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Curbside Consult with Dr. Jayne 7/21/14

July 21, 2014 Dr. Jayne 4 Comments

A lot of people are talking about the recent JAMIA article that looked at whether Stage 2 Certified EHRs are ready for prime-time interoperability. It concluded that four key areas need to be addressed to improve CCDA quality. One area is “terminology vetting” for the multiple vocabularies used including SNOMED, LOINC, and RxNorm. Another area is reducing the amount of data that can be “optional” with a product still receiving certification.

I agree with both of those, as well as the paper’s assertion that document quality needs to be assessed in “real-world clinical environments.” However, it’s highly focused on the technical aspects of document exchange rather than the actual intellectual quality of the document being exchanged. I wrote about the quality (or lack thereof) of some physician notes a couple of weeks ago. Unfortunately, there are more elements besides the provider’s narrative and abbreviations that are problematic.

My health system is the ultimate best-of-breed nightmare, so I can attest to the fact that some vendors’ incorporation of the clinical problem list into the CCDA reads like one of those “choose your own adventure” novels. Is it an active problem, chronic problem, recurrent problem, or something that just happened once in the past? With some of our documents, I just cannot tell what it is trying to depict. I often feel like I have chosen a path to nowhere, just like the books.

There are fundamental differences between how physicians and other clinicians are trained to sort information. When I trained at a fairly “classical” medical school, we were taught that all of the patient’s problems were part of the Past Medical History, even those that were not truly past such as chronic hypertension, diabetes, obesity, etc. When I helped bring our organization into the EHR universe more than a decade ago, it took while for providers to get used to the idea of a chronic problem list being different from the PMH because many providers still wanted to include everything in the PMH.

Now we’re at the point where we have to educate them on the SNOMED-codified Problem List and how it differs from the ICD-10 Assessment List, even though there may be two codes that represent a single disease. I have finally gotten over it, but many of our physicians are still struggling with the concept despite having been trained two or three times.

Some of the CCDAs seem to comingle the two. It’s maddening. I’m tired of opening vendor support tickets to try to figure out if they’re functioning as designed or just messy. They must meet the letter of the law to receive certification, but that doesn’t necessarily mean they’re good for patient care or educating the patient on the conditions noted in his or her record.

Whether or not Eligible Providers are meeting the letter of the law or the spirit of the law with Meaningful Use is another hot topic. Lately, my running habit has been taking a toll on my feet, which prompted a trip to my favorite foot specialist. He’s a good friend of mine and part of a husband and wife team practice. They’re fiercely independent and have successfully deployed a Certified EHR over the past couple of years. We always chat about EHRs and where they stand.

I knew they were getting ready for attestation when the rooming technician came in with a wrist blood pressure cuff. In practice, I’ve found those kinds of cuffs to be notoriously unreliable, so I asked him if he wanted me to just self-report some numbers that would be accurate. He declined my offer and proceeded to document the 141/87 that the cuff read out. My blood pressure hasn’t ever been that high, but now it’s in my chart. When my colleague came in, I asked him what he thought about it. He wasn’t thrilled and said it sounded like some coaching was in order.

We talked a little bit about integrated vital signs monitors that would make things easier. He then he admitted that they’re thinking about throwing in the towel on MU. Their vendor has been doing a good job helping them dot the Is and cross the Ts, but the thought of an audit scares them. With all the points that must be perfect for an honest attestation, they are wondering if it’s worth the risk. Right now their patients are happy, their staff is happy, and their practice is running well enough from a business standpoint, so why upset the apple cart?

I don’t disagree with them. At times it doesn’t seem like it’s worth it. A lot of practices are just operating out of fear of future penalties or fear that commercial payers will adopt the CMS standards. Fear isn’t really a healthy way to run a business, however.

Since we’ve been friends for a long time, I offered to do a peer audit for them using my knowledge of MU to see how close to compliance they are. There are plenty of professional consulting firms that will do practice audits and they may want to ultimately do that, but are interested in seeing where they sit from a friendly point of view.

In the olden days (or in a truly free market economy) we could have traded some consulting for a free cortisone shot or something like that, but the insurers would take a dim view of that, I’m sure. Given my CMIO role, I also have to be careful about doing anything that could be interpreted as a donation from the health system so I don’t run afoul of any anti-kickback rules. When all is said and done, it will be interesting to see how many providers end up opting out of MU and what percentage of them are independent physicians.

Are any of your providers opting out of MU? Email me.

Email Dr. Jayne.

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Currently there are "4 comments" on this Article:

  1. Clarity for MU is on the horizon next year with the implementation of ICD-10-CM/PCS along with linkage to SNOMED and The National Quality Forum (NQF)! It’ll take sometime to grasp this new linkage concept but the value and quality aspect will be beneficial to both practitioners and patients. TPD!

  2. Re: Providers opting out of MU.

    A recent EHR Intelligence survey of 18,500 providers found 22% of respondents were disregarding or opting out of MU.

  3. This article gets to the real meat of the matter, it’s not about formats and standards, but how is it going to be used in the real world. And I’m sorry for saying this to someone who seems to be an extremely knowledgable and caring doctor, but in my opinion – MU is for the patients to decide not the doctors.

    That being said – I would challenge anyone to find a single patient who is not in Health IT to even explain what a CCD, CCR, CCDA, SNOWMED, ICD-9/10 is. Consider this – How much do you know about DNS, TCP/IP, SSH, HTTP, SMTP, DHCP. As a consumer you don’t really know and don’t really care, but what you do want is the website to come up when you click on the link. All of these lower protocols need to work in order for the end result to happen.

    I was at DARPA from 1987-1992 when the Internet really took shape (it was not even called the Internet when I got there). We are in a similar place in time with regard to Health IT standards. Until every day consumers – and I don’t mean doctors – can use their medical information without any knowledge of underlying technology, none of these efforts are going to be valuable to the consumers (sometimes called patients when they are having bad days). I know that the IT world focuses on the business users, but if we learned anything from Apple, we should learn that consumers are quite a powerful force (Apple does only 2% of it’s business in commercial and government space and it’s the largest company in the world).

    The comments in this article are valid – Forget about things like SNOWMED vs. ICD9 encoding – try bigger issues like – Why are EHR vendors putting HTML inside CCDs? Why can’t we have real time/date stamps for events (GMT + timezone offset) like the rest of the IT world has had for the past decade? Has anyone even quality assurance reviewed the CCDs that come out of these vendors? I can tell you that looking through some of the top 10, I’ve seen completely missing immunization records (they exist in the EHR but not in the CCD), completely missing Vital values (the ranges and observation codes are there, just no values), and the practical things that would actually be hugely meaningful like:

    Upcoming Appointments
    Doctors Notes
    Discharge Instructions

    They aren’t part of the CCD. You tell me, wouldn’t that be kind of “meaningful” and wouldn’t you get an improved outcome if you had easy access to these three things?

    (what follows is kind of a product pitch – so please stop reading now if that offends you!)

    I could go on – but I think you get the point. The good news is that my company has spent the last 18 months developing a consumer centric (patient centric I think people like to call it), mobile solution that can take whatever is offered in the CCD, CCDA, BlueButton files for most of the major vendors and providers and let you use them on your phone or tablet. It’s going to be free and launching in September. So if you are interested in seeing truly meaningful use, watch for Well – a mobile App for the consumer in September, 2014







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