Randall Oates, M.D.

What Will Health Care Look Like in 2015?

2011-03-01T07:35:00.000-08:00

Guest post by Allen R. Wenner, M.D.

"I am sitting here quietly listening to Pandora Radio while I work. I am thinking how it will totally change how people listen to music. I am listening to a music channel that is totally customized and specific for my listening tastes. This transformation is more dramatic than other changes. I think that is what is happens - each change is bigger than the last. Pandora Radio will send Satellite Radio the way of the Satellite Phone. It will downsize the Clear Channel listeners to people who do not have internet or drive an older car without an input jack. Radio stations will become essentially worthless.

Amazon transformed how people bought books bankrupting Books a Million and finally Borders. Now the Kindle, Nook, iPad are transforming reading again. Verizon announced it will no longer publish a phone book in many markets as search engines have replaced them. The same thing is happening to how people watch television as networks become less valuable and streaming via NetFlix becomes the video standard.

Transformations all come to medicine last. Medicine is the last industry to computerize information, but the transformation is likely to be the most dramatic, Although the digitalization has started, the workflow transformation has not occurred. Many providers still act like the computer is paper under glass. As more and more medical systems become digital, then the evolution of medicine itself will occur. With 49,000,000 million US citizens getting health care insurance at the same time growing millions of Baby Boomers are seeking care while patient satisfaction with care is already at generational lows, 2015 could be the time for real health care change. The Meaningful Use incentives will be over and the medical system will be divided into two tiers - those that are still paper-based and those that are totally paperless. The former will fade like mom and pop grocery stores as these doctors grow old with their patients.

The question becomes what will happen to health care delivery. The web enabled handheld device will play a critical role in changing health care. It will become the front door to the medical practice. 3G Doctor is an example of how patients will interact with the health care system. No longer will patients call up and get an appointment. The patient will complete an expert interview, Instant Medical History™, as described by Bachman in his study of e-visits.(1) The clinician will review the information before deciding on the plan: 1) come to the office; 2) go to ancillary service; 3) have a test; 4) conservative management; 5) go to specialist; 6) get treatment and schedule appointment later. The clinician will be at least twice as productive. Perhaps 50% of current office visits will be virtual, as safe,(2) and preferred by patients.

Care will be home centered with many point-of-service lab devices in the patient's bathroom. The current outdated reimbursement schemes that prevent this today will fail as population based payment renders quantity based payment obsolete. Home prothrombin devices will render Coagulation Clinics unneeded. These skilled coagulation nurses will manage ten times the number of patients using web devices like smart phones. Home blood pressure readings will be the standard. Diabetes will be a home health disorder. In-home video and clinical measurement devices connected to smart phones will allow new management of chronic medical issues. Face-to-face visits will be far more complex with two or more clinicians and others video conferencing about patients. Specialists will no longer have brick and mortar offices. They will have procedure suites and offices in hospitals where they can carry out virtual discussions. The primary care physician will manage the details of the treatment plan."

(1) Bachman, John, http://www.mayoclinicproceedings.com/content/85/8/704.full
(2) Munger, Mark http://www.mayoclinicproceedings.com/content/83/8/890.full

Will Electronic Records Cure Healthcare?

2011-02-28T10:17:00.000-08:00

Guest post from Joe Weber:

"Implementing an electronic health record (EHR) costs tens of thousands of dollars for each physician. Soon, taxpayers will be footing the bill. That would be fine if we’re certain it will make our healthcare costs go down. But how can we be certain of that? There is no question that there will be some benefits resulting from the operational efficiencies and clinical alerts of EHRs. But do we really believe these systems will make healthcare all that it can be?

Until we are totally confident we know how to design and deploy EHRs in a manner that will dramatically improve healthcare, why would we want to proliferate these systems? The thinking is that EHR interoperability will solve healthcare's crisis. But ask yourself: Whenever you've received inadequate care, what was the root cause? Was it (1) because your doctor couldn't access a medical record that was in some other doctor's office? Was it (2) because your doctor did not have access to the clinical knowledge that would have led to accurate diagnosis and/or effective treatment? Or was it (3) because medical science, itself, just does not know enough?

Of those 3 causes for suboptimal healthcare, I believe the first one (lack of EHR interoperability) is actually the least impacting. For most clinical episodes, the treating physician is not truly handicapped by not being able to see what’s in some other physician’s record of your prior care. The second one seems to be considerably more instrumental. No physician can learn all s/he needs to learn, remember all that was learned, and apply it effectively during a brief clinical encounter. So we should clearly enable access to whatever is currently known by medical science, by providing computer-retrievable knowledge at the point of care. Not to do so is just plain foolish…or professionally arrogant.

The third cause, in my opinion, is actually the most significant deficiency in healthcare. Medical science just does not know enough. The reason for this is that healthcare does not learn from its own experiences. No one is retrospectively analyzing all the clinical encounters every day, to determine the early signs of what eventually become definitive diagnoses. No one is evaluating what treatments actually work best for various conditions, and under what circumstances. Medical science only moves forward via controlled clinical studies, which are too targeted and expensive to be our only strategy for advancing the science. We need to mine the data on real-life clinical encounters – nationwide. If you doubt this assertion, think about hormone-replacement therapy. The message here is that data interoperability, attained through a standardized clinical vocabulary, is more critical than operational interoperability.

Once we have determined, through data analyses (while controlling for potentially confounding variables), how to diagnose and treat more effectively, we must convert that learning into a "clinical guidance system", operational at the point of care. We would monitor outcomes, assuming we can figure out how to measure them, so that the system can be empirically enhanced – thereby establishing continuous quality improvement (CQI) for healthcare. That, along with systematization of healthcare delivery, via processes like triage and rational incentives, is the only way that we can prevent the current crisis from turning into an apocalypse.

We need to conduct pilots of alternative EHR approaches, rigorously analyzing both the financial and clinical outcomes – so that we can learn what truly works best. The point-and-click documentation requirement of most existing EHRs has ironically been demonstrated to decrease the productivity of physicians. That is the last thing we need…particularly if there are no offsetting benefits derived from improved quality and value. Let’s figure out how to do it right: How to make data entry physician-friendly and highly efficient. Let’s bring the best minds together to design and evaluate these systems, which will determine the future of our nation’s healthcare. Let's not throw money at this devastating problem until we know for sure it will buy the cure."

Joe Weber, CEO
Valadoc, The Medical Coordinator Company

HIMSS 2011 Report

2011-02-27T17:24:00.000-08:00

The Health Information Management Systems Society, or HIMSS, conference this week in Orlando was a most interesting, and often delightful, experience. For me, it was almost continuous networking/meetings with entities that are seeking the best methodologies for delivering patient centered, value-based care. This movement is still a sideshow to the heavily capitalized power elites chasing the traditional volume-based health care delivery products. However, there is a definite shift taking place. I first detected this shift at last year’s show, and it is quickly gaining steam as both the government and several major players in the industry have more openly advocated the necessity of moving from industry-centric to patient-centric information management. There are relatively few at this gathering of over 31,000 that understand what this really means and even fewer that have any real experience. Because the SOAPware team has had this focus for almost 2 decades, we had the ear of many industry and government leaders during a dozen or more side meetings during the week. There is a recognition and movement toward the true interoperability and open standards (focusing on the Internet) that will be necessary to disrupt what is currently so dysfunctional.

At times, during the conference, when on the exhibit floor between many monstrous booths, I could not help but wonder if what most around me were experiencing would subsequently prove to be very similar to what the passengers of the Titanic experienced... the day before...

This next year, as healthcare policy rolls out promoting Accountable Care Organizations and Patient Centered Medical Homes, there is going to be a great acceleration away from the traditionally monolithic, siloed information systems that currently dominate the healthcare world. This is also going to finally open the industry to innovation and more efficient/appropriate uses of clinicians other than turning them into harried, distracted, data entry clerks. The interest in SOAPware’s approach to using medical coordinators and patients to perform almost all of the data entry is clearly the future. I predict the recent past, and current times, will soon prove to have been the darkest of eras for patients and the doctors deserving of their trust.

Time permitting… I will make some comments in the near future as to some more of the specifics.

We May Finally Be Moving Beyond Faxing to Exchange Clinical Information

2011-02-25T06:34:00.000-08:00

I had a very rewarding week in Washington D.C. last week dealing primarily with issues and projects related to being able to exchange clinical information. The highlight was the Press Announcement - American Academy of Family Physicians Unveils New Secure Electronic Messaging Service for Physicians Based on Surescripts Network for Clinical Interoperability

Here is my quote regarding this initiative:

“Medical record information exchange in the United States has not been able to expand beyond the fax machine for more than 90 percent of medical practices and their patients. This initiative by AAFP and Surescripts could prove transformational by finally overcoming most of the pervasive obstacles that have prevented progress up until now. Finally, here is an initiative that promises practical transfers of patient information at a fraction of the cost and hassle of most current efforts. AAFP Physicians Direct also can deliver working solutions in an almost immediate time frame, rather than having to wait for years. We simply do not have years to wait for positive change in our health care system.”

We, at SOAPware, Inc. have been facilitating and encouraging this more simple approach to information sharing for years, and publically demonstrated its feasibility years ago -
AAFP/SureScripts/MinuteClinic/SOAPware Provider-to-Provider Clinical Messaging Demo'd at TEPR

Here is a summary of what this initiative intends to deliver:
AAFP Physicians Direct is an affordable and easy-to-use electronic messaging service for physicians that:
• Enables physicians to share patient health data through a secure network.
• Breaks down communication barriers between health care providers.
• Accelerates the digital transformation of the nation’s health care system.
The Benefits
• Improve communication among providers
• Enhance continuity of care
• Support achievement of Meaningful Use
• Advance the Patient-Centered Medical Home
The Technology
AAFP Physicians Direct is built on the Surescripts Network for Clinical Interoperability, making the new service available to family physicians and other health care providers nationwide. The AAFP, Surescripts, and many other organizations have collaborated with the federal government to create the standard protocols to make this type of electronic clinical communication possible.
The Cost
Unlimited messaging per physician: $15 monthly

Even though this is being announced/sponsored by the AAFP, it will be available to any physician of any specialty. The only requirement is that the prescribing clinician be connected to the Surescripts network. Many physicians are already connected and using it now to prescribe electronically. Surescripts is opening the network to now share more than just prescriptions. It is anticipated that just about any document type can be shared, and this includes CCR, CCD, .pdf, Word documents, images, etc.
The protocols for sharing are being based on the NHIN Direct Project which is national in scope and part of the federal initiatives for information sharing. Most regional health information exchanges, such as state HIE projects are going to be required, to some extent, to also support message transfers using the Direct protocols. Undoubtedly, there is going to be confusion amongst physicians as to why they would be interested in the Physicians Direct initiative when they have been approached to participate in one or more regional HIE projects. This blog post - Direct Model or HIE Model – http://www.emrandhipaa.com/emr-and-hipaa/2011/02/15/direct-model-or-hie-model/ - IMHO, does a pretty good job of explaining the Direct vs the HIE approach. Realistically, in the short term, it is going to likely be a both/and for most. The PHR that is projected to be at the center of the Direct model in this blog post is not yet tied into the Physicians Direct project, but may well be an option at a later phase. The Physicians Direct project provides a secure means to directly transfer electronic information from one physician to another. So, for now, this project could soon deliver a practical, more immediate, lower cost means to accomplish transfers of information beyond the limited faxing of today. Tomorrow, it may very well provide the tools to meet the interoperability requirements of Stage 2 and 3 of meaningful use with far greater practicality and lower cost (with less risk of being victimized by connectivity extortion) than some other options.
I predict, in time, the more national, Direct approach will subsume the regional HIE models when the latter run out of government fundings. I don't anticipate medical practices will be eager to pay for more expensive, regional information sharing networks when simpler, lower cost, national options are going to be available.

Another good read regarding the Direct approach to information sharing can be found here -
Getting DIRECTly to the Point: The Role of the Direct Project in Fast-Tracking Health IT Interoperability - http://e-caremanagement.com/getting-directly-to-the-point-the-role-of-the-direct-project-in-fast-tracking-health-it-interoperability/

IMHO, Surescripts and the AAFP are to be commended on their efforts toward encouraging more patient-centric and physician-friendly approaches to information sharing.

The other major meeting I attended this week in D.C. was the hearings related to the PCAST report. A good summary is found here - Comments to ONC: PCAST HIT Report Becomes a Political Piñata
http://thehealthcareblog.com/blog/2011/01/23/pcast-hit-report-becomes-a-political-pinata/

The Basics As to How to Receive Medicare "Meaning Use" Bonus Payments

2011-02-15T04:50:00.000-08:00

In order to obtain the Medicare “Meaningful Use” bonus, you must:

1. Register for the Meaningful Use Incentive Program (plan for 20-60 minutes).

2. Use an ONC certified EHR such as SOAPware 2011 (use for 90 days in 2011).

3. Subsequently attest to meaningfully-using SOAPware (plan for 20-60 minutes).

1. Register for the Meaningful Use Incentive Program (plan for 20-60 minutes).

The first step is to get the EHR Certification number:

-Go to http://onc-chpl.force.com/ehrcert/

-Select “Ambulatory Practice Type.”

-In the middle grey box, ensure Product Name is selected from the drop-down, and type soapware in the “Search for” field.

-Click the Search button.

-Click on the Add to Cart link.

-Click the Get CMS EHR Certification ID button on the right-side. This gives you the number you will need when you subsequently attest for “meaningful use.”

The second step is to register for the Meaningful Use Incentive Program:

Preview the information at the https://ehrincentives.cms.gov/hitech/ prior to registering for Meaningful Use. At that location is a very good video explaining the process. The information from the video is also available in document form from: http://www.cms.gov/EHRIncentivePrograms/Downloads/EHRMedicareEP_RegistrationUserGuide.pdf

2. Use an ONC certified EHR such as SOAPware 2011 (use for 90 days in 2011).

Again, SOAPware 2011 is certified on ALL certification criteria, and on ALL NQF Quality Reporting Measures. Any eligible professional can use SOAPware 2011 to meet Meaningful Use requirements, including primary care and specialists. SOAPware 2011 expected to be available late February. Start now by reviewing the SOAPware 2011 Meaningful Use Guides online at http://soapware.screenstepslive.com/spaces/documentation/manuals/mu_overview

Much more information and several videos explaining and demonstrating the "meaningful use" of SOAPware are in the works for release within the next few weeks and the process will be fine-tuned over the next few months. (Warning!! Avoid any EMR/EHR implementation that does not demonstrate the step-by-step processes in advance.)

3. Attest to meaningfully-using SOAPware (plan for 20-60 minutes).

For Stage One, which is 2011-2012, providers only have to attest that they have used a ONC-certified product for at least 90 days in calendar year 2011. It will have to be used for all 12 months in 2012. Attestation will occur online, but the website to self-attest is not yet available. It is expected sometime in April, 2011. More information can be found at https://www.cms.gov/EHRIncentivePrograms/01_Overview.asp

In this Industry… 1. Anything Is Possible… 2. Given Enough Time and Money

2011-02-13T06:45:00.000-08:00

I have recently been amazed at how often #1 is put forward and #2 is ignored. 2011 will prove to be an interesting year, and I am going to make a prediction that with the products that currently exist in the marketplace, no more than 50% of medical practices planning to capture meaningful use payments will actually do so. I am also going to predict that over 80% of EMR/EHR purchased in 2010 and 2011 will fail to receive meaningful use bonuses. Practices simply will not have enough time and/or money to carry through. It is my perception the bulk of recent purchases have been (and are currently) to acquire golden spoons for situations where backhoes are needed.

The sad realities are that, increasingly, purchasing and implementation decisions are being made by entities that really do not adequately understand the monsters associated with comprehensive EMR use. The persisting naiveté regarding what is needed at the point of care is nothing less than astonishing.

There simply is not enough time or labor available to dig foundations with spoons, no matter how expensive and “golden” the spoons might prove to be. As a result, I predict that there will be a lot of chaos and inconvenience for the majority of physicians that have recently taken, or are in the process of making, the EMR/EHR plunge. There will even be more chaos and transition at the CIO/CMO level, and in the EMR/EHR vendor world, when expected deliverables are not forthcoming.

It is also a sad reality that sources of information often used to assist in EMR/EHR selection and implementation are often misguided. For example, one of the most prominent vendor ranking/survey entities recently gave an acropolitic, 100% positive ranking to a vendor who has practically no significant, successful EMR/EHR implementations within busy practices. Look for this particular EMR/EHR vendor to sell out to an acquirer in late 2011 or early 2012 which will likely deliver immunities to their principles who have been unconditionally promising meaningful use reward payments to their customers. Also, look for this ranking company to continue, unabated, in their tradition of ranking many products at the top that will continue to have a greater than 50% failure rate. This has been the pattern for the past decade, and some things predictably don't change.

Another recent EMR/EHR survey included, as their top, recommended vendor, one who has only met 40% of the requirements for meaningful use, so it is only a “modular” rather than complete EHR system. Users of this “free” system currently have little probability of actually receiving meaningful use payments. Will this vendor be able to get enough, additional venture capital money (or ad sales?) in time to force cold fusion? Realistically, even if they do successfully add the necessary functionalities, the cumbersomeness of using this system to actually capture and report the data from the point of care is most likely to be more daunting than practical.

It is anyone's guess what will happen to some of the REC entities who are so prominently promoting golden spoons? Will they be allowed to fail, or will the taxpayers be pleased to come to their rescue?

So, for the next year, I predict somewhere north of 50% of medical practices will not have either the time, energy, or the money to persist in their currently misguided EMR/EHR purchases and implementations. We hope to be an exception to the norm. It is our goal for no less than 90% of SOAPware users who intend to receive meaningful use payments be successful in doing so. Rather than being focused on making promises, out of context, to potential purchasers, we are mostly focusing on assisting our users properly implement our software and see that they properly submit their attestations to the ONC. More to come on both of these key issues. It is our sincere intent to accomplish this in fashions that actually improve the well-being of patients and the doctors deserving of their trust.

SOAPware and "Meaningful Use" Status

2011-02-12T16:23:00.000-08:00

Here are the official SOAPware 2011 - ONC-ACTB Certification Details

On January 14, 2011, SOAPware 2011 by SOAPware, Inc. received the 2011/2012 ONC-ACTB Complete EHR Certification* by the Certification Commission for Health Information Technology (CCHIT®), an ONC-ATCB, in accordance with the applicable certification criteria adopted by the Secretary of Health and Human Services. This certification does not represent an endorsement by the U.S. Department of Health and Human Services or guarantee the receipt of incentive payments.

Here are some further resources for information as to how SOAPware is dealing with meaningful use issues - SOAPware Meaningful Use Resources

Hold Onto Your Hat

2010-09-10T07:12:00.000-07:00

Vince Kuraitis at the e-CareManagement blog has done a great job of relating some big picture issues regarding the “meaningful use” transformation that is imminent. I invite everyone to review Overview: Here Come Stages 2 and 3 of HITECH!
I think it is especially important to notice how low the bar is set to meet stage 1 of “meaningful use” when this is compared to stages 2 and 3.
It is my opinion that few to no EMR vendors have articulated even a plan for a path to stages 2 and 3 that is either practical or affordable. Most of the current generation of simple, or “paper behind glass” EMR products primarily being sold to independent physician practices, and most of the current generation of comprehensive EMR products being sold to enterprises are not likely to prove to be viable solutions beyond stage 1 without major rewrites of their software and a radical change in their business models. This promises to be a major burden that most physicians now using EMR products will have to somehow manage at the same time that major shifts will be taking place in how payments for healthcare services are taking place.
Equally enlightening is Vince’s essay discussing the differences between data interoperability and workflow interoperability- Geek Wisdom: “Interoperability” Must Include Process Collaboration.
IMHO, the most important themes he so well articulates are that having the technical ability to exchange information is of little value unless the more challenging issues related to workflow interoperability are addressed. None of the interoperability projects I have reviewed to date seem to understand just how critical this is. The greatest successes in the future will go to the entities that begin to understand and address this issue sooner rather than later.

What is the status of your ACO?

2010-08-26T09:10:00.000-07:00

I would be interested to learn how many of you and your local ACO initiatives are similar to and different from what is illustrated in this video - In Search of an Accountable Care Organization (ACO)

The sad reality is that few health systems are developing, or even considering ACO solutions that are friendly to patients and physicians. Particularly, the currently available information technology solutions that are usually being considered are arguably hostile to both. This is a key reason SOAPware, Inc. has been working very hard to see that more patient-centric solutions will soon be available, and is the reason we are strongly collaborating with larger entities that can reach across the community in a fashion to best serve patients.
Our nation is on the verge of a dramatic change in how health information technology is utilized, how care is delivered, and how it is funded. Few understand the implications.

My Perspective on Smarter Healthcare

2010-08-10T05:44:00.000-07:00

This is a cross-post linking to Building a Smarter Planet - A Family Doctor's Perspective on Smarter Healthcare.

Further commentary:
At SOAPware, we are pleased that IBM and ActiveHealth have publically announced a project that has been in the works for some time now. The Collaborative Care Solution is EMR/EHR agnostic. The intent is to make it as open-platform as is possible. It’s greatest value is likely to be that it is inclusive of any/all vendors that will adopt the Health Information Exchange (HIE) specifications defined in the solution. IBM is probably one of the only entities that can finally overcome some of the obstacles that have thwarted true interoperability.
The SOAPware Clinical Suite is an option, but not the only option, for sites and practices joining the collaborative who have not yet invested in an EMR. The intent in the CCS is to preserve the current, comprehensive EMR user’s choices where and when that is possible. Likewise, SOAPware Clinical Suite is being incorporated into other HIE initiatives. The future belongs to inclusivity and not the proprietary exclusivities of the past.

Digital Dr. Deliverables: Conquering Cost & Complexity in Healthcare

2010-08-05T07:04:00.000-07:00

Guest blog: Dr. Paul Grundy, IBM Director of Healthcare Transformation

A major problem in healthcare is getting the right information in the right hands at the right time to make better decisions. Meanwhile, patients are becoming more active consumers and expect to receive real-time, accurate, timely insight. Today, the two biggest challenges with health technology infrastructure are cost and complexity.

However, healthcare is the latest industry undergoing a digital transformation (in terms of clinical use) applying technology and analytics to improve healthcare systems offering more effective, meaningful patient services.

Health analytics and clinical decision support provide the ability to lower costs, inform consumers, and deliver better patient care outcomes. IBM and ActiveHealth have brought together deep healthcare industry expertise to deliver a Collaborative Care Solution that marries the capabilities of deep clinical insight with IBM’s strength in technology. The new system works with SOAPware’s innovative EMR capabilities to deliver a comprehensive solution to give doctors what they need, when they need it.

Physicians can connect to the technology via the Web in a secure, private cloud-based service hosted by IBM. The solution sifts through the mountains of data with sophisticated mathematical models to distill what’s most important and relevant to treating each patient. For patients, it can help ensure they get better care. (Video)

Using a smart cloud-based computing model, healthcare organizations buy only what they need -- per physician per month – avoiding upfront costs and the challenge of updating systems when clinical guidelines or reporting requirements change or when patient loads grow.

This unique model combining the power of deep analytics and clinical decision support wrapped around SOAPware EMR technology provides an innovative approach to achieving the goals of patient centered medical home or accountable care.

This is an important step toward transforming our healthcare system.

SOAPware Clinical Suite Launched

2010-07-30T09:43:00.000-07:00

The official announcement

SOAPware® Launches Integrated EMR/EHR and Practice Management Software; Technology Supports Optimized Delivery of Patient Care Services with an Affordable Price Tag

Final Rules for “Meaningful Use” for Electronic Health Records

2010-07-13T14:04:00.000-07:00

This morning, the final regulations to satisfy “meaningful use” were announced. A good summary is available here - The “Meaningful Use” Regulation for Electronic Health Records.
My summary is that the team brought together by the ONC, led by Dr. David Blumenthal, has done a great job in creating a reasonable process to satisfy the requirements in order to receive bonus payments for EHR use. They have obviously worked hard and listened.
This will dramatically increase the level of interest and the number of physicians that participate. It is now within reasonable reach of even small medical practices.
Once testing entities are established for EHR certification, later this year, we intend to obtain the necessary ARRA/HHS Certification so that practices using SOAPware will have all the necessary technical capabilities to satisfy meaningful use.

Are Scylla and Charybdis the Only EMR Implementation Paths?

2010-07-11T08:42:00.000-07:00

No.... the 2 sea monsters that Homer described in the Odyssey actually offered Ulysses an enviable situation compared to what today’s physicians assume they face when implementing information technology. The latter seemingly have perceived they must choose a path between one of about 6 monsters. At least with Ulysses, it was only an either/or between Scylla or Charybdis.
There is much angst out in the real world of real doctors actually attempting to deliver care. There is some degree of awareness that current, fee-for-service, volume-based healthcare models will be waning soon. However, future, ”value-based” models (PCMH, ACO, P4P, MU, PQRI, etc.) are little more than unfunded or underfunded alphabet soup at this point. Regardless, there is increased awareness that the future will require dramatically different practice resources based on different information management strategies. The comprehensive EMR usages required for this transformation have been elusive. Only 4-6% of current EMR implementations can meet the requirements, and these typically have up-front costs of $30-80k per clinician. Currently, 20-40% of installed, comprehensive EMRs are subsequently de-installed. Then, add to this that over 50% of comprehensive EMRs that are not de-installed have been implemented in such a fashion they are arguably doing more harm than good with the doctor having to pick between paths that often lead to monsters:

Doctrolus - This one turns clinicians into distracted data trolls when seeing patients.
Enslavus - This witch forces clinicians to spend huge chunks of their life, when not seeing patients, feeding her with data.
Hemsucus - This blood thirsty monster trickles away clinician's productivity life blood.
Rubishus - A frightfully ugly beast forces clinicians into “Documentation by Exception” which is the auto-entry of a bunch of default, normal findings which creates a lot of garbage. This is probably the most egregious monster as it has forced the widespread proliferation of… “canned” notes. Today, any clinician caring for patients will relate frustration about having to access medical records that contain 90% canned garbage. This makes it difficult and sometimes impossible to get to the useful 10%.

Understandably, a majority of clinicians have either found none of the comprehensive EMR implementation-methodology monsters, above, to be acceptable (so they often bounce around among them), or chose a less comprehensive beast, below. Many clinicians are just now beginning to awaken to the reality they will likely have around a 30% income differential in 2-3 years, and lose “quality” status due to lack of information technology capability. However, most of them are waking up only to choose one of the following:

Alchemus - This ghoul preys upon clinician's desire to at least get started, so she deceives them into using an EMR as mainly paper-behind-glass (e.g. choose a “simple” EMR product, continue transcription, or move to speech recognition, etc.) that is unable to adequately collect and manage the data to practically meet forthcoming meaningful uses, PCMH, etc. Doctors just hope that some day, some how, some way, their records can magically morph into real data... easier to turn lead into gold. The Sirens may call on you to give up the mineral rights to your property because it is either popular, simple, or free to do so. It might be wiser to look for ear plugs?
Cephinrectumus - This contorter tricks clinicians into "just say no" to EMR altogether. She deludes them into hoping this all goes away.... it won’t. She connives to keep doctors oblivious and in a dark, little world until it is too late. She is deceiving enough to be the most popular path chosen.

The good news... new trails are being mapped that bypass these monsters.
Alternative paths are necessary for any EMR product and implementation if a core value of the vendor is to "Do No Harm."

Also see - The Critically Sequential Path to Success and Alternatives to Doctors as Data Trolls?

Hubris in Healthcare Reform?

2010-07-10T08:22:00.000-07:00

I am concerned we may be about to enter another cycle in healthcare where the hubris of high managements ultimately brings down another healthcare system restructuring that, again, harms the interface (i.e. patients and their trusted physicians). Borrowing some thoughts from Peter Drucker, management guru, who elegantly identified this “blind” high level forced management as undesirable, and touted the requirement of MWA (management by walking around), I believe it's well known that if you don't ask those that do, you'll do what you shouldn't do. Having lived through several previous failed cycles in healthcare…

• Capitation in the 80’s

• Managed care in early 90’s.

• Physician Management Organizations and hospitals buying medical practices in late 90’s

…I have real concerns the healthcare reform initiatives (PCMH, ACO, bundled services, etc.) are at risk for failure for the same reasons these other cycles failed. Those making decisions are not getting appropriate input from the interface. I continue to be amazed at the gap between the visions of policy makers (and administrators at all levels) and the realities at the point of care.
I see a strong need for a trusted, respected true physician’s guild to advise those administering healthcare delivery. This needs to be an entity that can truly represent the interface between healthcare and the patient. Its membership needs to be inclusive of all the major medical professional organizations, but its leadership needs to be filled by true representatives from the interface.
What might provide the nidus for just such a guild?
It is a bit frustrating that I visit with enlightened physicians almost daily who want to promote patient-centered care, yet can identify that their organizations and heathcare reform initiatives do not yet adequately understand or address the real obstacles. Many of these organizations and initiatives are close, but not close enough. A guild to advise organizations that is led by individuals that do not have to answer to organizational bureaucracies could actually strengthen many of these organizations for the very reasons they have weakened.
Otherwise, what evidence is there that we are not just entering another cycle, and are about to do more harm than good?
For patients and their physicians, I really would rather see reform float than sink. At least we don't have to worry about the captains, as history confirms their ability to just jump over to the next passing ship.

SOAPware Value Statements

2010-07-08T10:14:00.000-07:00

What we are about is - Improving Healthcare and Quality of Life

Who we serve are - Medical professionals and patients

How we do it is via - Innovative technology and services

Mission Statement:

Improving healthcare and the quality of life, by empowering medical professionals and patients with innovative technology and services.

Our Core Values:

Be Accountable – We believe people should do what we say we are going to do. It requires a level of ownership that includes making, keeping, and proactively answering for personal commitments. We believe it’s acceptable to respectfully hold each other accountable. Organizational results come from collective, not just individual, activity. We believe in both individual and joint accountability.

Continuously Improve – We believe being great at something is a starting point, not an endpoint. Whether it is, personal skill sets, processes, services or applications, we believe we have the responsibility to continuously grow and improve.

Be Truthful – We believe truthfulness is a foundation to building trusting relationships. We must be honest and open about all our actions and motives. It holds us to legal limits and makes us play fair because we are being transparent and accountable to both ourselves and our customers.

Be Healthy – We believe people should maintain a healthy mind, body and spirit. Keeping this balance will translate into both our personal and work lives. We encourage people to enjoy their work life, and help others do the same. We encourage caring for one another and laughing together.

Do No Harm – We believe, as a company that holds Patient Information for millions across the globe our first responsibility is to “do no harm”. We should protect their data, taking measures to keep its integrity and privacy during all operations. We want our technology solutions to add value to the patient / provider relationship.

SOAPware, Inc. Quality Metrics

2010-07-07T11:58:00.000-07:00

I have been alluding a bit to a transformation that is taking place at SOAPware, Inc. Several very talented people, including a new COO, Don Butcher, and CTO, Kyle Rogers, have joined an already talent-laden team. A key directive has been to implement metrics in order to promote quality improvement. Our support manager, Ryan Petty, and Brad Hampton, our key "community" developer, really took the lead on this and created an online survey to ask users of their experience when they engaged support. They started doing this last January, and 2452 surveys have been completed to date. Currently, the survey asks 4 questions:

1. Please rate your SOAPware experience: Excellent, Good, Mediocre or Disappointing.
2. Please rate your remote support experience: Excellent, Good, Mediocre or Disappointing.
3. What’s the status of your problem? Solved, Partially Solved or Not Solved.
4. Any additional comments

The negatives that we currently see in the comments are most often about appointments with support that were late, or return calls that had delayed response times. These are part of our growing pains, and we are taking actions to address these issues.
I wish to extend our gratitude to everyone who contributed to this survey, and a special thanks to those taking the time to offer comments as to how we can improve.
I also wish to express my gratitude to the Support and Implementation-Training teams here at SOAPware for their efforts. They really do a great job, even when challenged by not being able to respond in as timely a fashion as they sometimes prefer.

Word Cloud of This Blog

2010-07-04T07:51:00.000-07:00

I thought this was interesting, a word cloud derived from my blog. Compliments of http://www.wordle.net/create ...

SOAPware Status Report, July, 2010

2010-07-03T09:05:00.001-07:00

This has been another incredibly busy and productive month at SOAPware. We have quietly released SOAPware v2010.2 containing our first phase billing software. It is now in use in more than 20 sites. We are doing this quietly until we are confident there are no significant flaws. All of the advanced e-prescribing within v2010.1 released a couple of months ago has been merged with the billing development in order to create v2010.2. The SOAPware billing project has been a parallel effort for almost 3 years, and the merge into v2010.2 has been huge. In spite of this, there have been few reports of quality issues to date.
Toward the end of this month, we will make announcements and reengage some marketing efforts to notify everyone that we now have a fully integrated (not just interfaced) clinical and practice management system that is all written in one language, one database, one installer, etc. This is fairly unique as most systems that claim integration are really only interfaced. The interfaced approach is going to be increasingly problematic in the future for multiple reasons that I will be explaining in the near future.
We have also made great progress on our open-platform SDK/API that opens our point of care solution to other entities. It is likely to be a couple of months before formal announcements regarding its capabilities are forthcoming.

SOAPware Status Report - Spring, 2010

2010-06-05T18:15:00.000-07:00

Needless to say, it has been very busy the past month. I am pleased to report that SOAPware v2010.1 with advanced e-prescribing has been released, and is now in live use at somewhere between 50 to 100 sites with good reports.
We have our hands full rolling out the private beta of SOAPware 2010.2 which is our first phase billing system. If all continues to go well, it could go into a public beta within a couple of weeks.
We are making good progress on our open-platform SDK/API that many are waiting for to integrate all sorts of third party products and health information exchanges.
Following the above will be 2010.3 (may be called 2011) with the features that can be submitted for ARRA/HHS certification for meaningful use.
As time permits, I will add more information.

Effective Use of Medical Assistants

2010-05-08T09:52:00.000-07:00

Exerpt from:
An effective way to use assistants - Training nurses and MAs to take histories and provide patient education boosts productivity, income, and quality of care.
Publish date: Aug 3, 2007
By: Ken Terry
Source: Medical Economics

http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?ts=1273337223786&location=http%3A%2F%2Fwww.modernmedicine.com%2Fmodernmedicine%2FMedical%2BPractice%2BManagement%25253a%2BStaffing%2FAn%252Deffective%252Dway%252Dto%252Duse%252Dassistants%2FArticleStandard%2FArticle%2Fdetail%2F443727&id=443727

Peter B. Anderson, a family physician in Newport News, VA, has three part-time nurses and a medical assistant--the equivalent of two full timers--who do nothing but take patient histories, document encounters, and teach patients to follow his treatment plans. These staffers cost a lot more than the single MA who supports the typical doctor. Yet in the four years since Anderson implemented "team-based care," he's seen his productivity-and his income--soar.

Patient satisfaction and quality of care are up, too. "Even if I didn't make a nickel more, I'd never go back to the old system. My charts are so complete that I'm not wasting time going down rabbit trails. And the patients love it," he says....

...When Anderson comes into the exam room, the nurse or MA hands him an EHR-generated list of current problems, meds, and lab results, and summarizes the patient's symptoms and history. The doctor follows up with the patient as needed, then conducts the physical exam while the assistant documents his findings and recommended treatment. The assistant spends another two to five minutes on patient education, while Anderson moves on to the next patient....

...Suppose you pay an RN $20 an hour, or $700 for a 35-hour, four-day week. If the average primary care visit nets $60, you'd have to see 12 extra patients a week to break even. "If you could see one more patient a day, or four patients a week beyond the break-even point, that's $240 a week for 48 weeks a year, or $11,520. Your only extra operating costs would be for drugs and supplies, which are about 4 percent of overhead. So the money in your pocket would be 96 percent of that $11,520," Scroggins says. Multiply that figure by the 10 patients or so beyond his break-even point whom Anderson is able to accommodate each day, and you can see why he's bringing home an extra $100,000 a year...

...With that kind of payoff, why are relatively few primary care physicians using this model? Scroggins attributes it to PCPs' reluctance to delegate any of their clinical duties, for any number of reasons. Some, like FP Jeffrey K. Pearson of San Marcos, CA, prefer to spend more time interacting with their patients. "I get a feel for what's going on by listening to them talk," says Pearson. Others may be afraid that having an assistant take histories will reduce patient satisfaction.

But that's not likely, argue Scroggins and Flora Nielsen, a former president of the American Association of Office Nurses. "The patient judges the total experience," says Scroggins. Adds Nielsen, "If the nurse takes the history and the doctor has all the significant data in front of him when he comes in and can focus better on the patient's problems, I don't think anyone would have a problem with that." ...

See the original article for more details.

Since 2007, the data shows that patient satisfaction increases, rather than decreases.

Performance Measures are Severely Misguided

2010-05-02T04:25:00.000-07:00

It is not currently possible to measure outcomes correctly. This is particularly true in small practices with too few patients in whatever subset is being measured. Also, patient performance, and thus outcomes, are only partially dependent on their doctor.
The payment model in Denmark appears to be well accepted by physicians. The primary care practices are largely privately owned, and there is a fee for services regardless of whether it is email, phone or face-to-face. Physicians are additionally given a PPPM. A small "performance" bonus is available, of which I am not clear on the details. I was under the impression the bonus payment, based on “performance,” measures was low, and there were measures of patient satisfaction included. It is my prediction that the PCMH models that succeed in the U.S. will be very similar to this. In Denmark, there is over 90% physician satisfaction. The PCMH model in the U.S. could largely reproduce this, if (big if) physicians can adapt quickly enough.
Physician acceptance will follow the pattern as Moore describes in Crossing the Chasm. My concern is less that most physicians will adapt, because they will as long as it is a win for them and their patients. My concern is if the rate of physician adaptation can be rapid enough considering the demoralization and skepticism they have (and for good reason). As always, there will always be a vocal class of laggards whose noise can slow healthy adaptation by the majority.
My greater concern with the transition to value-based payment systems is that the current power elites in the healthcare system will succeed in promoting ACO models that are not founded on PCMH principles. This will fail, and I encourage physicians to oppose these vigorously.

Accountable care can not happen without PCMH

2010-05-01T10:39:00.000-07:00

The following was written by Paul Grundy, M.D. and is posted with his permission. Emphasis added is mine.

Accountable care can not happen without PCMH it is the only way it can work or should work. IBM , DOD, the European Union want this as the very standard of care we all want to buy. Care has to be built on a meaningful relationship. Plus why would one not want to build high quality lower cost care on the second strongest relationship to humanity - the doctor patient relationship. My employees tell me they want a real relationship, better communication, real access all part of and key to PCMH.
I do not want a hospital system saying they are an ACO when they are really a milking machine an ATM for body parts and my strongest defense for that is to insist as a buyer that the base of any ACO has and accountable relationship (PCMH is the agreed principles for that) as its very foundation. I want my patient to look their doctor (personal doctor who is willing to deliver comprehensive care) in the eye and say is this the best for me doc is it the care you would deliver to your mother.
You see when we have the tools to deliver real care coordination at the point of care the only logical place to have that coordination function is in the hands of the person doing comprehensive care and again is stronger more powerful in a relationship of trust. I want my wife, my mother, my employees to have the kind of relationship so when it comes to difficult conversation (death panel conversation) they have someone they know trust and who has comprehensive information and understand of my family member employee.
Going forward in time because we now have the tools the power to do real care coordination and increasing we will have real data, real clinical decision support we will reach a place in the not to distant future when it will be consider unethical immoral against any and every oath we take to do harm – to deliver uncoordinated care to deliver episode based car not comprehensive care to deliver disintegrated care vs integrated care.
In order to be meaningful this relationship has to support the longitudinal and comprehensive care of patients. Technology can support that relationship by improving communication. It can allow expanded communication with a patient; it can empower the doctor not to forget to ask an important question be it about the patient’s personal life or a key factor in the healing process. Smarter healthcare can send reminders of care compassion, reminders that express a doctor’s investment in a person who yearns for a personal relationship with their healer. A smarter healthcare system can help ensure that critical information and updates, that might otherwise be missed in a busy doctors office and presented in dashboards – front and center, or are sent via email or text messages to Care Coordinators. Smarter healthcare makes sure the right drug is used on the right patient at the right time, taking into account the person’s genetic makeup and other medications they are using. It ensures the authenticity of pharmaceuticals and the security of patient information. It changes everything from how healthcare organizations do business to how they enable their employees to collaborate and innovate.
But in all of this there needs to be accountability and it need to be done down at the coal face of the doctor patient relationship in the face of a caring relationship.
Look the VA gets it they are migrating 100% to PCMH, Kaiser gets it Geisinger gets it these are all “ACO” that are now going back to a base of PCMH why would we want to do that mistake all over again.
Bottom line PCMH/ACO same thing one view from the top down one from the bottom up if we try and make them two different items we fail.
NCQA needs to have PCMH/ACO, ACO/PCMH one can not qualify for and ACO unless you have a foundation of PCMH period. Going forward in the future no ethical doc should be part of any care deliver that does not have PCMH the principles that all of primary care agrees on as it foundation.
First and foremost -- Patient Centered Medical Home is an effort to address the high cost/low value situation we find ourselves in as large employer buyers of care. Study after countless study shows that when a patient has a primary care physician that cares about them has and uses the tools to practice comprehensive care centered on the patient needs they get the care they need at a price we can afford.
But we the buyers have been part of the problem (as Pogo said so long ago I see the enemy it is us) in not demanding systems of payment and practice organization that encourage and enable the comprehensive, patient-focused primary care we desire. There is no money paid for the necessary investments in teams and health information systems so essential to the delivery of comprehensive, cost-effective, patient-centered care. Current payment methods richly reward medical procedures and discourage spending time with patients in such essential activities as history taking, physical examination, diagnosis, planning treatment, counseling, coordination, and prevention. This must change. ,
When one compares the U.S. health care system with those of other industrialized countries, one is led to the more specific conclusion that the two major problems in U.S. health care are the way we 1) fail to deliver comprehensive primary care (PCMH) and 2) the way primary care is financed (ACO). Our premise is that someone agreeing to be a comprehensivist like a primary care doc or an infectious disease doc caring comprehensively for their patient is the only natural locus of control of health care quality and costs. Point two this need to be funded and financed in an accountable way and ACO it the way to do that. PLEASE PLEASE do not try to separate how the money flows (ACO) from the principles all primary care has agreed on (PCMH) if you do we are in real trouble and the readers should all know that.
Primary Care/comprehensive care as defined by the principles of the PCMH It is the only entity that is charged with the longitudinal care of the patient. It is the only entity whose job it is to consider the whole patient, the health of the whole person, including mental and physical.
As large employers our national focus on disease management programs is a good example of the failure of primary care and the failure of our efforts to improve care as a work around of the core problem and not face the real issue head on. If stand alone disease management programs are considered necessary today, it is because primary care is not doing its job. From a primary care perspective/comprehensivist, the treatment of chronic conditions, such as diabetes, congestive heart failure, and asthma, with the right tools is basic and straightforward. The care of these conditions is simply not that difficult. However, the quality failures in the treatment of these conditions are well documented. Stand alone disease management programs which are not delivered at the point of care present a Band-Aid approach to problem solving. These kinds of work a rounds instead of addressing those problems directly have in fact created additional, expensive, fragmented responses to the primary problem.
For some reason, the healthcare industry and we as the buyer have demonstrated an inability to develop a sharp focus on solving core problems. We seem much more willing to create complicated responses to our problems than we are to fix the core problems of our delivery system. Again, disease management is a perfect example. If primary care is not delivering high quality care for those with chronic conditions, we can either find a way to work around primary care or we can find a way to fix it. Our willingness as large employers to "pay any price” for that episodic care which for example provides for a Diabetic amputation of a limb but our unwillingness to open our eyes and understand that the reason for the amputation was our failure to be willing to pay for the prevention and primary care.
Although we tend to focus on the problems we face, there are reasons for a great deal of optimism-optimism due to the opportunities we have to improve and redesign care. Medical practice redesign is happening today. It is taking hold and has become a movement that is gaining momentum. We the large employers for the first time are at the table with the national health benefit companies and primary care professional societies. Let’s seize this opportunity and make the fundamental changes we have been asking for as large employers.
While I would not argue that primary care/ comprehensive care should be all things to all people, it should be designed to achieve much higher performance than it achieves currently. Such a redesign of primary care is possible today. However, if primary care is not successful in its core tasks of prevention, wellness, and the care of common conditions including many chronic conditions, it will not be possible to control either quality or cost of care in the United States. Again, hospital care and Part-ecialty (specialty) care are crucial to health care, but their use is all too often the failure of upstream care. And look we have to start somewhere lets get really focused and address this lack of a foundation in are primary are delivery system and build onto a PCMH the better hospital and Part-ecialty we also need.
For the first time in history, we have both the knowledge and the capabilities (if we work hand in hand with our primary care providers) to force together substantial change. We are at a unique time in the history. In five or ten years, we might well look back with amazement at the pace of the changes that are currently taking place. The route is clear: We know what to do. We know how to make the system better. The crucial question is whether we have the courage to take on this difficult solution. But are strength lies in the fact that the primary care physicians want to help us take this on a wholesale transformation at the Micro primary care practice level in exchange for payment reform at the Macro level.
So how do we as large employers join the ranks of other systems like the VA and Denmark that have driven as much as 60% of the inefficiencies out of the system.
In step lock with our partners, the primary care providers, we are making it clear to the healthcare benefit companies that we deal with that as an employer buyer it is no longer business as usual. Let also be counted on as employers to send the same message to the other large healthcare buyers Health and Human Services, CMS, Medicaid, Federal Employees, DOD TRICARE, the White House, Congress, State and local government and others.
We demand as the buyer we demand of ourselves and our Healthcare benefit companies:

Comprehensive, continuous, patient centered personal and holistic primary care which is based on strong relationships between patients and their physician -- this is foundational to good health. Practice and payment reform are the prescriptions for achieving it.

You try to stand up a separate ACO without PCMH we will reject it totally and completely Honest – it will not happen!!

To reiterate, no matter how well-intended, if other entities (hospital systems, payer networks, etc.) are put in control, the ACO projects will simply fail. I encourage physicians to get involved and only support initiatives that best serve their patients.
Perhaps there might soon be opportunities to chose to play a role other than the victim?

What's that noise?

2010-04-27T22:01:00.000-07:00

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

2010-04-27T11:52:00.000-07:00

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?