5 Questions with Gary Singer, MD Midwest Nephrology Associates

Gary Singer, MD is the owner of Midwest Nephrology Associates in Wisconsin. The practice, which uses EClinicalWorks and PHR technology from Healow, achieved Stage 2 of Meaningful Use last year and is still actively participating in the program. It employs three physicians, one NP, one practice manager, and five staff members to care for an average of 25 patients each day. As an EClinicalWorks customer, the practice will be able to take advantage of the Carequality Interoperability Framework, which will enable it to exchange data with practices using participating EHRs.

How do you foresee the Carequality framework aiding in your practice’s ability to share health data with other providers?
The Carequality framework will provide significant improvements, specifically allowing organizations utilizing Epic to directly access our progress notes, eliminating the time consuming process of faxing. The process will save time and increase efficiency.

What are your thoughts on vendors opening up the Carequality network directly to patients?
Although I’m certain patients will widely accept and adopt the patient portals on the Carequality [framework], security has to be the highest priority.

Do you think your patients will take advantage?
Yes, specifically the older population. More than ever, people are wanting to be in control of their health and in turn, request access to their medical information. By providing patients access to the data via Carequality, it will finally give them the control they desire and deserve.

In your experience, what barriers do physician practices most often face in their interoperability efforts?
Located in southern Wisconsin, we are a small private practice surrounded by numerous hospital-owned organizations. Unfortunately, like many organizations, our systems don’t communicate and the cost of building interfaces is prohibitive to us. Once more practices adopt interoperability, we will have the ability to communicate, exchange data, and better serve our patients.

Who do you see as the biggest driver of interoperability efforts – the government, vendors, providers, or patients?
While providers and staff should be the drivers for universal adoption of interoperability, in reality the EHR vendors are driving the change. The answer should be providers, but I think it is vendors who want to facilitate interoperability between clinical systems in community-wide settings.  Providers have similar goals, but are uncertain as to how to begin the process.

How do you anticipate greater interoperability will impact patient satisfaction, access, and outcomes at your facility?
As adoption of interoperability increases, I believe patient satisfaction will improve immensely. It will increase patient safety, security and well-being, and improve their overall quality of care. 

Contacts

Jenn,  Mr. H, Lorre, Dr. Jayne, Dr. Gregg

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5 Questions with Shawn Purifoy, MD Malvern Family Medical Clinic

Shawn Purifoy, MD is the owner of Malvern Family Medical Clinic in Malvern, AR. With the help of two NPs, a dozen full-time staff, and two part-time employees, the clinic cares for an average of 70 to 100 patients per days depending on the season. The clinic, which is an EClinicalWorks shop, is working on the first year of Stage 2 Meaningful Use, has applied for the Comprehensive Primary Care Plus program, and is also participating as a PCMH in the Arkansas Medicaid program. The clinic recently signed on to join Aledade’s first ACO in the state.

Why did your practice decide the time was right to participate in an ACO?
As an independent practice in a small town, we have been very worried about the changes in healthcare delivery, as well as the new requirements on the horizon. It is my intention to remain independent for as long as possible. We knew that we needed a support system including a way to better utilize our own practice data, and I did not want to partner with a hospital. It seemed like joining an ACO was the natural fit for us. This is our first ACO experience.

Why did you decide to partner with a third party like Aledade, rather than building it out on your own?
I think trying to coordinate with other practices without some entity to manage the data, as well as the personalities that go along with multiple medical practices, would be extremely difficult at best. In our case, we had absolutely no experience in this arena, and I would not have even considered taking on the task of learning the ins and outs of being a part of an ACO without the help of outside expertise.

What role will the Arkansas Foundation for Medical Care play in the ACO?
The AFMC has been a blessing for us on many levels. They provide us with an onsite practice transformation specialist who comes to our office on a weekly basis. She assists us in making the transformation from a totally fee-for-service model to a more accountable care-type system by working directly with my office manager, clinical care coordinator, and myself. AFMC offers training and support while aligning our efforts with other programs we are working on. They play a key role in helping us manage a steep learning curve, and I really don’t know if we would have been able to succeed without their assistance.

What goals does your practice have for its ACO participation?
We want to help the ACO achieve savings, but honestly, we did not join with the intention of making money. We felt that joining was our way to learn the skills we will need to be able to survive in a new world of medicine. We are striving to use the tools that Aledade provides in order to better understand our patients and their needs. We hope to be able to provide smarter and more focused care for our patient population. I believe that if we make our best effort to adopt the advice that we are getting from Aledade, we will not only accomplish these goals, but probably also be able to save money as well.

What technology benefits are you most excited about with regard to setting up and running the ACO?
Aledade has made a wonderful app that assists us on a daily basis. It targets high-risk patients, frequent ER users, and patients who have been admitted to the hospital. We can use this information to contact these patients and get them into the office for follow up. We can also see exactly what charges have been applied to the patient, and we can drill down to actually see which physicians and specialists have billed the patient. More importantly, I can use this information to compare specialists and how they are charging the patients. This can potentially help me to identify duplicate tests and unnecessary procedures. All of this helps me be a more effective primary care provider for my patients.

They have also been very responsive to all of the physician and staff suggestions for improving the app as it has been used, and I am excited about how this will help streamline much of the work that primary care practices are now required to do. I wonder sometimes if other independent practices will be able to make it without this type of support. I certainly don’t believe my practice would be able to do it, and I’m very thankful for the support they’ve given me.

Contacts

Jenn,  Mr. H, Lorre, Dr. Jayne, Dr. Gregg

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Readers Write: Improving Clinical Documentation Through Better Physician Engagement

Clinical Documentation Through Better Physician Engagement
By James Fee, MD

As a physician, I am passionate about bridging the gap that often exists between clinical documentation improvement (CDI) specialists and the medical staff. Collaboration between the two groups is becoming increasingly important as we shift to a value-based system. This is true for both physician hospital documentation and office notes.

For example, CDI programs are being asked to expand their focus beyond case mix to include documentation improvement opportunities across the care continuum — including ambulatory, physician practice, and post-acute care. Likewise, more physician practices are looking to CDI specialists to maximize efficiencies in the revenue stream and ensure accurate quality report cards through better clinical documentation. As CDI teams work to collaborate with physicians in ways they never have, there are some definite rules of engagement and workflows that will prove effective for both sides of the CDI equation.

Start with a Pre-Bill Review of Clinical Documentation

The first important step in maximizing communication is to understand documentation gaps by conducting a pre-bill review. The review must be completed within 24 hours of discharge to minimize impact on DNFB while also attaining a wealth of information about your medical staff’s current documentation practices.

Based on a program’s maturity, a pre-bill analysis should consider each of the following, and provide a clear roadmap of where gaps with physicians are occurring. The success of a pre-bill review hinges upon establishing an initial focused outcome target with ongoing process refinement. All items cannot be done at once, so the process must be fluid and grow over time. Start with Medicare cases and eventually expand to all payers including a review of:

• CC/MCC capture rates for all MS-DRGs, thereby CMI accuracy.
• MS-DRG frequency and impact by facility.
• Impact of documentation on expected length of stay.
• Hospital-acquired conditions.
• APR-DRG severity assessment.
• Quality measures with associated risk adjustment – readmission, mortality, patient safety indicators.
• Compliance risk due to documentation gaps.
• ICD-10 coding issues (including changes in impact of diagnoses).
• Hierarchical condition categories (HCCs) within ambulatory settings.

Assemble a team of professionals including coders, CDI, and physician advisors to attack these gaps. Strategize and set objectives based on existing data, and then establish a methodology to coach physicians — one specialty at a time. Here are seven common pre-bill documentation discoveries:

• Incorrect diagnosis and procedure code assignment.
• Overlooked opportunities regarding application of coding guidelines.
• Opportunities for specification of physician documentation for conditions suggested by clinical indicators.
• Compliance risks due to conditions documented that lack clinical validity.
• Errors in documenting complications of medical or surgical care.
• Lack of specific documentation that impacts inclusions and exclusions from quality metrics.
• Missed opportunities for maximizing risk and severity.

Once there is good data in hand and a methodology in place, use findings to drive physician educational efforts.

Seven Physician-Focused Strategies that Work

The success rate in working with physicians is dependent on CDI specialists connecting with them in a meaningful way. Presenting actual quality data as part of the initial interaction sets a valuable tone and quickly engages physicians. The goal is to continually use hard data and real-case scenarios to demonstrate the value of complete and accurate clinical documentation for inpatient and ambulatory cases. There are a number of educational approaches that have proven effective for stronger physician engagement, including the following:

1. Emphasize the four primary benefits of improved clinical documentation – patients, payment, performance and profiling.
2. Conduct peer-to-peer specialty-directed education. When physicians are coached by others in their specialty, educational efforts carry more weight. Peers can also answer specific questions about diagnosis concerns.
3. Use clinical trend analysis from pre-bill reviews to direct concise education. Break pre-bill review findings into a few digestible chunks so physicians begin to see CDI specialists as their go-to experts who can help shore up documentation areas that data shows are weak.
4. Organize by service line with a unique approach for hospitalists as opposed to “nuts and bolts” for medical and surgical specialties. In other words, present the data in a manner that makes sense for each specialty’s way of absorbing information.
5. Extend into ICD-10 CM/PCS documentation issues with a specialized task force that crosses multiple disciplines.
6. Include the use of secure mobile technology for CDI queries, sharing evidence-based documentation guidelines and communicating about specific documentation issues. This circumvents challenging schedules and workloads by giving physicians the ability to work on documentation at a time and place that is convenient and doesn’t interrupt their time with patients.
7. Build a physician advisor program to solidify the outcomes of education and continually build the relationship between CDI specialists and the medical staff.

Could You Be a CDI Physician Advisor?

A physician advisor will enhance the clinical understanding of other physicians, while also providing expert opinion regarding clinical validity assessments and query development for the CDI team. Specialty-specific, line-of-service leaders will impact the area of quality outcomes and ICD 10-CM/PCS unique to their specialty.

The role of the physician advisor will be multifaceted — first, to act as liaison between the CDI team and medical staff. This person should attain specificity while educating other physicians and CDI team members on key issues. Expect query validation and development consistent with best clinical practices, which are evidence based. The advisor can provide peer-to-peer mediation with an explanation of global and individual impact of documentation. And most certainly, this person will facilitate ongoing education with medical staff.

Integrate this role into the pre-bill review process discussed earlier. There is no question that physician involvement enhances pre-bill, so engaging physicians in the process by way of the physician advisor will maximize revenue streams in the most efficient way.

The Future Is Upon Us

A data-driven documentation model with fully engaged physicians will maximize revenue stream, and establish a process for success under value-based reimbursement at both the hospital and physician practice level. A good CDI mantra is this: Put doctors in a good place to practice quality care AND get credit for it!

The benefits of engaging physicians in the documentation process early on, and in ways that make sense, include fiscal responsibility and transparency with accountability. With the shift to quality-based payment programs like MACRA, MIPS, and APMs, we see the increased importance of a physician-centric documentation workflow as the source for accurate quality reporting and financial success.

James Fee, MD is vice president of Enjoin in Collierville, TN.

Contacts

Jenn,  Mr. H, Lorre, Dr. Jayne, Dr. Gregg

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DOCtalk with Dr. Gregg 9/26/16

Vendor Apologies Work

This Saturday morning, as usual, I got up very early and started my typical routine, which includes checking my EMR to see what labs, prescription refill requests, consultant notes, and ER or urgent care notes may have come through since the night before. Only problem was, this morning, as compared to every other Saturday morning since we started on our current EMR, something was wrong – very, very wrong.

Not only couldn’t I access my EMR, I couldn’t even get to the sign-on page. (Yes, it’s a browser-based system.) All I could see when I tried to open the login screen was a blank, totally white page. Hmmm … that’s different …

I tried a couple of tricks in that browser with no luck. Well … maybe it’s a browser issue, I thought. Went to browser 2 … same problem. Hmmm …

All vendors have periods on downtime, you know, for system maintenance and upgrades and whatnot. However, before any scheduled downtime, most vendors notify their clients, as ours always does. Maybe I missed just such a notice thought I, so I double-checked my emails, including Junk and Spam folders. Nada. Hmmm, hmmm …

Well, glitches happen, my coffee hasn’t kicked in yet, and maybe I’m not really awake and am just dreaming. Maybe I’ll just go on about some business financial stuff (bills – ugh), run through emails, and then double back to this in a while.

However, an hour or two later, the same blank white browser page kept staring me down. “Maybe there is a system problem” now became my number-one thought.

Before I began to panic with dreadful doom-and-gloom thoughts, I decided to send the EMR support folks an email detailing what was happening on my end. Knowing I’m in the Eastern Time Zone and that they are West Coasters, I figured they may take a bit to respond – you know, wake up, grab coffee, etc. – so I sent the email and proceeded onto the aforementioned doom-and-gloom mental scenarios, such as:

• What if my EMR vendor has unexpectedly gone under, just shut the doors and shuttered the Web access? (Unlikely. They just raised a snootful of investor capital.)
• What if the system has had an irreparable glitch, maybe a total system failure? (Doubtful. They use some pretty great system architecture. Plus, at least some redundancies are in place to prevent total loss.)
• What if hackers have breached the system and are holding our data captive for some ungodly sum of ransom? (Prob’ly not. That investor money still wouldn’t make them as likely a target as many other, more prominent and likely more cash-rich, EMR vendors out there.)
• What if I somehow, for whatever the reason, we lost all access to all of our patient records? (Naw. But, still, a very scary mental picture came to mind, if only for a fleeting, though rather frightening, instant.)

OK, so I played the game of “Fear Factor” in my head and decided it might be best to walk away for a bit and give the support folks a chance to respond. Otherwise, I could envision doom-and-gloom overtaking my day, and it’s SATURDAY! No way I’m wasting a lovely, end-of-summer weekend on HIT anguish and angst.

After some workout time, some dog time, and some home puttering time, I returned to find that my EMR was fully back online, and that support had sent me a response email to say the system was back, and that it was “very unprecedented” and they had “put measures in place to ensure this will not happen again.” They also extended “sincerest apologies.”

OK, the world is once again spinning in greased grooves, and I go on about my patient-related morning duties with no signs of any lingering digital hiccup. My fears have abated, but my curiosity is still nagging away wondering what had actually occurred. Thus, later in the day, I responded to the support person’s email that I had received asking if she’d mind letting me know what exactly had “problem-ized” the system.

I didn’t hear back. Not Saturday. Not Sunday. No biggie, as I’m sure they have better things to do than explain their issues to some little trench grunt. Still, curiosity nagged a bit.

Come Monday, though, my curiosity quotient was fully addressed. In my email inbox, I received – and I’m sure all other clients of this EMR did as well – a wonderful email not only providing a full-blown apology for this “first time in [EMR’s] history that the service has been down for anywhere near this length of time,” but also a sufficiently detailed description of the problem. (Apparently there was a “system infrastructure upgrade” that was not expected to cause any downtime or service interruption whatsoever. Ah, the best laid plans …) It was the first time in their entire corporate history that such an unexpected and lengthy disruption had ever occurred.

But – and here’s the best part – the email didn’t end there, nor even with some politically-correct, corporate-speak apology. No, instead they proceeded to list important addresses to this issue should such an unintended disturbance reoccur:

• First, such a “system infrastructure upgrade” would be addressed in future so that such surprises were avoided. Additional redundancies were being deployed as well;
• Second, they started a public “status webpage” to communicate application status and any communications or solution estimates in real time;
• Third, they instituted a dedicated emergency phone number that will be monitored by in-house staff (read that as “not outsourced”), because they understood that the “inability to talk to someone when you aren’t able to access your records is very stressful and has a great impact on your practice;”
• Fourth, they offered a very sincere-sounding apology, directly from the co-founders;
• And, fifth, and what was especially high on my “Well, Ain’t That Cool” list, they sent us the personal cell phone numbers of both of the co-founders to use until the 24/7 emergency line was fully implemented!!

That last one takes commitment to your clients, personal integrity, and a bit of moxie to float out the cell numbers of the top brass for any old trench grunt to use. (I promise, guys: I’ll try never to abuse it.)

I hope this very cool response, apology, and good-faith gesture sets a standard for any and all other HIT vendors to emulate. Stuff happens, to say it politely, but it’s the response to the “stuff” that lets clients know how much – or how little – you care.

From the trenches…

“If God doesn’t destroy Hollywood Boulevard, he owes Sodom and Gomorrah an apology.” – Jay Leno

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is chief medical officer for Health Nuts Media, an HIT and marketing consultant, sits on the board of directors of the Ohio Health Information Partnership, and is the semi-proud author of “Monsters Don’t Fart!”

Contacts

Jenn,  Mr. H, Lorre, Dr. Jayne, Dr. Gregg

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News 9/22/16

Top News

Yahoo makes headlines, announcing a 2014 breach that resulted in the theft of data from at least 500 million accounts. (For perspective, the LinkedIn breach involved 100 million accounts, and the Anthem breach involved 80 million.) Rumors are swirling regarding the culprit, with some speculating it could be a case of espionage by a “state-sponsored actor.” The FBI remains mum on the rumor.

HIStalk Practice Musings

I got a lot out of the Oliver Wyman Health Innovation Summit in Chicago, though I spent a little less than 24 hours on site. I made a point to pack every hour in with activities and networking. The highlight had to be the immersion tour several other folks and I took to Oak Street Health, a chain of primary care clinics serving Medicare patients in underserved Chicago neighborhoods. It’s extremely rare for me to get a chance to visit physician practices – for self care or otherwise – and so I was excited to tour the clinic and pepper the co-founders Mike Pykosz and Griffin Myers with questions.

Founded just three years ago, the company operates 15 facilities and plans to open at least two more by the end of the year. It’s a challenging work environment, according to Pykosz, who’s also CEO. He half-jokingly told us that it is in fact hard to find PCPs with a passion for serving dual-eligible patients in a team-based environment that cares more about value-based care than fee-for-service traditions. Oak Street staff – and it’s patients, for that matter – all seemed happy enough working in what I was told is a very ED-like command center.

Regarding healthcare technology, the company uses Greenway, and seems resigned to the fact that no EHR is perfect. Physicians, all of whom were carrying around laptops, are accompanied by scribes to give physicians more eye-to-eye contact with patients. My interest was especially piqued when Myers explained that the clinic had recently begun offering telepsychiatry, partnering with local startup Regroup Therapy for the IT.

As the tweet above illustrates, Oak Street has really made an effort to connect with people in the communities where it operates. Its clinics now typically serve as daily hang-out areas for its elderly patrons, which in turn makes them more comfortable coming to see their physician. Bingo games, bridge clubs, book clubs, and other community organizations are typically taking up space in clinic common rooms on any given day. It was heartwarming to me to see that Oak Street Clinics not only provide healthcare, but socialization and a sense of community for all involved.

After last night’s evening reception and a good but short night’s sleep, today dawned bright, early and breathtaking. I did in fact make it to the 5k and was fortunate to find a group of likeminded “runners” to hang back with. Imagine my surprise when I found out that I was running alongside Neil Solomon, MD co-founder of Atlanta-based telemedicine company MedZed. (I had the opportunity to chat with Neil for “The House Call Comeback” in July.)

My conference experience was made complete when Aledade CEO Farzad Mostashari, MD walked by. I’m bummed that I’ll miss his evening keynote tonight. Having seen him present at HIMSS as National Coordinator, I can attest that his enthusiasm for healthcare transformation knows no bounds.

Today’s post will be the last regular news update until October 3rd. I’ll be attempting to take a digital sabbatical next week in the Smoky Mountains, and have coerced several industry movers and shakers to contribute content in my absence. See you in next month!

Webinars

September 27 (Tuesday) 1:00 ET. “Put MACRA in your Workflow – CDS and Evolving Payment Models.” Sponsored by Stanson Health. Presenters: Anne Wellington, chief product officer, Stanson Health; Scott Weingarten, MD, MPH, SVP and chief clinical transformation officer, Cedars-Sinai. Reimbursement models are rapidly changing, and as a result, health systems need to influence physicians to align with health system strategy. In this webinar, we will discuss how Stanson’s Clinical Decision Support can run in the background of every patient visit to help physicians execute with MACRA, CJR, et al.

October 13 (Thursday) 2:00 ET. “Glycemic Control During Therapeutic Hypothermia.” Sponsored by Monarch Medical Technologies. Presenter: Tracey Melhuish, RN, MSN, clinical practice specialist, Holy Cross Hospital (FL). Using therapeutic hypothermia (TH) as a method of care can present risks of hyperglycemia, hypoglycemia, and blood glucose variability. Maintaining safe glucose levels during the cooling and rewarming phases of TH reduces the risks of adverse events. Tracey Melhuish, author of “Linking Hypothermia and Hyperglycemia,” will share best practices for optimal glucose control during TH and the success Holy Cross Hospital sees while using a computerized glucose management software.

Contact Lorre for webinar services. View previous webinars on our HIStalk webinars YouTube channel.

Announcements and Implementations

Sarasota Interventional Radiology (FL) replaces Allscripts MyWay, which was discontinued several years ago, with AbbaDox EHR from IDS.

Bizmatics updates its EHR and PM software with the launch of PrognocisDenali, which features enhanced order management, EOB processing, data analytics, and dashboards.

Sacramento, CA-based Sutter Health affiliate Sutter Physician Services adds CloudMedX’s clinical AI tool to its care delivery and RCM services for providers as part of a joint marketing agreement.

Ontario Telemedicine Network CEO Ed Brown, MD develops PracticalApps.ca to help family physicians advise patients on healthcare-related apps, which are rated by MDs for clinical validity, usability, privacy and security, accessibility, safety, and reliability. The idea seems like a good one, though I’m wondering how Brown and his team will drive physicians to it. Perhaps it can pick up as a physician resource where app certification services like the failed Happtique left off.

People

Rita Schaefer (ChartLogic) joins MedSphere as CFO.

David Shedlarz joins Teladoc’s Board of Directors.

Government and Politics

And I thought EHRs were everywhere: The Northampton County Health Department in North Carolina approves a contract to purchase or purchase an EHR for the department. It will now be eligible for $63,750 over six years for participating in the NC Medicaid EHR Incentive Program.

Telemedicine

CoolDoctors adds voice, messaging, and enhanced video capabilities from Genband to its telemedicine solution for ophthalmologists and optometrists. CoolDoctors opened up its technology for provider licensing this summer.

Research and Innovation

A new report from ResearchAmerica highlights the money companies are spending on healthcare research and development. Total spend in 2015 was $158.7 billion, with private industry making up 65 percent of that figure. It’s one that boggles my mind when I think about how that money could have been used to better address social determinants of health. I continue to wonder how much impact splashy initiatives like the Cancer Moonshot and Precision Medicine Initiative will have versus pouring money into making sure the elderly and underserved have access to basic services like heat and transportation to work, not to mention healthcare appointments.

Contacts

Jenn,  Mr. H, Lorre, Dr. Jayne, Dr. Gregg

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