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!

2019 CPT Codes To Cover Remote Monitoring And Digital Care Coordination

Posted on September 10, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

The American Medical Association has released CPT code set changes 2019, and among them are some new options specific to digital health practices.

While providing such codes is a no-brainer — and if anything, the AMA is late to the party – it’s still a bit of noteworthy news, as it could have an impact on the progress of digital care.  After all, the new codes to make it easier to capture the value of some activities providers may be self-funding at present. They can also help physicians track the amount of time they spend on remote monitoring and digital care coordination more easily.

The 2019 release includes 335 changes to the existing code set, such as new and revised codes for adaptive behavior analysis, skin biopsy and central nervous system assessments. The new release also includes five new digital care-related codes.

The 2019 code set includes three new remote patient monitoring codes meant to capture how clinicians connect with patients at home and gather data from care management and coordination, and two new “interprofessional” Internet consult codes for reporting on care coordination discussions between a consulting physician and the treating physician

It’s good to see the AMA follow up with this issue. To date, there have been few effective ways to capture the benefits of interactive care online or even via email exchanges between physician and patient.

As a result, providers have been trapped in a vicious circle in which virtual care doesn’t get documented adequately, payers don’t reimburse because they don’t have the data needed to evaluate its effectiveness and providers don’t keep offering such services because they don’t get paid for performing them.

With the emergence of just five new CPT codes, however, things could begin to change for the better. For example, if physicians are getting paid to consult digitally with their peers on patient care, that gives vendors incentives to support these activities with better technology. This, in turn, can produce better results. Now we’re talking about a virtuous circle instead.

Obviously, it will take a lot more codes to document virtual care processes adequately. The introduction of these five new codes represents a very tentative first step at best. Still, it’s good to see the AMA avoid the chicken-and egg-problem and simply begin to lay the tracks for better-documented digital care. We’ve got to start somewhere.

 

AAFP Proposes Tactics For Reducing EHR Administrative Burdens

Posted on February 12, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

The American Academy of Family Physicians has proposed a series of approaches it says will reduce the administrative burdens EHRs impose on primary care doctors.

The recommendations, which come in the form of a letter to CMS, address health IT simplification, prior authorization and standardization of quality measurement. However, the letter leads off with EHR concerns and much of the content is focused on making physician IT use easier.

Few would argue that the average physician spends too much time struggling with EHR-related administrative work. The AAFP backs this assertion up with a couple of studies, including one finding that primary care physicians spend almost 6 hours per day interacting with EHRs. It also cites research concluding that four types of specialist spent almost 2 hours using the EHR for every hour of direct patient care.

To address these concerns, the AAFP recommends taking the following steps:

  • Eliminating HIT utilization measures in MIPS: The group argues that such measures are not needed anymore now that MIPS includes quality, cost and practice improvement measures.
  • Updating documentation requirements: With the agency’s Evaluation and Management recommendation guidelines having been developed 20 years ago, prior to the widespread use of EHRs, it’s time to rethink their use, the letter asserts. Today, the group says, they have a negative impact on EHR usability and hinder interoperability. The group recommends eliminating documentation requirements for codes 99211-99215 and 99201-99205 entirely and allowing any care team member to enter medical information.
  • Rethinking data exchange policies: The AAFP is asking CMS and ONC to focus on how and when data is exchanged rather than demanding that specific data types be included. The group also urges CMS and ONC to penalize healthcare organizations not appropriately sharing information, using its authority granted by the 21st Century Cures Act.
  • Creating standardized clinical data models: To share data effectively across the healthcare ecosystem, the AAFP argues, it’s necessary to develop nationally-recognized, consistent data models that can be used to share data efficiently. It recommends that such principles be developed by physicians and other clinicians rather than policymakers, vendors or engineers.

I don’t know about you, but I find much of this to be a no-brainer. Of course, the decades-old E/M guidelines need to be reformed, consistent data models must emerge if we hope to improve interoperability and physicians need to lead the charge.

Unfortunately, it’s hard to tell whether CMS and ONC are willing and prepared to listen to these recommendations. In theory, leaders at ONC should be only too glad to help providers achieve these goals and CMS should support their efforts. But given how obvious some of this is, it should have happened already. The fact that it hasn’t points up how hard all of this could be to pull off.

The “Enthusiasm Gap” in Health IT

Posted on January 5, 2012 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

My next piece is published at Townhall.com:

 

Despite the success of information technology (IT) in transforming many parts of the economy, the health care sector has proven itself immune to the seduction of smart phones and iPads.  This is puzzling at first glance.  It is certainly not due to any shortage of health IT products.  The problem appears to be on the demand side.

A recent article by Olga Khazan in The Washington Post provides some explanation. She reports on the third annual mHealth Summit, held earlier this month in Washington D.C.  The event has attracted such notables as Bill Gates and Ted Turner, according to the mHealth website.  The piece laments the “enthusiasm gap” between Health IT startup companies offering dozens of miracle products and those darn stick-in-the-mud physicians who just can’t get with the program.   But meetings like the mHealth Summit actually hurt the movement of Health IT that they profess to support.

The poster child for Ms. Khazan’s article is Dr. Eric Topol, one of the Summit’s keynote speakers.  HHS Secretary Kathleen Sebelius joined Dr. Topol behind the podium.  Together they offered Health IT Utopia – where “you can take a video of a rash on your foot and get a diagnosis…without making a doctor’s appointment.”  Then they criticized practicing physicians using the same old Obamacare propaganda.  Ms. Sebelius continued, “Americans still live sicker and die sooner than many of the people in other nations…Healthcare has stubbornly held on to its cabinet and hanging files.”  Dr. Topol called the medical community “ossified” regarding the adoption of health information technology.  The author starts the online post-article comment thread herself with the question, “How do we encourage doctors to be more open to these technologies?”

This kind of meeting is common in the Health IT (HIT) community.  A bunch of self-described HIT experts get together, pump each other up about the absolute perfection of their products, and then start bashing physicians because – literally and figuratively – we aren’t buying it.  At similar meetings I have heard HIT people brag about walking out on their doctor the minute he pulled out a paper prescription pad.  Doctors are called fearful, stupid, or rich fat-cats protecting their turf.  Now thanks to our “colleague” Dr. Topol we can add, “ossified” to the list of unflattering terms.  It comes as no surprise that the government is happy to join in the sing-along.  It is a free opportunity to serve Obamacare Kool-Aid.

I am a dedicated supporter of HIT.   Our practice’s EMR implementation reached a reasonable level of maturity long before Obamacare, HITECH incentives, and Ms. Sebelius came along.  We became Meaningful Use – compliant the first of October.  I believe in the potential of HIT to revolutionize the practice of medicine by reducing costs and improving efficiency and quality of care.  But I do not believe the HIT community is on a course that will take us to that vision.

Read the rest of the article here at Townhall.com

The Nitty-Gritty of Meaningful Use – Part 2

Posted on September 18, 2011 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

This is the second in the series of how our practice is getting the work of MU done.  The first of the series can be found here.

Starting with Core Set Item #7:

7.   Record demographics as structured data.  We have been doing this for a long time but MU requires us to add race and “ethnicity.”  Isn’t ethnicity the same as race but more specific?  If you have the latter you don’t need the former.  Furthermore we have had patients push back on asking this question.  Some find this question offensive.  They shouldn’t; since many diseases are race / ethnicity – specific the question is medically appropriate.  Fortunately MU considers the term “undetermined” as acceptable for this data point.

8.  Record vital signs as structured data.  This conflicts with lower level CPT E/M coding with does not require vital signs.  Once again the left hand of government doesn’t know what the right is doing.  Nobody thought it through.

9.  Record smoking status.   No problem here.  Medically appropriate for all specialties.

10.  Quality measures.  These are poorly designed and confusing.  There are 2 redundant measures both dealing with tobacco use and cessation, and these are both redundant (but not identical) to core set #9.  Weight screening is reasonable enough but the follow-up requirements are ambiguous and burdensome.  Are we really supposed to bombard our local dietician with weight loss consultations?

11.  Decision support rule.  We will configure our EMR to prompt for hearing loss screenings in patients over 50 years old.  Fair enough.

12.  Provide an electronic copy of health information to the patient upon request.  Who are they kidding?  This should have been delayed to Phase two.  Qualified EMRs can do this easily enough but the product is exported to your remote server desktop; it is cumbersome to copy from there.  We have had few such requests from patients; I wonder if those few are asking just to prove a point.  I don’t know that for sure.

13.  Provide clinical visit summaries.  Again should have been delayed to Phase two.

14.  Exchange key clinical information between systems.  This one is unbelievable.  Fortunately, as I understand it, you only have to do it once.  You are supposed to upload all or part of someone’s chart (or perhaps a test chart or other hypothetical data) to portable media, go to someone else’s EMR and try to upload the data.  Doesn’t matter if you succeed or not.  Am I misunderstanding this one?  If anybody has a better handle on this one please leave a comment.

15.  HIPAA security risk analysis.  Although I hate paying for it I must admit that is a good idea.

 

The last installment will cover the Menu Set Measures.

The Nitty-Gritty of Meaningful Use – Part 1

Posted on August 11, 2011 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

To this point I have contemplating Meaningful Use from 10,000 feet above the landscape.  I have done my reading, been to meetings, and met with our EMR vendor…all the usual things.  But this week it was time to roll up our sleeves and go down from 10,000 feet to cut through the jungle at ground level and bring MU to our practice of 19 physicians.

We faced the maddening task of reviewing 15 Core Set Measures and choosing 5 out of 10 Menu Set Measures, and then getting them done.  I have to admit that some parts of meaningful use are not too bad.  But there are other parts that are confusing, redundant or totally ridiculous.

Regarding the first 6 of the 15 Core Measures:

CPOE for Medication orders.   The concept is fine but the requirement is not structured well.  It reads, “More the 30% of all unique patients with at least one medication in their medication list seen by the EP (eligible provider) have at least one medication entered using CPOE.”  Read it carefully.  It says if a patient walks in my door and reports to be on any medication, I have to prescribe another medication whether the patient needs one or not.  Most doctors write enough prescriptions that by luck of the draw this won’t be a problem.  But we have 2 docs that don’t write a lot of prescriptions and they are currently don’t meet this measure even though they rarely, if ever, write a paper prescription.

Drug-Drug interactions and Drug-Allergy Interactions.  No problems here.

Maintaining a Structured Problem List.  Certified EMRs do this automatically and this function is essential to quality measurement and outcomes research.  Some of us (me included) need to change our documentation habits to get the proper data capture.   By personal habit I prefer writing unstructured paragraphs instead of distilling a patient visit down to a bunch of ICD-9 codes.  I’ll get over it.

 E-Prescribing.  Obviously an appropriate requirement.  But it sets the bar higher than the CPOE for Meds requirement (see #1 above), so why bother having the CPOE requirement at all?

 Maintain structured active medication and allergy lists.  Also a reasonable requirement.  This has always been a part of the physician’s visit routine.  The only problem is that the EMR requires the doc to check a box for each of these requirements.  I am going to try to modify our existing templates to make that task as painless as possible.

 

In future installments on this topic I will cover how we are handing the remainder of the MU requirements.  Stay tuned.

 

 

Lessons Learned from Anesthesia EMRs

Posted on July 24, 2011 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

Several years ago one of the hospitals where I operate spent 6 figures on an anesthesia EMR system.  After several months and a huge amount of money the whole thing was scrapped because it was so cumbersome to use.  They have not tried again.

A few weeks ago the anesthesia group that covers our surgery center got an EMR.  The product is called Anescan and apparently has many successful installs.  It runs on Windows 7 tablets that communicate with a central server.  Needless to say I was curious to see how this system differed from the failed system I had seen years ago.  What I learned was very interesting.

Medical record keeping in anesthesia is different from all other medical specialties.  The job includes monitoring vital signs constantly and documenting them in the anesthesia record every few minutes.  It is a task that begs to be automated.  Such technology would presumably free the anesthesiologist from mundane repetitive documentation, allowing more efficient and effective monitoring of the patient.   The necessary technology has been available for years and was used in the failed hospital system from years ago.

I was surprised to learn that Anescan avoids that technology.  A conversation with the Anescan rep revealed that is was precisely that technology which caused earlier systems to fail.  It’s easy to measure blood pressure, heart rate, respiratory rate, and blood oxygen level and push that data to an EMR.  The problem is that the data are often riddled with artifact.  If an EKG lead or pulse oximeter comes loose, or if the surgeon leans on the arm-mounted blood pressure cuff, it is not unusual to get an automated pulse or blood pressure of zero.  The anesthesiologist / anesthetist can easily recognize what is happening, fix the monitors and record accurate vital signs.  This often happens several times during a case and is no big deal.

The automated system makes it much worse.  By the time the bad data are recognized the automated system has already pushed that zero pulse and BP to your EMR.  Now the anesthesiologist / anesthetist has to open some kind of editing function in the EMR and delete, edit, or explain away the false readings…AND at the same time troubleshoot the monitors that sent the bad data in the first place…AND by the way your patient is still asleep and you can’t stop watching him.  AND you only have a couple of minutes to get caught up before the monitors send the next the next set of (? bad) vital signs to the EMR.  The potential downward spiral is easy to see.

Anescan avoids this problem.  The tablet PC presents an image of a standard anesthesia paper record with the patient demographics and other data already in place as structured data.  Vital signs are recorded with “digital ink.”   Use the stylus to record vital signs on the form, on the tablet.  When the case is complete the form images are sent to the server for centralized record keeping and billing.   A paper copy is printed for the surgery center chart.  This is an elegant solution that automates only those parts of record keeping where it is practical.

Someday the artifact problem will be solved either through better monitors or better error recognition within the EMR.  But today this serves as yet another example of too much IT and automation in health care causing more problems than it solves.

Our Disaster Recovery “Fire Drill”

Posted on February 20, 2011 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

Last Friday our practice had an opportunity to practice our disaster recovery protocol.  This was actually good news; we are replacing our 6 year old servers with virtual servers and a storage area network (SAN).  The implementation plan required more down time than a weekend would provide so we added a Friday to it.

Unlike a real disaster we had the opportunity to prepare immediately before, knowing exactly when the system was going down.  We printed our clinic schedules and printed the clinic note from the last visit for patients who had appointments.  We did not cancel appointments or reduce the number of patients seen.  For appointments requiring other documentation (i.e., pathology reports for post-surgery visits) we printed those.  We also printed a generous number of our most common handouts and got our paper prescription pads ready.

The day was free of major problems and the staff performed very well.  The experience was very interesting:

  1. My description above is a little too rosy.  We ended up searching for some documents at the last minute.  We ran behind schedule and there was a mild degree of disorganization throughout the day.
  2. Patients were very understanding about the delay and about our EMR being down.  Everyone understands that computers go down and I was thankful to see that our patients remembered that.  In some cases I had to ask patients to refresh my memory regarding prior visits since I didn’t have the entire chart available.  No one seemed to mind.
  3. I was still able to use my PC and Dragon Speech. Dragon runs locally on my desktop.  I dictated notes in Notepad and saved a separate note for each patient.  On Monday, my assistant will create Friday’s chart notes in the EMR, enter their data (vital signs etc.) and route the notes to my desktop.  Then I will copy / paste my notes into the EMR chart.
  4. Dictating unstructured chart notes into my PC was refreshing.  It was also an impressive reminder of how much garbage CPT forces us to add to our notes.  Even for complicated, new patients I was able to record everything relevant in less than two-thirds of a page.  Adding the CPT-required material almost doubles the size of the note without adding any relevant, useful data.
  5. With the system down the front office could focus on patient service without having to obsess over data entry.
  6. With all the extra paper floating around the back office was a mess.  I can’t imagine going back to paper charts.
  7. We were still compromised operationally when we had a patient who needed to schedule surgery.  Without the EMR workflow engine we could not print customized surgical packets.  Handwriting surgical consents is not acceptable.  We will have to catch up on this workflow next week.

Take home lessons:

We need to improve our disaster readiness, but at the moment our readiness is not too bad.  Our new SAN is configured to perform incremental backups every night and full backups every weekend.  The virtual servers and SAN will allow us to redirect workload in the event of a server or hard drive failure.  For a network failure we can follow the protocol we just rehearsed, but we should take the time to update our hard copies of handouts and surgical consents.  This is interesting because on more than one occasion we have had IT vendors try to push their way in to our practice using our presumed lack of disaster readiness as their excuse.

Once our new servers and SAN are settled in I may look into an automated method of copying appointment schedules and recent chart notes for patients with appointments to a local PC in each office rather than wasting all that time and paper every day.

I understand that all that front office data entry is a necessary evil.  But I never realized how much it distracts the front office from tending to patients.  I am going to double my efforts to make it attractive for patients to enter their own data online in advance of the visit – or at least have them use the patient portal to enter their own data in the waiting room.  As much as we have tried so far, our patient portal still has not caught on with our patients in the waiting room, and there has been only moderate use from home.  I don’t think our web portal is good enough yet.

A Process for Replacing CPT Codes

Posted on January 27, 2011 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

Those of you who have been kind enough to read my blog know I criticize CPT coding on a regular basis.  Finally after my last tirade, a comment from John finally said what I have been dreading to hear:  “I’d love to hear more about what you think a good replacement to the current CPT system would look like.”

That is the question, isn’t it?   I’ve been criticizing long enough.  Time to put up or shut up.  A brief Internet search does not reveal any significant activity regarding a replacement for CPT except for vague “pay for performance” concepts that would pay for results rather than the care itself.  I must confess that despite thinking about CPT replacement for the past few months I don’t have any bright ideas either.

But since I raised the question in the first place I’m willing to take a shot at it.  Ignorance has never stopped me before…

I would like to begin a 4 step brainstorming process with you:

  1. Outline the shortcomings of CPT coding
  2. Translate those shortcomings into desired characteristics for a replacement system
  3. Explore applicable technologies that allow us to leverage the use of EMR to create an IT-based payment system with the desired characteristics
  4. Formulate proposals to replace CPT

I’m going to resist the urge to write my usual 1000 word post and stop here.  Please share your thoughts regarding the wisdom of this project and whether or not these 4 steps are the best way to approach the question of a replacement for CPT.

The Frightening Political Side of EMR

Posted on January 17, 2011 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

What truly frightens me about HITECH is that it demonstrates the government’s enthusiasm for juxtaposing itself into the EMR movement.  I am frightened, but obviously not surprised.  Like any powerful technology, EMR can be used for benefit or harm.  Used properly EMR can fulfill the promise of lower costs, improved efficiency and higher quality of care.  But if controlled by sinister forces, EMR will become a vehicle to undermine the doctor-patient relationship by limiting treatment choices and covertly monitoring /controlling doctor-patient behavior.  Make no mistake: there are elements within our government that have recognized the potential of EMR as an instrument to bring health care under their control.  If you think that notion is a bit paranoid, consider the words of the new director of CMS, Dr. Donald Berwick:  “It’s not a question of whether we will ration (health) care, it is whether we will ration with our eyes open.”  Regarding Britain’s National Health Service (NHS), which rations care to British citizens, Dr. Berwick says, “I am romantic about the National Health Service. I love it.”  The NHS limits spending on life-saving care to $44,000 per year.

It is not difficult to understand how a government EMR system could be used to control and ration care.  Remember the FDA’s recent withdrawal of its approval of the drug Avastin for breast cancer?  Although doctors are powerless to reverse this unfortunate decision, at least it was formally announced and subjected to public scrutiny and debate.  And Avastin is still available to use “off-label.”  If EMRs were government controlled, no announcements would be necessary.  The “Avastin button” would simply be removed from the physician’s treatment option screen.  And it would be easy to program a government-controlled EMR to enforce an NHS-type spending limit to extend life.  When a patient’s spending limit is reached, the system locks out that patient’s chart and no more care can be given.

Ridiculous, perhaps?  The HITECH program, through EMR certification, already has established a mechanism to force EMR vendors to make their products comply with government requirements.  It would be a simple regulatory step to “upgrade” those requirements to include a method of government “back door access” to any EMR. Such access would allow the government to establish and codify within EMRs methods of limiting and rationing care.  It would also allow the government to monitor physician-patient behavior and deliver sanctions if it so desired.

I am not suggesting we storm Dr. Berwick’s office with torches and pitchforks.  But I would like to offer some thoughts to serve as a “moral compass” as we continue our work on the EMR movement:

  1. EMR should only be used in a manner that supports the doctor-patient relationship.  EMR should be used to reduce costs, improve efficiency, improve quality of care, enhance doctor-patient communication and protect the physician’s ability to properly practice medicine.  EMR and related technologies, such as health information exchanges, should be used to efficiently move data among providers and to automate those parts of health care workflow that are appropriate for automation.
  2. It is inappropriate to use EMR as a vehicle for the government or any third party payer to force itself into the practice of medicine and into the doctor-patient relationship. EMR must not be used to enforce any restriction of treatment choices.  It is improper to use EMR as a tool for the government or any third party payer to covertly monitor physician / patient behavior.
  3. The HITECH incentives are a mixed blessing. While the incentives certainly encourage EMR adoption they may also deprive the medical culture of the necessary time to make a stable, controlled cultural change to an information technology environment.  This increases the risk of failure and may paradoxically increase the time and resources that are ultimately required to complete the cultural transition.   It will take extra time and money for some medical practices to recover from poor decisions made in haste.
  4. The HITECH incentives are also harmful because they create a paradigm in which government sets the goals and the medical and IT cultures follow.  The result could be a health care IT system that serves the whims of politicians, not the needs of patients.  This is unacceptable.
  5. Let’s start thinking about a better physician payment system than CPT. The CPT coding system was created by the American Medical Association (AMA) over 40 years ago and has become an antiquated, overly burdensome set of documentation requirements.  The coding compliance industry must siphon billions of health care dollars away from patient care to help physicians comply with these incredibly complex guidelines.  The AMA profits approximately 50 million dollars a year selling CPT and ICD-9 materials to physicians.  Their support of CPT is not objective and cannot be trusted.  The CPT coding system assumes paper-based documentation.  Through EMR we have learned that a fully CPT-compliant chart note is almost useless to the clinician.  The relevant data are buried in a sea of white noise: patient demographics, irrelevant historical data, normal physical findings, and diagnosis / billing codes.  The result is lengthy documentation that is dedicated to CPT compliance rather than to communicating useful health care information. EMR gives us the opportunity to replace CPT with a new physician payment system based on information technology instead of paper charts.  Such a system will allow us to re-direct limited health resources from regulatory compliance back into patient care.
  6. Technology always brings unintended consequences.  Health information technology will certainly bring unintended consequences, including unintended and undesirable de facto changes to the standard of care.  We must watch carefully for these changes and protect physicians from these unplanned changes in the standard of care until they are examined, modified if necessary and formally recognized.

Recent political events clearly demonstrate a significant change in the relationship between America’s government and her citizens.  Those who work in health care information technology must be aware that EMR technology could be utilized as a government instrument to covertly take control of our health care system in the name of “social justice” and cost containment.

Busting the Myths about EMR Implementation

Posted on January 11, 2011 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

I am still crazy over the ridiculous EMR cost study recently published by CDW.  This regrettable study was obviously put together by a bunch of newbies that had no idea what they were doing.  A few weeks ago, during a rant on a previous post on this topic I promised I would review our practice’s implementation strategy.  It’s time to live up to that promise.

The CDW group assumed, as I imagine many still do, that EMR should be implemented as quickly as possible minimize the financial impact of decreased patient volume.  In our practice we took the opposite approach, realizing that if we brought in EMR slowly enough we wouldn’t have to decrease patient volume at all.  We overcame both the cultural and the financial barriers to EMR by creating an approach that was different from the prevailing wisdom at the time. Conventional project management principles don’t work in the physician practice setting.

  1. We recognized that EMR was not a project with a defined end point – it would instead be an ongoing “work in progress.”
  2. We avoided big “go-live” dates and hard deadlines for abandoning paper charts.  Paper charts were eliminated gradually, via attrition, over 2-3 years.   Docs are already uptight and uneasy about EMR; deadlines only make it worse.
  3. We rejected the notion that we would have to decrease patient volume and lose revenue, even temporarily, to get EMR implemented.  Don’t even think about suggesting to a doc that (s)he will have to decrease patient volume.  We can’t tolerate it financially.
  4. Every office and every physician was allowed to progress along its own timeline.  Every office has its own set of assets and liabilities – its own subculture.  It made no sense to force the same timeline on everyone.  We also offered (and continue to offer) each office / physician a fair amount of latitude on exactly how the EMR is used.  Some docs use speech recognition, some don’t.  Some offices didn’t scan outside records at first.  In the early days we didn’t care if docs wrote paper prescriptions.  The script pad is one of the hardest cultural icons for the physician to let go.

We had one physician who resisted EMR for almost a year.  I was approached several times to pressure this doc to “give in.”  I declined.  Then one day he discovered Dragon Speech and started EMR almost overnight.  We docs are self-selected fiercely independent souls; our training reinforces those characteristics.  I know this physician well; he had to do EMR on his timing and his terms.  If I had pressured him it would have backfired badly.  I probably would have behaved similarly.

To accommodate the physician’s need for independence the EMR adoption process was broken down into a large number of incremental steps.  After a short teaching session each physician had a training version of the EMR, complete with fictitious doctors and patients, installed on his/her laptop.  Over a few evenings the physician would work with the program to get used to the basic operations and functions.  Once the physician was comfortable we put the server communication software on the doc’s PC and showed him/her how to log in and use the same training EMR program on the server.  The training EMR on the server was configured with our custom templates.   The physician was then instructed how to create chart notes using our templates.  Then he/she could spend more time practicing at home, logging onto the server from there.

Then it was time to use the “real” EMR program on real patients.  But not all at once. Start with only one patient, the last patient of the day. Those first few notes took forever to complete.  But with our approach that was no problem.  For a while many of the docs printed out the completed EMR note and put it in the paper chart.  Why bother doing that?  It was a cultural trust issue.  With time, trust in the EMR increased and the practice disappeared naturally.

We advanced each doctor at his/her own pace.  Do EMR for the last 2 patients of the day, then the last 3, etc.  When ready, take on a half day of patients, then an entire day.  If there is a problem, back off.  Get the issues resolved and try again.   There were no deadlines and no pressure.  After getting settled with documentation move on to workflows such as prescriptions, ordering tests and imaging.  Then finally learn CPT/ ICD-9 charge code entry.

This process serves 2 goals.  First it allows the cultural change to an IT setting to progress at an acceptable, sustainable rate.  It also allows EMR to come in without decreasing patient volume.  It took almost a year to get 20 physicians in 15 offices implemented with basic EMR functions – but there was no panic, only modest chaos and no loss of patient volume.  We had our frustrating moments, but I am convinced that they would have been far worse with a conventional implementation plan.