Valentine’s Day may be behind us, but I still wonder how many providers would be willing to write love notes to their EHR vendors, especially with rumors swirling that CMS will release Meaningful Use Stage 2 requirements in the next few weeks. (John Moore at Chilmark Research is apparently taking bets via Twitter, if anyone’s interested in doing a bit of gambling in preparation for the big HIMSS event in Vegas next week. He predicts it will be the Friday after HIMSS. I think it might just make good fodder for Farzad Mostashari’s keynote next Thursday morning, as he has been vocal about delaying the start of Stage 2 until 2014.)

Whether they’re released during or after the show, I decided it would be a good idea to bone up on Stage 1 versus Stage 2, and how what may or may not be included in Stage 2 will lead providers to love (or hate) their systems all the more.

I fortunately came across a very well written and comprehensive (though not too long) report from CSC entitled “Moving Ahead with Stage 2 of Meaningful Use,” which provides a very clear-cut picture of the challenges providers found with Stage 1, and what they are likely to encounter as challenges in Stage 2. It’s a brief, informative read that I highly recommend folks take a look at before they head to HIMSS in just a few days.

My biggest take away from the report was that the providers surveyed had done very little in Stage 1 to engage patients and coordinate care, which is not surprising given that most were concentrating on getting their EHRs up and running in time to fully attest for Stage 1. Combine this with the fact that formal ACO rules weren’t released until late last year, and I can understand why engaging patients and coordinating care just wasn’t on the radar of most healthcare facilities.

But oh what a difference a few months can make! The CSC report notes “Stage 2 is coming soon and a full year of operational use of capabilities will be required (rather than three months for Stage 1). Waiting until the final rule is issued to start moving is simply not an option.

“Now is the time for organizations to work in earnest to build capabilities to engage patients, coordinate care and electronically report on quality.”

And finally, the report notes that:

Three essential areas where organizations need to start now are:

1. Providing patients with access to their health information electronically through patient portals or directly from EHR systems.
2. Electronic capture of physician notes, including diagnosis and treatment, plus rationale for excluding patients from treatment recommendations.
3. Exchange of patient information at transitions in care.

I’d be interested to hear from our readers that have successfully attested for Stage 1 how they view these predictions for Stage 2. Are they manageable? Do they fit with your organization’s current strategy? Please share your thoughts in the comments below.

Recent news that Kaiser Permanente has made its patients’ electronic health records available via mobile devices comes as no surprise. Kaiser often seems to be at the forefront of interoperability and coordinated care, in large part due to its integrated nature and sheer volume of patients. As the company’s press release mentions, it maintains the “largest electronic medical records system in the world.” Now, 9 million of its patients can view their EHRs via a mobile site or Android app, with an iPhone app expected to launch in the near future.

On a macro level, I think this is a great step towards further empowering patients to take control of their health. By giving 9 million folks instant access to their own health information, I’d like to think that this will in turn prompt their friends and relations to ask, “Why doesn’t my doctor do that? What benefits am I missing out on?” And perhaps these same folks will then have a conversation with their provider about adopting this type of mobile access.

I’d be interested to see six months to a year from now, statistics comparing use of the mobile app/site to use of the tools found on the traditional website. Will Kaiser see a tremendous increase in the amount of emails between doctors and patients via its mobile apps? Are its doctors prepared for the potential onslaught of correspondence? I wonder if a few have balked at the possibility of being overrun by emails from particularly communicative patients.

Will they be able to tie these usage statistics to a jump in quality outcomes? Will mobile access ultimately become a criteria measured within accountable care models or patient-centered medical homes? Will mobile health truly equal better health?

On a micro level, I would certainly appreciate the effectiveness of access like this, which includes the ability to view lab results, diagnostic information, order prescription refills and the aforementioned email access to doctors. I can’t tell you how many times I’ve been on the phone with a pediatric advice nurse and drawn a blank when asked what my child’s current weight might be. It would be nice to be able to quickly pull that data up on my cell phone, especially while we’re on the go or out of town. I could eventually see patient charting apps being layered on top of this, so that in the event of a high, overnight fever, I could log temperatures via the mobile app and review them with our pediatrician – possibly alerted every time a new temp or symptom is entered – the next morning.

The possibilities seem endless. I think the big goal for Kaiser now is to get folks engaged and using these new access points.

I recently saw a tweet to the National Conference of State Legislatures (NCLS) list of “Top 12 Legislative Issues of 2012.” It’s an interesting look into issues that state legislatures will be dealing with in 2012. Plus, it makes an interesting observation at the outset that state budgets have been cut so much in past years that lawmakers won’t have to focus all of their initial energy on budget shortfalls.

Most of the list is not surprising with managing the state budget and jobs are at the top of the list. However, there are a couple healthcare and health IT related sections in their list of top government issues as well.

One of the issues is Medicaid: Efficiencies and quality. It talks about how the tough economy is making the Medicaid budgets in states a real challenge and many are looking for cost containing actions. Plus, it points to ACO type reimbursement based on patients’ health outcomes, medical homes and streamlining services. The ACO part was quite interesting to me. I wonder how much of an effect lack of Medicaid budget will push forward a new model of healthcare.

The disturbing part of the report comes in the “Health: Reform in the states, health care exchanges, technology and benefits. Here’s the section on health IT, the EHR incentive money and HIEs.

HEALTH INFORMATION EXCHANGE: One focus for state legislatures in 2012 will be how to move health care providers, especially those participating in the Medicaid program, toward the adoption of certified electronic health records (EHRs). Essentially, instead of having a different health record at each doctor or provider you visit, an EHR will serve as one file that all of your doctors can see. EHRs, once fully implemented, are expected to provide doctors and health professionals with easier access to patient histories and data, resulting in cost-savings and better health outcomes by removing costly errors and duplications in services.

I love how this basically assumes that by having widespread adoption of EHR software, that we’ll then have one patient record that each doctor you visit can see instead of having a different health record at every doctor. Of course, those of us in the EHR world know that this is a far cry from the reality of EHR software today. In most cases you can’t even share a patient record with someone using the same EHR software as you let alone sharing a patient record with a doctor who is using a different EHR.

The sad part is that whoever wrote these legislative issues must have realized that there was some issue with EHR software exchanging information, because then they wrote the following about the state HIE initiatives.

In addition, states are responsible for building and implementing health information exchanges (HIEs) where those EHRs can be accessed by health care providers. HIEs function like an online file cabinet where your medical record is securely stored, and can be accessed by any doctor or health care professional you visit. By mid-year 2012, every state should have Medicaid EHR Incentive programs in place and will be working toward building an HIE by late 2014 or early 2015 as required by deadlines attached to federal cooperative agreements.

So, wait. If EHR software has created one file where any doctor can access our patient record, then why do we need “an online file cabinet” for our medical records? We know the answer is that we need the online filing cabinet because EHR software isn’t connected and there isn’t one patient record. Each doctor maintains their own patient record and that’s not going to change any time soon.

The above quote also implies that every state is working towards an HIE program per the federal program. I must admit that I haven’t gone through every state, but is every state working on an HIE? I certainly know there are a lot of states working on some sort of HIE project, but I didn’t think that every state had funding for HIE. I guess maybe the question is whether there is any state that doesn’t have some sort of HIE program in the works.

Reading issues described like this, you can understand how government passes legislation with limited understanding. Based on this resource, EHR software creates one patient record. Wouldn’t that be nice if it were the case?

I thought this blog post on the 3M blog made a good point about ACO’s finally having some action behind them thanks to the Pioneer ACO awards that were announced recently. Until now, we’ve basically just had people talking to each other about the idea of an ACO, how an ACO should take shape, etc etc etc. It’s nice to see us starting to move beyond discussion of ACO models and now starting to see some real people and companies that have to start taking some ACO action to see what they can create.

I have a feeling that much of this initial ACO work is going to be like most startup companies: failures. In the startup world, it’s just expected that at least 9 of 10 companies will fail. That’s part of the algorithm of innovation that has worked so well in the entrepreneurial environment we know as tech startup companies. I imagine we’ll see the same with a bunch of these ACO models in healthcare as well.

One major problem I do have with this comparison is that the ACO programs that we see now aren’t entrepreneur or market driven, but instead are driven by some sort of government money. This means that those that participate have a bunch of perverse incentives.

The blog post mentioned above provides some interesting suggestions on how to improve healthcare. In response I offered these thoughts in their comment section:

The suggestions you make are reasonable and interesting, but they seem to ignore the idea that what people are really going to do with ACO legislation is find the simplest way to extract the most amount of money out of the regulation. There will be some exceptions, but this is how it works with most government programs.

I imagine some will see this as a bit cynical. I personally just see it as realistic. If we want to talk about real solutions we have to talk about the stark realities that face us and not the idealized models that could happen “IF…” ACOs are no different. Enough with the IFs and let’s talk about action.

I have been thinking more and more about ACOs coming together and the ACO movement in general lately. Everything seems to be heading straight towards the ACO reimbursement model and so I think we all better start to consider what that’s going to mean to a clinic. Plus, in my case I’m particularly interested in how EHR software will enable the ACO to work properly.

It is quite clear to me that EHR software and technology in general will be one of the core pillars to a successful ACO.

As I thought about ACOs, the question came into my head: How will an ACO deal with a non-compliant patient?

Since the ACO reimbursement is tied to the health of the patient, then patient non-compliance becomes a really important issue. Plus, patient non-compliance is an incredible challenge since the physician only has so much control over a patient once they leave their office. In fact, they only have so much control of their patient even within their office.

I certainly don’t have all the solutions to this problem, and I’m not sure how reimbursement will handle a doctor who did everything right to improve the healthcare of a patient and they chose not to comply. However, this makes me start to think of ways that technology could help a doctor to improve patient compliance.

I’ve written before about some really great mobile health applications for people with diabetes. It was amazing to see how simple text message reminders could improve compliance by patients with diabetes. There are probably dozens and maybe even hundreds of other models where mHealth could improve patient compliance.

One of the real challenges I see with this is that much of this compliance could best be served by an EHR software connected to the patients. Unfortunately, most EHR software is so busy helping the doctor do what he needs to do in the office and meeting government guidelines that EHR software doesn’t have the focus to create these types of connections with the patient which could improve patient compliance. I’m not sure they will ever have this focus.

This is why EHR vendors need to fully embrace the idea of creating an ecosystem where smart “app developers” can create these patient compliance apps that connect directly into the EHR software. This won’t be easy for EHR companies to embrace, but those that do and do it well will be wildly successful. Plus, they’ll improve healthcare in the process.

Are there other ways that ACOs will deal with non-compliance by patients? I’d love to hear what people think.

Time for the next entry covering Shawn Riley’s list of 101 Tips to Make your EMR and EHR More Useful. I met someone at a conference who commented that they liked this series of posts. I hope you’re all enjoying the series as well.

15 Avoid multiple sign-ins if possible.
One thing seems abundantly clear to me: healthcare IT will be a heterogeneous environment. This is particularly true in the hospital world. Even the biggest behemoth of an HIS can’t satisfy all of the healthcare IT requirements of a hospital. So, getting a great SSO (single sign on) solution will be really important and turns out to be a great thing for your users and your help desk.

14 Make sure security is solid, but not prohibitive.
One thing about healthcare security and HIPAA that’s often misunderstood is that it should protect patient’s information, but it should also not get in the way of a clinician doing what they legitimately need to accomplish. Many security policies go too far and make legitimate healthcare work too hard. This is a huge mistake.

13 PDSA – Use it! Plan – Do – Study – Act
In this one, Shawn talks about the idea of continuous improvement which is a really good one. I also think far too many companies get stuck in the planning and do far too little doing and acting. All four steps of the process are important and useful, but don’t over think it either.

12 LEAN
Lean isn’t about being cheap. Lean isn’t about providing substandard care. Lean is about spending where it matters most. It’s about focusing on what’s most important and creating value from the things you spend money on. I’d love to see more LEAN concepts used in healthcare.

11 Buy MORE printers
Yep! Printing increases dramatically with an EHR. Almost all those forms that you use to print in bulk will now be coming out of your printer. Also, just because somewhere is fully electronic doesn’t mean that they are paperless. Paperless is a mythical creature that will likely never be achieved in our lifetime. Make the printers accessible for your providers.

If you want to see my analysis of the other 101 EMR and EHR tips, I’ll be updating this page with my 101 EMR and EHR tips analysis. So, click on that link to see the other EMR tips.

Time for the next entry covering Shawn Riley’s list of 101 Tips to Make your EMR and EHR More Useful. I met someone at a conference who commented that they liked this series of posts. I hope you’re all enjoying the series as well.

20 Data collaboration is key to patient safety
I think this tip might need to be worded, “Data collaboration should be key to patient safety.” Unfortunately, it’s a mostly unrealized dream at this point. You might even be able to say that data collaboration will be key to patient safety. There really are amazing use cases where data collaboration can improve the care patients receive. It’s a sad state of affairs that so many of the major EHR companies are dead set on protecting their walled gardens. One has even gone so far as to say that patient safety is in danger with multiple systems. Certainly there are some risks associated with multiple systems, but the benefits far outweigh the risks. In fact, patient safety is at stake thanks to those who won’t participate in healthcare data collaboration.

19 Know how customizable the clinical work flows are!
This is a good tip when doing your EMR selection. It’s incredibly valuable to understand how the EMR handles clinical workflows and how well those workflows fit into your established clinical workflows. I’m a proponent of doing the best you can to use established workflows when implementing an EHR. Then, over time adjusting those workflows as needed to gain more efficiency.

18 How easy is it to customize the system overall?
I’d take this EHR tip from a couple angles. First, is how easily can you customize the EMR system. Yes, some of it could be the EMR workflows that I talked about in EMR Tip #19 above, but it could be a whole set of other options (billing, scheduling, messaging, etc). The second part of this suggestion relates to how well this EHR will adapt to the constantly changing clinical environment. Will they be able to handle ICD-10 without too much pain for you? Will you be able to make it work in an ACO environment? Healthcare is constantly changing and so you want to make sure your EHR can be customized to fit your changing needs.

17 Know work flow can be hard coded to ensure compliance.
There are times when hard coding the workflow is incredibly valuable. Certainly this will frustrate some providers, but if done correctly most will understand the need to hard code the workflow to ensure compliance. It’s a fine line to walk, but there are plenty of instances where hard coded workflows can do wonders to improve the care you provide.

16 Ensure easy access to the system via multiple platforms.
As much as providers might not like checking in on the EMR remotely, it’s often absolutely necessary. So, it’s important to ensure that your EMR is available on every medium possible. Can it be connected to remotely? Does it work on the latest devices? Yes, the iPad has a huge portion of the physician market share right now, but we’ll see how long that lasts. Every year a new device comes out and you’ll want an EMR vendor that’s keeping an eye on this movement and making the EMR available on the best technology.

If you want to see my analysis of the other 101 EMR and EHR tips, I’ll be updating this page with my 101 EMR and EHR tips analysis. So, click on that link to see the other EMR tips.

There’s a lot of talk in the healthcare industry right now about bringing health management tools to the consumer. Whether it’s apps for your iPhone or iPad, games to play on your Wii, or free-standing health-and-wellness kiosks at your local pharmacy, digital applications seem to the delivery method of choice right now. I think those of us in the healthcare IT industry sometimes take for granted that not everybody in the US has a smartphone, computer or even Internet access, which to me always begs the question: How great are these bright and shiny health apps if the populations that need them most don’t have access to them? And aren’t Meaningful Use and Accountable Care incentives/payments targeted towards government-sponsored healthcare recipients? The most likely patient population to NOT have reliable access to the Internet?

It’s this concept of a digital divide in healthcare that I am starting to believe will truly bend the curve when it comes to absolute interoperability – the secure sharing of information between patient, provider, payer, vendor, government, etc., anytime, anywhere. Only those patients who have access to these digital healthcare technologies will begin to clamor for them at their next doctors’ visits. Only patients’ whose doctors in turn have reached out to them via email, text or social media regarding the switch to electronic medical records, development of health information exchange and the benefits to care these will hopefully bring will be ready and willing to go with the digital flow.

I was intrigued by a recent news story on NPR the other morning that detailed a recently unveiled government plan – the Connect to Compete Initiative – to offer cheaper broadband access and computers to low-income families. The story pointed out that “about one-third of Americans – that would be 100 million people, give or take – do not have Internet access in their homes.” (I’d be interested to know how many of that population are on Medicare or Medicaid, or have no insurance at all.) Participating companies will offer broadband service to eligible families for $10 a month, while others will offer computers for as little as $150.

Further investigating into the story dug up a more detailed report from Reuters, which explained that eligible families will be those who have at least one child enrolled in the National School Lunch Program. According to a recent Commerce Department report on U.S. broadband adoption, only 43 percent of households with annual incomes below $25,000 had broadband access at home, while 93 percent of households with incomes exceeding $100,000 had broadband.

I think this is a step in the right direction, and am pleasantly surprised that it’s being enacted by the government – who got this digital healthcare ball rolling downhill fast in the first place.

As more and more low-income/average/middle-class Americans – or whatever we want to call ourselves – begin to speak out about the systemic inequalities we experience in this country’s financial, healthcare and educational systems, it’s nice to think (naively perhaps) that somebody just might be listening. As we see an increase in adoption of digital technologies in the consumer space, so too do I think we’ll see a correlating increase in adoption of healthcare IT by the providers that care for them.

Time for the next entry covering Shawn Riley’s list of 101 Tips to Make your EMR and EHR More Useful. I met someone at a conference who commented that they liked this series of posts. I hope you’re all enjoying the series as well.

25. Care coordination is much easier in an EMR and should be evaluated to be used
The idea of care coordination has never been more important in the history of healthcare. It’s the future of healthcare (at least in the US). Whether they end up being called ACOs or some other term, the switch to needing to coordinate care in order to improve the health of a population is happening as we speak. Luckily, EMR software is a great way to facilitate this care coordination.

24. Take advantage of E-Health tools
I actually think that this is a big call to EMR vendors to integrate their EMR software with the various e-health tools out there today. EHR vendors that think they can create every e-Health tool a doctor could want are going to be left behind by those systems which support the most popular consumer health tools on the market. However, that’s not to say that doctors can’t do their part. Start getting your patient using the e-health tools that will benefit them as a patient and then start requesting that your EMR vendor support the tools you’re using.

23. Make certain all caregivers know that logs are kept for any system overrides
Don’t hide the fact that everything is logged. Let everyone know that whatever is done on the system is logged. While some may see this as big brother watching them, most will realize that the logs are a protection for them. They log exactly what was done and said and who did it.

I remember one time there was some problem in our EMR system. I can’t remember the specific issue. Well, it was brought up in our staff meeting and the director said, whoever made this mistake is going to be providing breakfast for the whole staff. I went into the logs to see who’d accessed the patient to do the offending task. Little did the director (who was also a practicing provider a few times a week) know that she was the offending party. Everyone in the clinic enjoyed a nice breakfast that week.

22. Give caregivers the ability to override the system when necessary
Mistakes happen in documentation in an EMR. We’re all imperfect human beings (except for my wife) who make mistakes. So, you need an option and likely a process for how and who can make corrections to what was done in the EMR. Just be sure that everything that’s “overwritten” is logged and the reason for the change is well documented.

21. Develop a root cause analysis process for the EMR
I’m not that familiar with root cause analysis processes, so I’ll just share what Shawn says about it:

You very likely already have a root cause analysis model for your practice. You will need to adopt that model to the EMR. If you don’t, you will create a likelihood for the same errors to continually repeat. The EMR process is different than a usual root cause analysis. You will need to take into account interfaces, security roles, single sign on, and several other things beyond the “simple” human process.

If you want to see my analysis of the other 101 EMR and EHR tips, I’ll be updating this page with my 101 EMR and EHR tips analysis. So, click on that link to see the other EMR tips.

I was on the phone recently with an insurance company representative, inquiring about their policies, premiums and hidden caveats. During the middle of my call, the rep tells me his computer seems to have frozen up, and that he can’t move forward with answering my questions because he literally can’t move to the next screen containing the answers. “But wait,” he says excitedly, “I do have some paper to read off of.”

I chuckled to myself thinking of how many times physicians have had a similar experience, much to the consternation of electronic medical records (EMRs) vendors. Ah, good ‘ole paper. Healthcare’s last bastion of pre-HITECH document keeping. It’s always there when you need it – if you still have it.

This thinking transitions nicely into the topic of “old-school” technologies physicians should consider before going completely digital with their documentation in the form of an EMR. Culled from several recent and not-so-recent articles (See “10 technologies to embrace before EMRs,” and “HIT Projects You Can Implement Today”), with a few of my own suggestions thrown in for good measure, the list below goes from extremely low-tech to on-the-verge-of-clinical technologies.

1. Copy Machine/Printer Combo
You may laugh at the simplicity, but if a doctor’s computer ever freezes up, a copy of a patient’s paper chart will come in very handy.

2. Fax Server
Again, simplistic in nature, but elemental in sharing data with other offices. Perhaps we’ll see resurgence in fax technology now that the government has eased EMR requirements associated with participation in accountable care organizations.

3. Instant Messaging
So 2008, but still a very effective method of communication amongst an office’s nurses, clinicians and front-desk staff.

4. Email
For the love of Dr. Quinn Medicine Woman, who didn’t have access to such an easy form of communication, set up an email account – at least for the business side of your office. It would be nice if ALL physicians (including my daughter’s pediatrician) had secure email messaging with their patients, but that’s a whole other blog.

5. IT Infrastructure
You’ve got to build the foundation before you can start wiring the house. As John Lynn mentions in the second article referenced above, “Good IT companies will come and do an analysis of your current IT setup for free.”

6. Microsoft Office and Google Apps
As HIT consultant Shahid Shah mentions in the first article referenced above, free tools will help an office get its feet wet before diving into a full-fledged EMR. These two in particular have “dirt simple” documentation management that allows everyone in the office to be on the same page.

7. Document Imaging
Most scanners come with basic imaging software already included, Shah explains, adding that once physicians are good at scanning and paper digitalization, they can move on to “medical grade” document management that can improve productivity.
What other tools would you suggest to providers looking to ease their way into EMR adoption? Please share your comments below.