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CMS Needs To Tighten Up Meaningful Use Procedures, OIG Says

It looks like members of Congress aren’t the only ones finding fault with how CMS handles Meaningful Use incentives. In fact, HHS’s Office of the Inspector General has concluded that CMS needs to do more to verify that providers have indeed met MU standards both before and after payments get made.

As the OIG notes in its new report, CMS estimates that it will pay out $6.6 billion in incentives between 2011 and 2016. As things stand, the payments will be based on data self-reported by professionals and hospitals. To get a sense of how well this method is working, the OIG reviewed CMS’s incentive program oversight for 2011, as well as analyzing the self-reported data and auditing the agency’s planning docs, regs and guidance for the  program.

What did the OIG find?  Researchers concluded that CMS faces obstacles to overseeing the EMR incentive program which could end up with its paying providers and hospitals that haven’t fully met Meaningful Use requirements.

More specifically, the OIG concluded that CMS hasn’t put strong prepayment safeguards in place, nor has it good mechanisms for auditing incentive disbursements postpayment.  Moreover, ONC requirements for EMR reports might be getting in the way of more accurate incentive payment processes, the report said.

The OIG’s recommendations include having CMS get and review supporting documentation from selected hospitals and professionals before it cuts Meaningful Use checks, a step CMS rejects as imposing too big a burden on providers and slowing the payment process too much.  (For the sake of providers that need timely checks, let’s hope it stays that way.) The OIG also recommended that CMS  issue specific examples of documentation that can be used to support MU compliance.

Meanwhile, the OIG would like to see ONC  change certification requirements for EMRs to make it more likely that they can produce reports for yes/no Meaningful Use measures where possible. It would also like ONC to improve the certification process for EMR technology to make sure EMRs generate accurate reports.

For the most part, the  OIG’s recommendations seem reasonable, if not capable of being done overnight.  But I’ve got to agree that auditing incentive payments before issuing them would throw a serious kink into the process. Let’s hope the OIG and CMS compromise on something reasonable here.

December 4, 2012 I Written By

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

EHR Vendors Using EHR Certification Excuse

As most of you have probably figured out by now, I’m not really a fan of EHR certification because I believe there is very little value provided by EHR certification. An interesting additional problem that comes from EHR certification and meaningful use has to do with how EHR vendors are using this as an excuse for why their EHR sucks doesn’t work the way doctors want it to work.

Don’t just think that I’m making this idea up. I first thought about this idea when a doctor wrote me about his experience with an EHR vendor that used EHR certification as an excuse for why their EHR software’s workflow was terrible.

The interaction went something like this:
Doctor: Why do I have to do these extra 5 clicks?
EHR Vendor: That’s required by EHR certification.
Doctor: That provides no value to the care I provide a patient.
EHR Vendor: Sorry, we have to do that for EHR certification.
Doctor: What about this other prompt I get in your EHR? Why does that come up and disrupt my workflow?
EHR Vendor: That’s another EHR certification and meaningful use requirement.

You’ll notice that I made the complaints generic, because they likely could apply to almost any measure in meaningful use and EHR certification requirement.

I’ve seen first hand the efforts that some EHR vendors have put forward to try and make sure that their doctors don’t have this discussion with them. You can be sure it takes a lot of time, energy, and skilled professionals to make meaningful use and EHR certification a seamless part of a practitioner’s EHR experience.

The problem is that many many EHR vendors just ran the EHR certification race and in an attempt to win that race they just slapped something together to meet the requirements. This I want to be the “first” EHR vendor certified mentality is causing many doctors to pay the price today.

Is it any wonder that many doctors look at meaningful use and are upset by the way it’s changing the way they practice medicine?

October 11, 2012 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus.

Switching EMR and EHR Software

I’ve long been concerned about the challenge of switching EHR software. I’ve recently got into some discussions with people asking why EHR certification and meaningful use didn’t require EHR data portability as part of the requirement.

I’d forgotten that Jerome Carter had pointed out in a previous EHR switching post where HHS asked for comments on EHR data portability in the proposed certification rule for EHR (PDF) under the section “Request for Additional Comments”. Here’s his comment with the page number that addresses it:

John, this series of posts on changing EHR systems is interesting. The data issues that arise when switching EHRs can catch providers off guard. In reading through the proposed certification rules for EHRs, I found a section on data portability that you might find interesting. It is on page 13872.

Link: http://www.gpo.gov/fdsys/pkg/FR-2012-03-07/pdf/2012-4430.pdf

It’s an interesting section to read. The key is that they acknowledge the need to have some EHR data portability if you’re a doctor. Then, they look at these 4 questions:
1. Is the consolidated CDA enough?
2. How much EHR data do you need to move to the new EHR?
3. Could they start with an incremental approach that could expand later?
4. What are the security issues of being able to easily export you EHR data?

These are all good questions. I’d answer them simply:
1. Is the consolidated CDA enough?
No, you need more.

2. How much EHR data do you need to move to the new EHR?
All. Otherwise, you have to keep the old EHR running and what if that old EHR is GONE.

3. Could they start with an incremental approach that could expand later?
I think they need to go all in with this. The consolidated CDA is basically an incremental approach already.

4. What are the security issues of being able to easily export you EHR data?
I always love to follow it with the opposite, what are the issues of not having this EHR data portability available? You do have to be careful when you can export all of your EHR data, but the security is manageable.

What are your thoughts on EHR data portability? I’d still love to find a way to help solve this problem. It’s a big one that would provide amazing value.

August 16, 2012 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus.

Are All Meaningful Use Implementations Created Equal?

In reaction to my post discussing a physician’s enlightening reaction to meaningful use one commenter highlighted what I think is a really interesting question: Are All Meaningful Use Implementations Created Equal?

The interesting thing is that the doctors comments mentioned above essentially highlight his belief that meaningful use has caused EMR software to not reach its full potential. I’d even take it a step further and say that meaningful use and its sister EHR certification have done much to level the playing field of EHR software. Instead of doctors choosing an EHR based on usability, recommendations, features, functions, workflow, etc etc etc, they’re asking if the vendor is a certified EHR and can get them EHR incentive money.

A cynical view would be that doctors are now evaluating EHR software based on how easily that EHR software can get them EHR incentive money. While this may be the case for some doctors, my feeling is that it’s not a widespread pandemic problem.

We can all be certain that doctors are evaluating meaningful use as a major component of their EHR selection process. Every EHR vendor I’ve talked to has said this, so it must be true. Since meaningful use is a standard set by the government and certified EHR software requires a certain set of standards, does that mean that in that list of requirements all EHR software are basically equal?

The answer is an emphatic: NO!

I can assure you that some EHR software vendors have slapped in the meaningful use requirements as quick as they could get it in there. I’m sure that some rushed it just to be able to say they were the first. The first to what I don’t know. In many ways, being the first to be a certified EHR with meaningful use baked in could be considered a badge of shame. Instead, if I were a doctor I’d want an EHR vendor that took their time and implemented meaningful use in a thoughtful way that will be as seamless and non-intrusive as possible.

I still love what Conan Fong and Kyna Fong of ElationEMR said to me about meaningful use and EHR certification: We’re trying to strip out the EHR certification and meaningful use requirements as much as possible so that the doctor doesn’t even know she’s doing it. It just happens in the natural flow of her work. [Obviously not an exact quote since it was a couple years ago, but you get the gist.]

Compare that approach to an EHR vendor that just slapped in some features to meet the requirements without much thought of how that will actually impact a doctor. Indeed, not all meaningful use EHR implementations are created equal.

It still gets under my skin a little bit to think that how well an EHR implemented meaningful use becomes part of a physician’s EHR selection criteria. Something doesn’t feel right about that to me. However, I expect that those EHR who thoughtfully approached meaningful use and EHR certification also did the same with everything else in their EHR and so maybe that’s not such a bad thing after all.

April 4, 2012 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus.

Meaningful Use Solidifies EHR as the Database of Healthcare

Earlier this month I wrote a post describing EHR as the Database of Healthcare. I believe this is a powerful and important thing to understand. It also led to some good conversation in the comments. As an entrepreneur I’m always interested to see the trends in the industry to hopefully better understand what is going to happen in the future. I think that this is one of those trends.

Just to make the case clearer, consider the effects of meaningful use on EHR software. Meaningful use stage 1 and EHR certification has already hijacked at least one EHR development cycle and you can be sure that meaningful use stage 2 and stage 3 will be hijacking another couple EHR development cycles. You heard me right. In order to meet the EHR certification and meaningful use requirements, most EHR vendors have to put a whole development team focused just on meeting those government requirements.

Meaningful use has codified EHRs into a box.

Instead of allowing EHR software to create innovative solutions it requires standards be met for storing and accessing info. Sure it also adds in security and tries to work towards interoperability, but those aren’t innovations that doctors want to see.

I expect many of the best healthcare innovators will build on top of the EHR base, not try and build the base again.

March 20, 2012 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus.

Epocrates EMR Killed Immediately After Launch

Back in 2010, Epocrates had its EMR ducks in a row. The company, known best for a very popular smartphone-based drug interaction database for physicians, announced plans to release a mobile SaaS EMR.  While Epocrates was jumping into a market more crowded than a barrel full of monkeys, one could see where leaders might see an EMR as an extension of the relationship it already had with physicians.

Now, Epocrates leaders have said “oops” and announced that they were killing the product,  telling investors and the public that building the darned thing was distracting it from its core business.  It does seem that the company was struggling with the EMR rollout process:  it didn’t roll out its first-phase product until August 2011 and didn’t get its Meaningful Use certification until February of this year. But this is the first time I’ve seen a company kill a product at this stage of development, particularly in such a high-profile manner.

It must have been more than a bit embarrassing to make the announcement during HIMSS12 when, of course, companies traditionally kick off products they’re planning to sell vigorously. As Epocrates was making plans to dump or sell their EMR, the company’s CMIO, Tom Giannulli, MD, was pitching the company’s new iPad EMR to editors.

As Epocrates itself pointed out, there aren’t too many dedicated iPad EMR offerings out there. So in theory, this should not have been a waste of the company’s time.  On the other hand, with the iPad still a new frontier for EMRs, we still don’t know whether it will ultimately work as a platform of choice for physicians.  As we’ve previously discussed on this blog, the iPad seems to be a pretty good medium for reading data but a very awkward one for entering data. Whether that’s a fatal flaw remains to be seen.

Truthfully, this looks like a failure of execution from start to finish, rather than a product that couldn’t possibly work. But these are tough times. Even the best execution may not work; and if so, Epocrates was probably wise to fold its cards before further damage was done.

March 15, 2012 I Written By

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

Quest Diagnostics Offers Big Discount On Its EMR-Practice Management System

In the past, I’ve written volumes about hospital attempts to lock in doctors by offering them access to a free or deeply-discounted EMR. I haven’t heard much about this strategy of late — either the approach was dropped or it’s gone underground — but it seems that other players are still giving it a shot.

This time, in what seems to be a fairly logical step, Quest Diagnostics has kicked off a program offering medical practices a steep 85 percent discount off of the retail price of its Care360 EMR and practice management bundle.  The announcement follows up on its 2011 regional giveaway program, which Quest says attracted thousands of physicians.

The deal, which reduces the physicians’ out of pocket cost to less than $100 per month,  also includes training, hosting, maintenance and 24/7 support for Care360. The lab giant says physicians can get Care360 up and running in about 45 days.

I can’t think of a reason why this wouldn’t make great sense for Quest; if my contacts are to be believed, it has no better reputation than its key competitors when it comes to customer service and follow-through on clinical testing.

On the other hand, if I were a doctor I’d think long and hard before agreeing to a deal like this, even though the software is just about free. There’s simply too much at stake to plunge in.

Yes, Care360 is ONC-ATB certified by CCHIT and, intriguingly, has incorporated the Direct Project specs allowing doctors to share information with patients and hospitals. And yes, it seems to have made efforts to support EMR access via mobile devices. This is all good. And of course, the price is right.

On the other hand, I’m not sure I’d want to make this big of a commitment to any particular service provider, be it a reference lab, a radiology provider or the people who stock my vending machines with sodas.

I’d argue that the more important the service is, the less you want to be beholden to the vendor. After all,what if Care360 isn’t your cup of tea?  Do you really want to disrupt your relationship with a critical provider like Quest?

Not only that, it’s risky to lock in an EMR just because it’s cheap. If Care360 takes 45 days to get installed (activated, configured, trained, etc.), it’s not going to be possible to uninstall it in a day or two, and that could mean misery on wheels if the product doesn’t work for you.

Besides, it’s possible to get Web-based, easy to adopt or drop EMRs for only a couple hundred dollars a month more. It wouldn’t make sense to go for an EMR that might not work just to save that little. (If your margin is tight enough that a savings of $200 or $300 a month is critical, you have worse problems than finding the right EMR!)

I guess I’m saying that even if the EMR is nearly free, caveat emptor. You don’t want to get saddled with an albatross system just because the price was right.

February 3, 2012 I Written By

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

A National Universal Health Record (UHR) Database – Doable Any Time Soon?

Could a single, mammoth database solve all our health data needs? Margalit Gur-Arie, whose writing and ideas I greatly admire, has been arguing for one quite passionately on her personal blog in a couple of recent posts (part I, part II).

The crux of her posts is this:
- There should be a single, standardized national database to which physician practises, and ultimately EMR vendors, must submit mandatory data, “in real time”. The requirements will be along the lines of current Meaningful Use requirements.
- This database will be accessible to vendors and entrepreneurs alike, and can have multiple EHRs or apps built atop them.
- Since the patient data is available, and easily accessible (no one “owns” the data, they only own the proprietary bells and whistles they perform on the data), this is a near perfect patient utopia.

It’s a great idea and perfect for an ideal world. Except:
- Massive databases cause massive headaches, as commenter Omowizard pointed out. There is a price to pay for data available at all times, all places, and by everyone. And if I may add, in Gur-Arie’s model, it’s not clear who’s left holding the bag. Presumably the government. Which opens a entirely different can of worms about data ownership.
- Real time updates of data is no joke. At my current place of work, we perform quasi-real time (twice daily) updates of patient visits to client databases from a central repository. The sheer volume is enough to bring down the database servers for a good hour or two.
- We haven’t been able to agree on a standardized schema passed for a healthcare database. What are the odds of this idea ever catching on?
- How are we going to mandate data population? After physicians and care organizations, will EMR vendors be the next recipients of government bribes/largesse/sops to induce them to populate the database?
- Gur-Arie herself points out that American enterprise being what it is, if there are no financial benefits to data ownership, they’re going to be a hard sell.

And while it’s easy for me to write a smart alecky blog post about the infeasibility of the mammoth database idea, I shudder when I think of what we have now: disjoint EHRs that don’t “speak” to one another, walled gardens and proprietary ownership of data that pretty much lock physician office in, PHR offerings from companies like Microsoft who will do God knows what with OUR health data.

I don’t think there are any easy answers. I’m leaning more towards an open source health “OS” platform rather than a single database. But at the very least, Gur-Arie offers some great food for thought.

January 31, 2012 I Written By

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

Is EMR a Four-Letter Word? You decide

For quite some time now, I’ve nursed my own doubts about:
- how effective EMRs are (disastrous in the short term, long term they’re supposed to make life easier, but we haven’t seen any evidence of that yet)
- why physicians are being paid to implement something that makes logical sense (you need something to nudge people out of status quo. And probably in the government’s thinking, what better use for taxpayer dollars, right?)

I came upon this blogpost, provocatively titled Why EMR is a four-letter word to most physicians. Adam Sharp, Par8o (“pareto”, not “par 80″) founder references this post from the Healthcare Blog. The discrepancy in the rates between adoption of any EMR is mind-boggling. It was projected to be close to 56.9% in 2010, vs. adoption of a fully functional EMR (projected to be close to 10.1% in 2010). (I’m not using the 2011 rates because the rates for fully functional EMR adoption in 2011 are not listed).

A reason Sharp gives for incentives and threats of decreased payment are “the industry and physicians have known for years that EMRs do not improve productivity and that it is highly questionable that EMRs lead to better patient outcomes”. While I would agree that in the short term, there is decreased productivity, I’m not so sure you can dismiss there is no productivity increase over the long term. This report about a UC Davis study for example, shows that the loss of productivity was just one month for internal medicine, and that productivity increased to pre-EMR implementation levels in the next six months. The not-so-good news is that productivity levels declined for pediatricians and family practices.

I interpret these findings like this: for specialties where there is loss of productivity, sure, the whole exercise needs a rethink. But in cases where your productivity is at par with your pre-EHR levels, I think there is a hidden benefit that detractors are more than willing to gloss over – the availability of patient data. Data is the holy grail – it’s up to us to figure out whether and how we use it.

Sharp also imagines some doomsday scenarios – of EMR vendors with uncanny abilities to do as they please.

“The goal of EMRs is to wrestle control of healthcare away from the doctor-patient relationship into the hands of third parties who can then implement their policies….by simply removing a button or an option in the EMR.”

Maybe I’m turning turncoat here and letting you guys in on the best kept secret of the IT industry, but every vendor I’ve worked for, past and present, figuratively quakes in his IT boots when it comes to contract renewal. Even for COTS products, vendors actually customize things here and there for customers, till you have 25 versions of the same code, all just to keep their customers happy and paying. While I’m pretty sure there are rogue vendors who can give you the best EMR nightmares money can buy, I also do think customers can, and do, help rein in errant ideas. In other words, vendors can’t simply remove buttons and options or randomly start charging you for stuff, not unless you let it happen. And you, the customer, hold the purse strings, ergo YOU, not the vendor, call the shots.

I don’t quite find myself agreeing with the cynical conclusion of the post which is that the point of EMRs is to wrest control away from doctors and patients into the hands of third parties who wish to regulate choice and eligibility. But there’s plenty there that’s food for thought. Go check it out.

January 23, 2012 I Written By

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

Guest Post: The Case for Modular EHR Over Complete EHR

Dr. Sullivan is a practicing cardiologist who joined DrFirst in 2004, just after completing his term as President of the Massachusetts Medical Society. He is known throughout the healthcare industry as the father of the Continuity of Care Record (“CCR”) and a leader on the future of healthcare technology. He is assisting DrFirst in ensuring that Rcopia continues to add the functionality necessary to maintain its leadership position both in electronic prescribing and in the channel of communication between various sectors of the healthcare community and the physician. Dr. Sullivan is active in organized medical groups at the state and national level, and is both a delegate to the AMA and the Chairperson of their Council on Medical Service as well as past Co-Chair of the Physicians EHR Consortium.

The buzz surrounding Electronic Health Records (EHR) is nothing short of constant.  The daunting task of selection, purchase and implementation is quite confusing, technical, and expensive, with many physicians, clinics and health systems uncertain of their needs and questioning how the technology is going to impact the way they practice medicine and their bottom line. It’s all about workflow and productivity.

More recently, Providers are faced with the intimidating task of deciding which kind of system to install. There are all inclusive systems, often referred to as fully paperless or standard EHRs and there are so called a la carte systems known as modular EHRs.

The Case for Modular

Modular EHR systems allow providers to take a stepping stone approach to health IT clinical documentation and order writing, by choosing the tools and functions which make the most sense in their practices and clinics; improving specialized workflow and efficiency.  Going the modular route can gradually ease the provider and the office staff into a more paperless environment without having to make a full and often-times difficult transition to a fully paperless workspace.

There is need for caution however. The sheer volume of modules available can make selecting appropriate ones an overwhelming task.  Not only do clinicians need to be wary of which modules they are choosing, but also what functions have been certified by an authorized organization.

By combining specific modular systems, it can become “qualified,” making the user eligible for the monetary reimbursements set forth by Title IV of the American Recovery and Reinvestment Act of 2009 (ARRA).

At DrFirst, our Rcopia-MUTM has taken all of the guess work out of this process and is a completely certified Modular EHR that physicians can implement and start earning incentive money directly out-of-the-box.

The implementation of a complete EHR system can be confusing and time consuming.  Herein lays some distinct advantages of implementing a modular EHR.  Practices that have already implemented e-prescribing or registry modules may not need to relearn a different system, or move their data from one to another (as long as the current module is certified).

Providers who are considering going the modular route can check the certification status of their options at Certified Health IT Products List. The cost for a modular approach is often much less expensive and providers can select the modules from various vendors to meet their financial and practice-based needs.  Upon implementation, providers must show they’re using certified EHR technology in measureable ways to receive their incentive monies from the Federal Government.  With this very high ROI, many providers see the advantage of using the modular approach to postpone the decision process in selecting a complete EHR and yet at the same time earn Meaningful Use incentive money to put towards the cost of  the much more expensive system.

According to the Centers for Medicare and Medicaid Services, doctors who have not adopted an EHR (either modular or complete) by 2015 will be penalized by Medicare — a 1% penalty to begin, then up to 3% within three years. Many providers are banking on the reimbursement that has been made available by the ARRA to help offset the initial costs.

What is your practice considering, complete EHR or modular? Do you see benefits of one over the other?

November 30, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus.