a lot of work to do. Even the speediest projects can take more time than this. Any further delay could cost doctors significant amounts in incentive payments.
So where to start? Fortunately, there are a number of useful resources available that can get physicians started on the road to meaningful use. The Office of the National Coordinator for Health IT has a handy guide on its website that walks medical professionals through the process from beginning to end. Additionally, each area of the country has a Regional Extension Center set up by the Office to provide in-person technical support and vendor-selection guidance.
Physicians who do not know where to begin should take advantage of these resources – the sooner the better. The clock is ticking on the possibility of earning major incentive payments. Any further delay could cost a medical professional the opportunity to really cash in.
A hospital that cares for the homeless generally doesn’t have the money for a comprehensive EHR system that can meet all its needs, and the robust computer resources to support such a system. But with its EHR implementation only partly in place, Christ House, a multi-service hospital for the homeless in Washington, D.C., still delivers excellent, life-saving care for free to a large, underserved population.
Founded in 1985, Christ House was the brainchild of Allen and Janelle Goetcheus, missionaries planning to work overseas. While waiting for visas, they got to know the plight of the ailing homeless and realized how great the need was for decent hospital care.
“Each day…Janelle walked past the abandoned building that is now the home of Christ House,” says the Christ House parent organization’s website. “Homeless people slept on the steps or snuck inside during cold weather. At the same time, Janelle became aware that hospitals would discharge the uninsured more quickly than other patients, meaning that homeless people had to recuperate from major illness or surgeries while living on the streets or in shelters.”
Janelle and Allen formed a “mission group” with others from their church, Church of the Savior. Endowed by a large anonymous donation and the Robert Wood Johnson foundation, they created a network of sophisticated, well-organized health facilities and outreach operations in the Washington, D.C. area.
Today, Christ House treats “just about anything that can go wrong with the human body,” said John, an R.N. at the hospital. The 24-hour, 34-bed facility treats wounds, illnesses, injuries, drug and alcohol addictions, and provides referrals to specialists as needed. The average patient stay is about a month, John said. Christ House also provides case management, guiding patients to recovery programs, vocational training, and other services as needed.
“A lot of the guys come in pretty edgy; a lot of the guys have done time,” John said, but they usually soon calm down at Christ House, realizing it’s a safe place where they’re cared for well and with compassion.
Christ House is now part of the Unity Health Care system, whose focus is delivering health services to the homeless and otherwise needy in the DC area. According to its website, almost 82,000 people used Unity’s services in 2010; of those, 12% were homeless, and the rest were “working poor” or “uninsured.”
One flavor EHR doesn’t fit all
Unity started using an EHR system, eClinical, in 2009. John said their EHR implementation is better suited for clinics than hospitals like Christ House. The system isn’t designed for the many daily entries that nurses record in real time into each patient’s records; for example, a nurse might need to note that a medication is making a patient feel different than he did two hours before, or record new symptoms that a patient is presenting that differ from those recorded earlier in the day. For these daily notes, Christ House uses paper charting. John is comfortable with paper charts; “they work well. It’s what I know.” John is not a hospital spokesman; his comments are his own. Unity spokespersons were not available by press time.
Does John feel that using paper charts for some records and EHR for others affects the quality of patient care? Not at all, he affirmed. And if they switch to EHR for 100% of patient records, “It’s not going to hurt or change patient care.” And, he admitted, “It would improve legibility and spelling.”
Christ House uses its EHR system for most other recordkeeping, such as billing, referrals, admission notes, lab reports, and radiology reports. John said there is EHR software on the market well-suited for hospitals, but such software might not communicate well with Unity’s current system. But resources are limited; Unity relies on government and grant funding and on donations, according to its website.
The government’s meaningful use program provides an unprecedented opportunity for physicians to claim financial incentives for using an Electronic Health Record (EHR)technology that could have many benefits for their practice. Of course, there are some caveats, but on its surface this is a great opportunity for doctors to get paid to use a technology they would probably want to adopt at some point anyway. So what do physicians think?
That may be a question not even the doctors themselves could answer. Because apparently, many are unaware of even the most basic tenets of the program.
A group of past and current government officials, including former national coordinator for health IT David Blumenthal, former CMS administrator Donald Berwick, and current national coordinator for health IT Farzad Mostashari, wrote an article in the latest issue of the Archives of Internal Medicine, which states that after about two years of existence, the meaningful use program still baffles some doctors.
The group wrote that many physicians are still unsure “how to register for, report, and attest to meaningful use.” This continues to be a major hurdle keeping greater numbers of physicians from jumping into the realm of EHRs with both feet. (As a side note, the article provides a relatively exhaustive explanation of all the steps physicians must take in order to qualify for meaningful use. It may be very helpful to those who are unsure of where to go with their technology initiative)
Aside from confusion over the requirements of meaningful use, the cost of EHR implementationy – both in terms of the system itself and the productivity losses – is keeping many doctors from adopting the technology, the article states. However, the fact that so many are unfamiliar with the requirements of the program suggests that a large percentage of physicians may not realize that the incentives could greatly make up for these initial expenses.
The article should provide a wakeup call for providers who have yet to give EHRs much thought. There will never be a better time to implement a system. There are several reason why now is the time join the world of 21st century medicine.
First of all, there are the direct financial ramifications to consider. Yes, an EHR system is expensive. But there are incentives available to help defray this cost. However, these incentives will not last forever. Eventually physicians who have not implemented qualifying EHR system will face payment reductions for their Medicare or Medicaid claims. For doctors who are reliant on treating Medicare and Medicaid patients, these penalties could end up being far more costly than an EHR system.
Then there is the fact that health IT tools are increasingly becoming an inevitable part of the future of healthcare. Doctors who are not using EHRs may eventually be viewed as irrelevant, both by patients and potential referring physicians. This could eventually send patients looking for medical offices that have more modern operations.
The bottom line is that every medical practice will have to implement an EHR system eventually. It only makes sense to do it now while financial incentives are available, rather than wait for payment reductions to kick in, and then be forced to bear the cost of the system in addition to penalties.
Physicians are running out of time, though. As the experts’ article points out, 2012 is the last year to implement a system and qualify for full incentive payments. Those who still have questions about meaningful use should look for answer before it is too late.
There have been a number of calls in the last few weeks for the Centers for Medicare and Medicaid Services to push back the deadline for the transition to Stage 2 meaningful use. This may sound like music to the ears of physicians who are currently struggling through Stage 1 and would like a little extra time to get used to their systems before they have to start thinking about upgrading them. So is a delay likely?
There is some reason to think the answer may be ‘yes’. Just within the past few months CMS has delayed enforcement of the new HIPAA 5010 regulations, extended the deadline for Stage 1 meaningful use attestation, and pushed back the transition to the ICD-10 code sets for an entire year. The agency has shown a pattern of giving in to pressure.
And there sure has been pressure on CMS to extend the Stage 2 deadline. Within the past week the American Hospital Association and the College of Healthcare Information Management Executives sent letters to CMS calling for an extension of the Stage 2 deadline. These two groups are heavy hitters in the health IT world, and given that they each represent so many hospitals and medical executives, they have rather loud voices. CMS would be hard-pressed to ignore their concerns entirely.
But I still wouldn’t bet on an extension of the Stage 2 meaningful use deadline. There may be good reason to think that a delay could be in the cards, but with all that is at stake, physicians may be left walking away from the table empty handed if they put all their chips on an extension. It’s just too risky a bet.
In the runup to the ICD-10 debacle a significant number of physicians had not taken even the smallest steps in the direction of preparation. A survey conducted by the Workgroup for Electronic Data Interchange conducted around the time of the delay showed that many hadn’t even begun an impact assessment. Fortunately, these late starters got bailed out. But there could have been serious consequences if they hadn’t been.
It would be a mistake to repeat this pattern when it come to meaningful use. Sure, there may be some reason to think the government could delay the deadline. But is it worth risking up $63,750 in incentive payments (not to mention the payment adjustments that could follow) on the assumption that CMS will give in to pressure like it has in the past?
What if the agency puts its foot down this time? A lot of physicians could be left in a difficult financial position if they have not made proper preparations for the transition to Stage 2. Given the high stakes, I would not want to be staring down the meaningful use deadline with no plan in place other than to hope for a delay.
In their letters to CMS both AHA and CHIME said that it will be difficult for EHR vendors to develop new systems that meet the requirements of Stage 2 in time for the deadline and physicians will face significant challenges in adopting qualifying systems. Since the deadline for complying with the Stage 1 regulations was extended, the amount of time physicians have to transition from one stage to the next got compressed. This could make things harder.
To be sure, this is all true. The industry will definitely face challenges as it tries to step up to Stage 2. But this isn’t an excuse for failing to plan. Not making the proper preparations for the Stage 2 transition could turn out to be a very costly bet.
When the proposed Stage 2 meaningful use rules were first published most commentators appeared to approve of the regulations. The new rules, experts said, represent a logical and feasible extension of the provisions initially laid out in the Stage 1 rules.
But in the following weeks we have seen a greater number of organizations question aspects of the new rules. Some have taken issue with specific requirements, while others are unhappy about the timing of the program. So what happened to all those positive thoughts that we initially saw?
Earlier this week the American Hospital Association sent a letter to Centers for Medicare and Medicaid Services administrator Marilyn Tavenner outlining a number of issues with the program. The group said that reporting periods for the meaningful use program should coincide with the payment year to which penalties will be assessed (currently, penalties will be assessed in 2015 for physicians who failed to implement EHRs in 2014).
The group also pointed out that when the Stage 2 rules were announced, CMS offered a one-year extension of the deadline for meeting the Stage 1 regulations. This was seen as generous initially, but there was no corresponding delay in the Stage 2 deadlines. Pushing one deadline back without adjusting the other means that physicians will have less time to transition from one stage to the next than originally planned.
Finally, the letter called for a greater number of menu options and fewer mandatory objectives, and for CMS to drop the regulation requiring physicians to get a certain number of patients to download information electronically.
This is a long list of grievances for a set of regulations that was initially greeted with little more than a yawn from many in the healthcare community. And the AHA is not alone. Numerous other physicians have called for regulators to drop requirements for patient interaction and to loosen the deadlines. So where is all the animosity coming from?
For starters, physician groups have finally had a chance to examine the regulations in detail. It was easy to say they supported the new regulations when all they had to go on was a brief outline of the rules, but now that they have had the opportunity to really unpack what is included in the regulations, some aspects may not look so attractive any more.
Most significant is the fact that we are rapidly approaching the close of the comment period. When the proposed rules were first published it triggered a 90-day period in which stakeholders were asked to send feedback to federal authorities. With the deadline for comments coming May 7, many organizations may simply be getting their recommendations together and making their concerns public.
Finally, some groups may simply be overplaying their hand in an effort to see what they can get out of the regulators. In negotiations it doesn’t hurt to overstate your case just to see what the other party is willing to concede. It may be that many of the commentators who are speaking up now do not actually find the regulations to be as onerous as they are making it sound.
Either way, it is interesting to see the support we initially observed when the new rules were announced fade, at least to some degree. It just goes to show that the relative worth of regulations cannot be judged so quickly. It takes time for the impact of new rules to be assessed by stakeholders. Rushed judgements are generally not accurate.
By the same token, those commenters who are upset by provisions in the current set of proposed rules may want to exercise patients before passing judgement. The past few months may have allowed them to develop expectations of how the regulations will affect their practice, but only time will tell how the stage 2 provisions will work out. The full implications may not be clear until after they have actually gone into effect.
It’s one of the most hotly contested claims surrounding electronic health records. Proponents say the technology will help lower costs, while skeptics say the situation isn’t so simple. Given the rapid, unchecked increases in healthcare costs, there is a lot riding on the ultimate truth to whether EHRs lead to lower costs or not.
So what’s the answer? The latest entrant into the debate is a group of researchers from Massachusetts General Hospital in Boston. After reviewing the records of nearly 100,000 chest CT exams that were ordered after using a decision support system, the team found that patients who had high utility scores (indicating the test was appropriate) were significantly more likely to have positive findings on the test than those who had less favorable utility scores (indicating the test may not be necessary). The results were presented at the 2012 Roentgen Ray Society Annual Meeting
The researchers said the findings indicate that decision support systems help physicians determine which patients will benefit most from imaging procedures and avoid ordering tests for those who are unlikely to have a diagnosable medical problem.
The team made no claim that their findings indicate that EHRs and decision support will lead to lower costs, but the implications are clear. When doctors know exactly which patients will benefit from a test, they are less likely to order costly imaging procedures for those who are unlikely to benefit. Eliminating unnecessary testing is widely believed to be a key aspect of the fight against high healthcare costs.
Of course, this by no means is the final piece of proof validating claims of the ability of EHRs to lower costs. Skeptics will continue to point to other findings, such as ones from the recent Health Affairs study, which found that doctors tend to order more lab tests when they have electronic access to their patients’ results. This is a debate that is likely to continue until more comprehensive proof emerges.
Up until now, most studies have looked at the effect of EHRs on individual aspects of a practice. But the costs of medical offices do not stem solely from how many tests they order. Obviously, the matter is more complicated than that. Investigations that take a more holistic view of the effect of EHRs on practices’ costs may do more to contribute to answering the question.
After all, a few studies may find that EHRs help doctors order fewer inappropriate tests, but what about that physician’s workflow? If a doctor is slowed down by his or her EHR and is able to see fewer patients in a day because of this, their costs are unlikely to go down, even if their test ordering is more efficient.
What may finally help to settle the debate would be an investigation that looks at the overall, system-wide costs of several medical offices that have made the decision to adopt EHRs or stick with paper-based systems. A true randomized trial may be difficult given all that is involved, but some inventive researcher may be up to the task.
Short of this, it seems we may not be able to settle the question of the effect of EHRs on costs any time soon. Even after the healthcare system has become fully networked, which seems more and more like an inevitability, it will be difficult to pin EHR adoption as the cause of any change in healthcare costs, as healthcare reform and many other factors are changing the way providers do business.
So the debate will continue. Both sides have their evidence and neither appears prepared to concede the facts of the other. At the very least the debate may help to keep some researchers busy for a while.
There is no doubt that physician interest in EHRs has increased over the last few years. Technology adoption is up, largely in response to the availability of incentives being offered by the federal government. But this interest may not necessarily translate into meaningful use.
A group of researchers from the National Center for Health Statistics recently surveyed nearly 4,000 medical professionals from across the country. The findings of the investigation, which were published in the journal Health Affairs, indicate that 91 percent of doctors were eligible to participate in the meaningful use program and about half said they intend to apply. However, only about 11 percent had EHR systems that would satisfy even two-thirds the Stage 1 meaningful use requirements.
Additionally, since the survey did not ask doctors about the remaining one-third of the meaningful use rules, the number of doctors that were found to be ready to attest may actually be overstated.
The results did suggest that many physicians may be planning to wait until they are really pressed to adopt an EHR system and then rapidly install the technology. Of those who did not currently have EHRs set up, 43 percent said they planned to complete implementation within the next 18 months.
However, the findings may also indicate that there is a mismatch between what physicians think they need to do to qualify for the incentive program and what the initiative actually requires of them. Obviously, it is easy to look at the possibility of tens of thousands of dollars in incentive payments and decide you are going to pursue the bonus. But many doctors may not realize how difficult the task can be.
Just selecting the right vendor can take hours of research and discussion among multiple team members. Getting the system set up and fully configured is another major task. Ensuring that all staff members are properly trained and continue to use the system in accordance with the meaningful use requirements may be the biggest hurdle.
This can require workflow redesigns and a significant investment of time spent on what essentially amount to non-billable tasks. Incentive payments may seem attractive at first, but physicians have to be ready to work for that bonus.
Going into the process of EHR implementation without a full understanding of all that will be required may be one reason why so many physicians want to participate but so few are actually ready. Still, there are many ways eligible professionals can get up to speed.
The authors of the report pointed out that regional extension centers are available to provide technical support and guidance to physicians who are struggling with EHR implementation or simply don’t know where to begin. These offices are distributed throughout the country and are funded by federal agencies, so there is no charge for their services. A practice’s EHR vendor may also provide guidance. A good company doesn’t simply drop off a box of software; it should provide at least some level of technical support.
Most organizations, including the Office of the National Coordinator for Health IT and the Health Information and Management Systems Society, agree that extensive planning is the key to successful EHR implementation. Fully understanding the meaningful use requirements and mapping out ways to satisfy them will help physicians qualify for the program.
The U.S. Department of Veterans Affairs (VA), a pioneer in the widespread, successful deployment of EHR, offers veterans access to their personal health records. The My HealtheVet program does not contain veterans’ complete health records, but does allow prescription refills. Hailed as a useful resource by many, the system has had its problems; the most serious ones have been fixed.
What it does and how to get it
To get a My HealtheVet account, veterans and servicemen and women must register in person at a VA facility. As a registered veteran or service member, once you have an account, you can:
• View portions of your VA personal health record
• Receive “wellness reminders”
• See when your appointments are
• Get online prescription refills
• Track your immunizations
• View lab results
• Send and receive secure messages to and from your VA healthcare providers
• View your DoD (Department of Defense) military service record (service dates, deployment and retirement information, pay rates, and so on).
• Access the VA’s “Health eLogs,” where you can enter and track your blood pressure, weight, cholesterol levels, and more.
• Browse a library of VA-approved health information
• Tools for behavioral health screening
First made available to veterans and servicemen and women in 2003, My HealtheVet started with Web-based educational health information. The appointment reminder tool, self-entered personal health information, and prescription refills were added over the next several years. In 2008-9, EHR was added as the system linked to certain VistA information.
My HealtheVet has had its share of trouble. A blog entry from May 2009 on “Government Out of Control” (http://mcgrew-fam.net/GOVBB/ ) highlights two bugs: “I have two associate degrees in engineering and… a Master’s in Information Technology… This My HealtheVet program could’ve been written by my five-year-old nephew. That’s how big this bug is. For the security of the system, I will NOT go into any details until the problem has been resolved*…. I for one am getting pretty annoyed at the VA… They keep blaming vets for missing appointments and costing tons of money. However, they won’t acknowledge that their computer system makes appointment[s] for veterans without telling them about the appointments. It’s happened to me once, my dad once, and my uncle twice.”
*The first bug referred to here was probably the one that resulted in drug dosage mistakes for many veterans. It has since been fixed.
Here is another example of the appointment problem, as posted as a question and answer on http://vets.yuku.com in March 2012:
[Question:] “I have been scheduled for surgery at the Martinez Ca. surgery center early next month. Normally, my appointments (including a previous surgery) are all visible under the appointments section of My HealtheVet. However, this particular appointment only shows up on the calendar on eBenefits.
Why would that be the case?”
[Posted reply:] “I have noticed that [the] eBenefits calendar of appointments somehow updates before My HealtheVet. It was actually updated ahead of the call from CBOC making the appointment (two days ahead of My HealtheVet). I think eBenefits will eventually be the source for veterans and service members for the largest majority of on-line activity with DoD and the VA.
The problem is getting all these government computer systems to talk to each other; then our information will be only a click away.”
What’s the easiest way to become a top-ranked healthcare provider? Part of the answer may be to implement an EHR system.
A report published last week by HIMSS Analytics found that hospitals on the Thomson Reuters 100 Top U.S. Hospitals list are more likely to use EHRs than those not on the list. Furthermore, these providers are more likely to use the technology for advanced functions and to have high levels of integration.
The level of the correlation is striking. According to the report, 21 percent of facilities in the top 100 list have achieved an Electronic Medical Records Adoption Model rating of 5 or high. By comparison, only 9 percent of hospitals not on the list have reached this point. The opposite was also true. Only 1 percent of hospitals on the top list were at Stage 0 or 1, which indicate inadequate or nonexistent EHR implementation. On the other hand, 17 percent of all U.S. hospitals were at this low level of implementation.
The authors of the report called this “objective proof” that advanced EHR use is correlated with improved quality. With more hospitals adopting the technology in order to attain incentive payments, they believe hospital performance will start to rise rapidly across the board.
Of course, with these types of studies it is always difficult to determine which came first. It could be that implementing an EHR system significantly improved the quality of care at these hospitals, but it is equally as likely that hospitals that were already top performers decided to add EHRs to their operations.
But if you look at the measures Thomson Reuters uses to judge top hospitals, it seems as though it’s no accident that many of these facilities use EHRs. The group says they look for high-quality patient care, operational efficiency, high patient satisfaction and financial stability. These are all benefits commonly associated with EHR use.
True, it may not be reasonable for healthcare providers to think that all they need to do to become a top performer in their field is to implement an EHR system. There is obviously a lot more to it than that. Systems need to be set up in such a way that they enhance – rather than hinder – efficiency. Furthermore, physicians need to understand the benefits of the system and become experts at using them to their fullest. Many practices have found that this is no small task.
Clearly, there are many things a medical group needs to think about. Simply adopting an EHR system in order to gain recognition as a top-ranked provider may lead to disaster. But the implications of the report do suggest that EHR adoption may at least play a role in improving quality and efficiency.
Ultimately, the findings serve as just one more piece of evidence supporting the use of EHRs. The benefits of the technology is something that has been debated somewhat in recent months, with most of the naysayers voicing their opinions on the heels of the Health Affairs study, which suggested that EHRs may contribute to higher medical costs.
While absolute proof of the effects of EHRs may never really emerge, we can surmise from the HIMSS study that EHRs are associated with – but do not necessarily cause – high-quality, efficient care. For providers who are sitting on the fence, wondering whether to implement the technology, this may be the most affirmative answer they can expect.
Selecting the right electronic health record systems is about far more than simply choosing a list of functionalities and finding the vendor that supports them. Physicians need to make sure the system fits with their style of medicine. Otherwise, they may encounter many unintended consequences.
Nowhere is this more apparent than with the computerized order entry function of an EHR system. When a system fits with what a practice does, this function can be a powerful tool for driving patient safety improvements and making sure that each patient receives the most appropriate care possible. However, when a monolithic system is bolted on to a practice’s operations, it can make life extremely difficult for physicians.
For example, a recent study published in the International Journal of Medical Informatics indicated that many doctors simply ignore the alerts that pop up when they are entering orders, rather than actually dealing with them. These alerts are intended to ensure that physicians do not mistakenly order the wrong medication or treatment. However, many CPOE systems inundate physicians with alerts to the point where doctors simply ignore the warnings.
In the study, researchers from the Roudebush VA Medical Center in Indianapolis examined how the facility’s doctors interacted with the order entry system. The team found found that the alerts that came up as doctors were putting in orders were generally more geared to the responsibilities of pharmacists, not physicians. Furthermore, many doctors were unsure why certain alerts were coming up.
The findings of the study underscore the importance of having an EHR system that is specifically designed for your practice’s individual needs. A poorly designed system or one that was not properly customized can lead to alert fatigue, which causes physicians to use the system improperly. This is a situation that may eventually jeopardize patient safety and possibly make it difficult to qualify for meaningful use incentives.
When searching for a new EHR vendor, physicians should think about the experience the technology company has supplying systems to other doctors in their specialty. Some vendors focus on ambulatory care and orthopedics, while others provide systems that are aimed at ophthalmologists or cardiologists. Choosing a vendor that has a proven track record of success within your specialty is key.
Next, it is important to explore the possibility of customizing the system. Some EHRs come out of the box more or less configured. On the other hand, some vendors allow practices to have a great deal of say over certain functionalities. They may even offer the ability to customize the alerts that pop up while entering orders electronically, which could help ensure the alerts that come up while entering orders are purely relevant and do not contribute to alert fatigue.
There are many reasons to ensure computerized order entry systems are usable. First off, the meaningful use rules require the use of these systems. Under the current Stage 1 regulations eligible professionals must use CPOE for 30 percent of their patients. Without doing so, the physician will not qualify for the incentive payments.
Beyond this there are the patient safety implications. Some studies have indicated that doctors who are forced to use burdensome order entry systems ignore up to 80 percent of the alerts they receive. Granted, many of these may be irrelevant. However, some of the alerts surely point to serious risks. Ignoring this many alerts may put patients in danger.
So doctors should not rush the decision of which vendor to go with. Taking the time to make sure the technology company can offer a system that is relevant to your practice may save you many headaches and help keep your patients safe.
The stage two meaningful use places a much greater emphasis on patient engagement and set high standards for making data electronically available to patients. Physicians should think about these requirements as they work to implement a new EHR system.
The new rules state that a professional must make electronic records available to 50 percent of their patients. Furthermore, 10 percent of a physician’s patients must actually view and download these records. This is a high bar, and some groups have expressed dissatisfaction about the fact that doctors’ incentive payments will be dependent upon patient behavior.
Regardless, the best response to the problem is for practices to start planning how they are going to meet these requirements. Of course, the meaningful use rules could still go through different iterations before being finalized and it is possible the provision could be dropped. But assuming this rule stays in place, doctors do not want to get caught flat footed. A proactive approach is best.
First, it is useful to look at the regulation from a practical standpoint. What technology will you need to make records available to patients? The most obvious answer is a patient portal.
Most EHR vendors have products that include patient portals. Simply selecting this functionality may be the easiest way to satisfy the meaningful use rule. When the patient portal and the EHR system are purchased and set up together, there will be no need for extensive integration efforts. They will come set up so that whatever a physician does in a patient’s record in his system will automatically update the record that is viewable by patients.
This means less time at the computer. It also means that creating an online patient record for each individual that has a corresponding EHR will be totally painless for physicians. Such simple integration should make it a snap for physicians to meet the quota of providing online access to 50 percent of patients.
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Next comes the hard part: How to get 10 percent of patients to actually view and download their information. Just because they have access to their records is no guarantee that they will do anything with them. Furthermore, surveys have shown very low interest in among regular people in using personal health records. Physicians are on the hook for finding some of way of generating interest.
The key is to show patients value in accessing their records online. Overall adoption of personal health records has been abysmal. Patients simply do not want to feel like they are putting in time and effort when it comes to keeping track of their data. However, individuals have shown support for specific elements and uses of the technology.
For example, a study published in the latest issue of the Journal of the American College of Radiology indicated that the majority of patients would like to have immediate online access to test results. Many others say that receiving results online after a short delay to give physicians time to interpret findings is preferable to having to wait for a doctor to call.
In order to get patients more engaged and downloading their records at higher rates physicians should sell their patients on these benefits. Furthermore, they should follow up this sales pitch by actually posting relevant information to patients online records. The more patients are aware of this kind of direct benefit, the more they will log on.
The meaningful use provision requiring physicians to get their patients to download their records will be difficult to satisfy. And with the opposition to it, it may still be dropped from the regulations before the Stage 2 rules go into effect in 2014. But assuming the rule will stay in play, physicians may want to start talking up the benefits of online records access to their patients now. This could make satisfying the requirement easier once the regulation goes live.
It wasn’t long ago that Health and Human Services secretary Kathleen Sebelius complained about the fact that most physicians are still using the same record-keeping technology that Hippocrates used. This comment was indicative of many experts’ frustration with the glacial pace with which the healthcare industry has moved to adopt electronic health records.
After all, people have thought these kinds of systems might be a good idea since the 1980s. Adoption rates may have picked up a bit since the government introduced its meaningful use incentive program, but the healthcare industry is still far from seeing anything close to a majority of physicians adopting systems.
So this must mean the U.S. healthcare system is woefully outdated and behind the times, right? It turns out, the answer to this question depends on how you look at things. Relatively speaking, doctors in this country may actually be slightly ahead of the game.
KLAS recently released a report indicating that EHR adoption has actually progressed much more slowly overseas than it has in this country. The findings indicated that about 3,000 hospitals outside the U.S. had successfully completed EHR implementation projects. The study looked at technologically advanced nations like the UK and German. Comparatively, there are nearly this many hospitals in the U.S. alone that currently use EHRs.
Furthermore, only a small handful of providers were using their EHRs for advanced functions. Very few international hospitals would be able to achieve HIMSS Stage 6 or 7 certification, which require things like clinical decision support, physician documentation and data continuity between emergency department and ambulatory providers and other specialists. By the end of 2011, there were about 277 hospitals in America at Stage 6 and 64 at Stage 7.
So clearly, if you judge the U.S. healthcare system against international standards, it is pretty far down the road to achieving widespread adoption. But is this necessarily the only standard that providers should be judged against?
Right from my home computer I can watch any TV show that I may have missed, transfer money from one bank account to another, and send an order to have my local pizza shop deliver a pie. You could find more advanced technologies being used at the nearest elementary school than you would seen in many doctors offices. Given how far technology has advanced in recent years and how deeply it has penetrated nearly every industry, it seems a little odd that there would still be doctors who are scribbling away on notepads.
The financial services industry is an excellent example of a sector that was quick to see the benefits of incorporating technology. Today, trades are executed much faster than in previous generations, analysts use programs to spot trends and look for opportunities, and systems track vast amounts of data. If it can work for this type of complex industry, why wouldn’t it for healthcare?
The question of why healthcare has been so slow to adopt IT solutions on a large scale is difficult to answer. The obvious reason is that EHR systems can cost a lot of money. But this is all the more reason why physicians should be jumping on the opportunity now to earn incentives for their EHR use rather than wait until they are under the threat of penalties. These incentives can help make systems much more affordable.
Clearly, things are moving in the right direction. Adoption rates are up and it seems like there will be no turning back at this point. But you still have to wonder what took the industry so long. We have been living in an information-driven world for the better part of two decades now. Paper records are clearly not up to the task. However, the fact that the industry appears to have seen the electronic light is encouraging.
The benefits of EHRs are well established. Substantial evidence suggests that when the technology is implemented properly it can improve patient care in a number of ways while at the same time boosting a physicians’ productivity. However, the operative phrase is “when implemented properly.”
At this point, many physicians may be familiar with colleagues’ horror stories about how EHR implementation went wrong or about how systems can interfere with workflow and patient care. These types of stories underscore the importance of effectively planning and managing implementation projects.
To be sure, getting an EHR system up and running can be a major undertaking. However, there is no reason why a practice should let this stop them from pursuing the benefits of the technology. Implementation is within the capabilities of any practice, as long as physicians keep a few points in mind.
A recent study published in the American Journal of Managed Care examined some of the themes that commonly attend successful EHR implementation projects. Researchers from the University of California, San Francisco, surveyed healthcare professionals at seven Veterans Affairs Hospitals across the country about their experiences with the technology.
The results showed that effective planning and change management make the difference between a practice having a successful technology initiative and having another EHR horror story to tell.
The researchers found that hospitals where EHR implementation appeared to have gone smoothly typically did five things. They put in place project management teams, developed and stuck with project timetables, made sure hardware was available to physicians, provided staff with adequate training, and managed the inevitable workflow changes.
At hospitals where the project fell apart, the exact opposite was true. Furthermore, problems that started to appear in the early stages of the initiative tended to become persistent. This shows how a failure to develop a detailed plan and stick with it throughout an implementation project can doom an initiative from the start.
Many physicians may view this kind of technology project in terms of how it affects their jobs, but the researchers said the implications of these initiatives go well beyond simple workflow changes. At the hospitals they examined where implementation was the worst, it actually created potentially dangerous situations for patients. Every doctor wants their system to make their job easier. But they may have far more pressing things to worry about if they do a poor job of planning the project in the early stages.
Of course, as mentioned above, there can be major benefits for practices that implement EHRs. So the potential problems that can result from a project should not scare a physician off from adopting the technology. The risks associated with ineffective implementation should simply provide doctors with something to think about. Giving full consideration to all the implications of the project may help individuals understand the importance of proper planning.
Once a system is up and running, many things may change at a practice. Staff responsibilities can shift, patient interactions may be altered, and billing practices may change. These are all things practices should think about when they are planning out their implementation project. Otherwise, the changes can catch staff off guard and leave them unprepared to respond.
With all that is stake, practices cannot afford to do a half-hearted job of planning. A well-thought out EHR project can greatly improve physicians’ efficiency and make care more effective. However, a failure to plan may actually make a doctor’s office a dangerous place. The only real difference between these two outcomes is the degree to which a practice plans out their project and executes it.
Listening to news coverage of the Supreme Court’s health reform hearings, you would think the justices were getting ready to overturn the Affordable Care Act tomorrow. Of course, no one can really predict the way the court will rule, but that hasn’t stopped the talking heads from trying. And many seem to agree that the outlook is grim for the future of healthcare reform in the U.S.
So what does this mean for your EHR implementation plans? Depending on your practice’s reasons for moving to an electronic record-keeping system, the answer is either a lot or a little. Some government programs encouraging EHR use would be affected by ACA repeal, while others would not. It all depends on which programs you are planning on participating in.
The government’s main initiative to encourage EHR use is, of course, the meaningful use program. This program is unlikely to be impacted by any Supreme Court decision regarding the Affordable Care Act. It gets the funding that goes to paying physician incentives from the HITECH Act, a separate piece of legislation that was signed into law prior to healthcare reform. It is wholly independent of the ACA.
This means that if you are planning on participating in the program in order to reap incentive payments for your use of EHRs you should not curtailing your implementation project. All indicators suggest that the funding is safe and you will likely still receive the promised incentives.
On the other hand, a number of other programs that could have encouraged more physicians to adopt the technology could be affected by ACA repeal. The health reform law may not have put in place any specific requirements for EHR use, but it did include several provisions that could have indirectly influenced physicians’ IT decisions. These programs could go away if the law is struck down.
One initiative that would be affected is the Centers for Medicare and Medicaid Services’ Bundled Payment program. The initiative allows physician groups to combine the bills they send to Medicare or Medicaid for all of the services a patient receives at one encounter, rather than billing for each service independently. The thinking is that when healthcare teams get paid as a unit they will be more likely to work collaboratively, producing more efficient, high-quality care.
The program does not specifically require participating physicians to use EHRs, but if you read between the lines, it is pretty clear that participation would be virtually impossible without an electronic record keeping system. It demands that various physicians communicate and collaborate with each other on billing as well as care. Sending paper records back and forth would be impractical.
The government’s efforts to encourage implementation of accountable care organizations would also be impacted by Affordable Care Act repeal. The reform law directed the Department of Health and Human Services to implement regulations governing the use of the care model and to pay incentives to practices that are successful in meeting these requirements.
Again, nothing in the ACO regulations specifically state that a practice must use EHRs to qualify for incentives. But the level of care coordination and delivery of evidence-based services required by the rules would be difficult to achieve without the technology.
What does this all mean for your technology initiatives? If you were planning on pursuing meaningful use incentives, you are safe. However, if you had your eyes on other technology-driven initiatives, you may want to reevaluate your reasons for implementing an EHR system.
Some experts feel that the healthcare system is moving in the direction of the health reform laws on its own. Insurance companies and other payers are increasingly looking for ways to improve quality while lowering costs. Things like bundled payments and accountable care organizations will likely hang around even if the Supreme Court wipes health reform from the books.
However, the immediate impetus to implement these solutions would be eliminated. The long-range prospects for a networked healthcare system may remain, but the near-term prospects could be severely altered.
Once a practice finishes implementing their EHR system and has qualified for meaningful use, the group may be tempted to think all the real work is behind them. After all, getting a system set up can be a major undertaking that requires a significant amount of work. It would be natural for physicians to ease up once all of the most demanding work is completed.
However, effective use of an EHR system requires constant assessment and monitoring to ensure that every physician in the practice is using the tool appropriately. There are a number of reasons why the period following EHR implementation should not be one in which staff let up in their efforts to make the system a success.
First of all, maintaining meaningful use certification requires constant efforts to refine the manner in which an EHR system is used. The Stage 1 rules mostly dealt with implementing a qualifying system. As such, the regulations were primarily focused on technical concerns. However, the proposed Stage 2 rules deal in much greater detail with matters of patient care.
In order to remain in good standing with the program, practices must exchange data, give patients online access to their data, use decision support tools and use their EHR in a number of other ways that are closely linked to patient care. This means that practices must constantly review their workflow to ensure that their systems continue to be used appropriately.
Another reason for doctors to remain vigilant about their EHR use is that they may spot new opportunities to use the system more efficiently or improve patient care. Remember that this kind of technology initiative is not a one-shot deal. The system will be with a practice for years. Assuming that it is implemented in accordance with the meaningful use rules, it will come to play a central role in all kinds of processes.
In order for an EHR system to have this kind of positive effect, physicians need to be sure that they are using it appropriately. This means that constant review and monitoring is necessary.
The Office of the National Coordinator for Health IT states that maintaining ongoing review of a technology initiative is one of the most important steps in ensuring its success. This enables a practice to know if workflow needs to be reevaluated, if more training is necessary, if the right data is being captured and if more hardware is needed.
These situations can change over the course of a few months. Perhaps patient volume picked up or maybe the practice brought on a new physician. Either way, these are things that can affect how an EHR system is used, whether or not a practice is eligible for meaningful use and whether the net effect of the EHR is positive.
During the early stages of EHR implementation, practices should draw up a plan detailing all the step necessary to make the initiative a success. However, it is inevitable that there will be at least minor deviations from this plan. Therefore, practices shouldn’t just assume the whole project is still on the right track once the system goes live.
Constant assessment is necessary for ensuring that EHR implementation is going well. This is true both for meeting the requirements of meaningful use as well as achieving quality and efficiency improvements. While the natural tendency may be to take the foot off the gas pedal, physicians should continue to take an active and engaged attitude toward their EHR system.
When implementing an EHR system, it is important to keep in mind priorities. There are lots of different systems out there that may have many different functionalities. Developing a clear set of priorities is the key to ensuring you end up with a system that meets your needs.
Many practices today are focused on implementing systems that will qualify them for incentive payments under the government’s meaningful use program. This is understandable. With payments of up to $63,750 on the line, what practice wouldn’t want to qualify?
If this is your goal, you’ll need a clear understanding of what is required by the regulations. Qualifying for meaningful use incentives can be a difficult process. You’ll need an approved system and you will need to use it in such a way as defined by federal regulators. Some practices find this to be a long process, but the government payments can make it worthwhile.
Despite the draw of incentives, some physicians have expressed a lack of interest in the program because they do not want to be burdened with so many regulations. This makes sense if they do not have a high volume of patients covered by Medicare or Medicaid. These practices may have other reasons for adopting an EHR system.
For example, numerous studies have shown that adopting an EHR system can lead to improvements in care quality. This, in and of itself, can be a powerful incentive. Some physicians say they were able to limit the amount of time they spend on administrative tasks once their system was installed and they were fully trained on it. Ultimately, patient care is the reason most doctors get into medicine. Reduced administrative burden can enable physicians to pursue their passions and make meaningful improvements in the health of their patients.
Other physicians may simply want to implement an EHR system just to stay current with the rest of the healthcare industry. Recent numbers from the government showed that about 35 percent of health systems are currently using the technology, with 85 percent expecting to have completed implementation by 2015. More physicians are adopting systems every day.
Furthermore, patients increasingly expect their doctors to be using electronic systems. In this way, adopting an EHR could play a vital role in a physician’s ability to retain current patients and attract new ones.
Ultimately, it is good for physicians to keep the bigger picture in mind when they are selecting their EHR vendor and implementing their systems. They may have started with the initiative to capture federal incentives, but these payments will run out after a few years. However, their system will be with them for the long-term. Therefore, it is important to think about how the EHR will impact operations and quality.
Dr. Robert M. Wah, chair of the American Medical Association’s Board of Trustees, recently wrote in American Medical News that EHR implementation isn’t really about technology – it’s about patient care. However, many practices get bogged down in the technical elements of their project. They lose sight of the reasons why they initially decided adopt a system. Given the fact the EHRs have the power to improve quality and lower costs, it would be a mistake to forget about their effect on patient care, Wah wrote.
EHR implementation can be a long road. Vendor selection, implementation, training and use can require a good deal of work. However, when a practice keeps in mind their initial priorities throughout this process, it may be easier to see the light at the end of the tunnel.