The Silent Majority Is Being Heard – Let’s Be Louder

The tide appears to be changing as the voices of the silent majority are finally being recognized in Washington. I have been repeatedly and emphatically expressing my concern that the needs of physicians—particularly high-performance physicians—are being ignored as the government attempts to encourage EHR adoption.

  • Last week, Gayle Harrell, an HIT Policy Committee member, made many of the same points that I have been making, as the Committee reviewed the initial set of recommendations on “Meaningful Use” and considered EHR certification. (Read the highlights in the post below, Finally, A Voice of Reason!)
  • In recent months, many of you have been speaking out on Straight Talk and other blogs. To the question asked in last week’s poll—is the government putting too much of a burden on physicians?—a resounding 90% of respondents answered “Yes.”
  • Physicians are voting with their pocketbooks, continuing to base their EMR purchase decisions on the best way to help their practices deliver the highest quality care in the most efficient manner, rather than on the promise of potential government incentives.
  • Even CCHIT (Commission for Certification of Healthcare Information Technology) has acknowledged these and other voices of reason. Just recently, CCHIT backed down on its all-or-nothing stance and proposed broadening its certification program to include alternative paths to EMR certification.

Comments like those of Dr. Boss (below) attest to the value of alternative, innovative solutions, such as the hybrid EMR, and to the importance of including them in the government’s plans for widespread EHR adoption:

“The best EHR system out there without a shadow of a doubt is SRS, even though it is not yet CCHIT certified. It is cost effective, user friendly to those of us who are not computer ‘geeks,’ and the company is extremely responsive to any needs of ours that arise. If the entire country was on SRS, a lot of our current difficulties would go away.”

Richard S. Boss, M.D.
Pine Medical Group, Fremont, MI
20-Physician Multi-Specialty Group

We will be sending you an e-mail tomorrow, giving you the opportunity to join us and have your voice heard before the final decisions are made in Washington.

From EMR Vendors: Fact or Fiction?

The Economic Stimulus legislation has presented an incredible opportunity for EMR vendors. Unfortunately, it seems that some of them are taking advantage of it by giving out misleading information and applying scare tactics so that practices will purchase their EMRs. Below is a sampling of such statements, which have been forwarded to me by physicians asking whether they are “fact or fiction.”

Have you had similar experiences? Please share them by submitting a comment at the bottom of this post.

What some EMR reps are saying:

  • “The government is requiring you to buy an EMR.” This one is a scare tactic since participation is voluntary.Section 3006 of the American Recovery and Reinvestment Act specifically states “…nothing in such Act or in the amendments made by such Act shall be construed to require a private entity to adopt or comply with a standard or implementation specification adopted under section 3004.”
  • “Your EMR must be CCHIT-certified to qualify for the incentive payments.” I hate to use the word “lying” but this statement comes close since the legislation neither identifies standards nor mentions any particular credentialing body, including CCHIT. The HIT Standards Committees, which just had its first meeting on May 15, is charged with recommending an initial set of certification standards by December 31, 2009. Recently, there has been a surge of rhetoric in the media expressing dissatisfaction with CCHIT, so it is by no means a foregone conclusion that CCHIT certification will be required.
  • “Simply buy a CCHIT-certified product, and you will qualify for the Stimulus money.” This remark is similar to “I have a great stock to sell you”—because EHR incentive payments are not guaranteed. Simply purchasing a “certified” EHR is not sufficient; the incentives require you to demonstrate “meaningful use” of the EHR every year, and to do so in the manner specified by and to the satisfaction of the government. “Meaningful use” has not yet been fully defined, and the legislation states that the requirements are to become more stringent over the period covered by the law.
  • “You must act now—buy an EHR now because in order to get the money from the government, you must be using the EMR by 2011.” As with used-car salesmen, “buy now” is always popular, but you actually have until 2013 to implement and potentially qualify for the lion’s share of the incentives. Even if you do not implement until 2014 (5 years from now), you would still be eligible for almost 80% of the money.

Have you heard any of these statements of “fact”? My advice: Do your due-diligence. Make sure you understand the real facts about the legislation and find an EMR that meets the needs of your practice. Have you heard other statements of “fiction?”—Please share them by submitting a comment at the bottom of this post.

The Risk of Automated EMR Coding

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.

Life After De-installing CCHIT

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.

The High-Performance Physician

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.

What Is a Hybrid EMR?

The continued success of hybrid EMR has prompted extensive debate about what actually constitutes one. While the Internet is now filled with discussions about EMRs, the number of conversations regarding hybrid EMRs has exploded. People are always asking me what it is that makes hybrid EMRs work so well and how they are different from traditional (CCHIT-type) EMRs. This is the first in a series of 3 discussions that will address this subject.

A hybrid EMR is a high-performance EMR that is successful in high-performance practices.

In 1997, SRS created the first hybrid EMR, concentrating on performance-driven practices, where high-volume physicians demanded unencumbered productivity. As others have followed our lead, hybrid EMRs continue to be designed with efficiency and speed in mind. This emphasis on performance criteria contrasts sharply with traditional EMRs. As a reading of the CCHIT criteria reveals, traditional EMRs are constructed for lower-volume, primary care practices where speed is not a primary driver.

SRS has built the largest national network of high-performance practices that successfully use an EMR. Our development process is driven by these practices and we work to facilitate the sharing of best practices among them.

In the next segment of the series, I will share my thoughts on a key defining characteristic of high-performance hybrid EMR—high usability.

ePrescribing—A Great First Step

In contrast to the concerns I have expressed in prior posts about the government’s EHR incentives plan, the Medicare ePrescribing program is an example of the appropriate way to reconcile the goals of the government with the needs and motivations of practicing physicians, on whose participation the success of the program depends.

The ePrescribing program should serve as a model for other government plans. It aligns the interests of all parties, delivering the healthcare-reform benefits the government has targeted—interoperability, sharing of data, cost savings, and improved quality of care through reduction of errors and adverse drug interactions—while simultaneously offering added value to physicians. The latter is the missing link in the proposed EMR incentives program.

With the right ePrescribing software, physicians improve practice workflow by using office staff more efficiently and by writing prescriptions in less time. At the same time, they make better-informed Rx decisions, reduce their malpractice exposure, and eliminate repeat patient calls that tie up staff unnecessarily—patient satisfaction increases.  All of these factors lead to increased revenue and greater opportunities for practice growth. In addition to the benefits that accrue to physicians, pharmacies receive accurate, legible scripts that eliminate the need for clarification calls, and insurance companies see fewer claims for multiple-sourced prescriptions. ePrescribing is a win-win-win program for all parties.

Clearly, ePrescribing is inherently less complicated than adoption of a complete EHR. Unlike dealing with all the complexities and nuances of the human condition and its maladies, prescribing drugs electronically is easy because it deals with a finite set of data that is perfectly suited for a digital solution.