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!

What Happens in Vegas … will be Tweeted During #HITMC

And the excitement in healthcare IT continues. Whether you’re worried about ICD-10, our government’s proclivity for voice votes, or the lack of response from one industry group or another, there has been no shortage of water cooler topics this week.

The impending Healthcare IT Marketing & PR Conference is at the top of my list when it comes to discussion topics. Regular readers of HealthcareScene.com may already know that it kicks off Monday, April 7, in Las Vegas. I’m looking forward to networking with many of my #HITsm friends, and speaking on a panel about social media ROI with several leading experts. I find tremendous value in social networking before, during and after events like this, so I thought I’d offer a list of speakers’ Twitter handles to help those of us getting ready for Vegas jump into conversations early. (You may also consider it my handy list of #FF mentions.) For those not attending, do yourself a favor and follow the #HITMC hashtag over the next several days and register for the live video stream (Note: It’s Free). I will definitely try to cover session takeaways via Twitter on @JennDennard.

Shahid Shah@ShahidNShah

John Lynn@techguy and @ehrandhit

Warren Whitlock@WarrenWhitlock

Julia Goebel - @goebeljulia

Marcy Fleisher@fleish

Jodi Amendolajamendola

Kate Ottavio@kottavio

Sam Stern@mHealthMarketer

Mandi Bishop@mandibpro

Joy DiNaro@TheSocialJoy

Cari McLean@carimclean

Dr. Patricia Salber@docweighsin

Scott Collins@sscottcollins

Tim Tyrell-Smith@TimsStrategy

Michelle Boucher@medmastermind

Sunny Tara - @SunnyTaraVegas

Christine Slocumb@CLSlocumb

Shane Pilcher - @spilcher

Thomas Knoll@thomasknoll

Chandresh Shah@chandresh27

Stacy Goebel@stacygoebel

Beth Friedman@HealthITPR

Erin Wabol - @HealthITMktg

Brad Dodge@braddodge

Don Seamons@donseamons

Kristine Schachinger - @schachin

Jeff Walker@ContentCarnivor

Check out the conference website for more details about what the experts above will be speaking about. See you in Vegas, or via the #HITMC hashtag!

April 4, 2014 I Written By

As Social Marketing Director at Billian, Jennifer Dennard is responsible for the continuing development and implementation of the company's social media strategies for Billian's HealthDATA and Porter Research. She is a regular contributor to a number of healthcare blogs and currently manages social marketing channels for the Health IT Leadership Summit and Technology Association of Georgia’s Health Society. You can find her on Twitter @JennDennard.

Barriers and Pathways to Healthcare IT

The following is a guest blog post by Andy Oram, writer and editor at O’Reilly Media.

Those who follow health IT for a long time can easily oscillate between overenthusiasm and despair. Electronic records will bring us into the 21st century! No, electronic records just introduce complexity and frustration! Big data will find new cures! No, our data’s no good!

Indeed, a vast gulf looms between the demands that health reformers make on information technology and the actual status of that technology. But if we direct a steady vision at what’s available to us and what it provides, we can plan a path to the future.

This is the goal of a report I recently wrote for O’Reilly Media: The Information Technology Fix for Health: Barriers and Pathways to the Use of Information Technology for Better Health Care. As part of a comprehensive overview, it dissects the issues on some topics that often appear on this blog:

  • Patient empowerment. After looking at the various contortions hospitals go through to provide portals and pump up patients’ interest in following treatment regimes, I conclude that the best way to get patients involved in their care is to leave their data in their own hands.

    But wresting data out of doctors’ grip will be heavy exercise. Well aware that previous attempts at giving patients control over data (Google Health and Microsoft HealthVault) have shriveled up, and that new efforts by Box and Apple seem to be taking the same path, I suggest a way forward by encouraging people to collect health data that will hopefully become indispensable to doctors.

  • What’s wrong with current EHRs? We know that doctors grab any opportunity handed them to complain about their EHRs. Even more distressing, the research bears out their pique; my report cites examples from the medical literature finding only scattered benefits from EHRs. Sometimes their opacity and awkward interfaces contribute to horrific medical errors.

    One might think that nobody is actually getting what they want from their EHR, but in fact plenty of providers are quietly enjoying their records–success has a lot to do with their preparation and whether they take the extra effort to make effective use of data gathered by the EHRs.

    New interfaces such as tablets, convenient storage in the cloud, and agile programming may be producing a new crop of EHRs that will meet the needs of more clinicians. But open source software would lead to the most widespread advances, enabling more customization and a better response to bug reports.

  • The viability of ACOs. Accountable care, pretty much a synonym for the notion of pay-for-value, is on the agendas of nearly all payers, from CMS on down. It certainly makes sense to combine data and keep close tabs on people as they move from one institution to another. But it’s really a job to be done on a national level, or at least a regional one. Can a loose collection of hospitals and related institutions muster the data and the resources to analyze patient data, created viable health information exchanges, and perform data analysis? I don’t think the current crop of ACOs will meet their goals, but they’ll provide valuable insights while they try.

  • Can standards such as ICD-10 improve the data we collect? What about the promise of new standards, such as FHIR? I’m a big believer in standards, but I’ve seen enough of them fail to know they must be simple, lithe, and unambiguous.

    That doesn’t characterize ICD-10 to be sure. Perhaps it does pretty well in the unambiguous department. But like most classifications, it’s a weak representation of the real world: a crude hierarchy trying to reflect many vectors of interlocking effects–for instance, the various complications associated with diabetes. And although ICD-10 may lead to more precise records, the cost of conversion is so burdensome that the American Medical Association has asked the government to just let doctors spend their money on more pressing needs. The conversion has also been ruthlessly criticized on the EMR & EHR site.

    FHIR is a radical change of direction for the HL7 standards body. For the first time, a standard is being built from the ground up to be web-friendly as well as sleek. It currently looks like a replacement for C-CDA, so I hope it is extended to hold patient-generated data. What we don’t need is another hundred vendors going off to create divergent formats.

    For real innovation, we should look to the open SMART Platform. Its cleverness is that it functions as a one-way valve channeling data from silo’d EHRs at health providers to patient-controlled sites.

We need to know what current systems are capable of contributing to innovative health solutions, and when to enhance what we have versus seeking a totally disruptive solution. I look forward to more discussion of these trends. Comment on this article, write your own articles on the topics in the report, and if you like, comment to me privately by writing to the infofix alias @ the oreilly.com domain.

April 3, 2014 I Written By

Planning a Successful Patient Engagement Strategy

On social media and at events like HIMSS, we hear a lot of discussion about this new trend called patient engagement. While there are certainly new tools to help an organization engage the patient, I don’t think it’s fair to say that patient engagement is a new strategy. Patient engagement has always been considered a good thing in practices and healthcare organizations.

The challenge is that we’ve never rewarded those who actually did engage the patient. Healthcare reimbursement has actually discouraged patient engagement despite providers natural desire to want to engage the patient. Every doctor I know would love to sit down with a patient for an hour and really engage them in their health. Unfortunately, we don’t pay them to do this.

While I don’t think we’ll see an over night transition to hour long visits with our doctors, the move to value based reimbursement will finally start rewarding providers who engage deeply with their patients.

The next question doctors should ask is where to start when it comes to patient engagement in this changing landscape. This whitepaper on 5 Elements of a Successful Patient Engagement Strategy would be a good place to start. It provides a realistic strategy for your organization to consider.

The whitepaper also has this great quote from Leonard Kish:

“If patient engagement were a drug, it would be the blockbuster drug of the century and malpractice not to use it.”

Those practices that choose to not have a patient engagement strategy are going to fall behind. This won’t be an issue right away, but it will catch up to many practices who don’t see the coming change.

April 2, 2014 I Written By

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

Reply to Dr. Jacob Reider on NIST Dissects Workflow: Is Anyone Biting?

One comment on my latest post, NIST Dissects Workflow: Is Anyone Biting?, deserves a more than casual reply.

Here’s the comment from Jacob Reider (Note: Dr. Reider is ONC’s Acting Principle Deputy National Coordinator and Chief Medical Officer. He has made major contributions to the HIT field and is one of its significant advocates.)

Carl, ONC’s UCD requirement references ISO 9241–11, ISO 13407, ISO 16982, NISTIR 7741, ISO/IEC 62366 and ISO 9241–210 as appropriate UCD processes.

We also require summative testing as defined in NISTIR 7742.

Might “Refuses to incorporate NIST recommendations” be a bit of an overstatement?

We solicited public comment in our proposed rule for 2015 certification and would welcome specific suggestions for how we can/should improve user experience of health IT products for efficiency and safety.

Dr. Reider, thank you for your comment – it certainly falls into the category of you never know who’s reading.

Let’stake a look at your last comment first, “Might ‘Refuses to incorporate NIST recommendations’ be a bit of an overstatement?”

Obviously, I don’t think so, but I am not alone.

I based my comment on ONC’s statement in its rule making that refers to NIST’s usability protocols. It says:

While valid and reliable usability measurements exist, including those specified in NISTIR 7804 “Technical Evaluation, Testing and Validation of the Usability of Electronic Health Records,” (21) we are concerned that it would be inappropriate at this juncture for ONC to seek to measure EHR technology in this way.

Sounds like a rejection to me, however, don’t take my word. Here’s the AMA’s response to this decision. First, they demur and quote ONC:

We disagree with ONC’s assertion in the Version 2014 final rule that, “[w]hile valid and reliable usability measurements exist, including those specified in NISTIR 7804 ‘‘Technical Evaluation, Testing and Validation of the Usability of Electronic Health Records,’’ we expressed that it would be inappropriate for ONC to seek to measure EHR technology in this way.”

It then says:

To the contrary, we believe that it is incumbent upon ONC to include more robust usability criteria in the certification process.  The incentive program has certainly spurred aggressive EHR uptake but has done so through an artificial and non-traditional marketplace.  As a consumer, the physician’s choice of products is limited not only by those EHRs that are certified but also by the constraint that all of these products are driven by federal criteria.  The AMA made several detailed recommendations for improving Version 2014 certification in our Stage 2 comment letter, which were not adopted, but still hold true, and we recommend ONC consider them for the next version.  Testimony of AMA’s Health IT Policy Committee’s Workgroups on Certification/Adoption and Implementation, July 23, 2013, pp. 5-6

I recognize that ONC says that it may consider the protocols in the future. Nevertheless, I think the plain English term rejected fits.

In the first part of his statement, Dr. Reider cites several ISO standards. With the exception of the Summative Testing, all of these have been referred to, but none have been adopted. Reference to a standard is not sufficient for its inclusion under the operation of the federal Administrative Procedure Act, which governs all federal agency rulemaking. In other words, these standards are important, but ONC simply calls them out for attention, nothing more.

I think two factors are at work in ONC’s reluctance to include the NIST usability protocols. The first is that the vendors are adamantly opposed to having them mandated. However, I believe there is a way around that objection.

As I have argued before, ONC could tell vendors that their products will be subject to a TURF based review of their product for compliance and that the results would be made public. That would give users a way to judge a product for suitability to their purpose on a uniform basis. Thus, users looking at the results could determine for themselves whether or not one or more non compliance was important to them, but at least they would have a common way to look at candidate EHRs, something they cannot do now , nor under ONC’s proposed approach.

The other factor is more complex and goes to the nature of ONC’s mission. ONC is both the advocate and the standards maker for HIT. In that, it is similar to the FAA, which is vested with both promoting and regulating US aviation.

It’s well established that the FAA’s dual role is a major problem. It’s hard to be a cheerleader for an industry and make it toe the line.

With the FAA, its dual mandate is exacerbated when the highly respected NTSB investigates an incident and makes recommendations. The FAA, acting as industry friend, often defers NTSB’s authoritative and reasonable recommendations to the public’s determent.

I believe that something similar is going on with ONC. NIST’s relationship to ONC is roughly analogous to that of the NTSB’s to the FAA.

NIST is not an investigative agency, but it is the federal government’s standards and operations authority. It isn’t infallible. However, ONC dismissing NIST’s usability protocols, in one word, inappropriate. It did this without explanation or analysis (at least none that they’ve shared). In my view, that’s really inappropriate.

ONC has a problem. It’s operating the way it was intended, but that’s not what patients and practioners need. To continue the aviation analogy, ONC needs to straighten up and fly right.

March 31, 2014 I Written By

When Carl Bergman’s not 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.

Time Using EMR, EMR Copy and Paste, and Larry Page on EMR


The good news is that EMRs will get better.


I’ve often said that it’s not copy and paste that’s bad. It’s how you use it. Many use it poorly which leads to bad data.


This whole interview with Larry (Founder of Google) is great. Plus, I adore Charlie Rose interviews.

March 30, 2014 I Written By

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

No Shortage of Excitement (This Week) in Healthcare IT

When I began contemplating the subject of this blog earlier in the week, I thought I’d make room for thoughts on recent improvements in EMR adoption in the small practice and physician community, and the general state of optimism and enthusiasm some op-ed pieces would have us believe is finally taking hold of the industry. But then came along the potential delay of ICD-10, which also begs a quick comment or two.

A bill that included an effort to delay the ICD-10 compliance date a full year was passed, but only after partisan drama over the fact that legislators received the proposed bill just a day before the vote on it was to take place. I tend to turn to AHIMA on ICD-10 matters, and its official stance is fairly obvious:

ahimaicd10tweet

Its reasoning is similar to that of the Coalition for ICD-10, which in a letter to the CMS, stated: “ … any further delay or deviation from the October 1, 2014, compliance date would be disruptive and costly for health care delivery innovation, payment reform, public health, and health care spending. By allowing for greater coding accuracy and specificity, ICD-10 is key to collecting the information needed to implement health care delivery innovations such as patient-centered medical homes and value-based purchasing.

“Moreover, any further delays in adoption of ICD-10 in the U.S. will make it difficult to track new and emerging public health threats. The transition to ICD-10 is time sensitive because of the urgent need to keep up with tracking, identifying, and analyzing new medical services and treatments available to patients. Continued reliance on the increasingly outdated and insufficient ICD-9 coding system is not an option when considering the risk to public health.”

AHIMA has even started a campaign to encourage its constituents to email their senators to urge them to also vote no when it comes to delaying ICD-10. At the time of this writing, the Senate vote is not yet scheduled. I don’t feel the need to restate my support of no further delay. You can read it here.

With regard to the other hot news items of the week, I was intrigued by the findings of the SK&A survey, which found that the EMR adoption rate for single physician practices grew 11.4%. One reason SK&A gave in the survey analysis was due to the “availability of more than 450 different solutions to fit their practice needs, size and budget.” Call me crazy, but I’m willing to bet that many solutions will not exist in the next three to five years thanks to market consolidation. What will these physicians do when their EMR vendor closes up shop? Time will tell, I suppose.

March 28, 2014 I Written By

As Social Marketing Director at Billian, Jennifer Dennard is responsible for the continuing development and implementation of the company's social media strategies for Billian's HealthDATA and Porter Research. She is a regular contributor to a number of healthcare blogs and currently manages social marketing channels for the Health IT Leadership Summit and Technology Association of Georgia’s Health Society. You can find her on Twitter @JennDennard.

The Time Has Finally Come for MU, It Really Is Now or Never

The following is a guest blog post by Lea Chatham.
Lea Chatham

The healthcare industry has been talking about Meaningful Use (MU) for years now. The program started in 2011, but there were discussions and planning going on years before that. It’s become a ubiquitous topic in healthcare publications and blogs. So much so that many providers probably still think that they have time to decide if they are really going to attest or not.

The truth is that 2014 is last year to initiate participation for Medicare to receive incentive payments. To avoid the first adjustment of 1%, providers must attest for Stage 1, Year 1 no later than the third quarter of 2014 (July 1 – September 30, 2014). You can still start MU in future years to avoid additional penalties, but you won’t get any incentives and you will still have the 1% deduction on your Medicare Part B Claims starting in 2015. That penalty doesn’t go away if you start MU in 2015 or 2016.

What this means is that the estimated 40% of America’s physicians who don’t’ have an EHR and haven’t yet begun to attest for MU have a decision to make—now. And there are essentially three options:

  1. Choose an EHR and attest in 2014
  2. Accept the penalty (which increases each year)
  3. Request a hardship exception.

Here is what you need to know about each of these options so you can make the right choice for your practice.

Choose an EHR & Attest

Over $16 billion in incentives has been paid out to providers who have been attesting for MU. If you start in 2014, you’ll still get $24,000 over three years for your efforts. You’ll also avoid the penalties, which start with 1% in 2015 and increase each year for a minimum of three years. The larger your Medicare pool of patients, the more sense this makes financially.

If you are going to adopt an EHR now, be sure to choose the right solution for your needs. Many of the providers who have not yet implemented an EHR, are small practices (10 or fewer providers). According to a survey conducted in January by SK&A, the smaller the practice, the lower the adoption rate. Small, independent practices don’t have staff, time, or money to waste. So it has to be right the first time. Take these factors into consideration:

  1. Cost: There are now free and low cost EHRs that can offer almost any specialty the tools they need to reap the benefits of an EHR.
  2. Cloud-based and Mobile: Its 2014, don’t choose an EHR unless it offers anytime, anywhere access and true mobile connectivity.
  3. 2014 Edition Certified for MU: As of January 1, 2014, you need a 2014 Edition certified EHR to attest for MU. Only about 12% of complete EHRs have this certification, which narrows the field.
  4. Total Integration: You can get more from your EHR if it is fully integrated with your practice management and billing system. You can meet MU and streamline many other functions. As a bonus it can actually increase both charges and collections. A UBM white paper showed that the average increase in revenue was $33,000 per FTE provider per year!

Accept the Penalty

So you are thinking you’ll just take the penalty. This may be because you don’t serve Medicare patients or at least not that many. It could also be that you are planning to retire soon and don’t think you’ll be around in another couple of years. But consider this, with MU, PQRS, and eRx penalties, it reaches over 10% in total adjustments to your Medicare Part B claims in five years. If you do start seeing more Medicare patients (as your patients age) or you don’t retire, 10% is nothing to sneeze at. If you are a solo doc and you generate an average of $30,000 a month and about 30% of your patients have Medicare, that’s $10,000 a month. A 10% cut adds up to $12,000 a year. To make that up, you would have to conduct about 100-120 more patient visits a year (if your average visit reimbursement is around $100-150).

And here is something else to consider. Perhaps you are willing to take that hit, and you are sure that you don’t want to attest for MU. But does that mean you don’t need to implement an EHR? Not these days. Patient expectations are changing, and to stay competitive you need to meet those expectations. A study conducted by the Optum Institute showed that 62% of patients want to correspond with their physician online and 75% are willing to view their medical records online. Another survey conducted by Deloitte showed that two-thirds of patient would consider switching to a physician who offers secure access to medical records online. You need patients to stay in business so take their changing needs seriously or you may struggle to stay competitive in changing times.

Request a Hardship Exception

The first thing that needs to be said here is that not everyone can apply for a hardship exception. If you’d like to attest for MU, but need more time AND you meet one or more of the criteria, then you should definitely consider this option. This is a summary, check the CMS tipsheet to find out more:

  1. Your area lacks the necessary infrastructure (i.e., no broadband)
  2. You’re a new provider
  3. Natural disaster or other unforeseen barrier
  4. Lack of face-to-face interaction with patients
  5. Practice in multiple locations
  6. EHR vendor issues (i.e., your current vendor was unable to certify for 2014 edition)

For most providers who are practicing full time in a single location and have not yet chosen an EHR, these exceptions won’t apply. This leaves you with choices and one and two above. You will still need to decide if you want to attest or not.

If you are still on the fence, consider this… Beyond MU, practices are facing the ICD-10 transition and a changing reimbursement landscape with ongoing reform from of the Affordable Care Act (ACA). Technology can be a very effective tool to help you manage these changes and turn this set of challenges into an opportunity to optimize your practice and position your business for success no matter what comes your way.


About Lea Chatham

Lea Chatham is the Content Expert at Kareo, responsible for developing educational resources to help small medical practices improve their businesses. She joined Kareo after working at a small integrated health system for over five years developing marketing and educational tools and events for patients. Prior to that, Lea was a marketing coordinator for Medical Manager Health Systems, WebMD Practice Services, Emdeon, and Sage Software. She specializes in simplifying information about healthcare and healthcare technology for physicians, practice staff, and patients.

March 27, 2014 I Written By

NIST Dissects Workflow: Is Anyone Biting?

Psst. Hey, Buddy, wanna see an EHR, visit’s workflow? Here it is, thanks to the National Institutes of Standards and Technology’s (NIST) new report, NISTIR 7988, Integrating Electronic Health Records into Clinical Workflow, etc.

Returning Patient Ambulatory Workflow NIST

What It Represents

NIST wants to make EHRs usable and useful. It first took aim at patient safety EHR functions that endangered, confused users or were error prone. To counter these, it developed and recommended EHR usability protocols.

Now, in an extensive report, it’s tackled EHR workflow to determine where problems occur. The result is a comprehensive work with significant findings and recommendations. The question is: Is anyone listening?

NIST’s Analytical Approach

NIST decided to create a typical workflow by interviewing knowledgeable physicians, who it calls Subject Matter Experts, SMEs. The physicians had different specialties and used different EHRs, though who they were, NIST doesn’t say.

From their discussions, NIST’s analysts created the above chart, NIST’s Figure 2. NIST’s authors recognize that actual workflows will vary based on setting, sequences, staffing, etc., but that it provides a useful way to look at these issues.

What They Did With It

Working with their physicians, NIST’s analysts broke down the workflow into three sections: before, during and after the visit. Then, they broke down, or decomposed, each of those sections, like opening nested Russian dolls. For example, they segmented the physician’s encounter, below, and once again, broke each down into its functions.

Returning Patient, Physician Encounter - NIST

What They Found

It was at this stage the analysts found significant variations among the EHRs used by their physicians,

[T]here appeared to be high variation in whether and how the EHR was used during this period, how extensive each of the activities typically were for each SME, different based upon the type of patient, how complex the patient was, context of how busy the day was, and other factors. NSTIR 7988, p 18.

Despite these differences, the physicians identified two issues that crossed their EHRs:

  • Working Diagnoses. The physicians wanted systems that let them create a working diagnosis and modify it as they worked until they made a final diagnosis. Similarly, they wanted to be able to back up and make changes as needed, something current systems make hard.
  • Multiple Diagnoses. Diagnoses usually involve multiple causes, not single factors. They wanted their EHRs to support this.

These types of issues aren’t new to those familiar with EHR problems. What’s new is NIST, as an independent, scientific organization, defining, cataloguing and explaining them and their consequences.

What They Recommended

From this work, NIST’s analysts developed extensive and persuasive recommendations, in three categories:

  • EHR Functions
  • System Settings, and
  • System Supports

EHR Functions

NIST’s recommends reducing practitioner workload, while increasing their options and supports. For example, they suggest:

  • Workload Projections. Give practitioners a way to see their patient workloads in advance, so they can plan their work more effectively
  • Notes to Self. Let users create reminder notes about upcoming visit issues or to highlight significant ,patient information. These would be analogous to their hand written notes they used to put on paper charts.
  • Single Page Summaries. Create single page labs summaries rather than making users plow through long reports for new information.
  • Single Page Discharge Summaries. Eliminate excessive boiler plate with more intelligent and useful discharge sheets.
  • Highlight Time Critical Information. Segregate time critical information. Often they get mixed in with other notices where they may be overlooked or hard to find.
  • Allow Time Pressure Overrides. When time is critical, EHRs should allow skipping certain functions.
  • System Settings

NIST recommendations echo the familiar litany of issues that characterize poor implementations:

  • Allow Patient Eye Contact. Exam room designs should put the doctor and patient in a comfortable, direct relationship with the computer as a support.
  • Login Simplification. Allow continuous logins or otherwise cut down on constant login and outs.

System Supports

The physicians recognized they often caused workflow bottlenecks. NIST recommended off loading work to medical assistants, nurse practitioners, physician assistants, etc.. For example, physician assistants could draft predicted orders for routine situations for the physician to review and approve.

Progress Note Frustrations

In the thorny area of clinical documentation, the report details physician frustration with their EHRs. All experienced excessive or missing options, click option hell, excessive output, puzzling terms, etc. These were compounded by time consuming system steps that did not aid in diagnosis or solving patient problems. The report discusses their attempts at improving documentation:

Several of the SMEs had attempted and then abandoned strategies to increase the efficiency of documentation. One SME reported that copying and pasting and “smart text” where typing commands generate auto-text had a “vigilance problem.” The issue was that it would be too easy to put the wrong or outdated information in or in the wrong place and not detect it, and then someone later, including himself, could act on it not realizing that it was incorrect.

One physician described an attempt to use automated speech recognition for dictation for a patient with scleritis, which is inflammation of the white of the eye. He stopped using the software when what was documented in the note was “squirrel actress.”

Another SME described that colleagues relied upon medical assistants to draft the note and then completed it, but they did not like that approach because it was too tempting to rely upon what was typed without reviewing it, and he felt the medical knowledge level was not high enough for this task.

One SME described a reluctance to use any scribe, including a medical student, because the risk would be too high of misunderstanding and thus not correctly documenting the historical information, diagnosis, and treatment plan. This was particularly problematic if the physician had information from prior visits, which contributed to these elements, which were not discussed in detail during the visit. NSTIR 7988, p. 28

Coding their diagnoses into progress notes also came in for criticism:

All SMEs described frustration with requirements to enter information into progress notes, …, which were applied to the notes in order to have sufficient justification to receive reimbursement for services. Although all of the SMEs acknowledged the central importance of receiving reimbursement in order to function as a business, this information was often not important for clinical needs. NSTIR 7988, p. 28

Role Based Progress Note

Unlike other areas of the report, the doctors could not agree on what to do, nor does NIST offer any specific cures for documentation problems. Instead, NIST recommends using a new, role based, progress note:

[T]he progress note for a primary care physician would have a different view from a specialist such as a urologist physician, who might not need to see all of the information displayed to the primary care physician. Similarly, the view of the note for primary care providers could differ from the view of a billing and coding specialist. … NSTIR 7988, p. 28

Will ONC Respond?

In this and its prior reports, NIST covers a lot of EHR issues making sensible recommendations that not only improve functionality, but more importantly improve patient safety. However, NIST’s recommendations are just that. It’s not a regulatory agency, nor is supposed to be one. Instead, its role is to work with industry and experts to develop usable, practical approaches to tough technical, often safety related, problems. To its credit, it’s done this in a vast number of fields from airplane cockpits, nuclear reactors, and atomic clocks to bullet proof vests.

However, its EHR actions have not gained any noticeable traction. If any EHR vendor has implemented NIST’s usability protocols, they haven’t said so. They are not alone.

Notably ONC, one of NIST’s major EHR partners, refuses to incorporate any of NIST’s usability recommendations. Instead, ONC requires vendors to implement User Centered Design, but does not define it, letting each vendor do that for themselves.

NIST has many answers to common EHR workflow and usability problems. The question is, who will bring them to bear?

March 26, 2014 I Written By

When Carl Bergman’s not 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.

The Changing EHR and Health IT Landscape

We’re entering a really interesting period for healthcare IT. I’d say this is the start of a really big transition period for the EHR market. The government induced demand for EHR will end soon and we’ll see very different dynamics going forward. With that said, I think we’re about to enter one of the most exciting periods of healthcare IT ever. The wheat is going to be sifted from the chaff and the cream will rise to the top. We’re about to enter a phase where people are more worried about how to get the most out of their EHR versus getting an EHR.

This is what makes us most excited at EMR and EHR. We’re entering a really exciting time where I believe we’re going to see some amazing new EHR uses. We’ll do our best to continue keeping you up to date on the latest happenings in the EMR, EHR, and health IT worlds.

I’m excited to say that we just passed our 1200th blog post on EMRandEHR.com. What an amazing body of work that we’ve created on this site. We couldn’t have done it without the support of our readers and advertisers. I deeply appreciate both groups more than I can express in a blog post.

As we usually do every 6 months, I want to highlight the new and renewing advertisers. If you appreciate the content we create on EMRandEHR.com, then I hope you’ll take a second to browse through these companies which support the work we do.

New EMR and EHR Advertisers
VM Racks – If you’re looking for HIPAA compliant web hosting, you should check out VM Racks to see what they have to offer. They provide a managed services environment that many health IT companies will find interesting. The great part is that right now they’re offering a free 30 day trial of their HIPAA compliant web hosting. I can see a lot of health IT startup companies that could benefit from the 30 day free trial, but a 30 day free trial is great for anyone who wants to get a feel for how well their hosting works.

HealthFusion – If you’re looking for a 2014 Edition certified EHR, then take a look at HealthFusion’s MediTouch EHR. In fact, they were one of the first to be 2014 Edition certified since they completed it on June 13th, 2013. They offer a number of interesting whitepapers like this one on “12 questions to ask before buying EHR software.”

Colocation America – I’ve written many times about the shift away from built in data centers or server rooms to outside data centers. Colocation America offers a variety of data center hosting options across the country and a number of HIPAA compliant hosting options.

Modernizing Medicine – I’ve written previously about the Modernizing Medicine approach to ICD-10 and their unique EHR interface. If you are looking for an EMR for dermatology, opthamology, otolaryngology, plastic surgery, orthopedics, or cosmetic surgery, then take a look at what Modernizing Medicine has created.

Renewing EMR and EHR Advertisers
I can’t thank the following advertisers enough for their support. As you can see, many of them have been supporting EMR and EHR for 2 or 3 years. I’m glad they still see value in supporting the work we do.
Ambir – Advertiser since 1/2010
Cerner – Advertiser since 9/2011
Canon – Advertiser since 10/2012
gMed – Advertiser since 8/2013

Check out our healthcare IT advertising page for more information on supporting EMRandEHR.com. Plus, this is the final week to register for the Health IT Marketing and PR Conference. If you’re on the fence about attending the conference, go and register now and you won’t be disappointed. We have two days with amazing content and great networking with attendees.

March 25, 2014 I Written By

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

Why ICD-10?

At least half a dozen folks have asked me to explain why HHS is mandating the transition to ICD-10. So I thought I’d write a blog post about the subject.

First, I’ll examine some of the benefits that proponents of ICD-10 site. Then, I’ll examine the cost of transition from ICD-9 to ICD-10.

There are about a dozen frequently cited reasons to switch from ICD-9 to ICD-10. But they can be summarized into three major categories:

1) The US needs to catch up to the rest of the world.

2) The more granular nature of ICD-10 will lend itself to data analysis of all forms – claims processing, population health, improved interoperability, clinical trials, research, etc.

3) ICD-9 doesn’t support the latest diagnoses and procedures, and ICD-10 does.

Regarding #1, who cares? Coding standards are intrinsically arbitrary. Sequels are not necessarily better than their predecessors.

Although #2 sounds nice, there are a lot of problems with the supposed “value” of more granular data in practice. Following the classic 80-20 rule of life (80% of value comes from 20% of activity), the majority of codes are rarely used. By increasing the number of codes six-fold, the system is creating 6x the opportunities to inaccurately code. There is no reason to believe that providers will more accurately code, but the chances of incorrect diagnosis are now significantly higher than they were before. Garbage in, garbage out.

Below are some specific examples of how increasing the number of codes will affect processes in the healthcare system:

Payers – payers argue that making codes more granular will improve efficiency in the reimbursement process by removing ambiguity. There is nothing further from the truth. Payers will use the new granularity to further discriminate against providers and reject claims for what will appear to be no reason. With 6x the number of codes, there are at least 6x as many opportunities for payers to reject claims.

Clinical trials – ICD-10 proponents like to argue that with more granular diagnosis codes, companies like ePatientFinder can more effectively find patients and match them to clinical trials. This notion is predicated on the ability of providers to enter the correct diagnosis codes into EMRs, which is a poor assumption. Further, it doesn’t actually address the fundamental challenges of clinical trials recruitment, namely provider education, patient education, and the fact that most patients aren’t limited to trials by diagnosis codes, but rather by other data points (such as number of years with a given disease and comorbidities).

Public health – ICD-10 proponents also claim that the new coding system will help public health officials make better decisions. Again, this is predicated on accuracy of data, which is a poor assumption. But the greater challenge is that the most pressing public health issues of our time simply don’t need any more granularity in diagnosis codes. Public health officials already know what the top 20 public health problems are. Adding 6x the number of codes will not help address public health issues.

Regarding #3, why do we need to reinvent the entire coding system and make the entire system more granular to accommodate new diagnoses and procedures? Why can’t we continue to use the existing structure and simply create new branches of the ICD tree using alphanumeric characters? Why do we need to complicate every existing diagnosis and procedure to support new diagnoses and treatments? We don’t. There are plenty of letters left to be utilized in ICD-9 to accommodate new discoveries in medicine.

Next, I’ll provide a very brief summary of the enormity of the cost associated with transitioning from ICD-9 to ICD-10. The root of the challenge is that a string of interconnected entities, none of whom want to work with one another or even see one another, must execute in sync for the months and years leading up to the transition. Below is a synopsis of how the stars must align:

EMR vendors – EMR vendors must upgrade their entire client base to ICD-10 compliant versions of their systems in the next couple of months to begin testing ICD-10 based claims. Given the timescales at which providers move, the burden of MU2 on vendors, and the upgrade cycles for EMR vendors, this is a daunting challenge.

Providers – providers don’t want to learn a new coding system, and don’t want to see 6 times the number of codes when they search for basic clinical terms. Companies such as IMO can mitigate a lot of this, but only a small percentage of providers use EMRs that have integrated with IMO.

Coding vendors – like EMR vendors, auto-coding vendors must upgrade their clients systems now to one that supports dual coding for ICD-9 and ICD-10. They must also incur significant costs to add in a host of new ICD-10 based rules and mappings.

Coders – coders must achieve dual certification in ICD-9 and ICD-10, and must double-code all claims during the transition period to ensure no hiccups when the final cut over takes place.

Clearinghouses – clearinghouses must upgrade their systems to support both ICD-9 and ICD-10 and all of the new rules behind ICD-10, and must process an artificially inflated number of claims because of the volume of double-coded claims coming from providers.

Payers – payers must upgrade their systems to receive both ICD-9 and ICD-10 claims, process both, and provide results to clearinghouses and providers about accuracy to help providers ensure that everyone will be ready for the cut over to ICD-10.

The paragraphs above do not describe even 10% of the complexity involved in the transition. Reality is far more nuanced and complicated. It’s clear from the above that the likelihood that all of the parties can upgrade their systems, train their staff, and double code claims is dubious. The system is simply too convoluted with too many intertwined but unaligned puzzle pieces to make such a dramatic transition by a fixed drop-dead date.

Lastly, switching to ICD-10 now seems a bit shortsighted in light of the changes going on in the US healthcare system today. ICD-10 is already a decade old, and in no way reflects what we’re learning as we transition from volume to value models of care. It will make sense to change coding schemes at some point, but only when it’s widely understood what the future of healthcare delivery in the US will look like. As of today, no one knows what healthcare delivery will look like in 10 years, let alone 20. Why should we incur the enormous costs of the ICD-10 transition when we know what we’re transitioning to was never designed to accommodate a future we’re heading towards?

At the end of the day, the biggest winners as a result of this transition are the consultants and vendors who’re supporting providers in making the transition. And the payers who can come up with more reasons not to pay claims. Some have claimed that HHS is doing this to reduce Medicare reimbursements to artificially lower costs. Although the incentives are aligned to encourage malicious behavior, I think it’s unlikely the feds are being malicious. There are far easier ways to save money than this painful transition.

The ICD-10 transition may be one of the largest and most complex IT coordination projects in the history of mankind. And it creates almost no value. If you can think of a larger transition in technology history that has destroyed more value than the ICD-9 to ICD-10 transition in the US, please leave a comment. I’m always curious to learn more.

March 24, 2014 I Written By

Kyle is Founder and CEO of Pristine, a company in Austin, TX that develops telehealth communication tools optimized for Google Glass in healthcare environments. Prior to founding Pristine, Kyle spent years developing, selling, and implementing electronic medical records (EMRs) into hospitals. He also writes for EMR and HIPAA, TechZulu, and Svbtle about the intersections of healthcare, technology, and business. All of his writing is reproduced at kylesamani.com