Today I read about a very interesting project focused on improving relationships between physicians and patients. I suspect the concept would make some doctors’ skin crawl — anytime you’re asked to give up over control of information, it smarts a bit — but I suspect we’re seeing a glimpse of the future.

The  OpenNotes project, which is being conducted at Beth Israel Deaconess Medical Center, Geisinger Health System and Seattle’s Harborview Medical Center, lets patients review the notes, e-mails and phone calls primary care doctors make after their medical appointment. Patients access the information via a secure Web interface.

In July 2010, researchers published baseline findings prior to the OpenNotes kickoff in the Annals of Internal Medicine. Since then, the project seems to have attracted a lot of interest, with more than 100 doctors and 20,000 patients participating.   It’s also gotten a lot of support from foundations;  the group has received grants from the Robert Wood Johnson Foundation Pioneer portfolio, the Drane Family Fund, the Koplow Family Foundation and the Katz Family Foundation.

Wondering how participants feel about this level of medical intimacy? Check out the OpenNotes site, where you’ll find a video  offering impressions from patients and doctors on how they feel about their level of communication.  As you’ll see, OpenNotes volunteer patients seem to enjoy having a closer relationship with their doctor, and more importantly, feel empowered to comment or even contradict the doctor if they see something that seems to be out of line.

“You can look at the comments that Bob writes down and sometimes you agree with him and sometimes you don’t,” says one patient. “Sometimes we clash on it, but then we work things out.” (Note the familiar title “Bob” the patient uses to address his doctor, which I doubt he would have otherwise.) Sounds like a better working relationship than I have with most of my providers!

Of course, there’s always questions as to whether approaches like these would work outside the confines of a grant-funded, academically-minded group of institutions and doctors.  Certainly that’s hard to tell. But it seems clear that at minimum, something worthwhile is going on here that might force vendors to think about patient facing data more deeply.  I’m impressed by what I see here and hope that we continue to learn from these efforts.

I heard an interesting statistic a few days ago during a very informative webinar – “The Future of Meaningful Use, EHRs and Accountable Care” – hosted by Greenway Medical’s Justin Barnes. He shared a huge amount of information during the hour-long presentation, but the fact that most stood out to me was that, according to Barnes, between 35 and 50 percent of EMRs will eventually be replaced after just one year of use. (Don’t quote him on the “year,” but I’m pretty sure that’s what he said.) His point being, of course, that providers need to think long and hard about what type of solution they need to fit their workflows before they spend time and money implementing an EMR.

This sentiment was echoed by Kimberly Harding of BCBS Florida in a panel at the iHT2 Summit in Atlanta. As part of a greater discussion on Meaningful Use, she made the comment that just because a healthcare IT product is certified doesn’t mean it’s the best fit for a particular facility.

My takeaway from both of these statements is that providers looking to adopt new healthcare IT tools like EMRs need to take a long, hard look at what their current needs are and what their future needs might be before they even think about demoing products.

They also need to adopt technologies that fit their workflows, not necessarily technologies that have a ton of bells and whistles. Added features won’t do anyone any good if they’re never used properly, never used at all, or used to the detriment of a physician’s productivity.

I kept this sentiment in mind when I read the results of a recent study of 250 hospitals and healthcare systems by consulting firm KPMG. The survey found that “71% of respondents’ organizations are more than 50% finished with their EHR adoptions. Will this 71% be satisfied with their EMRs once fully installed and adopted? How many will realize their product of choice wasn’t the right call? If we apply the Greenway statistic, that could be as many as 125 facilities!

So where is the disconnect? Why are providers making poor choices with presumably the best of intentions? Why has the term “rip and replace” become so well known in healthcare? Are physicians misinformed, or not educated enough? Are they feeling so rushed by Meaningful Use deadlines that they don’t perform proper due diligence? Are vendors part of the problem? If so, shouldn’t they be part of the solution? What role do regional extension centers have to play in all this?

If you have answers, please let me know in the comments below.

Many of you will likely remember my series of posts on EHR down time: Cost of EHR Down Time, Reasons Yor EHR Will Go Down, and SaaS EHR Down Time vs. In House EHR Down Time. Needless to say, it’s pretty much inevitable that sooner or later you’re going to encounter EHR down time. The key to EHR down time is to think ahead about how you’re going to deal with your EHR being inaccessible.

I started thinking about this a bit more when I came across this FAQ item on Practice Fusion’s EMR user forums.

When there’s a planned maintenance ahead:
•Print your daily calendar for the next day’s schedule
•Know your offline alternatives for handling labs and prescriptions
•Have a plan to document your patient visits so you can input them in the EMR later
•Clear out your To do list and complete any pending Rx refill requests the day before
•Update your web browser and Adobe Flash to the current version

Preparing your office:
•Have a prepaid wireless 3G hub or other back-up internet system ready to go in the event your main internet is down
•Use laptops with good batteries and connect computers to surge protectors and battery back-ups for short term power interruptions
•Identify a second location that you could use temporarily in the case of a serious, long-term outage such as a fire or flood

I’ll always remember the reaction of the director of the health center where I first implemented an EMR to the discussion about “What do we do if the EMR is down?” She basically said, “We can still take care of the patient. We just might have to ask a few more questions.”

Now I’m sure there are cases where a physician might choose not to treat a patient without access to their EHR. There are certainly also cases where you can treat a patient better, faster and with more information with an EHR, but those can either be rescheduled if that’s the case. It’s certainly bad customer service and you should employ techniques to minimize EHR downtime as much as possible. My point is that it’s usually not life or death when the EHR is down. Think about how many patients are treated in an ER every day with no access to the patient’s medical record.

With that said, it is a disruption to the clinic and will be a BIG disruption to your clinic if you don’t have a solid plan of attack for when (not if) your EMR is inaccessible.

I’d focus your efforts in two areas:
•Minimize EMR Down Time
•Plan of Action for When Your EMR Goes Down

Most people do a pretty decent job with the first part. The second part people don’t often give much thought. You can start with some of the comments from Practice Fusion above to build out your plan. I also think it’s worth making a plan for short down time versus long down time. It’s quite different to deal with 5 minutes of down time than 5 days. You should consider both options.

One of the many things that seems to be getting lost in the mix of all the noise about EHR software and the EHR incentive money is medical billing software. As I think through all of the presentations from EHR vendors and discussions I’ve had with doctors, consultants and other professionals in the Healthcare IT industry, I think the practice management system is getting lost in the EHR shuffle. Let me ask some important questions:

Does anyone care about the billing software now? What if the billing software that comes packaged with your EHR sucks?

A regular reader of my sites John Brewer often talks about how many of the benefits we like to talk about with technology in a practice are coming from the practice management system, not the EHR. These days most people seem to consider the EHR and PM one package. Yet, I’ve seen people spend little time really understanding whether the billing side of the EHR is going to work for their practice.

In contrast to this comment though is that I haven’t seen an uproar of people complaining about implementing an EHR and their billing going down the tubes. Does this mean that medical billing software has basically become a commodity that every EHR vendor has done to a reasonably sufficient level that no one has a problem? Or maybe we don’t hear about it much because most doctors aren’t business people.

While I don’t have anything but anecdotal evidence of the disregard to medical billing software, I think this is going to eventually come back to bite us. Although, in our generally provider driven world the EHR matters more in the daily workflow and so this isn’t a surprise that we see the EHR bias during medical software selection. Once the physician sees the reimbursement levels lower, they’ll likely wake up to the reality that you need both a solid EHR and a solid PM.

I’m a regular reader of a number of venture capital bloggers. I love entrepreneurship and consider investing a hobby that I love learning about. One of the best VC bloggers out there is named Mark Suster. I recently saw one of his posts titled, “The Danger of Crocodile Sales.” While Mark takes his post in a few different directions I think we have our fair share of Crocodile Salespeople in the EHR world.

Before I get into some thoughts, here’s how Mark describes a crocodile salesperson: “My favorite was when a guy told me to beware of Crocodile Salesmen. What’s that? ”You know, big mouth and no ears.””

I know I’ve been in some EHR sales presentations that were off the charts good at selling and demoing an EHR product. Based just on that sales presentation I could see how a physician would be very interested in buying that product. Everything went like clock works. They hit so many of the buzz points for doctors that make for a really compelling sell.

The problem comes that with half of the things that are said, in the back of my mind I’m thinking…and now let’s hear the rest of the story. Or the related…what about this, this and that nuance?

Don’t get me wrong. I think there are a lot of really good EHR salespeople who have the best interest of the physician at heart. Plus, there are a number of EHR companies that support this type of sales process. The challenge as I see it is helping the doctors to ask the right questions so they get the right information.

A crocodile salesperson, as described above, makes it a challenge for a physician and their practice to get the information they really need. In some cases you can see why an EHR salesperson exhibits the crocodile characteristics. Some of them just don’t have the in depth knowledge of their product to be able to veer off their sales demo script. They’ve nailed the sales demo, but fall apart when you veer into uncharted territory.

This is exactly why a doctor should make sure to take the EHR salesperson off script. You don’t have to be a jerk about it in the process. You just need to make sure that the sales presentation covers the points that you need covered. Do it in a polite and appropriate way and great EHR salespeople will be happy to go the direction you want to take the presentation. I know doctors time is limited, but it’s worth taking the extra time to get the right information. Ask any physician who’s switched EHR software if they’d wish they’d spent a little more time understanding their first EHR selection. I argue that it is the most important part of an EHR implementation.

My best suggestion to a doctor is to always consider how the EHR software being demonstrated will work in their office. Don’t get so caught up in the bells and whistles of what the product could eventually do in your office that you forget about how you’re going to do your regular tasks. Another common error is for physicians to be so rigid in their requests that they’re not open to any deviation from the processes they’ve used for the past years. No EHR will fit every physician workflow in every way. Consider whether you can see reasonable alternatives to your current processes.

If you want some other suggestions on asking good questions during your EHR sales demo, check out my e-Book on EHR selection. There’s a whole section of it devoted to the topic.

Selecting the right EHR is a hard thing to do. Getting the right information about an EHR and how it will work in your practice is critical. So, be sure to ask the right questions and don’t let crocodile salespeople waste your time and theirs. Make sure that they understand the specific needs of your practice before they start showing you how their EHR software solves those needs. You’ll both be better for it in the end.

Not long ago, American Medical News ran an article on training up medical practice staffers for EMR use. The piece concluded that while practices may save some bucks on the front end, they generally end up regretting it later.  An anecdote from the piece:

Nine months after All Island Gastroenterology and Liver Associates in Malverne, N.Y., went live with its electronic medical record system, practice administrator Michaela Faella realized things had not gone as smoothly as planned.

Even though the staff had used other health information technology systems for many years and considered itself tech-savvy, it had taken everyone six months to learn how to use the new EMR system. Several months later, the staff still had not become proficient at it.

The problem was not with the staff, but that the practice cut training short to save time and money. “Training was not placed high on the priority list, and we paid the price for it,” Faella said.

As the piece notes, many practices assume that the training bundled into the cost of their new EMR will meet their needs, and find out to their regret that this isn’t the case.  (In fact, I’d argue that this is more the rule than the exception, based on anecdotes I hear in the field and in conversations with physicians.)

A consultant quoted in the piece suggests that practices should consider three main issues when planning for training:

1) How much data they’ll be dealing with, which can vary greatly depending on whether all data is imported in advance or done patient by patient

2) Whether the practice will be integrating new systems into the EMR, such as e-prescribing, or conversely, adding an EMR to existing systems

3) Whether using the EMR will call for using new hardware such as tablet computers

Personally, I’m not satisfied by that list at all.

What about, first and foremost, assessing the staff’s existing skills more precisely, walking staffers through the various layers of the EMR on a daily basis, forming teams of superusers within the organization to help the less skilled and taking steps to be sure EMR problems don’t interrupt critical functions (a backup/workaround plan for the short term)?

What do you think?  Does the list above cover the critical EMR practice integration issues?  Am I just being testy?

About the same time last month, I brought your guys some unwelcome news – that physician access to electronic records perhaps doesn’t reduce the number of tests subsequently ordered, and hence doesn’t reduce healthcare costs as much as previously thought.

Except that maybe it does. At least that’s according to an article in Chicago Tribune that summarizes the findings of a study by Partners Healthcare, and a research letter published in the Archives of Internal Medicine (full text, PDF).

According to the study:
- It looked at health information exchange and test data between Mass. General Hospital and Brigham and Women’s over a 5 year period from Jan. 1, 1999 to Dec. 31, 2004.
- The study looked at 117,606 patients during this period. Of these, 346 patients had recent off-site tests, of which 44 were done prior to the HIE rollout.
- The study found that for patients with recent off-site tests, there was a 49% reduction in number of tests ordered.
In number terms, the number of tests ordered per person reduced from 7 in 1999 to 4 in 2004.
- There was however a slight increase in number of tests ordered for the population that didn’t have any prior testing done during the same time period – increasing from 5 per person to 6 per person.

These findings directly contradict the Health Affairs study that I mentioned earlier. The Chicago Tribune article has a little researchers-play-nice subsection at the end where the Health Affairs and Partners researchers try to interpret each other’s contradictory results.

If I may add my 0.02:
- Even though the Partners study follows a larger population of patients, the data that is used to calculate the reduction (346 and 44) is way too small
- The Health Affairs studied some 28,000 patients spread across 1,187 doctor’s offices, while the Partners study followed a larger population of patients at two huge Mass. hospitals that entered into a partnership with each other.

While this not directly discounting anything each group has found, I would think the HA study is more representative of what’s going on in different parts of the country, where doctors are using different (in capability/costs) EMRs and labs to get their results. In Partners case there may well be a tacit agreement on EMR brand, or even tacit trust between the labs/facilities that each hospital uses.

Very interesting though, and I’d really love to see what else comes out on EMR and healthcare costs.

Today I happened to meet with someone who was working a Las Vegas job fair. It was convenient for me to stop by while he was there, so I did so we could talk business. I’ll be honest that it bothered me a little bit personally to see the hundreds of people standing in line waiting to enter the job fair. Sure I’d seen and heard the reports of the 5000 people who showed up for 750 jobs. Although, it’s quite a different thing to see it first hand. Thankfully, I had my business discussion and left before I had to hear the hard stories that I’m sure many of them could share. Then again, I’m sure I would have also seen some amazing optimism and excitement from those looking to land a job to change their life.

On my drive home, I couldn’t help but think about the healthcare IT job situation. We’ve often written about the shortage of qualified healthcare IT & EHR talent to be able to service the onslaught of EHR software that we are seeing right now. Even for EHR vendors it’s a bit of a dog fight to get the very best people to work for them. Yet, I’ve also heard on EMR Thoughts from far too many healthcare IT certificate program students that can’t find a job. I’m not going to lie to say it makes my heart break. I do what I can and refer them to people I know who help with this stuff for a living, but it’s hard.

I think Jennifer Dennard must feel very similar to me since she’s written on the healthcare IT Worforce development and social media resources for healthcare IT job seekers to just name a few of her posts on the subject. It’s just a hard contrast for me to see hospitals and other healthcare related companies that can’t find qualified people and so many people still without jobs.

I’m not sure how many people know that I have an EMR and EHR job board. It’s not a real big thing, but it has a ton of different EMR, EHR, HIPAA, and Healthcare IT related jobs posted there. Here are a few that were posted specifically for the EMR and EHR community:
EMR Software Programmer
Director, HIPAA Compliance
Ambulatory EMR Server Administrator

The jobs listed above appear in the sidebar of many of the Healthcare Scene websites. Hopefully this is one small way to help both EHR and Healthcare companies find qualified talent and help those searching for a job in healthcare IT learn more about the needs and open jobs.

Given the pressure to produce, produce, produce, most doctors squeeze far more patients into their day than they’d prefer, and often, the endless rush leads to many clerical mistakes. In the emergency department, the problem is even worse, as EDs handle immense, variable volumes of encounters which make it hard to allocate staff to meet patient care needs, much less check basic patient demographic and personal data for accuracy.

In both environments, it’s easy for patient name misspellings or identity mismatches to slip by. In fact, according to vendor MiddleGate Med, fact-checking and finding say, updated addresses for clients can be so taxing that many hospitals simply give up and send out bills which patients never see. This costs U.S. hospitals $30 billion per year, according to the company.

Right, hospitals write off more then 12 percent of all revenue on bad debt, according to some researchers. “That means they’ve already tried to clean up their database and get this right, and they haven’t managed to change it,” said one hospital executive.

MiddleGate’s new product, IdentiCare, is designed to help hospitals verify patient information quickly and accurately.  It comes as Web-based system, which then ties into the hospital database through an HL7 interface.  ”We just want to make sure that the hospital has current and accurate information on them so you can get bills out of A/R.”

Another benefit, which MiddleGate doesn’t stress (but should) is that better patient identification techniques can help make sure that hospitals meet the FTC’s Red Flag rules requirements, which are designed to prevent medical identity theft.  Since hospitals aren’t used to following the standards set for typical creditors, any help here is welcome, no?

All that being said, has MiddleGate taken the right approach to closing leaks in the hospital revenue cycle?  Are there other pressure points which are equally important in improving hospital collections and profitability? (For example, might it be better spending time on how to streamline online communication, especially rapid claim adjudication, from the inarguably solvent carriers rather than chase down $20 co-pays?)  What do you think?

P.S.: By the way, a former client of mine estimates that if you don’t collect the co-pay before the patient leaves your office or ED, much less bill them accurately and quickly, less than 20 percent will ever pay at all.  I can’t vouch for that number, but my guess is that the CEO I worked with is right.  But I’ll share more of his conclusions in another piece.

I got just a glimpse yesterday of what clinicians must feel like when they log into an EMR for the first time – giddy with anticipation, hopeful that its use will ultimately lead to better patient outcomes and easier workflows for all. On the flipside, there was also frustration, impatience, and a bit of confusion.

Just before bedtime, I fired up Calorie Counter, my newest iPad app. As with any community you join, I first had to fill out a member profile, which took some time. I then had to learn through trial and error how to navigate through the program – search for, find and choose the foods I had eaten earlier that day, make adjustments for portion sizes, then log the data. The app’s drop-down menus included some of the foods I ate, but not all. “How do I add foods to the stock menu?” I wondered, thinking at the same time that this must be what doctors feel like when they can’t find what they need in an EMR.

It didn’t take long, and I’m sure now that I’ve at least done it once, future data entry will be more intuitive, and quicker. I do wonder about the rate of retention for this type of app, though. Do people stick with it for more than a few days or weeks?

I’ll have to either keep a running paper list of the foods I eat throughout the day, or bring my iPad with me wherever I go in order to log my calories. I was bummed that I couldn’t find this particular app for both the iPad and iPhone. (Those that were developed for both just didn’t seem to be as robust.) Perhaps this twinge of disappointment has been felt by doctors who have fallen in love with their new EMR, only to realize they can’t access it via their chosen mobile device.

It will take dedication on my part to keep up with daily logging of calories and activity, but I am convinced it will be worth it. After just one day, I’ve already had a nutritional wake-up call: Just seeing how much cheese I eat has made me decide to cut back before bathing-suit weather.

The beauty of the app isn’t the comprehensive list of foods already plugged in from which to choose from, but the calorie recommendations it makes based on members’ profiles (weight/height/activity level/age/gender, etc.) and the analytics that will result after I have a few days/weeks/months logged. Patterns will emerge that will give me a clearer picture of my diet – foods I should keep eating, those I should eat in moderation, and those I should avoid all together as long as I’m trying to reach a certain daily caloric intake. Not quite as important, but still similar in my mind to the aggregating power EMRs have when it comes to clinical data.

Other than keeping up with the daily log, I also have the option of joining the Calorie Counter community on Facebook, and I think there’s a brief tutorial out there I can take a look at. Depending on my time available, I may not do either – a course of action I’m sure a few doctors also opt to take with their EMRs, which I assume is ultimately detrimental to the results they’ll see with the technology.

In addition to trying to get a bit healthier, I’m overcoming my resistance to change (as if I really want to eat less cheese!), which as my colleague John pointed out in a recent post at EMRandHIPAA.com, is “the number one reason doctors aren’t adopting EHR software.”

But change is usually good, and as John also points out, “resistance to change is going to be the reason why EHR adoption will become the norm.” I’ll let you click over to his post to find out why. In the meantime, I’m going to try and resist the bagel with cream cheese that seems to be calling my name from the kitchen.