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Is the Concierge Model A Real Option for Providers?

Posted on February 25, 2015 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 article last month in Crain’s New York Business talks about the pressures that primary care doctors are facing and how those financial pressures are getting many of them to try cash-only or concierge practices. Here’s an excerpt from the article:

To stave off the pressures prompting many physicians to sell their practices to hospital systems, Manhattan internist Peter Bruno has tried a number of creative solutions. They have ranged from forming a now-disbanded group practice with 60 colleagues to his ongoing strategy of working at a nursing home one day a week to supplement his income in his current solo practice.

With reimbursements dropping, Dr. Bruno made the bold move in July of converting his six-employee private practice on East 59th Street in Manhattan to a hybrid concierge model. In concierge care, patients pay an annual fee or retainer to get more immediate, customized care. Hybrid practices treat both concierge and traditional patients. He worked with SignatureMD, a Santa Monica, Calif.-based network that assists physicians in doing so.

I don’t think we need to cover the financial realities of being a solo physician here. You’re all to aware of the challenges. However, I’m interested to hear what you think about the potential for the concierge model of medicine for primary care doctors? Is that an option for most primary care doctors?

I ask this because I’ve seen concierge medicine work in the rich areas (the above case is Manhattan for example), but I have yet to see it really work in poorer areas. If we’re shifting to concierge medicine, what does that mean for the poorer areas of the country?

Here in Las Vegas, they have an interesting hybrid model that they’re trying where concierge medicine is part of the insurance plan. In fact, it could be part of the insurance plan your employer provides. I just signed up for the plan, so we’ll see how it goes.

I’m also watching how the EHR market is adapting to this trend as well. Over on EMR and HIPAA I wrote an article titled “An EHR Focused On Customer Requests, Not MU” which talks about what an EHR would look like that was just focused on patient care and how Amazing Charts was offering that product.

Just today SRSsoft announced their new SRS Essentials product that’s a non-MU EHR as well. Although, they offer an interesting wrinkle that allows their SRS Essentials customers to move up to an meaningful use certified EHR should they decide they later want to take part in meaningful use (or whatever that program eventually becomes).

Of course, SRSsoft focuses mostly on the specialty market and not general medicine. Although, maybe this physician focused EHR product will be of interest to the emerging concierge and direct primary care doctors as well.

What do you think of these new models of medicine? What’s their place in the healthcare world? Where are they going in the future? Will their technology needs be different than other doctors?

Why Are So Many Big Health IT Companies from Small Cities?

Posted on February 23, 2015 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 was reading over something on HIStalk the other day that talked about how many major healthcare IT and EHR companies have come out of small cities. In fact, when you think about the EHR world, there are only a handful of EHR companies that have come out of the tech hub of the world, Silicon Valley, and they’ve all been started within the past 10 years.

In the article HIStalk mentioned the town Malvern, Pennsylvania. I hadn’t even heard of the town, but a look at Wikipedia has Siemens Healthcare, Ricoh Americas, and Cerner as among the companies based in Malvern. I think the Cerner mention in the list must be because Cerner just purchases Siemens Healthcare, so they are now claiming them. However, Cerner is definitely a Kansas City based company. Either way though, Kansas City is not a HUGE city either and certainly hasn’t been the hub of technology (although, I know they have some cool tech things happening now, like most cities).

The healthcare IT behemoth, Epic was founded in Madison, Wisconsin and now has headquarters in Verona, Wisconsin. If you aren’t in healthcare IT, my guess is that you’ve probably never even heard of Verona.

Those are just a few examples and I’m sure there are many more. Why is it that so many of the large healthcare IT companies have come from small cities? Will that trend continue or will large cities like San Francisco, Boston, New York, and LA start to dominate?

I’m a bit of a young buck in this regard. So, I don’t have the answer. Hopefully some of my readers do. I look forward to hearing your thoughts. Is there an advantage to being from a small town when going into healthcare? It’s exciting to me that healthcare innovation can come from anywhere. I hope that trend continues.

Patient Wait Time Tracking – Can We Learn Something from Fast Food?

Posted on February 19, 2015 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 was recently asked by @HIMTrainer (Jennifer Della’Zanna if you prefer) if I knew where my article was that I wrote about having a “patient wait” timer in an office. I vaguely remember talking about the idea, but couldn’t find and don’t remember specifically posting about the topic. However, the idea of a timer that tracks a patient’s wait time was interesting.

I’m sure that most of you are familiar with these timers at fast food restaurants. They track how long you’re waiting for your food and they often have some promise of free food if it takes over a certain amount of time. I’ve always found these timers interesting. In fact, I can’t remember a time when I’ve been to a restaurant with one of these timers that I ever had to wait very long for my food. Is that because of the timer or is that the nature of the restaurant and this was just a marketing mechanism? The answer is that it’s likely both.

The timer is a visual display of how long you’re really waiting. Time is a funny thing. A wait time that is relatively short can feel really long. We often lie to ourselves about how long something is, but that’s our perception. A timer helps to readjust that perception to the proper perspective. Of course, on a bad day it can also illustrate how much the restaurant needs to improve.

The other value of the timer is that it encourages the staff to work faster. At first this probably means the staff will feel some anxiety over the timer. However, over time it will just be a visual indication of how quickly or slowly their working and will help to ensure a consistent speed of service from most employees.

Now I’m sure that many of you are thinking that Fast Food is an awful comparison to healthcare. Fast Food is a pretty consistent product with a consistent request. Healthcare is a pretty inconsistent product with a wild variety of requests (almost limitless). Plus, I’m sure that many people’s gut reaction will be that this is an awful idea and corrupts the practice of medicine. I can already hear the cries for “Where’s the humanity in medicine?”

Certainly an organization could take this too far. However, maybe there’s something we can learn from the wait time clock that could help healthcare improve. Plus, when people cry fowl over something, that really makes me want to dig into that idea and see how it can help.

What’s Realistic in Healthcare?
There’s no way you’re going to see an actual clock at the check in or check out window in healthcare. I can’t even imagine how that workflow and tracking would work. So, it won’t be the same as fast food, but there are certainly a number of options available to track how long a patient is waiting. In fact, in many cases you can get quite granular.

Built in EHR Status Tracking
10 years ago when I first implemented an EMR system (yes, it was EMR, not EHR at the time), we could track the patient wait times in our EMR system. It wasn’t a perfect process, but you could get a good idea of how long a patient was in the office, how long they waited to be put in a room, how long they waited from the nurse to the doctor, and then when they checked out. Of course, you can add it all together and get an idea of how long the patient was in the office.

We simply used the statuses in the EHR to track this time data. It worked out pretty well with a few exceptions. If we didn’t have something that was specifically queued off of that status, then the data would be incorrect. For example, the nurses knew to bring a patient into an exam room based on the front desk changing them to a checked in status. So, the front desk always did this. The doctor would know to go into the room based on the nurse changing the status of the patient, so the nursing staff always did this. The patient was marked as discharged when the patient was making their payment (or checking to see if they had payments) and so this final status change was always done. Nothing was queued off of the doctor changing the status, so this often failed and so that data wasn’t very accurate.

Running these reports was fascinating and we could slice and dice the data in a variety of different ways. We could see it by provider, by appointment type, etc. Seeing the data helped us analyze what was taking the most time and improve it. We were also able to exclude any outliers that would skew the data unfairly to a provider who had a crazy complex case or in case a status change was missed.

Proximity Tracking
While EHR status tracking is good, there’s an even more powerful and effective way to track patient wait times in an office. I saw this first hand at the Sanford Health clinic in Fargo, ND at the Intelligent Insite conference. The entire clinic was wired with proximity tracking and other wireless monitoring technology that could track everyone in the clinic. Every nurse, doctor, MA, etc all had this technology embedded in their badge. Patients were issued a tracking device when they checked in for their appointment.

With this technology in place, you can imagine how the workflow for my above tracking is totally automated. They would actually immediately room the patient upon the patient’s arrival. In this case, the room would automatically know that the patient was in the room and provide an indication to the nursing staff that the patient was ready and waiting. I can’t remember the exact times, but they worked to have a nurse go into the room with the patient almost immediately after the patient got in the room. No doubt that’s a unique setup, but with these tracking devices they could know how well they were doing with the goal.

I won’t dive into all the other details of this workflow, but you can imagine how all of these tracking devices can inform the flow of patients, nurses and doctors through your office. Plus, all of this data is now trackable and reportable. The nurse, doctor, or patient don’t have to remember to do anything. The proximity devices do all the tracking, status change, etc for you.

I asked them if many patients walk out of the office with their tracking device. They told me that they’ve never had that happen, but they have returning the device as part of their checkout procedures so that could be why.

Informing the Patient
I think we’re just getting started on all of this. The price of this technology will continue to come down and we’ll do a much better job of tracking what happens in a practice. Plus, it offers so many interesting workflow benefits. I wonder if one of the next steps is to inform the patient of their wait time.

If we’re tracking the wait time, it’s not that far of a stretch to share that wait time with the patient. Kick off a clock that starts counting once they check in for their appointment. Maybe that wait time is displayed in an app on the patient’s smartphone. Maybe the wait time could be integrated into the Epion Health tablets a practice gives the patient during their office visit. If it’s a fast visit, do you prompt them to do a review of the doctor on a social site like Yelp or HealthGrades? Would doctors be ready for a patient to see front and center how long they’ve been waiting?

Final Thoughts
I’m sure that many doctors and practices will be afraid of this type of transparency. Plus, I’ve seen some general medicine doctors in particular make some serious arguments for why they run behind. Maybe the app could take this into consideration and inform the patient accordingly. While there are many unreasonable patients that are going to be unreasonable regardless of the situation, many other patients will have a much better experience if they just know more details on what’s going on.

While the comparison to a fast food timer clock is a stretch, the concept of tracking a patient’s time in an office is a discussion that is just starting. As providers work to differentiate themselves from their competitors, I’ll be interested to see how all these new technologies combine to make the patient experience better.

Remote Patient Monitoring and Small Practices

Posted on February 18, 2015 I Written By

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

We’ve started to see the proliferation of wireless health devices that can track a wide variety of health data and more of these devices are becoming common place in the home. Here’s a great tweet that contains an image of some of the popular devices:

While many of these devices are being purchased by the patients and used in the home, there are a number of other programs where healthcare organizations (usually hospitals) are purchasing the devices for the patients who then use the device at home. These programs are designed for hospitals to remotely monitor a patient and identify potential health issues early in order to avoid a hospital readmission.

For those who work in hospitals, you know how important (financially and otherwise) it is for hospitals to reduce their readmissions. While this is great for hospitals, how does this apply to small practices and general and family practice doctors in particular. There’s no extra payment for a small practice doctor to help reduce the readmission of their patient to the hospital. At least I haven’t seen a hospital pay a doctor for their help in this service yet.

What then would motivate a small practice doctor to leverage these types of remote patient monitoring tools?

Sadly, I don’t think there is much motivation for the standard small practice office to use them. It’s easy to see where a concierge doctor might be interested in these technologies. As a concierge doctor or direct primary care doctor, it’s in their best interest to keep their patient population as healthy as possible. As this form of care becomes more popular, I think these types of technology will become incredibly important to their business model.

The other trend in play is the shift to value based reimbursement and ACOs. Will these types of remote patient monitoring technologies become important in this new reimbursement world? I think the jury is still out on this one, but you could see how they could work together.

I’ve recently had a number of doctors hammering me on Twitter and in the comments of blog posts about how technology is not the solution to the problems and that technology is just getting in the way of the personal face to face connection that doctors have been able to make in the office visit of the past. Their concern is real and those implementing the technology need to take this into account. The technology can get in the way if it’s implemented poorly.

However, these people who smack the technology down are usually speaking from a very narrow perspective. EHR and other technology can and does disrupt many office visits. We all know the common refrain that the doctor was looking at the computer not at me. This is a challenge that can be addressed.

While the above is true, how impersonal is a rushed 10-15 minute office visit with a doctor? How impersonal is it for the doctor to prescribe a medication to you and never know if you actually filed it? How impersonal is it for a doctor to prescribed a treatment and never follow up with you to know if the treatment worked? How impersonal is it for the doctor to never talk or interact with you and your health unless you proactively go to that doctor because you’re sick?

Technology is going to be the way that we bridge that gap and these remote patient monitoring technologies are one piece of that puzzle. I believe these technologies and others make healthcare so much more personal than it is today. It changes a short office visit to treat a chief complaint into actually caring for the patient.

This is what most doctors I know would rather be doing anyway. They don’t want to churn patients anymore than the patient wants to be churned, but that’s how they get paid. Hopefully the tide is changing and we’ll see more and more focus on paying providers for using technology that provides this type of personal care.

Small Meaningful Use Penalties for Small Practices

Posted on February 17, 2015 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.

Michelle has posted an interesting CMS analysis of the price of EHR penalties for physicians:

CMS reports that the majority of physicians who will be penalized this year for not having met MU requirements will lose less than $1,000 of their Medicare reimbursement; 34% of the penalties will be $250 or less, while 31% will exceed $2,000.

The adjustments will impact approximately 257,000 eligible providers. While no one likes losing money, the CMS penalty “stick” is pretty small compared to the overall cost of implementing an EHR.

Unfortunately her link to the CMS report seemed to be the wrong link. I’d love to dig into the 31% of doctors who will exceed $2000 in penalties. $2000 still isn’t very compelling to most doctors I know, but if it scales from there we could see how many doctors are really going to suffer from the EHR penalties.

What’s also not clear to me is if this includes the PQRS penalties as well. All of the penalties start to add up. I also heard one doctor talk about the feared 22% Medicare cut that’s been delayed for a decade or so (I lose track of the number of years). I’ll be surprised if those cuts aren’t delayed again, but it’s interesting that many doctors fear these cuts even if they’re likely to be delayed. Perception is still very important.

Back to the meaningful use penalties, $1000 penalty is not something most doctors will bat an eye at. Even those who have an EHR are opting out of meaningful use stage 2. The math doesn’t work out for small practices. $1000 of penalties certainly won’t balance the equation either. I expect a very small number of small practices to do meaningful use stage 2. Hospitals on the other hand are a different story.

Restructure and Reform Meaningful Use: Here’s a Way

Posted on February 12, 2015 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.

It’s no secret that ONC’s meaningful use program’s a mess. I’m not sure there is an easy way out. In some respects, I wish they would go back and start over, but that’s not going to happen. They could do something to see daylight, but it won’t be either easy or simple. As I‘ll outline, ONC could adopt a graduated system that keeps the MU standards, includes terribly needed interoperability and usability standards, but does not drive everyone crazy over compliance.

MU’s Misguided Approach

ONC has spent much time and money on the MU standards, but has painted itself into a corner. No one, vendors, practioners or users is happy. Vendors see ONC pushing them to add features that aren’t needed or wanted. Practioners see MU imposing costs and practices that don’t benefit them or their patients. Users see EHRs as demonic Rube Goldberg creations out to frustrate, confuse and perplex. To boot, ONC keeps expanding its reach to new areas without progress on the basics.

Most the MU criticisms I’ve seen say MU’s standards are too strict or too vague. Compliance is criticized for being too demanding or not relevant. Most suggested cures tinker with the program: Eliminate standards or delay them. I think the problems are both content and structure. What MU needs is a return to basics and a general restructuring.

Roots of the MU Program’s Problems

It’s easy to beat up on ONC’s failures. Almost everyone has a pet, so I’ll keep mine short.

MU1: Missed Opportunities. MU’s problems stem from its first days. ONC saw EHRs as little more than database systems that stored and retrieved encounters. Data sharing only this:

Capability to exchange key clinical information (for example, problem list, medication list, medication allergies, diagnostic test results), among providers of care and patient authorized entities electronically.

Compliance only required one data exchange attempt. ONC relied on state systems to achieve interoperability. Usability didn’t exist.

MU2: Punting the Problems. ONC’s approach to interoperability and usability was simple. Interoperability was synonymous with continuity of care and public health reports. Every thing else was put off for future testing criteria.

ONC’s usability approach was equally simple. Vendors defined their usability and measurement. The result? Usability’s become a dead topic.

Interoperability

ONC has many good things to say about the need for interoperability. Its recent Roadmap is thoughtful and carefully crafted. However, the roadmap points out just how poor a job ONC has done to date and it highlights, to me, how much ONC needs to rethink its entire MU approach.

Changing ONC

In one of his seminal works on organizations, C. Northcote Parkinson said it’s almost impossible to change a failing organization. His advice is to walk away and sew salt. If you must persist, then you should adopt the heart of a British Drill Sergeant, that nothing is acceptable. Alas, only Congress can do the former and I’m way too old for military service, so I will venture on knowing it’s probably foolhardy, but here goes.

New Basic Requirements

A better approach to MU’s core and menu system would allow vendors to pick and choose the features they want to support, but require that all EHRs meet four basic standards:

  1. Data Set. This first standard would spell out in a basic, medical data set. This would include, for example, vitals, demographics, meds, chief complaints, allergies, surgeries, etc.
  2. Patient ID. A patient’s demographics would include a unique patient identifier. ONC can use its new freedom in this area by asking NIST to develop a protocol with stakeholders.
  3. Interoperability. EHRs would have to transmit and receive, on demand, the basic data set using a standard protocol, for example, HL7.
  4. Usability. Vendors would have to publish the results of running their EHR against NIST’s usability standard. This would give users, for the first time, an independent way to compare EHRs’ usability.

All current EHRs would have to meet these criteria within one year. Compliance would mean certification, but EHRs that only met these criteria would not be eligible for any funding.

Cafeteria Program. For funding, vendors would have to show their EHR supported selected MU2 and MU3 features. The more features certified, the more eligible they’d be for funding.

Here is how it would work. Each MU criteria would have a one to ten score. To be eligible for funding, a product would have to score 50 or more. The higher their score, the higher their funding eligibility.

Provider Compliance. Providers would have a similar system. ONC would assign scores of one to ten for each utilization standard. As with vendors, implementing organizations would receive points for each higher utilization level. That is, unlike current practice, which is all or nothing, the more the system is used to promote MU’s goals the higher the payments. This would permit users to decide which compliance criteria they wanted to support and which they did not.

Flexibility’s Advantages

This system’s flexibility has several advantages. It ends the rigid nature of compliance. It allows ONC to add new criteria as it sees fit giving it freedom to add criteria as needed or to push the field.

It achieves a major advancement for users. It not only tells users how products perform, but it also lets them choose those that best fit their needs.

Vendors, too, benefit from this approach. They would not only know where they stood vs. the competition, but would also be free to innovate without having to include features they don’t want.

Meaningful Use Is Dead?

Posted on January 29, 2015 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.

Over on EMR and HIPAA, I got the following passionate response on my post titled Meaningful Use Created A Big Need for Certified MAs that I thought many readers on this site would enjoy.

In the EP world, MU is dead. There are some larger groups, especially primary care still struggling to overcome the huge hurdles of MU2, but most I know have given up and running for the hills. There is a ginormous gap between what ONC is peddling in terms of numbers and real MU use.

This is good example of another hidden cost of trying to MU. We have some excellent MA’s, and I could not tell you which are and are not certified. Makes no difference. Sadly, CMS and ONC, do not realize that they are literally driving EPs from accepting Medicare patients, especially us specialists. And once we are gone, or severely limit new patients with Medicare, we are not coming back.

So the 17 times in 11 years fix for SGR, PQRS, VBM, MU, CPQ, ICD10, HIPAA, RAC audits, sequester cuts, etc. Its too much cost. clicking, paper work to take care of these patients. We actually had a serious discussion with our hospital about cutting back severely on doing Medicare total knees and hips next year due to all this. And the hospital initiated the conversation. So its not just us, even EHs are looking into this.

We all know that CMS and ONC want something, anything in terms of numbers to report anything to Congress, but this is the wrong way to do it. Again, everyone out there that is sitting in their cubicle Monday morning quarterbacking our care for these patients, will be very sad, very soon as we will just stop seeing them.

You can see by the numbers, if 250,000 EPs are taking the first MU hit this year, just wait until the rest give up. EPs can see that MU does not equate to better care, safer care, or more efficient care. We all may use an EHR, but could care less about attestations and audit risks and counting numerators/denominators forever. Again now that at least half the EPS are out, the rest will be right behind.

CMS and ONC need to realize that penalties NEVER work. Incentives like the heady days of MU1, got people to try EHR, but the costs are now piling up, big time. Everyone wants their piece of the pie. But as the incentives have gone away and the clerk like data entry has gone up, EPs have left the program. And are never, I mean never, coming back.

This provider makes an interesting assertion about meaningful use being dead. Do you think that MU is dead?

I thought this post’s timing was interesting given the announcement that CMS is changing the meaningful use stage 2 reporting period to 90 days. Correction…they intend to change it, but I think we all see that it’s going to happen. Just let the rule making process take it’s course.

Before this announcement, I would have largely agreed that meaningful use was pretty close to dead. I know some people have sifted through the meaningful use stage 2 attestations and have said it’s better than we thought, but I think those are the early birds and not the majority. With this announcement, I think the majority will take a much deeper look at taking on MU stage 2. If CMS can simplify some things, I could see many participating to get the incentive money, but to also avoid the penalties. Penalties aren’t the end all be all for doctors, but they represent a big chunk of money for many doctors.

I’d love to hear your thoughts. What are you seeing in the trenches?

ONC Annual Meeting – Who’s Going?

Posted on January 28, 2015 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.

ONC’s Agenda – February 2-3, Washington, DC

Next Monday, ONC holds its annual meeting in downtown DC. I’m going, one small advantage of living here. Here’s the agenda. To see day two, click on the agenda header.

I’m particularly interested in these topics:

  • Adverse event reporting,
  • Interoperability standards,
  • Meaningful Use program’s future, and
  • Usability.

Looking at the agenda, I should stay busy with one exception. There isn’t much on usability. The word’s only on the agenda once. Not a surprise since ONC has pretty much relinquished any role to the vendors.

How important do you think the ONC meeting and also the ONC run Healthdatapalooza now that meaningful use has kind of run its course? Will these two meeting gain steam and influence or will organizations start to go other places? I’ll be interested to watch that trend as I attend the event.

If you can’t attend, you can follow on various webcasts and twitter. If you do plan to attend, I’d love to see you there. To email me, click on my name in my profile blurb, or at carl@ehrselector.com.

Clinical Decision Support Should Be Open Source

Posted on January 26, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://radar.oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Clinical decision support is a long-standing occupant of the medical setting. It got in the door with electronic medical records, and has recently received a facelift under the term “evidence based medicine.” We are told that CDS or EBM is becoming fine-tuned and energized through powerful analytics that pick up the increasing number of patient and public health data sets out in the field. But how does the clinician know that the advice given for a treatment or test is well-founded?

Most experts reaffirm that the final word lies with the physician–that each patient is unique, and thus no canned set of rules can substitute for the care that the physician must give to a patient’s particular conditions (such as a compromised heart or a history of suicidal ideation) and the sustained attention that the physician must give to the effects of treatment. Still, when the industry gives a platform to futurists such as Vinod Khosla who suggest that CDS can become more reliable than a physician’s judgment, we have to start demanding a lot more reliability from the computer.

It’s worth stopping a moment to consider the various inputs to CDS. Traditionally, it was based on the results of randomized, double-blind clinical trials. But these have come under scrutiny in recent years for numerous failings: the questionable validity of extending the results found on selected test subjects to a broader population, problems reproducing results for as many as three quarters of the studies, and of course the bias among pharma companies and journals alike for studies showing positive impacts.

More recently, treatment recommendations are being generated from “big data,” which trawl through real-life patient experiences instead of trying to isolate a phenomenon in the lab. These can turn up excellent nuggets of unexpected impacts–such as Vioxx’s famous fatalities–but suffer also from the biases of the researches designing the algorithms, difficulties collecting accurate data, the risk of making invalid correlations, and the risk of inappropriately attributing causation.

A third kind of computerized intervention has recently been heralded: IBM’s Watson. However, Watson does not constitute CDS (at least not in the demo I saw at HIMSS a couple years ago). Rather, Watson just does the work every clinician would ideally do but doesn’t have time for: it consults thousands of clinical studies to find potential diagnoses relevant to the symptoms and history being reported, and ranks these diagnoses by probability. Both of those activities hijack a bit of the clinician’s human judgment, but they do not actually offer recommendations.

So there are clear and present justifications for demanding that CDS vendors demonstrate its reliability. We don’t really know what goes into CDS and how it works. Meanwhile, doctors are getting sick and tired of bearing the liability for all the tools they use, and the burden of their malpractice insurance is becoming a factor in doctors leaving the field. The doctors deserve some transparency and auditing, and so do the patients who ultimately incorporate the benefits and risks of CDS into their bodies.

CDS, like other aspects of the electronic health records into which it is embedded, has never been regulated or subjected to public safety tests and audits. The argument trotted out by EHR vendors–like every industry–when opposing regulation is that it will slow down innovation. But economic arguments have fuzzy boundaries–one can always find another consideration that can reverse the argument. In an industry that people can’t trust, regulation can provide a firm floor on which a new market can be built, and the assurance that CDS is working properly can open up the space for companies to do more of it and charge for it.

Still, there seems to be a pendulum swing away from regulation at present. The FDA has never regulated electronic health records as it has other medical software, and has been carving out classes of medical devices that require little oversight. When it took up EHR safety last year, the FDA asked merely for vendors to participate voluntarily in a “safety center.”

The prerequisite for gauging CDS’s reliability is transparency. Specifically, two aspects should be open:

  • The vendor must specify which studies, or analytics and data sets, went into the recommendation process.

  • The code carrying out the recommendation process must be openly published.

These fundamentals are just the start of of the medical industry’s responsibilities. Independent researchers must evaluate the sources revealed in the first step and determine whether they are the best available choices. Programmers must check the code in the second step for accuracy. These grueling activities should be funded by the clinical institutions that ultimately use the CDS, so that they are on a firm financial basis and free from bias.

The requirement for transparent studies raises the question of open access to medical journals, which is still rare. But that is a complex issue in the fields of research and publishing that I can’t cover here.

Finally, an independent service has to collect reports of CDS failures and make them public, like the FDA Adverse Event Reporting System (FAERS) for drugs, and the FDA’s Manufacturer and User Facility Device Experience (MAUDE) for medical devices.

These requirements are reasonably light-weight, although instituting them will seem like a major upheaval to industries accustomed to working in the dark. What the requirements can do, though, is put CDS on the scientific basis it never has had, and push forward the industry more than any “big data” can do.

HIM and Where It’s Heading with Charlie Saponaro

Posted on January 23, 2015 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.

Lately I’ve started to really see the importance of HIM In the future of healthcare. I like to break HIM work into: managing the record (ie. Avoid Lawsuits), improving the coding/documentation (ie. More $$), and HIPAA compliance (ie. Avoid penalties). While their future has been questioned during the shift to EHR, I think they have a very important future in these areas.

With this as background, I did an interview with Charlie Saponaro, President and CEO of Medical Record Associates, to talk about the State of HIM. We talk about some major HIM trends like remote HIM and outsourced HIM for example. If you’re over HIM, in HIM or interested in the future of HIM, you’ll enjoy this chat with Charlie.