Time Capsule: Notice of Proposed Rulemaking: Everybody Must Watch Jay Leno at 11:35 Eastern

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in January 2010.

Notice of Proposed Rulemaking: Everybody Must Watch Jay Leno at 11:35 Eastern
By Mr. HIStalk

I’m excited about the government’s encouragement (or mandate, depending on your perspective) that doctors use electronic medical records. Mandatory progress must go on despite the gripes of a few malcontents (i.e., the majority of doctors, patients, and taxpayers).

It is a travesty that more healthcare providers don’t use computers. Software can make healthcare as transparent, efficient, and consumer-driven as other organizations that have spent billions of taxpayer dollars on technology (such as the IRS, the military, and Medicare). The federal government must intervene when minimally educated and technologically illiterate doctors refuse to adopt EMRs voluntarily in their private businesses.

(It worked for TVs. The government decided that Americans should enjoy the benefit of watching cultural programming such as “Judge Judy” and “America’s Next Top Model, in visually stunning high-definition glory. The FCC ordered broadcasters to switch exclusively to HDTV, thus stimulating the economy by selling tons of imported flat panel TVs, enriching lenders as financially strapped citizens let the balance ride on their high-interest credit cards, and increasing landfill employment to bulldoze now-useless tube models.)

In fact, I believe that this “cure all ills” administration needs to take a step further. It’s time to support the most visible employee of the biggest EMR vendor company – Jay Leno.

Jay’s audience, like that of EMRs, has been pathetic in number and more indifferent than loyal. Hype and gimmicks weren’t enough to entice viewers (even the large number of unemployed ones with nothing better to do) to sit through an hour of his cheaply produced and repetitive nightly show.

Jay is a national treasure, too important to be left to the whims of fickle TV viewers. It is therefore essential to mandate, for the economic good and the image of America worldwide, that every one of those new LCD TVs must be tuned to NBC’s “Tonight Show” every night once Jay comes back.

(NBC’s owner GE bought back Jay’s 11:35 slot with $40 million of its own cash. Admirably, it did not ask for a federal Conan bailout.)

To encourage the development of cultural refinement in appreciating Jay’s hilarity and keen interviewing skills, it will be necessary to equip cable and satellite receivers with sensors that will detect households that are not compliant at least four of five consecutive weeknights. Those tuning in will receive a rebate on their bills that non-watchers will forego. After a few years, those non-adapters will have a “Jay support surcharge” included on their bills.

Each viewer must also be a Meaningful Viewer, jotting down Jay’s bon mots for repeating later, paying attention to the commercials, and laughing with significant amplitude at Jay’s latest carefully constructed John Edwards quip (rim shot!) This, too will be monitored electronically.

Jay is an experienced late-nighter, so it would not be prudent to spent taxpayer money on untested hosts such as Conan O’Brien. Therefore, Jay alone has been certified for the 11:35 slot. All other programs, such as the Magic Jack infomercial or “Cake Boss” marathons, are not permitted even when Jay has on dull guests such as Paris Hilton or Larry the Cable Guy.

Lastly, it is imperative that Jay receive feedback about which of his jokes and sketches are working. Technology will be added to the set-top box to solicit constant feedback about the quality of Jay’s humor, which will be de-identified and aggregated quarterly for analysis by the same crack NBC executives who couldn’t make his show work before. With this information, Jay can develop monologue templates that the government will mandate for use by up-and-coming comics, thereby protecting viewers from edgy humor from fresh newcomers.

All of this government spending will actually prove profitable to taxpayers, according to bailout expert Timothy Geithner. While Jay’s show will probably never make money, it will provide an effective advertising platform for the upcoming Chevrolet Volt. What’s good for GM is good for the country, given that the country now owns 61 percent of GM.

Does Jay think this bold, essential plan will work? You bet! His new sidekick Triumph the Insult Comic Dog (merged from a previously retired product line) says you can “bank” on it (rim shot!)

Morning Headlines 1/3/14

President Obama Announces More Key Administration Posts

Leon Rodriguez, director of the Office for Civil Rights of HHS, will be nominated to take over as the Department of Homeland Security’s director of the United States Citizenship and Immigration Services.

Other new NC laws taking effect with the new year

In North Carolina, a law that took effect on January 1 requires that all hospitals connect with the North Carolina HIE and submit data on any services paid for by Medicaid.

Pentagon Kicks Off Procurement To Maintain Current Health Record Until 2018

The DoD initiates a procurement process that will allow it to stick with its existing EHR until 2018.

Cerner ‘seals the deal’ on $4.3 billion office plan at Bannister site

Cerner completes its purchase of a 237-acre property outside Kansas City where it will build a $4.3 billion campus over the next 10 years, eventually providing office space for 15,000 employees.

Digital Health Funding: A Year In Review

Health IT startups raised $1.9 billion in VC funding during 2013, a record breaking year and 39 percent increase over last year. Most money went to EHR vendors, big data startups, population health tools, wearable biosensors, and patient engagement platforms.

News 1/3/14

Top News

President Obama announces that he will nominate Leon Rodriguez, director of the Office for Civil Rights of HHS that enforces HIPAA, for Director of Citizenship and Immigration Services in the Department of Homeland Security.

Reader Comments

Photo: Brian Snyder/Reuters

From DZA MD: “Re: Baystate Medical Center. Cerner PowerChart crippled with record inpatient census and Nor’easter in full effect. Unable to process timely discharges before brunt of storm arrives.” Unverified. As I write this Thursday evening, Massachusetts is about to get nailed by a winter storm that will bring up to 30 inches of snow in places with wind chill as low as 20 degrees below zero and even colder Friday night.

From Dirk Benedict: “Re NextGen lawsuit. Mountainview Medical Center in Montana sues NextGen, saying it didn’t install its $441,000 EHR system as promised.” The six-bed hospital contends that NextGen was to install a system “which would permit MVMC to demonstrate ‘meaningful use’ of such electronic health records through all stages of applicable federal regulations” and was to complete implementation by October 1, 2013. According to NextGen’s website, NextGen Inpatient Clinicals EHR 2.6 is 2014 Edition certified as a modular EHR, so it’s difficult to determine what the exact issue(s) might be. NextGen provided us with this statement:

We cannot comment on the pending litigation, other than to say that we firmly believe the allegations made by Mountainview Medical Center are without merit and we will defend against them vigorously. We confidently stand behind the quality and performance of our products and offerings.

From Intractable Vermonting: “Re: Vermont health insurance exchange. The cost overruns have been tremendous and the politicians responsible pass it off as ‘changing project scope costs money.’ 99 percent of all IT leaders in the US would be fired if they managed a project in this fashion. Also, security is the last thing that is built into the technology before it goes live and I am sure there were shortcuts taken with all these exchanges. The hackers know that most sites require Social Security number to register.” The Vermont Health Connect insurance exchange website is the most expensive IT project ever undertaken in the state, running up a tab of $172 million, of which the federal government contributed $48.7 million. One big contractor was the ever-present CGI, which managed to turn its $42 million contract into $84 million worth of billables while missing key deadlines that kept the site from being ready on October 1. CGI was smart: the state says the delays cost $26 million, but CGI’s contract says it can be penalized a maximum of $5 million.

HIStalk Announcements and Requests

It’s time for the HISsies nominations. What’s your choice for “Stupidest Vendor Action Taken,” “Most Overused Buzzword,” “Industry Figure With Whom You’d Most Like to Have a Few Beers,” and “HIStalk Healthcare IT Industry Figure of the Year?” Enter your nominations, from which the most-nominated choices will go on the final ballot in a week or so. That means no complaining if your choice isn’t on the ballot and you didn’t nominate them.

HIStalkapalooza registration will open up the week of January 13. Read HIStalk religiously for the link to the signup notice in the next couple of weeks. We fill up really fast every year. Above is a photographic hint of the venue for those wondering. The primary sponsor has a couple of co-sponsors whose support will allow the event to be even bigger and better. If your company is interested in getting exposure as a HIStalkapalooza co-sponsor, let me know and I’ll connect you since they are willing to take on two more.

Welcome to new HIStalk Platinum Sponsor healthfinch (they tell me it’s supposed to be all lower case). The company offers RefillWizard, which improves doctor efficiency as a “Team-Based Decision Support System” that improves patient safety while reducing refill turnaround time by up to 95 percent. They begin by preparing a customized savings document like the one above and making recommendations to optimize the refill process. They have found that 62 percent of refills can be selectively and safely delegated to clinical staff, reducing the staff time to 34 seconds (some PCPs spend 1-2 hours per day just managing refills.) RefillWizard, which just won the Allscripts Open App Challenge, works either with paper protocols or integrated with the EMR. HIStalk readers probably know DrLyle (Lyle Berkowitz, MD), the company’s chairman and chief medical officer. Thanks to healthfinch for supporting HIStalk.

I found this healthfinch RefillWizard overview on Vimeo.

Upcoming Webinars (Times are Eastern) 

January 7 (Tuesday), 1:00 p.m. Clinical Analytics for Population Health Management. Sponsored by HIStalk. Presenter: Core Sharma, principal analyst, Chilmark Research. As providers move from fee-for-service to value-based payment models, they must not only comply with ever-proliferating quality metrics, but also transition from a cost-plus business model to one of cost containment. 

January 9 (Thursday), 2:00 p.m. Beyond the Summits. Sponsored by HIStalk. Presenters: Ed Marx, SVP/CIO, Texas Health Resources, and Elizabeth Ransom, MD, FACS, EVP/clinical leader North Zone, Texas Health Resources. Everyday healthcare executives share leadership and teamwork principles they learned from climbing some of the world’s highest peaks over the last four years. 

January 16 (Thursday), 1:00 p.m. Advanced Efforts to Identify and Eliminate Waste from Healthcare. Sponsored by Health Catalyst. Presenter: David Burton, MD, executive chairman, Health Catalyst. Based on a breakthrough analyses using several large healthcare data sets as representative samples, Dr. Burton and team will present insights designed to help executives struggling to identify, quantify and extract waste from their systems

Acquisitions, Funding, Business, and Stock

Healthcare Data Solutions acquires StratCenter, a provider of healthcare provider data.

Stryker Corporation will acquire surgical sponge counting technology vendor Patient Safety Technologies, Inc. for $2.20 per share. The company’s market cap is $85 million.

Sales

In the UK, King’s Mill Hospital signs a five-year, $5.9 million EHR contract with Specialist Computer Centres and McKesson.

Medical billing company Medorizon Partners selects InstaMed’s patient payment plan technology.

The Defense Logistics Agency awards TeraRecon a maximum $30 million fixed-price contract for the procurement of radiology systems and services.

Central Georgia Health System will implement Infor’s healthcare business automation applications.

People

CareTech Solutions hires Daniel Lincoln (Palace Sports & Entertainment) as corporate controller.

CMS announces the retirement of COO Michelle Snyder, who supervised development of HealthCare.gov. The agency says Snyder had originally planned to retire in 2012 but stayed on at the request of CMS chief Marilyn Tavenner.

CareView Communications, which offers patient flow and safety solutions, promotes Steven G. Johnson from president to CEO, taking over for Samuel A. Greco, who is retiring for health reasons. Careview also names Sandra K. McRee (McRree Consulting) COO and appoints Jason T. Thompson to the board, replacing his father, Tommy G. Thompson.    

Direct Consulting Associates promotes Frank Myeroff to president.

Announcements and Implementations

Baptist Memorial Health Care (TN) goes live on Epic this week at four minor medical centers and at its Baptist Medical Group clinics. Four Memphis-area hospitals are scheduled for a March 11 go-live.

Government and Politics

A new North Carolina law requires hospitals with EHRs to connect to the state’s HIE and submit data on services paid for with Medicaid funds.

The Department of Defense issues an RFP to keep AHLTA and CHCS running through the end of 2018 after plans for a joint DoD-VA EMR were scrapped last year when costs were estimated at $28 billion. The value of the new contract is estimated at $250 million to $1 billion. DoD is looking at a commercial replacement for contractor-developed AHLTA, whose estimated cost to taxpayers was up to $5 billion.

Innovation and Research

A study of 295 smartphone apps that claim to prevent, detect, or manage cancer finds no published studies that prove their usefulness, effectiveness, or safety.

Technology

The FDA extends the Kinsa Smart Thermometer the first-ever 510(k) clearance for a smartphone-connected thermometer.

The US Patent and Trademark Office issues CommVault Systems a patent for efficient data management improvements, such as docking limited-feature data management modules to a full-featured data management system.

Other

Riverside Health System (VA) announces that a now-terminated LPN inappropriately accessed the records of 919 patients over a four-year period.

Cerner completes the purchase of the 237-acre tract for its planned $4.3 billion office development in south Kansas City.

Sponsor Updates

• Sunquest releases new versions of Sunquest Laboratory and Sunquest Molecular.
• The Boston Globe profiles Sumit Nagpa, CEO of Alere Accountable Care Solutions.
• Jason Fortin, senior advisor for Impact Advisors, discusses the impact of Meaningful Use in 2013.
• EDCO Health Information Solutions posts a Point of Care Scanning Process video.

EPtalk by Dr. Jayne

I received a lot of feedback about this week’s Curbside Consult. I’ll be posting more responses to the original reader email in the next Curbside Consult, but wanted to share some quick responses in the interim.

One reader asked for more detail about how we’ve tied the physician bonuses to EHR use. I can’t claim credit for the approach since we copied it from another organization, but it has worked well. It only applies to employed physicians using the group’s EHR platform. We have a couple of practices that we have acquired that are on other systems and are not yet converted, so they are exempt for now.

Physician bonus amounts are determined by three factors: patient satisfaction, clinical quality scorecard results, and productivity. A sliding scale is used for each element. For example you might receive 100 percent of your patient satisfaction and productivity bonuses but only 80 percent of your quality bonus.

The EHR plays into that in two ways. Since we’ve been fully adopted on EHR for many years, all of our quality reporting is now derived from EHR data (no more manual chart reviews). If providers are not documenting in the EHR, their scores will be low. We initially did a hybrid approach with both manual chart review and EHR reporting while physicians were adopting, but that has been phased out. Our staffing for compliance reviews has dropped significantly. They used to take three full work days per physician and now they take two to three hours per physician.

The major way that EHR applies to the bonus, however, is simple. All visits must be documented in the EHR and must meet our minimum data standards. These aren’t a lot different than the paper chart. The visit has to be complete within 24 hours of the patient visit and has to include certain critical data elements that essentially align with CMS coding requirements. For example, documentation has to have a chief complaint, history of present illness, review of systems, review of pertinent patient history, physical exam, and an assessment and plan.

We expected this to be present in the paper world and now it’s actually easier since the data is shared across the multispecialty group rather than living in separate paper charts by location. Providers can review histories with one click rather than having to dig for histories that may have been mentioned in various progress notes. Our physicians were not particularly good at keeping the paper problem list and past / family / social history face sheets up to date on paper.

For some practices that were challenging implementations, we actually had to physically visit the practice and make sure they didn’t have shadow charts. One site didn’t have charts, but had “jackets” for each patient. We didn’t just fail them outright but gave them three months to remediate, then audited them again. Over the last few years that the EHR requirements have been attached to the bonus structure, we’ve been fair about doing pre-audits so people know where they stand, then allowing enough time for them to remediate before their final audit.

The reader also asked about the “standards” that I mentioned our physicians have to meet to stay employed. Some are pretty simple – no OSHA or CLIA violations, favorable scores on coding and compliance audits, and getting along with their partners and staff. Some are more rigorous. We have high standards for clinical quality, and physicians are graded on blood pressure control, appropriate use of drugs for coronary artery disease, cholesterol control, influenza vaccination, cancer screening (colorectal, breast, prostate), diabetes management, and a couple of others. Physicians who can’t keep their scores in the desired range are remediated (as are their office staff – many of the metrics can be improved by leveraging staff and using standing orders including vaccination and screenings).

Finally, physicians are expected to be productive – specifically, to be above the 75th percentile based on MGMA data. That’s a lot to ask, but the group makes it clear when physicians join and it’s actually spelled out in the contract. Our compensation parallels this – our physicians consistently earn salaries in the top 20 percent based on MGMA data. If they choose to work less than full time, the productivity expectations are scaled accordingly. Our retention rate has been very good. Most of the providers who leave within five years of joining have a family reason. For example, they may only work with us for a year or two while they wait for their spouse to receive a residency or fellowship appointment that requires relocation.

In addition to their bonuses, our providers also received a hefty chunk of their Meaningful Use payments as a cash bonus. This differs from most organizations I’ve talked to that tend to keep the MU payments at the corporate level. I think the way we shared them is especially surprising given the fact that our providers don’t pay anything for EHR software, training, or maintenance. The only EHR-related charge that the practices incur is for hardware, which averages $8,000 – $10,000 per provider every three to four years.

Another reader asked how we handle the EHR records with a physician who chooses to leave the organization (or is let go) yet wants to keep his or her patients and office location. It’s actually pretty easy. We have a subsidized EHR offering (under the Stark exception) so we already have local private physicians on our EHR database with independent practice data. We simply copy the charts of active patients (those seen by the provider within the last three years) into a new practice in the EHR. Only clinical data is copied, no financial data and no accounts receivable.

If the provider is on staff at one of our hospitals, he or she may be eligible for a subsidy. Otherwise they pay fair market rate and we host it similar to a SaaS model offering. Although the providers can still share data with the employed practice, they have to do it through our private HIE rather than sharing a direct chart within the multispecialty practice. Providers are charged $0.50 per chart for the copy. That’s a holdover from our old contract when we had paper charts and they paid that much for the paper charts. I have no idea where that number came from — it’s been in place for at least 15 years.

If they choose not to stay on our platform, we have a third-party consultant perform an extract based on the new vendor’s specifications. It’s the same very skilled consultant we use when we acquire practices and bring the data into our system. Once the drive goes into the Pelican case and enters the physical transport protocol, though, it’s out of our hands.

I’ve seen two physicians treated poorly by their new vendors. One took several months to move the extracted data onto the new EHR. Another simply turned the data into PDFs and parked it in the new EHR’s scanning system, which is pretty sad considering the level of discrete data we can provide. Providers can also buy a system directly from our vendor and we’ll do the extract in that situation as well.

I’ve shared a lot of fairly specific information this week, so I hope it doesn’t come back at me. Stay tuned for the next Curbside Consult. I’ll be sharing my thoughts on infrastructure and interoperability as well as what happens when you try to drive a Ferrari in a corn field.

Contacts

Mr. H, Inga, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis, Lorre

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 1/2/14

White Sulphur Springs hospital says company never installed health records system

Mountainview Medical Center (MT) is suing NextGen Healthcare Information Systems for failing to install a certified EHR by a contractually agreed upon install date of June 1, 2013. When the date passed, the NextGen and Mountainview agreed to a new delivery date of October 1 but, according to the lawsuit, the extra time did not resolve the underlying issues and no system was ever installed.

3 hospitals start new year at Stage 7

Hilo Medical Center (HI), Round Rock Hospital (TX), and White Health System (TX) are all named to the HIMSS stage 7 list. Round Rock and White Health’s ambulatory clinics received stage 7 ambulatory designation as well. Both run Epic across their networks, while Hilo is a Meditech 6 site.

Stocks of KC firms large, small did well in 2013

Cerner is profiled by the Kansas City Star newspaper in a year-end review of the city’s top performing businesses. Cerner shares grew 43 percent in 2013.

Advisory Panel: Alarm Fatigue

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: Is your organization using or considering IT solutions to the challenge of alarm fatigue?

Note that while I was thinking specifically of physiologic alarms at the bedside, I didn’t state that explicitly, so some answers reflect clinical alerts in traditional IT systems. Seven responses indicated a “no” answer with no IT solutions being considered.

We struggle to balance harm prevention and user design.  We are biased toward harm prevention.

We haven’t found a good solution yet. We’re looked at things like alarms that start out low and increase in volume if not addressed, but many/most vendors haven’t embraced that idea yet. We’re looking at routing alarms to phones, but that also has challenges. If you find a good solution, let me know.

We are currently considering a few IT solutions to address this, but no decision has been made to move forward.

We are currently investigating tools to consolidate alarm management but we have not yet developed an RFP or even a vision for the future.

We are currently investigating and likely to pilot a solution to integrate nurse call bells into nursing phones to improve the alarm fatigue of the ears. In the EHR environment, we are continually analyzing the alerts that fire for their utility, appropriateness, and actionability and working to reduce those that are more "noise" than "signal".

Alarm fatigue happens when the technology was not supportive of the end user – it should not exist if each vendor really knew the topic and client being served.

We have explored alarm management systems, but I was left with the realization that the devices can alarm on anything and it’s up to each organization to determine what’s important. I am not aware of any national standards.

We learned early on to be very judicious with alarms and try and keep them to a minimum. As we’ve merged in some additional physician groups, the governance of managing alerts will get increasingly interesting however. I’d be curious what type of IT helps with alarm fatigue (i.e. do they make alarms more sensitive/specific somehow?)

I wish !!! Turning off the drug duplicate alerts would be like manna from heaven as they are invariably uninformative and annoying. For example, renewing a drug always gives a duplicate alert even though the system obviously knows that if you click "Renew" it will automatically stop the current order and start the new one. But the current order is still active when the system compares the new order to the med list. Ergo, duplicate alerts gone wild. One of my other favorite alerts tells me that the patient is taking two non-phenothiazine antipsychotics.  If I was really concerned about duplication, I would want to know if they were taking two antipsychotics period. Whether it’s a non-phenothiazine makes no difference whatsoever.

Primarily focused on refining medication alert rules to reduce unnecessary noise.

I assume you are talking about actual alarms, vents and IVs and tube feeding pumps and such, not EMR alerts. Since noise levels can exceed OSHA standards 80 percent of the time in an ICU, we are keenly interested in the twin problems of noise from alerts and the false positive / false negative rates of the alerts. We do not have a good answer, but I would be happy to buy one that worked.

We’re still trying to reliably deliver secondary alerting. Alarm fatigue getting some notice, but no definite intervention as of yet.

Yes, considering FDB AlertSpace to achieve what should be included in their product in the first place (we’re on Epic/FDB).

Readers Write: Ten Steps for Surviving ARRA and ACA Requirements in 2014

Ten Steps for Surviving ARRA and ACA Requirements in 2014
By Dick Taylor, MD

The 2009 American Recovery and Reinvestment Act (ARRA) changed the healthcare IT landscape for providers by offering money in exchange for the adoption and implementation of electronic medical records. One year later, the Affordable Care Act (ACA) upped the ante with new regulations for privacy, accountable care, and insurance coverage. The combination of the two acts has left most providers and provider organizations struggling to see the forest through the trees as we enter 2014, and the deadlines for both acts draw ever closer.

Controversial from the start, the Affordable Care Act (ACA) was landmark legislation three years ago. It remains front and center after being tested by the Supreme Court, a presidential re-election, and most recently, a government shutdown. Like the ARRA, much of it is yet to be written, requiring tens of thousands of pages of regulations to explain the details. Like the ARRA, it is deeply flawed in places and will require many years of refinement.

The ACA tries to supercharge the required transition from a reactive, episodic care based payment system to one that might reward preventive care, wellness, and patient outcomes. Providers generally see the promise, but they almost universally question the ability of the law to achieve its outcomes, particularly in light of modern medicine’s rapidly changing cost factors.

Healthcare is getting more expensive, and the healthcare IT transition mandated by the ARRA has not yet reached the break-even point for expense control for many (if not most) provider organizations. Demand is down in many segments, particularly for inpatient and elective procedures, and margins are under heavy pressure.

To make matters worse, regulatory oversight is rising and is highly unpredictable. As an example, on September 1, 2012, CMS finalized a rule that gave eligible providers until July 1, 2014 to begin attestation for Meaningful Use. Up to that point, providers generally believed that they had 15 months longer. In contrast, the ICD-10 implementation date was arbitrarily delayed a full year in August 2012 from October 1, 2013 to October 1, 2014. Regulatory changes of this nature are difficult to predict and require both flexibility and preparation from providers.

As we enter 2014, the final sprint toward ARRA and ACA’s deadlines, surviving this environment will require providers to focus on achieving the following goals over the course of the coming year.

1. Reduce expenses, both per-patient and fixed overhead. Admittedly, this is easier said than done.
2. Where practical, grow larger through acquisition or affiliation. This spreads fixed overhead over a larger patient volume and allows much more efficient team-based and whole-patient care. Growth must however, be calculated and managed to capture these savings. Rapidly growing organizations must be especially watchful to avoid operational and cultural traps.
3. Achieve Meaningful Use and avoid ARRA Medicare penalties. Providers who have missed Meaningful Use to date are now looking at reduced awards and penalties (amounting to small but significant percentages of CMS billing) beginning in just over a year.
4. Achieve ICD-10 compliance on time (by 10/1/14) without destroying the organization. While ICD-10 is critical (not billing with ICD-10 is simply not survivable for most providers), this has become the Y2K for healthcare. Caution, particularly around involving physicians and mid-level providers in the minutiae of coding, is strongly advised.
5. Pursue transparency for quality outcomes and cost. Payors, employers, and patients are all watching these very carefully, and organizations who are not forthcoming will become less favored over time.
6. Pursue transformation in long-term healthcare, including population health, chronic disease management, and wellness. Fee-for-service is likely to become far less sustainable as a primary business model over time.
7. Reduce clinical variation, both by pursuing good evidence (where available) and by achieving agreement on leading practices among providers. Much of the variability in clinical care is not associated with improved outcomes and some of it is actively harmful, both in cost and patient outcomes.
8. Recognize and honor the risk you own. Health systems have always owned the risk for charity and self-pay patients. The ones who recognize and accept this are much more likely to provide good care and keep costs under control.
9. Look for whole-patient (“accountable”) care opportunities within your own orbit. While the ACA set out the framework for Accountable Care Organizations, the reality is that these are still embryonic. Organizations that begin at home will be ready for risk-sharing moving forward.
10. Treat your IT expenditures as long-term investments, not expenses. Organizations should expect to spend an increasing percentage of capital dollars building technology assets. Acquire standards-based IT assets that will stand the test of time. Expect, plan, and capture the hard- and soft-dollar returns from them. Organizations that view IT simply as an expense will forego future profits in the pursuit of short-term efficiency.

Dick Taylor is managing director and chief medical officer of MedSys Group of Plano, TX.

Readers Write: 2014 Resolutions

2014 Resolutions
By Vince Ciotti

I’m getting ready to wrap up the HIS-tory series with the final episodes on McKesson, so it’s apropos to take a break and look at the future a bit with these 2014 New Year’s resolutions for today’s leading HIS vendors (in order of their 2012 annual revenue).

McKesson

They’re doing so well with Paragon that they made a resolution to rename their other legacy systems:

• Horizon = Parazon
• Series = Seriegon
• Star = Staragon
• Practice Partner = Practice Partagon
• RelayHealth = ParlayHealth
• Homecare = Homecaragon
• InterQual Online = InterQual Paragonline
• Capacity Planner = Capacity Paranagon
• Performance Analytics = Performagonalytics
• Patient Folder = Patient-Paper-Folder-Gone
• (you get the idea…)

On another front, McKesson announced plans to open Paragon’s first international office in either Aragon or Patagonia, depending on negotiations with their governments about minor changes to the spelling of their names.

Cerner

Will make an epic move of their HQ from Kansas City to Salt Lake City and re-name Millennium HNA as Millennium IHCNA.

Siemens

After cutting 15,000 jobs worldwide over the past two years, Siemens will announce several openings in its HR recruiting department for 2014.

Allscripts

Will join Cerner, McKesson, athenahealth, Greenway, and RelayHealth in the CommonWell Health Alliance to promote EHR interoperability in 2014 in 49 states (excluding Wisconsin).

Epic

Will be recognized as the KLAS act in 2014 by becoming the only HIMSS Stage 8 vendor in Gartner’s Magic Quadrant.

GE

Will announce a program in 2014 whereby any hospital buying Centricity will receive a free refrigerator for every nurse station.

Meditech

Will announce the 2014 version of Release 6.0, which will be called Focus, er, MAT, I mean, 6.0.1, that is 6.1, or maybe 6.0.A…

NextGen

Will announce the 2014 re-packaging of Opus, Sphere, and IntraNexus as “ThisGen.”

CPSI

Will sets the goal of having 500 of their clients attest for MU by the end of 2014, a total of over 1,000 beds.

Harris

A subsidiary of Constellation Software Inc. (from Canada) announces a project for 2014 of using the other Harris (from Melbourne, FL) CareFX interoperability workflow solutions to differentiate their company names.

NTT Data

ヴィンスがこれらの不快な言語の策略を用いるのを止めてください。

HMS

After being re-named Medhost, company executives will announce a joint effort with the AHA to launch a campaign in 2014 that re-defines all US hospitals as ancillary departments of their emergency rooms. 

Healthland

Will resolve to combine its two corporate offices in Minnesota (Glenwood and Minneapolis) once the roads are plowed in August 2014.

Vince Ciotti is a principal with H.I.S. Professionals LLC.

Morning Headlines 12/31/13

10 things to know about Karen DeSalvo

Karen DeSalvo, the new national coordinator for health IT, is profiled in a GovHealthIT article that reviews her past accomplishments and experiences.

Hospital patients can track care with bedside tablet computer

Ohio State University’s Wexner Medical Center is profiled by local media after piloting Epic’s myChart Bedside, a patient portal designed for patients currently admitted to the hospital. The app allows patients to see pictures and profiles of their care team, review their daily plan as well as lab results, and read or watch patient education material.

The December deluge: 1.1 million have enrolled on HealthCare.gov

Healthcare.gov turns in its best month to date, with 975,000 newly enrolled in December, for a total of 1.1 million since launch.

Dermatology practice settles potential HIPAA violations

A dermatology practice in MA pays $150k in fines to HHS over HIPAA violations after an unencrypted thumb drive with the ePHI of 2,200 patients get stolen from an employees car. Officials from HHS say this case marks the first time that a covered entity has been fined for not having implemented the breach notification provisions of the HITECH act.

Curbside Consult with Dr. Jayne 12/30/13

One of my favorite readers shared last week’s EP Talk with one of her struggling physicians. He made a lot of good points and they’re similar to those expressed by many physicians out there, so I thought I’d take a stab at responding to some of them. If you work directly with physicians and end users, they should resonate.

Dr. Jayne makes using the EHR seem like a piece of cake. I would like to see how it is working in her organization.

Actually, lots of people have seen how it works for us. We’re a reference site for several vendors (ambulatory, hospital, hardware) so we have sales prospects come on site to see how our physicians work with the system. We’ve also served as a reference site for existing clients who want a “do over” after failed implementations.

Our model has worked well for us and has been cloned by other clients and even by some who didn’t end up buying from our vendor. Keep in mind, though, that we’re seven years into our EHR journey, but I’d say most of the major kinks were worked out in the first 18 months while we were implementing. Key things that have made us successful compared to our peers:

• Heavy use of piloting for everything we do, whether it was the initial rollout, adding a module, adopting PCMH workflow, etc. You name it, we pilot it first. Would-be pilots have to apply – it’s not a political giveaway and they have to understand what piloting means. It’s not a cakewalk. We use them to break the product and re-engineer the workflows to make it better before mass rollout. Sometimes it’s not pretty. Sometimes they never ask to pilot again, and that’s OK. It’s supposed to be shared learning.
• We heavily incent our physicians to do the desired workflows and gather specific discrete data. We initially hoped for compliance through altruism or desire for quality, but what made the difference was cash. It’s remarkable what tying an annual bonus to EHR use can do to a physician’s attitude. We phased the requirements in over three years for legacy physicians, but new hires are expected to be immediately compliant.
• Strong governance. We’re not afraid to terminate disruptive physicians or to encourage those who can’t meet our standards to leave the organization. Our non-compete is written so that providers can purchase their practices and keep their panels and stay in the same location as long as they don’t go to work for a corporate competitor. This lets those who are not a good fit depart without losing their livelihood. This is rare, but it’s one element of our success.

The quality of EHR progress notes is much worse than it was on paper. You get consults back with 5-6 pages of fluff but lacking the important information. This is only because the truly useful medical data is limited by the data entry speed.

I agree. Some of the notes that I receive are unmitigated garbage. Documentation quality is part of our peer review process as well as our coding review process. We’ve heavily modified the “stock” vendor notes for formatting, font, layout, and overall readability. Chart notes are in the APSO format with Assessment and Plan first rather than traditional SOAP format where the important information is at the bottom. We permit providers to dictate assessment and plan so that it’s readable and data entry speed is not a concern.

We assume wrongly that the doctors can be taught fast typing. The young doctors who learned at a young age will be proficient. And voice recognition sucks at this time, even for physicians without accent.

From experience, I disagree. Many of our more seasoned physicians are proficient with touch typing and with the EHR in general. One of them often reminds me how well he does with his favorite statement: “Young lady, I have been waiting for an electronic medical record since before you were born. I’d go up against any of you young pups with it.” He’s not kidding, either. For those who can’t type, they’re allowed to dictate through voice recognition.

Incidentally our voice recognition also does navigation and complex macros within the EHR templates. It’s truly amazing. I wasn’t specific about this in the EPtalk piece last week. A couple of readers reached out to me about similar systems in their organization and I agree they’re extremely valuable and very helpful for physicians who are challenged by EHR.

The training phase for voice recognition can’t be short cut. Our vendor has worked one-on-one with physicians who are having difficulty. We didn’t struggle so much with accents as we did with what I’ll call “surgical mumblers” who are used to hospital-based transcriptionists who slow down the dictation to listen at molasses speed so they can make out the words. When they complained about the system, I went and shadowed them. Frankly, I couldn’t tell what they were saying, so I wasn’t surprised that the system had problems with it.

Patients aren’t happy that we don’t give them undivided attention during the visit. Some physicians can multitask but others can’t, but the impression on patients is the same.

Again from experience (and also from data), I disagree. We actually surveyed the patients (during pilot phase of rollout) about EHR use by the staff and used it to reshape workflow during the rollout. Before they’re ready to go live, physicians have one-to-one coaching sessions and mock patient visits where they are critiqued on how they use the EHR. I’ve personally taken a Sawzall to office cabinetry when maintenance was taking too long and the exam room layout was a barrier.

If physicians still struggle, we’ll bring them to our residency program practice (which has cameras in the exam rooms) and work with them both in person and with mock patients. It’s not cheap and I don’t know any other organization that does this to the degree that we do, but it has saved a couple of physicians from leaving when they truly wanted to be successful.

Those physicians who did multitask before (such as performing physical exam while talking to the patient) do well on EHR. Those who didn’t multitask before don’t do so well with it. No surprises there.

What we do, though, is help those who don’t multitask by identifying what tasks must absolutely be done in the room (meds, allergies, orders, and patient plan is our policy) and the rest they can do immediately after the patient visit. We don’t force everyone into a cookie cutter workflow. We also include questions about EHR and the visit on our patient satisfaction surveys. Those results factor into physician bonus payments as well.

Looking at patient satisfaction scores before and after EHR, we noted no substantial differences on a per-provider basis. Those who struggled with patient satisfaction continued to do so after EHR, and some worsened. Those who were doing OK continued to do well. A fair number even improved, although most patients indicated patient portal and decreased wait times due to better scheduling as causative reasons rather than bedside manner.

Our product doesn’t work properly in Windows 7, only Windows XP, which is an issue. A good EHR should be multi-platform, should work on Apple computers, Linux, and other operating systems as well.

I absolutely agree with you here. Many vendors have struggled with this issue. I ran across one the other day whose product only runs on Google Chrome. I actually like Chrome, but it’s not exactly the most widely used, and is especially problematic considering that the limitation also applies to their patient portal. Chrome isn’t as popular among the Social Security set who seem wedded to Internet Explorer. I think they’re going to regret that narrow niche and I do wonder what exactly is going on with the programming that it won’t even run correctly on Firefox.

For client-server apps, the popularity of Citrix has helped systems feel more agnostic to end users, although Citrix itself can be a complicating factor in support and maintenance.

There were quite a few more comments, but I’m going to save them for the next EPtalk. What do you think about these issues? Leave a comment or email me.

Email Dr. Jayne.

Advisory Panel: Telehealth Projects

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: Is your organization running or planning telehealth projects?

Assuming the term telehealth includes scope of technologies included in the HRSA definition, we run remote ICU monitoring across our WAN. In addition, we continue to expand the use of mobile clinics that roam around our geography. These clinics include videoconferencing between clinic providers, patients, and remote specialists. We are planning additional work with a national telehealth provider.

No, my organization is still struggling to implement CPOE, keep the beds full, reduce readmissions, etc., etc., and we have not got that far yet.

This shows up in our annual strategic plan every year and it’s there this year too. But I haven’t been able to generate much interest among my medical staff, even the members who travel hundreds of miles for outreach clinics. We run a telemedicine epilepsy clinic and we have the usual teleconferences, but that’s about it. So I’ve retained some consultants to explore options like e-visits, home monitoring, and video visits using webcams with the med staff.

We have a few telehealth services we consume for a couple of specialties. For example, we have a small pediatric hospital and will perform remote echoes with specialists at a leading children’s facility for special patient cases. We do not have any plans to provide any additional telehealth services within our organization or service areas at this time.  

Multiple coordinated efforts related to telehealth as we are approaching from a number of perspectives. More traditional eICU, using remote monitoring of multiple ICUs from a centralized location where critical care physicians and other clinicians are monitoring beds across multiple hospitals. Tele-psych consults in our emergency departments. Developing newer capabilities for virtual ambulatory visits, more acute or urgent care conditions where audio/video is effective in connecting a patient and a provider. Our EMR is really helping with efficiency in this service area and also with tele-psych and ICU areas. The key being that tele-X software, hardware can help best facilitate the patient encounter but it’s important to realize our EMR is needed for order entry, documentation, communication with the local hospital pharmacy, etc.

We currently have a monitoring station set up in our ICU for pediatrics so that our patients can be “seen” by a specialist at a large teaching hospital in the state.  We are currently proposing to provide healthcare services to our local detention centers. If accepted, we’ll go the telehealth route.

ANGELS – Antenatal & Neonatal Guidelines, Education, and Learning System – consists of 23 hospitals and clinics who receive clinical services from us, as well as 18 hospitals who participate in a tele-nursery with us as the hub. Neonatal mortality rates for Medicaid declined from 4.5 per thousand to 3.3 per thousand. ANGEL EYE – one-way video from NICU to authorized family members. AR SAVES – Stroke Assistance Through Virtual Emergency Support – consists of emergency support for 42 hospitals across the state. Increase delivery of TPA from <1 percent to 29 percent in participating hospitals. Other telemedicine services – psychiatry, pediatrics, geriatrics, rehab medicine, cardiology, internal medicine, burn, trauma, genetic counseling.

We’re doing projects with telehealth, telepsych, home health monitoring, remote hospitalist consulting, and have others we’re thinking about. While telemedicine has been around for decades now, it seems to be really heating up lately.

[from a vendor member] We are working with several organizations who are planning telehealth projects. However, it is like NLP at this point – all talk, no action.

We are on the receiving end in that we use a telehealth service (neurology consults) in our ED. It works well, although the service and support has proved problematic. The cart contains all the video components, but when there was a problem, they had no local service techs. This left it to our staff to troubleshoot – if we were a smaller very rural hospital we may not have had the expertise to troubleshoot their equipment on our end. Overall the service has been a benefit to the hospital in that we have a shortage of these specialists to take call.

We actually do a lot of telemedicine, both inside our health system and with external partners and that program is continually expanding. Our main service lines at this point are Neuro, Pediatrics, and Psychiatry. The primary locations served tend to be emergency departments in order to deliver otherwise unavailable specialty care to patients.

Yes, for various disease states and ethnically diverse populations.

A year and a half ago, we agreed to work with a vendor on a case study to determine if telehealth would positively impact outcomes. Telehealth was new to them and they struggled to develop a website for data collection and patient interaction. For the research study we needed IRB approval and a contract with us. Once the attorneys got involved, everything came to screeching halt. A year later, we have a contract and pending IRB approval. Perhaps in the near future we can begin the study with our diabetes and CHF patients.

We have long offered telehealth via phone and web visits for mild, acute problems (e.g. URI, UTI), and we charge a separate fee for those. We are also now looking at using telehealth technology to do remote care at corporate clients.

Vague talk only about telepsychiatry to local ERs and jails.

Telehealth in use for burn, stroke, and psych consults. All working very well with different technology solutions including iPad and a mobile robot looking device.

To meet requirements for Level 1 nursery, we have neonatology sub-specialists on tap, credentialed and available. This is a great solution to consultations that would otherwise require transfers. It is another question entirely whether early transfers are in the baby’s best interest; it may be that telehealth consultations get an actual consultation in the odd hours, where if the baby were in the actual institution providing the consultants, there would be more of the "I’ll see them in the morning" mentality. Of course, in that setting, the consultant is probably more comfortable with the nursing and ancillary staff, so it may be about the same outcome. Still, it feels good to have an actual clinician to clinician discussion about a specific case.

We’re doing a lot of tele-stroke work. A real smart stroke neurologist with an interest in the technology. He’s serving other organizations and when not on site, he starts care using his tablet and the stroke robot in the ED supported by a stroke nurse-practitioner or neurosurgery PA.

Virtual visits are part of our future plans, none running yet.

We are rolling out telemedicine to support our network of six rural health clinics. This will be essentially to push the access to our specialists. Rollout is over next three months.

Radiology uses NightHawk services from the other side of the globe for night preliminary reads, but that’s it.

Morning Headlines 12/30/13

PCORI Awards $93.5 Million to Develop National Network to Support More Efficient Patient-Centered Research

The Patient-Centered Outcomes Research Institute will invest $93 million in a new project aimed at developing a collaborative network of health systems, payers, and patient groups working together to conduct more efficient health research.

Use of a Text Message Program to Raise Type 2 Diabetes Risk Awareness and Promote Health Behavior Change (Part I): Assessment of Participant Reach and Adoption

A study published in the Journal of Medical Internet Research designed to measure the participation and adoption rates of a text-based type 2 diabetes program finds that only 39 percent of enrolled participants completed the 14 week program, leading researchers to conclude that text-based programs may not be appropriate for everyone.

HIMSS Career Services to Focus on Veterans

HIMSS will launch a program aimed at introducing military veterans to " future careers in the health IT industry." The program, which was government funded, will be located on the exhibit floor at HIMSS14. Any military veterans that might be interested in the health IT industry need only get themselves down to the HIMSS conference, pay $575 for a single day conference pass, and then proceed to the “A Hero’s Welcome to Health IT” booth. Once there, they’ll meet other veterans that are working in health IT that will be able to answer questions for them, and they’ll learn about HIMSS entry-level certification exams.  

Monday Morning Update 12/30/13

From Informatics Doc: “Re: PCORI. Announces who they will fund to build clinical data research networks and patient-powered research networks, which has a fairly ambitious national goal. MU-compliant EHRs will be a key component to several networks.” The Patient-Centered Outcomes Research Institute, a non-profit created as part of PPACA/Obamacare,  approves $93.5 million to fund 29 clinical research data networks that will form PCORnet, a national network that will study clinical outcomes. Of the 29 participating organizations, 11 are hospitals, plans, and health networks that will provide real-time patient encounter information, while the other 18 are patient-operated, condition-focused groups. Quite a bit of technology is involved, including interoperability and data collection from EHRs such as Cerner and Epic, data standardization, patient-facing applications, and population health management tools. Harvard Pilgrim Health Care Institute won a $9 million contract in September to run the program, naming as directors Richard Platt, MD, MS from Harvard Medical School along with Robert Califf, MD from Duke University Medical Center. I think it’s a great idea, although the politics and special interests involved in translational research make it hard to predict whether it will be successful in turning new medical data into health-improving and cost-saving principles. 

From The PACS Designer: “Re: iPhone 5S. With the gifting completed for the holiday, TPD thought it would be useful to post instructions for the HIStalkers who may have received the iPhone 5S. Since it can be daunting getting started with the 5S,  providing detailed instructions will get you going sooner.”

Barely more than half of poll respondents think Karen DeSalvo was a good choice to be Farzad’s replacement as National Coordinator, although none of those who voted added a comment to explain their position. The suck-up organizations (which is pretty much all of them) can’t say enough good things about her even though most of their flattery is either superficial or irrelevant, so to you naysayers, what don’t you like about her? Leave a comment on this post if you like. New poll to your right: how would you grade Medicare’s fraud prevention efforts?

The Associated Press Oregon names Cover Oregon’s botched insurance exchange website as the state’s top news story for 2013, summarizing:

Once considered a national health care leader, Oregon produced the worst rollout in the nation of the new national health insurance program. While the crippled federal website eventually got up and walked, Oregon’s remained comatose, unable to enroll a single person online. The state had to resort to hiring 400 people to process paper applications. Officials lay much of the blame on the primary information technology contractor, Oracle Corp., and withheld some $20 million in payments. But state officials’ own actions played a role, too. In the face of disaster, they insisted on doing things The Oregon Way, clinging to a grandiose vision of creating a grand health IT system that would not only enroll new people in the national health insurance program, but also provide other vital services. In the midst of the finger-pointing, executive director Rocky King went on indefinite medical leave, and chief information officer Carolyn Lawson resigned.

Massachusetts, whose healthcare programs inspired Obamacare, has paid $11 million of a $69 million contract for creating its health insurance exchange website, which has enrolled only 2,800 people due to technical problems. The state says the system, built by Healthcare.gov lead contractor CGI, is slow, displays random error messages, and times out. It requires applicants to submit their information online, then wait for a mailed letter before signing up for insurance. Both Massachusetts and Vermont have halted payments to CGI for their insurance exchange sites, saying the company isn’t meeting its obligations.

Canada-based CGI, whose Healthcare.gov contract is worth around $300 million of that site’s $700 million cost so far, has a market cap of $10.6 billion. It’s one-year share price chart is above, with GIB in blue and the Dow in red. Vanity Fair’s profile of CGI is unflattering, citing previous unhappy customers and creative acquisition-related accounting practices (the company is made up of 70 acquired entities.) Industry long-timers will remember its 2004 acquisition of American Management Systems (AMS), from which quite a few hospitals bought medical records scanning and workflow applications. Including my hospital at the time, which earned AMS/CGI strong consideration for my “worst vendor” list. The article summarizes:

The story of how the Obama administration and the Centers for Medicare and Medicaid Services (CMS), the agencies tasked with implementing the Affordable Care Act got it so wrong is still unfolding. Much of the blame has to fall on an insular White House that didn’t want to hear about problems, and another chunk has to land on CMS, which instead of hiring a systems integrator, whose job it would have been to ensure that all the processes feeding into healthcare.gov worked together, kept that role for itself. As anyone who has worked with the federal government on such projects knows, it is utterly inept when it comes to technology.

Palomar Health’s Glassomics incubator for Google Glass releases a demo video of potential medical applications, including real-time integration with patient monitors and the EHR.

Hawaii Governor Neil Abercrombie releases $21.7 million in state capital funds for healthcare projects, of which Hawaii Health will receive $14.3 million for EHR-related projects.

Venture Beat predicts the hot tech buzzwords for 2014: “growth hacker” (data-driven marketing people); “nth screen” (sharing across devices); “design thinking” (human-focused innovation); “ephemeral sharing” (Snapchat-like shared data that disappears); and “hyperdata” (cooler than the now-unhip term “big data,” but meaning about the same thing).

In England, NHS and Department of Health create The Walk, an exercise app that combines a pedometer with a mystery story that unfolds as more steps are accumulated toward 500 miles of walking. It was developed by the creators of Zombies, Run!, which similarly combines a mystery story with running.

Hope Phones collects unwanted cell phones, allowing individuals and companies to outfit global health workers with the erased and furbished devices. Donation couldn’t be simpler: just print a postage-paid label from their site and put your phone in the mail. It’s part of Medic Mobile, a San Franciso-based public charity that uses mobile technology to improve health.

A Hero’s Welcome to Health IT, a government-funded program, will introduce military veterans to careers in health IT at the HIMSS conference. It offers mentoring and entry-level certification.

ONC’s annual meeting will be held January 23-24 at the Washington Hilton in DC, with 1,200 attendees expected.  It will probably be the first public appearance of new National Coordinator Karen DeSalvo, MD, who will start at ONC on January 13. 

The txt4health mobile personalized messaging program for diabetes management launched by three ONC-designated Beacon Communities reached a good many participants in Michigan, Ohio, and Louisiana, but more than half of them dropped out of the 14-week program, many of them apparently just ignored the messages, and only 3 percent of active participants tracked their weight. The article generously concludes that “this type of approach may not be appropriate for all.”

The board chair of a children’s hospital in Greece is arrested for demanding a $34,000 bribe from an advertising company that had been awarded a $262,000 contract to develop an anti-obesity campaign for children. He was also fired from his full-time position with the National Bank of Greece. The bribe was paid by an informant wearing a wire, which recorded the man’s stated rationale: “What kind of an idiot would I be to have made a 190,000-euro deal and not kept a cent for myself?”

Strange: parents of a newborn sue a Pittsburgh rabbi, claiming he severed their son’s penis while circumsizing him. Surgeons reattached it during an eight-hour microsurgery that involved six blood transfusions, two months in the hospital, and leech therapy. According to the rabbi’s website, “A doctor’s medical circumcision, usually performed in the hospital on the second or third day after birth, does not fulfill the requirements of a Bris Milah and is not considered valid according to Jewish law.”

Sponsor Updates

The annual holiday fundraiser held by Surgical Information Systems raised $15,000 from employees to support Cookies for Kids Cancer, Donor’s Choose, Toys for Tots, USO Wishbook, and The Weekes House.

Employees of ESD donated toys for Lucas County Family Services, which supports abused and neglected children.

The Lab Executive War College and CHUG (Centricity Healthcare User Group) donate hundreds of extra conference backpacks annually to Coffee Creek Backpacks project, run by Frog Pond Church in Wilsonville OR, which provides women newly released from the local correctional institute with essentials to help them return to society.

Contacts

Mr. H, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis, Lorre.

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 12/27/13

Centers for Medicare & Medicaid Services (CMS) and Office of Inspector General (OIG) Extend Sunset Dates for Electronic Health Records (EHR) Subsidy Rules

CMS extends the sunset date on the Stark exception to December 31, 2021. The decision will allow hospitals to continue to finance EHR implementations for referring physician practices without breaking anti-kickback laws.

More partnerships between doctors and hospitals strengthen coordinated care for Medicare beneficiaries

123 new ACOs are announced, bringing the national total to 360.

MaineHealth increasing spending on software system that was involved with billing glitches

MaineHealth will increase the budget on its Epic install from $145 to $200 million. Bill Caron, president of MaineHealth, says that the health system underestimated the total cost of training all its staff on Epic, and acknowledges that it was a mistake to start the install at 600-bed Maine Medical Center, the systems largest hospital.  The additional funding will be used to provide end users additional Epic training.

EMR alert cuts sepsis deaths

Active surveillance alerts generated by the EHR at Mount Sinai Hospital (NY) have led to earlier detection of sepsis in its inpatient census, resulting in a 40 percent reduction in its sepsis mortality rate.

News 12/27/13

Top News

CMS adopts final rules that extend the Stark exception sunset date from December 31, 2013 to December 31, 2021. The amendment allows healthcare entities to continue subsidizing physician purchases of EHRs and includes additional rule modifications, including:

• The exclusion of lab companies from donating EHR items and services
• The elimination of the e-prescribing capability requirement
• Updates to the interoperable provision
• Clarification of the requirement prohibiting any action that limits or restricts the use, compatibility, or interoperability of donated items or services.

HIStalk Announcements and Requests

   Mr. H whisked away Mrs. H for a little holiday this week, but he should be back this weekend. We’re about to be in the midst of the pre-HIMSS fury so I am glad he took time for R&R with Mrs. H before the craziness begins.

  News was slow on HIStalk Practice this week but you’ll want to check out the letter Dr. Gregg sent to Digital Santa before St. Nick jumped on his sled.  Thanks for reading.

Acquisitions, Funding, Business, and Stock

The HIMSS Foundation and the National eHealth Collaborative merge their organizations and announce plans to create the HIMSS Center for Patient- and Family-Centered Care and to integrate NeHC’s educational and HIE programs with existing HIMSS resources.

PM and RCM service provider Medical Transcription Billing files a registration statement for a proposed IPO.

The Singapore government invests $500,000 in Ring.MD, a telehealth startup focused on improving access to high-quality physicians in Asia. The company was founded by Justin Fulcher, a 21-year-old entrepreneur who has been coding since he was seven and started his first business as a preteen.

Sales

Big Bend Hospice (FL) selects Allscripts Homecare software.

CareTech Solutions will provide consulting services to Medicine Bow Technologies (WY), which is developing a disaster recovery plan for services impacting Invinson for Memorial Hospital.

People

Cerner names former Indiana governor/current Purdue University president Mitch Daniels to its board of directors.

Family Health West (CO) hires Pam Foyster (Quality Health Network) as clinical informatics director.

Announcements and Implementations

Jamaica’s minister of health says his country will being implementation of an $50 million EMR system for hospitals and primary care clinics during the first quarter of 2014.

Maine Medical Center will increase its Epic EMR investment from $145 million to $200 million and dedicate about two-thirds of the funds for additional employee training. Health system officials admit they originally underestimated the resources required for training and may have made a mistake by starting the implementation at its 6,000-employee Maine Medical Center, rather than a smaller pilot facility. Earlier this year the hospital’s CEO said the Epic rollout and incorrect billing issues contributed to a $13.4 million loss in the first half of its 2013 fiscal year.

Weems Memorial Hospital (FL) goes live on its $450,000 EMR from CSS.

Sagacious Consultants launches Sagacious Analytics to help hospitals improve reporting and make better use of EMR data for performance measurement.

Vermont Information Technology Leaders makes radiology and transcribed reports from Fletcher Allen Health Care available to providers via the state’s Medicity-powered HIE.

Government and Politics

CMS announces the formation of 123 new accountable care organizations, bringing the total number of established ACOs to more than 360.

Innovation and Research

A new influenza forecasting method developed by Columbia University’s Mailman School of Public Health is proving almost twice as reliable as traditional approaches that rely on historical data. The system combines real-time estimates from Google Flu trends and CDC surveillance programs.

Technology

Apple secures a patent for an embedded heart rate monitor for smartphones.

Other

A USA Today article looks at how the adoption of HIT and preventative care are improving healthcare and lowering costs. David Blumenthal, MD highlights areas requiring more work, including moving from fee-for-service payment models to risk-sharing or team-pay systems; improving care coordination through the use of IT; educating consumers on how to choose better care based on quality and lower costs; and, increasing the use of standards to lower administrative costs.

Mount Sinai Hospital (NY) reports a 40 percent decline in its sepsis mortality rate since implementing an early warning system within its EMR. The system triggers an alert whenever staff enter vital signs that match the criteria for early sepsis.

Over two-thirds of HIT professionals participating in a HIMSS compensation survey report receiving a salary increase in 2013; the average reported salary was $110,269.  Almost half of the 1,126 survey participants also received bonuses with the median bonus equal to three to four percent of annual salaries.

Sponsor Updates

• NextGen posts its January webinar schedule.
• Optum opens an on-demand health and wellness clinic in  Overland Park, KS.
• Imprivata hosts its second user conference HealthCon 2014 May 4-6 in Boston.
• Forbes profiles Ping Identity founder and CEO Andre Durand.
• As the industry shifts to P4P and ACOs, API Healthcare VP of nursing Karlene Kerfoot predicts a shift in healthcare jobs from hospitals to home care agencies, outpatient surgery centers, and urgent care clinics.
• Info-Tech Research Group names Informatica a Champion in its Data Integration Tools Vendor Landscape.
• EDCO posts a video highlighting its point of care scanning process for clinical staff.

EP by Dr. Jayne

It’s a very slow week here since a good portion of our department took vacation days around the Christmas holiday. I’ve enjoyed the relative quiet and am glad to see that people are staying off of email. CMS shared some holiday cheer by emailing providers to remind them that if they didn’t e-prescribe in 2012 or 2013 they will receive their penalty in 2014. I don’t know why they insist on calling it a “payment adjustment” rather than a penalty. Penalties related to Meaningful Use will begin on January 1, 2015 so if you’re going to avoid them you need a solid strategy now.

I’m keeping my eye out for exciting opportunities in the New Year and was interested to see a couple of CMIO postings pop up at organizations that haven’t had a CMIO previously. Although it may be exciting to be the first CMIO and to be able to define the role, I don’t envy anyone taking a job at an organization that is just now figuring out they need one. A couple of the job descriptions were nebulous to the point where I’m wondering if the hospital even understands what they are looking for.

Medical Economics recently did a piece on the survival of the doctor-patient relationship. Physicians cite administrative burdens as the highest threat (41.9 percent) followed by EHR at 25.8 percent. I’m glad the article makes the point that some of the tasks could be assigned to other office staff members. I still struggle with physicians who insist on doing work that could be done by support staff including printing lab requisitions, tracking down test results, processing refill requests, and dealing with insurance paperwork.

The article addresses the EHR challenge more specifically – citing anecdotal stories of physicians who spend 10 minutes of a 15 minute appointment typing. I’m continually surprised by the number of my peers who refuse to learn to type. If you’re going to use free-text rather than structured documentation, typing skills are essential. I remind our physicians that if they mastered biochemistry and tying surgical knots they can learn to touch type but they still resist. I’ve even tried a games-based approach to try to harness their competitive natures, but haven’t had a lot of success.

Another physician states he spends “eight to 10 minutes per chart entering information not directly related to patient care, mainly tied to quality metrics.” Based on conversations with some of our providers I’d have to challenge that statement. We have a large employed provider base and it’s always a shock when someone thinks that a particular clinical quality element is “not my problem” especially in the ACO environment. We’re fortunate to have an EHR where the quality metrics are baked into the documentation – there’s not a lot of extra work to do. I know many sites don’t have this advantage but for us there’s no excuse.

I recently went a couple of rounds with a surgeon who said the patient’s morbid obesity was “not my problem.” I countered that if he plans to do any procedures on her, it certainly is his problem because of the risk of complications directly related to the obesity, not to mention the need to find out if there is diabetes related to the obesity because that alone can complicate wound healing. The same thing applies to our orthopedic surgeons who don’t want to check blood pressures. Fortunately our organization has made measurement of vital signs part of the required elements for physicians to receive bonus payments, so it makes it easier for me to push back at them.

I know there are a lot of EHRs out there where the documentation isn’t so simple and having used a couple of them I’d encourage physicians to look for alternate strategies to make it easier. I did a stint as a locum tenens where the physicians dictate using voice recognition and then staff post-loads the discrete data elements that the system doesn’t recognize. It worked well and the physicians had a high level of satisfaction. Essentially the extra two patients a day they could see by using voice recognition allowed them to pay for the extra staff needed to load the data. It was revenue neutral but the physicians felt better not clicking as much as they used to.

I think the key to managing quality indicators is having a plan on when they are going to be addressed. I see a lot of physicians struggling to try to address every indicator at every visit and it’s just not necessary. My EHR allows me to filter and only see those items that are due in the next three months, six months, etc. so that helps somewhat. Our group also has policies about when the indicators are to be addressed. For example, patients in for an annual preventive visit should have all preventive services due during the next 18 months addressed. This covers them for the next year and a little bit extra should their return appointment be delayed.

The article also cites the amount of time needed to have a conversation with the patient about screening services as a barrier. We provide extensive training to our medical assistants (no nurses in our world) on how to address preventive services with patients during the intake and rooming process so that the patient knows it will be a topic of discussion. The staff can provide educational materials for the patient to read before the physician enters the room, which can make some of those conversations easier and faster. Additionally, providers are not expected to address all preventive services on acute visits. We rely on our automated outreach mechanisms to catch those patients who don’t come in for preventive visits or who have lapses in care. This has been a major physician satisfier because the acute visits remain fairly quick and they don’t have to spend time worrying about patients falling through the cracks.

Having policies on when to address what kinds of services doesn’t have anything to do with the EHR – we actually had these policies in place in the paper world – but they’ve made a great deal of difference. We also provide training for support staff on completing pre-authorizations and pre-certifications so that work can be handed off even in a small office that doesn’t have dedicated referral staff. Looking at the operational workflow and staff training has helped physician satisfaction and hopefully will be one of the things bolstering the patient-physician relationship in our organization. Does your organization have any secret recipes for success? Email me.

Contacts

Mr. H, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis, Lorre

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 12/26/13

Technology, prevention will move health care costs down

In a USA Today article, David Blumenthal, MD, outlines a multi-pronged plan for reducing national healthcare costs.

Investing in the nation’s health

In a Washington Times op-ed piece, NIH director Francis Collins says that spending cuts on top of small annual budgets have weakened NIH’s ability to carry out its mission of turning scientific discoveries into better health. Still, he holds hope for the administrations BRIAN initiative, as well as the rise of big data.

The year in HIE: Public, private sectors prodded to interoperability

In a 2013 year end review, various developments in the HIE sector are discussed.

Readers Write: ‘Twas the Night Before ICD-10

‘Twas the Night Before ICD-10
By Luke O’Cyte

‘Twas the night before ICD-10, when all through the payer
Not a claims engine was stirring, not even a benefits layer;
The mappings were hung in the systems with care,
In hopes that St. Remediolas soon would be there.

The coders were nestled all snug in their beds,
While visions of F30.2’s danced in their heads;
And the CTO in her ‘kerchief, and I in my cap,
Had just settled down for a long winter’s nap,
When out in the data warehouse there arose such a clatter,
I sprang from the bed to see what was the matter.

Away to the office I flew like a fiend,
Tore open the laptop and threw up the screen.
The moon on the breast of the new-fallen snow
Gave the lustre of mid-day to my screensaver though,
When, what to my wondering H54.2’s should touch base,
But a miniature claim, and eight tiny 278s,

With a little old coder, so lively and fast,
I knew in a moment it must be St. Remediolas.
More rapid than eagles his W55.39XA’s they came,
And he whistled, and shouted, and called them by name;

“Now, Procedure! Now, Diag! Now, Surgical and Provider!
On, Vendor! On Member! On, EPM and Auditor!
To the top of the pend list! to the top of the queue!
Now adjudicate! adjudicate! adjudicate do!”

As invalid claims that before the wild eligibility fly,
When they meet with a benefit rule, mount to the sky,
So up to the mainframe the W55.39XA’s they flew,
With the sleigh full of ICD-10 codes, and St. Remediolas too.

And then, in a twinkling, I heard on the servers
The prancing and pawing of each little W55.32XS.
As I threw down my mouse, and was turning around,
Down the office hall St. Remediolas came with a bound.
He was dressed all in fur, from his S00.93 to his T69.02,
And his clothes were tarnished with rejects and errors too;
A bundle of claims he had flung on his back,
And he looked like a payer just opening his pack.

His eyes — how they twinkled! his dimples how merry!
His cheeks were like 284.81, his nose like a cherry!
His droll little mouth was drawn up like a bow,
And the beard of his chin was as white as the snow;
The stump of a pipe he held tight in his teeth,
And the E869.4 it encircled his head like a T59.81;
He had a broad face and a little round belly,
That shook, when he laughed like a bowlful of jelly.
He was 278.00 and E66.3, a right jolly old elf,
And I laughed when I saw him, in spite of myself;
A wink of his eye and a W50.2 of his head,
Soon gave me to know I had nothing to dread;

He spoke not a word, but went straight to remediation,
And ICD-10 coded all claims; then turned with attention,
And laying his finger aside of his nose,
And giving a nod, up the elevator he rose;
He sprang to his claims, to his team gave a 271,
And away they all flew like a mainframe batch run.
But I heard him exclaim, ere he migrated from sight,

“Happy Remediation to all, and to all a good-night.”

….with apologies to Clement Clarke Moore

Morning Headlines 12/24/13

HIMSS Foundation and National eHealth Collaborative Merge

The board of directors from both the HIMSS Foundation and the National eHealth Collaborative have approved a merger of the two organizations, effective December 23. NeHC was created five years ago by HHS as an independent, non-profit organization that worked closely with the ONC to encourage effective use of health IT. The original five-year funding agreement from ONC ended in 2013.

Taking the EHR penalty: More doc offices may opt out

The financial incentive to continue along with Meaningful Use may not be strong enough to persuade eligible providers to adopt Stage 2 and 3 functionality, according to the American Academy of Family Physicians, whose Center for HIT director Dr. Jason Mitchel commented, “We saw a 17% drop off of meaningful users that engaged in 2011 but didn’t in 2012. I think it’s going to be more for 2013.”

Editor’s letter: 10 years and 6 czars into HIT, where are we now?

Diana Manos reviews the 10 year history of the ONC, which, if you include the newly named Karen DeSalvo, MD, has been led by six national coordinators.

Top Scientific Discoveries of 2013

Healthcare dominates Wired’s list of Top Scientific Discoveries of 2013, which included: Genome editing, imaging advancements that allow researchers to render the brain transparent, building functioning organs from stem cells, and a variety of implantable electronics designed to improve health.