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EHRs and Keyboarding: Is There an Answer?

Posted on November 28, 2017 I Written By

When Carl Bergman isn’t rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com, a free service for matching users and EHRs. For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manger doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst.

One of the givens of EHR life is that users, especially physicians, spend excessive time keying into EHRs. The implication is that much keyboarding is due to excessive data demands, poor usability or general app cussedness. There’s no end of studies that support this. For example, a recent study at the University of Wisconsin-Madison’s Department of Family Medicine and Community Health in the Annals of Family Medicine found that:

Primary care physicians spend more than one-half of their workday, nearly 6 hours, interacting with the EHR during and after clinic hours. The study broke out times spent on various tasks and found, unsurprisingly, that documentation and chart review took up almost half the time.

Figure 1. Percent Physician’s Time on EHR

This study is unique among those looking at practitioners and EHRs. They note:

Although others have suggested work task categories for primary care,13 ours is the first taxonomy proposed to capture routine clinical work in EHR systems. 

They also make the point that they captured physician EHR use not total time spent with patients. Other studies have reached similar EHR use conclusions. The consensus is there too much time keyboarding and not enough time spent one to one with the patient. So, what can be done? Here, I think, are the choices:

  1. Do Nothing. Assume that this is a new world and tough it out.
  2. Use Scribes. Hire scribes to do the keyboarding for physicians.
  3. Make EHRs Easier. Improve EHRs’ usability.
  4. Make EHRs Smarter. Adapt EHRs to physician’s needs through artificial intelligence (AI) solutions.
  5. Offload to Patients. Use patient apps to input data, rather than physician keyboarding.

Examining the Alternatives

 1. Do Nothing. Making no change in either the systems or practioners’ approach means accepting the current state as the new normal. It doesn’t mean that no changes will occur. Rather, that they will continue at an incremental, perhaps glacial, pace. What this says more broadly is that the focus on the keyboard, per se, is wrong. The question is not what’s going in so much as what is coming out compared to old, manual systems. For example, when PCs first became office standards, the amount of keyboarding vs. pen and paper notations went viral. PCs produced great increases in both the volume and quality of office work. This quickly became the new norm. That hasn’t happened with EHRs. There’s an assumption that the old days were better. Doing nothing acknowledges that you can’t go back. Instead, it takes a stoic approach and assumes things will get better eventually, so just hang in there.

2. Scribes. The idea of using a scribe is simple. As a doctor examines a patient, the scribe enters the details. Scribes allow the physician to offload the keyboarding to someone with medical knowledge who understands their documentation style. There is no question that scribes can decrease physician keyboarding. This approach is gaining in popularity and is marketed by various medical societies and scribe services companies.

However, using scribes brings a host of questions. How are the implemented? I think the most important question is how a scribe fits into a system’s workflow. For example, how does an attending review a scribe’s notes to determine they convey the attending’s clinical findings, etc. The attending is the responsible party and anything that degrades or muddies that oversight is a danger to patient safety. Then, there are questions about patient privacy and just how passive an actor is a scribe?

If you’re looking for dispositive answers, you’ll have to wait. There are many studies showing scribes improve physician productivity, but few about the quality of the product.

3. Make EHRs Easier. Improving EHR usability is the holy grail of health IT and about as hard to find. ONC’s usability failings are well known and ongoing, but it isn’t alone. Vendors know that usability is something they can claim without having to prove. That doesn’t mean that usability and its good friend productivity aren’t important and are grossly overdue. As AHRQ recently found:

In a review of EHR safety and usability, investigators found that the switch from paper records to EHRs led to decreases in medication errors, improved guideline adherence, and (after initial implementation) enhanced safety attitudes and job satisfaction among physicians. However, the investigators found a number of problems as well.

These included usability issues, such as poor information display, complicated screen sequences and navigation, and the mismatch between user workflow in the EHR and clinical workflow. The latter problems resulted in interruptions and distraction, which can contribute to medical error.

Additional safety hazards included data entry errors created by the use of copy-forward, copy-and-paste, and electronic signatures, lack of clarity in sources and date of information presented, alert fatigue, and other usability problems that can contribute to error. Similar findings were reported in a review of nurses’ experiences with EHR use, which highlighted the altered workflow and communication patterns created by the implementation of EHRs.

Improving EHR usability is not a metaphysical undertaking. What’s wrong and what works have been known for years. What’s lacking is both the regulatory and corporate will to do so. If all EHRs had to show their practical usability users would rejoice. Your best bet here may be to become active in your EHR vendor’s user group. You may not get direct relief, but you’ll have a place, albeit small, at the table. Otherwise, given vendor and regulatory resistance to usability improvements, you’re better off pushing for a new EHR or writing your own EHR front end.

4. Make EHRs Smarter. If Watson can outsmart Kent Jennings, can’t artificial Intelligence make EHRs smarter? As one of my old friends used to tell our city council, “The answer is a qualified yes and a qualified no.”

AI takes on many, many forms and EHRs can and do use it. Primarily, these are dictation – transcription assistant systems. They’re known as Natural Language Processing (NLP). Sort of scribes without bodies. NLP takes a text stream, either live or from a recording, parses it and puts it in the EHR in its proper place. These systems combine the freedom of dictation with AI’s ability to create clinical notes. That allows the theory maintains, a user to maintain patient contact while creating the note, thus solving the keyboarding dilemma.

 The best-known NLP system Nuance’s Dragon Medical One, etc. Several EHR vendors have integrated Dragon or similar systems into their offerings. As with most complex, technical systems, though, NLP implementation requires a full-scale tech effort. Potential barriers are implementation or training shortcuts, workflow integration, and staff commitment. NLP’s ability to quickly gather information and place it is a given. What’s not so certain is its cost-effectiveness or its product quality. In those respects, its quality and efficacy is similar to scribes and subject to much the same scrutiny.

One interesting and wholly unexpected NLP system result occurred in a study by the University of Washington Researchers. The study group used an Android app NLP dictation system, VGEENS, that captured notes at the bedside. Here’s what startled the researchers:

….Intern and resident physicians were averse to creating notes using VGEENS. When asked why this is, their answers were that they have not had experience with dictation and are reluctant to learn a new skill during their busy clinical rotations. They also commented that they are very familiar with creating notes using typing, templates, and copy paste.

The researchers forgot that medical dictation skills are just that, a skill and don’t come without training and practice. It’s a skill of older generations and that keyboarding is today’s given. 

5. Offload to Patients. I hadn’t thought of this one until I saw an article in the Harvard Business Review. In a wide-ranging review, the authors saw physicians as victims of medical overconsumption and information overload:

In our recent studies of how patients responded to the introduction of a portal allowing them to e-mail health concerns to their care team, we found that the e-mail system that was expected to substitute for face-to-face visits actually increased them. Once patients began using the portal, many started sharing health updates and personal news with their care teams.

One of their solutions is to offload data collection and monitoring to patient apps:

Mightn’t we delegate some of the screening work to patients themselves? Empowering customers with easy-to-use tools transformed the tax reporting and travel industries. While we don’t expect patients to select what blood-pressure medications to be on, we probably can offload considerable amounts of the monitoring and perhaps even some of the treatment adjustment to them. Diabetes has long been managed this way, using forms of self-care that have advanced as self-monitoring technology has improved.

This may be where we are going; however, it ignores the already crowded app field. Moreover, every app seems to have its own data protocol. Health apps are a good way to capture and incorporate health data. They may be a good way to offload physicians’ keyboarding, but health apps are a tower of protocol Babel right now. This solution is as practical as saying that the way to curb double entering data in EHRs is to just make them interoperable.

What’s an EHR User to Do?

If each current approach to reducing keyboarding has problems, they are not fatal. I think that physician keyboarding is a problem and that it is subject to amelioration, if not solution.

For example, here’s Nordic’s Joel Martin on EHR usability:

… In reality, much of this extra work is a result of expanded documentation and quality measure requirements, security needs, and staffing changes. As the healthcare industry shifts its focus to value-based reimbursement and doing more with less, physician work is increasing. That work often takes place in the EHR, but it isn’t caused by the EHR’s existence.

Blaming the EHR without optimizing its use won’t solve the problem. Instead, we should take a holistic view of the issues causing provider burnout and use the system to create efficiencies, as it’s designed to do.  

The good news is that optimizing the EHR is very doable. There are many things that can be done to make it easier for providers to complete tasks in the EHR, and thereby lower the time spent in the system.

Broadly speaking, these opportunities fall into two categories.

First, many organizations have not implemented all the time-saving features that EHR vendors have created. There are features that dramatically lower the time required to complete EHR tasks for common, simple visits (for instance, upper respiratory infections). We rarely see organizations that have implemented these features at the time of our assessments, and we’re now working with many to implement them.

In addition, individual providers are often not taking advantage of features that could save them time. When we look at provider-level data, we typically see fewer than half of providers using speed and personalization features, such as features that let them rapidly reply to messages. These features could save 20 to 30 minutes a day on their own, but we see fewer than 50 percent of providers using them.

Optimization helps physicians use the EHR the way it was intended – in real-time, alongside patient care, to drive better care, fewer mistakes, and higher engagement. Ultimately, we envision a care environment where the EHR isn’t separate from patient care, but rather another tool to provide it. 

What does that mean for scribes or NLP? Recognize they are not panaceas, but tools. The field is constantly changing. Any effort to address keyboarding should look at a range of independent studies to identify their strengths and pitfalls. Note not only the major findings but also what skills, apps, etc., they required. Then, recognize the level of effort a good implementation always requires. Finally, as UW’s researchers found, surprises are always lurking in major shake-ups.

Join us for this week’s #HITsm chat on Using Technology to Fight EHR Burnout to discuss this topic more.

In The Hot Seat Again: eClinicalWorks Faces Billion-Dollar Suit Over Alleged Software Problems

Posted on November 27, 2017 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.

Earlier this year, eClinicalWorks agreed to pay $155 million to the U.S. Department of Justice to resolve allegations that it had faked its conformance with Meaningful Use criteria. The DoJ suit alleged that by withholding information needed for certification, eCW violated the False Claims Act.

Now, the vendor is facing what could be an even more serious legal threat, according to a news report appearing in Becker’s Hospital Review. BHR is reporting administrator of the estate of a deceased cancer patient is suing the vendor over data display errors that may have affected the patient’s care.

What makes the stakes so high in this case is that the complaint is asking the court to certify the case as class action, with members to include “all persons residing in the United States whose physicians used eCW to record and store their medical records at all dates relevant.” The suit is asking the court to award plaintiffs $999 million in damages, Becker’s Hospital Review reports.

According to the complaint, which was filed by Kristina Tot, administrator of the estate of the deceased Stjepan Tot, errors with eCW software began to appear before the cancer patient’s death. For example, “he was unable to display his medical history or progress notes,” the complaint reportedly states.

The cancer patient’s problems were far from unique, however, the suit asserts. According to the complaint, important eCW software functions didn’t work or violated regulatory guidelines. The filing claims the vendor didn’t provide accurate and reliable health information, displayed incorrect panels and didn’t record EHR user actions in audit logs.

The bottom line, the suit claims, is that millions of patient records were compromised, leaving patients and physicians unable to rely on the eCW platform.

I am not qualified to speak on whether there’s any merit to the latest suit against eCW, though I think it’s reasonable to assume that the company may not have its act together. (You might also want to check out the angry eCW critiques on this site — whose publisher, like our fearless leader John Lynn, I know to have an impeccable reputation for honesty.)

Ultimately, it’s hard to say whether this latest suit is largely blowback from the previous certification problem or yet another (extremely) costly headache. Either way, if I were part of its leadership team I’d be more than a little shaken by recent events even if the recent complaint gets dismissed.

Elderly Doctor May Lose Medical License Due In Part To Lack Of Computer Skills

Posted on November 10, 2017 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.

Do physicians need to be computer-literate to run a safe and effective medical practice? The question has come into high relief recently as an 84-year-old New Hampshire physician fights to get her medical license reinstated.

Dr. Anna Konopka, who recently lost her license due in part to a lack of computer skills, is suing the New Hampshire Board of Medicine in an effort to get it reinstated.

Back in September, Konopka had signed an agreement to surrender her license with the medical board. The agreement settled pending allegations regarding her “record-keeping, prescribing practices, and medical decision-making,” according to an article in Ars Technica. The agreement reportedly permits her to apply to regain her license, but to succeed in doing so she’d have to prove that she did no wrong.

In her interview with the publication, the elderly physician denied any misconduct and said she was under duress when she voluntarily surrendered her license previously. She has said that she wants to continue practicing medicine, but does not want to participate in what she calls “electronic medicine.”

“I am getting the patients from the system [her term for the medical bureaucracy surrounding the use of EMRs today], and I see how badly they are mistreated and misdiagnosed or not diagnosed at all,” she told Ars Technica. “Therefore, I am not going to compromise patients’ lives or health for the system.”

For what it’s worth, Konopka’s troubles with the state medical board didn’t arise from computer use or lack thereof. They were triggered when a formal complaint was filed with the board alleging that she treated a young patient with asthma incorrectly.

The dispute resulted in a formal reprimand from the medical board in April 2017. The board also required her to undergo 14 hours of medical training as a condition of continuing to practice. After that, other investigations followed, including disputes over the scope of her original agreement with the medical board.

Ordinarily, Konopka’s struggles for reinstatement might never have come to public view. What differentiates them from others is the role her unwillingness to use computers has played in the process. Specifically, unless she learns to use the Internet, she won’t be able to comply with the state’s new law requiring her to access an online opiate monitoring program. (As part of her attempts to regain her license, she’s agreed to do so.)

It’s hard to tell who is right in this particular case, but the situation does raise interesting questions about the role of computer use in medical practice generally.

Should physicians be required to use computers as part of their practice in this day and age, and if so, what level of competency should they be required to attain? Are there specific pieces of software, such as EMRs, they have become as important to medicine as a stethoscope was in a prior era? Should use of health IT software be a required part of all medical training at this point?

I don’t have any answers to these questions, and you may not either. But if a doctor’s license can be threatened, even in part, by failing to use computer technology, we’d better work on finding some.

Patient Generated Data, Workflow and Usability Coming Into Focus for EHR Vendors

Posted on October 16, 2017 I Written By

Colin Hung is the co-founder of the #hcldr (healthcare leadership) tweetchat one of the most popular and active healthcare social media communities on Twitter. Colin speaks, tweets and blogs regularly about healthcare, technology, marketing and leadership. He is currently an independent marketing consultant working with leading healthIT companies. Colin is a member of #TheWalkingGallery. His Twitter handle is: @Colin_Hung.

At the recent Medical Group Management Association annual conference (MGMA17), I made a point of visiting as many of the EHR vendors in the exhibit hall as I could so that I could ask them two questions:

  1. What are you working on right now, given that there is a bit of a lull between ONC requirements?
  2. How do EHRs and EHR vendors need to evolve over the next 5 years?

Below are some of the best responses I received.

Steve Dart, Senior Director of Product Management at AdvancedMD believes that both EHRs and EHR companies need to fundamentally change their paradigms in order to thrive over the next five years. “EHRs should facilitate the job that needs to get done rather than serve as a documentation repository,” says Dart. “What is that job? Helping patients live healthier lives while at the same helping physicians be happier at work. We really missed the boat during the Meaningful Use (MU) gold rush. We neither helped patients be healthier nor did we make physician lives easier. In fact, as an industry we generally made things more difficult for doctors.”

AdvancedMD is charting a new path forward, instead of just fixing their user interface (UI), they are rethinking their entire approach to their EHR. The company is taking full advantage of the lull in MU requirements by using the time to bring together designers, UI experts, physicians and office managers to design a brand new EHR. Dubbed the “connect the dots” strategy, AdvancedMD is centering their next generation on clinical and administrative workflows.

“When you think about it, healthcare is really just a journey of sequential workflows,” Dart explains. “A patient starts by experiencing symptoms, then moves to research physicians online, schedules an appointment, comes in for their visit, goes to get lab tests done, comes back to discuss the results and fills a prescription. What EHR companies have done is create whole bunch of point solutions for each one of these situations. What we haven’t done well is connect these all together with technology. We siloed everything. Instead what we need to realize is that each situation is actually a complex workflow and we journey from one workflow to another as patients. What we need now, and what AdvancedMD believes, is that we should build technology that enables these workflows – make them easier and more seamless for patients and physicians. Data collection, for example, should happen on devices that both doctors and patients already use and in a way that doesn’t detract from the visit.”

To illustrate that AdvancedMD is doing more than just giving their theory lip-service, Dart showed an early design prototype of an EHR interface that provides a longitudinal view of a practice. Instead of clicking down into one patient to order labs or renew prescriptions and then clicking down into the next patient to do the same, the new interface groups all lab orders together and all the prescriptions together. One click and the physician can see all that they need to do and clicks once to push the orders ahead. The new interface is highly intuitive and functional.

Juan Molina, VP of Strategy and Business Development at CareCloud also believes that EHRs need to radically change. “EHRs need to allow doctors and their staff to do their jobs better,” says Molina. “We have to stop asking doctors to be data entry clerks and documentation specialists. They need to go back to being 100% focused on the patient and providing care. As an industry we have focused too much on checking the box. We need to move beyond that through better use of technology – especially modern cloud-based architectures.”

Mollna is most excited about the potential of real-time analytics and Artificial Intelligence (AI) at the point of care. He feels that the promise of precision medicine and true personalized care will only be possible if “massive amounts of health data is crunched and context from that data delivered to the doctor at the time when they are seeing a patient.” CareCloud is using the freedom from compliance requirements to work on new partnerships for deep analytics, AI and patient experience (read about their partnership with First Data here).

It is refreshing to hear EHR companies talk about collaboration. Over the past several years it was frustrating to see vendors attempt to build everything themselves only to end up with inferior solutions to what was readily available in other industries from other vendors. Partnership and collaboration are a welcome shift in EHR strategy.

athenahealth is actively pursuing partnerships as part of their More Disruption Please (MDP) program. “We are constantly expanding and improving our cloud-based platform to align with our vision,” says Stephanie Zaremba, Director of Government and Regulatory Affairs at athenahealth. “We want to see a healthcare industry free from administrative burden, enabled to care for diverse and disparate populations, and one that ultimately lets doctors be doctors. We believe that the current paradigm of federal regulations hinders, rather than helps, our industry from making this vision a reality. The innovation we so desperately need can’t flourish in the confines of check-the-box requirements that do not grow and evolve with technological advances. But even if we’re stuck with the regulatory status quo, in the next five years, we hope that vendors will continue to embrace their collective potential, shifting from competitors to collaborators in an effort to create a more provider-friendly, patient-facing, and connective tech landscape that captures the full continuum of care.”

The announcement of the partnership between Pulse Systems and InteliChart at MGMA17 is a prime example of this newfound collaborative spirit. For years Pulse offered a perfectly serviceable patient portal, yet they recognized that they would never pour as much time and effort into that area of their solution versus a company like InteliChart.

“We are pursuing an open-EHR strategy,” explains Chris Walls, President & CEO of Pulse Systems. “Although we provide a comprehensive solution, we recognize that clients may not want every component from our stack. They may want to keep a best-of-breed solution that they already have in place. Rather than force our clients to change, we are working to ensure we can integrate and play nice with others.”

Pulse arrived at this open approach by listening closely to clients and prospects. What they found was an under-current of a best-of-breed approach. Physician offices wanted to use different tools and applications from different vendors but the lack of integration and internal IT resources forced them to go with a single monolithic solution instead.

Through this listening exercise, Pulse also realized that it was more than an EHR vendor to its clients. Many of their clients are smaller practices which do not have ready access to technical support. Rather than deflect their client’s calls for help with mundane things like anti-virus updates, internet connection issues and printer failures, they leaned into it. They created a dedicated IT Field Support team that handles calls for routine IT issues and will even fly out to help a client if needed.

By proactively helping their clients in this manner, Pulse has found that they reduce EHR issues down the road and they engender tremendous loyalty. When you think about it Pulse is essentially applying a Population Health approach to their own clients – offering preventative maintenance to avoid more costly support calls in the future.

Most impressive is how Greenway Health is using this lull in compliance requirements. “Now that we are freed from working on ONC compliance work, we are putting focus on customer requested enhancements” says Mark Janiszewski, EVP of Product Managmeent & Corporate Development at Greenway. “Much to the delight of our customers, we can now apply resources to the enhancements that they have asked for, but that were lower in priority compared to what was needed to comply with regulations and the Meaningful Use program.”

Greenway is also using their “found time” to take a serious look at EHR usability. They recognize that there is tension between physicians and EHR makers caused by the endless clicking and confusing user interfaces. Greenway is hoping to relieve that tension by collaborating with clients to improve their system. According to Janiszewski, the company has planned a series of customer visits where a team of designers and engineers can observe how people interact with their system over a 2-3 day period.

The team has already identified several areas of improvement after observing how admin staff were copying down ID numbers from one screen onto post-it notes in order to key it in on a different screen to bypass a lengthy click-path. The team is hard at work to ensure data is transferred across the system more seamlessly.

Over the next five years, Janiszewski believes that EHR companies will have to embrace the concept of multiple care settings and multiple data sources: “EHRs will need to have a higher degree of interoperability as patients move between care settings – from acute care to rehab to home care or from acute care to elder care. EHRs will also need to solve for Patient Generated Data. We are all wearing fitness trackers and using apps to track our health. This data needs to be incorporated in a meaningful way into the EHR. “

The responses from MGMA17 demonstrates that companies are well aware of the negative feelings healthcare providers have towards EHRs. What is very encouraging is that fixing the user interface is only one of many different solutions being pursued by EHR companies. Rather than myopically focusing on the shiny object in front of them, companies like Greenway, Pulse, athenahealth, CareCloud and AdvancedMD are taking a step back and looking at healthcare with a broader perspective in order to identify opportunities for improvement. It will be interesting to circle back with them a year from now to see what progress has been made.

Usability, Interoperability are Political Questions: We Need an EHR Users Group

Posted on October 6, 2017 I Written By

When Carl Bergman isn’t rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com, a free service for matching users and EHRs. For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manger doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst.

Over the years, writers on blogs such as this and EMRandHIPAA have vented their frustration with lousy EHR usability and interoperability problems. Usability has shown no real progress unless you count all the studies showing that its shortcomings cost both time and money, drives users nuts, and endangers patient lives.

The last administration’s usability approach confused motion with progress with a slew of roadmaps, meetings and committees. It’s policies kowtowed to vendors. The current regime has gone them one better with a sort of faith based approach. They believe they can improve usability as long it doesn’t involve screens or workflow. Interoperability has seen progress, mostly bottom up, but there is still no national solution. Patient matching requires equal parts data, technique and clairvoyance.

I think the solution to these chronic problems isn’t technical, but political. That is, vendors and ONC need to have their feet put to the fire. Otherwise, in another year or five or ten we’ll be going over the same ground again and again with the same results. That is, interop will move ever so slowly and usability will fade even more from sight – if that’s possible.

So, who could bring about this change? The one group that has no organized voice: users. Administrators, hospitals, practioners, nurses and vendors have their lobbyists and associations. Not to mention telemed, app and device makers. EHR users, however, cut across each of these groups without being particularly influential in any. Some groups raise these issues; however, it’s in their context, not for users in general. This means no one speaks for common, day in day out, EHR users. They’re never at the table. They have no voice. That’s not to say there aren’t any EHR user groups. There are scads, but vendors run almost all of them.

What’s needed is a national association that represents EHR users’ interests. Until they organize and earn a place along vendors, etc., these issues won’t move. Creating a group won’t be easy. Users are widely dispersed and play many different roles. Then there is money. Users can’t afford to pony up the way vendors can. An EHR user group or association could take many forms and I don’t pretend to know which will work best. All I can do is say this:

EHR Users Unite! You Have Nothing to Lose, But Your Frustrations!

Health System Sues Cerner Over Billing-Related Losses

Posted on October 5, 2017 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.

If I asked you what issues cause the biggest conflicts between EMR vendors and their clients, you might guess that clinical data management disputes or customer service issues topped the list. But actually, in my experience the most common problems health systems encounter in their EMR rollouts are billing-related.

For example, Dana-Farber Cancer Institute just announced a $44.2 million operating loss for the third quarter of fiscal 2017. The Boston-based hospital attributes at least part of its losses to billing issues associated with its Epic system. Leaders at Dana-Farber said that these billing issues had cost the hospital roughly $25 million since it rolled out Epic in May 2015, according to Becker’s Hospital CFO Report.

Another instance comes from Healthcare IT News, which reports that Cerner is being sued by a health system accusing the vendor of selling it faulty billing software.

The suit, by Wisconsin-based Agnesian Healthcare, accuses Cerner of fraud and breach of warranty, and asserts that issues with Cerner’s revenue cycle software led to losses of more than $16 million. The hospital system contends that these problems have damaged its reputation and generated $200,000 a month in damages. (Cerner disputes these allegations, of course.)

According to HIN, the hospital system went live with Cerner’s RCM software in 2015, for which it paid $300,000. Agnesian’s suit says that problems with the Cerner package began shortly after rollout, generating widespread errors in its patient billing statements.

According to the health system, its billing process was so compromised that it had to send out statements by hand. (Yes, I can feel you cringing from here.) Given the delays inherent in relying on manual processes, Agnesian ended up with a huge backlog of unprocessed statements, some of which it deemed uncollectible and wrote off.

When the health system alerted Cerner about its concerns, the vendor got involved, and in 2016 it told Agnesian that problems have been addressed.  Nonetheless, this year the health system found “major additional coding errors” which led to another round of lost revenue, Agnesian says.

And brace yourself for more cringing: according to the suit, the Cerner RCM software had been writing off reimbursable charges without informing the health system. If you’re an RCM leader or CFO, this is the stuff of nightmares.

Ultimately, Cerner agreed that the RCM solution needed to be rebuilt given the depth of the coding errors found in the software, but that didn’t happen, the suit says. In a final indignity, the personnel tasked with rebuilding the RCM solution left Cerner before completing the rebuild.

Given all the aforementioned mishegas, it will be many a month before billing processes normalize even if Cerner fixes its RCM software, the health system says. And of course, it’s likely to end up writing off more bills under the circumstances, which has got to be very painful by this point.

Agnesian’s suit asks the court to cancel the Cerner contract and award it direct, indirect and punitive damages. Cerner, meanwhile, seems to want to go into arbitration. We’ll see which side blinks first.

A Look At Share Everywhere, Epic’s Patient Data Sharing Tool

Posted on September 28, 2017 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.

Lately, it looks like Epic has begun to try and demonstrate that it’s not selling a walled garden. Honestly, I doubt it will manage to convince me, but I’m trying to keep an open mind on the matter. I do have to admit that it’s made some steps forward.

One example of this trend is the launch of App Orchard, a program allowing medical practices and hospitals to build customized apps on its platform. App Orchard also supports independent mobile app developers that target providers and patients.

Marking a break from Epic’s past practices, the new program lets developers use a FHIR-based API to access and Epic development sandbox. (Previously, Epic wouldn’t give mobile app developers permission to connect to its EMR unless a customer requested permission on its behalf.) We’ll have to keep an eye on the contracts they require developers to sign to see if they’re really opening up Epic or not.

But enough about App Orchard. The latest news from Epic is its launch of Share Everywhere, a new tool which will give patients the ability to grant access to their health data to any provider with Internet access. The provider in question doesn’t even have to have an EHR in place. Share Everywhere will be distributed to Epic customers at no cost in the November update of its MyChart portal.

Share Everywhere builds on its Care Everywhere tool, which gives providers the ability to share data with other healthcare organizations. Epic, which launched Care Everywhere ten years ago, says 100% of its health system customers can exchange health data using the C-CDA format.

To use Share Everywhere, patients must log into MyChart and generate a one-time access code. Patients then give the code to any provider with whom they wish to share information, according to a report in Medscape. Once they receive the code, the clinician visits the Share Everywhere website, then uses the code once they verify it against the patient’s date of birth.

As usual, the biggest flaw in all this is that Epic’s still at the center of everything. While patients whose providers use Epic gain options, patients whose health information resides in a non-Epic system gain nothing.

Also, while it’s good that Epic is empowering patients, Direct record sharing seems to offer more. After all, patients using Direct don’t have to use a portal, need not have any particular vendor in the mix, and can attach a wide range of file formats to Direct messages, including PDFs, Word documents and C-CDA files. (This may be why CHIME has partnered with DirectTrust to launch its broad-based HIE.)

Participating does require a modest amount of work — patients have to get a Direct Address from one of its partners — and their provider has to be connected to the DirectTrust network. But given the size of its network, Direct record sharing compares favorably with Share Everywhere, without involving a specific vendor.

Despite my skepticism, I did find Share Everywhere’s patient consent mechanism interesting. Without a doubt, seeing to it that patients have consented to a specific use or transmission of their health data is a valuable service. Someday, blockchain may make this approach obsolete, but for now, it’s something.

Nonetheless, overall I see Share Everywhere as evolutionary, not revolutionary. If this is the best Epic can do when it comes to patient data exchange, I’m not too impressed.

What’s Involved In Getting To EHR 2.0?

Posted on September 22, 2017 I Written By

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

While the current crop of EHRs have (arguably) served a useful purpose, I think we’d all agree that there’s a ton of room for improvement. The question is, what will it take to move EHRs forward?

Certainly, we face some significant obstacles to progress.

There are environmental factors in play, such as reimbursement issues.

There’s the question of what providers will do with existing EHR infrastructure, which has cost them tens or even hundreds of millions of dollars if next-gen EHRs call for a new technical approach.

Then, of course, there’s the challenge of making the darn things usable by real, human clinicians. So far, we simply haven’t gotten anything that solves that issue yet.

That doesn’t mean people aren’t considering the issue, however. One health IT leader that’s stepped up to the plate is Dr. John Halamka, chief information officer of the Beth Israel Deaconess Medical Center and CIO and dean for technology at Harvard Medical School.

In his Life As Healthcare CIO, Halamka lays out the changes he sees as driving the shift to EHR 2.0. Here are some of his main points:

  • Regulators are shifting their focus from prescribing certain types of EHR functionality to looking at results technology achieves. This supports the healthcare industry’s movement from a data recording focus to an outcomes focus.
  • With doctors being pulled in too many directions, it will take teams to maintain patient health, this calls for a new generation of communication and groupware tools. These tools should include workflow integration, rules-based escalation messages, and routing based on time of day, location, schedules, urgency, and licensure.
  • With value-based purchasing gradually becoming the norm, EHRs need new capabilities. These should include the ability to document care plans and variation from those plans, along with outcomes reported from patient-generated healthcare data. Eventually, this will mean the dawn of the Care Management Medical Record, which enrolls patients and protocols based on their condition then ensures that patients get recommended services.
  • EHRs must be more usable. To accomplish this, it’s helpful to think of EHRs as platforms upon which entrepreneurs can create add-on functionality, along the lines of apps that rest on top of mobile operating systems.
  • Next-gen EHRs need to become more consumer-driven, making patients an equal member of the care team. Although existing EHR models do have patient portals, they aren’t robust enough to connect patients fully with their care, and they don’t include tools helping patients navigate their care system.

As far as I can tell, Dr. Halamka has covered the majority of issues we need to address in transitioning to new EHR models. I was also interested to learn that regulatory bodies have begun to “get it” about the limitations of demanding certain functions be included in an EHR system.

I’m still left with one question, however. How does interoperability fit into this picture? Can we even get to the next generation of EHRs without answering the question of how they share data between one another? To me, it’s clear that the answer is no, we can’t leave this issue aside.

Other than that, though, I found Dr. Halamka’s analysis to be fairly comforting. Nothing he’s described is out of reach, unless, of course, vendors won’t cooperate. I think that as providers reach the conclusions he has, they’ll demand the kind of functionality he’s outlined, and vendors will have no choice but to pony up. In other words, there might actually be light at the end of the EHR tunnel.

Why Delaying the Transition to 2015 Edition Technology Would Be a Problem for Patients and Families – MACRA Monday

Posted on September 11, 2017 I Written By

The following is a guest blog post by Erin Mackay, Associate Director, Health Information Technology Policy and Programs, National Partnership for Women & Families.  This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program (QPP) and related topics.

The National Partnership for Women & Families recently weighed in on the Centers for Medicare & Medicaid Services’ (CMS) proposed rule for 2018 updates to the Quality Payment Program (QPP). In our comments, we express concerns that many of the proposed requirements would have a chilling effect on the country’s badly needed transition to a health care system that rewards quality and value over volume. Of particular concern to us is the proposed delay in clinicians’ transition to the 2015 Edition electronic health record (EHR) certification requirements.

Putting off requirements to use more advanced health IT would be a one-two punch to health transformation. First, new models of care that demand high-quality, efficient practices and coordinated care rely on robust health IT. Likewise, these new models only succeed when patients have the information – about their medications, health status, diagnoses and treatment received – they need to participate in their care and make informed decisions with their health care teams.

Here are three ways the proposed rule would delay critical functionalities that are foundational to a patient and family-centered health care system:

1) Delaying Availability of APIs for Consumer Access
It would undermine the commitment to patient engagement to delay the availability of application programming interfaces (APIs) as a way for patients and their caregivers to access, download and share health data. When available, APIs will let consumers choose from a range of apps that pull in health data from various health care providers and hospitals, helping form a comprehensive picture of their health and health care and facilitating information sharing. Gone will be the days when patients and family caregivers struggled to remember passwords for multiple patient portals, or were able to view only one aspect of their medical history at a time.

2) Slowing More Robust Collection of Demographic Data
To enhance health equity, we must first be able to identify disparities by gathering standardized, granular demographic data. Right now, certified EHRs are not designed to distinguish among Chinese, Indian or Vietnamese patients, for instance, instead collapsing these identities into a single “Asian” category. Similarly, EHRs cannot currently store structured information about patients’ sexual orientation or gender identity. In both these examples, this information has clinical relevance and is vital for improving health outcomes. For example, too often transgender individuals do not receive appropriate “gendered” preventive screenings such as Pap tests, mammograms and prostate exams.

3) Failing to Capture Information on Social Determinants of Health
In addition to better demographic information, to best support providers in delivering patient- and family-centered care, EHRs should also capture information about non-clinical factors pertinent to individuals’ health. The 2015 Edition includes a new criterion to capture relevant social, psychological and behavioral data. This includes information on financial resource strain, educational attainment, stress, depression, physical activity, alcohol use, social connection and isolation, and intimate partner violence. At the individual level, this information could help clinicians and care teams determine treatment options that address the unique needs of the patients and families they serve. To improve population health, clinicians, hospitals and community organizations need this information to identify communities that need additional support in order to get and stay healthy.

Conclusion
Overall, the proposed rule for QPP 2018 raises a number of concerns for the National Partnership, particularly the proposed delay of 2015 Edition certified health IT products. We strongly encourage CMS to maintain the current requirements and timeline for clinicians transitioning to the 2015 Edition to provide the necessary infrastructure for the kind of patient- and family-centered health system our country urgently needs.

Xerox Files Patents For Blockchain-Based Tech With Healthcare Applications

Posted on September 5, 2017 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.

According to a site focused on blockchain technology, Xerox has filed patents for technology using blockchain to securely revise electronic documents. The patent application was filed in February of last year, but the move became news this month when it was reported by Coin Telegraph.

According to the site, the patent filings propose a network of nodes that can create and update documents and share data using blockchain technology. The system can be used by regional hospital organizations to exchange electronic health records, Xerox says in its application.

In a more-recent blog post, Xerox India’s director of global document outsourcing, Ritesh Gandotra, asserts that the use of blockchain can offer unique benefits.

“Historically, EHRs were never really designed to manage multi-institutional and lifetime medical records,” he writes. “…Adopting the blockchain structure to EHRs will help manage authentication, confidentiality, accountability and data sharing while allowing medical researchers to access insights into medical treatment.”

Xerox is hardly the first organization to take an interest in blockchain’s potential as a backbone for health data management. Not only that, but leaders in the industry are developing what look like practical models for using blockchain in this manner.

For example, my colleague John Lynn recently shared an infographic outlining a use case for blockchain in healthcare. You’ll probably learn more by clicking through and looking at the infographic yourself, but in summary, the model outlines a process in which:

  • Health organizations direct administrative information to the blockchain via APIs and track clinical data in parallel using existing health IT
  • The blockchain stores each transaction with a unique identifier
  • When they need information, healthcare organizations query the blockchain
  • Patients share their identity with healthcare organizations, using a private key that links their identity to blockchain data

Not only that, high-profile industry thinkers like John Halamka, MD, CIO at Beth Israel Deaconess Medical Center, have developed their own models for the use of blockchain in healthcare. (In a Harvard Business Review article, Dr. Halamka describes a system for managing EHRs using blockchain which he and his co-authors call “MedRec.”)

What’s striking here is that while Xerox may have filed some patent applications, it probably doesn’t know anything we don’t. The applications it describes for blockchain in healthcare document management certainly sound fine, and may be the basis for something great in the future.

If you look around the web, however, you’ll see that virtually anyone with an interest in health IT is out there making predictions about its applications for healthcare. What will really be interesting is when we get beyond ideas — as intriguing as they can be — and pilot some real, concrete technology.

In the meantime, let the blockchain games continue. Obviously, Xerox won’t be the last company angling for a piece of this market. There’s little doubt it will come to something eventually, and the rewards will be great for the company that helps to shape its future.