The Worst Practice Climate I've seen in 30 Years

26% of Solo Practitioners Polled on Sermo Forced to Close Due to Financial Hardships

http://www.sermo.com/about-us/pr/02/february/3/26-solo-practitioners-polled-sermo-forced-close-due-financial-hardships

How sad that the payer system in healthcare has become so dysfunctional and corrupt that the physicians most deserving of patient’s trust are often the ones forced to close. Practices will either learn to be smarter, or it will be harder to keep the doors open.
We are on the verge of a revolution as to how medical practices manage themselves. Today, there are some virtual solutions that can help with the revenue cycle management available. However, these typically take 6-7% of the practice collections right off the top. How sad.
The good news is that, within 6-12 months, I foresee options that will begin to offer superior RCM within this dysfunctional system that will have costs more in the 3-4% of collections range for medical practices. This, along with some other redesigns of practice business and clinical processes are some of the only glimmers of hope that I see coming within the next year. These solutions will not have the typical, huge upfront expenses or need for a large I.T. staff in the practice. More to come.

"Meaningful Use" Might Become More Meaningful

I continue to be pleasantly surprised by the evolution of federal efforts to make “Meaningful Use” meaningful. In general, the teams at HHS’s Office of the National Coordinator for Health information Technology (ONC or ONCHIT) are really doing a good job with the mess of an ARRA Stimulus Bill handed to them by Congress. Their effort to shift an industry-centric view of health information technology to one that is more patient-centric is most interesting.
This week, one of the key committees making recommendations to the ONC has suggested some relaxations of “Meaningful Use” requirements that are insightful if their intent is to promote EMR adoption in most practices.

Policy Panel Endorses Relaxation of 'Meaningful Use' Requirements

Panel recommends making meaningful use requirements more flexible

The Health IT Policy Committee on Wednesday recommended that federal officials ease up the meaningful use requirements, allowing providers to defer some of them and still earn bonuses under the American Recovery and Reinvestment Act.

IMHO, this move to require practices to meet only 80% of the requirements, rather than 100% reflects a better understanding of what it actually takes to promote adoption. If this change to 80% is adopted, it will dramatically increase the number of medical practices that will consider upgrades of their information management systems. This more measured approach is in stark contrast to other certification initiatives in this industry that require all or none.

Alternatives to Doctors as Data Trolls?

I want to provide a link to the writings of a couple of thought leaders I respect, Joe Conn at Mondern Healthcare and Lyle Berkowitz, M.D - http://drlyle.blogspot.com/2010/02/scribes-may-be-answer-to-emr-adoption.html


The cat is out of the bag, so to speak, about a potentially revolutionary approach that has been in development for the past 3 years. The remote scribing approach has almost no similarity to the convention approach to using traditional scribes or medical transcription in any fashion. It is all about clinicians being empowered to be able to work smarter, rather than harder. I have not meet a clinician yet that would not embrace a solution if it allowed them to increase the quality of care delivered especially if it involved less time, effort, and expense than what they are doing now. The unique combination of technology and practice redesign via real, not artificial intelligence, is finally solving many of the challenges I see in the EMR industry. More to come, but only when it is ready.

BTW, I see a new role, soon, for many medical transcriptionists who have reasons to see the current methods of implementation of SOAPware as Scary software.

One Physician's comments regarding MU Bonuses

David Voran is real world practicing physician who I have known and respected for many years. I thought his "Meaningful Use" Comments deserved a little wider audience...

What I see enfolding just reaffirms my contention CMS' approach is immensely flawed. They should not be providing ANY financial incentive to any physicians to use an EMR. Instead they should completely underwrite the connectivity of a physician's EMR to other EMRs, reference labs, hospitals, 3rd party payers and other entities that participate in the care of any one patient.

By simply helping some physicians purchase EMRs they are doing nothing to promote interoperability or reducing the cost of interoperability and as such are doing nothing the promulgating the mom-and-pop, episodic approach to clinical care that's undermining the health of this country.

IMHO it's government's responsibility to focus on infrastructure, connectivity, logistics and a whole host of other issues instead of helping individuals purchase things.

David Voran, MD


To clarify what I think he is saying:
- It does patients little good to help defray the costs for physicians to acquire an EMR if the infrastructure is not in place to deliver the real value of the EMR... Interoperability.
- Little is in place to address the prohibitive costs of interoperability. There is much hype and talk, but there is very little on any fast tacks to deliver.

What really bugs me is how often physicians are actually ending up being the ones paying for the high interoperability costs (often far exceeding the cost of the EMR itself) that benefits everyone else to a greater extent. This flawed approach is what should be addressed by government initiatives that should be only to create a level playing field that allows innovation to take over.

IMHO - Uncertain Carrots and Certain Sticks

I have little doubt the penalties for not using an EHR will come. I have less confidence the Feds will really deliver on the promises of the bonus.
Here is another good read from David Kibbe in Family Practice Management. He asks...


How can we decide whether to buy an EHR when the future is so uncertain?

Can we trust the government to run this program any better than the Physician Quality Reporting Initiative (PQRI)?

What if CMS isn’t able to handle the data?

Will Congress really penalize doctors who don’t comply?


While I see EHR adoption as critical for most practices going forward, and while I am confident SOAPware will be able to qualify/certify, I am questioning the wisdom of promoting EHR adoption based on expecting government incentive payments.

Predicted Healthcare Priorities in 2010

Take a look at this article at AAFP News Now... By Sheri Porter on 2/8/2010

PricewatehouseCoopers Assesses 'Top 10' Health Issues for 2010
http://www.aafp.org/online/en/home/publications/news/news-now/practice-management/20100208pwc-top-10.html

Priorities will include

* reducing heath care costs,
* adjusting to health care reform legislation,
* paying physicians to adopt health IT,
* cracking down on fraud and abuse,
* expanding the technology and telecommunication sectors,
* adding pharmaceutical and life sciences companies to the health care delivery team,
* renewing interest in physician and hospital partnerships,
* increasing the options in care delivery models,
* elevating the emphasis on readiness for a disease outbreak, and
* funding new community health initiatives.

Again, it is my perspective that the medical practices that thrive, going forward, are those that can shift to better information management and connectedness.

Core Changes being forced in EMR/EHRs

This is a great read for those interested in the higher level thinking that intends to change the core of health information technology.


EHR Redux - By DAVID C. KIBBE

http://www.thehealthcareblog.com/the_health_care_blog/2010/02/ehr-redux.html#comments



TERMS and ACRONYMS used in the blog post "EHR Redux."

My apologies about the acronyms used in the article. Here are some brief explanations for readers. I greatly appreciate the feedback:

EHR = generally used for "electronic health record" software used by doctors and hospitals, often replacing older term EMR, or electronic medical record. Often confusing, as some people use EHR to mean the content or output of a software program, rather than the software application itself.

HHS = Department of Health and Human Services of the U.S. government. The Secretary of HHS is a cabinet level position, and is currently occupied by Kathleen Sibelius, former governor of the state of Kansas.

ARRA = American Recovery and Reinvestment Act of 2009.

NPRM = notice of proposed rulemaking, the normal way that our government agencies make regulations. i

In this case we're referencing the NPRM published Dec. 19, 2009, on "meaningful use," interpreting and putting into effect the EHR incentive programs that were included in the stimulus bill, the American Recovery and Reinvestment Act, or ARRA, passed and signed into law in February, 2009.

HITECH = that portion of ARRA that specifically covers the EHR incentive program, and other health IT related grants and programs.

Meaningful Use = under the ARRA/HITECH legislation, physicians and hospitals will be eligible to receive incentive payments for the "meaningful use of certified EHR technology." Meaningful use is described and its criteria give in the NPRM referenced here.

IFR = interim final rule, another way that agencies of the federal government publish regulations, but when they are on a fast track and there is urgency, essentially by-passing the NPRM stage.

CCR = Continuity of Care Record standard, a content messaging standard that uses XML to create a summary of a person's relevant medical data, in computable and human readable format. Basically, the building block for EHR interoperability. One of two standards using XML for this purpose included in the IFR discussed here.

February "Meaningful Use" Update

We are in the process of attempting to simplify the discussion by focusing on explaining how medical practices seeing Medicare patients can qualify for the $44,000 ARRA bonus (over a 4 year period). These discussion (today and those to come) will largely exclude Medicaid and Hospital related issues. Some key points:

* SOAPware v2010 is on track, to be certified for "Meaningful Use." Earlier versions of SOAPware will not be able to be certified.
* Practices using SOAPware will be able to qualify for ARRA bonuses if they accomplish the 25 "Meaningful Use" tasks (below).
* Bonus payments amounts will be greatest for practices ready to accomplish the MU tasks no later than October, 2011.
* Practices should focus, now, on MU Stage 1 requirements due for 2011.
* Designate an MU officer in your practice, now, to keep up with evolving rules and requirements.


Meaningful Use Tasks

1. Order Entry for 80% of Orders
2. Med Order Checking/Alerts
3. Problem Lists for Patient Conditions
4. E-Prescribing for 75% of Permissible Scripts
5. Med List of Ongoing, Active Medications
6. Allergy List - for Medications
7. Demographics - for Patients
8. Vital Signs
9. Smoking Status
10. Structured Lab Results
11. Patients Lists by Condition
12. Report Quality Measures to CMS/states
13. Patient Reminders
14. Five Clinical Decision Support Rules
15. Insurance Eligibility
16. Electronic Claims
17. Provide Patients Copies of Records
18. Provide Patients Access to Records
19. Encounter Summary to Patients
20. Care Summaries - Provide Information Exchange for referrals, etc.
21. Medication Resolution - Regular Updates of Active Meds
22. Immunization Registry Reporting
23. Lab Data to Public Health Surveillance
24. Surveillance Data to Public Health Agencies
25. Data Protections


Comments

* It is not likely wise for a medical practice to implement any EMR if there is any significant loss of productivity (fewer patients seen or more charting time for clinicians). This consideration should be far greater than a theoretical bonus payment from the government.
* If a medical practice has no EMR, or if it is using SOAPware v4, v5, or v2008, it is time to begin the planning for implementation of SOAPware 2010. The implementation should only be undertaken if it reduces clinician clerical-administrative-charting time/tasks.


Much more to come...

Continuing Health Information Exchange Disconnects

Let me preface my statements by proclaiming that the real value of health information technology and clinician use of electronic medical records will not be achieved until there is an ability to share information between the teams delivering health care and their patients.
By now, it should be apparent to everyone that healthcare policy makers in the U.S. are aggressively pushing for the creation of health information exchanges (HIE) of various types. Many acronyms come to play there such as Regional Health Information Exchange Organizations (RHIO), National Health Information Network (NHIN), and others.
Setting aside the disconnects as to how the planners typically approach privacy/confidentiality/security issues here in the states, I continue to be amazed how many health information exchanges continue to be architecting business models based on charging clinicians for the privilege of putting their data into the system. This is a key reason that few (if any?) health information exchanges have achieved any sustainable business models. I will make a prediction that none of these will see long term financial success until the business models create mechanisms that financially reward clinicians based on the value of the information they offer into the exchange. The exchanges will also figure out how to pay clinicians at rates that reflect the value of the information uploaded. There will be very little payment for sharing “paper behind glass” such as scanned documents and traditional narratives/text documents. A little more financial reward will be delivered for exchange of structured information (i.e. CCR/CCD formatted, etc.). The exchange of structured information based on decision support rules, that the evidence shows is of highest value to the patient, will result in the highest financial return to the clinician as well.
IMHO, this is yet another example of the paradox where many brilliant and often well-intended individuals are unable to see what is exceedingly simple.

Attention SOAPware Community

I am pleased to report that SOAPware 2010.0 has finally made it out of beta, and around 300 sites are now on SOAPware 2010! It is a far better product than previous versions, and we are strongly encouraging users to upgrade as soon as is possible. SOAPware v5 and v2008 users should especially appreciate the improved stability and speed.

We are now tuning up SOAPware 2010.1, including advanced e-prescribing capabilities, for a release in the Spring, and we are making progress on our billing system, for which we anticipate a beta in late Spring.

We have also begun developing an SDK/API in order to make our product suite more open and accessible to other systems and solutions.

All of this is designed to transition SOAPware into an information system capable of allowing our customers to deliver “meaningful use," as defined in the ARRA Stimulus Bill.

My involvement with these activities, plus recruiting several new SOAPware team members, has consumed me the past month and limited my attention to blogging.