Visiting the exhibitors at the HIMSS 2010

The second half of my day I did have the opportunity to walk through the exhibit halls. And while it is overwhelming at first, I had my list already prepared of vendors I wanted to meet up and discuss their products. I categorized the vendors I wanted to visit into the following sections. This is just a tiny list of the ones I visited, but this was my initial list I created before hitting the exhibit hall:

EHR vendors
GE, AllScripts, Greenway, NextGen, e-MDs, eClinicalWorks,DDS Inc. (OpenVista)

Technology and Hardware vendors
DELL, IBM, CDW, Microsoft, Fujitsu, JAOTech

Solutions, Service providers
MEDNET, Claim processing with CPeople, Online Backups, MeDecision

Standards and HIE
Hl7, NHIN, NCHICA

Vendors with the coolest toys for my 3 year old.

Too cool to miss:
Microsoft Surface, NHIN (participating vendors and the IHE)

My first day at the HIMSS 2010

So, the HIMSS 2010 is still going on, but I definitely needed to take this opportunity to collect all my thoughts and review my notes to see what I have learned so far.

My first day went as follows:

It started out with a great presentation done by the Governor of Vermont Jim Douglas. He discussed several of the advantages of having electronic health data and also how it will help the states improve healthcare and reduce the costs. He recognized that most governor are dealing with difficulties balancing their budgets while trying to avoid making any major cuts to critical services. He also covered that a big chunk of his state’s budgets is taken by Medicaid (26% to be excact) and that with the help of healthcare information exchange he is encouraged to see that there will be some potential cost reductions.

One very interesting subject that was brought up and cough my attention is what credentialing and jurisdiction will need to be applied when Telehealth becomes widely adopted. As we all know, TelHealth is when providers from out of state are providing care to local patients or providers instate are caring remotely for patients in other areas. This poses the questions on who gets taxed, what credentialling entities will be used and so forth.
While he did not discuss in details his thoughts on what is going on in capitol hill in regards to the “healthcare/insurance reform”, he did point out that it is a far more challenging task for each of the state governors ahead in reguards to dealing with balancing their books and continue to cope with the ever increasing healthcare costs.

Some of the additional sessions I attended included the review of "Meaningful Use" presented by Sanjay Shah and how the ARRA affected their hospital. He discussed how they have started planning on going paperless several years prior to the enactment of the ARRA. He was able to provide some very good insight to what hospitals need to plan for, and how the three stages of Meaningful Use will impact everyone.

In the presentation he did outline how there are still some areas where his hospital is facing some potential Meaningful Use Gaps. This included e-prescription needs, CPOE implementation outside of the ED, and potential upgrade requirements once the certification is announced.

Next came a presentation by Gregory T. Fairnak the Chief Architect of CONNECT Gateway project. And as he started talking about Opensource and some of the technical aspects of the solution, I was in cloud nine. This was one of the highlights of my day. As a junior software architect and a developper, getting to interact with Greg was a delight, and a great opportunity to pick his brain on some of the details of the CONNECT. I also had the opportunity to meet another icon “in the Opensource arena”. As many in the interfacing world already know, Mirth Project has been in the front lines of the EDI and Interfacing . I have personally assisted many of our clients overcome some of the high costs of interfacing by utilizing this powerful FREE solution. I had the chance to have a short conversation with Gary Teichrow one of the creators of Mirth. It was such a delight to hear how the product came about. I expressed by appriciation to his product creating and thanked him for such a great contribution to health informatics.
It is critical to also note that some of the Mirth components are being utilized by the NHIN (National Health Information Network) which as everyone already knows is the backbone of the federal healthcare information exchange for CMS, SSA, DoD and other federal entities.

This concludes one part of my day at the HIMSS!

North Carolina gets its share of the stimulus money and a boost to help with EHR adoption

Today the white house announced what has been awarded to the different states to support Health Information Exchange and assist care providers with training and technical support with Electronic health records.

This makes the state of North Carolina one of the 41 states to get $ 12.9 million dollars in funding to facilitate HIE for the state. While there are several other already established health record exchange initiatives, the NC HWTF (North Carolina Health and Wellness Trust Fund) has greater potential to get a strong NC HIE started.

In addition, with the establishment of the regional extension centers and their awarded 13.6 Million dollars available through North Carolina Area Health Education Centers Program (AHEC) North Carolina care providers will have better access to onsite technical assistance to help with the adoption of electronic health records.

For a full list of grants awarded visit: http://www.whitehouse.gov/the-press-office/sebelius-solis-announce-nearly-1-billion-recovery-act-investment-advancing-use-heal

Top 10 EHR failure contributing factors

With the Economic Stimulus bill recently enacted into law by president Obama, and recent relaxation of the Stark Rules allowing hospitals to subsidize up to 85% of implementation costs of HER many are renewing their interest in an EHR purchase. But while many are excited about the encouraging subsidize available, others are still fearful on undertaking such a complex project after many “horror stories” they hear.

One must wonder what is really the source and true factors that contribute to the de-installations and or lack of return on investment on EHR. By reviewing these items, we can separate fact from fiction and expose what can be done to avoid these pitfalls.

The following are the top 10 biggest contributors to an EHR failure for certain products available in the market place:

1. Lack of strong follow up from the EHR vendor:

After Go live date some of practices begin to sense that the honeymoon period is over. Faced with new workflow challenges and staff not always sure what to-do and resort to a best guess on how to perform certain tasks, frustration grows and lack of confidence of the product begins to show.

2. Lack of training:

With a constant reminder of budgets and economic downturn some practices often resorting to less training and more self discovery tends to be another step into dangerous waters. With Computer Illiteracy many realize that they are still not comfortable with the product and don’t know enough to resolve some of the obstacles that accompany such products.

3. Unreliable infrastructure:

While many of the subsidies have reduce actual implementation/training and licensing costs of an EHR, weak and unreliable IT back bone infrastructure tends to offset the efficiencies that are meant to be gained. Far too many cases slow response, unreliable wireless and reoccurring system outages leave a terrible after taste of the EHR when it should be the one of the lack of infrastructure.

4. Not very user friendly:

While all care providers and clinical staff understand that when they are seeing patients all their attention is rightfully given to their patient, but too often they fall victim to the overwhelming screens, 2 dozen buttons to click or all flashing indicators reminding you that you have more work to follow up on.

5. Lack of interoperability:

It is clear that interoperability is “essential” for coordination of care and reduction of medical errors due to lack of information, and unfortunately many software makers lack to capital and expertise to arm their products with the ability to enable practice to participate in exchanging electronic health records within their community or just simply with a nearby hospital or IDN. In addition, it has been stated time after time that the ARRA’s ultimate goal is to promote exchange healthcare information to improve patient care.

6. Slow and painful ROI:

Statistic after statistic shows us that adoption rates for EHR have been slow, despite the growing enthusiasm. In some cases incentive payments can provide a boost, but often we find that citing a positive ROI is largely anecdotal. While upfront costs can range from 10,000 to 25,000.00 per provider in costs, it can take from 3 to 4 years before an actual positive ROI is seen in some cases.

7. Same engine under the hood for years:
As a developer I am guilty of trying to recycle applications I have created in the past and just performing a facelift on the interface. Unfortunately this trend has contributed to lack of new functionality and features for some of the products being used today. By simply changing a 10 year old product screen from black DOS screen to a “windows” based program with still the same engine under it. Many practices are still facing outdated functionalities and lack of new and much improved and newly discovered efficiencies.

8. Lack of sufficiency data visualizations:
Whether a healthcare organization is looking to identify the most common CPT codes used, performing internally RAC audits, or simply identifying trends in patient outcome measures, medical organizations are looking to EHR vendors to answer the calling. But with very few able to provide access and usable data, many are faced with the reality that data visualization is nothing but a dream. It is hard to truly understand the power information, but as stated in a recent article in the BusinessWeek written by Maria Popova: “Ultimately, data visualization is more than complex software or the prettying up of spreadsheets. It's not innovation for the sake of innovation. It's about the most ancient of social rituals: storytelling. It's about telling the story locked in the data differently, more engagingly, in a way that draws us in, makes our eyes open a little wider and our jaw drop ever so slightly. And as we process it, it can sometimes change our perspective altogether. “

9. Lack of or unreliable integration:

In the current healthcare environment, there are many connecting devices, entities and stakeholders. Whether you are ordering blood work or waiting for a pathology report to be downloaded integration is the glue that holds it all together. In certain cases missing labs, down interfaces and failure of communication can lead to dangerous and risky outcomes for the practice. Many of these situations lead to frustration and mistrust of the technology and products.

10. Loss of confidence:

At the center of it all, lack of staff buy-in poses the most common management mistake made that leads to complete EHR implementation failure. Many leaders discover after working hard on making sure the right product was selected for the right price that their staff is not confident in the adopted direction of the management. This leads the practice to face significant struggles. Ultimately, every staff member needs to buy-in to the change, and for this to occur successfully it is important to involve everyone in the process and ensuring they are part of the solution.

It is commonly cited that the practice should hold most of the blame for the failures of EHR projects and implementation. But who are we kidding here; it is like asking an IT engineer to manage a busy restaurant’s kitchen just because they watched few episodes of hell’s kitchen. The burden of a successful EHR should be shared amongst the product vendors who have far more experience in project management and technology as well as the team effort of an EHR committee from within the practice. Both parties must commit to proper education up front, continued education and follow ups to ensure that the product is being used the way it should be. The success of the project will benefit both vendor and customer.

In conclusion, while many of the indicated struggles above are contributing factors to failures of some of the EHR implementations out there. It is important to know that not all products have these challanges. In addition, many of the items listed can be resolved by taking the appropriate corrective measures. When in doubt always contact your vendor or a qualified healthcare IT export to assist you and your organization ensure that you are in the right path.

Healthcare Round II, ARRA has passed now let’s see what AHCAA has to offer

There is a new kid in town and his name is AHCAA (Affordable Health Care of America Act)!!! This bill might send some software vendors back to redesign their booth and replace "Guaranteed stimulus money from ARRA" to something like "Our products are now more affordable than the free OpenSource as part of the AHCAA"

Travelling to conferences recently showed me an interesting trend, and that is of software vendors providing along with their package a "Guaranteed Certifiable Product" or "Guaranteed Stimulus Money". While some of the requirements have been described, it is alarming to see that this trend is spreading like wild fire and gaining momentum. Much of the concerns should be around how practices will gather the resources and the right stakeholders to apply meaningful use and implement policies and procedures as part exchange of electronic health records.

So, while we are coming to a better understanding of the ARRA HITECH, we are now facing a new round of recommendations and new potential incentives. On October 29th, 2009 House Speaker Nancy Pelosi announced a new Bill by the 111th Congress titled: Affordable Health Care for America Act".

After reviewing some of the sections that are relating to health care technology or HITECH, I discovered some very encouraging items in the bill. I will just list the very basic AHCAA HITECH summary of the areas I got through reading:

• The bill recommends that a study be conducted to see if providing higher rates of reimbursements or other incentives would increase the adoption of certified EHR.
  
• The secretary will have until January 1st, 2012 to develop a plan to integrate clinical reporting on quality measures which would include the following items:

o The development of measures that can demonstrate meaningful use of HER, and clinical quality of care furnished to an individual.

o The collection of health data to identify deficiencies in the quality and coordination of care for individuals eligible for benefits.

• Extension of Incentive payments from Act 42 USC 1395w -4(m) (1) where 2010 payments would be replaced by 2010, then instead of 2009 inserting 2010.

• Promoting low-cost electronic health records software packages that are available for use. Examples (can anyone say Medsphere is loving the AHCAA) which is based on the package of the Veterans Administration.

This was an abvious expectation from any bill that was upcoming. Making the push for electronic health records part of a public option, the motives are to encourage the adoption of EHR after many healthcare providers showed some resistance ARRA plans.

Between requiring electronic clinical data reporting, to adopting meaningful use, it to note that adopting some Electronic Health Record system will improve coordination of care, reduce medical error, and provide faster access to data when it is most needed. At this stage the only debatable factor of any EHR package is whether it offers a true Positive ROI.

This is the challenge that much of the current vendor must prove to the rest, otherwise everyone will look to OpenSource and vendors will lose a substantial market share.
　
　

How can the billing department increase efficiency

The billing or financial department:

Much of the practice’s income depends on this department. This is the team in the organization that ensures that your money is tracked down and retrieved from the Payers and challenging patients. So how can we assist through technology and how can different solutions enable them to be more efficient.

Easy to look up EOB:

First we will start by implementing an open source OCR product Click here. That’s right 0$ solution that will reduce the look up time of an EOB by at least 50%. A billing staff member can locate a document simply by searching the DOS (Date of service) or simply the patient insurance id and with the results displayed in a Google fashion.

Post patient payments electronically:

Next stop is to reduce or even eliminate the need to manually post payments. Now this solution depends on the organization’s billing system whether the PMS or HIS supports electronic remit (X12N 835 format) or not. This is the format that payers return their EOB. Fortunately that format can be utilized to post patient payments as well that have been made electronically through a web portal or from processed check payments. This dramatically reduces overhead by requiring staff to spend less time doing data entry.

Deposit payments from your office:

Let’s be honest here, checks will be around for few more years, just like when we were told that with Check Cards checks will cease to exist. Well, I am sure checks will continue to survive for a little longer. So, let’s see how we can still be more efficient around them. How about reducing or eliminating the couriers services for check deposits. If you can today deposit a check simply by taking a picture of it through your phone(ImageNet Mobile Deposit(TM)), then medical practices have got to be able to use the remote deposit feature that’s offered with many of today's banks.

Elegability Check:

Ok, if a practice is still not utilizing these services that are offered by most clearing houses, then this is the appropriate time to try them out. It is a very powerful tool, especially when it reduces your claim denials and patient balances that end up going to collections with 20% of your potential revenue.

While there are many additional ways to create efficiencies through out the practice, the billing department is a great place to realize cost savings immediately without major adjustments. Whether you employ claim adjudication, document management or simply outsource statement printing, it is very important to continuously talk to your vendors and stay connected with what is the latest and greatest.. This will ensure that you are constantly evaluating and implementing what matters to your practice.

P4P Quality measure with CPT is not in our future

History

“The system is broke”, is a far more common phrase we continue to hear. Whether it is a politician eager to promote more support for healthcare reform, or a patient who is too frustrated due to the sheer volume of bills they get from 10 different entities, just to have one procedure for appendix removal. Even physicians who are penalized for using too many CPT codes or procedure count to treat a complex condition and get penalized from the payers for it under their P4P programs are saying it.

So this begs the question, is P4P Quality measures with CPT the right thing? We are seeing that many of these programs have not shown a tremendous adoption from physicians. Take the PQRI initiative, statistics have shown an average of $700.00 return per physician which is relatively low comparing it to the costs the practice has incur. This begs the question, is it worth looking at P4P programs and worrying about implementing them? Is the technology available to measure the outcomes of patient treatment over time?

Is it possible that physicians will be paid based on treatment outcome?

Well, if you review the ARRA and what 2015 will bring you will a clear indication as part of the meaningful Use goals to be“clinical outcome measures, efficiency measures and safety measures”, you will realize that there is a tremendous emphasis on outcome measures this might not mean that you care providers would be required to follow the recommendations, but it will mean that if CMS does make the outcome measure as a mean to reimburse you on patient treatment, then as we know Payers will usually just follow.

What are the current facts?

The good news this possible change would not affect the way physicians provide care. Many care providers do see and treat the patient based on some mental measurements and grading if the patient is or is not improving. But it does get sticky when a group needs to report on it on paper. Take for example a patient being treated for a broken wrist. We can measure the outcome of the treatment based on the level of Pain, we can track the range of movement of the wrist after the cast is done and we can measure the improvement on the amount of time it took to have the cast off. While in many cases the person’s body will dictate some of those results, but we can still benchmark the treatment outcome.




However, when you consider the patients with chronic disease such as End-Stage-Kidney disease then the complexity increases tremendously. During a recent presentation by CTG, they had a very interesting approach to this challenge. They basically created a Master Patient Complexity index that they can use measure the patient condition through well defined scientific measures such as: Age, Hemoglobin, Creatinine, Bun, BMI, Calcium, Potassium and so forth. With a plot as radar spokes as shown here(Values are based on fictitious data and do not represent actual patient information).

Result and the impact of this direction

This can potentially result in a shift of paradigm. Physicians may not be paid on how many procedures done, but the improvement of their patient’s overtime using a proven Master Patient Complexity index. The current recommended model by CTG looks very promising and may as well be a starting point. There have been implementations of similar models by other groups such as Mayo Clinic. This would also mean that EMR/PMS products would need to have a different approach to how payors are billed and properly display the progress or patient treatment outcome of time. It is just another fun day for BI (Business Intelligence) and health analytics.

Conclusion:

While physicians continue to focus on providing care to their patients one must remember that doctors do have to be compensated appropriately. Using CPT for a way to measure care quality is definitely not an acceptable method of measuring the improvement on quality care, so considering other approaches is a must, and looking for technology as a tool to facilitate makes more sense than ever. It also means that physicians must become more involved in product and measure development. This will ensure that future EMR products will answer to the providers needs, improved measures to assist patients with complex conditions and create an efficient reimbursement system.