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#HIMSS16: Some Questions I Plan To Ask

Posted on February 1, 2016 I Written By

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

As most readers know, health IT’s biggest annual event is just around the corner, and the interwebz are heating up with discussions about what #HIMSS16 will bring. The show, which will take place in Las Vegas from February 29 to March 4, offers a ludicrously rich opportunity to learn about new HIT developments — and to mingle with more than 40,000 of the industry’s best and brightest (You may want to check out the session Healthcare Scene is taking part in and the New Media Meetup).

While you can learn virtually anything healthcare IT related at HIMSS, it helps to have an idea of what you want to take away from the big event. In that spirit, I’d like to offer some questions that I plan to ask, as follows:

  • How do you plan to support the shift to value-based healthcare over the next 12 months? The move to value-based payment is inevitable now, be it via ACOs or Medicare incentive programs under the Medicare Access and CHIP Reauthorization Act. But succeeding with value-based payment is no easy task. And one of the biggest challenges is building a health IT infrastructure that supports data use to manage the cost of care. So how do health systems and practices plan to meet this technical challenge, and what vendor solutions are they considering? And how do key vendors — especially those providing widely-used EMRs — expect to help?
  • What factors are you considering when you upgrade your EMR? Signs increasingly suggest that this may be the year of the forklift upgrade for many hospitals and health systems. Those that have already invested in massiveware EMRs like Cerner and Epic may be set, but others are ripping out their existing systems (notably McKesson). While in previous years the obvious blue-chip choice was Epic, it seems that some health systems are going with other big-iron vendors based on factors like usability and lower long-term cost of ownership. So, given these trends, how are health systems’ HIT buying decisions shaping up this year, and why?
  • How much progress can we realistically expect to make with leveraging population health technology over the next 12 months? I’m sure that when I travel the exhibit hall at HIMSS16, vendor banners will be peppered with references to their population health tools. In the past, when I’ve asked concrete questions about how they could actually impact population health management, vendor reps got vague quickly. Health system leaders, for their part, generally admit that PHM is still more a goal than a concrete plan.  My question: Is there likely to be any measurable progress in leveraging population health tech this year? If so, what can be done, and how will it help?
  • How much impact will mobile health have on health organizations this year? Mobile health is at a fascinating moment in its evolution. Most health systems are experimenting with rolling out their own apps, and some are working to integrate those apps with their enterprise infrastructure. But to date, it seems that few (if any) mobile health efforts have made a real impact on key areas like management of chronic conditions, wellness promotion and clinical quality improvement. Will 2016 be the year mobile health begins to deliver large-scale, tangible health results? If so, what do vendors and health leaders see as the most promising mHealth models?

Of course, these questions reflect my interests and prejudices. What are some of the questions that you hope to answer when you go to Vegas?

Our First Year with a Patient Portal

Posted on August 11, 2013 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 month marked the end of our first year with our web portal.  It has been a steep but worthwhile learning curve.  Similar to every other component of our IT system there were many bumps along the way.  Here are some observations worth sharing:

  1. If you build it – and promote it – they will come.  There is no question that patients in our North Atlanta market like the portal.  Over the first 12 months 12,518 patients have signed up and completed over 130,000 health, demographic and general consent forms.  Participation has increased steadily as we have refined web page usability and improved the reliability of the system.  Subjectively I think about 2/3 of my new patients are using the portal to enter their demographic and personal health information prior to their initial appointment.
  2. Overpromotion backfires.  Our telephone-greeting message says, “To schedule an appointment, dial 0 or go to www.entofga.com.”  Sounds reasonable enough, but patients have misinterpreted this message as meaning that we don’t want to talk to them.
  3. If it doesn’t work, patients get angry – with good reason.  Nothing is more frustrating than spending 45 minutes filling out all your information at home and then getting handed the same forms on paper at the office because your online data was lost.  The IT folks seem to think if the explanation for the failure is fancy enough that will make everything OK.  It doesn’t.
  4. Patients who choose not to use the portal at home don’t want to use it in the waiting room, either.  We have tried iPads, laptops and desktop kiosks.  We have trained our front office folks to promote it and even “walk patients through” the portal.  Nothing has worked.  We have considered recruiting those patients with a different technology such as scanned #2 lead pencil bubble forms, at least for the discrete data.
  5. Patients have little interest in using the portal as an ongoing tool.  After the initial creation of the account, data entry and first appointment, they rarely use the portal again.  Last month with over 12,000 patients enrolled we got only 6 prescription refill requests and 24 “ask the doctor” questions.   Appointment requests were slightly better at 134.  Our telephone appointment schedulers tell me they frequently get calls from folks who made an appointment request online but then immediately call for the same appointment because they were not comfortable with the online appointment concept.  One could argue that this is unique to our specialty practice or that the online forms and workflow need improving.  That may be true, but I am convinced that at least a part of this phenomenon represents cultural pushback from patients.
  6. The ROI on the web portal is in some ways an all-or-nothing situation.  For a while the portal was passing to EMR only about 15 of the 20 data fields required to complete our demographic database.  Intuitively one would think the portal was therefore “75% useful”.  The problem is if I have to pay staff to open the patient’s file to manually enter the 5 remaining fields, I may as well have them manually enter all 20 fields.  That makes the portal 0% useful.  I can’t reassign staff to better things until the portal passes 100% of the data to the EMR.  This also relates to the reliability issues described above.  Until we reach near 100% reliability the return on investment is limited.
  7. As with every health IT product we have ever tried, it doesn’t work completely as advertised.  Although the new patient workflow is going fairly well other features remain severely compromised.  In our vendor’s defense this is partly because our parent EMR has had some upgrades which in turn requires our vendor to update the portal to adapt to the EMR changes.  The point is that none of these products is “plug and play” and the industry has a long way to go before these products become easy to use and practical for everyone.
  8. There are unintended consequences of a web portal.  Unbeknownst to us our portal was directing patients to the vendor’s personal health record product.  The transition is apparently pretty seamless so patients often still thought they were still inside our portal when they encountered very personal questions (i.e., sexual history) that had no relevance to their ear / nose  / throat appointment.

As an “early adopter” practice we are pleased overall with the portal but I’m not sure how a more typical practice would feel.

e-Prescribing: First Impressions

Posted on July 8, 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.

A couple of weeks ago we rather unceremoniously added e-prescribing into our EMR system.  Because of my mistaken interpretation of the CMS guidelines on Medicare e-Rx incentives and penalties we rushed e-Rx a bit.  I thought each of our physicians had to do 10 Medicare e-Rx prescriptions before June 30.  It turns out you are exempt from the 1% Medicare penalty if you have a certified EMR.  The CMS guidelines are incredibly difficult to understand.  No surprise there.

My thoughts after the first 2 weeks:

  1. The concept is sound and very useful. Although it only takes a second to grab a printed script off the printer and sign it, eliminating that step is refreshing and streamlines clinic operations much more than I would have thought.   We have far fewer pieces of paper to push around.  There might even be some cost savings on paper.
  2. Cultural acceptance has been effortless. I wondered if patients would be unhappy without that precious paper prescription.  I should have known better.   We have been calling in scripts forever.
  3. The darn thing works! I held my breath waiting for the wave of angry phone calls from patients and pharmacies.  It never came.  For the first few scripts we called the pharmacies to be sure they received the script.  There was never a problem.
  4. The workflow changes will be interesting. Some changes are obvious.  We had to get the front office staff to get pharmacy information from each patient and enter it in the system.  Other implications are less clear.  Do we really need printers in every exam room now?  Do tablets become more useful over other PCs?
  5. Mistakes are rare and easy to fix. This evening on call I got a message from one of my partner’s patients alleging that her prescriptions were not “called in.”  I got into the EMR from home and saw her e-scripts were created but were never signed.  This was because we took the system off line at about the same time the chart note was created.  We had to install a patch.  I signed the prescriptions and fixed the problem in a second.
  6. The Surescripts HIE is WORTHLESS. This is the feature that allows the EMR to upload a patient’s medication list based on his/her recently filled prescriptions.  But the feature forces a “workflow paradox:”
    1. Uploading prescription histories takes considerable time.  The upload needs to be done in advance of the patient visit so it doesn’t impede workflow.  I don’t understand why it is so slow.
    2. The upload cannot be performed until the patient gives consent.  So you can’t do the upload until the patient arrives at the office and signs the form.

I suppose we could work around this via giving consent on the web portal; that would be very cumbersome.    Even if it worked well the feature does not improve our workflow.  The medication reconciliation step may make it worse.  The bottom line is I don’t care what is in the Surescripts database.  We ask patients what their medications are and they tell us.  Done.

 

Lessons Learned from our EMR Upgrade – Part 3

Posted on June 29, 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.

It is after 11 PM and I have just arrived home after a meeting with our practice leadership.   Why so late?  The meeting doesn’t start until 7 PM.  We docs can’t afford to take time out of our practices to meet during the day.  We moonlight as CEOs, CIOs, managers, etc. for our own practices.

This was the first meeting since March that was not dominated by unhappy discussions about the system upgrade.  It wasn’t even mentioned.  Tonight’s EMR discussions were forward looking, including e-prescribing, which just went live for us yesterday, and the pending results of our meaningful use gap analysis that will come out next week.  I think we have reached an appropriate point to take some perspective on our difficult upgrade.

To state the obvious first, we bit off too much at once.  Going 6 years without a software upgrade is bad enough.   But doing a major database conversion at the same time?  And buying all new servers?  And switching to VMware?  What the heck were we thinking?

As I mentioned yesterday we were afraid of using the database merge program (a.k.a. the migration tool) on our precious database until the vendor got more experience with it.  We also thought it was a reasonable strategy to feel all the pain all at once rather than spread it out over several smaller steps.  Regarding our 6 figure server purchase we were trying to cheat the old rule that any computer you buy will be obsolete by the time you get it home and plug it in.

In retrospect those were all good thoughts.  They just weren’t enough.  We failed to realize that while the migration tool was getting better through time, our database and applications were at the same time getting bigger and more complicated.  Every year we added an average of 50,000 new patients to our database.  We also added applications like our web portal and more automated document scanning / indexing.  Time also allows strange things to happen…such as when one office accidentally started scanning clinical documents into the practice management database.  Tens of thousands of documents were in the wrong place.  We picked up on it ahead of time and thought we had fixed it but the migration tool still had a problem with those image files.  Sometimes I wonder if we should have upgraded sooner and taken our chances with a less mature migration tool running on a smaller, less complicated, less entropy-riddled database.

The upgrade was harder and far more stressful than the original implementation in 2005.  I think this was because we no longer had paper charts as a lifeboat when the system wasn’t working well.  The gradual, no-hassle approach to EMR implementation that I wrote about months ago is not an option when you are switching databases.  I have a new found respect for practices that are forced to switch EMR programs.

VMware was a much bigger hassle than I expected.

When one considers that the upgrade occurred at the end of 6 years of relatively hassle-free system performance it really wasn’t that bad.   But it sure felt bad at the time, not knowing when or if we were going to get the bugs fixed.

 

Lessons Learned from our EMR Upgrade – Part 2

Posted on June 28, 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.

As I discussed in the last blog post we were very busy this past spring with our biggest EMR upgrade to date:

  1. Upgrade from the 2005 software to the 2010 version (2011 upgrade delayed on the advice of our VAR), making a big jump.
  2. Purchase new servers and new memory (SAN)
  3. Switch to virtual servers / VMware
  4. Convert our database from 2-database structure to single database to accommodate the 2010 software.

This was more of a system replacement than an upgrade.  The only parts that weren’t completely replaced were the network components and some peripheral applications (web portal and document scanning).

Despite realistic expectations the upgrade took longer than expected.  Some problems took many weeks to solve.

  1. Despite a successful test run, the dual-to-single database conversion was fraught with problems and took longer than expected.  The computer that was running the conversion software (called a “migration tool”) had a RAM failure during the operation, which slowed the conversion down but didn’t kill it.  When we saw the operation slow down we had a dilemma – do you stop to troubleshoot or let it keep running slowly?  We have over 250,000 patient records in our database so the conversion was expected to take well over 72 hours – longer than a weekend.  That meant we were already looking at EMR down time during office hours.  We stopped the migration to diagnose and replace the RAM.  Then the migration tool itself failed, forcing another interruption and requiring our vendor to troubleshoot and patch the migration tool.  The migration tool is an unusual piece of software.  You only need it once so about the time you have learned to use it you don’t need it anymore.  On the vendor side, every customer’s database / hardware situation is different, so the migration tool is never totally debugged.  That is why we delayed our upgrade so long – we wanted the vendor to gain some experience with the migration tool before we used it.  We were still by far the largest database conversion they had ever done.  In spite of the difficulties the result was an intact single database that gave us no further trouble once the migration was completed.
  2. Another contribution to our delay in upgrading was waiting for our vendor to support VMware and give us hardware specs.  Even with that accomplished VMware was a nightmare to set up.  Performance was very slow initially and took days to correct.  The biggest problem was the printers.  Printer preferences were lost several times a day and it was not unusual for my documents to get printed at a member practice across town despite having reset my printer preferences several times that day.  That wreaked havoc on clinic operations and took over a month to fix.
  3. We were blindsided by a bizarre “failure” of a T1 line to one of our offices.  The line was somehow put in some sort of diagnostic mode, rendering it unable to function but showing it as normal to our monitoring.  For days we assumed that office’s performance problems were related to the upgrade.
  4. Some issues were purely our fault.  We did not adequately staff our upgrade operations.  We had only our chief operating officer and our IT specialist to handle problems and questions; they couldn’t get off the phone long enough to fix anything.  This also impaired communications significantly.  To make things worse each of them had immediate family members become suddenly ill, requiring that they take some time off during the upgrade.

The next post will be my analysis of this great adventure.

 

Subsidiary Modules in Certified EHR Products

Posted on June 2, 2011 I Written By

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

Carl Bergman, from EHRSelector.com, sent me the following email which poses some interesting questions about various certified EHR vendors and the software that they depend on to be certified.

Many of the [certified EHR] products relied on several other software companies to function. Usually this was Dr. First’s Rocopia, Surescripts, etc. However, many others had required several subsidiary modules to work. For example, Pearl EMR lists: MS .NET Framework 3.5 Cryptographic Service Provider; SureScripts; BCA Lab Interface; Oracle TDE.

There is nothing inherently wrong with this, but it raises three questions. Does the vendor include the price, if any, for subsidiary software? More importantly, how well integrated are these programs integrated into the main program? Does the vendor take responsibility if the subsidiary software changes making them incompatible?

He definitely asks some interesting questions. I’d say that in most cases, there will be little issues with the dependent software. Any changes by the dependent software are going to have to be dealt with or in some cases replaced by the EMR vendor. That will just be part of the EMR upgrade process that the EMR vendor does for you.

The only exception might be things like the third party ePrescribing software. Depending on how this is integrated it could be an issue. In most cases, integration with the ePrescribing software can be very much like an interface with a PMS system or even a lab interface. If you’ve had the (begin sarcasm) fun (end sarcasm) of dealing with these types of interfaces you know how it can be problematic and often a pain to manage. I believe the interface with an ePrescribing module is less problematic, but it will exhibit similar issues depending on how the EMR software works with the ePrescribing.

Personally, I don’t have much problem with these types of integrations. As long as the EMR vendor is providing all of the software for you. The reason this is important is because if you get the EMR software from one vendor and the ePrescribing software from another vendor and then tell them to work together, you’re just asking for a lot of finger pointing. However, if your EMR software chooses to integrate a third party software to flesh out the certified EMR requirements and provides you all of the software, then you’re in a much better position. As they say, then you only have one neck to ring if something goes wrong. You don’t want to have to call both vendors and have each vendor point the finger at the other. That’s a position that no one enjoys.