Free EMR Newsletter Want to receive the latest news on EMR, Meaningful Use, ARRA and Healthcare IT sent straight to your email? Join thousands of healthcare pros who subscribe to EMR and EHR for FREE!

One Example Of An Enterprise Telehealth System

Posted on August 30, 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.

While there’s a lot of talk about how telehealth visits need to be integrated with EMRs, I’m not aware of any well thought-out model for doing so. In the absence of such standardized models, I thought it worth looking at the approach taken by American Well, one of a growing list of telehealth firms which are not owned by a pre-existing provider organization. (Other examples of such telemedicine companies include MD Live, Teladoc and Doctor on Demand.)

American Well is now working with more than 170 health plans and health systems to streamline and integrate the telehealth process with provider workflows. To support these partners, it has created an enterprise telehealth platform designed to connect with providers’ clinical information systems, according to Craig Bagley, director of sales engineering for the firm.

Bagley, who recently hosted a webinar on EMR/telehealth integration for AW, said its system was designed to let providers offer telehealth consults labeled with their own brand name. Using its system, patients move through as follows, he said:

  • First, new patients sign up and enter their insurance information and demographics, which are entered into AW’s system.
  • Next, they are automatically connected to the provider’s EMR system. At that point, they can review their clinical history, schedule visits and get notifications. They can also contact their doctor(s).
  • At this point, they enter the telehealth system’s virtual “waiting room.” Behind the scenes, doctors can view the patients who are in the waiting room, and if they click on a patient name, they can review patient information collected from the EMR, as well as the reason for the visit.

Now, I’m not presenting this model as perfect. Ultimately, providers will need their EMR vendors to support virtual visits directly, and find ways to characterize and store the video content generated by such visits as well. This is becoming steadily more important as telemedicine deployments hit their stride in provider organizations.

True, it looks like AW’s approach helps providers move in this direction, but only somewhat. While it may do a good job of connecting patients and physicians to existing clinical information, it doesn’t sound as though it actually does “integrate” notes from the telehealth consult in any meaningful way.

Not only that, there are definitely security questions that might arise when considering a rollout of this technology. To be fair, I’m not privy to the details of how AW’s platform is deployed, but there’s always HIPAA concerns that come up when an outside vendor like AW interacts with your EMR. Of course, you may be handing off clinical information to far less healthcare-focused vendors under some business associate contracts, but still, it’s a consideration.

And no matter how elegant AW’s workaround is – if “workaround” is a fair word – it’s still not enough yet. It’s going to be a while before players in this category serve as any kind of a substitute for EMR-based conferencing technology which can document such visits dynamically.

Nonetheless, I was interested to see where AW is headed. It looks like we’re just at the start of the enterprise-level telemedicine system, but it’s still a much-needed step.

MIPS Performance Categories and the MIPS Composite Score – MACRA Monday

Posted on August 29, 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.

As mentioned, next up we’re going to cover the 4 MIPS performance categories. Each of these categories are listed in the graphic below and will contribute to what is called your MIPS Composite Score.
MIPS Performance Categories

At first, these four new category names might be confusing, but here’s the translation you need to know for each category that will illustrate how MIPS really just rolls up three existing programs and adds one new program as follows:

  • Quality Performance Category – PQRS Replacement
  • Resource Use (Cost) Category – Value Based Modifier Replacement
  • Clinical Practice Improvement Activities Category – New
  • Advancing Information Category – Meaningful Use (EHR Incentive Program) Replacement

I’m not sure why the government thought we needed new names for each program, but they decided that was the best route. Maybe they wanted to leave the past behind and move forward without the baggage that exists with the previous names. Regardless, 3 of the 4 MIPS performance categories are programs that most of you probably already know about. There are slight changes with each of the 3 programs (PQRS, Value Based Modifier, and Meaningful Use) under MIPS which we’ll cover in a future part of this series. In most cases, each of those 3 programs was simplified under MIPS.

In order to determine your MIPS Composite Score, each provider will receive a score on a 100 point scale. Each of the 4 performance categories contributes to the 100 point scale and have been weighted as follows:
MIPS Performance Categories Weighting - Year 1

Yes, that means that if you are already doing PQRS (Quality) and Meaningful Use (Advancing Care Information), then you’ll be well positioned for 75% of the points for the MIPS composite score. If you’re only doing PQRS, you’re still in a position to get 50% of the MIPS composite score without too many changes from what you’re doing today. Of course, that assumes you continue those efforts under the modified MIPS requirements in 2017. If you’re not doing PQRS, meaningful use, or value based reimbursement, then you’ll have some serious work to do in order to not be penalized under MIPS.

Once CMS calculates your MIPS composite score, they’ll compare that score against the threshold to determine the adjustment received. Speaking hypothetically, let’s say the MIPS threshold was set at 64 and your MIPS Composite Score was 64. Then, you wouldn’t receive an increase or decrease to your reimbursement. Of course, if you scored above a 64, then you’d receive a bonus payment. If you score below a 64, you’d be penalized.

CMS has said they intend to publish the benchmarks and thresholds prior to 2017. Given the short time frame, this is going to be a real challenge and is likely another reason why it’s possible that MACRA could be delayed. However, it’s good to know that they’re planning to publish the MIPS threshold in advance so practices can plan accordingly. The great part of this scoring system is that unlike meaningful use which was all or nothing, this scoring gives providers credit for partial performance.

It’s worth also noting that the MACRA program must be budget neutral. So, if more providers are getting penalized than are getting incentives, the HHS Secretary will use a scaling factor to increase the incentives paid to participating providers that qualify. HHS also has $500 million available separate from the normal incentive payments to reward exceptional performance. I have yet to see details on this, but it will be interesting to watch and see what they use as the criteria for exceptional performance. I wonder how much higher of a composite score you’ll need above the threshold to be considered an exceptional performer.

Next week we’ll start going through each of the performance categories at a high level and discuss the changes made to each program that’s been rolled into MIPS and the new Clinical Practice Improvement Activities category.

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

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.

What Do Med Students Need To Know About EMRs?

Posted on August 16, 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.

Recently, I was asked to write an introduction to EMRs, focusing on what medical students needed to know in preparation for their future careers. This actually turned out to be a very interesting exercise, as it called for balancing history with the future, challenges with benefits and predictable future developments with some very interesting possibilities. Put another way, the exercise reminded me that any attempt to “explain” EMR technology calls for some fancy dancing.

Here’s some of the questions I tackled:

  • Do future doctors need to know more about how EMRs function today, or how they should probably function to support increasingly important patient management approaches like population health?
  • Do med students need to understand major technical discussions – such as the benefits of FHIR or how to wrangle Big Data – to perform as doctors? If so, how much detail is helpful?
  • How important is it to prepare med students to understand the role of data generated outside of traditional patient care settings, such as wearables data, remote monitoring and telemedicine consults? What do they need to know to prepare for the gradual integration of such data?
  • What skills, attitudes and practices will help physician trainees make the best use of EMRs and ancillary systems? And how should they obtain that knowledge?

These questions are thornier than they may appear at first glance, in part because there no hard-and-fast standards in place as to how doctors who’ve never run a practice on paper charts should conduct themselves. While there have been endless discussions about how to help doctors adopt an EMR for the first time, or switch from one to the other, I’m not aware of a mature set of best practices available to med students on how next-gen, health IT-assisted practices should function.

Certainly, offering med school trainees a look at the history of EMRs makes sense, as understanding the reasons early innovators developed the first systems offers some interesting insights. And introducing soon-to-be physicians to the benefits of wearable or remote monitoring data makes sense. Physicians will almost certainly improve the care they deliver by understanding EMRs then, now and their near-term evolution as data sources.

On the other hand, I’m not sure it makes sense to indoctrinate med students in today’s take on evolving topics like population health management or interoperability via FHIR. These paradigms are evolving so rapidly that pinning down a set of teachable ideas may be a disservice to these students.

Morever, telling students how to think about EMRs, or articulating what skills are needed to manage them, might actually be a bad idea. I’m optimistic enough to think that now that the initial adoption frenzy funded by HITECH is over, EMRs will become far more usable and physician-shapeable over the next few years, allowing new docs to adapt the tool to them rather than adapt to the tool.

All that being said, educating med students on EMRs and health IT ancillary tools is a great idea. I just hope that such training encourages them to keep learning well after the training is over.

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.