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How EMR Process Issues Screwed Up One Small Practice

Posted on January 31, 2011 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Here’s a story which I’m sure could be retold in practices around the U.S.  It’s a tale of how EMR process issues slowed down care to a crawl.

I recently visited small OB/GYN practice — a busy and seemingly prosperous one in a wealthy suburb — which had just implemented a popular EMR package. Knowing how small practices are struggling to make EMRs/EHRs work, I took a suspicious look around.

From the looks of things, everything was in place:  the EMR was available at every workstation used by clinicians and nurses, doctors had carts to roll their e-charts into exam rooms, and the use of paper was minimal.

Then, it was my turn to be seen, and the EMR (in theory) came into the picture. Whoops!  Things went downhill pretty fast.

First, I had my vitals taken by a medical assistant, all of which went onto a piece of paper.  Couldn’t she have had access to one of those carts?   Was the practice too cheap to buy enough terminals to make this not-so-cheap EMR a success? Process failure #1.

Then, I was moved along to a nurse to be asked some additional questions. Though the nurse seemed patient and careful, she had to ask me about my medications three times, because something about the system interface led her to dump the data over and over.  I’m not blaming the nurse (I blame the vendor and their UI) but that was definitely process issue #2.

Then, I finally had a talk with the doctor.  She didn’t make use of  the EMR at all!  She did look at some of the paper I turned in during my waiting room stay, and clearly listened carefully to my concerns, but didn’t take notes during the whole conversation, EMR or no.

I thought one of the great things about an EMR was to normalize how notes were taken and preserve the value of them from the point of care on.  Process issue #3 and the EMR is outta there!  (Well, I wanted to pitch it anyway.) Just how much clinical value could they be getting from this fractured way of doing things?

Folks, I have no idea how long the EMR had been in place there. This could have just been growing pains.  But my instinct is that more likely, the place is going to keep running its EMR in a hodgepodge style until it  begins losing clients or gets punished harshly for its inefficiency. Which do you think will happen first?

Health IT And Cloud Computing: A Promising Start

Posted on January 28, 2011 I Written By

Priya Ramachandran is a Maryland based freelance writer. In a former life, she wrote software code and managed Sarbanes Oxley related audits for IT departments. She now enjoys writing about healthcare, science and technology.

Note: This piece was written by Priya Ramachandran, a former IT auditor and freelance writer who blogs at www.pramwriter.com. We’d like to welcome her to EMRandEHR.com.

You gotta hand it to the IT folks.    Once they come up with a catchy phrase like cloud computing, it spreads like crazy, and now it’s come to mean just about any architecture you can imagine. This Wikipedia entry explains how “cloud” might mean anything from software and services available on the web, to virtual servers created off of physical servers. Adding to the confusion, some leading names in IT willfully obfuscate the terms.

I really like Rob Pegoraro’s definition of the term and that’s all cloud computing is going to mean for the purposes of this post:  cloud computing is “having an Internet site host your data and the programs you use instead of keeping them on your computer.”

Some benefits to putting health data in the cloud:

Now in the case of health IT, there are compelling reasons why a cloud may benefit your organization:

— Increased processing power:  If you leave it to the folks who provide these services, you won’t have to administer/upgrade your own hardware

— Pay as you go:  Pay for only those services that you end up using

— Data portability:  If you keep your customers’ health IT records online, it’s a lot easier for you and your customers to access said data

— Freedom from the IT department guys:  Yeah, it might be a pipe dream, but when you’re with a good cloud service, IT is really your vendor’s headache

— Security:  Which, as we will see later, can be something of a double edged sword

Some models of cloud computing have evolved to better address data integrity. The costlier and most robust solution would be to create a private cloud. Open source cloud solutions such as osCloud allow healthcare organizations with some IT muscle to design their own.

Third party vendors often work with healthcare providers to create a secure version of the cloud for private use. The costs of this approach are significantly higher than investing in a public solution, where all your patient data is on a nebulous cloud. Pragmatic hybrid cloud solutions abound too, fixing the security concerns of a public cloud, and with costs cheaper than a private cloud solution.

Use cases in healthcare:

For health IT, there are several uses cases where cloud computing is probably a great option. Some of the more interesting ones I’ve come across:

— For hospital surveillance and security – Awarepoint, a fully managed service, provides GPS style RTLS (Real Time Location Systems) tracking of patients, personnel, equipment for reducing hospital theft prevention; Denver Children’s Specialists is utilizing ControlByNet’s cloud-based, hosted video security surveillance solutions, to monitor six locations on the cloud. The group moved from separate DVRs to ControlByNet’s solution to monitor its six locations throughout Colorado.

— Cheaper and better transcription services –  Details courtesy of Lauren Richman, healthcare marketing director at Nuance Healthcare: “The doctor dictates a patient record (via phone or into an electronic health record system), the voice file is sent to the cloud where it runs through a speech recognition engine, a draft medical record is created and sent to a transcriptionist for review/editing and then sent back to the doctor for final sign off. Leveraging this cloud-based technology saves time on documentation for doctors and transcriptionists, which speeds efficiency and significantly reduces costs.” A whitepaper published by Nuance shows that 39 customers saved over a million dollar each for a total savings of 93 million dollars.

— Access and collaboration between specialists: ClickCare, a HIPAA compliant SaaS and iPhone application combines pictures, text, sounds, and videos to improve collaboration between healthcare providers. In one instance, at the Wound Institute in PA, 70 patients were treated solely over ClickCare with an overall healing rate of 93% and an estimated savings of $24,000 in transportation costs.

— Other business activities: SuccessFactors is a vendor that works with several hospitals to streamline their HR processes. Presidio Health, a service created by a former ER physician, helps hospitals enables hospitals, health systems and urgent care centers to efficiently collect patient payments at the point of service. (Interesting statistic provided by Presidio: once a patient leaves the ER, the facility only has a 20% chance of collecting any amounts due from the patients)

If you live next door to a mafia don, you’re more likely to get shot:

All these success stories in the media must make everyone else in the healthcare field salivate. But, moving to the cloud shouldn’t cloud one’s judgment about this relatively new IT paradigm. When you’re housed in some cloudy barracks, you have little say over what services you receive, as pharmaceutical giant Eli Lilly found in its experience with Amazon web services. Eli Lilly had long been promoted by Amazon as its poster (client) child, but found that it could ask (and receive) few guarantees from Amazon about power outages, security breaches and other unsavory aspects.

Also as in real life, the ‘hood you decide to live in might very well affect how secure your data is. Amazon Web Services found itself having to boot Wikileaks after it (Amazon) was targeted by groups intent on bringing Wikileaks down. Even though Amazon might be better able to protect itself against a DOS (Denial of Service) attack, its visibility might mean it is attacked more than an average client.

Bottom line:

I’m excited by the services that are now available on the cloud, and even more excited about how much they can revolutionize healthcare. But given my background as an IT auditor, I’m wary of getting too excited about cloud computing just yet.  Let’s see what the next year or two brings.

EMR and EHR Reader Survey

Posted on January 27, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Time for my first ever EMR and EHR reader survey. I’d really like to get a feel for who reads EMR and EHR and how I can make the content on EMR and EHR better. So, don’t be shy in your comments. It’s a simple 13 question anonymous survey and none of the questions are required so just answer the ones you feel comfortable answering.

The survey is embedded below, but if you’re getting this by email then here’s a link to fill out the EMR and HIPAA Survey.

My apologies to those of you who read EMRandHIPAA.com and have already done the EMR and HIPAA survey. If you have, I’d still appreciate you spending 30 seconds to answer the multiple choice questions in the survey for EMRandEHR.com below as well. It’s nice to at least know who’s reading the site.

How Smart Chart Abstraction Can Speed EHR Deployment

Posted on January 26, 2011 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Caught an interesting analysis this week from the California HealthCare Foundation, which has been studying EHR deployment within community clinics and health centers since 2006.

In most cases, chart abstraction creates a major bottleneck which can slow the transition to EHR use to a crawl, while cratering caregiver productivity in the process.  But if it’s done thoughtfully, you can avoid some of the chaos, the study suggests.

In its new paper, the foundation shares chart abstraction techiques that used by members of its California Networks for EHR Adoption initiative.

Here’s some strategies CHCF has identified which seem to speed  up the process — and in turn, streamline EHR deployment. (This is just a small sample; I highly recommend you check out the paper itself for detailed case studies and advice.)

Some of the research group’s suggestions:

* Start with a strategy: Decide in advance what information will be entered, when, and by whom — and decide how closely the EHR data should resemble the paper version.  Just as importantly, decide whether any given piece of data is really worth entering at all.

Don’t abandon paper too quickly: How do you abstract paper chart data?  Usually, you consider scanning charts, migrating data from legacy systems, entering data manually or going for a mix of all of the above.  While each can work, the key is not to drop paper charts too quickly.  To reassure staff, the clinics in CHCF’s initiative typically kept paper on hand all the way through the EHR go-live period — and sometimes for a while afterwards.

Fine-tune your abstraction approach: Clinics that did well with the abstraction process had make near-constant adjustments to their process.  For example, one clinic had to move quickly from traditional scanning to a software solution which gave the docs smart headers, after staff wasted countless hours poring over cryptically-named scans. Then, when that wasn’t enough, it had to develop a hierarchical naming system for scans not long after.

Readers, are you struggling with chart abstraction process as you prepare for EHR deployment?  Has staff productivity taken a big  hit?  Perhaps most importantly, how long do you think it will be before the paper-to-electronic- data process stops being an issue?

Many Hospitals May Not Meet MU Goals By 2015

Posted on January 25, 2011 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

John’s Note: I’d like to welcome accomplished healthcare journalist, Anne Zieger, to EMR and EHR. Anne has a long history in the healthcare IT space and I’m really looking forward to her contributions to EMR and EHR. I’ll still be posting on EMR and EHR as well and of course on EMR and HIPAA. However, I’m excited to bring another voice to EMR and EHR. Welcome Anne!

Nobody said that meeting Meaningful Use standards for EMRs would be easy, but if a new Accenture study is any indication, things are even worse than they seem out there.

Accenture argues that hospitals have a a staggering amount of work to do, and that few are ready. If they hope to get to MU compliance by 2015, hospitals going to have to think differently about change management, plan for a long, tough project, spend heavily and find qualified new personnel.

According to the study, less than 1 percent of health systems were mature EMR users in 2009.  What’s more troubling is that if Accenture is right, only half of U.S. hospitals will meet MU criteria by  2015. That could mean penalties of $3 million to $4 million per year for a 500-bed hospital, the consulting firm estimates.

Why are hospitals and health systems lagging behind?  They’re underestimating how hard the MU compliance job is — and getting blindsided what can be an 80% jump in costs during the transition.

My question:  are these massive transformation headaches and eye-popping costs are inevitable if you want to prove Meaningful Use of an EMR?  Or will hospitals that run lean IT and plan well enjoy a smoother ride?

Screwed Up Meaningful Use (at least for specialists)

Posted on January 24, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I regularly get passionate emails from readers of EMR and EHR (and of course my other site EMR and HIPAA. I don’t always agree with the emails, but I almost always find them interesting. The following is one such email. It wasn’t intended to be published, so excuse the format. However, I find much of the comments about ONC’s approach to specialists spot on. The hard part is that I think ONC realizes this as well. The question is whether ONC in meaningful use stage 2 is going to do anything to address the specialist problem. I think this is a topic we need to voice to ONC.

The EMR’s basically started with certification requirements from CCHIT…ONC took that starting point…and moved to MU from it…without regard to specialty. Properly done, they should have started with MU by specialty…then figured out what the product certification requirements should be from there—for that specialty: Orthopedic guys see lots of patients (50-70 per day, and lose two days/week to surgery), mostly NEW patients with specific problems (broken bones or joint replacements)…no big longitudinal charts…and need to dictate complex notes; Dermatologists have lots of lab/biopsy tests, need to draw pictures and annotate them, not dictate; Pediatricians need growth charts and long medical histories and trends; Oncologists need detailed treatment histories, dosages, outcomes; Ophthalmologists need lots of technical data, measurements and interfaces to optic devices. Yet ONC made a set of rules that really only apply to Primary Care…which is where much of the CHRONIC conditions (and a large portion of the medical cost issues) are quarterbacked…and have the best chance of prevention.

Besides…all the data from specialists should flow back to the PriCare docs anyway…why try to keep it coordinated in both places? I think we have a long way to go to get all healthcare “communitized”…and powers that be need to recognize how different things are for various specialties…and define MU from each specialty’s point of view…and find out that the current certification standards are WAY overkill for most of them…unnecessary complexity and, thereby, cost….to do the irrelevant things to qualify for incentives. After five years, they will stop doing those things anyway, when incentives run out. Having a data pathway between in-patient and out-patient (ambulatory) is a great goal…that should come first..the ability to share data…even if via documents. That could be done today. Trying to devise interoperability standards for 400 EHR’s, a dozen or so major Hospital-based vendors…and registries, labs and other participants….that is a LONG way from being reality

Will be interesting to see how the “success stories” pan out this year starting in May for EP’s. Thank goodness ONC has made it almost impossibly easy for specialists in Stage I….they can opt out of almost everything required and get incentives the first 2 years($30k)…is that a good use of taxpayer money?

Great Chart Comparing Meaningful Use Stage 1 with Stage 2 and 3

Posted on January 21, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Today I came across this really great chart that compares the meaningful use stage 1 requirements with the proposed requirements for meaningful use stage 2 and 3. The comment period is still open for meaningful use stage 2 and 3 so make your voice heard.

Here’s the roadmap as described by John Halamka:
Jan, 12, 2011: release draft Meaningful Use criteria and request for comment
Feb-March, 2011: analyze comment submissions and revise Meaningful Use draft criteria
March, 2011: present revised draft Meaningful Use criteria to the HIT Policy Committee
2Q11: CMS report on initial Stage 1 Meaningful Use submissions
3Q11: Final HIT Policy Committee recommendations on Stage 2 Meaningful Use
4Q11: CMS Meaningful Use NPRM

See the comparison chart embedded below.


Getting Your CMS EHR Certification ID Number

Posted on January 19, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Drummond Group has updated their FAQ with an interesting question about how to obtain a CMS EHR certification ID and the difference between the CMS EHR certification ID and the ONC EHR Certification ID that Drummond Group issues.

Q: How do I obtain a CMS EHR Certification ID? Is it the same as my ONC EHR Certification ID I received from Drummond Group?

A: The unique ONC EHR Certification ID issued by Drummond Group is associated with the CMS EHR Certification ID but distinct from it. The ONC EHR Certification ID is one of the “inputs” into the calculation and creation of the CMS EHR Certification ID. However, it is ultimately the CMS EHR Certification ID number which EPs and hospitals will use for the incentive payments.

The ONC Certified Health Product Listing functionality was updated December 24, 2010 and it now has the addition of a shopping cart to create CMS EHR Certification ID number. Users can obtain the CMS EHR Certification ID number by following these steps:

1. Go the ONC CHPL website: http://onc-chpl.force.com/ehrcert

2. Following the instructions on the site, search for the certified EHR products. There are many ways to search, but one option is to search by the ONC EHR Certification ID assigned to the vendor.

3. When the EHR product(s) is found, select the link on its row called “Add to Cart”. There is a shopping cart icon next to it.

4. When all EHR products used by the EP or hospital have been added to the cart, select the “View Cart” link at the top right which also has a shopping cart icon next to it.

5. Now in the Certification Cart section, verify the products in the cart are correct. Then, select the “Get CMS EHR Certification ID” button in the top right corner to request a CMS EHR Certification ID. However, the button will not be activated until the items in your cart meet 100% of the required criteria. If your EHR product(s) do not meet 100% of the Meaningful Use incentives, then a CMS EHR Certification ID number can not be issued.

6. Finally, you will see the CMS EHR Certification ID. It is typically a 15 digit string made up alphanumeric characters.

Interesting that the CHPL website has been redesigned to be able to know which EHR are certified to which module and knows if you’ve reached a 100% certified set of software.

Looks like it also pays off to have a number for your EHR product name so that you’re listed first on the CHPL site.

EMR Doctor’s Blog: Ways to Save Money in a Modern Electronic Medical Practice: Part Two

Posted on January 18, 2011 I Written By

Here’s another tip I learned over the first year in my solo practice that has really added efficiency and productivity to my office.

Tip #2. Use an electronic health / medical record system (for free, if you can).

I’ll admit I’m biased here. I hate buying something that I can get legally for free.  And as far as EMR systems go, there’s more than one option on the market at the present time.  In my office, we use the guilty pleasure of Practice Fusion and have been pretty freaking happy for a year now. Mitochon Systems is another company that offers such an EMR system, although I confess I haven’t tried it.  Practice Fusion now claims about 60,000 users, although these are not all physicians. For a recent review of their stats, an interview with the CEO can be found at HisTalkPractice.com.  These companies often use alternative sources of income in order to avoid passing on their business costs to the providers and staff using their systems. In the case of Practice Fusion, we see small ads for medications at the bottom of the screen or off to the side.   For me, this is tolerable, and I don’t feel any pressure to prescribe these drugs. They are not popup boxes that would require you to close before being able to work on patient charts, and so this allows them to be minimally invasive into your daily activities.

In bipartisan fairness, there are a variety of systems that you can pay for if desired, and indeed there is a pay-for option to use Practice Fusion without the ads for around $100 per month.  If you have ethical qualms about using a reportedly “free” system due to supposed “hidden costs”, financial and “otherwise”, that someone else will need to pay for, then you may wish to pay yourself. Just please please please don’t make the mistake of thinking that free systems are somehow less capable or functional, simply because they are free to users, and “after all, how good could it be if it’s not expensive?”.  As the old saying goes, “Don’t knock it until you’ve tried it.”  Now, as for my soapbox on drug companies and their tactics to ruin physicians’ ability to choose drugs they would really like to prescribe, we’ll have to save that one for another post…

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.

Full Disclosure: Practice Fusion and Mitochon Systems are both advertisers on EMR and EHR, but I’m not sure Dr. West even knew this when he wrote the post. Plus, Dr. West didn’t get paid to write this post either. He just loves EMR and is glad to share his good and bad experiences with it.

Nephrologists (Dialysis Centers) and EMR Stimulus Money

Posted on January 17, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I often get questions from readers of my sites and I often don’t know the answer. So, instead of acting like I know the answer, I like to put it out to my readers to see what they have to say about the topic. This is one of those cases. Here’s the question I got about Nephrologists and Dialysis Centers and EMR stimulus money.

I am interested in finding out how dialysis centers qualify for the EHR incentive money and best practices for Nephrologists, NPs, and/or PAs running dialysis centers for attestation.

This is an area I’m not that familiar with. So, if you know more than I (which many of you do), let us know your thoughts in the comments. I’ll update the post if needed too.

My only general thought is that it wouldn’t seem like I’ve seen an exception that would exclude nephrologists so I assume they could be considered an “eligible provider.” I also imagine that they probably have a large number of Medicare patients so that they can easily meet the Medicare reimbursement requirements and they might even meet the Medicaid requirements.

I guess the real question might be whether nephrologists and dialysis centers use a “certified EHR” or not. If not, then they’re likely up a creek. If they do, then my next question is whether or not it’s worth their time to ask their patients if their smokers (amongst other meaningful use requirements) every time they come for a visit.

Talk amongst yourselves in the comments.