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Reply to Dr. Jacob Reider on NIST Dissects Workflow: Is Anyone Biting?

Posted on March 31, 2014 I Written By

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com, a free service for matching users and EHRs. For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manger doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst.

One comment on my latest post, NIST Dissects Workflow: Is Anyone Biting?, deserves a more than casual reply.

Here’s the comment from Jacob Reider (Note: Dr. Reider is ONC’s Acting Principle Deputy National Coordinator and Chief Medical Officer. He has made major contributions to the HIT field and is one of its significant advocates.)

Carl, ONC’s UCD requirement references ISO 9241–11, ISO 13407, ISO 16982, NISTIR 7741, ISO/IEC 62366 and ISO 9241–210 as appropriate UCD processes.

We also require summative testing as defined in NISTIR 7742.

Might “Refuses to incorporate NIST recommendations” be a bit of an overstatement?

We solicited public comment in our proposed rule for 2015 certification and would welcome specific suggestions for how we can/should improve user experience of health IT products for efficiency and safety.

Dr. Reider, thank you for your comment – it certainly falls into the category of you never know who’s reading.

Let’stake a look at your last comment first, “Might ‘Refuses to incorporate NIST recommendations’ be a bit of an overstatement?”

Obviously, I don’t think so, but I am not alone.

I based my comment on ONC’s statement in its rule making that refers to NIST’s usability protocols. It says:

While valid and reliable usability measurements exist, including those specified in NISTIR 7804 “Technical Evaluation, Testing and Validation of the Usability of Electronic Health Records,” (21) we are concerned that it would be inappropriate at this juncture for ONC to seek to measure EHR technology in this way.

Sounds like a rejection to me, however, don’t take my word. Here’s the AMA’s response to this decision. First, they demur and quote ONC:

We disagree with ONC’s assertion in the Version 2014 final rule that, “[w]hile valid and reliable usability measurements exist, including those specified in NISTIR 7804 ‘‘Technical Evaluation, Testing and Validation of the Usability of Electronic Health Records,’’ we expressed that it would be inappropriate for ONC to seek to measure EHR technology in this way.”

It then says:

To the contrary, we believe that it is incumbent upon ONC to include more robust usability criteria in the certification process.  The incentive program has certainly spurred aggressive EHR uptake but has done so through an artificial and non-traditional marketplace.  As a consumer, the physician’s choice of products is limited not only by those EHRs that are certified but also by the constraint that all of these products are driven by federal criteria.  The AMA made several detailed recommendations for improving Version 2014 certification in our Stage 2 comment letter, which were not adopted, but still hold true, and we recommend ONC consider them for the next version.  Testimony of AMA’s Health IT Policy Committee’s Workgroups on Certification/Adoption and Implementation, July 23, 2013, pp. 5-6

I recognize that ONC says that it may consider the protocols in the future. Nevertheless, I think the plain English term rejected fits.

In the first part of his statement, Dr. Reider cites several ISO standards. With the exception of the Summative Testing, all of these have been referred to, but none have been adopted. Reference to a standard is not sufficient for its inclusion under the operation of the federal Administrative Procedure Act, which governs all federal agency rulemaking. In other words, these standards are important, but ONC simply calls them out for attention, nothing more.

I think two factors are at work in ONC’s reluctance to include the NIST usability protocols. The first is that the vendors are adamantly opposed to having them mandated. However, I believe there is a way around that objection.

As I have argued before, ONC could tell vendors that their products will be subject to a TURF based review of their product for compliance and that the results would be made public. That would give users a way to judge a product for suitability to their purpose on a uniform basis. Thus, users looking at the results could determine for themselves whether or not one or more non compliance was important to them, but at least they would have a common way to look at candidate EHRs, something they cannot do now , nor under ONC’s proposed approach.

The other factor is more complex and goes to the nature of ONC’s mission. ONC is both the advocate and the standards maker for HIT. In that, it is similar to the FAA, which is vested with both promoting and regulating US aviation.

It’s well established that the FAA’s dual role is a major problem. It’s hard to be a cheerleader for an industry and make it toe the line.

With the FAA, its dual mandate is exacerbated when the highly respected NTSB investigates an incident and makes recommendations. The FAA, acting as industry friend, often defers NTSB’s authoritative and reasonable recommendations to the public’s determent.

I believe that something similar is going on with ONC. NIST’s relationship to ONC is roughly analogous to that of the NTSB’s to the FAA.

NIST is not an investigative agency, but it is the federal government’s standards and operations authority. It isn’t infallible. However, ONC dismissing NIST’s usability protocols, in one word, inappropriate. It did this without explanation or analysis (at least none that they’ve shared). In my view, that’s really inappropriate.

ONC has a problem. It’s operating the way it was intended, but that’s not what patients and practioners need. To continue the aviation analogy, ONC needs to straighten up and fly right.

Time Using EMR, EMR Copy and Paste, and Larry Page on EMR

Posted on March 30, 2014 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.


The good news is that EMRs will get better.


I’ve often said that it’s not copy and paste that’s bad. It’s how you use it. Many use it poorly which leads to bad data.


This whole interview with Larry (Founder of Google) is great. Plus, I adore Charlie Rose interviews.

No Shortage of Excitement (This Week) in Healthcare IT

Posted on March 28, 2014 I Written By

As Social Marketing Director at Billian, Jennifer Dennard is responsible for the continuing development and implementation of the company's social media strategies for Billian's HealthDATA and Porter Research. She is a regular contributor to a number of healthcare blogs and currently manages social marketing channels for the Health IT Leadership Summit and Technology Association of Georgia’s Health Society. You can find her on Twitter @JennDennard.

When I began contemplating the subject of this blog earlier in the week, I thought I’d make room for thoughts on recent improvements in EMR adoption in the small practice and physician community, and the general state of optimism and enthusiasm some op-ed pieces would have us believe is finally taking hold of the industry. But then came along the potential delay of ICD-10, which also begs a quick comment or two.

A bill that included an effort to delay the ICD-10 compliance date a full year was passed, but only after partisan drama over the fact that legislators received the proposed bill just a day before the vote on it was to take place. I tend to turn to AHIMA on ICD-10 matters, and its official stance is fairly obvious:

ahimaicd10tweet

Its reasoning is similar to that of the Coalition for ICD-10, which in a letter to the CMS, stated: “ … any further delay or deviation from the October 1, 2014, compliance date would be disruptive and costly for health care delivery innovation, payment reform, public health, and health care spending. By allowing for greater coding accuracy and specificity, ICD-10 is key to collecting the information needed to implement health care delivery innovations such as patient-centered medical homes and value-based purchasing.

“Moreover, any further delays in adoption of ICD-10 in the U.S. will make it difficult to track new and emerging public health threats. The transition to ICD-10 is time sensitive because of the urgent need to keep up with tracking, identifying, and analyzing new medical services and treatments available to patients. Continued reliance on the increasingly outdated and insufficient ICD-9 coding system is not an option when considering the risk to public health.”

AHIMA has even started a campaign to encourage its constituents to email their senators to urge them to also vote no when it comes to delaying ICD-10. At the time of this writing, the Senate vote is not yet scheduled. I don’t feel the need to restate my support of no further delay. You can read it here.

With regard to the other hot news items of the week, I was intrigued by the findings of the SK&A survey, which found that the EMR adoption rate for single physician practices grew 11.4%. One reason SK&A gave in the survey analysis was due to the “availability of more than 450 different solutions to fit their practice needs, size and budget.” Call me crazy, but I’m willing to bet that many solutions will not exist in the next three to five years thanks to market consolidation. What will these physicians do when their EMR vendor closes up shop? Time will tell, I suppose.

The Time Has Finally Come for MU, It Really Is Now or Never

Posted on March 27, 2014 I Written By

The following is a guest blog post by Lea Chatham.
Lea Chatham

The healthcare industry has been talking about Meaningful Use (MU) for years now. The program started in 2011, but there were discussions and planning going on years before that. It’s become a ubiquitous topic in healthcare publications and blogs. So much so that many providers probably still think that they have time to decide if they are really going to attest or not.

The truth is that 2014 is last year to initiate participation for Medicare to receive incentive payments. To avoid the first adjustment of 1%, providers must attest for Stage 1, Year 1 no later than the third quarter of 2014 (July 1 – September 30, 2014). You can still start MU in future years to avoid additional penalties, but you won’t get any incentives and you will still have the 1% deduction on your Medicare Part B Claims starting in 2015. That penalty doesn’t go away if you start MU in 2015 or 2016.

What this means is that the estimated 40% of America’s physicians who don’t’ have an EHR and haven’t yet begun to attest for MU have a decision to make—now. And there are essentially three options:

  1. Choose an EHR and attest in 2014
  2. Accept the penalty (which increases each year)
  3. Request a hardship exception.

Here is what you need to know about each of these options so you can make the right choice for your practice.

Choose an EHR & Attest

Over $16 billion in incentives has been paid out to providers who have been attesting for MU. If you start in 2014, you’ll still get $24,000 over three years for your efforts. You’ll also avoid the penalties, which start with 1% in 2015 and increase each year for a minimum of three years. The larger your Medicare pool of patients, the more sense this makes financially.

If you are going to adopt an EHR now, be sure to choose the right solution for your needs. Many of the providers who have not yet implemented an EHR, are small practices (10 or fewer providers). According to a survey conducted in January by SK&A, the smaller the practice, the lower the adoption rate. Small, independent practices don’t have staff, time, or money to waste. So it has to be right the first time. Take these factors into consideration:

  1. Cost: There are now free and low cost EHRs that can offer almost any specialty the tools they need to reap the benefits of an EHR.
  2. Cloud-based and Mobile: Its 2014, don’t choose an EHR unless it offers anytime, anywhere access and true mobile connectivity.
  3. 2014 Edition Certified for MU: As of January 1, 2014, you need a 2014 Edition certified EHR to attest for MU. Only about 12% of complete EHRs have this certification, which narrows the field.
  4. Total Integration: You can get more from your EHR if it is fully integrated with your practice management and billing system. You can meet MU and streamline many other functions. As a bonus it can actually increase both charges and collections. A UBM white paper showed that the average increase in revenue was $33,000 per FTE provider per year!

Accept the Penalty

So you are thinking you’ll just take the penalty. This may be because you don’t serve Medicare patients or at least not that many. It could also be that you are planning to retire soon and don’t think you’ll be around in another couple of years. But consider this, with MU, PQRS, and eRx penalties, it reaches over 10% in total adjustments to your Medicare Part B claims in five years. If you do start seeing more Medicare patients (as your patients age) or you don’t retire, 10% is nothing to sneeze at. If you are a solo doc and you generate an average of $30,000 a month and about 30% of your patients have Medicare, that’s $10,000 a month. A 10% cut adds up to $12,000 a year. To make that up, you would have to conduct about 100-120 more patient visits a year (if your average visit reimbursement is around $100-150).

And here is something else to consider. Perhaps you are willing to take that hit, and you are sure that you don’t want to attest for MU. But does that mean you don’t need to implement an EHR? Not these days. Patient expectations are changing, and to stay competitive you need to meet those expectations. A study conducted by the Optum Institute showed that 62% of patients want to correspond with their physician online and 75% are willing to view their medical records online. Another survey conducted by Deloitte showed that two-thirds of patient would consider switching to a physician who offers secure access to medical records online. You need patients to stay in business so take their changing needs seriously or you may struggle to stay competitive in changing times.

Request a Hardship Exception

The first thing that needs to be said here is that not everyone can apply for a hardship exception. If you’d like to attest for MU, but need more time AND you meet one or more of the criteria, then you should definitely consider this option. This is a summary, check the CMS tipsheet to find out more:

  1. Your area lacks the necessary infrastructure (i.e., no broadband)
  2. You’re a new provider
  3. Natural disaster or other unforeseen barrier
  4. Lack of face-to-face interaction with patients
  5. Practice in multiple locations
  6. EHR vendor issues (i.e., your current vendor was unable to certify for 2014 edition)

For most providers who are practicing full time in a single location and have not yet chosen an EHR, these exceptions won’t apply. This leaves you with choices and one and two above. You will still need to decide if you want to attest or not.

If you are still on the fence, consider this… Beyond MU, practices are facing the ICD-10 transition and a changing reimbursement landscape with ongoing reform from of the Affordable Care Act (ACA). Technology can be a very effective tool to help you manage these changes and turn this set of challenges into an opportunity to optimize your practice and position your business for success no matter what comes your way.


About Lea Chatham

Lea Chatham is the Content Expert at Kareo, responsible for developing educational resources to help small medical practices improve their businesses. She joined Kareo after working at a small integrated health system for over five years developing marketing and educational tools and events for patients. Prior to that, Lea was a marketing coordinator for Medical Manager Health Systems, WebMD Practice Services, Emdeon, and Sage Software. She specializes in simplifying information about healthcare and healthcare technology for physicians, practice staff, and patients.

NIST Dissects Workflow: Is Anyone Biting?

Posted on March 26, 2014 I Written By

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com, a free service for matching users and EHRs. For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manger doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst.

Psst. Hey, Buddy, wanna see an EHR, visit’s workflow? Here it is, thanks to the National Institutes of Standards and Technology’s (NIST) new report, NISTIR 7988, Integrating Electronic Health Records into Clinical Workflow, etc.

Returning Patient Ambulatory Workflow NIST

What It Represents

NIST wants to make EHRs usable and useful. It first took aim at patient safety EHR functions that endangered, confused users or were error prone. To counter these, it developed and recommended EHR usability protocols.

Now, in an extensive report, it’s tackled EHR workflow to determine where problems occur. The result is a comprehensive work with significant findings and recommendations. The question is: Is anyone listening?

NIST’s Analytical Approach

NIST decided to create a typical workflow by interviewing knowledgeable physicians, who it calls Subject Matter Experts, SMEs. The physicians had different specialties and used different EHRs, though who they were, NIST doesn’t say.

From their discussions, NIST’s analysts created the above chart, NIST’s Figure 2. NIST’s authors recognize that actual workflows will vary based on setting, sequences, staffing, etc., but that it provides a useful way to look at these issues.

What They Did With It

Working with their physicians, NIST’s analysts broke down the workflow into three sections: before, during and after the visit. Then, they broke down, or decomposed, each of those sections, like opening nested Russian dolls. For example, they segmented the physician’s encounter, below, and once again, broke each down into its functions.

Returning Patient, Physician Encounter - NIST

What They Found

It was at this stage the analysts found significant variations among the EHRs used by their physicians,

[T]here appeared to be high variation in whether and how the EHR was used during this period, how extensive each of the activities typically were for each SME, different based upon the type of patient, how complex the patient was, context of how busy the day was, and other factors. NSTIR 7988, p 18.

Despite these differences, the physicians identified two issues that crossed their EHRs:

  • Working Diagnoses. The physicians wanted systems that let them create a working diagnosis and modify it as they worked until they made a final diagnosis. Similarly, they wanted to be able to back up and make changes as needed, something current systems make hard.
  • Multiple Diagnoses. Diagnoses usually involve multiple causes, not single factors. They wanted their EHRs to support this.

These types of issues aren’t new to those familiar with EHR problems. What’s new is NIST, as an independent, scientific organization, defining, cataloguing and explaining them and their consequences.

What They Recommended

From this work, NIST’s analysts developed extensive and persuasive recommendations, in three categories:

  • EHR Functions
  • System Settings, and
  • System Supports

EHR Functions

NIST’s recommends reducing practitioner workload, while increasing their options and supports. For example, they suggest:

  • Workload Projections. Give practitioners a way to see their patient workloads in advance, so they can plan their work more effectively
  • Notes to Self. Let users create reminder notes about upcoming visit issues or to highlight significant ,patient information. These would be analogous to their hand written notes they used to put on paper charts.
  • Single Page Summaries. Create single page labs summaries rather than making users plow through long reports for new information.
  • Single Page Discharge Summaries. Eliminate excessive boiler plate with more intelligent and useful discharge sheets.
  • Highlight Time Critical Information. Segregate time critical information. Often they get mixed in with other notices where they may be overlooked or hard to find.
  • Allow Time Pressure Overrides. When time is critical, EHRs should allow skipping certain functions.
  • System Settings

NIST recommendations echo the familiar litany of issues that characterize poor implementations:

  • Allow Patient Eye Contact. Exam room designs should put the doctor and patient in a comfortable, direct relationship with the computer as a support.
  • Login Simplification. Allow continuous logins or otherwise cut down on constant login and outs.

System Supports

The physicians recognized they often caused workflow bottlenecks. NIST recommended off loading work to medical assistants, nurse practitioners, physician assistants, etc.. For example, physician assistants could draft predicted orders for routine situations for the physician to review and approve.

Progress Note Frustrations

In the thorny area of clinical documentation, the report details physician frustration with their EHRs. All experienced excessive or missing options, click option hell, excessive output, puzzling terms, etc. These were compounded by time consuming system steps that did not aid in diagnosis or solving patient problems. The report discusses their attempts at improving documentation:

Several of the SMEs had attempted and then abandoned strategies to increase the efficiency of documentation. One SME reported that copying and pasting and “smart text” where typing commands generate auto-text had a “vigilance problem.” The issue was that it would be too easy to put the wrong or outdated information in or in the wrong place and not detect it, and then someone later, including himself, could act on it not realizing that it was incorrect.

One physician described an attempt to use automated speech recognition for dictation for a patient with scleritis, which is inflammation of the white of the eye. He stopped using the software when what was documented in the note was “squirrel actress.”

Another SME described that colleagues relied upon medical assistants to draft the note and then completed it, but they did not like that approach because it was too tempting to rely upon what was typed without reviewing it, and he felt the medical knowledge level was not high enough for this task.

One SME described a reluctance to use any scribe, including a medical student, because the risk would be too high of misunderstanding and thus not correctly documenting the historical information, diagnosis, and treatment plan. This was particularly problematic if the physician had information from prior visits, which contributed to these elements, which were not discussed in detail during the visit. NSTIR 7988, p. 28

Coding their diagnoses into progress notes also came in for criticism:

All SMEs described frustration with requirements to enter information into progress notes, …, which were applied to the notes in order to have sufficient justification to receive reimbursement for services. Although all of the SMEs acknowledged the central importance of receiving reimbursement in order to function as a business, this information was often not important for clinical needs. NSTIR 7988, p. 28

Role Based Progress Note

Unlike other areas of the report, the doctors could not agree on what to do, nor does NIST offer any specific cures for documentation problems. Instead, NIST recommends using a new, role based, progress note:

[T]he progress note for a primary care physician would have a different view from a specialist such as a urologist physician, who might not need to see all of the information displayed to the primary care physician. Similarly, the view of the note for primary care providers could differ from the view of a billing and coding specialist. … NSTIR 7988, p. 28

Will ONC Respond?

In this and its prior reports, NIST covers a lot of EHR issues making sensible recommendations that not only improve functionality, but more importantly improve patient safety. However, NIST’s recommendations are just that. It’s not a regulatory agency, nor is supposed to be one. Instead, its role is to work with industry and experts to develop usable, practical approaches to tough technical, often safety related, problems. To its credit, it’s done this in a vast number of fields from airplane cockpits, nuclear reactors, and atomic clocks to bullet proof vests.

However, its EHR actions have not gained any noticeable traction. If any EHR vendor has implemented NIST’s usability protocols, they haven’t said so. They are not alone.

Notably ONC, one of NIST’s major EHR partners, refuses to incorporate any of NIST’s usability recommendations. Instead, ONC requires vendors to implement User Centered Design, but does not define it, letting each vendor do that for themselves.

NIST has many answers to common EHR workflow and usability problems. The question is, who will bring them to bear?

The Changing EHR and Health IT Landscape

Posted on March 25, 2014 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.

We’re entering a really interesting period for healthcare IT. I’d say this is the start of a really big transition period for the EHR market. The government induced demand for EHR will end soon and we’ll see very different dynamics going forward. With that said, I think we’re about to enter one of the most exciting periods of healthcare IT ever. The wheat is going to be sifted from the chaff and the cream will rise to the top. We’re about to enter a phase where people are more worried about how to get the most out of their EHR versus getting an EHR.

This is what makes us most excited at EMR and EHR. We’re entering a really exciting time where I believe we’re going to see some amazing new EHR uses. We’ll do our best to continue keeping you up to date on the latest happenings in the EMR, EHR, and health IT worlds.

I’m excited to say that we just passed our 1200th blog post on EMRandEHR.com. What an amazing body of work that we’ve created on this site. We couldn’t have done it without the support of our readers and advertisers. I deeply appreciate both groups more than I can express in a blog post.

As we usually do every 6 months, I want to highlight the new and renewing advertisers. If you appreciate the content we create on EMRandEHR.com, then I hope you’ll take a second to browse through these companies which support the work we do.

New EMR and EHR Advertisers
VM Racks – If you’re looking for HIPAA compliant web hosting, you should check out VM Racks to see what they have to offer. They provide a managed services environment that many health IT companies will find interesting. The great part is that right now they’re offering a free 30 day trial of their HIPAA compliant web hosting. I can see a lot of health IT startup companies that could benefit from the 30 day free trial, but a 30 day free trial is great for anyone who wants to get a feel for how well their hosting works.

HealthFusion – If you’re looking for a 2014 Edition certified EHR, then take a look at HealthFusion’s MediTouch EHR. In fact, they were one of the first to be 2014 Edition certified since they completed it on June 13th, 2013. They offer a number of interesting whitepapers like this one on “12 questions to ask before buying EHR software.”

Colocation America – I’ve written many times about the shift away from built in data centers or server rooms to outside data centers. Colocation America offers a variety of data center hosting options across the country and a number of HIPAA compliant hosting options.

Modernizing Medicine – I’ve written previously about the Modernizing Medicine approach to ICD-10 and their unique EHR interface. If you are looking for an EMR for dermatology, opthamology, otolaryngology, plastic surgery, orthopedics, or cosmetic surgery, then take a look at what Modernizing Medicine has created.

Renewing EMR and EHR Advertisers
I can’t thank the following advertisers enough for their support. As you can see, many of them have been supporting EMR and EHR for 2 or 3 years. I’m glad they still see value in supporting the work we do.
Ambir – Advertiser since 1/2010
Cerner – Advertiser since 9/2011
Canon – Advertiser since 10/2012
gMed – Advertiser since 8/2013

Check out our healthcare IT advertising page for more information on supporting EMRandEHR.com. Plus, this is the final week to register for the Health IT Marketing and PR Conference. If you’re on the fence about attending the conference, go and register now and you won’t be disappointed. We have two days with amazing content and great networking with attendees.

Why ICD-10?

Posted on March 24, 2014 I Written By

At least half a dozen folks have asked me to explain why HHS is mandating the transition to ICD-10. So I thought I’d write a blog post about the subject.

First, I’ll examine some of the benefits that proponents of ICD-10 site. Then, I’ll examine the cost of transition from ICD-9 to ICD-10.

There are about a dozen frequently cited reasons to switch from ICD-9 to ICD-10. But they can be summarized into three major categories:

1) The US needs to catch up to the rest of the world.

2) The more granular nature of ICD-10 will lend itself to data analysis of all forms – claims processing, population health, improved interoperability, clinical trials, research, etc.

3) ICD-9 doesn’t support the latest diagnoses and procedures, and ICD-10 does.

Regarding #1, who cares? Coding standards are intrinsically arbitrary. Sequels are not necessarily better than their predecessors.

Although #2 sounds nice, there are a lot of problems with the supposed “value” of more granular data in practice. Following the classic 80-20 rule of life (80% of value comes from 20% of activity), the majority of codes are rarely used. By increasing the number of codes six-fold, the system is creating 6x the opportunities to inaccurately code. There is no reason to believe that providers will more accurately code, but the chances of incorrect diagnosis are now significantly higher than they were before. Garbage in, garbage out.

Below are some specific examples of how increasing the number of codes will affect processes in the healthcare system:

Payers – payers argue that making codes more granular will improve efficiency in the reimbursement process by removing ambiguity. There is nothing further from the truth. Payers will use the new granularity to further discriminate against providers and reject claims for what will appear to be no reason. With 6x the number of codes, there are at least 6x as many opportunities for payers to reject claims.

Clinical trials – ICD-10 proponents like to argue that with more granular diagnosis codes, companies like ePatientFinder can more effectively find patients and match them to clinical trials. This notion is predicated on the ability of providers to enter the correct diagnosis codes into EMRs, which is a poor assumption. Further, it doesn’t actually address the fundamental challenges of clinical trials recruitment, namely provider education, patient education, and the fact that most patients aren’t limited to trials by diagnosis codes, but rather by other data points (such as number of years with a given disease and comorbidities).

Public health – ICD-10 proponents also claim that the new coding system will help public health officials make better decisions. Again, this is predicated on accuracy of data, which is a poor assumption. But the greater challenge is that the most pressing public health issues of our time simply don’t need any more granularity in diagnosis codes. Public health officials already know what the top 20 public health problems are. Adding 6x the number of codes will not help address public health issues.

Regarding #3, why do we need to reinvent the entire coding system and make the entire system more granular to accommodate new diagnoses and procedures? Why can’t we continue to use the existing structure and simply create new branches of the ICD tree using alphanumeric characters? Why do we need to complicate every existing diagnosis and procedure to support new diagnoses and treatments? We don’t. There are plenty of letters left to be utilized in ICD-9 to accommodate new discoveries in medicine.

Next, I’ll provide a very brief summary of the enormity of the cost associated with transitioning from ICD-9 to ICD-10. The root of the challenge is that a string of interconnected entities, none of whom want to work with one another or even see one another, must execute in sync for the months and years leading up to the transition. Below is a synopsis of how the stars must align:

EMR vendors – EMR vendors must upgrade their entire client base to ICD-10 compliant versions of their systems in the next couple of months to begin testing ICD-10 based claims. Given the timescales at which providers move, the burden of MU2 on vendors, and the upgrade cycles for EMR vendors, this is a daunting challenge.

Providers – providers don’t want to learn a new coding system, and don’t want to see 6 times the number of codes when they search for basic clinical terms. Companies such as IMO can mitigate a lot of this, but only a small percentage of providers use EMRs that have integrated with IMO.

Coding vendors – like EMR vendors, auto-coding vendors must upgrade their clients systems now to one that supports dual coding for ICD-9 and ICD-10. They must also incur significant costs to add in a host of new ICD-10 based rules and mappings.

Coders – coders must achieve dual certification in ICD-9 and ICD-10, and must double-code all claims during the transition period to ensure no hiccups when the final cut over takes place.

Clearinghouses – clearinghouses must upgrade their systems to support both ICD-9 and ICD-10 and all of the new rules behind ICD-10, and must process an artificially inflated number of claims because of the volume of double-coded claims coming from providers.

Payers – payers must upgrade their systems to receive both ICD-9 and ICD-10 claims, process both, and provide results to clearinghouses and providers about accuracy to help providers ensure that everyone will be ready for the cut over to ICD-10.

The paragraphs above do not describe even 10% of the complexity involved in the transition. Reality is far more nuanced and complicated. It’s clear from the above that the likelihood that all of the parties can upgrade their systems, train their staff, and double code claims is dubious. The system is simply too convoluted with too many intertwined but unaligned puzzle pieces to make such a dramatic transition by a fixed drop-dead date.

Lastly, switching to ICD-10 now seems a bit shortsighted in light of the changes going on in the US healthcare system today. ICD-10 is already a decade old, and in no way reflects what we’re learning as we transition from volume to value models of care. It will make sense to change coding schemes at some point, but only when it’s widely understood what the future of healthcare delivery in the US will look like. As of today, no one knows what healthcare delivery will look like in 10 years, let alone 20. Why should we incur the enormous costs of the ICD-10 transition when we know what we’re transitioning to was never designed to accommodate a future we’re heading towards?

At the end of the day, the biggest winners as a result of this transition are the consultants and vendors who’re supporting providers in making the transition. And the payers who can come up with more reasons not to pay claims. Some have claimed that HHS is doing this to reduce Medicare reimbursements to artificially lower costs. Although the incentives are aligned to encourage malicious behavior, I think it’s unlikely the feds are being malicious. There are far easier ways to save money than this painful transition.

The ICD-10 transition may be one of the largest and most complex IT coordination projects in the history of mankind. And it creates almost no value. If you can think of a larger transition in technology history that has destroyed more value than the ICD-9 to ICD-10 transition in the US, please leave a comment. I’m always curious to learn more.

You might be an #HITNerd If…

Posted on March 23, 2014 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.

You might be an #HITNerd If…

HIPPA and HIMMS make your skin crawl.

Find all our #HITNerd references on: EMR and EHR & EMR and HIPAA and check out the new #HITNerd t-shirts, hat, and phone cases.

NEW: Check out the #HITNerd store to purchase an #HITNerd t-shirt of cell phone case.

Note: Much like Jeff Foxworthy is a redneck. I’m well aware that I’m an #HITNerd.

Taking the Anxiety out of Healthcare IT (and Cost of Care)

Posted on March 21, 2014 I Written By

As Social Marketing Director at Billian, Jennifer Dennard is responsible for the continuing development and implementation of the company's social media strategies for Billian's HealthDATA and Porter Research. She is a regular contributor to a number of healthcare blogs and currently manages social marketing channels for the Health IT Leadership Summit and Technology Association of Georgia’s Health Society. You can find her on Twitter @JennDennard.

I’m prone to anxiety when it comes to unexplained aches and pains, though I tend to internalize it in an effort to not come across as a hypochondriac. I’m sure I let my inner, extreme worrier come through just a tad during a recent doctor’s appointment. I was visibly relieved to learn that what I had been quietly fretting about for weeks was in fact quite normal. My relief must have been extremely visible, because my doctor was quick to explain that what patients often consider irregular, doctors treat as run of the mill. What I lose sleep over, they don’t bat an eye at. (If only her practice offered a patient portal with secure email, so that we could correspond about my health at our leisure.)

She then told me of a recent trip to the doctor with her mother, and that she had a newfound appreciation for the patient’s side of the visit as she saw things from her mother’s point of view. It was quite refreshing to hear. I might temper my anxiety before my next appointment by playing this mobile game, should it ever be made available in the app store. According to a recent study published in Clinical Psychological Science, 25 minutes of play reduces levels of stress and anxiety. Researchers are looking to see if the effects are the same with shorter bursts of playtime. It’s got to be a cheaper (and healthier) alternative than a prescription for Xanax, right?

Speaking of healthcare costs, I read with interest the news that not only did Castlight Health’s IPO perform better than expected, but that it also partnering with the Leapfrog Group to analyze hospital survey data. Castlight seems poised for success because it is striving to do what healthcare desperately needs done – to bring transparency to and better understanding of healthcare costs in this country. With the Leapfrog project, it seems they are set on tackling quality, safety and patient satisfaction, too. It would be nice, as a patient, to have one trusted resource to go to for consumer-friendly healthcare information so that we could make smart decisions for our families and ourselves.

It would be interesting for a company like Castlight to combine financial, quality, safety and satisfaction data with a notation as to whether hospitals and physicians use EHRs. I noticed that recent results from the latest NCHS Data Brief from CDC show that 42.8% of physicians in Georgia have EHRs – not significantly different than the national average, according to NCHS survey findings. Only nine states ranked above the national average for EHR usage.

I’m off on a tangent here, but I have to ask, when will all 50 states get above 50%? When will everyone be above the national average? With budgets tightening, hospitals closing, and IT deadlines looming, I have a feeling it will be later rather than sooner – if at all.

What do you think? When will your state reach 100%? How do you relieve stress before a doctor’s visit? Would knowing a physician had competitive prices and secure messaging impact your decision to book an appointment? Please share your thoughts in the comments below.

What if the FDA Started Regulating EHR?

Posted on March 20, 2014 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.

In the world of mobile health, we’ve often talked about what will happen if the FDA starts to regulate the various mobile health apps out there. In fact, the FDA has come out with some pretty detailed guidelines on what mobile health applications and devices need FDA clearance. To date, the FDA has stayed away from any regulation of EHR software.

On my ride to the airport after the Dell Healthcare Think Tank event, we had an interesting and engaging conversation about the FDA when it comes to EHR software. Some of the discussion was around whether the FDA would start regulating EHR software.

Shahid Shah suggested that it was extremely unlikely that the FDA would touch EHR software at least until meaningful use was complete and the current President was out of office. He rightfully argues that this administration has hung their hat on EHR and the FDA wasn’t going to step in and stop that program. Plus, Shahid suggested that ONC wouldn’t let the FDA do it either. Janet Marchibroda from the Bipartisan Policy Center was hopeful that Shahid was right, but wasn’t as confident of this analysis.

After hearing them discuss this, I asked them the question:

What would happen to the EHR Market if the FDA started regulating EHR?

Shahid quickly responded that the majority of EHR vendors would go out of business and only a small handful of companies would go through the FDA clearance process. Then, he suggested that this is exactly why the FDA won’t regulate EHR software. FDA regulation of EHR would wipe out the industry.

This is a really interesting question and discussion. The reality is that there are a lot of similarities between EHR software and medical devices. One could make a really good case for why the FDA should regulate it like medical devices. One could make a case for the benefit of some rigor in the development of EHR software. However, there’s no appetite for such a change. In fact, the only people I’ve seen calling for it are those who think that EHR is unusable and potentially harmful to patients. I’m not sure FDA regulation will make them more usable though.

Now, juxtaposition the above conversation with this post by William Hyman titled “A Medical Device Recall of an EHR-like Product” In this case, the FDA announced McKesson’s voluntary recall of it’s Anesthesia Care system. This software was tightly integrated with other FDA regulated medical devices. I wonder what this means for other EHR software that is starting to integrate with a plethora of FDA cleared medical devices and other non FDA cleared medical devices.

I’m personally with Shahid in that I don’t think the FDA is going to touch EHR software with a long pole. At least, not until after meaningful use. After meaningful use, I guess we’ll see what they decide to do.