What is HCIT Friction?

Khal Rai

Khal Rai

Senior Vice President, Development at SRS Health
Khal oversees the Software Engineering, Business Analysis, Quality Assurance, and Product Management teams at SRS. His 17+ years’ experience in software development and healthcare IT have resulted in a true passion for collaborating with customers, then translating their needs into innovative solutions and better service experiences. He believes that motivated employees and satisfied customers are keys to maintaining business success. He has a B.S. degree in Computer Engineering from the University of Cincinnati, and an M.S. degree in Electrical Engineering from Purdue University.
Khal Rai

Latest posts by Khal Rai (see all)

wheelThe Truth Is Stranger Than Friction

I just returned from two eye-opening experiences: HIMSS, the largest health IT event in the industry, and AAOS, the country’s largest orthopaedic conference. Of course, I heard about the amazing benefits of many new technological and medical breakthroughs . . . But what really got my attention was hearing some physicians say that when it comes to productivity, they wish they could return to the days of paper charts.

What? Since when do medical professionals want to turn back time on medical technology advancements like productivity solutions? All of those innovations were designed with an important goal in mind: to help doctors have more time to help more patients. However, due to many reasons, the data collection process is getting in between doctors and patients. That friction is rubbing both parties the wrong way—and the need to get beyond that friction was the clear message I took away from both HIMSS and AAOS.

Friction isn’t inherently bad: it is the force that allows our tires to grip the pavement, lets us steer the way we want to go, and enables our brakes to stop us from crashing. However, excess friction hinders movement and wastes energy: that’s what’s happening right now in the world of EHR solutions. What we need are systems that work with—not against—physicians while they perform their very important work. By creating smarter solutions, we can transform friction into traction: positive momentum that takes us where we want to go, faster—in a way that enhances, instead of interferes with, the doctor-patient experience.

In order to really help advance healthcare, the next generation of EHR solutions must do more than just capture data. They must be intelligent technologies that go beyond frictionless, creating the traction to:

  • Operate in the way that best supports each doctor’s work style, so that physicians can concentrate on patients, not iPads
  • Enable seamless data collection during patient interactions, so that doctors are not spending hours recording data later
  • Leverage mobile platforms and predictive technologies that not only keep up with busy specialists but actually help move them forward

Turning meaningless friction into meaningful traction is the driving force behind what we are calling Smart Workflows. Living and practicing in the Information Age, the only way to go is forward—not to reduce the technology involved, but to reduce its intrusiveness by developing software that easily captures required data while actually prioritizing the physician’s role in medicine. That’s something no EHR has ever done—nor any paper chart, for that matter.

To frictionless and beyond!

~ Khal Rai

Audit Risk: EHR Coding, Cloning, and Templated Notes

Audit Risk: EHR Coding, Cloning, and Templated NotesPhysicians beware: CMS recently expanded RAC audits (Recovery Audit Contractors) to include office visit (E&M) claims, with the goal of identifying inflated coding and aggressively pursuing fraud and abuse. A recent New York Times article, “Medicare Bills Rise as Records Turn Electronic”, alleged that “EHRs may be contributing to higher Medicare costs because they make it easier to bill more for services.” This is a natural outgrowth of the pre-meaningful use origins of many EHRs—they were typically designed to create a clinical note that would maximize reimbursement. The point-and-click, templated notes of many EHRs will also be subject to intense scrutiny—because the notes often include copied and pasted text and omit the nuanced information that is critical to truly meaningful documentation.

In a sternly worded letter to hospital and medical association executives on September 24, HHS Secretary Kathleen Sebelius and Attorney General Eric Holder warned that they “will not tolerate health care fraud” and will take steps “to ensure payment accuracy.” They expressed serious concerns that some providers are misusing EHRs to increase reimbursement by cloning medical record documentation and by upcoding visits.

This new focus on auditing E&M coding was spurred by the findings of a report by the OIG (Office of the Inspector General) issued in May 2012, “Coding Trends of Medicare Evaluation and Management Services.” Over the last 10 years, physicians have increased their billing of higher-level E&M codes and reduced their billing of lower-level codes. Therefore, the OIG recommended that CMS have its contractors review physicians’ billings for E&M services and that they review—for appropriate action—those physicians who bill higher-level codes.

One of Medicare’s administrative contractors, (National Government Services), recently announced that it will not accept cloned documentation. “Cloned documentation will be considered misrepresentation of the medical necessity requirement for coverage of services due to the lack of specific individual information for each unique patient. Identification of this type of documentation will lead to denial of services for lack of medical necessity and the recoupment of all overpayments.”

These audits pose a significant risk since auditors are paid based on the amount they recover from providers.

The Case for Centralized Quality Reporting: A Perfect Example

The Case for Centralized Quality Reporting: A Perfect Example’ TimeQuality measure reporting is one of the 3 basic tenets of the EHR Incentive Program—the other 2 being ePrescribing and data sharing (interoperability)—as identified in ARRA, the program’s defining legislation. It is a key component to improving the quality of patient care. In a recent EMR Straight Talk post—“A Waste of Physicians’ Money and Vendors’ Time”—I proposed a more cost-effective method of analyzing clinical quality measure (CQM) data that would deliver more useful information for quality improvement than the approach currently in place for meaningful use. I suggested that rather than requiring each of the 472 vendors of certified EHRs to program the same CQMs (no longer 125 as initially proposed, but still a burdensome 64), EHRs should simply collect and report the data, and CMS or its designate should provide the analytics. Such a centralized approach would not only be more efficient, but it would produce more consistent and reliable data. Most importantly, it would allow for the immediate implementation of any changes to measure specifications as necessitated by the availability of new medical information.

Recently, I confronted a perfect example of the ineffectiveness of the current system and the opportunities that a centralized approach would afford. A physician informed me that a new CVX (immunization) code was created for the influenza vaccine—CVX code 144. While I told this client that we could easily add this code to the EHR for his use in documenting vaccinations (which we did), these vaccinations would unfortunately still not be reflected in the numerator for NQF 0041 (Preventive Care and Screening: Influenza Immunization for Patients over Age 50)—a fact validated by CMS. New electronic specifications for CQMs will not be implemented until 2014, and the current specifications remain in force for 2012 and 2013.

As an EHR vendor, I certainly appreciate the fact that we are not subject to the expectation that we will reprogram measures off-cycle. That would wreak havoc with our development roadmap and resource planning. Furthermore, changing the calculations to accommodate the new codes would compromise data comparability. So now we have comparable—but incorrect—data that does not reflect actual vaccination status. Under this system, how will we ever stay current as medicine constantly evolves?

Just imagine if everyone could begin using the new CVX codes immediately because the electronic specifications were updated in one centralized location with one effort. This is just one example from a potential 64 CQMs. How much more value would we derive from all the work that we demand of physicians in capturing the CQM data? How can we accelerate healthcare improvement if we are always 2–3 years behind?

The Future of Meaningful Use

The Future of Meaningful Use
This week, I came upon two blog posts that I thought were interesting in light of my last EMR Straight Talk post, which suggested that EHR adoption was being driven to the tipping point by the meaningful use incentives. Increasing numbers of physicians—many of whom were initially motivated by the government’s incentives—are beginning to question the real value of complying with the program’s ever-more-demanding requirements. Whether or not meaningful use thrives as the program progresses will ultimately be determined by the physician market, but sentiment is clearly mounting that too much is being demanded.

In a recent post on the venerable HIStalk blog, Dr. Jayne reminds physicians of why they went into medicine, and she challenges the government to justify new requirements by “providing concrete evidence that jumping through the hoops you’re holding in front of us will actually help patients in a truly meaningful way.” Analyzing the trade-off between the incentives and productivity, she worries about not only the impact on physician income, but also the impact on the number of patients who can receive care. I particularly appreciated her conclusion that what we should be seeking is “evidence-based Meaningful Use.”

An editorial published on the AMA’s American Medical News website, titled “Meaningful Use’s Stage 2: A Recipe for Failure,” highlights the AMA’s concerns about the Proposed Rule, concluding that the requirements are simply “too demanding” and will turn physicians into cynics, rather than participants in the EHR program.

100% EHR Success – A Clinical Approach

Last week’s EMR Straight Talk post, “Are EHRs Being Oversold,” hit a nerve, judging by the number of readers and the volume and intensity of comments submitted by physicians. Sadly, for every one of the physicians who took the time to write, there are scores of others enduring similar experiences. The following excerpts from their comments are reflective of their frustrations:

  • We are a year into [EHR] implementation and it has been horrible and costly. What little efficiencies gained have been lost to a decrease in productivity.
  • I now require a scribe to maintain the [same] patient flow that was seen four years ago we began using the system.
  • The trouble with most EMRs is the horrible user interfaces that are designed by committees who have no concept of ease of use for ophthalmologists.
  • The programs are user unfriendly in the extreme, cumbersome and inflexible. The learning curve is seriously long and even when mastered takes a terrific amount of time away from the patient.
  • The joy-killer was encountering the endless barriers to putting my own ideas to work.
  • Training is lengthy, expensive, and markedly disruptive in an office.

Every one of these stories breaks my heart as a staunch EHR proponent—particularly since the situations could have been easily avoided.

The Root of the Problem

The problem lies in the EHR selection process. When it comes to dispensing medications, for example, no physician prescribes without knowing the success rate for that particular drug for that particular type of patient and problem being addressed. Yet, typically, physicians do not make EHR purchase decisions in the same way that they make clinical decisions—using empirical evidence and data to predict outcomes.

I’d wager that for each of the disillusioned physicians above, the EHR selection process was nearly identical:

  1. The group chose 5 to 7 vendors for consideration;
  2. Each vendor demoed their product in front of an EHR selection committee whose task was to narrow down the field to 2 or 3 finalists;
  3. The finalists performed one or more demos to a wider group of physicians and staff;
  4. The vendors each provided 2 or 3 practices as references, with specific contact names;
  5. One or two physicians and staff members spent a day visiting one reference site for each of the vendor finalists; and
  6. They selected an EHR.

Why does such an exhaustive and time-consuming selection process so often lead to failed EHR implementations?

Preventing an EHR Failure in Your Practice

To prevent an EHR failure in your practice, the flawed selection process must be altered. The first thing to understand is that the rosy experience of one or two handpicked vendor references will not guarantee a similar experience for you and your colleagues. If a vendor has sold its EHR to 100 practices and has as few as 5 successful implementations, you will be referred to one of these 5 practices. A visit to 1 or 2 of these 5 successful practices may leave you with a warm and fuzzy feeling and the expectation that, because they were successful, your success is virtually assured. In this case, however, your real probability of success would only be 5%.

Separating the Wheat from the Chaff

So how do you quickly eliminate vendors with lackluster success records before you and your staff waste hours watching slick sales demonstrations of sexy software with “must-have” features? Separating the wheat from the chaff is simple—just ask all your initial set of EHR vendors for lots of references. If a vendor cannot produce at least 2 references for each year they have been in business, run the other way. Do not accept any excuses for being unable to provide you with the number of references that you seek. (A common excuse is that the vendor wishes to protect the privacy of its clients.) If they had lots of references, they would give them to you in a heartbeat—happy customers are always willing to show their successes to others.

Many of the initial vendors chosen will not be able to produce a satisfactory number of references. This should narrow down the number left for you to consider, and it will save a tremendous amount of valuable physician and staff time.

Statistically Significant Reference Checking

At this point, your list of vendors will likely include just the one or two that have provided you with a meaningful reference list. You may have to accept the bias created by the fact that the references are carefully handpicked by the vendor(s), but it is imperative that you do not limit your inquiries to the specific physicians identified by the vendor. Typically, these are the practice administrator and one or two physicians who had spearheaded the EHR purchase for the practice; as a matter of pride, they are more likely to paint a rosy picture of the EHR than to acknowledge its shortcomings. The only way to avoid this trap is to speak with other physicians at the reference practices. This is easy to do. When you get the reference list from an EHR vendor, ask them to include the practice websites, then randomly choose physicians to call from the physicians’ bio pages. These physician-to-physician calls should be short (only 10 minutes each) and you should ask specific questions about cost, efficiency, and number of patients seen.

  1. When did you install your EMR?
  2. How long was the installation/implementation process?
  3. How would you describe the installation/implementation process?
  4. Was the system as user friendly as the demonstration by the salesperson?
  5. How many patients per hour/per day did you (and your partners) see before the installation/implementation of your EMR?
  6. How many did you see after?
  7. Approximately how much more time do you devote to entering exam data into your EMR now compared to how you documented exams before you began using an EMR?
  8. How do you like the quality of the EMR-generated exam notes?
  9. Have you had to hire scribes to enter data for you? If so, how many and what is their annual cost?
  10. Has your EMR completely eliminated the paper charts in your practice?
  11. Given your practice’s experience with your EMR, would you recommend it to a similar practice?

How much of your time should this type of random reference checking take? Not much! Ten 10-minute calls (less than 2 hours of time) to randomly chosen physicians will yield more valuable data on your chances of success than having a slew of vendors demo their products to your doctors and staff for hours on end. Only after having conducted the due diligence described above will you be able to derive real value from spending your time seeing demos—because you will only be seeing demos of the one or two EHRs that you now know are likely to deliver success.

Are EHRs Being Oversold?

I am a firm believer in the tremendous value that the right EHR can deliver to physicians, so the historic dissatisfaction with the EHR industry—as reported in studies and anecdotal conversations—has long disturbed me. The alarming intensity of this dissatisfaction was brought home by visitors to my company’s booth during the recent AAO (American Academy of Ophthalmology) meeting.

I was truly appalled by the abject frustration and anger expressed by numerous physicians about their EHRs. One visitor described his experience by saying, “It has taken the joy out of practicing medicine.” Another said that he felt like he should put a picture of his face on the back of his head so that his patients could see him—because he was forced to focus on the computer and enter data while the patient provided information. Physicians universally complained about the “productivity-killing” impact.

From AAO - Are EHRs Being Oversold?Why is this so? I know there are good EHR products in the market that physicians enjoy using and that enhance, rather than reduce, their productivity. Why are physicians not more successful in finding these?

The answer is that EHRs are being oversold. There are many EHRs that are marvels of software, capable of doing incredible things, but the selection process that physicians typically employ is flawed, and the sales process capitalizes on this shortcoming. The salesperson dazzles them with a demo, or they take prospective purchasers to see a physician—typically just one or two—who adeptly uses the software. This creates a false sense of ease-of-use, and the physician prospect leaves the site visit expecting that he or she will be able to use the EHR just as successfully. But not all physicians are alike—they may all be very intelligent and have tremendous medical expertise, but they are not all equal in technological inclination or skills. Their success—or lack thereof—with a particular EHR will vary significantly.

This brings us back to the importance of doing due diligence—something I have talked about before. Call and/or visit a variety of physicians who represent a wide spectrum of proficiency. Go to the reference practice’s website and select physicians on your own—don’t rely on the vendor’s selection. Ask the kind of questions listed in the last EMR Straight Talk. This is the only way to increase the odds of a successful EHR experience, and to avoid making a painful and costly mistake.

EMR Straight Talk Centennial Blog—It’s Still About Productivity

This is my 100th EMR Straight Talk post, and a lot has changed in the EHR world since the blog’s inception—but some things have not. Productivity is still the name of the game in EHRs, especially for specialists.

There is no question that the government incentives have stimulated interest in EHR adoption, but according to a recent physician survey, that is not the primary reason that providers are looking to implement one. “Quality and efficiency” ranked higher than the EHR incentives as the goal of EHR implementation, according to this report by CapSite—a healthcare technology research company. Heightened interest in efficiency is not surprising, given that in another study (by MGMA), physicians identify rising operating costs as a tremendous challenge.

Although the above data was not cut by specialty, I know from my experience in the field that these issues are magnified in specialty practices. MGMA found that of all physicians, orthopaedists face the greatest challenge in successfully implementing EHR systems. Ophthalmologists have such distinct needs that the American Academy of Ophthalmology took the time to publish an article defining the specific characteristics that an ophthalmology EHR must have to be valuable in their members’ practices.

When you read through the list of requirements, they all tie into the impact on productivity and efficiency—factors critical to both of these specialties given their particularly high patient volumes. The implications for EHR selection are significant, and have not changed since I wrote my first EMR Straight Talk post.

Thank you for reading and commenting!