May 3 2010 8:53AM GMT
Posted by: margalitg
ARRA requires that EHR systems be certified. ONC published an IFR outlining certification criteria supporting Meaningful Use as defined by CMS. Later on ONC proposed rules for the creation of EHR certification authorities, and NIST is currently defining brand new testing procedures. In the past CCHIT certified EHRs and large portions of CCHIT certification criteria came from HL7’s work on various functional profiles.
All this means is that hundreds of functional points were required to be present, in very specific form, for an EHR system to achieve certification.
There are functional points mandating what data to capture, how it is recorded, how it is stored, how it is displayed and when it should display. Incorporating all these certification requirements into a software application created very comprehensive products with the ability to do many things, or as they came to be known “bloated EHRs”. But there is another, probably unintended, consequence when trying to enforce such incredible detail; the certification process was in effect dictating particular work flows and distinct user interfaces. That was the point where the grumblings about lack of EHR usability and complaints of EHRs not being built with physicians and patients in mind, started gaining steam.
I cannot count the times when my only response to a complaining physician was that the offending piece is required by CCHIT. Many vendors searched for places where the system need only have “the ability” to do something and created customizations allowing physicians to turn off said ability. Nothing more so than the endless, and mostly useless, alerts. At one point you could tell at first glance if an EHR was or was not CCHIT certified. All the certified ones had this strange little dropdown box next to each diagnosis in the problem list, where you could select if the problem was acute, chronic, resolved, bi-lateral, controlled, etc. I have never seen it used in real life. Does anybody think that unless we mark it chronic, there is a danger that a doctor will assume that DM is acute or bi-lateral?
Well, if it’s all so counterproductive, why are we certifying EHR technology? Honestly, I don’t know that we should. The original thought was that certification will assure prospective buyers that the system is able and willing to do the job, thus separating the wheat from the chaff. Unfortunately, certification acted in a more simplistic way and separated the heavy from the lite, regardless of usability, value and stability.
The new thought at ONC is that certification should provide a guarantee that one can achieve Meaningful Use by employing a certified system. So instead of trying to dictate every detail, the ONC certification is all about the specific criteria of Meaningful Use; 25 criteria for Stage 1. As a result, some small uncertified vendors of very lite EHRs are expressing interest in the ONC certification, if the price is right, of course. CCHIT gracefully turned on a dime and created a much slimmer ARRA certification process. But is it possible that the slimming and trimming process is going too far?
Is it possible to certify too little?
It is probably too soon to tell if the new ARRA certification will be able to strike an acceptable balance between allowing vendors the freedom to innovate and ensuring that Meaningful Use can be achieved with a certified product. However, the proposed NIST test procedures indicate a possibility of certifying too little.
For example, certifying that a piece of software is capable of receiving electronic lab results in discrete format, while allowing the vendor to choose the structured format in which lab results are received could lead to the inability of future users of the software to meet Meaningful Use requirements, if the vendor selects anything other than HL7 for their preferred structured format. Laboratories do not send results out on a regular basis in either CCR or CCD, which are specifically allowed by NIST, or any format other than HL7. An EHR, or EHR module, capable of receiving lab results in a CCD format exclusively, may become ARRA certified, but its proud owner will be unable to become a Meaningful User.
A different and more troubling issue arises from looking at a requirement in a very narrow way and neglecting to account for ramifications not directly related to the particular Meaningful Use criterion. For example, testing for the ability to modify a medication list without concern for historical integrity of the list creates a strange and dangerous situation where adjustments made to the SIG (strength, dosage,etc.) of a particular prescription are allowed to overwrite the entire history of said prescription (think Warfarin). The narrow scope of testing that modifications are possible fails to assert the need for those modifications to be made in accordance to general principles enforcing the integrity of the medical record. Presumably this larger concern is left to vendor discretion. Existing vendors that certified their products under the old regime will probably provide a reliable product anyway, but new innovative vendors, writing software to published specifications and test procedures could easily create a certifiable, yet clinically unsafe product.
We are all aware that an over prescriptive certification process has not produced massive improvements in EHR offerings. The temptation to err on the side of oversimplification is large, particularly since the time is short and we must come up with a temporary certification process sooner rather than later. However, if we look at certification as a process designed to help vendors build better products and assist buyers in selecting tools to achieve Meaningful Use, then we must make sure that, while not overbearing, ARRA certification is indeed meaningful.
Apr 26 2010 8:00AM GMT
Posted by: margalitg
(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.
Next Review: Amazing Charts
Apr 22 2010 8:56AM GMT
Posted by: margalitg
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.
Apr 13 2010 9:07AM GMT
Posted by: margalitg
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 October 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 years 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.
Apr 6 2010 10:21AM GMT
Posted by: margalitg
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.
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Introduction
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.
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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).
If you follow the health IT media, you cannot escape the new and obligatory word, Innovation. Every self-respecting article, blog post, press release or casual comment on line is not complete unless some reference is made to Innovation, its derivatives (innovators, innovative, etc.) or compounds (foster innovation, disruptive innovation, etc.). By now I am ready to add Innovation to the infamous Do Not Use category, along with Synergy, Turn-Key and One-Stop-Shop, to name a few.
