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.

In my ongoing series of Major EHR Developments from John Halamka (see my previous EHR In The Cloud, Modular EHR Software and A Network of Networks posts), his fourth major EHR development from the Technology Review article is: Engaged, Connected, E-Patients.

I think this is one of the sections that Halamka makes some of the most interesting points about the future of healthcare. You should go read this whole section. One major conclusion is that patients are going to be much more involved in their healthcare. Gone are the days that patients just come into the office largely trusting what the doctors tells them. Part of that is likely do to the changing culture of question everything and the other part of it has to do with the access to healthcare information that the internet has provided.

Halamka does mention that research shows that shared decision making between doctors and patients results in better outcomes and that an engaged patient is less likely to sue. Both great reasons for doctors to want an engaged patient. Yet, there are still many of them that don’t like this change. However, most have come to realize that they really won’t have much choice going forward.

Halamka also mentions the new reimbursement models that focus on keeping patients healthy (see all the ACO talk) as opposed to paying best on services rendered (often called fee for service). I’m not sure how much this will be a driver in the engaged, connected, e-Patients. I think the patients will actually run over the doctors with their desire for engagement and their involvement in their healthcare well before any reimbursement model changes occur.

Yes, I think patients will start to demand (in the customer demand sort of way as opposed to the arrogant demands kind of way) their doctors support new forms of engagement. Certainly this will include a number of devices that monitor a patients health. Also, the teleconsultation will become very big as technology brings your doctor back into your home.

As I’ve written about before, I’m excited by the idea that a new form of doctor will be treating “healthy” patients.

My recent blog about Sandhills Pediatrics and its successful implementation of an EMR prompted, fortunately, a very intriguing comment from Chip Hart, a Director of Sales and Marketing at Physicians’ Computer Company who also maintains the blog “Confessions of a Pediatric Practice Consultant: True Stories from the land of Pediatric Practice Management.” He wrote: “I’ll spare everyone the diatribe about how ARRA deals with pediatricians and how only about 1/2 of them qualify, as I write to make one quick statement.” There’s a story there, I thought to myself. So, being an avid observer of pediatric EMR news and views, I reached out to him to gauge his thoughts on where healthcare IT solutions fit in the world of pediatricians.

What sort of challenges are you seeing pediatric practices facing when it comes to implementing EMR systems?
“On one hand, most of the challenges they face are hardly unique to pediatrics: resistance to change, practice differences, the lack of time and resources to be trained and configured properly, poor support, etc.

“Specific to pediatrics, there are two major issues.  First, children are not simply small adults and EMRs, as a rule, are written for adult medicine. There are many pediatric-specific features and functionality that a pediatric practice needs that simply aren’t met by your large, generic system. Simply claiming “pediatric templates” isn’t enough.

“Second, although every specialty complains about the hit that EMRs take on their productivity, pediatricians are obviously in the worst shape. Their volume is the highest and their payment is the lowest. Just adding a minute to each encounter means an extra 30 minutes of charting a day … and I hear stories, daily, of practices adding another 1 to 2 hours! Pediatricians can’t afford to see 5-percent fewer patients. Radiologists can. And pediatricians really like to eat dinner with their families.

“One second-tier issue is that less than 50 percent of all pediatric practices don’t qualify for ARRA and the regional extension centers (RECs), as a rule, don’t understand the Medicaid rules well.  Thus, we have clients and potential clients calling us to ask how they can get money they’ll never get, or to tell us some crazy thing a REC person told them.”

Are there different sets of challenges for those that are private practices versus those that are hospital/healthcare system affiliated?
“Unquestionably – the big one being that hospital/health system pediatricians simply won’t have a choice or even a voice in the process. Yes, I’ve worked with some who appear to be at the table, but in the end … you get what they hand you. Right now, Epic is pushing everyone out but that pendulum will swing back.

Also, those employed physicians don’t have to consider the impact on their productivity in the same way. I’ve met too many peds offices whose docs didn’t take home checks for a few months after implementation – that’s not right.”

Why do you think practices like Sandhills “get it” in terms of moving forward with HIT implementations, and just being forward thinkers in general?
“If I could answer that question, I’d only be working with those practices! Every successful practice I know is successful in a different way for different reasons, but there is one common trait I see in many of them: They run their practices like the businesses they are. Keep the docs in the exam rooms, where they can generate revenue, and hire professionals to actually run the business. Just because it says “MD” after your name doesn’t mean you’re the best-qualified person to run your office. Would Dirk Nowitski or Lebron James make good coaches? I doubt it.

“In the case of Sandhills, they have some excellent, excellent staff who bring some non-healthcare experience to the table. Although I’ve seen it fail, having some management that comes from outside the healthcare system to ask and answer some tough questions pays off for a lot of practices.

“We’ve enjoyed working with them.  I should also add that they, like the other ‘heads up’ clients I know, realize that we’re on the same team. That helps tremendously.”

How long have you offered the PCC EMR? What sort of up tick in implementations have you seen since ARRA/HITECH came about?
“Our PM has had pediatric clinical features (immunization tracking, registry interfaces, well visit recall, etc.) for almost 30 years, but the official EMR itself was released about 2 years ago.

“When ARRA was first announced, we received a lot of calls, all along the lines of, “Where do I get my free money?”  It was very frustrating to explain that it would be state dependent (about a quarter of them still can’t get it) and half of our clients will never qualify due to the Medicaid requirements.

“Things are starting to settle down and get organized.  Still, we are busier right now than we have ever been. We are telling potential clients they might get installed in May or June. A nice problem to have, but it’s not fun to get some excited only to explain it will be 6 months, especially when it used to be 6 weeks!”

Are any of your pediatric clients thinking of becoming involved in ACOs?
“Thinking?  Yes.  They’re all being told how if they don’t get big, they’ll be out of business, which is utter BS. The rules, as we know them now, seem to make no sense whatsoever for pediatricians. I did see a compelling presentation by Colleen Kraft at the AAP NCE last week that very much supported the ACO-esque model she employs, but I think her situation is both unique and not potentially an ACO.

“With some issues – 5010, PCMH, etc. – we take a pro-active stance. With ACOs, I’m glad to let someone else jump first.”

How will your solutions enable your customers to integrate with ACOs or coordinated care programs?
“Far too soon to tell.  In general, I can say, “Hey, we have had really good reports that have tracked patient populations for years.”  Our clients use them all the time, as it’s both good medicine and good business.  As a practical tool, I’d put our patient recall program up against anyone’s – your front desk can crank out a list of kids who need flu shots or asthma followups in seconds – but we don’t know quite what the ACOs will need.

“One thing we’ve learned, though: when a small peds office puts its data in the hands of a large entity, it’s worth double-checking the results. For more than 20 years, I’ve helped our clients fight insurance companies (which an ACO emulates) and the insurance companies never have the data right. Ever. So if a private peds office can work with us and still be in an ACO, they’ll be able to confirm the accounting.

“Here’s my prediction: As ACOs grow, the practices who participate are going to regret losing control of their data. I’m really going out on a limb there, I know.

What do you think is the greatest challenge being faced by pediatrics when it comes to keeping up with healthcare IT?
“Not getting run over by the Juggernaut.  Everyone else’s demands are put ahead of the pediatricians and the peds usually get served what everyone else is eating.  And it rarely suits them.

“I also tell them all the time: ignore the Meaningful Use money. Completely. And ignore the “deal” that you can get from your local hospital/IPA/etc. Pick the EHR that suits you the most and go with that. All the discounts or federal checks in the world won’t make up for even a 5-percent hit in your productivity or having to spend an extra 10-20 hours a month on charting or IT work. If you do like the local deal, great!  But don’t feel like you have to leap in.”

So there you have it folks. I’d be interested to hear from a pediatrician or two who has gone through or is going through some sort of HIT implementation as a follow-up to these views. Feel free to get in touch with me via the comments section below.

I don’t know about you, but I’m not exactly sure what an Accountable Care Organization is. In fact, I’m betting nobody is — there’s a bunch of harrumphing and throat clearing out there, but I haven’t seen any crystal-clear descriptions out there.  Shall we say that ACOs are more honored in the breach than in the observance and leave it at that?

Now, we come to the puzzling part of this piece. If nobody’s managed to define an ACO clearly, how can any particular EMR be a better ACO tool than another?  We’ll have to ask KLAS about this one, since they’re the ones that discovered this “fact.”

Today, KLAS announced that it had interviewed 197 providers at 187 organizations to see how ACOs are forming up. A third of the respondents said that they were pursuing a formal Medicare ACO designation, and the majority were felt ACOs were the future, KLAS reported.

Sure, considering that ACOs are just risk-taking organizations with a capitated feel, some people already have a sense of what to expect. But throw an EMR into the mix and we’re in new territory — hopefully good territory, but new nonetheless.

So, tell me how providers know that Epic and Cerner are the most ACO-ready? Apparently, respondents believe that Cerner already has many of the IT pieces needed to run ACOs; moreover, they say Cerner is working closely with providers interested in the ACO model.

Survey takers also gave a nod to Epic, which they see as being close to ready (though behind in analyics and ability to share data with non-Epic users).

Wait a minute — let me get this straight.  Respondents know Cerner has the right pieces, even though the ACO doesn’t exist yet?  They like Epic, even though it doesn’t share data outside of its walled garden?  KLAS is kidding, right?

At this point, I’ll be kind and say that Epic and Cerner users are a bit brainwashed, which I too might be if I’d spent the kind of money those folks have on an EMR.

But the voice in my suggests that KLAS might have had its finger on the scales just a little bit. I will not publicly state that Allscripts, CPSI, GE Healthcare, McKesson, MEDITECH, QuadraMed and Siemens scored worse because they didn’t pay for play…but something sure isn’t right here.

There seem to be three big acronyms when it comes to healthcare IT and interoperability – EMR (electronic medical record), HIE (health information exchange) and ACO (accountable care organization). Implementing one does not always necessarily lead to the implementation of another. I’m sure everyone will agree, however, that an EMR most likely leads to connectivity to a HIE, which increases the likelihood of participating in an ACO or coordinated care program. I consider these technologies and concepts to be the interoperability triumvirate, if you will.

Of these three, the HIE seems to have seen its day in the sun. Enthusiasm for the concept and its surrounding technologies – at a fever pitch at tradeshows and in the media last year, in my opinion – seems to have been eclipsed by Meaningful Use incentive payments for EMRs and the general consternation related to ACOs. Which is why my interest was piqued when I came across news from a company called NexJ and its new Health Exchange solution.

In order to learn more about the product, touted by the company as one that “brings together the numerous electronic health records systems and applications that exist within healthcare organizations – many of them old, out-dated legacy systems – into one place so that healthcare providers can deliver better, safer, more comprehensive care,” I reached out to Oz Huner, Vice President of Health Solutions at NexJ Systems.

JD: What type of healthcare facility would be the typical customer for your new HIE solution?
OH: “The NexJ Health Exchange solution facilitates the sharing of patient information between healthcare organizations such as hospitals and healthcare providers, ACOs, HIEs, and public health and government agencies.

“Our customers are choosing our solution because it enables them to move from paper-based workflows to electronic workflows and gain such benefits as complete access to accurate information, improved quality of care and patient empowerment.”

Can you give me a specific example of how this HIE can potentially (or has already) improve patient outcomes at a client facility?
“In a current project we’re working on, NexJ is helping meet the challenges emergency department physicians and staff face by providing timely access to the patients’ primary care provider records when they arrive at the hospital admitting department. The NexJ Health Exchange solution connects the patient’s medical record directly with the emergency department systems, improving information sharing between community health providers and the hospital, and improving patient safety.”

Is there a limit to the number of EMRs and applications that can be connected within the NexJ health exchange?
“No, there is no limit to the number of EMRs and applications that can be connected using NexJ Health Exchange. It is highly scalable and can address the needs of the even largest healthcare organizations.”

Does it work with some EMRs better than others?
“No. NexJ Health Exchange provides open, standards-based integration to any EMR system. Its secure, Web-based portal and flexible architecture enables connectivity with legacy and proprietary systems, support for global messaging standards (HL7v2.x and HL7v3.x), exchanging of clinical document formats (CCR and CCD), and support for multiple standardized clinical terminologies (SNOMED, LOINC).

Based on your interactions with providers, do you feel that more and more are finally coming around to the idea of adopting EMRs and eventually HIEs? Or do you find that many providers still think they aren’t worth the expense?
“It is our opinion that EMRs have historically been of great value to healthcare organizations, but since they’re often siloed, such information technology has not been ubiquitously adopted. As an element of a HIE, however, we believe there will be greater EMR adoption as government incentives and programs encourage healthcare providers across the country make the switch to EMRs. As more physicians move to EMRs and become net receivers of patient information, they will realize the benefits of access to accurate information, improved quality of care and patient empowerment.”

Are you working with any regional extension centers around the country to promote your EMR and HIE solutions?
“Indirectly, yes. Through our partnership with Open Health Tools, NexJ is a member of the Platform Implementation Project (PIP), which is working on an open HIE solution for state agencies. The focus is currently on southeast Texas, but is by no means limited to that region.”

NexJ will be at the Health 2.0 conference in San Francisco next week. If you plan on going, stop by their booth and let me and your fellow readers know what you think about this new health exchange solution. Is HIE the buzzword worth bringing back?

A new study sponsored by the American Hospital Association has concluded that developing an Accountable Care Organization is likely to be substantially more expensive than CMS has projected.  Not surprisingly, the AHA expects buying and managing EMRs and clinician decision support systems to be a major percentage of the added expense.

CMS has estimated it will cost an average of $1.8 million to start and sustain an ACO.  But the AHA dismisses that number as far short of the mark. Its own research, conducted by McManis Consulting, concluded that the actual startup and first-year costs for ACOs range from $11.6 million for a 200-bed, one-hospital system to $26.1 million for a 1,200 bed,  five-hospital system.

The AHA estimates that hospitals will spend anywhere from $2 million to $7 million to buy an EMR, and hundreds of thousands to integrate the system and build a health information exchange.  Not only that, health systems are likely to spend anywhere from $1.5 million to $3.9 million per year to maintain the EMR, manage the integration process and keep building out the HIE.  (My instinct is that the study’s estimates of systems integration and HIE linkages are rather low;  check out page two of the report and let me know what you think.)

If the AHA has it right — and I suspect it does — something is out of order here.  It’s hard for me to imagine how the agency could underestimate health IT costs so significantly, unless there’s some political game afoot here.

I’m not surprised to read that HIT costs are just as heavy a burden as recruiting, managing and and supporting affiliated physicians.  And I’m pretty sure that hospital CIOs aren’t kidding themselves on this front either.

Somehow, though, the Medicare folks have made some rather flawed assumptions and embedded them in the proposed  Medicare Shared Savings Program for ACOs.  If you agree that CMS is on the wrong foot here, I encourage you to submit comments on the proposed rule.  (See the beginning of the document for how to file those comments.) You have until June 6, so have at it!

Everyone in healthcare is currently talking about the recently released proposed rule on Accountable Care Organization (ACO). In fact, I posted on EMR and HIPAA a guest post about the ACO Legislation and its ties with healthcare IT, meaningful use and EMR. It’s definitely worth a read.

This move to ACO’s (and to some extent healthcare IT) were described nicely by Maria Todd on Twitter:

@ehrandhit Traditional HIT? The days for business as usual in healthcare ARE OVER!

April 4, 2011 11:22 am via webReplyRetweetFavorite

@AskMariaTodd

AskMariaTodd

As many have said, the ACO train has left the station. In an October article, HIStalk posted about the movement of hospital organizations acquiring physician practices and offered some lessons learned from similar movement back in the 1990′s.

An interesting analysis: hospitals are buying up primary care practices to prepare themselves to become Accountable Care Organizations, which could be the end of the line for small, independent practices. Hospitals are looking at increasing PCP salaries like a Wall Street analyst looks at price-to-earnings ratios, knowing that internists and family practitioners generate hospital revenues at nine times their average salaries, while expensive specialists generate a multiple of only five times their salary. For industry noobs, it’s time for hospitals to get taken to those 1990s cleaners all over again, because:

1. Docs sell out precisely because they don’t want to work  as hard for their new hospital employer as they did for themselves (duh).
2. Hospitals are notoriously bureaucratic and inefficient managers, making them particularly unsuited for running a low-overhead medical practice in every way from EMRs to personnel policies to regulatory compliance.
3. Private practice docs hate and distrust everything about hospitals except the money they have and don’t usually change their opinions or behaviors just because they sell them their practices.
4. Doctors resent taking orders and being told how to practice medicine, especially from suit-wearing hospital MBA-types who fancy themselves business experts despite always having worked for a paycheck instead of themselves, making it likely all these deals will fall apart in 4-5 years like they did last time around, with the docs scrambling to start up new practices without the benefit of a location, an EMR, or patients that they sold away to the local hospital in a frenzy of co-opetition.
5. Patients aren’t much more enthused about hospitals than doctors are, so they aren’t exactly thrilled to see the big sign go up over their friendly little doctor’s office knowing it’s the same folks with ED waits, bad cafeteria food, and terrible parking.

I’ll be really interested to see how these ACO organizations play out and if it is indeed the end of the small physician practice. Although, my gut feeling say that this is cyclical.

While hospitals buying physician practices is one method for creating an ACO, I’d love to hear other models that might be used to create an ACO. Feel free to sound off in the comments with your thoughts and ideas.