Wednesday, April 28, 2010

Saving Dr. Marcus Welby

(The Sequel to "The End of Dr. Marcus Welby")

Now that the health reform bill has passed and political debates are about financial regulations, climate control and immigration, the health care policy experts are beginning to turn to the monumental task of implementing the new law and the basic question to be answered is how we provide better care for less money to more people. Not a small task indeed.

Today, health care in America is uneven. For some we provide too much and for others too little; for some we pay too much and for some we pay too little; some care is very efficient and other is wasteful and expensive. The assumption is that a Goldilocks approach must be found and such approach will not only feel right, but also have the right price tag. The reform bill, while providing definitive solutions to health insurance coverage, provides only guidance and an independent infrastructure for actual health care reform. It will be up to various committees and HHS, to try out proposed solutions and find the golden path. There are three broad themes standing out from the thousands of pages of newly minted legislation: change the care delivery model, change the provider reimbursement model and computerize health care. It is expected that each one of these efforts and all three combined will achieve better care for less money for more people. Let’s take a closer look at the emerging trends of thought.

The Delivery Model


Health care in America today is delivered mostly by small physician practices. 47% of doctors practice in groups of 5 or less and most are Primary Care physicians. These are the modern day descendants of Dr. Marcus Welby and the new theories of efficiency would soon drive them to extinction. The common wisdom is making the same argument that was made when Supermarkets and Mega Stores were created. The small practice is an inefficient business unit and consolidation will bring economies of scale and better ability to manage the business, from supply chain to FTEs, to ability to better serve customers. [Dr. Osler must be turning in his grave]

These proponents of consolidation are drawing from examples such as the Mayo Clinic in making the case for large groups of multi-specialty and salaried physicians, and against the current “cottage industry” model of delivering care. The Mayo model has been around since the nineteen century and while able to provide stellar health care for complex patients, it did not spread much during a century of existence. There are no Mayo clinics in Harlem or the Ozarks, just like there are no glitzy, well stocked, open 24 hours Supermarkets. I wonder why… Maybe for such areas, we should be happy with the 7-11 in a gas station version of health care convenience. They too can show economies of scale. The vast majority of cottage practices are serving both Medicare and Medicaid patients. Mayo seems to be unable to provide services for measly Medicare fees and some are wondering if large groups would constitute a better venue for extracting larger payments from private insurers. There may very well be economies of scale in consolidation, but it is unclear who will be benefiting from such economies. A pound of pink, waxy, fragrance free tomatoes at the Supermarket costs $2.99. A pound of red, sun-warm, freshly picked tomatoes at a farmer stand costs $0.99.

And then there is the Patient Centered Medical Home, a wonderful concept pioneered by pediatricians taking care of sick kids. The term is Medical Home, not Medical Complex, or even Medical House. The word Home has a very specific meaning to most people. It connotes intimacy, security, comfort, family and a safe haven where you can let your guard down and be yourself. The Medical Home calls for a personal physician, not a personal Department of General Practice augmented by the hospitalist du jour. Maybe they were referring to a personal Dr. Marcus Welby after all. We may never know.


The ranks of the Welbys are shrinking. Fewer and fewer medical students are choosing Primary Care. It seems everybody wants to be a sub-specialist. Specialists make a lot more money and the prestige of being a Cardio-Thoracic surgeon often trumps the "calling" of family medicine. Does filling out paperwork and referring patients to specialists (real doctors who actually treat patients) even qualify as Medicine, as Science? When you graduate at the top of your college class and have perfect MCAT scores to match your earlier perfect SAT scores, do you really seek a career as an underpaid hamster rushing through encounters at $35 apiece? Maybe educated physicians should just stick with the “hard” stuff and let someone else do all this Primary Care simple stuff. [By now, Dr. Osler should be clawing his way out of his grave]

Sure enough, the recent conversation is mentioning that NPs could very well lead Primary Care clinics with no physician supervision. They are very well educated, many have PhDs, and maybe their less scientifically rigorous and more humanities driven education would be a better fit for what Primary Care has deteriorated into. Not to mention that we should be saving a bundle if we delegate Primary Care to non-physicians. After all, NPs are providing good care to a wide range of patients in physician led clinics. Most folks are basically healthy and only a few have half a dozen comorbidities and twenty medications that need to be juggled. Three or four Internal Medicine specialists could easily take care of those complex cases. Did we just blow all that bundle of savings on Primary Care? Probably. A Boeing 747 requires a Captain and a co-pilot to fly the plane. The co-pilot is almost as good as the Captain and most of the time the plane is flown by the computer. We could probably save tons of money by getting rid of the Captain for the routine uneventful flights. Trouble is you never know when you’ll have to deplane via the Hudson River.


The health care reform bill has some provisions for modest increases in Primary Care reimbursement. More interesting are the authorized experimentations with alternative models of payment such as the Accountable Care Organizations (ACOs). Generally speaking these are large groupings of various types of providers organizing together to provide complete care for panels of patients. ACOs are rewarded if able to provide quality care for less than a regional benchmark. There are many questions to be answered and many details to be ironed out, but the most likely leaders of ACOs are either Hospitals or very large physician groups by virtue of their ability to provide proper management and financial coordination. In either case the Primary Care doctor will be further marginalized and relegated to the secondary role of providing care according to rules and regulations dictated by financial interests of a corporation who will be receiving and dispersing payments and quality bonuses. For years large provider organizations have been leveraging their sheer size to extract undue financial remuneration from private insurers. We are now proposing to place these same providers in control of reimbursements to loosely affiliated, or completely assimilated small practices. It is not clear where Medical Homes fit in with ACOs, but from both a patient perspective and a Primary Care doctor’s point of view, this could very well become HMO déjà vu. In any case these new reimbursement models do not make any changes to the basic fee for service model, or the bureaucracy associated with obtaining payments. If anything a brand new layer of ACO specific paperwork, measurements and reporting is likely to be put in place. Looks like Dr. Welby will still have to spend a large portion of his day filling out forms, fighting with payers and now also with the ACO powers to be.

Information Technology

Technology is everywhere in health care. Technology is one of the major health care cost drivers in the form of new equipment, new devices, new therapies and new drugs. Almost 100% of financial transactions in health care are electronic and so is patient registration and scheduling. One would be hard pressed to find a medical practice without a computer and a host of other electronic devices. The one glaring exception is of course the Electronic Health Record (EHR). EHRs are too expensive, too clunky, take too much time to implement, provide no real value, etc. However, EHRs are also the inevitable future of medicine and the entrance ticket to Medical Homes, ACOs and every other opportunity to keep up with where health care is headed. And right now, the Government is offering to pick up the tab. It won’t do so forever. EHRs and the promise of uninhibited electronic communications between doctors, patients and the entire spectrum of care providers are a prerequisite to saving Dr. Marcus Welby. Today’s generation of physicians is not interested in 80 hour work weeks. Personal values have changed and medicine has gotten complex and laden with bureaucracy.  It is likely that what was accomplished by one doctor years ago, will require virtual collaboration of several small practices today. [Dr. Osler would probably try his hand at a patient centric EHR]

The Rescue Mission

There is enormous evidence suggesting that strong Primary Care is conducive to better population health and lower overall cost. Primary Care cannot be strong without fully qualified Primary Care physicians who can treat all conditions and effectively advocate for their patients when dealing with specialists and Hospitals. Strong and effective Primary Care must have roots in the community, and by community I do not mean the common usage of the term as “poverty stricken area”.  Not everybody lives in Rochester, MN and most folks cannot afford Rochester prices. Most of us would be perfectly satisfied with a small and intimate Medical Home a few blocks down the street. Finally, Primary Care cannot be strong with no young people willing to follow a time honored tradition.

The AAFP estimates that we need about 2000 more Primary Care graduates every year. Let’s pay for their education and have them commit to practice in shortage areas for a certain number of years – that’s a well spent $300 million per year. Let’s decide to pay fair wages for honest labor and compensate Primary Care docs for their time and quality of work. Let’s empower Primary Care docs along with patients to make care decisions instead of subordinating them to Hospitals, specialist groups and other corporate interests. This is arguably the only stakeholder group that wasn’t feeding at the health industry trough for the last several decades. They were too busy seeing patients.

Dr. Marcus Welby’s fictional character embodies the means and the power to provide better care for less money to more people. He will have to trade in his black bag for an EHR, and his house calls for e-visits. He will have to have a supporting team and he will have to collaborate with a network of his peers, but we can save his integrity, compassion, professionalism and competency, if we can avoid temptation and muster the wisdom to forgo the big shiny things and the cheap little shortcuts, and instead restore Primary Care to what it was when we did not have a health care crisis in this country.

Friday, April 23, 2010

EHR Bargains Review – Office Ally

(Survival Tips for Small Practices)

Most of us know Office Ally as a free clearinghouse for medical claims processing. Over time Office Ally has consistently added web based services to their original claim processing offering. First came Office Mate, a Practice Management System, then came Patient Ally, a Personal Health Record and now we have the Office Ally EHR. Since most offerings are completely FREE to physicians, I thought this would be a good time to review the Office Ally option for a cash strapped small practice attempting to go electronic and qualify for government incentives.

The Concept of FREE

Unlike most other FREE products on the market, the Office Ally model is very easy to understand. Office Ally’s revenue stream comes from its clearinghouse operations and originates with payers. All clearinghouses receive transactional payments from insurers and in addition they also charge monthly fees from submitters. Office Ally is forgoing the submitter fees, which average about $100 per provider/per month, for electronic claims, electronic remittance and eligibility checks.

Office Ally’s web based services do not require lengthy contracts. You use it if you like and you stop using it if you don’t. Most “free” clearinghouse services require that you outsource your billing and pay between 5% and 8% of net collections. Office Ally does not offer an outsourced billing service and you may continue to do your billing in house. As far as I can tell, the products are not ad supported, so you will not see Diabetes Wonder Drug ads every time you access a chart with a documented ICD-9 of 250.00. Since the products are web based, your data will be residing at the vendor data centers. I have not seen a public statement on Office Ally’s policy regarding their use of deidentified patient data collected from their customers. This should be clarified before you sign up for the service.

Office Ally EHR

The new Office Ally EHR is web based and has the ability to integrate a certified electronic prescribing solution from NewCrop. The EHR is not free. The subscription fee is $29.95 per provider/per month. You can cancel the contract with a 30 days’ notice and get your data exported for a flat fee of $39.95. The electronic prescribing module runs at $30.99 per provider/per month for the full service as required for Meaningful Use. This brings the total package monthly cost to $60.94 per provider. This comes to about half the price of Amazing Charts, the Gold standard for affordable EHR solutions. To be sure the Office Ally EHR does not include advanced functionality like clinical decision support, order sets, quality reporting, lab interfaces and other advanced features available to the CCHIT certified Amazing Charts users. These features will be required for government incentives. It is possible that Office Ally will be adding features and eventually will be applying for Meaningful Use certification, but at this point in time there are no expressed guarantees and I would expect the current subscription fees to increase for a fully certified product.

Practice Mate

Practice Mate is a typical Practice Management System with registration, scheduling and billing management functionality. It is free to clearinghouse users. While lacking bells and whistles functionality, Practice Mate should serve a small practice well enough. There is a phone reminders service that can be added for a volume based fee.

Patient Ally

The patient portal, or PHR, is completely free and integrates directly into the Practice Mate and the new EHR. It has the basic functionality found in most patient portals, such as secure patient communications, refill requests, appointment requests, viewing results, etc.

Office Ally Billing Clearinghouse

This is the original flagship service offering. It is free for providers submitting more than 50% of their claims to commercial payers (not Medicare/Medicaid). Otherwise, there is a flat fee of $19.95 per provider per month. The clearinghouse is in wide use and the payer list, while not covering 100% of payers, is steadily growing. The clearinghouse can be, and is, used in conjunction with other EHR/PMS software, through direct access by paper based offices or as part of the entire suite of Office Ally suite of products.

Bottom Line

The Office Ally EHR is the most recent addition to a historically billing focused company, probably in an effort to offer the client base a path to achieving Meaningful Use, while creating a new revenue stream for Office Ally. All in all, the EHR is very basic and will need to quickly add a host of feature/functionality in order to certify for Meaningful Use. The price point is very attractive for a small practice and so is the completely web based model. From what I could see, the EHR software is as clear and simple as the older Office Ally minimalistic modules. This is good news for a practice trying to save money on training and implementation.

If the EHR becomes Meaningful Use certified, while maintaining the lean look & feel and a price point well below $100 per provider/per month for an entire integrated suite of clinical and business products, I would rate it as a definite Best Buy. Right now I would say it is definitely worth adding to a small practice short list of products to review.

07/18/2011 Update: Office Ally EHR is certified as a Complete EHR by an ONC-ATCB for 2011-2012. It is also CCHIT 2011 pre-market certified. Last week Office Ally announced that its "full suite of office support tools for healthcare providers is now compatible with all Apple products, including MAC computers and iPads".

Next Review: Amazing Charts

Wednesday, April 21, 2010

Meaningful Patient Engagement

A prerequisite to any Meaningful Use discussion is the need to keep in mind that the current HIT effort, and appropriation of funds, originated from a legislative act whose primary goals were to reduce health care costs and create jobs in a faltering economy. The secondary goals of increasing quality of care and reducing disparities are assumed to be supportive of the primary goals.

One could easily argue that patient engagement in the health care process can have cost lowering effects on the entire system. Patients are by far the least costly resources in the continuum of care and the more tasks we can delegate down to these practically free resources, the lower the cost of care will become. Coupled with the widespread enthusiasm for patient participation as exhibited by numerous advocacy groups as well as representatives of the medical profession, engaging patients seems to be a win-win proposition.

However, after listening to testimony offered to ONC and after reading various statements and survey results, it seems that the number one concern of consumer advocates is to make medical records available to patients and delegate control over aggregation and dispersal of medical information to the patient. With control comes responsibility, and with responsibility comes accountability.

If we assign responsibility for the maintenance of complete records to patients, we are de facto releasing physicians, mostly primary care physicians, from accountability for care coordination and continuity of care efforts. This may very well lower the operation costs for the practice, but disparities in people’s ability, and willingness, to manage medical records will translate into amplification of existing disparities in quality of care. I am not sure how the overall cost of care will be affected.

On the other hand, if the responsibility for aggregating and maintaining longitudinal medical records is formally placed with the primary care physician, as it mostly is today, we would be taking a big step towards the creation of medical homes with empowered primary care and with distinct incentives for primary care first contact. There is an abundance of studies showing the cost effectiveness of strong primary care stewardship.

To me patient engagement is more about collaboration, education and participation in informed decision making. I believe there are strong indicators that, when informed and consulted, patients tend to choose less costly treatments and are more likely to actively and effectively manage their condition. Technology will evolve, is evolving, to push health care out to less expensive venues. The generation now entering the Medicare stage of life will demand independence from traditional care settings. This too should contribute to better quality of care, reductions in disparities and ultimately lower cost of care.

There is no doubt in my mind that every person should have a right to see, copy, download, dispute, share and even publish their medical records. Medical records, regardless of where they were created or stored, are, or should be, the patient’s exclusive property and should be treated as such, whether identified or deidentified, which is really a separate issue and has very little to do with patient engagement and much more to do with the anticipated financial exploitation of “data liquidity” by certain sectors of the industry.

In summary, while it is imperative that we move forward with computerization of medical records, and full unfettered access to medical records for their rightful owners, we must also be aware of the unintended consequences of our actions and be mindful of the primary goal placed before us by the taxpayers who are footing the multi billion dollar bill associated with HITECH.

Sunday, April 18, 2010

Patient Centered Medical Home for your PHR

In 1967 the American Academy of Pediatrics (AAP) published the Standards of Child Health Care suggesting the following:

"For children with chronic diseases or disabling conditions, the lack of a complete record and a ‘medical home’ is a major deterrent to adequate health supervision. Wherever the child is cared for, the question should be asked, ‘Where is the child’s medical home?’ and any pertinent information should be transmitted to that place"

This is the first known mention of the term Medical Home, and its meaning was a physical repository for a comprehensive and complete medical record for each child; a record continuously updated by all other agencies providing care for that particular child; a Personal Health Record (PHR).

By 1992, the AAP Medical Home concept evolved beyond its original medical records definition to include accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care. Over the years the Medical Home model of care gained support from various agencies and medical associations and expanded beyond pediatrics and beyond chronic disease management. In 2007 the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP) and the American Osteopathic Association (AOA) joined the AAP in support of a Patient-Centered Medical Home (PCMH) approach for providing primary care to all patients based on seven principles: personal physician, physician-directed team, whole-person orientation, coordination of care, quality and safety, enhanced access, payment reform.

In 2010 the Patient Protection and Affordable Care Act (PPACA), a.k.a. the health care reform bill, is authorizing Medicare to participate in the various privately led PCMH pilot projects and to initiate its own (delayed) demonstration projects.

The NCQA has defined criteria for a qualified PCMH and those criteria are pretty heavy on Healthcare IT. An interesting new study by Ferrante et all, just published in the Annals of Family Medicine is examining preventive care in PCMH settings, and concludes:

PCMH principles are associated with higher rates of preventive services delivery in community primary care practices, with the high-touch relationship-centered principles more highly correlated than information technology capabilities”.

This study should serve us all as a reminder that, at its heart, PCMH is very much like Cheers, the famed Boston establishment, a place where everybody knows your name. It is a place where you can always see your own physician, with whom you have a long and trusting relationship; a place where you are regarded as a whole person and an active and equal partner in health decisions; a place where continuity of care is not abbreviated to CCD and CCR and does not refer to a software standard, but instead it is the embodiment of a commitment from your doctor and his supporting team to always be there for you.

This is not to say that Healthcare IT is not necessary in a PCMH. In order for a PCMH to be competent and efficient in today’s complex and highly fragmented health care environment, it will need to utilize technology for care coordination, communications with patients and evidence based decision support. But most of all the Medical Home, as conceptualized from its inception, will use computer technologies to maintain complete medical records for all its members. The Patient Centered Medical Home is the most logical aggregator and steward of PHRs.

There are various software products and services in today’s market that allow people to either aggregate their medical records on their own, or view and interact with electronic medical records maintained by their physicians. The latter is usually a Patient Portal attached to an EHR, and the former, confusingly named PHR, is a service provided over the Internet by independent companies like Google or Microsoft, or by large employers like Walmart. A recent survey by CHCF suggests that there is a small, but increasing interest in using such software and its mere usage may have positive impact on wellness.

If you are one of the very few lucky Americans who have a Medical Home, the Patient Portal provided by the PCMH is as close as we are today to a true PHR. It probably lacks the ability for you to contribute your own content or connect your own input devices, and it most likely does not contain your entire record from birth to the present day. As more features are added, the portal should allow you to add your own content and connect home devices. The portal’s main function is to facilitate direct communications between you, your physician and your PCMH team. It should also display all information your PCMH receives from specialists, hospitals, pharmacies and any other care provider you interact with.

If on the other hand you are the proud user of a commercial PHR, or a patient controlled PHR, you most definitely can create your own content and connect devices and clinical advice feeds approved by the PHR provider. You will need to request every care provider you encounter along the way to upload data into your commercial PHR and you will be able to control what each provider sees, if anything at all. It’s not very likely that you will be able to pay your bills, or make an appointment or ask a doctor a question, but maybe as technology improves, that will be possible too. This PHR will not contain your entire record either, but you may enter data from memory as best you can.

As time goes by and America comes to the inevitable conclusion that strengthening and empowering the partnership between primary care physicians and their patients is the only equitable way to reduce health care costs and minimize disparities in care quality, Medical Homes will become the standard of care. By then the Patient Portal and the commercial PHR software will become very similar in functionality. At that time people will probably have to choose whether they want their Medical Home to aggregate and maintain their medical records as part of a trusted partnership, or they prefer to do the footwork and aggregation themselves, and store their life records with an unrelated third party corporation who is providing a PHR service for free to all comers, most likely out of the goodness of their heart or perhaps to fulfill a civic duty to society.

If given the choice, I think I would prefer to manage my medical records in the relative privacy of my Medical Home.

Thursday, April 15, 2010

Good News: Physicians are Watching and Waiting

There is a new blog post entering the hype circuit today, signaling yet another hand wringing phase in the manic depressive cycle of HITECH. First quoted at the MSDN blog and picked up by Healthcare IT News (Priming the Pump), it seems physicians are not buying EHRs fast enough. Ergo, ARRA is slowing down HIT adoption because docs want to wait until all the rules and regulations are finalized and the confusion is removed.

Here is the thing; this is exceedingly good news for ARRA and HITECH and EHR adoption. Why?

My biggest concern when the ARRA was enacted was that docs would rush headlong into buying software just to get the legendary $44,000 check. Considering that the EHR vendor community initiated aggressive and very shiny marketing campaigns around the stimulus, complete with guarantees and interest free loans, the EHR market looked eerily similar to the mortgage market from a few short years ago, and we all know what happened there.

If things proceeded according to the vendors’ expectations, we would end up with tens of thousands of physicians mired in lengthy implementations of software that is not a good fit for their practice and carrying a sizable debt to boot (interest free of course). When the dust cleared and the Meaningful Use regulations became final, and probably scaled back significantly, many purchasers would find out that the guarantees have small print attached requiring physicians to actually use the system in a certain way that may, or may not, be possible in their particular practice. The result of course would be an army of angry docs and a flurry of articles and blog posts bewailing the failed Government initiative and probably something about Obamacare thrown in there for good measure.

Instead, physicians proved that they are pretty savvy customers. Yes, incentives are nice and yes, they are interested in getting them, but not until they understand exactly what they need to do and what the cost will be to their practice. Fire sale tactics notwithstanding, there is a year and a half left until a doctor has to become a meaningful user and almost two years before Medicare will start shaving off pieces of the $44,000. There is ample time to shop around, take a good look at the final rules, see who certifies and who doesn’t, make sure practice revenue is adequate and then, and only then, make an informed decision.

I am so proud of every physician out there. What is worrisome to vendors of current products and services is actually a very good sign for ARRA and its ultimate success.

Monday, April 12, 2010

Reconciliation of Meaningful Use

The long drawn battle over Health Care reform has concluded with a process that merged together the wants and needs of multiple legislative constituencies. Nobody got exactly what they started out with, but we now have a workable solution. Following the same reasoning, Meaningful Use could benefit from Reconciliation with Reality.

As various provider constituencies analyze the proposed tasks required from a Meaningful User, it appears that Meaningful Use (MU) as defined by CMS is quickly becoming an insurmountable barrier to adoption of EHRs.  The HIT Policy Committee has proposed some relaxation to MU by allowing providers to defer 6 items from the original 25 requirements list (see below). While this proposal is most definitely a step in the right direction, it is not enough. By contrast AMA has proposed retaining only 5 criteria. Now that CMS is poring over the public comments to the proposed MU criteria, which seem to be calling for relaxation, it may be a good time to heed passionate calls as the one made by Dr. David Kibbe on THCB on behalf of the majority of health care professionals who practice in small underfunded settings.

Unlike the ONC IFR for EHR certification criteria which is now final, the CMS MU proposal is only a proposal and, as such, can be altered. Certifying EHR technologies based on the full 25 criteria, per the ONC IFR, is actually a good thing as it ensures available technology as HIT adoption, and meaningful use of it, progresses. However, unless we take on step back on MU, moving forward becomes a very uncertain proposition. We should also keep in mind that the discussion here is limited to MU Stage 1, which can be initiated by physicians as late as ctober 1st 2011, and Stage 2 is slated to begin 15 short months thereafter. There may be a need for considering the general time lines at some point.

An Honest Look at Meaningful Use Criteria

Out of 25 proposed criteria, 9 are either simple or a prerequisite to the business of medicine and there is no question that these should be required. One would be hard pressed to find a provider disputing the necessity of any one item below, except maybe #6 and the charting part of #5, which should be limited by specialty. In reality, most providers already satisfy these requirements in electronic format.

Green Light List – All Clear!

1. Maintain an up-to-date problem list based on ICD-9-CM or SNOMED CT®
2. Maintain active medication list
3. Maintain active medication allergy list
4. Record demographics
5. Record and chart changes in vital signs
6. Record smoking status for patients 13 yearss and older
7. Generate lists of patients by specific conditions to use for outreach
8. Submit claims electronically to public and private payers
9. Provide clinical summaries for patients for each office visit

The second chunk of 7 MU criteria is a bit more complex and will likely require adjustments to current work flows. However, most can be achieved with simple means and all make perfect sense from an immediate patient care perspective. For example, the last three could be achieved simply by adding a Patient Portal to an existing EHR, and the first two could be satisfied by incorporating one of the many standalone electronic prescribing modules available on the market.

Yellow Light List – Proceed with Caution.

10. Generate and transmit permissible prescriptions electronically
11. Implement drug-drug, drug-allergy, drug-formulary checks
12. Send reminders to patients per patient preference for preventive/follow-up care
13. Check insurance eligibility electronically from public and private payers
14. Provide patients with an electronic copy of their health information upon request
15. Provide patients with electronic access to their health information within 96 hours of availability
16. Provide summary care record for each transition of care and referral

The last 9 MU criteria are very difficult to implement and with one exception, #25, there is no immediate benefit to patient care, although CDS (#20), if done correctly, can have immediate benefits for some specialties. Interestingly, three of these criteria are defined as capabilities. Capabilities belong in the vendor Certification realm, not Meaningful Use. Medication reconciliation is utterly useless at this time. I cannot imagine any use case where two medication lists exist in an EHR for a given patient, unless codified exchange of information between providers is actually happening. Therefore, #21 should be defined as a capability and moved into the vendor certification area. The other major offender is #19 (quality measures), which particularly for primary care is bewilderingly complex and has no immediate effect on patient care. CPOE and structured lab results should really go together to be meaningful and there are multiple objective hurdles to implementation. The last item on the list, Privacy & Security, although presenting a huge burden, must be part of any EHR system.

Red Light List – Stop!

17. Use CPOE
18. Incorporate clinical lab-test results into EHR as structured data
19. Report ambulatory quality measures to CMS or the States
20. Implement 5 clinical decision support rules relevant to specialty  and track compliance
21. Perform medication reconciliation at relevant encounters and each transition of care
22. Capability to electronically exchange key clinical information among providers of care and patient-authorized entities
23. Capability to submit electronic data to immunization registries and actual submission where required and accepted
24. Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice
25. Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities

Reconciliation Proposal

A Meaningful User, must attest adherence to all 9 Green Light criteria, at least 3 Yellow Light criteria of their choice and at least 1 Red Light criterion not to exclude item # 25 - Privacy & Security.

This is slightly over 50% of the original MU criteria and it may very well be the optimal place to start, optimal in the sense of encouraging computerization of medical records.

Sunday, April 11, 2010

EHR Mythology 101

Healthcare IT is bustling with activity these days. There are big changes in the air and, only time will tell, but we may be witnessing a defining moment in HIT. Naturally, everybody involved has an opinion and some folks, yours truly included, have more than one.
Below are some of the more popular opinions amongst physicians and a considerable portion of industry analysts.

The current EHRs on the market are outdated legacy systems – This is the battle cry of every new entrant to the market. First the ASP, or web based, vendors referred to the existing client/server vendors as legacy systems. This is about to change once the iPhone EHR vendors start calling the web EHRs legacy systems. One common thing that new vendors tend to gloss over is the fact that the existing vendors did not stop writing software in 1995. Most incumbents are releasing updates and major new versions on a regular basis, and by now most Visual Basic code has been replaced by .NET and the latest Java technologies. True, here and there, you can still find MUMPS platforms, but even the VA’s VistA is in the process of getting a major upgrade towards generic web based capabilities, not to mention the futuristic bombshell veteran EHR vendor e-MDs is about to toss into the mix.

One small reminder to the swooning fans of upcoming iPod/iPhone/iPad EHRs would be that these inevitable iEHRs are nothing more than a return to a closed platform proprietary (OS and hardware) client/server paradigm, when compared to platform agnostic applications like athena Clinicals, Practice Fusion, Ingenix Care Tracker or many other pure browser based offerings which can be accessed across the globe without having to purchase a specific brand of computer and without having to download a bunch of proprietary software first and without having to obtain permission to develop the product to start with.

EHR prices are small fortunes – You can buy, or subscribe to, the top of the market, eClinicalWorks EHR for $250 per physician per month. You can subscribe to Practice Fusion’s EHR for FREE. You can get Amazing Charts for less than $150 per physician per month, including the Practice Management system with the most expensive interface costing $500, and most are free. I spend more than that on Starbucks. True, if you need new computers, you will need to spend more money, but I have not heard of any futuristic EHR slated to run without hardware. Also true, there are some very expensive EHRs out there. The Bugatti Veyron sells for $1,700,000. Does that mean that cars are unaffordable? Do you even want a Bugatti? I don’t know, but I couldn’t fit my kids and dog into one of those, so I’d rather drive a Jeep.

EHR implementations fail because the software is unusable – True, implementations do fail and by fail I mean everything from throwing the vendor out to using only a small portion of the product. The question is why do they fail? Before answering that, let’s note that most implementations do not fail. Implementation failure is not limited to certain EHRs or certain specialties or certain practice sizes or certain demographic groups. It has been linked however to lack of change management, poor choice of product, wrong expectations, insufficient training, lack of commitment and all sorts of peripheral lack of preparedness. If EHRs should be as easy as driving a car, then everybody should have to take Drivers Ed. or log 200 hours of supervised driving before taking the Bugatti to the Autobahn or even to LA during rush hour.

CCHIT certification doesn’t mean anything – True, CCHIT is not an ONC approved certification body at this time, but it will most definitely be as soon as ONC approves any certification authority. 2008 CCHIT certified EHRs are very close to being able to qualify for HITECH incentives and 2011 CCHIT ARRA certified software is perfectly adequate. Considering the ONC certification plans, it is expected that multiple certifying authorities will come into existence, which is not the same as saying that CCHIT will become irrelevant. It will just have some well-deserved company. Also true, there are several smaller EHRs that have no CCHIT certification and are fully capable of qualifying for the upcoming ONC certification and they may very well apply for certification.

EHRs should be like Facebook – Social media is the hottest kid on the block. Everybody tweets, blogs and writes on other people’s walls. We have laptops, netbooks and smart phones and we are always connected to each other. I know someone who tweets in the shower. The logical conclusion must be that consumers should be able to access their EHR from the bathtub and post updates to the provider’s wall, or maybe the other way around. True, both patients and physicians should be able to access medical records from any location, but most EHR work is, and always will be, performed in a clinical setting. EHRs are tools for providing health care. For care providers EHRs are tools of the trade, not much different than CAD tools are for engineers and Visual Studio is for developers and QuickBooks is for accountants. For patients, EHRs are tools to manage health status or chronic disease, maybe a bit similar to paying bills and preparing taxes online. Nobody needs to access TurboTax in the shower.

EHRs should be about Clinical care not Billing – True, most EHRs contain coding advice and even automated E&M calculators. Most template-based EHRs go to great lengths to facilitate documentation as required by CMS to justify a particular level of reimbursement. However, as any EHR user will attest, EHRs do not force users to create convoluted, billing-justifying documentation. So why do physicians keep creating such documentation while complaining of how terrible the notes look? Probably it is because, at the end of the day, every doctor wants to get reimbursed adequately for his/her work. EHRs did not invent our reimbursement system. CMS did. EHRs are tools designed to reflect reality not utopia.

Big monolithic EHR products are bad – Modular vs. monolithic software development is an old controversy dating back to the large kernels vs. microkernels debate. In the EHR context, the single vendor vs. best of breed argument has been going back and forth since hospitals started installing MUMPS based systems. At least for hospitals, it seems that Epic has put the argument to rest in favor of the single vendor approach for EHR. For small practices, with practically nonexistent IT expertise, aggregating and integrating and supporting an array of software modules from different manufacturers, with no guarantees of ability to integrate them, may prove to be a very frustrating money pit.

Unless you are a computer whiz kid, you don’t usually go to a computer supply store and buy a motherboard and a case and a hard drive and video and sound cards and all sorts of paraphernalia to take home and assemble your laptop. You go to BestBuy and buy a Dell. Granted Dell, didn’t make all the laptop innards, but instead assembled them much like the whiz kid did, but you don’t care and you don’t need to worry about it, because if your Dell breaks, Dell will fix it, no matter who manufactured the capacitors on the motherboard.

As to the end product assembled from simple little modules, I think what Linus Torvalds, the colorful creator of the utmost open platform, Linux, said about microkernels applies very well to our discussion:

"The fact that each individual piece is simple and secure does not make the aggregate either simple or secure."

Physicians should wait until the perfect EHR is ready – Let me go out on a limb and make one prediction here: Unless the Almighty creates an EHR for us, perfection will never be attained. Large hospitals and large physician groups are buying EHRs and are getting connected. If small practices have any chance at survival in our quickly transforming health care environment, they must find ways to increase efficiency and they must be able to participate in the soon to be mandated information exchange. Whether the canteen is half full or half empty depends on how dehydrated you are. Pouring the water in the sand because you are seeing a vision of lush palm trees and waterfalls on the horizon may not be the wisest decision you can make.

Thursday, April 8, 2010

The Privacy of a Learning System

The original goals of an electronic medical record for every American by 2014 were centered on continuity of care, reducing errors and reducing waste from duplication of tests.

Somehow the goals have evolved to include a Learning System, defined by ONC as “a system that is designed to generate and apply the best evidence for the collaborative health care choices of each patient and provider; to drive the process of new discovery as a natural outgrowth of patient care; and to ensure innovation, quality, safety, and value in health care.”

While the original goals could be achieved by the creation of a patient centric longitudinal medical record available, or transportable, to all care agencies, including patients and families, at the point of care, the new Learning System shifts the emphasis to a data centric system where medical records are available in aggregate for Learning purposes, the results of which will be shared with patients and care givers in a meaningful way. The Learning System derives value as an “outgrowth” of patient care and funnels it back into patient care in the form of evidence based cost effective care. This is a far cry from the humble proposition to make a comprehensive record available to all providers, by facilitating interoperability between providers of care. This is a major shift in paradigm.

The Learning System, by definition, requires large data repositories aggregating millions of records and trillions of discrete data elements, residing in dozens of data centers. The repositories could be governed by States, regional health organizations, the Federal Government or technology vendors. This sort of construct brings up three major concerns: Technical Feasibility, Security and Privacy. Technical Feasibility is by no means guaranteed or even simple to ensure, but the concept is, well, technical. Bytes, bits, metals, plastics, composites and sets of standards and protocols are pretty straight forward to negotiate. Security, the hound dog protecting Privacy, is also very technical and unambiguous.
But what is Privacy? What is it we are trying to protect?


Right to privacy is a fairly recent legal notion. The landmark definition of privacy as the “right to be let alone” originated in a Harvard Law Review article by Warren and Brandeis in 1890. Interestingly enough, the eventual inclusion of privacy considerations in common law were spurred by technology advances (photographic cameras in this case). While there are several tort categories of Privacy, the one most pertinent to our discussion would be the Intrusion category (Intrusion - A physical, electronic or mechanical intrusion into someone's private space. This is an information-gathering, not a publication, tort. The legal wrong occurs at the time of the intrusion; no publication is necessary). Public Disclosure may be pertinent too, if it follows Intrusion.

When it comes to medical information, Privacy has a very different origin. Physicians would easily recognize the following sentence “Whatever, in connection with my professional practice or not, in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret.” as part of the Hippocratic oath. Guarding the privacy of patients is an ethical obligation for a doctor.
While most states have licensure requirements and some have statues or case law indicating a fiduciary responsibility of physicians (and hospitals) to hold medical information private, there is no explicit Federal law to that extent, although Justice Brennan, addressing computerized data, has warned over 30 years ago, in Whalen v. Roe, that the day may come when we will have “the necessity of some curb on such technology”.

More recently, The Nationwide Privacy and Security Framework for Electronic Exchange of Individually Identifiable Health Information, published by the ONC on December 15, 2008 and adopted by the current ONC Health IT Strategic Framework published on April 1, 2010, has very thoughtful principles guiding Privacy and Security solutions. Just like HIPAA, these frameworks are concerned with “Individually Identifiable” information and just like HIPAA it’s not very clear either who can obtain this information or for what specific purpose it can be obtained.

Moreover, the definition of Individually Identifiable Information is not clear cut. A few decades ago, information was considered no longer Individually Identifiable upon removal of such demographics as name, address, phone number, SSN and similar family members’ information. Today, this may not be nearly enough. As shown by Dr. Latanya Sweeney over a decade ago, simple database algorithms and joining of de-identified data from various sources can produce Individually Identifiable Information.

One is therefore forced to inquire whether the protections proposed by HIPAA and both ONC Frameworks pertain only to clinical data that includes individual identifiers, or more inclusively, to data that lends itself to re-identification using advanced algorithms and additional data sets, either publicly available or obtained from other clinical or non-clinical sources.
In an environment where personal information is collected, bought and sold at street corners (by government too), and security breaches are common, we may need to step back and evaluate the implications to Privacy rights in a Learning Environment.

A Health Care Learning System is a beautiful, visionary idea, which in due course will save lives and vanquish disease. However, a Learning Environment needs data in order to exist, and a responsible Learning Environment needs to manage its data responsibly, with an enforceable legal and fiduciary responsibility to the rightful owners of such data and their “right to be let alone”.
Either Congress steps in and enacts adequate privacy laws for this information age, or we wait until significant and irreversible damage is done and the inevitable case winds up in front of the Supreme Court, where I suspect serious “curbing” of technology will occur.

Tuesday, April 6, 2010

Achieving Meaningful Use – A Roadmap for a Small Practice

A few days ago, while reading one of my favorite EHR forums, I ran across a post from a typical Primary Care physician, practicing in a typical small practice, seeking advice on EHR adoption. There was nothing unusual about his post, except the last line:

“So confused.  All I want to do is see patients.  Any suggestions”

This may be the most succinct and accurate description of the situation out there. We the “experts” are reading hundreds of pages of legislation and rulemaking cropping up on a daily basis, participating in public meeting and public comments and writing heaps of articles and blog posts all over the Internet. However, the typical doc, in the typical small practice, does not have either the time or the inclination to become an expert. All these physicians have is incomplete and sometimes misguided information.

For the anonymous doc from my forum and for the hundreds of thousands of his/her colleagues, I committed to writing a guide to the times, or a simple guide for achieving the national goals for HIT, starting with Meaningful Use.  This is not another lofty guide to policy. It is a hands on (do this first, do that second, and so forth) guide to researching, deciding, selecting, buying, implementing and using EHR technology, in accordance to the newest regulations.

This is work in progress, and only the first Chapter and two appendices have full content.  I would normally wait until the paper was complete before posting anything. However, I think we’re running out of time and these doctors need answers. So I decided to build this guide in a public, as-you-go process. Below is a synopsis of the first Chapter and a link to the Draft document. I expect comments and questions and suggestions, which will be incorporated in the final version.
The buzz word is Meaningful Use. You go buy one of those CCHIT certified EMRs and the Government will send you a check for $44,000. Not sure what Meaningful Use is, but many vendors guarantee that you will get your check. There are two options here, trust the vendor and buy something. Trust no one and wait and see.
And then there is the prudent option. Start educating yourself so you can make an informed decision. This paper will provide a roadmap for a typical small practice with no special affiliations to a hospital and no other immediate source for freebies.

Part I – Pre Decision to Buy

Step 1: Estimate your incentive amount
That $44,000 figure is not for everybody. You could qualify for more and you could qualify for a lot less, maybe even nothing. . It all depends on how many Medicare or Medicaid patients you see on a regular basis. Where you see patients is also extremely important.

Step 2: Understand Healthcare Transformation
Whether you have seen EHRs in action and deeply disliked them, or haven’t experienced them at all, but heard all sorts of good/bad things from your colleagues, please be aware that the computerization of medical records is inevitable. We may not be certain of the shape or form it will take, but sooner or later paper will have to go away.

Step3: Survey the Landscape
There are literally hundreds of EHR options out there ranging from glorified word processors to super complex packages that will do everything short of actually examining the patient, or so they claim. The prices range from completely “free” to tens of thousands of dollars and everything in between. Some come with “warranties” and some are sold “as is”. Caveat emptor is the prime directive.

Full text draft of Part I, a synopsis for Part II and miscellaneous content are posted here [PDF].
This  documented will be updated frequently until complete (ETA - a couple of weeks).

Monday, April 5, 2010

Health Care and You - A Student's Perspective

(Tonight is the big night for the Duke Blue Devils, so I thought of sharing my favorite Dukie's thoughts on Healthcare Reform, uncut and unedited)


Change. Yes we can. All those chanters supporting President Barack Obama’s campaign proved they really could make some changes, at least with respect to health care.

The Patient Protection and Affordable Care Act was signed into law by Obama this past Tuesday. The administration was so excited it entirely forgot to strap on Vice President Joe Biden’s muzzle, and the result was an expletive-laced congratulations unbecoming of a sitting vice president (unless your name happens to be Dick Cheney).

Whether the law stands or falls will be determined in the next few months in our courthouses, but until then, what can we expect from such a monumental bill?

The first and perhaps most significant impact will be witnessed by millions on cable television. The text of the act is full of ways to assess how the various new programs are working, but the most immediate test will be broadcast pre-recorded for us all to see. Starting July 1, a 10 percent excise tax will be levied on indoor tanning services. And MTV must be salivating, because this tax just added a whole new ripple to the second season of the “Jersey Shore.”

What will DJ Pauly D and Mike “The Situation” do now that their GTL (gym, tan, laundry) regimen is under fire? Will the men have to work harder at their day jobs to make up the costs and spend less time partying? Will the stress carry over into the home, with even more drama this season than before?

According to extensive Twitter research, shooting for this upcoming season is only in its earliest stages. Will MTV try to squeeze in a whole summer of fun before the doomsday date of July 1, or will we all play witness to the utter chaos the Patient Protection and Affordable Care Act will unleash onto the beaches of Miami?

MTV played this game well by hedging their bets. Not only will the “Jersey Shore” cast be challenged, but the act opens new possibilities for the cast of “16 and Pregnant.” Sections 10211-10213 of the act provide new services for pregnant women and teenagers. Will the president save the day for a budding prom queen needing to find affordable daycare for her newborn daughter? Could this be the moment when the show transforms from a teen pregnancy deterrent into its unwitting advocate? This could translate into a cultural sea change: Did Congress just provide incentives for high school and college women to have babies? Only time, and MTV, will tell.

But certainly not all college students will admit to watching such shows. Still, this act has quite a bit in store for them too. For computer scientists, the act encourages greater use of electronic health records and other data storage. Congress and the Obama administration have almost unequivocally decided that the future of the doctor’s office lies in digitization.

For medical and health scientists, the bill offers grants galore to study human ailments and assess current treatment mechanisms. Section 4305, for example, encourages further research into the pain treatment. For economists and public policy analysts, sections 3013-3015 and 4301-4302 offer grants to analyze national data on medical assessments and health disparities, and then formulate policy proposals to better the new system. Look no further for a thesis topic!

The greatest benefits, however, accrue to future medical professionals. Section 5101 creates the National Health Care Workforce Commission, charged with helping medical, nursing and medical ancillary staff students finance their professional education. The same section also proposes a loan repayment program to encourage greater medical access in low-income and high minority population areas. Sections 5202-5210 offer further loan repayment programs and workforce retention mechanisms. Sections 5301-5315 establish greater incentives to lure doctors into specific medical fields.

The last of these sections includes a national plan to train more doctors through direct programming at qualified institutions. By the time all of the act’s programs go into effect, we may become a nation of healers.

No matter what seat you hold in the academic world, be it the nice study chair in the library or the couch in front of the television, this act has just rocked your world. And to think that the test for health care policy’s efficacy, for the guiding vision of our nation’s moral and fiscal future, might just lie in the hands of the one they call Snooki.

Elad Gross is a Trinity senior. His column runs every other Friday. This article appeared first in the Duke Chronicle on March 26 2010

Friday, April 2, 2010

An iPad a day......

(Casual Friday Fun Series)

I think Stephen Colbert figured out a great Healthcare app for the iPad.
It's all about healthy nutrition.....

The Colbert ReportMon - Thurs 11:30pm / 10:30c
Stephen Gets a Free iPad
Colbert Report Full EpisodesPolitical HumorHealth Care Reform

Thursday, April 1, 2010

EHR - Whose Record Is It Anyway?

(Privacy, Security, Consent & Property Rights)

On March 23, the HHS released an excellent Whitepaper on Consent to Electronic Information Exchange of Medical Records. Also on March 23, Dr. Deborah Peel, founder of Patient Privacy Rights has published an opinion in The Wall Street Journal emphasizing the absolute need for obtaining patient consent prior to sharing private information.

The HHS Whitepaper is examining various forms of Consent, various existing implementations of Consent in Health Information Exchanges across the country and abroad, existing laws regulating the need for patient Consent and provides in-depth analysis of the technical challenges in implementing Consent policies.

Before we look at Consent to share records, we should probably clarify what it is exactly that we propose to share, with whom do we share and for what purpose.

All of us at some point or another signed the HIPAA consent form in a doctor’s office and thus, allowed the doctor to share identifiable Personal Health Information (PHI) “for treatment, payment, or health care operations purposes”. While nobody really understands what “health care operation purposes” really are, we assume that our physician will share information with our other care providers and insurance companies and nobody else.

Does this mean that de-identified information (re-identifying is very possible) can be shared with anybody without our consent? Does it mean that our doctor is now empowered to share ALL our information with insurers and other providers? If our employer is self-insured, can the doctor share our information with the employer as well? Do health care operations include public health (Government) and research (private)?

Some answers do exist. For example, the Genetic Information Nondiscrimination Act of 2008 (GINA) generally prohibits the collection and use of genetic information by insurers and employers. So information regarding our family history or anything available from direct genetic testing cannot be shared with insurers and employers. GINA does not prohibit use of such information for other purposes. Other answers are unclear.

Electronic Medical Records can contain information on disease, medications, treatments, social habits, drinking habits, smoking status, sexual activity and orientation, abuse, depression, mental health, financial class, ethnicity, education, family circumstances, diet and exercise, residence, SSN, employment, travel, hobbies and whatever else providers choose to ask and we choose to answer. Electronic Medical Records can be, and will be, the most comprehensive description available for an individual in a computerized discrete data format, ripe for analysis and mining. Unlike their paper counterparts, Electronic Medical Records are “liquid” and easy to share and they will be shared. The only decision left to us is how they will be shared.

Sharing Medical Records between providers to improve an individual patient’s care is an obvious and tested notion. Sharing Medical Records to foster public health is a good intention and certain roads are largely paved by good intentions. Creating rules and regulations to govern Privacy and Security of information by requiring patient Consent and technology to secure data, is imperative, but not nearly enough. Security will be breached (it is so already) and data will be improperly disseminated and used (occurring already). The law should impose real and severe penalties, not just financial slaps on the wrist. And the law should be enforced.

For various constituencies, or “stakeholders”, the wealth of information contained in EHRs is directly translatable into tangible wealth measured in hard dollars. Thus, information in EHRs (identifiable or not) should be considered Property. Treating information as property has precedence. In the business world Intellectual Property is a well understood and well regulated term. Medical Record Property deserves, at the very least, the same protection.