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Last Day for Medicare Eligible Professionals to Register for 2013 EHR Incentive

Posted on March 31, 2014 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.

Today is the last day to register for the 2013 EHR incentive money. If you haven’t done so already, you’ll want to go and do that now. Unlike ICD-10, I don’t see this being delayed.

Here’s an email from CMS with details of the deadline:

If you are an eligible professional, today is the last day you can register and attest to demonstrating meaningful use for the 2013 Medicare EHR Incentive Program. You must successfully attest by 11:59 p.m. Eastern Daylight Time, to receive an incentive payment for your 2013 participation.

CMS extended the deadline for eligible professionals to attest to meaningful use for the Medicare EHR Incentive Program to allow more time for providers to submit their meaningful use data and receive an incentive payment for the 2013 program year.

Medicaid Eligible Professionals
Eligible professionals participating in the Medicaid EHR Incentive Program need to refer to their state deadlines for attestation information.

Payment Adjustments
Payment adjustments for eligible professionals will be applied beginning January 1, 2015, to Medicare participants that have not successfully demonstrated meaningful use. For more information, visit the payment adjustment tipsheet for eligible professionals.

You must attest to demonstrating meaningful use every year to receive an incentive and avoid a payment adjustment.

If you are only eligible to participate in the Medicaid EHR Incentive Program, you are not subject to payment adjustments.

Resources

Plan Ahead
Review important dates for the EHR Incentive Programs and all CMS eHealth programs using this Interactive Timeline.

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

Posted on 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.For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manager 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 role he recently repeated for a Council member.

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.

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

Posted on March 30, 2014 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.


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.

The Job Killing ICD-10 Delay Program

Posted on March 28, 2014 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 thought I’d offer a little of my own spin in the headline since those in DC only like to read spin. Unfortunately, I don’t think those in DC will really hear the message and I believe the ICD-10 delay will be passed. I still think that most of congress is voting on the SGR part of the bill and not the ICD-10 delay, but this vote will support the many doctors who don’t want ICD-10 implemented at all ever. This is a strong and large group of doctors that congress does care about.

However, I can’t help but highlight the thousands of coders that will be affected as well. In the link above I quoted a coder who’d paid for the ICD-10 course and now it’s wasted money (and it’s not like coders have a lot of excess income).

Add to that story this story from an educator who switched their educational program to ICD-10. If the ICD-10 delay happens, then all of those newly trained ICD-10 professionals won’t be able to find a job. Read more below from Kelly Fast, MS, RHIA, CMT:

I am a program director of an HIT program in candidacy with CAHIIM. The program began in the summer of 2012. We anticipated we would have graduates this year, the year of the implementation. We went with the assurances from HHS that there would not be another delay. All of our coding curriculum has been taught with ICD-10 (with a nod to ICD-9 from a historical perspective). We now have graduates. As we are all aware, it is so difficult for new graduates to secure coding positions. This delay, if it happens, will definitely not be a competitive advantage for our students! We went with the implementation date sticking and the training in ICD-10 being a positive thing for our students in the workplace. It is so disappointing that this is even being considered.

From the perspective of how many students this will affect nationally — there are over 17,000 students in CAHIIM accredited health information programs.

I think of our students — our job is to prepare them as best we can for the workplace! Are our students going to be given a break on their student loans until October of 2015? I think not. Are our students going to have their loans forgiven when the skill they have gone into debt to learn is a distant memory to them, due to no fault of their own? Again, I think not.

To all students — keep practicing, practicing! At some point the new classification system will be implemented and you will have the opportunity to shine!

So far, AHIMA is keeping the implementation date for the RHIT exam with ICD-10 the same. That is one silver lining for the students. But, yes, this looming delay will have far, far reaching effects. We will be evaluated as a program as to how many of our students pass the exam. So thank you AHIMA for so far not pushing out the date of the switch of the exam from 9 to 10 for the RHIT. Also, we will be evaluated on how many of our students are able to become employed in healthcare. That one will definitely not be helped by any delay.

Also, we had scheduled an area ICD-10 training for next month on our campus. That will be postponed if the Senate passes this bill intact. Just the time and effort in getting all of the leg work done for that has been a lot, and it will all have to be repeated. When you are coordinating large gatherings of people, it isn’t as simple as reworking the dates. When I think about multiplying that effort for training rescheduling over and over for organizations all across the country…wow.

Here’s another personal story that illustrates the personal impact of the ICD-10 delay:

I’d like to chime in as a student about to graduate from an HIT associate degree program. Thank you for all your posts. Like all of you I am shocked by this turn of events. I am a single mom who enrolled in this program after my divorce which pulled the rug from under me and put my kids and I out of our home and, after being a stay at home mom, left me with no income. I’ve worked hard, sacrificed, and have been excited to enter this field that would be a perfect fit for me and would allow me to get back on my feet. I am only trained in ICD10 since the college I attend stopped teaching 9 because of the switch that was supposed to happen this year. I was planning on getting certified and entering the workforce this fall. I need to start earning an income or we could be out on the street. Where will this leave people like me? Congress apparently could care less how they mess with peoples lives. I too have contacted my senator. I pray they will hear us.

Unfortunately, I’m afraid the Congress looks more at the macro and political impact of this bill instead of the personal impact this will have on many people. I hear we’ll have to wait until Monday for the Senate to vote on the bill.

No Shortage of Excitement (This Week) in Healthcare IT

Posted on 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.

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.

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

Posted on March 27, 2014 I Written By

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.

BREAKING: Possible ICD-10 Delay … Again – AHIMA Call for Action

Posted on March 26, 2014 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.

UPDATE: It looks like this bill has passed the house with a voice vote. I believe it still needs to be passed by Congress and not be vetoed by the President.

UPDATE 2: Late on 3/31/14, the Senate passed the bill which delays ICD-10 by a vote of 64 – 35. Barring a veto from the President, the bill will go forth and the ICD-10 implementation date will be moved to October 1, 2015. All of the discussion for the bill was around the SGR fix with no conversation around the ICD-10 delay. It’s unlikely that the President would even consider a veto of this bill.

A bill that would adjust the SGR (Sustainable Growth Rate) was introduced to the US House and Senate with a 7 line provision that would effectively delay ICD-10 another year until October 1, 2015. Here’s the section of the bill:

The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD–10 code sets as the standard for code sets under section 1173(c) of the 13 Social Security Act (42 U.S.C. 1320d–2(c)) and section 14 162.1002 of title 45, Code of Federal Regulations.

This is really interesting news after the discussion we’ve been having in this Why ICD-10? post. No doubt there are a lot of strong feelings on both sides. Some really want a delay and some really want it to keep going forward. I wonder if Congress will get a mix bag of calls from both sides of the debate which won’t sway them either way.

AHIMA is definitely on the side of those calling for no delay to ICD-10. They sent out the following call to action to their community:

Call Congress Now to Request Removal of Delay Provision

Again, this bill is expected to go to the House floor tomorrow for a vote. AHIMA urges members and other stakeholders to contact their representatives in Congress today and ask them to take the ICD-10 provision out of the SGR bill.

Go to our website now and use your zip code to look up phone numbers for your representatives and senators in Congress. http://capwiz.com/ahima/callalert/index.tt?alertid=63161891

Phone Script Available Below for Use in Contacting Your Legislator:

“Hello Representative XX/Senator XX, my name is XXX and I am a concerned member in your district, as well as a healthcare professional. I am calling to voice my opposition to the language in the SGR patch that would delay ICD-10 implementation until October, 2015. CMS estimates that a 1 year delay could cost between $1 billion to $6.6 billion. This is approximately 10-30% of what has already been invested by providers, payers, vendors and academic programs in your district. Without ICD-10, the return on investment in EHRs and health data exchange will be greatly diminished. I urge you, Representative XX/ Senator XX to oppose the ICD-10 delay and let Speaker Boehner and Senate Majority Leader Reid know that a delay in ICD-10 will substantially increase total implementation costs in your district as well as delay the positive impact for patient care.”

My question is if they delay ICD-10, will ICD-10 ever happen? A strong argument will then be made to move straight to ICD-11. Although, all of those people who spent hours coding their applications for ICD-10 won’t like that change.

Like many people, I’m somewhere in the middle on this. Some certainty would be the most valuable thing. I’m certain that HHS wants ICD-10 to go forward. That’s certain. However, congress may have different ideas.

NIST Dissects Workflow: Is Anyone Biting?

Posted on 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.For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manager 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 role he recently repeated for a Council member.

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?

The Changing EHR and Health IT Landscape

Posted on March 25, 2014 I Written By

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

We’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.

ICD-10 Frequently Asked Questions (Including Update on Revised CMS-1500 Form)

Posted on March 24, 2014 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.

The following is a guest blog post by Dana Deardorff.

Are you concerned about the upcoming changes in coding? The following are answers to frequently asked questions that will help you prepare for the changes ahead. Please note the deadline for the first significant change is April 1, 2014.

What does ICD-10 stand for?

ICD-10 is an abbreviation. It stands for the International Classification of Diseases, 10th Revision. It is used when referring to either the Clinical Modification (ICD-10-CM) or Procedure Coding System (ICD-10-PCS).

How will ICD-10-CM be used?

ICD-10-CM will replace ICD-9-CM codes, Volumes 1 and 2. It will be used when reporting clinical setting diagnoses.

How will ICD-10-PCS be used?

ICD-10-PCS will be used by hospitals to report inpatient procedures.

Who has to convert to ICD-10?

Health care providers, clearinghouses, payers and physicians all are required to convert to ICD-10. This is not optional and includes any HIPAA covered entity.

What will happen if I don’t convert to ICD-10 by the October 1st deadline?

If you submit ICD-9 codes after October 1, 2014, those transactions will not be accepted. Those transactions will be denied. This will cause you to lose out on reimbursements. You may need to apply for a line of credit to prepare for cash flow disruptions that may occur due to noncompliance problems. This will help protect you from negative impact if your medical practice partners do not convert to ICD-10 in time.

What is the deadline for the ICD-10 conversion?

The deadline is October 1, 2014.

What is this April 1, 2014 deadline I keep hearing about?

The April 1 deadline is for the revised CMS-1500 form used for submission of paper claims. The CMS-1500 form is an intricate part of the ICD coding system. The new form (version 02/12) is replacing version 08/05. As of April 1, 2014 providers need to use version 02/12 of the CMS-1500 form. The old form will no longer be accepted.

How is the revised CMS-1500 form tied into the ICD-10 transition?

Physicians will notice that the revised CMS-1500 form provides fields for the new ICD-10 codes. However, your payors may not have made the transition from ICD-9 to ICD-10. Physicians should use ICD-9 codes until you have confirmed that the payor has made the transition to ICD-10. After October 1, 2014, your payors should have all made the transition to ICD-10, and you should be able to use the new codes from that date forward.

What is different about the revised CMS-1500 form?

The revised CMS-1500 form:

* Provides fields and indicators for both ICD-9 and ICD-10 codes

* Provides documentation space for up to 12 diagnosis codes

* Offers qualifiers to aid in the identification of provider roles in the furnishing of services

* Uses letters instead of numbers as diagnosis code printers

You will want to upgrade your practice management software or order 02/12 forms immediately if you have not done so already. Discard any 08/05 forms after April 1, 2014.

When should physicians start using the revised CMS-1500 form?

Providers can start using the revised form on January 1, 2014, but all providers must switch to using the revised form as of April 1, 2014. Your (PM) Practice Management/EMR/EHR practice vendor can help you determine what you need to do to remain in compliance as you transition to ICD-10.

About Dana Deardorff of MediPro
MediPro is a full-service medical billing software company offering practice management (PM) software, electronic health records (EHR) and electronic medical records (EMR) from McKesson and IMS.

Since 1995, MediPro, Inc. has been a nationally recognized, award-winning medical billing software company offering practice management systems and electronic health record solutions. MediPro’s mission is to deliver and support integrated solutions to the healthcare community. MediPro recognizes the need for a comprehensive, interactive and cost-effective suite of applications that are customized to address the specific needs of healthcare offices.