What's that noise?

In my high school days, I worked at a farmer’s co-op that sold feed, seed, fertilizer, tires, batteries, auto accessories, and all nature of farm supplies. Even then, I was a bit of a gadget freak, so I was the one that often sold and serviced the mowers and chain saws. Living at the base of the Ozark Mountains, I often had the pleasure to serve hillbilly customers who rarely came to town and often were very much living in the past. I can recall one experience when a young hillbilly came up and asked, “Do you have one of them chainsaws?” I explained that we had a full line of some of the very best brands. He went on to state, “I herd you cun cut more than 5 cords a farwood a day usen one of em.” I explained that amount was indeed possible. I fixed him up with a shiny new chainsaw, explained how to use it, and sent him on his way.
Two days later he came back complaining that that the danged saw slowed him down and made him less productive. He was going through far more motions with every stick he cut. He couldn’t even cut one cord in a day with this new-fangled saw. It wasn’t worth a darn, and was a curse. So, I proceeded to check it out. The blade was sharp, it had the proper tension, and there was plenty of gas and oil. I then set the choke, and gave it a jerk to start it up. At that point the hillbilly instantly jumped up and back about 3 feet. With startled and wide eyes, he gasped, “what’s that noise?”
This story is imaginary, but the stories I too often hear today are not. I hear many complaints how a danged EMR slows down a practice, and forces the clinicians to take too many more steps for every patient seen. I sometimes feel like I am in the movie “Ground Hog Day” where the story line keeps repeating. In a typical week, I get several opportunities to demonstrate how to turn on an EMR. More often than I prefer, the presentees all but jump back in startled disbelief and alarm. But the reality is that in order to properly turn on (start up) an EMR, it is necessary to take the necessary steps the new-fangled device requires. There must be gas (medical assistants and patient entry/involvement), and you have to choke off some old ways of thinking and working. Sure, gas is expensive, but a little bit of gas in the high-tech saw goes much further than elbow grease with the old, analog saw. This allows most of the repetitive work needing to be done managing documentation to be delegated and actually improved. It is fascinating how few can even recognize the new saw can actually improve the cuts (documentation).
I reckon you can bring some of the hillbillies out of the hills, but you can’t take the hills out of all of the hillbillies?

The Critically Sequential Path to Success

It is really important to understand that without the proper phasing when introducing health information technology (HIT), there are significant risks of doing more harm than good. The pervasive approach in the industry today is to think that bringing in the right technology will lead to benefits or “meaningful use.” The bulk of the real evidence, suggests otherwise. The evidence is that starting the transformation by either first trying to select the right technology, or by first focusing on PCMH/MU requirements gives the following options:
#1. Turn clinicians into data trolls. Patient care then is more about dibbling around with a computer, staring at a screen (rather than patients), and then fuming as the waiting rooms backs up with coughing, puking patients.
#2. Clinicians spend evenings with the new EMR mistress entering data.
#3. Clinicians limp along with significant productivity losses at the point of care, and just hope the crutches from the profit centers will hold out.
#4. To avoid the above, clinicians get a paper-behind-glass EMR solution and imagine that it goes anywhere needed. This is sort of like the kid in the pedal airplane. Not bad, as imagining is fun, but you will never actually get there.
#5. Clinicians just say no! Be either a little scroogy, or pretend to be ostrich with head buried. This approach will become increasingly unpleasant as the real world changes. It is really interesting the degree to which the focus in the industry remains primarily on the incentive (or lack of) in the Medicare/Medicaid Stimulus Bonuses for “Meaningful Use.” The effects of losing out on this initiative are going to pale compared to the effects from what other payers are going to do. Most private payers are now waking up and realizing that the gig is just about up on volume-based, fee-for-service health insurance products. Whether the future is Accountable Care Organizations or Patient-Centered Medical Homes (or likely a combination), the medical practices unable to manage their own information in means that serve them and their patients are going to see major losses of income, status, and quality of care. Not starting the transition is not so much about losing out on the $44k stimulus bonus, but is more about:

Accept a 30% income difference in 2-3 years due to lack of information technology capability. Or wait another year to get started, and only have perhaps a 10-20% income differential in 2-3 years.

Now is the time for paper-based medical practices, along with most using non-comprehensive EMR systems, to start the journey. Now is the Time, Here is the Path. The 10 steps in this link were written as a path to PCMH, but the steps are pretty much the same for any type of medical practice.
The 10 steps are critically sequential. Starting at step 6 with an EHR while skipping the Team Care and earlier steps will leave you with one of the choices above.

Pick a number?

Again, why would any clinician prefer to work harder, not be able to justify their quality of care, and experience significant losses of income when the opposite is possible today?

Location, Location, Location

The old adage regarding real estate is the top three value considerations are location, location and location. As healthcare transitions into more value-based payment designs, the same adage will hold true for health information technology. Data residing only on a server within a medical practice will likely put that practice not only off any main roads, but will likely marginalize it all together.
We have long recognized this revolution was coming, and that is part of the reason why we have been getting up to speed by initially offering a solution (S.H.S) that I prefer to describe as a “platform as a service” or PAAS. In a nutshell, we allow for medical practices to move their own, individual, unique server from the closet in the back to a virtual server within the Internet "cloud." This appears to be a more practical solution for medical practices than us offering a single software as a service or SAAS. This SAAS approach is most commonly referred to as an application service provider (ASP). However, rarely does a medical practice only want just the single software application that an ASP provides. Almost all clinics need to have an ability to virtually have access to several software applications from different vendors. The PAAS delivers this multi-application capability today, and that is a big reason we are now offering a more robust PAAS rather than a more limited ASP.
The next big step for us in this transition will come later in 2010 when we release our integration toolkit (i.e. SDK/API). It is our intent to make SOAPware as “open-platform” as is reasonably possible. Almost daily, we are approached by end-users, developers and vendors with wonderful solutions that could serve many specialized niches within the SOAPware community. It is our intent to create a SOAPware platform rather than a monolithic application that attempts to provide everything for everyone. This summer, we will have the core system of electronic medical records and billing system in place. About the same time, with the release of the open-platform SDK/API, we intend to create an opportunity for third parties to be able to provide applications. Thus, SOAPware will become more like an iPhone providing the platform on which many others can build applications. To get the ball rolling on our iPhone-like platform, we have had to initially focus on a limited set of third parties (i.e. registries, portals, personal health record systems, etc.). The links to the first generation are being created now. However, we will be eager to see the second and third generation solutions grow rapidly. Why should all practices have to have a choice of only one registry or PHR, etc.?
We are really eager to complete our core, SOAPware Suite within the next few months so that we can more actively engage and facilitate the Clinical Groupware movement.

SOAPware Billing Webinars

We are hosting some webinars to demonstrate our new SOAPware Billing. Below are the times available. Please respond with your email and desired session to sign up! We will then email you the meeting invite!

- Friday, April 23rd, 12noon-1:00pm CST
- Monday, April 26th, 1:00pm-2:00pm CST
- Wednesday, April 28th, 11:00am-12:00pm CST

First, Do No Harm

From: As Doctors Shift to Electronic Health Systems, Signs of Harm Emerge
http://huffpostfund.org/stories/2010/04/doctors-shift-electronic-health-systems-signs-harm-emerge#ixzz0lrOrJ6Y1

PUBLISHED 9:22 PM | 20 Apr 2010
By Fred Schulte and Emma Schwartz
Huffington Post Investigative Fund

...phase in the systems gradually. Without greater attention to safety, several experts said in interviews, the stimulus plan might backfire, eventually discouraging their use, as risks and costs eclipse advertised benefits....

...federal officials aren’t doing enough to keep tabs on hundreds of tech companies aggressively marketing new versions of the complex software...

...These systems have lots of potential to improve safety but if they aren’t implemented correctly they might worsen safety

...Classen points to his recent research testing CPOE systems at 62 hospitals, which found that the systems caught medication errors only about half the time, including some that would have resulted in serious injuries and possible death. Systems from the same manufacturers performed better at some hospitals than others....

...automated warnings aren’t taken seriously. “They are a joke,” Koppel told the Investigative Fund. He blames manufacturers for producing systems that rely on what he called “not ready for prime time software.”...

...Blumenthal said that CPOE is critical to the success of the electronic health records initiative. “We need to support it and make sure it happens,” he said. “How fast and in what form remains to be seen.”...

Read more: http://huffpostfund.org/stories/2010/04/doctors-shift-electronic-health-systems-signs-harm-emerge#ixzz0lrOIb5a5

EMR Success Survey Results

From: How To Succeed At Electronic Medical Records

By Nicole Lewis
InformationWeek
April 20, 2010 12:42 PM

Cultural change, training and communication are key to solid EMR implementations, survey says.

Two key points:
• "it's important to see the effort as an exercise in change management, not an IT initiative"
• "Budgets should be built to account for the unexpected"

Smarter vs. Harder

I had the recent pleasure of attending a presentation by Dr. Peter Anderson demonstrating “Team Care.” The results are stunning.
It is all about an effective way to use assistants.
It continues to amaze me how most physicians are unable to comprehend that they can work less, have happier/healthier patients and staff, make more money, and do a better job. I have not seen anyone articulate it more clearly than Dr. Anderson.
The evidence is growing, and I am now discovering practices at least weekly who are seeing the light.
It is equally stunning just how many practices are strangling when they could be thriving.
Wake-up docs!

The Future - Rewarding Value rather than Volume

PCMH and VBID will be what realigns incentives on the delivery and demand sides to improve health care quality. The follow is from http://www.pcpcc.net/files/vbid.pdf

Aligning Incentives and Systems - Promoting Synergy Between Value-Based Insurance Design and the Patient Centered Medical Home

VBID (Value-Based Insurance Design) is an employer-driven benefit design strategy to optimize use of higher-value health care services and reduce use of lower-value services. The goal is to generate
better results from employer health care expenditures.
The underlying premise of VBID is getting more out of
the health care dollar by removing barriers for essential,
effective services. VBID is a demand-side initiative that
focuses on patient incentives to enhance use of medical
services of proven value.
-Poor health care costs money.
- True cost is more than just health care expenses.
- Employees are influenced by out-of-pocket costs and incentives.

1. Design by service. Waive or reduce copayments
or coinsurance for select drugs or services, such as
statins or cholesterol tests...
2. Design by condition. Waive or reduce copayments
or coinsurance for medications or services, based on
the specific clinical conditions with which patients
have been diagnosed.
3. Design by condition severity. Waive or reduce
copayments or coinsurance for members with a
particular condition who are believed to be at high
risk for excessive health care costs in the near future.
4. Design by disease management participation.
An extension of the third design approach, this
VBID solution provides reduced or waived
copayments or coinsurance to high-risk members
who actively participate in a disease management
program.

(For example) IBM recently announced
that it will cover all primary care and preventive
services with no copayment, a clear sign that the company
is investing in a preventive strategy.

VBID is most effective as an information-driven endeavor
based on either the employer’s data or the use of predictive
modeling tools. For the most part, the more effort
expended to ensure the right population is receiving the
benefit, the more likely that group is to have improved
health outcomes as a result of the VBID design.

VBID is a value purchasing strategy, not simply
a low-cost purchasing strategy.

The PCMH (Patient-Centered Medical Home) is a supply-side mechanism to enable clinicians
to deliver better-quality care more efficiently. The PCMH
fosters relationships between patients and providers,
improves access and increases quality and consistency of
care. PCMH incorporates re-created office processes and
payment systems to reward an ongoing physician-patient
relationship and high-quality, coordinated care. The
PCMH requires an investment in financing, through either
up-front payments or redesigned reimbursement, to help
providers implement and sustain the model. Through
better information management, use of guidelines and
coordinated care, the PCMH theoretically may contribute
to better quality, which in turn drives cost reductions
through avoided hospitalizations and emergency
department visits.

The PCMH fosters relationships between patients
and providers, improves access, and increases quality and
consistency of care. PCMH incorporates re-created office
processes and payment systems to reward an ongoing
physician-patient relationship, which may also improve
physician and patient satisfaction.

In addition to enhanced infrastructure, the PCMH
incorporates payment reform. It shifts funding back to
primary and preventive care and reduces costs of higherintensity
services. A high-quality, coordinated medical
home can help patients avoid hospitalizations and
emergency department visits, thereby reducing costs.

Patients do not routinely receive high-quality care.
Patient-physician partnerships are important to care
outcomes.
Information management is essential to care coordination.

The medical home is widely discussed in the current health
care reform debate. Several early demonstrations have
shown significant improvements over traditional models
of care.

...even the best designed
benefits cannot succeed at improving
health outcomes unless the care delivered is
outcomes-driven, efficient and evidence-based.
Further, unless care is delivered in a systematic
manner, wasteful redundancies and
readmissions will make benefits progressively
more cost prohibitive—and also take a toll...

The current reimbursement model for primary care
practitioners does not pay for qualitative services and
enhanced care management, and has become a de facto
financial disincentive to delivery of primary care services.
Like VBID, PCMH incorporates financial incentives to act
as levers that promote delivery of appropriate, valued
health care services. In this case, provider payments reward
coordinated care focused on early intervention and
prevention. Physician incentive payments in the medical
home model encourage provider adoption of integrated
systems for tracking and delivering evidence-based care.
This contrasts with the current system that rewards volume
of care and specialty care services and offers physicians no
capital for investment in information technology. Medical
home initiatives reengineer health system incentives to
shift care to information-driven care.

The basic premise of a clinically
nuanced design is that when barriers to high-value
medical services are kept low, more health is
achieved at any price point.





This nation is in the throes of debate on health care
reform. While there is little agreement on the specific
mechanisms, there is general consensus that the health
care system is not delivering acceptable value in clinical
outcomes for the dollars spent. Many of the solutions
proposed are highly consistent with the underlying
principles of VBID and PCMH:
• Better delivery of evidence-based practices
• Increased reliance on information management
in health care
• Cost sharing and reimbursement aligned with
high-value services
• Coordinated, multidisciplinary care
• Increased engagement of and attention to patients

Also see video - Patient-Centered Medica Home
Or - a summary .pdf at - Patient-centered medical home
And - a slideshare

Near the Tipping Point?

Physician resistance to EHRs weakening: report
By Joseph Conn / HITS staff writer
Posted: April 12, 2010 - 5:59 am ET

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20100412/NEWS/304129961/1153#

...“What surprised us, quite frankly, was the number of practices,” interested in EHRs delivered as “software as a service,” or "SaaS,"...

...the field is still wide open.

...“System certification, or even satisfaction of meaningful use, does not guarantee that provider needs are being met,” according to the report.

Hidden Pearl in the PPACA?

From - Flat-Fee Health Care Option Provides Patients and Small Businesses Lower-Cost Alternative to Traditional Insurance Plans


...A relatively little-known provision in H.R. 3590, the Patient Protection and Affordable Care Act, signed into law by the President today, creates an affordable new choice for individuals and businesses by allowing flat-fee direct primary care practices, commonly referred to as "medical homes," to compete within the state-based insurance exchanges where many Americans and small businesses will be able to shop for health coverage beginning in 2014...

..."Whether or not you support the health reform bill in its entirety, I think we can all agree that allowing affordable, innovative solutions to compete with traditional insurance-based plans to bring down the high cost of health care is a good thing," said Garrison Bliss, MD, co-founder of the Direct Primary Care Coalition, who is also co-founder and Chief Medical Officer, Qliance Medical Management Inc., which operates three clinics in Washington State. "Health insurance adds tremendous value for expensive, unpredictable medical needs that fall outside the scope of primary care, and this new law will mean insurance companies can now create lower cost 'wrap-around' policies to cover what direct primary care does not."...

..."The direct primary care provision is the only part of the health reform bill that is going to reverse the high cost of today's health care," said Dr. John Muney, founder of AMG Medical Group, which operates five direct primary care clinics serving all five boroughs of New York. "We applaud the work of Congress and those members who support this provision and fought to make sure Americans were provided a new choice for accessing health care."...

...Direct primary care medical homes can typically service approximately 90 percent of the medical issues most people need to see a doctor for. By removing time-consuming and costly insurance reimbursement processes from routine and inherently low-cost services and procedures, direct primary care practices eliminate approximately 40 cents of every dollar currently wasted in traditional insurance models...

Physicians are going to have to get one

If EMRs were airplanes, and physicians have no choice but to become world travelers…

Which picture is more representative of the likely results?





Or...




What are the similarities and differences?

Another 10 Good Lessons

Another 10 Good Lessons for EMR Implementation at Medical Economics

10 lessons form practices - Physicians and practice managers share the best lessons they learned about selecting and adopting and electronic medical record system by Morgan Lewis Jr. Go to - http://digital.modernmedicine.com/nxtbooks/advanstar/medec_20100205/#/36

1. Involve the whole staff
2. Study your workflow
... physicians noticed they had more administrative tasks, such as medication refill or lab work orders. Although it took only a few taps on a tablet, the administrative duties were becoming too intrusive - and an inefficient use of the physicians' time. "We had providers doing a lot of data entry that really should've been delegated to clinical staff." Glennon says. "It took a long time to correct that and engineer it out of or processes."
Glennon set up new protocols at the offices. Routine tasks, such as medication refill phone calls, or referral request updates, went to other clinical staff and were confirmed later by the physicians.
3. Ask for help
4. Consider a patient portal
5. Customize your Notes
6. Consider a digital pen
7. Start with the basics
8. Learn the whole system
9. Go live only when ready
10 Tech support must be accessible.

Another good reference regarding the EMR challenge

Here is another great reference article giving insight to the nature of the health information technology challenges and risks.


EMR Woes Point to Greater IT Challenge
Written by Mary Jander

"Physicians, in particular, have been critical of EMR, perceiving it as an 'extra thing to do' in their daily practices," says Mary E. Shacklett, president of IT consultancy Transworld Data. "And admittedly, EMR is not perfect in every way. It can miss the mark in terms of the intuitive and 'soft' skills that are an integral part of the doctor-patient relationship."

Does the Shoe Fit?

A big mistake the medical software industry continues to make is to allow software developers and decision makers to be focused on lists of features.

Below is from a very relevant blog post - Shoes and Software

It all reminds me of the software business. The industry is obsessed with touting features while the public is obsessed an entirely different set of criteria: Does it solve my basic problems and is it easy to use? Does it make sense? Do I understand it?
The real lesson for me is this: People want the basics done well. Does it look good, does it feel good, is it comfortable, is it clear, is it easy? No matter what you’re selling, those seem to be the things that really matter. Get those right and you’ve got a great shot at building a successful product and business.

Contrary to what many may think, doctors are people too.

SOAPware Alethia Solution

Alethia was the Greek Goddess of Truth.
We are considering the creation of a SOAPware Alethia solution to be available later in 2010. For 3-4% of a practice's collections, it will offer a complete EMR/PMS and revenue cycle manager system. All the practice will need is Internet connectivity. This package will be designed to include a guarantee the practice will meet meaningful use requirements. Also, the package will be available without the guarantee for a yearly discount of $11,000 for the first 4 years.
Any interest?

The EMR Challenge, Part 4 - SOAPware Action Plan

This morning, I shared a very gratifying GoToMeeting with a practice who recently went live with SOAPware 2010. This site has 13 primary care physicians who seem to really have a focus on serving their community with excellence. I was stunned to learn how elegantly they had used Microsoft Project to manage their implementation. Equally stunning was their use of a macro program, Macro Express Pro to make routine work flows more efficient. This validated the hard work and passion we are directing toward a somewhat revolutionary approach to EMR implementation. Below is an overly concise summary of our implementation initiative:

1. Publish an EMR implementation project plan (Guide/Milestones, etc.)
2. Create a phased implementation process that brings immediate value today, with an incremental progression to the more comprehensive, advanced EMR functionalities needed in the future.
3. Create adequate awareness of the importance of implementation planning within the entire practice team (i.e. have adequate communication and measure the effectiveness of intra-practice communications).
4. Across the nation, create a network of implementation service providers because 60% of EMR users will need at least some on-site facilitation.
5. Utilize virtual and remote implementation tools and services as much as possible to reduce costs.
6. Create instruments to identify EMR sites needing more active facilitation.
7. Change SOAPware pricing/marketing to allow for the implementation processes to be adequate to meet individual practice's needs.
8. Simplify the graphical user interface and work flows, and increase the speed in the EMR.
9. Simplify the data entry process in the EMR. (Add more organization to the structured content; Remote scribe project)
10. Incorporate outside, structured data into the EMR as much as possible. (Personal Health Records, Instant Medical History, Health Information Exchanges, etc.)

We are now exploring the architecting of a monthly EMR pricing model where initial, up-front costs are insignificant. Then monthly pricing, the first few months, is likely to be somewhere in the $200 to $500 per month range (i.e. for EMR and PMS) depending on whether we host the practice's software/server or the end user obtains their own server. This model builds in an ability for our implementation partners to offer the services to assess the practice's implementation needs, etc. If the practice meets the implementation milestones during the first few months, the monthly pricing will drop to minimal levels going forward. If the practices can't get the implementation process going and are not meeting milestones, then the higher monthly pricing will persist for as long as it takes in order for our Partner Network to intervene and help them cross the chasm.
Make sense?