News 3/20/14

Saint Peter’s Healthcare System (NJ) selects athenahealth’s athenaOne EHR, PM, and communication system for its 176 hospital- and clinic-based physicians.

American Family Care, which operates 160 urgent care facilities across 26 states, agrees to pay the federal government $1.2 million to resolve allegations that it knowingly submitted claims using billing codes higher than appropriate for the actual service rendered. The case stems from a whistleblower lawsuit filed by one of the organization’s former claims processing directors.

Nationwide 62 million people have no or inadequate access to primary care given local shortages of physicians, according to a report by the National Association of Community Health Centers. Not surprisingly the Association recommends the government provide community health centers with plenty of funding to help address access challenges, but I think the fix requires more than just more money. I’m reminded of a session during  HIMSS featuring occasional HIStalk contributor Lyle Berkowitz, MD, who correctly stresses the need for innovation and technology in healthcare to improve access:

If we don’t adopt new technology and change the way we deliver care, it will be harder and harder to get to see a doctor, it will cost more, the rich will cope, the poor will suffer. Many will die earlier than they would have if cost effective treatments were available. We have to act now before the healthcare system goes into meltdown.”

The Drummond Group certifies Kareo EHR for MU 2014 Stage 2.

CMS releases Road to 10, a free online resource to help physicians in small practices in their transition to ICD-10. The tool to build an action plan (actually a  “catch-up plan”) looks pretty handy and allows providers to customize their roadmap based on practice size, specialty, and  the type of technology used in the practice.

Not so surprising findings from a RWJF-funded study: physician practices participating in ACOs tend to be relatively large, members of an IPA or PHO, less likely to be hospital-owned, and more likely to use care management processes and EHRs as compared to practices not participating in ACOs. Researchers found that 61 percent of practices have no plans to participate in ACO, which raises the question of how to get the balance of practices on board with ACOs, if in fact the ACO model proves to provide better and more cost-effective care.

Welcome to new HIStalk Practice Platinum Sponsor Arcadia Healthcare Solutions, which is headquartered just outside of Boston and has additional offices in New York, Seattle, and Nashville. Arcadia provides services and technology for EHR outsourcing; data integration and population analytics; and care delivery transformation and coaching. Clients of the 12-year-old company include five Pioneer ACOs, leading academic medical centers, national health systems, managed care organizations, and several Blues. Arcadia’s advisors can help practices  improve key ambulatory network measures 15 to 30 percent in six months by bringing together EHR and claims data and helping providers use it. Some of its EHR optimization accomplishments include reducing log-in time by 50 percent, improving system performance by 27 percent, and increasing physician satisfaction by 20 percent. Arcadia provides expert advisors rather than, as it says, “high-priced management consultants who leave nothing behind but PowerPoint.” Thanks to Arcadia Healthcare Solutions for supporting both HIStalk and HIStalk Practice.

InstaMed launches InstaMed Go, which allows providers to collect patient payments via smartphones from any location with the payments posted automatically to their practice management systems and receipts emailed to patients.

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News 3/18/14

From Soothsayer: “Re: Castlight Health fallout. Given Castlight’s tremendous IPO success, look for more HIT companies to follow suit. A few we might see within the year: Practice Fusion, CareCloud, and ZocDoc.” Castlight’s share price surged 149 percent during its Friday IPO, giving the company a valuation of more than $3 billion. That’s a pretty impressive debut, especially considering Castlight had $13 million in revenues and a $62 million net loss in 2013. There’s clearly a lot of interest in the HIT sector so I’m with Soothsayer on this one.

CMS wants to recoup improper payments made through its PQRS and e-prescribing incentive program and will launch a four-year program to look for potential errors, inconsistencies, and gaps related to data handling, program requirements, and clinical quality measure specifications. According to a Federal Register notice, CMS will survey 400 group practices, registries, and data submission vendors and perform a limited number of follow-up interviews.

Disturbing: researchers from the University of Illinois at Chicago find that transitioning from ICD-9 codes to ICD-10 could lead to a significant loss of data, based on an analysis 220 hematology-oncology and outpatient diagnostic codes. Specifically researchers found the transition affected eight percent of state Medicaid codes and one percent of codes in the University of Illinois Cancer center; potential costs associated with the information loss totaled $479,299. What’s particularly troubling is that the study focused on hematology-oncology codes, which involve fewer ICD-10 codes and thus less convoluted mappings than codes in other specialties.

The House passes legislation to permanently repeal Medicare’s SGR payment formula, but, full passage of the law is unlikely because it includes a provision to delay the ACA’s mandate requiring all individuals obtain health insurance. Without a repeal or a temporary patch, doctors face a 24 percent cut in Medicare reimbursements as of April 1.

UnitedHealthcare, Aetna, BlueCross BlueShield, and Humana tell the AAFP they’ll be ready for ICD-10 by the October 1 deadline, though some of the carriers express concerns that small, private practices are behind in their preparations.

What employed physicians like most about not being self-employed: not having to deal with the business of running an office and not having to deal with insurers and billing. According to a Medscape survey of 4,600 doctors, employed physicians complain about the lack of input into how they practice, but 70 percent of physicians who were once self-employed report being happier employed.

On the heels of a recent study questioning the effectiveness of the PCMH model in improving care and reducing costs, the NCQA previews 2014 PCMH recognition standards, which include more emphasis on team-based care. Other areas that NCQA is “raising the bar,” include:

• Care management focus on high-need populations
• Alignment of quality improvement activities
• Additional integration of behavioral health

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Practice Wise 3/13/14

Open letter to EHR users

Now I know for sure this is going to put in me in the unpopular kids group, but I have to say it! EHR users are costing vendors excessive amounts of support time and resources supporting users who refuse to admit they might actually be causing the problem.

I’m not saying this as a rebuke to users who truly have EHR problems and vendors who won’t/don’t address them effectively. However, as an organization that provides both consulting services and direct support, we see this scenario way too often and I think it’s time to address it head on!

For example, a customer complains that the system keeps doing something nefarious and is out to ruin their practice. Vendor asks typical level one support questions such as ‘are you sure you have not hit the (any) key?’ Customer insists they are not hitting that key, and is not shy in stating how offended they are that the vendor would even consider that ‘they’ might be causing their own problem. After hours of support, escalation and development time spent on this issue, customer is audited on site, they hit the key they swear they never hit, and sheepishly say, ‘oh, I guess I sometimes do hit that key’. And instead of swallowing a little humble pie and offering an apology, they deflect by saying something else like ‘but the system does this other thing that is really ruining my practice!’

Seriously, what EHR users really need to understand is that most software vendors have the same goals as they do: to have a successful implementation with expert users who fully utilize the system for optimum use. There are certainly vendors who have badly designed products and poor support. Let’s just assume we are not talking about any of them here.

This behavior is top down in most practices. The most successful implementations and ongoing adoption of all things EHR are in practices where the doctors themselves display a positive attitude about the change, are engaged in the process, and are supportive of their team as they all struggle to grasp the new program and develop the muscle memory that leads to mastery. There are fewer of these practices overall. The general experience is that doctors believe EHR is being forced on them, that no vendor could ever make a product that doesn’t slow them down, that it doesn’t print out documents that sound like they would speak, etc. And when the project starts at that level of negativity, it permeates the whole team.

What happens in an EHR implementation is that a magnifying glass is held over all your processes and procedures. If you are a well-developed process-based organization, this is a good thing, your shining moment. If you are an organization that has just always done things on the fly or ‘this way because that’s how it’s always been done’ and not open to new processes that might actually improve your practice, you will have a hard time hearing valuable recommendations from your consultants and implementation team.

When the internal practice attitude towards the project is negative, the doctors become abusive to their team and to the vendors who support them. I don’t use this word lightly. Talk to any implementation person and they can rattle off a litany of horror stories of doctors throwing fits, calling them idiots, throwing laptops across the room, etc. Here’s my theory (not very scientific, purely observational): doctors are used to being smart and good at what they do. This process unmoors them to some extent. Once they accept the process and decide to move forward, they generally do well the first week of go-live because they believe they shouldn’t know the system, so they don’t typically get snarky that week. However, week two rolls around and they assume that since they are smart and quick learners, that they should have mastered the darn thing, and then the snarky, rude behavior comes out. When the staff sees/hears the doctors abusing the vendors, they do the same when they are frustrated because they believe it’s how to get things done in the practice.

I’ve worked in other industries besides healthcare, and never in my professional life have I experienced this kind of rude abuse by a customer to a vendor as I have in this field.

Here’s my message to providers: we are here to help you. If your practice succeeds, we succeed. Your implementation failure is our failure. We want you to be the best users you can be, and we want you to master the system to the fullest. However, when you don’t speak nicely to us, call us names, make threats etc., we are less likely to want to go that extra mile to hold your hand in your time of need.

I had an IT vendor tell me on the phone the other day that he doesn’t care that the darn doctor can’t access the VPN from home and fixing it is low on his priority list because the doctor is so rude to him and always hangs up on him when he doesn’t get the answer that he wants.

That’s what happens when you’re rude to your support vendors: we tend to put you at the bottom of our priority list. Here are a few ideas of ways you can navigate through this difficult transition, with everyone pulling for your team and working towards your success:

1. Accept that you are changing your processes and getting an EHR. Doesn’t matter why, it just is, so accept it and get over it.
2. Project a positive attitude within your organization, encourage your partners and staff to do the same. Be the champion!
3. Buy the hardware as recommended by your EHR vendor. Don’t try and cut corners and save money buying your own computers and equipment at discount sales if you really don’t understand the hardware specifications. Your IT vendor is not a magician; if you don’t buy what’s recommended, he can’t make it do what you need it to do, and you’ll be frustrated and likely blame the IT vendor and the software vendor.
4. Take advantage of ALL training opportunities offered by your vendor. The more effort you put into your training, the less frustrated you’ll be. This is one area that frustrates the vendors; doctors are ‘too busy’ to do the training, yet want to be masters of the system. It’s not magic; it’s learning. You had to go to med school to become a doctor – they didn’t just hand you a degree. Same theory here!
5. Put effort into doing the customizations offered to tailor the system to your practice. Many systems have great malleability and trainers who can help you design your workflows in a way that helps you document in your comfort zone. This effort on the front end will reduce your stress on the back end.
6. Create a position for an EHR super user in practice. The person’s sole responsibility is to make sure your needs are getting met, your changes are addressed quickly, and is dedicated to you. Treat that person nicely even when they can’t give you exactly what you want. You cannot expect your vendors to drop everything and meet your demands all the time, especially when you make demands and don’t ask nicely for help.
7. BE NICE to everyone. We are all doing the best we can at any given moment to support you! We all have the same goals – your successful implementation and continued success in your practice.

I love working in healthcare and supporting doctors. Some call me crazy! However, I think most doctors really do have the best intentions and just need to know that in the end, it will all work out fine. At least we’re not asking you to work 100 hour/week rotations. You survived residency, you’ll survive this too!

Julie McGovern is CEO of Practice Wise, LLC.

News 3/13/14

From Harry C: “Re: CEHRT Hardship Exception Guidance. The move is not surprising given the number of vendors that are late releasing their Stage 2 versions, giving providers little time to get up to speed. Add in the fact that Stage 2 and ICD-10 must be implemented at the same time is too much for a lot of practices. The hardship will help practices that don’t have enough time to implement all the changes in workflow.” CMS revises its hardship exemption criteria to avoid 2015 Medicare payment penalties, allowing providers to indicate “2014 Vendor Issues” as the reason for the required exemption. I understand that providers are facing the perfect storm of deadlines but I find it ridiculous that CMS indicates it will rubber stamp hardship exemptions for any one that asks, rather than push back the official deadline.

Drchrono announces that its free EHR platform will be certified for MU Stage 2 “later this year.” Drchrono reports that over 60,000 medical professionals use its EHR platform. Given drchrono’s vague deadline for the release, I’m confident that a good number of drchrono physician users will be immediately jumping onto the CMS website to register their hardship exemption.

Physicians recognize the value of EHRs in concept and appreciate better access to remote patient information, but also believe EHRs undermine professional satisfaction and can negatively impact patient care. Those are some of the findings reported in a Rand Study on physician professional satisfaction based on data collected from 30 practices across six states. While less than one in five physicians would prefer to return to paper medical records, providers raised specific concerns about EHRs, including:

• Poor usability that doesn’t match clinical workflows
• Time-consuming data entry
• Interference with face-to-face patient care
• An overwhelming number of electronic messages and alerts
• The inability to exchange health information electronically with all providers
• The degradation of clinical documentation
• Expenses that were significantly higher than anticipated

The authors recommend that better EHR usability be an industry-wide priority and a precondition for EHR certification.

The ONC’s HIT Policy Committee releases preliminary Stage 3 MU recommendations, the majority of which are updates to objectives included in Stage 2. For example, Stage 2 requires providers to give at least 50 percent of patients to view their health information within four days of the information becoming available to the provider. Stage 3 requires providers to make the information available within 24 hours. The recommendations include 19 measures, which is two-thirds of the number included in initial Stage 3 proposals.

Qatar Foundation Primary Health Care Center becomes the first healthcare facility in the country to implement Cerner’s ambulatory EHR.

Greenway’s VP of industry and government affairs Justin Barnes participates in several recent White House summits, briefings, and panels to discuss HIT, patient engagement, privacy, the US economy, and related topics.

Not to take away from Barnes thought leadership and achievements but I was disappointed not to see a single female in the above picture.

University of Colorado Physicians goes live on the DocASAP self-scheduling system.

EClinicalWorks opens registration for its 2014 National User Conference, which runs October 17-20 in Orlando.

The EHR Association elects NextGen Healthcare CMO Sarah Corley to its executive committee.

E-MDs customer John Bender, MD of Miramont Family Medicine (CO) tells Medical Economics that his use of Lean management principles and use of IT have helped him to manage escalating costs and consistently grow the practice 45 percent.

A NIST report says that inadequate workflow integration forces users of ambulatory EHRs to develop system workarounds, suggesting that EHR vendors develop these capabilities:

• At-a-glance physician views of patient schedules
• Task reminders from previous patient visits
• Redacting and summarizing lab results
• Draft creation of patients orders in advance
• Conversion of working diagnoses to formal diagnoses
• Skip or defer tasks when workload requires
• Role-based views of progress notes
• Visually differentiate copied-and-pasted progress note text from newly entered documentation
• Manage referral and consultation messages with specialists
• Track scheduled consults and lab results review

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News 3/11/14

Primary care providers need EHRs to move beyond documentation to interpreting and tracking information over time, according to an AHRQ-supported article.The authors note that EHRs are currently focused on disease rather than the whole person and ignore factors such as personal risk, behaviors, family structure, and occupational and environmental influences. Stage 3 MU focus needs to include not only an emphasis on outcomes, but also EHR functionality, including the expanded use of patient portals, integration with better external applications, and advancement of national infrastructure and policies.

Twenty-two legislators also weigh in on Stage 3 MU criteria and ask HHS to consider ways to reduce health disparities by leveraging HIT. Some of their specific recommendations for inclusion: improved data collection requirements and better use of collected data; increased functionality to support health literacy and communication; and, better access to health information and healthcare on mobile platforms.

Kareo introduces an ICD-10 Success Plan Checklist poster that is in a tasked-based format and helps practices identify specific transition tasks, deadlines, and project owners.

Six Republican senators call on CMS to “immediately clarify details” for its plan to grant MU Stage 2 exemptions to certain providers. During her HIMSS keynote address last month, CMS Administrator Marilyn Tavenner confirmed that the deadline would not be extended, though some “narrow” hardship exemptions would be granted. All politics aside, the senators are right: the clock is ticking and providers deserve some clarity in quick order.

A Government Accountability Office report finds that participation in the MU program increased substantially from 2011 to 2012 but 16.3 percent of EPs participating in the Medicare program dropped out in 2012, as well as 60.8 percent of Medicaid EPs.  Some reasons noted for the dropouts include providers had switched EHRs and weren’t ready in time to submit EHR data; providers were unaware of program deadlines and the need to participate in the program again; and, providers found more difficulties than anticipated going from a 90-day reporting period in the first year to a full-year reporting period in the second year. The GAO notes that estimating future participation in EHR programs is difficult because of various program changes, the increasingly stringent MU measures, and the introduction of penalties in 2015. My guess on EP participation: though providers will continue to embrace EHRs, an increasing number of providers will opt out of the MU program because the financial incentives and avoidance of penalties aren’t worth the effort.

A Chat with Albert Santalo, president and CEO of CareCloud

During HIMSS I spent a few minutes chatting with CareCloud CEO and President Albert Santalo.  Here’s a short summary of our conversation:

• CareCloud achieved 100 percent growth in 2013.
• Currently the company has about 5,000 providers on its system; about 20-25 percent of those are on EMR.
• Santalo expects to add 8,000 new customers in 2014.
• The company primarily targets independent physician offices rather than large health systems with employed or affiliated providers.
• The EHR platform is certified for Stage 2 MU.
• I asked Santalo if and when the company would go public. He danced around the answer a bit but admitted an IPO is something that may happen within the next 18 months.
• While CareCloud has no plans to develop or sell a core in-patient system, the company will look to offer more products like CareCloud Community, which provides patient engagement and care collaboration tools that can be used across different venues of care.
• CareCloud views itself as one of athenahealth’s few direct competitors because both offer a cloud-base platform and a full range of RCM and back-office services. Unlike athenahealth, however, CareCloud customers are not required to subscribe to the full service model. Santalo believes that making the full RCM model optional has helped CareCloud win business with practices wanting to reserve the option of keeping billing in-house.
• Santalo said CareCloud’s KLAS scores are “getting better.” In looking at the KLAS website I believe CareCloud still falls into the “not-rated” category because of an insufficient number of customers ratings.

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