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?

Location, Location, Location

2010-04-24T07:56:00.000-07:00

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

2010-04-23T08:56:00.000-07:00

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

2010-04-22T12:50:00.000-07:00

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

2010-04-21T07:10:00.000-07:00

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

2010-04-20T18:44:00.000-07:00

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

2010-04-17T13:43:00.000-07:00

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?

2010-04-14T07:01:00.000-07:00

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?

2010-04-12T06:25:00.000-07:00

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

2010-04-11T10:26:00.001-07:00

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

2010-04-10T11:49:00.000-07:00

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

2010-04-08T12:57:00.000-07:00

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?

2010-04-04T05:06:00.000-07:00

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

2010-04-02T12:51:00.000-07:00

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

2010-04-01T12:01:00.000-07:00

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?

The EMR Challange, Part 3 - Root Causes

2010-03-31T16:15:00.000-07:00

Now, let's get down to the most basic root cause analysis as to why EMRs do not have adequate implementation. Again, it is primarily because implementation is not adequately valued.
Why? Because most underestimate the scope of implementation and assume it is little more than training.
Why? Because most assume it is little more than just automating what clinicians do now (i.e. just move the paper behind glass).
Why? Because most do not have an experience base to be able to understand the complexity of implementation and the nature of emerging requirements necessitating more comprehensive EMR uses.
Why? Because inadequate implementation resources (time/budgets/interest) are available.
Why? Because most are too overwhelmed just with the complexities and demands of what they have to do now within their current environments.

Every EMR vendor provides options for training. A very few go beyond to offer basic, preliminary implementation tools (project planning, guide of suggested milestones, etc.).
In order to get beyond the current challenge, shouldn't EMR vendors incentivize for greater implementation awareness in some fashion? What are the alternatives?

The EMR Challenge, Part 2 - Current Situation

2010-03-30T10:12:00.000-07:00

The current situation is that potential, new users contact an EMR vendor; an EMR is sold with almost no assessment of clinician/practice readiness and with little matching of implementation/training to the practice needs. The end result is that we have an industry situation where greater than >10% new users are less than pleased with the whole EMR thing.
It is also prudent to be aware that recent surveys by both the NEJM and CDC reveal < 10% of medical practices are using EMRs in a comprehensive fashion.
From More on EMR Failures:

"Under these conditions, the relatively small number of very successful installations is not enough to pull the average EHR return into positive territory, and the CBO is right in concluding that “By itself, the adoption of more health IT is generally not sufficient to produce significant… savings”.

Most clinicians just don't recognize it is impossible to expect to be able to use simpler, free text and narrative documentation in a comprehensive fashions, and only a handful of EMRs manage both narrative and structured data well. Unfortunately, almost all EMR solutions designed primarily for comprehensive use (i.e. structured data entry) experience 20-40% de-installation rates, and >80 of their clinician users are not actually using them, comprehensively, at the point of care. The most miserable group of clinicians tends to be those that are using the comprehensive systems, are forcing themselves to troll in the structured data, and typically are experiencing an average of 30% loss in productivity. This has all but become the norm in many (most?) situations where decisions are made by someone other than those in the trenches. Who cares if the doctors are having to spend 2 more hours, daily, creating documentation? As long as they don't see a lot fewer patients, and as long as they are shuttling patient's into the delivery system's profit centers, isn't everyone happy? I wonder if fewer will be happy once the profit centers become less profitable with the coming "reforms," and the practices are then seen more vividly as cost centers? Will we see another cycle of integrated systems unloading acquired clinics again (as was the cycle in the 1990s)? Do you think patients will end up even having access to their own data when this next shake-out happens? When will control of the data become an epic question?
A key challenge, for SOAPware, and the handful of other multi-capable EMRs, is to make efforts to not be seen as less desirable by both clinicians looking for "paper behind glass" solutions and by those looking for an EMR to collect structured data. We have our work to do to demonstrate how SOAPware is an ideal transition tool from simple to comprehensive, and to help end users understand why that even matters.
Due to this confusion by potential EMR users, several industry “experts” are suggesting that SOAPware do what many other EMR vendors are doing and just raise our prices and guarantee the practices will get $44k for meaningful use over 4 years. In order to make this work, we would have to triple our software price and charge around $15k per year for just the software. Then, we could simply plan to pay back $11k to the practices yearly for 4 years if they can't change their styles in order to meet M.U. We would actually be more financially profitable, while costing less than most other comprehensive EMRs, and might even end up with patient data controlled by something that is a little less enamored by their profit centers.
Pretty cleaver... No?

The EMR Challenge, Part 1 - Definition

2010-03-28T06:49:00.000-07:00

Let's face it, no comprehensive EMR (which includes adequate practice analytics, registry reporting, connections to personal health records, etc.) vendor has an adequate implementation process that will allow for >90% of users to be able to adopt the advanced functions. What makes this especially challenging is that few adequately understand what adequate implementation planning/guidance even means. So, the current situation is that the EMRs that clinicians are actually using at the point of care are not comprehensive (e.g. SOAPware v4 and similar) because these require less implementation planning/guidance than more comprehensive/capable EMRs (i.e. SOAPware 2010). However, emerging EMR requirements (being met by SOAPware 2010) are much more complex and demanding.
Emerging, comprehensive EMR functionality requirements (mostly set by non-users of EMR) often exceed what EMR users can initially adopt without adverse disruptions to patient care. Therefore, clinician EMR users tend to gravitate into one of 3 groups:
1. Use simple EMR, as paper-behind-glass repository of narratives and free text, and remain unable to meet emerging requirements for more comprehensive use.
2. Use comprehensive EMR to capture more structured data and accept adverse practice disruptions (average 30% loss in productivity, reduced patient interaction, clinicians become data trolls).
3. Acquire comprehensive EMR, and accept clinicians will not actually use it at the point of care. They continue dictation/paper and leave EMR interaction to others.

My current career passion is to oversee the creation of a suite of comprehensive EMR implementation products/services allowing >90% of clinicians to adopt advanced, comprehensive EMR and advanced H.I.T. functionality at the point of care while increasing everyone's satisfaction and productivity. The scope of the challenge is about to be more clear once the ARRA "meaningful use" criteria are finalized. It appears these are likely to be complimentary to the specifications for the Patient-Centered Medical Home (PCMH) specified by NCQA.

Health Insurance Reform

2010-03-27T07:32:00.000-07:00

O.K. I have held off as long as I can in making comments about recent events. We have seen a 2,700 page bill (Patient Protection and Affordable Care Act) passed that shifts, somewhat, who/how health care products are purchased and does little to change the product itself. However, it is true that it includes some initiatives to change the product, but in a top-down fashion. Top-down is an approach that all of history confirms is fundamentally flawed. How much more evidence do we need? Real health care, rather than health insurance, reform has to come from the bottom up or it results in just another system of games, and manipulations in order to get a bigger piece of the public coffers. At the least, we can look forward to a more complicated gaming system.
Anyone who believes the CBO forecasts of lowered costs is delusional. Again, the plan doesn't promise much effectual change to the product itself which contains 40-50% waste comprised of:
- Defensive Medicine – 30-40%
- Administrative Costs -20-30%
- Products and services not improving outcome – 10-30%
- Duplicative Services – 10-20%

Certainly, I am pleased to see that 32 million people will theoretically have more access to care. Extending the social contract appears to be an immediately, honorable undertaking. However, how honorable is it if it saddles our children with insurmountable debt combined with a pervasive sense of entitlement? Amazingly, it has already started. This is a true story... from an M.D. on 3/23/2010:

“A guy called my office today wanting to schedule his "free complete physical." I kid you not. He yelled at my receptionist when she explained we didn't provide free physicals. "Don't you people listen to the news?! The President signed free health care into law yesterday." He ended by threatening to report us to Consumer Affairs.”

Actually, there are some hidden gems of opportunity to positively change the system that are hidden deep with the pages of the legislation. Once the politics plays out a bit, and key players are named, I will post some comment.

If you need a tax break, have a baby?

2010-03-15T18:06:00.000-07:00

Excellent article - E-Medical Records: 10 Steps To Take Now at InformationWeek Healthcare.

It includes discussion of the following:

1) Get buy-in and sponsorship from your organization's top leadership, including influential clinicians and the CEO. "Solicit your leadership team and actively communicate with upper management,"

2) Decide how you'll fund the project--remember stimulus dollars don't start flowing until 2011.

3) Start evaluating your workflow and processes. Figure out what steps you're doing now waste time and money, and can be eliminated with the new system.

4) Find out where key information resides in your organization.

5) Look at EMR and other health IT products for the ones that fit your organization's needs.

6) If you're not ready for a big bang approach to EMRs, consider modular software and components that let you add functionality in increments.

7) Determine whether you have the resources and staff to handle an on-site system--both to implement it and keep it running.

8) Get your infrastructure ready to deal with new systems.

9) If you were already planning or implementing health IT systems prior to the HITECH legislation passing in February 2009, don't change things now.

10) Finally, don't jump into poorly thought out health IT plans just to try getting the stimulus rewards. "Don't do it just for the money," said Wilson. "It's like having a baby just for the tax break."

How about... why don't you marry somebody today so you can have possibly have a baby with them next year for for a tax break for 4 years? Yes, probably about as absurd as expecting the Repubs will do well in November, and then rescind a bulk of the ARRA stimulus funds?

High-Tech and High-Touch

2010-03-15T15:29:00.000-07:00

In a recent email thread on a physician list serve, Dr. Lowell Kleinman of Family Practice of San Clemente started what I consider a very revealing couple of lists:

Hi-Tech
1. EMR
2. Portal
3. eRx
4. Staff e-messaging
5. Patient recall
6. Preventive Med pop-ups
7. Practice Website
8. Emailing patients
9. Patient Links
a. "How's Your Health"
10. Physician Links
a. up-to-date
b. FRAX

Hi-Touch
1. Planned visits
2. Call backs
3. High 5's
4. Whole family care encouragement
5. Open Access Scheduling
6. Asking about personal matters

I think this is worth a pause. Which list is most valued by patients, and which is most valued by healthcare policy makers? What is the significance of the difference?
Is it possible that over-focus on the first list sometimes detracts from the second?

It's Not About Meaningful use... From THB

2010-03-14T11:14:00.000-07:00

John Moore has yet again cut to the chase and stimulated some great discussion over at the Health Care Blog. I encourage everyone to go there for the full discussion. I could not help but create some excerpts:

...adoption hurdles are not so much about MU criteria, but more about productivity losses in adopting an EHR

...EHR, from one of the big names in ambulatory systems, has been a complete disaster for the clinic.

...The clinic puts the blame squarely on the EHR, which has severely constricted their ability to see patients and as all readers know, clinicians get paid for seeing patients, not trying to use a complex and difficult to use EHR. They are losing money far in excess of what HITECH Act incentives will provide. This story is, unfortunately, not unique, though few EHR vendors will come clean on the productivity hit to a practice.

...Workflow is always a challenge but rarely if ever should one try to code existing workflow practices into a new enterprise software solution be it ERP or EHR. A recipe for disaster. A very delicate balance must be struck between adopting out of the box workflow and customization to existing workflow practices. Careful review of a vendor's solution is required to best match capabilities to needs (doubt many in this industry, esp small practices, have the skills to do this assessment correctly and doubt RECs will be much better).

Then, some real pearls in the comments:

...Many physicians with whom I speak are angry that anyone, including the government, could be so tone deaf as to suggest they should adopt technology that creates even greater economic stress.

David C. Kibbe, MD MBA

...Technology is supposed to help but most vendors don't get why and where they're the problem.

Until we design software and/or devices that take into account the different contexts a clinician finds himself/herself during their daily workflow we will have little success in getting them to implement technology.

Other factors that bring down productivity while implementing an EHR or EMR are:

1. Low clinician buy-in,

2. No clarity or a roadmap that others can follow, the implementors don't understand the needs of the clinicians and the clinicians have no idea what is going to happen next,

3. Lack of training before implementing,

4. Poor workflow analysis, cookie-cutter approach is detrimental to the practice/clinic,

5. Lack of a champion withing the practice/clinic,

6. Poor support, most vendors have very few support people to follow-up on the implementation,

7. Complexity of software, most try to do so much that they end up doing very little,

These are just a few of the ones I have encountered in a career lifetime of implementing software in hospitals, clinics and practices.

The EHR Guy

...According to the top doc at Sermo, 80% of docs feel EHR is good idea but few feel they can afford the upfront/ongoing costs and productivity disruption they inevitably induce.

I feel that the industry would be better served by first implementing the technology that has the capacity to improve care, lower costs, and at least maintain the status quo productivity.

Thomas Schwieterman MD

...I completely agree with Dr. Waldren's analysis. If you look at industries that used IT to computerize the business and realize efficiency, they all automated very well defined manual processes. There are very few of those in health care, and the ones that are standardized enough, like prescribing meds, or billing, have been computerized successfully.

...many doctors come to expect that implementing an EMR is like buying a new car. Sign the check and drive away. It is not. It's more like getting new orthodontic braces.

...I am not sure why, but these very well prepared physicians, seem to understand that implementing an EMR is a process, not a task and they are in for the long haul... They demand training and on site support and often are willing to pay the extra dollars...
At the other end of the spectrum are the physicians that just want an EMR because everybody is getting one, and "would you be so kind to have it installed while I'm on vacation next week?" (real story). These folks will fail miserably and suffer all the way through.

Practicing medicine is probably more complex than flying a plane, and the software to assist in medicine is probably more complex than the software assisting the pilot. In both cases, it takes time to become proficient, and the expectations should be set accordingly.

The Government has asked for input on their proposed EHR certification model. Why not submit your comments, so the Government gets an idea of the prevailing concerns out there?

You cannot affect change unless you make your voice heard.
The comments are public, thus cannot be ignored.

Here is the URL for commenting. You have until 5/10/2010.
http://www.regulations.gov/search/Regs/home.html#submitComment?R=0900006480ab9d0e

Margalit Gur-Arie

...Human factors and making the software work into existing ways of working are usually the weakest point because that requires initial observation and incremental interaction with the users to find out how they would best interact with the system.

Wellescent Health Forums

... This post and it's subsequent thread reveal a truth I have seen since the beginning of my interest in RHIOs and HIE way back in 2003. IT is seductive, everyone thins IT can do things doctors and hospitals cannot. I've used several EMR systems and none of them save time. First of all it turns me into a secretary and I have to assume other peoples' duties. The IT application may improve efficiency by allowing bureaucracy to rule, and also by shifting more of the work load to the physician. One has to delegate many of the systems functionality to nurses and others such as e-prescribing with the physician reviewing and signing off...

Gary L

Back from HIMSS 2010

2010-03-13T15:12:00.000-08:00

Well, I’m about recovered from the annual Health Information and Management Systems Society (i.e. HIMSS) conference in Atlanta 2 weeks ago. In the past, it often took me about 4 years to detox from this conference. This year’s conference was the first one that I actually enjoyed. We, at the SOAPware exhibit, were swamped with interest in how SOAPware can be a part of a solution to empower physicians deserving of their patient’s trust.
In the past, having a focus of using technology to empower physicians, and thus patients, seemed to be all but out of place. The conference has typically been more about industry-centric, rather than patient/physician centric solutions. Industry-centric solutions are more administrative in design with an intent to maximize profits. Don’t get me wrong, having solutions that improved quality and patient care were always considered to be the icing on the cake, but never were the core.
I can recall one of the more depressing HIMSS conferences I went to had one vendor of EMR solutions for ambulatory care raffling off a Hummer. They also had a stretch Hummer limousine that burned through a lot of gas during the conference. They used the limo-Hummer primarily to pick up prospective customers and transport them from the airport to their hotels. It was also used to take the same decision makers (i.e. for EMR purchases) to fancy dinners in the evenings. In visiting with several of those decision makers, it became apparent that improving the well-being of physicians and patients was not high in their priority list. Actually, a majority were fairly clueless as to the challenges in the trenches of delivering care, but they could not conceive of their cluelessness as even a possiblity. Even mysister could have seen through what was happening.
Unfortunately, an overwhelming majority of practices that installed the Hummer solution subsequently hummed right into a nightmare of failed implementations.
Interestingly, the "Hummer solution" received multiple (probably even the most) industry awards that year, and just about all the popular entities that rank medical software consistently had this solution at the top of their listings. The subsequent reality revealed this product was so bad that it is now in the process of being abandoned. Once the product actually tanked, another big boy acquired it, and now they are trying to move users to their other latest/greatest "solution."
HIMSS always includes an exhibit hall covering several acres with hundreds of similar “solutions.”
For me, at this year’s conference, the focus and tone had shifted enough that it was actually enjoyable. There were a greater number of conference attendees appearing to be better informed and less susceptible to the payola schemes. There is a growing interest in solutions that, collaboratively, better serve patients. I am even looking forward to the conference next year. It is my understanding that there is a real interest in making future HIMSS conferences more useful for physician attendees. I welcome and support that intent. If anyone identifies any other conferences/conventions that are proving useful for physicians in their efforts to implement more realistic solutions, please let me know.

The Worst Practice Climate I've seen in 30 Years

2010-02-25T06:49:00.000-08:00

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

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

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

"Meaningful Use" Might Become More Meaningful

2010-02-19T06:24:00.000-08:00

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

Policy Panel Endorses Relaxation of 'Meaningful Use' Requirements

Panel recommends making meaningful use requirements more flexible

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

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

Alternatives to Doctors as Data Trolls?

2010-02-17T15:08:00.000-08:00

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

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

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

One Physician's comments regarding MU Bonuses

2010-02-17T13:01:00.000-08:00

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

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

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

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

David Voran, MD

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

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

IMHO - Uncertain Carrots and Certain Sticks

2010-02-10T06:15:00.000-08:00

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

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

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

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

Will Congress really penalize doctors who don’t comply?

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

Predicted Healthcare Priorities in 2010

2010-02-09T11:44:00.000-08:00

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

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

Priorities will include

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

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

Core Changes being forced in EMR/EHRs

2010-02-08T10:04:00.000-08:00

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

EHR Redux - By DAVID C. KIBBE

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

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

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

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

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

ARRA = American Recovery and Reinvestment Act of 2009.

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

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

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

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

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

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

February "Meaningful Use" Update

2010-02-07T09:33:00.000-08:00

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

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

Meaningful Use Tasks

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

Comments

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

Much more to come...

Continuing Health Information Exchange Disconnects

2010-02-06T10:06:00.000-08:00

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

Attention SOAPware Community

2010-02-04T11:49:00.000-08:00

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

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

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

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

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

Something is rotten in the United States?

2010-01-12T06:42:00.000-08:00

This is worth a read as a vision of the future - Denmark Leads the Way in Digital Care

I spent several weeks in Denmark looking at their health information technology both from the perspective at the point of care, and then from the top, looking down. The experience felt similar to a trip to Fantasy Island. Our healthcare policy makers are wise to learn what does and does not work, and why that is.
Why do clinicians and patients generally love and embrace their information technology in Denmark, and how was this accomplished at a fraction of the cost that is anticipated in the United States?

Happy New Year!

2010-01-06T06:59:00.000-08:00

While I have not had much time to blog this past month, I have not been idle. There has never been a busier time at SOAPware, Inc. Even though we have not yet released SOAPware 2010, there are just under 200 sites using the beta with good reports. In actuality, the beta of 2010 is more stable and has far better performance than SOAPware 2008. We are determined for the releases of 2010 to have the speed and stability that has been our tradition up until 2007. At that time we entered a rapid development mode so that we would be prepared for the future (including certification for meaningful use). The rapid development left us with a backlog of performance and stability issues that we are just now moving beyond. Even faced with the delayed product release, there were more new SOAPware licenses sold in December than in the previous 6 months. As the meaningful use requirements for medical practices to receive stimulus funds have become more solidified, the interest in our approach at SOAPware has increased greatly. In fact, we have experienced such growth at the end of 2009 that we are now in the process of greatly expanding the SOAPware team over the next few weeks.
Personally, my time and focus this month, and for the next few months, is on how to best address the following:
• Data reporting tools
• Patient access to their medical records
• Interoperability or the ability to electronically share information
• Practical and efficient implementation tools that make all of this possible in medical practices having limited resources.
The current solutions in this industry to accomplish the above tasks are very limited and have usually proven to be too cumbersome and expensive even if they are available. We have been diligently addressing these challenges in fashions that we expect will leap frog the current approaches. Hopefully, by the end of Q1 of 2010, we can start to announce and make public more of the specifics.

2009 in Retrospect

2009-12-07T06:29:00.000-08:00

Another good read that supports that significant shifts are taking place is over at the Health Care Blog:

December 06, 2009
2009: A Year of Surprises and Change for the EHR Technology Market
By DAVID C. KIBBE and BRIAN KLEPPER  

Below are the bullets from that post that discuss the shifts that have taken place in 2009:

• Payment for Meaningful Use of EHR technology, not for the software and hardware itself.
• It's become PC to ask tough questions about EHRs, quality, and health care costs
• CCHIT's loss of invulnerability and the displacement of its monopoly on EHR certification
• The Power Shift Away from Legacy HIT Firms
• Interest in HIT by Big Technology Companies

I am in strong agreement!
As a strong advocate of Patient-Centered Collaborative Care, these developments are the most promising I have seen in more than 2 decades. Transformation to PCCC is simply not possible without these shifts. Much more needs to take place, but these are definitely steps in the right direction. These shifts contain many validations of what I have felt compelled to be blogging about this year.

Meaningful Use Rules Due this Month

2009-12-02T11:46:00.000-08:00

Below are more good quotes from:

Reading the Tea Leaves: CMS to Release MU Rules this Month

December 2, 2009 by John Moore, Chilimark Research

1) "HIT vendor pronouncements and promises that they will meet any and all MU criteria are extremely misleading.
Yes, HIT vendors may put in the minimum feature set to become a “certified EHR” (we still do not know what a certified EHR is yet) and they will likely have the capabilities embedded in their solution to meet MU criteria (especially in 2011), but the challenge is not so much the software, but how it is implemented. Implement it poorly and physicians/hospitals will struggle mightily to demonstrate meaningful use of their EHR.

2) CMS will release MU rules with very low barriers to entry in 2011, but 2013 will have much higher barriers/hurdles to jump and same holds true for 2015.

3) The biggest challenge in 2011 and for that matter the entire HITECH Act is the successful implementation of certified EHRs that have a glide path leading the adopter on a clear upgrade and workflow optimization path for meeting MU criteria in 2013 and 2015.

4) The infrastructure for data exchange in support of care coordination is simply not there."

The points about vendor pronouncements and the implementation challenges are spot-on!

More Good EMR Implementation Advice Coming from the Top

2009-11-25T09:05:00.000-08:00

Standards group offers 10 guidelines to make HIT adoption easier
November 20, 2009 | Diana Manos, Senior Editor
HeathcareIT News

Below are the main points from the above reference:

1. Start small and simple.
2. Don't let perfection be the enemy of 'good enough.'
3. Keep cost as low as possible by eliminating royalties, licensing fees and other expenses.
4. Make adoption easy for providers from small practices.
5. Don't try to create a one-size-fits-all system that adds burden and complexity.
6. Separate content and transmission standards.
7. Create publicly available vocabularies and code sets that can be easily downloaded.
8. Leverage standards that already work on the Internet.
9. Position quality measures so they motivate standards adoption and strive for the automation of quality reporting.
10. Support the implementation. – give HIT adopters readable guides and open-source reference implementations.

It is thrilling to see more and more of these more practical and effective approaches in the press. The current alternative that most enterprises are selecting appear to be just about the opposite.

1. Start with too much functionality and complexity so that the technologies interfere with patient care.
2. Choose systems that match the most functions in an RFP rather than select systems that best serves patients and the physicians deservng of their trust.
3. Purchase exorbitantly expensive solutions that silo health information and makes interoperability unaffordable.
4. Make adoption a nightmare for small practices lacking implementation resources.
5. Try to force an inflexible approach to workflows (primarily driven by non-clinicians) into the point of care.
6. Buy into a vendor's initial sales pitch that they can provide whatever information transfer is needed.
7. Choose products that can only update their vocabularies and code sets via expensive and intrusive, bulk upgrades.
8. Adopt systems that are only supporting awkward and overly complex, standards that are proprietary to the current, medical-industrial complex, rather than those that are widely used by all other industries on the Internet.
9. Try to force clinicians to change their workflows to capture data that theoretically will allow "quality reporting" tomorrow while degrading the patient care process today.
10. Expect EMR vendor training, alone, will be adequate to on-ramp clinicians into the systems.

Laying bare the ARRA Stimulus Bill and its pitfalls

2009-11-23T20:42:00.000-08:00

John Moore at Chilimark Research has again summed up the current situation

PHAT: Mash-Up on Healthcare IT

November 19, 2009 by John

I want to include one of his quotes, below...

Bell: “There has been plenty of talk on HIT standards but woefully little on implementation guidance, i.e., how to bring data in, incorporate it into workflow, make it actionable and facilitate efficiencies in care.” Amen.

He pretty much sums it up by implying that it may likely end up being the taxpayers that end up out in the cold when the health information technology industry's emperors are discovered to have no clothes.

Meanwhile, hundreds of doctors are being forced into purchasing lots of expensive EMR pumpkins that will never make it into any meaningful use pies. The insanity will only end when the doctors get more involved in the process and demand a more sane and proven approach that improves, not impairs, their ability to care for patients.

What’s in a Metaphor :-?

2009-11-16T22:18:00.000-08:00

In an earlier blog post, I alluded to a metaphor that the fashion in which many clinicians are currently transitioning to using EMR’s are akin to going from walking to riding bicycles at a time they need airplanes. The fashion of use of most EMR’s is little more meaningful than moving paper to be behind glass. This certainly has some advantages, and there is some evidence that many users of these systems are often quite happy. After all,they have transitioned from walking and obtained “airplanes” of sorts. These clinicians tend to report amazing cost savings compared to what others are spending on airplanes.

It appears I was also in error by implying that today’s more “comprehensive” EMR offerings tend to expect clinicians to walk out on the tarmac, jump into a plane, and take off with often disastrous results. I have found evidence of clinicians literally powering through their charts using comprehensive systems. It appears that some implementations that are limited to “training” are sometimes adequate for flight after all. It has been widely reported, with comprehensive systems, that younger physicians tend to go higher and further. Some of these systems even facilitate that all scripts can be transferred electronically at the same time that general electric bills in the practice actually fall. Why wouldn’t all practices partner with one of these?

To top it off, some appear to believe there is a wise, Greek goddess somewhere that can almost magically guarantee to deliver meaningful information technology use to clinicians at the point of care. Unfortunately, being unable to find any evidence, in the real world, I will assume it to be myth.

Health Data Exchange - The New Health Internet vs. the Old NHIN Models

2009-11-16T12:51:00.000-08:00

November 16, 2009
The Health Internet vs. the NHIN -- A Matter of Control, Cost, and Timing
By DAVID C. KIBBE and BRIAN KLEPPER
The Health Care Blog

Below are summary quotes from the above blog post:

“…Now is a good time to re-visit the plans for a National Health Information Network (NHIN), since we can finally observe and compare different health data sharing and exchange models in the marketplace. NHINs represent an older model that tries to use regional health information organizations (RHIOs) to establish secure networks, privately owned and operated by large provider organizations, mostly hospitals and health systems. The idea was that, over time, each private regional network would develop a gateway to other networks, creating a "network of networks" that would allow Stanford to talk to Partners Health, or Kaiser to Mayo. This communications model was enterprise/provider-centric. Patients/consumers were relegated to depending upon each RHIO's policies for access to their health information. It was also a massively expensive and time consuming - think decades - way to build a health data network…”

“…The Health Internet, on the other hand, has the obvious advantage of not "re-inventing the wheel." As former Intel CEO Craig Barrett famously said, "We already have a network for health data, it's called the Internet." Proponents of the Health Internet argue that, while health data and privacy and security are very important, the data themselves are inherently no different from financial data or the kinds of personal information routinely -- and very securely -- transported over the Internet using fair market encryption and other security technologies to protect it from intrusion, capture, or breach. So why go backwards to create the equivalent of Prodigy or AOL in every state? It could take forever.

We want to give credit to David Blumenthal, the Obama health team members and the folks at HHS who are taking a hard look at how best to create a secure and efficient method for health data transfer in this country…”

Also, see - Covisint Jumps onto PaaS Bandwagon by John at Chilimark Research.

Another article showing little benefit in current EMR implementations

2009-11-16T12:11:00.000-08:00

Little Benefit Seen, So Far, in Electronic Patient Records

By STEVE LOHR
Published: November 15, 2009
New York Times

More of the same… the current approaches to EMR in the U.S. deliver little benefit. Some quotes from the article

…“The way electronic medical records are used now has not yet had a real impact on the quality or cost of health care,” said Dr. Ashish K. Jha, an assistant professor at the Harvard School of Public Health, who led the research project…”

“…The differences, Dr. Jha said, were “really, really marginal.”
To Dr. Bell, the results of the study suggest that government policies should focus on helping physicians, hospitals and the public health system use the technology more effectively.
“It’s not going to be easy or quick,” Dr. Bell said, “but the better information at the point of care, the better health care we will have.”

How much more evidence is it going to take?

Physicians… take your time and beware.

Fascinating Week!

2009-11-14T06:42:00.000-08:00

This week has seen several announcements that are very encouraging for those of us that want to see our health care system evolve from one that is industry centric to one that is patient centric. Particularly exciting is this letter from David Blumenthal at the ONC, who is leading the government's effort to transform our healthcare information systems. He stresses the need to break down barriers to data exchange. Subsequently, Mark Leavitt announces he is leaving the helm of CCHIT. I do have great respect for Mark, but, as I have blogged in the past, I have not felt CCHIT has always represented the best interests of the larger community. Commentaries on recent events by people I greatly respect are below:

Further on the US Healthcare IT Standards Debate – Wes Rishel at the Gartner Group

Blumenthal Beats HITECH Drum – John Chilimark at Chilimark Research

Mark Leavitt Leaves CCHIT - John Lynn at EMR and HIPAA

The Genius of the AND by John Halamka.

John Halamka’s Stunning 180: “Dogs and Cats Should Live in Harmony” by Vince Kuraitis at e-CareManagament

Conspiracy theory Friday (FDA & CCHIT related) by Matthew Holt at The Health Care Blog

For those of us who see the current direction of health care “reform” legislation as fundamentally flawed, this commentary is most intriguing - Will Business Force Reform Back To The Drawing Board? – by Brian Klepper and David Kibbe at the Health Care Blog.

I have spent much of the last month traveling to the East coast, and meeting with leaders in the industry, government, and professional organizations. Particularly, the time I spent in D.C. was most fascinating. There are some cracks appearing in the Bastilles of special interests.

Listen to Muffin

2009-11-12T09:24:00.000-08:00

I was blessed in my youth to have had many great mentors. One of the greatest was a beagle named Muffin.
I no longer hunt rabbits, but I have fond memories of the days when the beagles and I would team to chase the wily rodents. Nobody, who has not had the experience, can quite understand just how connected and integrated one can become with the dogs and the world. It is a real delight to let out the dogs, watch their noses go to the ground, and anticipate the excited yelps once a rabbit’s trail is discovered. One quickly learns to determine, based on the level of excitement in the yelp, how convinced the dog has become that he/she is on a fresh trail soon to lead to the prize.
It can be a very rewarding experience, just as long as there are not too many inexperienced dogs involved. You see, inexperienced dogs will get a faint whiff of something/anything that smells somewhat interesting, and then they will go to howling and yelping so loud that they will even get the more experienced dogs, who should know better, all distracted. If inexperienced dogs are allowed to lead the effort, it leads to lots of howls and yelps, but few prizes. More often than Muffin and I want to admit, he would glance over at me and just shake his head in disgust. He knew that he and I should have known better than to listen to a bunch of inexperienced beagles who were often in error, but seldom in doubt.
The decision-makers in this industry are too often very similar to a bunch of inexperienced beagles. They are quite capable of getting all excited and distracted, and less capable of delivering. This is only going to worsen.
So... physicians... perhaps it would be wise to take Muffin’s advice, and not succumb to intense-misguided yelps and howls. If you have not already, you will likely experience someone showing up promising that if you will just follow their nose, you will end up with a bunch of rabbits.
Stick to the evidence rather than the hype, and follow your nose. Sometimes, the kindest response to hype/yelps and inexperienced decision-makers is a gracious "no thanks" until the path meets your own sniff test.

Who Notices the Difference Between the Pumpkin and the Pie?

2009-11-11T08:50:00.000-08:00

http://www.healthcareitnews.com/blog/meaningful-use-explained

Here is another picture that can reveal far more than words. Way too many still do not understand the meaning of “meaningful use” as defined by the ARRA Stimulus Bill. Why this is important is that medical practices will theoretically be able to benefit from bonuses for “meaningful use” of a certified EMR in 2011. Please notice this subtle, but extremely important separation of what is necessary for practices to receive the ARRA bonus.

1. Acquire an HHS/ARRA certified EMR (this is not the same as CCHIT certification)
2. Report “meaningful use” of the EMR.

Both the HHS/ARRA certification and meaningful use criteria will be defined in the coming months. Entities, other than CCHIT, will be offering this certification.

• Today, no EMR systems are HHS/ARRA certified!
• By 2011, when practices can qualify for bonuses, SOAPware will be just as HHS/ARRA certified as any other EMR.

Using the picture containing the pumpkin and the pie as a metaphor, SOAPware will be just as much of a pumpkin as any other EMR system. However, that is not the end result that is sought. In order to have the pie, the pumpkin has to be put to meaningful use. Lot’s of EMR vendors are lining up to supply medical practices with pumpkins. However, few are delivering much as to the pie-making process itself. Most EMR vendors would have practices and decision-makers believe that the pumpkin and the pie are the same. It is only after physicians are delivered a pumpkin does it become apparent what the difference is between the pumpkin and the pie. At this point, the chefs-clinicians are typically told that before they can have a pie, they must open the pumpkin and individually point-and-pick out every individual seed. Never mind that it should not be necessary for clinicians to personally do this in order to have a tasty pie. This is just how it must be done if the clinicians want to turn a vendor’s particular pumpkin into a pie.
Hopefully this current phase where certain EMR vendors are promising that practices will receive meaningful use pies using their pumpkins can soon be seen for what it really is.

Physician beware!

Who is deciding your "solutions?"

2009-11-05T12:37:00.000-08:00

Survey: U.S. physicians lag behind those in other countries in IT use
November 05, 2009 | Bernie Monegain, Editor
HealthcareIT News

http://www.healthcareitnews.com/news/survey-us-physicians-lag-behind-those-other-countries-it-use

"The patient-centered chronic care model originated in the U.S., yet other countries are moving forward faster to support care teams including nurses, spending time with patients, and assuring access to after-hours," she added. "The study underscores the pressing need for national reforms to close the performance gap to improve outcomes and reduce costs."

I have been to several of the nations referenced in this article (i.e. New Zealand, Sweden, Denmark) and seen their information technologies in action.

In these successful nations, the approach is upside-down to what continues to be happening in the U.S. The patient’s primary physician groups were largely the final decision makers. In the U.S. it is largely politicians and various administrator-experts of some type deciding the “solutions.” Until we, as a nation, can learn the very simple, proven reality that decisions have to be patient-centric, it is only going to get worse.

Hopefully, this phase of blaming doctors for not adopting systems that are not designed by them, for them, will soon become obvious for what it is.

EHR use falls short

2009-11-05T09:31:00.000-08:00

Survey: electronic health records not getting full use

http://www.mlive.com/business/west-michigan/index.ssf/2009/11/survey_electronic_health_recor.html

By Mark Sanchez | Business Review West Mich...
November 04, 2009, 2:00PM

Hopefully the entities making EMR purchasing decision for clinicians will start to get more of a clue as an increasing number of these types of articles and reports are published. Below are quotes. Click the above link to get the full story.

">There’s still a lot of work to be done to fully utilize these systems,” he said. “They (EHRs) could be a lot more help there in terms of how they (doctors) could take advantage of what they have….”

“…Part of the problem is that health care lags other industries in the use of I.T. for business operations, Hamilton said. To get the full benefits an EHR and other I.T. systems offer, physicians have to re-engineer their businesses practices, as well — and there are some doctors who aren’t always able or ready to make those kinds of changes in how they run their practice….”

“…As a result, “the whole health care industry is way behind adopting business practices that others businesses around the globe have long adopted,” Hamilton said….”

“…A PricewaterhouseCoopers Health Research Institute report estimated that a typical medical practice with three doctors could spend as much as $296,000 over two years to acquire and maintain an EHR system….”

“…Like any major strategic move in business, transitioning to an EHR is a significant undertaking for medical practices, Hamilton said….”

“… “It’s a real challenge for physicians to try to implement this on the fly,” he said….”

“…But for those able and willing to make the investment and alter their business practices and models, there is a return on investment over the years through improved efficiencies and productivity on a number of fronts, Simpson said….”

“… “It’s a big investment up front, but there is a payoff that will come over time,” she said.

The federal government is pushing doctors to fully adopt and integrate EHRs into their practices to improve quality and patient safety and generate cost savings. Funding of up to $44,000 is available to doctors through federal economic stimulus money beginning in 2011, though doctors will have to make “meaningful use” of EHRs and comply with federal standards by 2015 or risk having their Medicare reimbursements reduced.

“It has to do more than just have a data base of patient records,” Hamilton said. “They have to implement it in a networkable type of environment”….”

The real challenge continues to be that even for the EMR vendors willing to help practices address the necessary change in business practices, this continues to not be budgeted. It is just too easy for an EMR vendor to accept payment to throw in a bunch of technology because some misguided decision makers decide that is what the practice needs. The practice ends up with little more than an expensive pile of bricks and bags of mortar with no masons around.

EHR Disruptions

2009-11-04T10:07:00.000-08:00

Here is yet another article that is getting out the message...

Physicians still worried about EHRs disrupting work
November 04, 2009 | Patty Enrado, Contributing Editor
HealthcareIT NewsDay

http://www.healthcareitnews.com/news/physicians-still-worried-about-ehrs-disrupting-work

Below are quotes with my emphasis added. Visit the link above for the full story.

...While financial incentives and penalties drive physicians to adopt health IT, the survey showed, they continue to be worried about upfront cost and workflow disruption...

...Not surprisingly, cost and workflow disruption were listed as the two greatest risks for EHR deployment, with 82 percent citing cost and 74 percent citing workflow disruption...

...The industry needs to educate the independent physicians who have not had a compelling business case to adopt in the past, LaFontana said. The legacy vendor community has largely focused on the multi-specialty, complex healthcare systems with deep pockets, she said.

With ARRA and a larger market of small physician offices, vendors have an incentive to develop innovative next-generation electronic health records, she said. Hosted EHRs with monthly subscription fees are providing much-needed new business and technology models for independent physicians...

...The way physicians are educated on health IT and EHRs also needs to change, LaFontana said, adding, "This is an opportunity to start talking about capabilities in the physician's office."

Technology should be seen as an enabler that brings new capabilities and efficiencies to a physician's office, she said. Physicians will be more receptive to health IT if the conversation is around better care and more efficiency of the whole system. For instance, physicians would value an EHR with its ability to identify their diabetic patients who have not had a hemoglobin A1c screening test in the past year.

The primary care physician's world is changing rapidly, LaFontana said. Fee and reimbursement schedules are changing, models of care such as the patient-centered medical home are being introduced, reporting quality meausures is required for participation in pay-for-performance programs. The small physician offices are overwhelmed with administrative complexity, clinical protocols and revenue cycle management issues, she said.

Legacy vendors have under-invested in the small group practices in the past. "You have to look at the entire physician's office," LaFontana said. Vendors and independent physicians need to establish the foundational capability in the office and the workflow around that in order to reap the benefits of health IT implementation...

Polititcal Digression

2009-11-03T14:57:00.000-08:00

Pardon me again as I go on record. It is important to me that our children and grandchildren can see that some of us publicly asked some tough questions at this point in time.

Could the following, written in 1787 be proving to be prophetic?

"A democracy is always temporary in nature; it simply cannot exist as a permanent form of government. A democracy will continue to exist up until the time that voters discover they can vote themselves generous gifts from the public treasury. From that moment on, the majority always votes for the candidates who promise the most benefits from the public treasury, with the result that every democracy will finally collapse due to loose fiscal policy, which is always followed by a dictatorship."

Please help me understand how this is untrue. The evidence might help me sleep a little better. Are we, as a nation, already fiscally irresponsible?

Now, for a little satire, click on the video - The Government Can.

Patient-Centric vs. Industry-Centric Information Sharing

2009-11-03T08:53:00.000-08:00

November 03, 2009
Back to Basics: Toward a Core Set of Relevant and Portable Personal Health Information

By DAVID C. KIBBE

http://www.thehealthcareblog.com/the_health_care_blog/2009/11/back-to-basics-toward-a-core-set-of-relevant-and-portable-personal-health-information.html#comments

…the reason why we as citizens lack routine access to even the most basic summary of our personal health information, and therefore can't put those data to work for us as individuals or as a society, is that we lack the political, cultural, and professional will to unite these disparate and unconnected bits and pieces of information together into a Continuity of Care Record.

But ARRA also states, in part, "...the individual shall have a right to obtain from such covered entity a copy of such information in an electronic format and, if the individual chooses, to direct the covered entity to transmit such copy directly to an entity or person designated by the individual, provided that any such choice is clear, conspicuous, and specific." This is, essentially, a re-statement of the requirements of HIPAA that patients/consumers have a right to their health information, and adding the obligation to make this information available in electronic (digital) format. Finally!
What is encouraging is that the definition of Meaningful Use issued by ONC, by way of turning the legislation into federal regulation, includes amongst its set of specific activities health care providers need to undertake to qualify for incentives from the federal government, a requirement that doctors and hospitals must do the following:
• Provide patients with an electronic copy of their health information (including lab results, problem list, medication lists, allergies) upon request.
• Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies).
• Provide access to patient-specific education resources.
• Provide clinical summaries for patients for each encounter.
Source: Health IT Policy Council Recommendations to National Coordinator for Defining Meaningful UseFinal- August 2009
http://ncvhs.hhs.gov/090518rpt.pdf ...

The growing interest and support for the CCR standard is another glimmer of hope that we are finally on the path to more of a patient-centric, rather than an industry-centric view of health information.

Staffing Issues with EMR Implementation

2009-11-02T10:44:00.001-08:00

The quotes below are pearls from - How electronic medical records affect staffing

http://www.ama-assn.org/amednews/2009/10/05/bisa1005.htm

Staffing needs will change after medical practices adopt electronic record systems. Some practices may be able to cut staff. But others may hire, and some may shuffle responsibilities.

By Pamela Lewis Dolan, amednews staff. Posted Oct. 5, 2009.

...One practice installed an electronic medical records system and cut 12 staff members. Another practice added two full-time employees.

These two very different scenarios help underscore one truth: The only definite aspect about determining post-EMR staffing needs is that there is no magic formula.

A variety of factors come into play, including practice size, scope and, most importantly, the practice's goals. What happens in terms of the number of staff -- and how the EMR changes what that staff does -- will largely depend on the problems the practice is looking to address with automation.

If the goal is to reduce costs, the end result will look much different than if implementation is to improve quality of care or to change a practice's branding, ...

...Other changes are not so easy to predict, and could depend on how willing your employees are to adapt and learn new skills.

...Mike Doyle, CEO of Carlsbad, Calif.-based Medsphere, which installs the VA-created VistA EMR in hospitals and physician practices outside of the Dept. of Veterans Affairs system, said he strongly believes that the more specific a practice's goals, the better the outcomes...

..."Some have this vision of Xanadu. That they just drop the thing in and somehow things are going to get a lot better. Unfortunately, I think some were sold a bill of goods from the EMR vendor about how easy it is and how seamless it is. Most underestimate [the transition process] greatly, particularly in the way of staffing," Kerr said...

..."If the practice isn't already spinning like a top, it can get ugly" after EMR implementation, said Dr. Pifer, who worked as an informatics officer for the University of Pennsylvania Health System when it rolled out EMRs to its outpatient practices...

...Mullins said practices that achieve buy-in from staff members early in the process will be able to set specific staffing goals more quickly. When the staff is excited about the impending implementation, they can then help define how their job responsibilities will change...

...Training staff to learn new skills can help grow the practice, Mullins said, as employees take a role in defining how the practice will operate moving forward. "If they are engaged in something, they will adopt and embrace it willingly."...

...A locally hosted system, the type often used by large practices, would likely require IT staff, either in-house, or via an on-call support contract. But many small practices are going with application service provider models, which means the server and data are stored online instead of in-house...

...Communicating with staff can help curb anxiety...

...Being open about expectations with employees from day one will make the transition smoother and ensure no one is blindsided, Dr. Donnersberger said...

...When employees feel they are a part of the process, they can help shape their post-implementation roles, even if it means that role is played out elsewhere...

...Bob Kleinbauer, chief operating officer of Community Care Physicians, a multispecialty group in Albany, N.Y., said constant communication with his 30-member office staff raised the interest level.

Some of the physicians became so excited about the project that they pursued new career paths within the practice, and now serve as health information technology leaders...

Great Image at the HealthBlog Sums it Up

2009-11-01T07:49:00.000-08:00

The first image on this blog post really sums it up:

See Why clinicians fear electronic medical records and what we can learn from Toyota and Disney for the story. by Bill Crounse, MD Senior Director, Worldwide Health Microsoft at http://blogs.msdn.com/healthblog/archive/2009/10/29/why-clinicians-fear-electronic-medical-records-and-what-we-can-learn-from-toyota-and-disney.aspx

Below are quotes from Dr. Crounse:

"...Have you ever wondered why so many physicians resist going “electronic”? Trust me, it is not because they fear technology..."

"...It is not because doctors and nurses are Luddites when it comes to using computers. It is because they fear losing time. It is because they resist using technology if it doesn’t, or they perceive it doesn’t, add value. Even if “meaningful use” of electronic records translates to fewer errors, safer care, and higher quality; unless it also fits like a glove into clinical workflow, saving time and saving money, the trade-off just isn’t worth it in the minds of most clinicians..."

The Comments on this blog post contain some gems:

"...You make a very valid point; for providers, you can't have "meaningful use" without the word "use" (any EMR/EHR has to be easy to implement and adopt) and from a consumer perspective, it's not about "meaningful use" at all but about "meaningful results" ..."

"...One size does not fit all – Each specialty has unique requirements for medical documentation and information viewing. The design of any system should begin with this premise, not have it discovered later. How information is displayed on the screen, how images are displayed and stored, how quickly certain items are retrieved for viewing and what items should always be displayed needs to be determined at the outset otherwise usability suffers..."

"...Easier on the other hand saves me time and helps me do my job documenting more quickly and efficiently so that I can focus on the important aspect of medicine, which is taking care of patients..."

"...we have to dramatically improve clinical workflow, care quality, patient satisfaction and even the cost of care..."

"...I think this stems from experience of too many poorly thought out systems which were introduced by managers without thought for the clinicians using them and their specific needs..."

"...Besides, while we all can appreciate what Toyota has done for cars, medical care is far from assembly line processing. In fact, my effort at using IT in practice has actually been to get rid of an assembly line type process, and reintroduce meaningful interaction between patient and clinician..."

"...The glaring omission I see is that IT companies have not utilized the expertise of clinicians in the trenches to build/improve systems that can actually work in clinical medicine..."

SOAPware Release Status

2009-10-31T07:51:00.000-07:00

After 7 months of testing and private beta, SOAPware 2010 has now gone into public beta. Even though it is a beta, it is much faster and more stable than the current release of SOAPware 2008. As of yesterday, it appeared that 14 sites had installed it. It is not possible to determine yet how many are using it live, but probably half are doing so. So far, few problems have been reported, so we are hoping we will be able to go into a full release sooner rather than later. This first installer is only for SOAPware 2008 upgrades, but next week we hope to complete the installer for versions prior to 2008. From there, we can start merging in the advanced e-prescribing and the billing system. Subsequent to that, we will be working on simplifying workflows and advanced SMARText management as we incorporate more robust information exchange (e.g. registries, portals, etc).

Poll on effect of Stimulus Bill on EMR adoption

2009-10-31T07:37:00.000-07:00

Houston Neal over at the software advice blog is running a poll on Obama’s EMR/EHR Stimulus of 2009 – Creating Buyers or Tire Kickers? Click on the link, and another couple of clicks is all it takes.

My Recent Interview at the EMR and HIPAA Blog

2009-10-25T06:42:00.000-07:00

A good blog to follow is EMR and HIPAA. John is doing a great job of telling it like it is rather than just sipping the spiked industry punch as a majority of industry shills seem to be doing. I was pleased to offer a recent interview:

October 21, 2009
Interview with President of SOAPware EMR – Randall Oates
Written by: John

I invite you to visit and follow that blog, and here are what I consider the main points I offered in the interview.

…2005 to present – Focus (i.e. the SOAPware team has focused) on transition to next generation, comprehensive EMR – We retreated from major marketing, and engaged a complete rewrite of the software. We are now focusing almost all resources on completing the product suite and simplifying what is presently an often overly-complex interface…

...Even though we will soon release our fully integrated system, we will continue to work with interfaced solutions...

...The paper superbills physicians tend to use, today, will have to expand from one page to at least ten pages (i.e. 2013-2015). This, along with the need for clinicians to perform accurate reporting of “performance measures” at the point of care, will likely render interfaced systems (with billing clerks expected to enter the data) as too cumbersome and limited to be practical...

...We already have waiting times for our training services, and this is likely to worsen in the short term. Long term, we are engaging several initiatives in order to be able to quickly scale up for the demand. Not only are we hiring more training staff, but we are creating a new “partner” program that is fairly unique. For example, our current users will be encouraged to become certified SOAPware trainers in their own communities. (Intuit has done this with great success with QuickBooks, and disrupted an entire industry as a result.)...

...We will definitely be going for HHS certification so that our users can qualify for the ARRA bonus payments. Whether or not we will also go for CCHIT certification in the future remains to be determined. Presently, CCHIT is the only entity on the immediate horizon to certify for HHS, but other certifying entities are likely in the works. It is just too early to announce who we will utilize for future, HHS certification...

...SOAPware can either be used either as paper behind glass or as a comprehensive system collecting real data. More importantly, our design facilitates a gradual migration from the simple free-text narrative to as much structured data as is necessary, and in fashions that are less likely to lower physician productivity along the way...

...The other down side to DNS (i.e. Dragon Naturally Speaking) is that it does not yet function ideally in either ASP or cloud-based solutions. While the past ASP approach to delivering technology solutions to practices has not seen great success, the emerging cloud-based solutions will likely trigger the EMR revolution. For example, our hosted, cloud-based solution, allows for the practice to have their own virtual server in the Internet cloud. This removes the expense and hassles of attempting to maintain a clinic server, network, back-ups, etc, but the practices are not just limited to only the software and solutions that the typical, more limited ASP approach can offer. I just hope the engineers can figure out how to make speech recognition more fully compatible with these hosted, virtual, or cloud-based solutions before the end of 2010.

...What is mainly missing (in the EMR industry) is an accurate perception of reality. That is… recognition that it is nothing less than insanity to expect physicians to become data entry clerks! In the future, we are going to look at the current approaches to EMR implementation in the same fashion as we now view the practice of leeching and blood-letting of the past...

... (Missing in the industry) A proper understanding of the necessary process changes practice need to make before even considering the available EMR solutions is generally missing. Along with this is a dearth of approaches advocating tolerable, incremental evolutions...

...We are missing standards allowing for the sharing of information that is patient-centric rather than industry-centric. The former tend to be easier and more practical for patients and small medical practices. The later tend to be what the current, moneyed-controlling entities in healthcare prefer...

...EMR’s need standards in order to be more open-platform in order to support best-of-breed solutions. No single vendor can deliver a monolithic application that is ideal for almost any specific practice...

...We have a very large community of SOAPware version 4 users (i.e. paper behind glass method) that now need to begin the process of migrating to more comprehensive use of information. This needs to be properly managed via clinician leadership and practice readiness assessments in order to be most efficient. These practices need to upgrade within the next few months, because the second half of 2010 needs to be free to add in the registry (i.e. population reporting) and patient portal (i.e. electronic communications) that are to follow the release of our integrated billing system. Again, these, more comprehensive functions, need to be added only after careful planning and practice preparation...

I wish I could come up with some little pithy witticism at this point. However, the problem with any humor regarding this industry (as with Jonestown) is that that joviality tends to either be a little on the dark side, or the punch lines are too long.

Now is the Time, Here is the Path

2009-10-21T11:33:00.000-07:00

Below, are quotes from - Ten Steps to a Patient-Centered Medical Home
Family Practice Management
September/October 2009
Anton J. Kuzel, MD, MHPE

...While these projects have obvious merit, I want to suggest what may be a simpler approach – one that does not depend on new models of financing and that follows a logical series of steps, each building on the one before to develop the capacity and infrastructure for a high-volume practice capable of sophisticated population care and management...

Step 1: Improve documentation and coding.

Step 2: Hire more nurses or medical assistants.

Step 3: Implement advanced access scheduling.

Step 4: Increase the number of patients you see per day.

Step 5: (Optional) Expand hours

Step 6: Buy and implement an EHR.

Step 7: Start doing systematic, population-based care.

Step 8: Buy and implement a patient portal.

Step 9: Work with local health systems to create electronic linkages.

Step 10: Improve management of high-cost patients.

...It seems to me that we have a clear opportunity to make our practices and our health care system much better than they are now, and we may actually already have the needed resources. It’s time to get started...

I greatly encourage a vist to this very valuable article to learn the essentials of this journey.

There Are Risks During the Interval Until the k-EMR is Available?

2009-10-17T05:42:00.000-07:00

In an earlier post, I described some of the main characteristics of the k-EMR. it does not yet exist.

Just about all the evidence indicates our impending national investment to promote current health information technology solutions is on a a tragic course to trigger even more skepticism and distrust by physicians and their patients. This is because present EMR initiatives (based on multiple, published surveys), are delivering failing solutions to the majority of medical practices. The evidence confirms that most physicians lose productivity because they are converted into data entry clerks. Patients, more often than not, end up with less, rather than more access to their trusted physicians.

Why spend a lot of effort and money until there is a proven path that at least provides a critical mass of efficient data generation and connectivity for physicians and their patients?

What evidence is there, anywhere, that the value propositions of current EMR initiatives being proposed (i.e. by those who are not patient representatives or their physicians) are wise investments for medical practices?

The EMR Market Challenge and Opportunity

2009-10-14T07:28:00.000-07:00

Few EMR customers perceive the importance of the necessary process change, so few will budget for it. They confuse implementation with training. Training is the 1/3 and implementation the 2/3rds.

Resources, that practices adopting EMR's currently allocate to software/training, need to be shifted to implementation.

Avoiding Failed EMR Implementations

$598 million from the ARRA Stimulus Bill is to be directed toward delivering the process change in small practices in 2010.

How the Feds will spend the first $1.16 Billion on HIT

Will the first $598 million really be invested toward meaningfully facilitating the change process that is necessary in typical medical practices? Or, will it be more of the same, flawed approaches?

More on EMR Failures

2009-10-13T04:14:00.001-07:00

From -Healthcare Informatics
Posted on: 7.31.2008 6:13:49 PM

EHR Failures: Can We Do Better Than the Average?

The following are exerpts from Healthcare Informatics. Please visit this site for the full story and others of value.

...To further develop this point: It’s difficult to distinguish between EHR failure rates that apply to physician practices vs. hospitals, but here are some of the percentages that are quoted:

- Oh no! Half of all current EMR’s fail! Technology for Doctors, 2007

- 19% of EMRs are uninstalled; 30 percent are not used by at least some physicians, Medical Records Institute, 2007

- Avoiding EMR meltdown: How to get your money’s worth (“About a third of practices that buy EMR systems stop using them within a year”) AMNews, 2006

- The failure rates of EMR implementations are…close to 50%.” Proceedings of the 11th Annual Symposium on Health Information Management Research, 2006

- “Industry experts estimate that failure rates of EMR implementations range from 50-80%.” A Commonsense Approach to EMRs, 2006

- “50% of EMR system implementations result in failure.” International Journal of Technology Assessment in Health Care, 1997

To use the lowest figure cited, let’s say that approximately twenty percent of hospital EHR installations fail and the system is removed. In these cases it’s likely that the entire investment in hardware, software, implementation costs, lost productivity (and other costs more difficult to measure) is lost. If this average investment is ten percent of annual revenues (or $100 million for a $1 billion IDN) the other 80 percent of EHR implementations must generate a return of 2.5 percent of annual revenues each just to get back to even.

Under these conditions, the relatively small number of very successful installations is not enough to pull the average EHR return into positive territory, and the CBO is right in concluding that “By itself, the adoption of more health IT is generally not sufficient to produce significant… savings”.

But what if you could increase the chances of success? Make it much more likely that your EHR would succeed than fail? Then the benefits demonstrated by the successes are well worth the investment. That’s the question at hand for hospital executives: “Can we do better than the average?” I believe the answer is yes, especially since the bar is set so low, but it will require a different approach to EHR implementation, one focused on system value (benefits) instead of just technical success or process changes.

As a long time owner of a technology training company and former CIO of an international technology training company I can say that what you are seeing in the EHR implementations is no different than what industries saw years ago in implementations of ERP applications such as SAP, Oracle, Bond and etc. Maturity has solved a part of their issue by understanding that a technology implementation is 80% change management/education and 20% technology.

Training is a key component to the success of a technology implementation that encompasses the change management and teaching the end user how to effectively utilize the new technology. The old "super user" training model does not work, but time and time again I hear and see that change management and training are merely an after thought at the end of an implementation. Assessing the trainee population is overlooked and an assumption that all users already have the requisite knowledge of computer usage is wrong... In fact in recent surveys, over 30% of the working public cannot effectively use a computer or navigate the internet, but yet we question why the adoption rate for an EHR implementation is so low and ends up in failure. Many implementations depend on a system analyst to design and configure the workflow and associated applications set up, then create training materials and deliver training! No wonder we have failures. Such little thought or importance put into what might be the most critical aspect is a formula for failure. Professionally designed courseware utilizing advanced adult education concepts, creating standard content templates, and measuring the effectiveness of training are all a part of a well defined implementation.

A few key considerations:

Who needs to be trained?
What do they need to know to do their job?
When do they need to be trained?
What is their base knowledge of the technology?
What do we need to do to have them at a minimum knowledge level prior to go live?
What resources are required?
How are we going to register, track assess and monitor training?
How are we going to deliver training?
How are we going to get our delivery staff prepped?
Do we have Executive buy in?
Are employees and management aware of the time commitment to get trained?
Do we have an effective communication plan including gathering and using feedback?
How are we going to measure the effectiveness of our Change Mgmt/Training program?
Have we adequately budgeted for training? ...

I encourage you to ask how your approach to EMR implementation is similar to and different from the current approaches to EMR implementation?

Based on the approach that you are taking, where is there any hard evidence that your likelihood of success can be any greater than the industry norm?

Who was it that said that those who do not study history are doomed to repeat it?

Current EMR Sales/Marketing Approaches are Misguided

2009-10-11T10:39:00.000-07:00

To be economically viable, today, the industry has largely had to focus sales and marketing efforts primarily upon products/services to serve the minority of practices that are atypical (i.e. early adopters and large and/or integrated practices). Both of these practice types contain resources beyond what is available to most physicians. This, combined with the fact that busy physicians are too challenged today with just surviving so that the scope of the change seems all but overwhelming. As a result, most practices will fail to be able to deliver the data needed to meet "meaningful use" without active facilitation. There is a continuum related to practice readiness for EMR and patient-centered collaborative care:

20% of medical practices can change their process without much need for outside facilitation.
20% of medical practices can utilize implementation surveys, checklists, peer groups and succeed with minimal facilitation.
60% of medical practices need active facilitation that is often on-site and more specific.

Real World Lessons in Practice Transformation

More – Real World Lessons

What if there was some nature of vetting, as to readiness, that is part of the pre-implementation analysis before EMR vendors were willing to sell into a practice?

The Process Change Necessary to Implement an EMR

2009-10-11T05:39:00.000-07:00

Again, EMR Implementations must start with the process rather than the technology, and must go through the following sequence to avoid high failure rates:

1. Pre-Implementation Practice Readiness - Issues are independent of EMR choice.
2. Implementation Change Management at Go-live - Issues are inseparable from EMR.
3. Continued Evolutionary improvements - Issues are inseparable from EMR.

• High Performing Patient Centered Practices
• A Remedy For Health-Care Costs
• A Medical Record Carol?

I continue to be amazed as to how few in the industry are really addressing this necessary, fundamental change process. However, a chosen few that have made strides. Examples include TransforMED and a few medical societies and quality improvement organizations (e.g. Monroe County Medical Society - Dr. Ali Loveys). The real challenge is less the creation of the necessary implementation surveys/checklists, and is more about having facilitators available to the practice that know how to use these tools within diverse practices that have limited resources.