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Apple EMR

Posted on August 24, 2016 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.

This tweet seems to have hit a nerve with me:

I realize that James Edwards was just being funny on Twitter, but I guess I’ve had too many people who seriously thought that Apple would get into the EMR business. They won’t. They never will. And I think it’s funny to think that just because Apple touches it, people think it will be all better.

Apple could pour its billions of dollars of cash into the EHR market and doctors would still complain about their solution. More and more I’m realizing that an EHR can only be so good because of the reimbursement and regulatory requirements that the EMR has to meet. Certainly, EHR software should be better than it is today, but it won’t be perfect until we see a sea change in the technology available (see my Video EHR idea) and/or the regulatory and reimbursement environment. Not even Apple can solve those.

However, beyond the fact that I don’t think Apple could make a beautiful EHR, I also think that Apple has no interest in being in the enterprise business. Yes, EHR software is an enterprise software and becoming more so every day. That’s not in Apple’s wheelhouse and they’re not going to get there either.

There are plenty of opportunities for Apple in healthcare. Consumer health devices and consumer health applications are the sweet spot for Apple and I could see them being a major player there. There’s so much opportunity there with their iPhone and iPad footprint. I think all of that is just a matter of time. Just stop talking about Apple entering the EHR space. It’s not going to happen.

A Look at the Olympic EHR

Posted on August 23, 2016 I Written By

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

I’ve always been interested in the United States Olympic Committee’s choice of GE as their EHR software. As part of the Olympics, GE put out this video where a bunch of the USOC support staff talk about how they use the GE Centricity Practice Solutions EHR with olympic athletes. Pretty cool to hear about some of the stuff they’re doing and the unique challenges they face as the doctors of these athletes.

My favorite part of the video is that they’re able to use the EHR to coordinate care of the athletes across 1000 doctors. Shows you that if there’s a desire to do so, it’s possible. Also, pretty interesting that they note that they take 45 minutes to get someone up to speed on the Centricity EHR.

Who’s Eligible for MIPS? – MACRA Monday

Posted on August 22, 2016 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.

This post is part of the MACRA Monday series of blog posts where we dive into the details of MACRA.

In years 1 and 2 of MACRA, those that are eligible to participate are going to be very similar to past programs. However, the secretary does have the option in year 3 to look at expanding the program to include other healthcare providers that don’t meet the initial requirements. You can see this illustrated in the graphic below.
MIPS Eligibility

There are three exceptions to the above graphic. The first exception is if you’re a first year partipant in Medicare Part B. This gives these doctors time to get up to speed before they’re required to participate in MIPS. They will have to participate in year two. There is also a MIPS exception for low volume providers. If you’re a provider that has Medicare billing charges that are less than or equal to $10,000 and providers care to 100 or fewer Medicare patients in a year, then you are not required to participate in MIPS. The third exception is those providers that are already participating as an advanced APM (see what we wrote about Advanced APM eligibility for more details) are not allowed to participate in MIPS. Here’s a summary of these exceptions:
Not Eligible for MIPS

If all of this Advanced APM and MIPS eligibility is confusing to you, here’s a flow chart which will walk you through the process of knowing whether you’re an advanced APM, whether you must participate in MIPS or whether you’re not subject to MIPS:
APM or MIPS - Where Do You Fit Into MACRA

Next up, we dive into the details of MIPS and the 4 MIPS categories.

Be sure to check out all of our MACRA Monday blog posts where we dive into the details of the MACRA program.

Should Clinical Research Options Be Integrated Into Every EHR?

Posted on August 19, 2016 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.

One of the amazing things of the internet and technology is the democratization of information. I recently heard that it’s not that the world is getting worse, but that our information is getting better (ie. we hear about all the bad things happening in the world). That really resonated with me. Although, it annoys me when information that could be useful still isn’t making it to the right people at the right place and the right time. The point being that our information could still be better.

This tweet and infographic illustrated how this is true in the world of clinical trials and research:

Clinical Research and Doctor Referrals

How often do research studies not get done because they don’t have the right patients? Far too many. How many patients don’t get treatment from clinical trials that could save their lives because they don’t know about it? Far too many.

All of this happens because there’s a disconnect in the information that’s available. As someone who’s spent so much time in the EHR world, the question for me is should every clinical trial option be integrated into every EHR? Should we casually alert doctors to potential clinical trials that could benefit the patient? The EHR could already pre-qualify them in many ways so that the doctor was only seeing trials for which the patient likely could qualify for. How many more studies would get done and patients lives would be saved?

The lack of clinical trial information in the EHR is why I think the above infographic shows a disconnect between doctors presenting patients clinical trial options or not. Technology and EHRs are the way we can bridge the disconnect between patients expectations and reality. This is why I believe that EHR software can be an incredible foundation for innovation. We’re just sadly not there yet. We should be when it comes to clinical trials.

Is Interoperability Worth Paying For?

Posted on August 18, 2016 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.

A member of our extended family is a nurse practitioner. Recently, we talked about her practice providing care for several homebound, older patients. She tracks their health with her employer’s proprietary EHR, which she quickly compared to a half-dozen others she’s used. If you want a good, quick EHR eval, ask a nurse.

What concerned her most, beyond usability, etc., was piecing together their medical records. She didn’t have an interoperability problem, she had several of them. Most of her patients had moved from their old home to Florida leaving a mixed trail of practioners, hospitals, and clinics, etc. She has to plow through paper and electronic files to put together a working record. She worries about being blindsided by important omissions or doctors who hold onto records for fear of losing patients.

Interop Problems: Not Just Your Doc and Hospital

She is not alone. Our remarkably decentralized healthcare system generates these glitches, omissions, ironies and hang ups with amazing speed. However, when we talk about interoperability, we focus on mainly on hospital to hospital or PCP to PCP relations. Doing so, doesn’t fully cover the subject. For example, others who provide care include:

  • College Health Systems
  • Pharmacy and Lab Systems
  • Public Health Clinics
  • Travel and other Specialty Clinics
  • Urgent Care Clinics
  • Visiting Nurses
  • Walk in Clinics, etc., etc.

They may or may not pass their records back to a main provider, if there is one. When they do it’s usually by FAX making the recipient key in the data. None of this is particularly a new story. Indeed, the AHA did a study of interoperability that nails interoperability’s barriers:

Hospitals have tried to overcome interoperability barriers through the use of interfaces and HIEs but they are, at best, costly workarounds and, at worst, mechanisms that will never get the country to true interoperability. While standards are part of the solution, they are still not specified enough to make them truly work. Clearly, much work remains, including steps by the federal government to support advances in interoperability. Until that happens, patients across the country will be shortchanged from the benefits of truly connected care.

We’ve Tried Standards, We’ve Tried Matching, Now, Let’s Try Money

So, what do we do? Do we hope for some technical panacea that makes these problems seem like dial-up modems? Perhaps. We could also put our hopes in the industry suddenly adopting an interop standard. Again, Perhaps.

I think the answer lies not in technology or standards, but by paying for interop successes. For a long time, I’ve mulled over a conversation I had with Chandresh Shah at John’s first conference. I’d lamented to him that buying a Coke at a Las Vegas CVS, brought up my DC buying record. Why couldn’t we have EHR systems like that? Chandresh instantly answered that CVS had an economic incentive to follow me, but my medical records didn’t. He was right. There’s no money to follow, as it were.

That leads to this question, why not redirect some MU funds and pay for interoperability? Would providers make interop, that is data exchange, CCDs, etc., work if they were paid? For example, what if we paid them $50 for their first 500 transfers and $25 for their first 500 receptions? This, of course, would need rules. I’m well aware of the human ability to game just about anything from soda machines to state lotteries.

If pay incentives were tried, they’d have to start slowly and in several different settings, but start they should. Progress, such as it is, is far too slow and isn’t getting us much of anywhere. My nurse practitioner’s patients can’t wait forever.

MIPS Overview – MACRA Monday

Posted on August 15, 2016 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.

This post is part of the MACRA Monday series of blog posts where we dive into the details of MACRA.

The Merit-based Incentive Payment System or MIPS as we now know it is going to be a big part of most practices future. As we mentioned previously, most practices will be participating in the MIPS program as opposed to the APM program under MACRA. Here’s a quick overview of the MIPS program. Over the next months, we’ll be diving deeper and deeper into the details of MIPS.

MIPS replaces 3 programs that will likely be familiar to most readers: PQRS, the Medicare EHR Incentive Program (Better known as meaningful use), and the Value-Based Payment Modifier (VBM). The last one might not be as familiar to people, but PQRS and Meaningful Use are likely very familiar. In future posts, we’ll dive into the changes to these programs that come as they’re rolled into MIPS.

It’s worth noting that these programs will continue to run in their current from through 2018. Plus, the Medicaid EHR Incentive Program and the Medicare EHR Incentive Program for Hospitals will continue. Along with rolling the 3 current programs into MIPS, MACRA also adds a new program to MIPS called the Clinical Practice Improvement Activities (CPIA).

The first performance period for MIPS is 2017 with MIPS adjustments happening in 2019. At least that’s the way it’s listed in the proposed rule. Many are suggesting that there’s no way that MIPS will be for all of 2017. They argue that it has to be either delayed or moved to a 90 day reporting period (which is basically a 9 month delay). We’ll see what they finally decide when the MACRA final rule finally comes out.

The potential MIPS adjustments to your Medicare Part B payment are 4% in 2019 and grow to 9% in 2022. Remember that these adjustments can be both positive and negative based on how well you participate in the MIPS program. We’ll dive into the MIPS Composite Score that determines your MIPS payment adjustment in a future post. Here’s a charge which illustrates the MIPS timeline and incentives:
MIPS Incentives and Penalties
That’s all for our MIPS overview. Next up we’ll dive into who is eligible for MIPS and who is not eligible for MIPS.

You can see how if you’re already participating in PQRS, Meaningful Use, and the Value-Based Modifier, then you are well positioned to do well in MIPS. This will become even more clear when we discuss the weighted scoring that each of these pieces of MIPS receives. Of course, if you haven’t been participating in these programs, then MIPS will definitely be a pretty big hill to climb.

Be sure to check out all of our MACRA Monday blog posts where we dive into the details of the MACRA program.

Are Devices Distracting Doctors the Same As Devices Distracting Children?

Posted on August 12, 2016 I Written By

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

I came across this tweet from Howard Green, MD that really made me stop to think.

I like the juxtaposition of his comment because it makes you stop and think about the decisions we’re making. Although, I think that Dr. Green takes it too far since no one ever asked doctors to stop interacting. In fact, the chorus I’ve heard is that doctors need to interact more with patients. That said, I get his point that the EMR can get in between the patient and doctor if you let it. And many have let it get in the way.

We can certainly talk about how EHR software could be more usable. We can talk about how the onerous regulations and things like meaningful use and MACRA have made documenting in an EHR a clickfest that provides little to no value to patients. We can talk about how EHR software isn’t connected to other EHR software and we’re living in this world of healthcare data silos. All of these are a pain and a problem for doctors and we should do better. What is unfair to say is that EHRs tell doctors to stop interacting.

It’s always amazing to me how the EHR gets all sorts of undeserved blame. I’ve seen plenty of doctors who use an EHR and still spend plenty of time interacting with their patients. In fact, people like Dr. James Legan have integrated their EHR use into their patient interaction and made their patient interaction better. Yes, the EHR can be a distraction, but it doesn’t have to be. The same way devices can ruin my children, but they don’t have to ruin them. It’s how you choose to use it.

ONC’s Budget Performance Measure Dashboards Makes Goal Tracking Easy

Posted on August 9, 2016 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.

I recently wrote a post how it’s not easy to compare ONC’s spending plans with what it actually did. That’s not the case with ONC’s Budget Performance Measures. Its Performance Measure dashboard makes those comparisons easy and understandable. For example, you can look up EHR adoption among office based physicians.

Here’s how to use it. On the dashboard page, Figure I, select a general area using the radio buttons. Depending on your choice, the system will list specific issues. You select the one you want from the drop down menu on the right. You can also adjust the period covered. Right clicking a graph downloads it.

Figure I – ONC Dashboard Menu

ONC Dashboard Menu

It’s in the graph that the dashboard excels. It clearly shows targets and results. For example, Figure II shows that while office EHR adoption has grown over the years, it’s running below ONC’s goals. If you’d only saw the actual – which is the case with ONC’s budget — you’d only see adoption going up. You’d have no clue ONC’s goal wasn’t met.

Figure II – ONC Primary Care Adoption

Office Based Primary Care Doc Adoption

These dashboards give the public a way to understand what ONC wants to do and how well — or not so well — its done toward its goals. In doing so, ONC has given us a scoreboard that not only measures what it’s doing, but it also allows the public to focus on benchmarks. ONC’s fiscal reporting isn’t the clearest, but with these dashboards they’ve done themselves well.

Mobile EHR Access Is Maturing

Posted on August 4, 2016 I Written By

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

Today I read a story that surprised me, though perhaps it shouldn’t have. A clinician, writing for a publication called Diagnostic Imaging, suggests that a “mobile EHR” is emerging, a new entity which embraces mobile technology rather than treating it as an add-on. I wasn’t surprised that this was happening, but it is remarkable that it’s taken us so long to get to this point.

As Saroj Misra, DO, notes, healthcare organizations are rolling out infrastructure for clinicians to access EHR data via mobile devices, and EHR vendors are ramping up development of mobile interfaces for their systems. And physicians are responding. According to a recent Physicians Practice survey, 78% of physicians are now using mobile-accessible EHRs, and more than 85% of doctors and practices were using mobile devices to do their jobs.

As he sees it there were three big issues which previously held back the development of mobile EHRs:

  • Mobile device screens were too small, and battery life was inadequate.
  • EHR vendors hadn’t created interfaces which worked effectively with mobile devices
  • Healthcare organizations weren’t convinced that mobile EHR access protected health data sufficiently

Today, these problems have receded into the background. Screens have gotten larger, battery life has been extended, and while security is always an issue, standards for protecting mobile data are gradually emerging. Also, healthcare organizations are developing mobile device management policies which help to address BYOD issues.

In response, EHR developers are embracing mobile EHR access. There’s vendors like drchrono, which is a mobile-native EHR, but that’s not all.  Other ambulatory vendors, like athenahealth, describe themselves as a “provider of network-enabled services for electronic health records,” and MEDITECH’s Web Ambulatory app runs on a tablet.  Also, Cerner’s PowerChart Touch solution is built for the Apple iPad.

At this point, I truly wonder why all EHRs aren’t developed primarily with mobile deployment in mind. Physicians have been engaged mobile device users since smartphones and tablets first emerged, and the need for them to manage patients on the go has only increased over time. I know desktops still have their place, but the reality is that empowering physicians to take patient data with them is overwhelmingly sensible.

My sense, after researching this post, is that ongoing security worries are probably the biggest roadblock to further mobile EHR deployment. And I understand why, of course. After all, many of the major health data breaches occur thanks to a stolen laptop “walking away” when it’s left unattended, and mobile devices may be just as vulnerable.

That being said, the benefits of giving doctors an elegant mobile EHR solution are substantial. With the right targeted security policies in place, I believe the benefits of robust mobile EHR deployment – particularly giving clinicians on-the-spot data access and getting immediate data back — far outweigh these risks. I sincerely hope the HIT software industry agrees!

ONC’s Budget: A Closer Look

Posted on August 3, 2016 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.

When HHS released ONC’s proposed FY2017 budget last winter, almost all attention focused on one part, a $22 million increase for interoperability. While the increase is notable, I think ONC’s full $82 Million budget deserves some attention.

ONC’s FY2017 Spending Plan.

Table I, summarizes ONC’s plan for Fiscal Year 2017, which runs from October 1, 2016 through September 30, 2017. The first thing to note is that ONC’s funding would change from general budget funds, known as Budget Authority or BA, to Public Health Service Evaluation funds. HHS’ Secretary may allocate up to 2.1 percent of HHS’ funds to these PHS funds. This change would not alter Congress’ funding role, but apparently signals HHS’s desire to put ONC fully in the public health sector.

Table I
ONC FY2017 Budget

fy2017-budget-justification-onc

What the ONC Budget Shows and What it Doesn’t

ONC’s budget follows the standard, federal government budget presentation format. That is, it lists, by program, how many people and how much money is allocated. In this table, each fiscal year, beginning with FY2015, shows the staffing level and then spending.

Staffing is shown in FTEs, that is, full time equivalent positions. For example, if two persons work 20 hours each, then they are equivalent to one full time person or FTE.

Spending definitions for each fiscal year is a little different. Here’s how that works:

  • FY2015 – What actually was spent or how many actually were hired
  • FY2016 – The spending and hiring Congress set for ONC for the current year.
  • FY2017 – The spending and hiring in the President’s request to Congress for next year.

If you’re looking to see how well or how poorly ONC does its planning, you won’t see it here. As with other federal and most other government budgets, you never see a comparison of plans v how they really did. For example, FY2015 was the last complete fiscal year. ONC’s budget doesn’t have a column showing its FY2015 budget and next to it, what it actually did. If it did, you could see how well or how poorly it did following its plan.

You can’t see the amount budgeted for FY2015 in ONC’s budget, except for its total budget. However, if you look at the FY2016 ONC budget, you can see what was budgeted for each of its four programs. While the budget total and the corresponding actual are identical -$60,367,000, the story at the division level is quite different.

                                   Table II
                    ONC FY2015 Budget v Actual
                                    000s

Division

FY2015 Budget $ FY2015 Actuals $ Diff
Policy Development and Coordination 12,474 13,112 638
Standards, Interoperability, and Certification 15,230 15,425 195
Adoption and Meaningful Use 11,139 10,524 (615)
Agency-wide Support 21,524 21,306 (218)
Total 60,367 60,367

 

Table II, shows this by comparing the FY2015 Enacted Budget from ONC’s FY2015 Actuals for its four major activities. While the total remained the same, it shows that there was a major shift of $638,000 from Meaningful Use to Policy. There was a lesser shift of $195,000 from Agency Support to Standards. These shifts could have been actual transfers or they could have been from under and over spending by the divisions.

Interestingly, Table III for staffing shows a different pattern. During FY2015, ONC dropped 25 FTEs, a dozen from Policy Development and the rest from Standards and Meaningful Use. That means, for example, that Policy Development had less people and more money during FY2015.

Table III
ONC FY2015
Budget v Actual Staffing FTEs
Division FY2015 Budget FTEs FY2015 Actuals FTEs Diff
Policy Development and Coordination 49 37 (12)
Standards, Interoperability, and Certification 32 26 (6)
Adoption and Meaningful Use 49 42 (7)
Agency-wide Support 55 55
Total 185 160 25

 

To try to make sense of this, I looked at the current and past year’s budgets, but to no avail. As best I can tell is ONC made great use of contracts and other non personnel services. For example, ONC spent $30 Million on purchase/contracts, which is $8 million more than it did on its payroll.

ONC’s budget, understandably, concentrates on its programs and plans. It puts little emphasis on measuring its hiring and spending abilities. It’s not alone, budgets government and otherwise, are forecast and request documents. However, if we could know how plans went – without having to dig in last year’s weeds  – it would let us know how well a program executed its plans as well as make them. That would be something worth knowing.