Meaningful Use Stage 2 Battle Lines Are Drawn

May 14th, 2012

Interested stakeholders have submitted their comments regarding the Proposed Rule for Meaningful Use Stage 2 [...]

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HIT Policy Committee Focuses on Physicians

May 3rd, 2012

A very positive conversation took place at yesterday’s HIT Policy Committee meeting [...]

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EHR Incentive Program Financed on the Backs of Physicians

April 19th, 2012

I was shocked to read the following paragraph, buried on page 379 of the 455-page Proposed Rule for Stage 2 Meaningful Use [...]

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Legislation without Representation

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May 12th, 2009

The 21 members of the HIT Standards Committee have been appointed, and unfortunately I was not among those selected. However, HHS Secretary Kathleen Sebelius and National Coordinator for Health Information Technology David Blumenthal did assemble a highly credentialed, very impressive group of health IT experts who will contribute much time and extensive experience toward the recommendation of the qualification criteria for EHRs under the Economic Stimulus Plan.

My concerns remain as anticipated—that the Committee, as impressive as it is, will not represent the interests of high-volume private practitioners, particularly the specialists, who are on the front lines of delivering patient care on a daily basis to the majority of Americans.

  • There are no full-time, private-practicing physicians on the Committee. The seven physician members spend most, if not all, of their time in informatics-focused positions at their respective institutions.
  • By virtue of its composition, the Committee will continue the focus on primary care—of the physicians on the Committee, five are internal medicine–certified, one is a pathologist, and the vendor representative trained as a neurologist. There is no one with first-hand experience regarding the vastly different issues facing specialists. Who will make sure that EHR use will be defined “meaningfully” for them?
  • Committee members are associated with large, closed-loop medical institutions, (albeit venerable ones, such as the Mayo Clinic and Kaiser Permanente.) Their environments facilitate utilization of EMRs in ways that are typically beyond the reach of independent, community practices.
  • The Committee appears predisposed toward CCHIT—one member is a CCHIT Commissioner and the vendor community representative is from a CCHIT EMR company (as is the vendor on the HIT Policy Committee). No alternative EMR technologies are represented—i.e., there are no alternative voices to broaden the Committee’s perspective regarding other EMR solutions with successful adoption track records.

Rest assured that, although I am not a Committee member, I will participate as a member of the public via Web access to the meetings. SRS Government Affairs will monitor both the HIT Standards and the HIT Policy Committees’ meetings, and I will keep you informed in future blogs. Stay tuned.

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No Use = No “Meaningful Use”

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May 6th, 2009

On Day 2 of the Government’s Hearing on Meaningful Use, there was finally some recognition of the need for physicians to be able and actually willing to use their EMRs. Three speakers from the audience, including SRS, presented testimony reminding Committee members of the dismal track record of traditional EMRs to date, and warning that different results should not be realistically expected simply because financial incentives are offered. It was clear from the concerned looks and head-shaking by the Committee members that they were starting to acknowledge that CCHIT was not the easy answer they had expected to the complex issues surrounding adoption and meaningful use of an EMR.

Dr. David Classen, from the University of Utah and Computer Sciences Corporation gave very interesting testimony in which he suggested that the focus must be on finding EMRs that anticipate the needs of users and are easy to use. While some standard criteria should be established, he maintained that the issue is implementation and use, not criteria alone. In fact, he shared results from a study in which a number of major CCHIT-certified products did not fare very well in meeting several test measures of improvement in quality of care. When asked about the correlation between performance on these measures and specific product criteria, he responded that he did not find any.

While no specific alternatives were put forth, “usability” was identified as an important criteria. This means more than simply adding a usability measure to existing CCHIT criteria. It means ensuring that the EMRs included in the legislation add value to physicians’ practices, and maintain or enhance, rather than decrease, their productivity. It also means “usable” by all physicians, not just primary-care physicians—the providers around whom the “meaningful use” discussion continues to be based. Our testimony, which was echoed by the other speakers, emphasized that the only way enduring adoption and true meaningful use will occur is if physicians themselves deem their EMR usable. There can be no “meaningful use” without actual use, and we will not see any of the anticipated quality-of-care and cost benefits if physicians are not using the EMRs we incent them to buy.

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Is Obama Listening to Physicians? Report from Day 1 of Government Hearing on “Meaningful Use”

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April 29th, 2009

Two SRS representatives are currently in Washington, D.C., attending the Hearing on “Meaningful Use” of Health Information Technology. They are listening to (and will provide) testimony to the government on what should constitute “meaningful use” of an EHR that would qualify physicians to receive the potential EHR incentive payments.

Noticeably absent from the testimony and discussion at the Hearing, so far, is any consideration of the impact that “meaningful EHR use” requirements would have on physicians. The proposed definitions all supported admirable goals of improved quality of care and better outcomes, interoperability, and reduced costs—all of which well represent the interests of varied healthcare system stakeholders. But the physicians are the ones who will be asked to take on the incremental burden of collecting the data in the required formats at the point of care. The result will be a decrease in productivity that will have financial implications for physicians, but will also impact their ability to take care of the increasing number of patients entering the healthcare system. As the population ages, and if President Obama is successful in his plan to extend healthcare coverage to the uninsured, the already existing physician shortage will be exacerbated. (Read “Shortage of Doctors Proves Obstacle to Obama Goals” in this past Monday’s New York Times).

Another concern is that medical specialists were not mentioned even once during the course of the day’s testimony—all of the discussion centered on primary care. The focus should be on primary care, since they are responsible for the management of most chronic illness; however, high-performance specialists have different workflows and EMR requirements. There must be a separate set of criteria and requirements for their demonstration of “meaningful use.”

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The Risk of Automated EMR Coding

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April 22nd, 2009

A frequent topic of conversation is how to improve the claims-coding process. If you are intrigued by the automated E&M coding offered by an EMR, I suggest caution. This feature has high marketing appeal—promising that office visits will be coded to the highest level of reimbursement possible. Unfortunately, however, EMR coding has led to severe financial and legal repercussions for practices, as reported in a recent study in the venerable Medical Economics journal.

An increase in average coding levels raises a red flag with payers, and EMR documentation does not stand up well in the resulting audits. According to the authors, who assisted several practices during Medicare audits, the danger is that EMRs automatically guide physicians to create records that document high levels of care, and the result can be a statistically significant (and noticeable) increase in the percentage of claims with level-4 and level-5 codes. The templated chart notes created by traditional (CCHIT-type) EMRs all tend to look the same and do not contain the information necessary to justify these higher levels of coding.

In a claims audit, typically between 20 and 100 charts per physician are reviewed, and the results are then extrapolated to the entire set of claims for that payer. For the practices discussed in this article, between 20% and 95% of the EMR-generated claims failed the audit, and the physicians were assessed penalties and subject to repayments to Medicare that ranged from $50,000 to $175,000 each.

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Life After De-installing CCHIT

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April 15th, 2009

Our recent announcement regarding a practice that has decided to de-install their existing CCHIT-certified EMR and replace it with the SRS hybrid EMR has been referred to as “gutsy” in the HISTalk blog and has generated a tremendous amount of interest. The determination to move away from a CCHIT-certified product may seem surprising in light of the Economic Stimulus Plan, but this is just the most recent in a series of de-installs/conversions that we have successfully completed.

SRS has been approached by an increasing number of practices interested in replacing their traditional EMRs with a hybrid EMR. This trend is dominated by high-performance, high-volume practices, even in the face of the government’s apparent interest in CCHIT-type EMRs.

These practices share a number of common experiences. They selected and purchased their EMR with high expectations and confidence that it would be implemented successfully throughout their practice and deliver a substantial ROI in a reasonable timeframe. Despite their best efforts to make it work, they have been frustrated by the inability to achieve universal adoption and to realize the anticipated benefits.

Although individual physicians within the practice may have been successful in using the CCHIT EMR, the majority have not embraced the technology. In almost all cases, the practice has not eliminated its transcription costs or changed its coding, which had been the driving forces for the purchase of an EMR initially. Physicians are still dictating their notes, refusing to be forced into productivity-sapping templating of patient exams.

In addition, practices are experiencing one of two things. They are either running simultaneous paper and EMR chart systems, experiencing the worst of both worlds, or they are using their EMR as a crude document management system. In many cases, they are still overrun with paper and the accompanying costly filing demands. Anticipated ROI has not materialized.

As our clients who found themselves in this position have testified, transitioning to a hybrid EMR can be accomplished relatively quickly and easily. Our hybrid EMR is built on a non-proprietary, OpenPath™ foundation, which allows for an easy, one-time transfer of data from the CCHIT EMR to the hybrid EMR. The transition to the hybrid EMR can be accomplished without repeating the protracted implementation process experienced by these practices with their first (and sometimes second) CCHIT EMR. Physicians quickly adopt the hybrid EMR and the practices quickly move toward realizing a true ROI.

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The High-Performance Physician

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April 8th, 2009

Two weeks ago, I described the hybrid EMR as a high-performance EMR, designed for and successful in high-performance practices. This has spurred conversations about the characteristics of high-performance practices, and why their needs for EMR technology differ so greatly from those of other practices.

There are two primary characteristics that differentiate physicians depending on their specialties—patient volume and total financial value of each office visit. Patient volume varies widely since the number of patients seen per day can vary from fewer than 15 for hospital-based, non-fee-for-service physicians to over 30 for pediatricians and dermatologists, and even far higher for many specialists such as orthopaedists and ophthalmologists. The total value of each office visit also varies widely, especially when adding in ancillary tests, procedures, and surgeries that may accompany office visits. Whereas the typical family practice physician generates less than $80 in total revenue per visit, ophthalmologists and orthopaedic surgeons can generate well over $200 per visit.

The High Performance Physician

This chart compares patient volume and revenue characteristics among different types of physicians. High-performance physicians are those who see a high volume of patients and/or generate significant revenue per visit. The orange shaded area of the chart highlights the high-performance specialties: orthopaedics and ophthalmology are high on both scales; OB/GYN is moderate in volume, but high in revenue due to in-house ancillary tests and surgeries; and cardiology is lower in volume but generates high revenue due to the battery of diagnostic tests that stem from many exams. It is these high-performance physicians who, despite having the financial wherewithal to purchase a traditional EMR system, have the lowest adoption rates of those systems.

This chart is by no means an evaluation of the quality or importance of the care physicians provide; rather, it’s a measure of the intensity of their practices, which is why their needs for electronic medical records solutions differ greatly. Traditional (CCHIT) EMR products have not gained a foothold in the orange-shaded, high-performance area because even a small decrease in productivity for these highly productive specialists is too great. On the other hand, CCHIT EMRs have found some success among lower-volume, lower-revenue specialties, which fall in the unshaded area of the graph. A thorough reading of the CCHIT Certification Criteria reveals CCHIT’s primary-care focus.

Productivity-driven, high-performance practices demand EMR solutions that are productivity-focused. Hybrid EMRs are the only EMRs to enjoy a proven track record of success in this marketplace.

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“Dear President Obama”

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April 1st, 2009

Last week, I talked about one of the defining characteristics of hybrid EMRs—that they are designed for high-performance, high-volume, and high-revenue practices. They are successful in these practices because physicians find them highly “usable.” I am sending the following letter to President Obama because this critical attribute, usability, has been overlooked in the design of the government’s plan to encourage EMR adoption.

Dear President Obama:

Like you, I place a high value on improving the quality and reducing the cost of health care for all Americans. As the CEO of a successful hybrid EMR company for the past 12 years, I clearly agree that bringing EMR technology to physicians will help accomplish these goals, but it must be the right technology—technology that front-line physicians, who provide the bulk of care to millions of patients each day, will find usable. I and others are deeply concerned that if the failure to align the interests of the government with those of practicing physicians is not addressed, it will prevent the Economic Stimulus Plan’s EHR incentive program from accomplishing its commendable goals.

As the first president to make use of social media to communicate with constituents, you are no doubt aware of the groundswell of concern being expressed by physicians. These front-line physicians are filling the Internet with comments about their failed attempts to implement CCHIT-type, traditional EMRs. They detail the negative impacts these EMRs have had on their productivity and on their ability to preserve the physician-patient relationships that are critical to providing high quality care.

Before spending $19.2 billion to encourage the purchase of failure-prone traditional EMRs, why not first spend a mere $1 million to $2 million of this money to determine which types of EMRs physicians find usable and adoptable? A reading of the CCHIT criteria reveals that “usability” was never a consideration. There are studies that show the positive impact of EMRs on other stakeholders, but numerous landmark studies have documented the negative impact traditional EMRs have on physicians. Even your Budget Director, Peter Orszag, testified before Congress last July that “Office-based physicians in particular may see no benefit if they purchase such a product—and may even suffer financial harm.”

There are EMR models, such as the hybrid EMR, which front-line, high-performance, high-volume physicians have embraced and find highly usable. They deliver the same quality of care benefits and facilitate the reporting of valuable clinical data without burdening physicians with the responsibility of collecting it themselves.

If usability is not one of the fundamental characteristics upon which EHRs are evaluated, the incentive program is doomed to failure. Either physicians will take the bait and buy an EHR, only to find they cannot “meaningfully use” it, or they will ignore the legislation and not implement an EHR. In either case, our goals will not be accomplished.

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