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All Things HIT

June 28, 2013  3:43 PM

Physician have an “ABN” dilemma during CPOE

Posted by: AllinHIT
ABN's, CPOE, Uncategorized

Computer physician order entry (CPOE), central to the meaningful use incentives, presents an interesting dilemma to physicians delivering services to Medicare patients. At the point of care, physicians using an an EHR approved by the ONC-Authorized Testing and Certification Bodies can automatically receive an advance beneficiary notice (ABN) when placing medical orders by utilizing CPOE. These ABNs are generated when the EHR communicates with the CMS’ Medicare Coverage Database (MCD), and the MCD determines that the order being placed is not covered. The ABN, appearing on the computer screen, typically gives two options to the physician. First, the physician can print the ABN, have the patient sign it as a promissory note, agreeing to pay for the services out of pocket.  The second option, is for the physician to associate the services with a different diagnosis code. Hence, the patient will not incur the cost, and the physician is able to continue with rendering the service. The ABN was originally generated because the diagnosis code did not reflect the service as necessary.

It is this second option that creates a dilemma for the physician, has an effect on revenue, and most importantly, determines the level of patient care. I understand one of the benefits of CPOE is to eliminate unnecessary tests and/or procedures, and lower the cost of care. However, a problem arises when the physician and CMS disagree with what is “medically necessary.”  Additionally, CPOE affects the revenue stream of the hospital or the clinic performing the services. If CMS will not pay for the service, and services are suspended by the physician, it could lower the amount of write-offs that would have occurred prior to implementing CPOE.  Conversely, it could increase revenue if the Medicare patient signs the ABN and does pay for the service. Most physicians, faced with the dilemma of using option one or two, will choose they second option if they feel the service is necessary. They will then find a diagnosis code which complies. This could pose some future risk, in case of Medicare audits these transactions can be exposed, scrutinized, and require re-payment to CMS.

In my role as an Epic consultant, I’ve discussed this dilemma with physicians, and I understand their perspective. They just want to focus on the patient receiving said services, anyway they can. It pains them not to deliver care they deem necessary, and allow a patient to leave their clinic. Physicians just want to practice medicine and deliver the best care possible. Being forced to address this dilemma at point of care just disrupts care. On the other hand, I understand the payer (in this case CMS) and the hospital perspective on why ABNs should be discussed with the patient. During this baby boomer age, combined with CMS’ efforts to control healthcare costs, ABNs are a necessary evil.  I guess the question is, “How can we get the physician out of the middle?”

June 23, 2013  6:47 PM

Double submittals: bad news for job-seekers AND hospitals

Posted by: AllinHIT
double submittal, Health IT jobs, Health IT market

This is a great time to be working in the health IT industry! Trainers, builders, analysts and PMs are constantly being contacted – some would say harassed – by staffing firms. With the industry so hot,  there a few cold facts health IT professionals should know.

One of those facts is, the more staffing firms you work with, the more likely you have faced the double-trouble, double submittal.  The term “double submittal” defines the situation when two or more staffing firms submit a candidate’s credentials for the same project, with the same client.

This is double trouble, because hospitals many times toss out the job-seeker’s duplicate resume, and thus miss out on a potential quality resource.  If more than one firm felt the candidate was perfect for the job, then it attests to the quality of the individual.  I could also say that this can also prevent the staffing firm from placing a quality candidate, but they will sometimes just give the hospital client another candidate.  Being a little “green” last year, I experienced this fate and I was very disappointed to be eliminated like this!  Hence, I developed a different action plan with some rules when dealing with staffing firms.

First, I decided to take control of the situation and narrow down the firms I would send resumes to.  I short-listed them based upon the answers to certain questions:

  • Give me some name of the hospital clients your work with?
  • What is your candidate submittal process?
  • Do I have a choice from being W2, 1099, or corp to corp?
  • After submitting candidates, what is the time frame I can expect in the selection process?
  • How long have you been in business and what projects have you staffed recently?
  • Are you exclusive to the client for this project?

These are just some examples of my questions!  The answers, along with candidate referrals, have assisted me in narrowing these firms down.

Second, I will never submit my credentials when the staffing firm holds back the name of the client!  This is a big problem because the staffing firm could submit a candidate to a hospital he or she is already communicating with. Some staffing firms will give general descriptions (e.g. “It’s a client on the West Coast”).  They will also ask who you are talking to, expecting you to remember all the projects you are submitted for.

Third, and related to the previous statement, I keep a list of all the jobs I have been submitted my resume for, and by what firm.  Hence, when I am asked the question of who am I talking with, I can really answer and am not relying on my ability to recite them from memory.

Lastly, I believe that hospital clients, along with the staffing firms, should better address the problem of double submittals.  For example, hospitals, as the client, can tell all their staffing partners they will interview candidates despite being double submitted, and let the candidate pick which firm they want as representation.  At the very least, how about tracking all candidates and develop first-come-first-serve protocol, i.e. the firm that submitted the candidate first wins!  That way, double submittals will only be trouble for the guilty party, the staffing firms!  This will eliminate double trouble for the hospital and the candidate.

After all, the good candidates are just trying to find good projects and the hospital is trying to get the best candidates. It’s all for the best in the pursuit of excellent careers in health IT.

March 29, 2013  12:14 PM

Adopt and grow RTLS with hospital consolidation

Posted by: AllinHIT
EHR systems, RFID, ROI, RTLS

In the early ’80s,  upon graduating from college, I was marketing pharmacy management systems to independent pharmacies in a joint venture between AmerisourceBergen (at the time it was Bergen Brunswig) and NDCHealth (now McKesson).  This was my first entrance into the healthcare space, and  I truly believe the result of my experiences drove my interest in both health IT and this blog, All Things HIT. It made me look at the relationship between systems and operations and the importance of inventory control, re-ordering points, and stocking levels, all of which affect cash flow and cost. Similarly, it made me both evaluate and sell return on investment (ROI) for theses systems.

The pharmacy management systems included a point-of-care application that allowed the pharmacy to control the “front end,” or the portion of the store selling consumerable items, and the “back end,” where they distributed prescription drugs.  The ROI on these systems was proven, and very much needed to manage the biggest investment of the pharmacy: its inventory.  My favorite lead generator was obtaining information on start-up pharmacies, then proving ROI to the owner(s).  This is when they had a capital expense budget, and had concerns about inventory investment.  In some cases, they had other existing stores, which meant using our system allowed them better inventory utilization based on market location, hence lowering their costs.

Some years later, I worked for Verizon Data Services, selling bandwidth (sometimes referred to as “pipe,” or internet access) and one of my largest customers was a hospital.  It was then that I learned about radio frequency identification (RFID), and the result was the same as my days with marketing pharmacy systems, learning about a necessary inventory management tool.

Today, as a health IT consultant, this area is addressed through real time location systems (RTLS). With RTLS, the spiel is the same: a necessary management tool for managing hospital inventory/assets and other resources (people, beds, medical devices, stretchers, wheelchairs, etc).  Just as I urged those pharmacies to improve their stores with these systems, I now urge hospitals to do so with RTLS.  Especially during this age of consolidation, which is in some ways similar to opening up a new store. It’s a perfect time to better manage the huge investment in devices, people, and consolidate those acquired assets allowing a better result from the acquisition.  If two hospitals are combining, a true picture of their combined assets for devices, wheelchairs and stretchers can not only prevent unnecessary purchases, but can also assist in the ultimate goal, enhancing patient care!

According to transparency market research, the RTLS market in 2011 was reported to be about USD $256 million, and is estimated to reach $4 billion by 2022.  This growth will be due in part to the rise of medical devices.  However, I hope the growth is in larger part due to hospitals consolidating with both each other and large ambulatory clinics with assets.

RTLS will allow for devices, equipment, and in some cases, people, to be utilized more effectively.  If a wheelchair is needed to transport a patient to med-surgery, for example, a hospital worker can easily check his or her mobile phone and use the RTLS system to identify the closest wheelchair.  This accommodates the patient faster, getting him or her to med-surgery faster and directly enhancing patient care!  This is just a small example of what can be done with RTLS for better patient care.  This can be applied to beds, stretchers, and the closest AED device for quickly addressing possible  infractions.

Besides patient care, of course, there is the ability to reduce cost from equipment leakage, avoid unnecessary purchases, and truly understand the value of what I call “your functional inventory for care.” Are you a hospital going through a consolidation/acquisition?  If so, I believe you should consider RTLS systems along with your possible EHR implementation, of course, with a step-by-step approach!  If I’m preaching to the choir,  take this survey.

March 21, 2013  2:32 PM

Big Data, retail & marketing: Huge picture for insurers

Posted by: AllinHIT
Big Data, health insurance exchange

There could be something amiss, and some will say right-infringing, concerning information emerging from “Big Data.”

The term Big Data is new but the ability to pull and analyze information from relational databases for the purpose of marketing products and learning about targets within those markets is not.  Using the term Big Data has played a major role in the four Ps of retail marketing – price, product, place and promotion – influencing go-to-market plans and strategies.  Retail organizations will purchase information about their market and targeted individuals’ buying habits from particular marketing firms, seeking answers to questions about consumers like, where do they shop? What do they buy? Now some employers and/or insurers are buying this same information, integrating it with their own Big Data and thus allowing employers and/or insurers to get a “bigger picture” of your health. This includes, more particularly, your eating habits.

Of course, integrating retail Big Data to formulate a “big picture” of one’s health by employers/insurers is in the name of “helping” the members.  Case in point: Blue Cross and Blue Shield of North Carolina recently bought data on 3 million  people in their employers’ plan. If Mary is a BCBS of NC member and purchases clothing from the plus-size store Lane Bryant, this information could indicate that Mary is obese.  Combine this information with recent claims and medications for Mary, and they can develop a specialized care plan with incentives for Mary to lose weight. Hence, making Mary healthier, reducing her dependency on medications, and benefiting from the snowball effect of reducing cost.  I can also envision Mary having access to their telehealth solution, OnlineCareNC.  This service will allow her to receive consultation from coaches and nutritionists through video, secure text chat, or phone.

As you can imagine, there are concerns from privacy pundits of abusing this data.  These concerns surfaced this week with CVS’s announcement that employees have to report their weight and other vitals or face a $600 penalty. I believe something must be done about the rising cost of healthcare as it relates to preventable conditions.  If you decide to be obese, hence more prone to diabetes, CHF, etc., then you should pay more for insurance.  I believe the insurer/employer should give you every opportunity to change, and should give you the incentive to do so.

I know there are many side problems that arise from using  Big Data in the way described here and I wish I had all the answers.  However, as technologists, it is important that we are part of the solution assisting with lowering the cost of healthcare and protecting patient rights.  I don’t think being on the sidelines is the answer if you truly care, which I do!

March 12, 2013  12:17 PM

CommonWell: Good three-fourths of an effort!

Posted by: AllinHIT
Cerner, CommonWell, Epic, HIE, HIMSS, HIMSS13, interoperability, McCesson

Last week, thousands of us gathered in New Orleans to attend HIMSS13! HIMSS is a great barometer for yearly concerns, challenges, and goals in health IT, and this year was no different.  I found myself engaging in discussions, attending seminars, and reading the daily HIMSS paper on interoperability, HIEs, mHealth and patient engagement.

What really dominated discussion, however was not Health IT, but the very interesting announcements on new products, acquisitions and partnerships. This year was no disappointment with the announcement of a new, non-profit entity called CommonWell Health Alliance.

This organization was created by five EHR vendors for the purpose of exchanging PHI on a cross-platform basis.  The five vendors, Cerner, McKesson, Greenway, AthenaHealth and Allscripts, said all the right things at their press conference.  John Hammergren, CEO of McKesson, stated, “This interoperability mission is really imperative for us. We know that it’s  going to take significant work.”

Cerner’s CEO, Neal Patterson, stated, “We really need the entire industry being here … to create a solution to this  problem (interoperability).”

These are great words to our industry!  Finally, big vendors will focus on integrating separate silos of information.  We know this is a critical step in reducing healthcare cost (i.e. duplication of tests), enhancing patient care (immediate access to critical PHI like allergies), and analytics (Big Data across platforms, makes it bigger!).

Although some were excited about the CommonWell announcement, others wondered loudly, “Where is Epic?”  Why would you not ask the fastest growing enterprise EHR, a 1.5 billion dollar enterprise, not to join your efforts?  I also wonder if Siemens, another player in the industry, was asked to join these efforts?  Together, Siemens and Epic represent close to a quarter of the market!  When asked about this, McKesson’s CEO stated that this alliance is open to any vendor. As some suspected, Judy Faulkner, Epic’s CEO, confirmed that her organization was not asked to join.  Hence, Epic executives believe this alliance is a marketing ploy designed to stop the momentum and growth of Epic.  I don’t know if that is true or not.  However, Epic not being asked to join prior to HIMSS makes one wonder.  Some say Epic would not have joined anyway, feeling their well-integrated CareEverywhere feature has an advantage in the marketplace (being Epic certified, I am trying not to be biased).  However, by not asking Epic and Siemens, we will never know if there is validity to those opinions.

What I think we all know is the CommonWell sandbox is missing a couple large “players.”  So large, in fact, those great words we heard in the press release were diminished to some. I say, it’s still a good three fourths of an effort. Better than nothing!

February 28, 2013  11:38 AM

Year of the EHR switch? Easier said than done!

Posted by: AllinHIT
Black Book Ranking, Cerner, EHR systems, EHR User Satisfaction Survey, EHR vendors, Epic, McKesson, Siemens, Uncategorized

Last week, the results from Black Book Rankings annual poll were released.

The most interesting headline from the poll, based on what everyone else is reporting, is that 17% of the 17,000 active, polled EHR users are dissatisfied with their EHR and plan to replace it this year.  Hence, I’ve seen headlines such as, “2013, the year of the EHR switch” and “EHR users unhappy, many switching.” Despite this statistic, I offer my own associated headline: “Not so fast.”  Here are my thoughts on this stat and others revealed in the poll.

To begin, switching EHRs is easier said than done.  Although the desire is there, the cost of switching when all the numbers are crunched can be an impediment to change.  Of course, there are the hard costs, but the soft cost for training, mapping desired workflows (which I recommend is done before the selection process), lost productivity, and implementation costs like consultant fees for the build and go-live can easily tip the scale in the other direction.

Secondly, if the practice has to attest to MU for stage 1 and that vendor is ATCB certified for stage 2, then the Eligible Provider, and especially an Eligible Hospital, may elect to complete the MU stages before switching.

And finally, if the existing EHR has been implemented recently (within the last two years of go-live), then “EHR fatigue” could be a factor for delaying the change.  Physicians, nurses, IT and other stakeholders just might “make do” until its absolutely necessary, which could be determined by unmet quality goals.

The poll featured many interesting stats associated with switching EHRs as well. For example, 82% of those considering switching plan on going to an ASP/SaaS solution.  This would have been unheard of three years ago, with security being the major concern.  I also remember the huge discussion we used to have concerning the question, “Who owns the data – the EHR vendor or the practice?” Clearly, these concerns are a thing of the past.

More revelations from the poll include the top two reasons practices want to change EHRs. First  is the vendor not meeting needs, like accommodating workflows.

Second, many practices did not assess their needs correctly before choosing the original EHR. This is something I’ve written about many times. It’s a result of not mapping out those workflows in every area of practice prior to the selection process. And I have to defend some vendors when it comes to this issue. Although their compliance to meet the various MU stages has taken up development dollars and resources, not being compliant would be more devastating to profits and sales than developing other user needs not associated with MU.  I know there are the Epics, Cerners, McKessons, and Siemens of the world that have the resources to do both.  However, their resources are not the norm across the vendor spectrum.  Wow…I think I just discovered a selling point for the fore-mentioned vendors, coming just in time for HIMSS!

February 19, 2013  11:51 AM

Gearing up for HIMSS, eHealth conference great precursor

Posted by: AllinHIT
eHealth Initiative, Epic, HIMSS, HIMSS13, social media

It’s getting close to that time of year again. Time for the biggest annual show in health IT: HIMSS!

HIMSS gives us all a chance to see the latest and greatest in Health IT, network with our peers at the many parties and social events and indulge in the almost always surprising press releases. We all know of the apps, strategies and methodologies one can use to maximize the benefits of attending this great event, and are likely watching HIMSS coverage closely. And as needless as it might be to say, this year’s host city is New Orleans, which will undoubtedly add an additional flair to HIMSS. New Orleans itself is very special to me, since I spent most of last year living there and working as a consultant on the “O2” project, Ochsners Epic implementation.

With my new Epic certification and credentialed training skills, I expected not to attend this year. If I did attend, I wouldn’t be on a project, billing hours. Hence I had mixed emotions! After giving it thought over the last few months, I decided I would really like to attend and be on a project. I would love to catch up with some of my friends from the project, too. Despite these challenges, I will not stop praying for the Utopian result of having both a project and attend the conference!

If I don’t attend HIMSS, at least I was able to attend a great precursor to HIMSS, the eHealth Initiative annual member meeting. The conference, held in my home base of Orlando, is a great gathering of health IT executives engaging in discussions, examining white papers and discussing the many facets of health IT.  This was my first time attending the conference and what struck me most was the quality of the speakers and attendees, the number of topics/discussions relevant to the “now” in health IT, and lastly, the welcomed intimacy of the conference. My discussions with David Will of Cerner, Gary Larson of eHealth Technologies and Mike Squires of Blueprint were all special and unhurried.

The last session addressing the use of technology to manage chronic conditions was especially enlightening. I came away with hope that big pharma, payers and vendors like AT&T are really looking at social media as a way to engage patients with these conditions. This is something I’ve written about a few times, using University of Toronto’s BANT product as a great example of managing juvenile diabetes. My discussion with an old friend, Tony Schueth of Point-Of-Care Partners, gave me more awareness on EHR’s effect on the dispensing – or non-dispensing – of new drugs (perhaps a good blog topic?).

Yes, this conference truly satisfied my thirst for knowledge last week.  They also recognized me, not only for being an Epic/Health IT consultant, but a journalist/writer/blogger on All Things HIT.  Their motto, “Real Solutions. Better Health,” is a noteworthy theme which I know we all aspire to abide by.  Thanks for allowing me to contribute my two cents to discussions, and I hope you’ll allow me the same courtesy next year, before I go to HIMSS!

February 10, 2013  6:14 PM

WSJ and InMedica reports: Telehealth on the rise

Posted by: AllinHIT
e-visits, MBANS, Remote patient monitoring, Telehealth, Uncategorized

I have often reported on telehealth and remote monitoring – both their growth, and, most of all, why they should be embraced (rural health/access to care) in the health care industry.  My last article on telehealth discussed how the formation of MBANS will positively affect telehealth growth and investment.  Now, after reviewing the high points of a recent study by InMedica, the encouraging news from some payers about future programs and initiatives  and hospitals using remote patient monitoring to avoid penalties from CMS for re-admissions, I am even more excited about the future of telehealth!

The InMedica report states that telehealth will grow six-fold by 2017.  Noting that this report is defining telehealth only as remote-patient-monitoring (RPM), I agree with the report.  However, I believe the pace will be much slower for other telehealth functions, such as e-visits.  Regardless,  the report predicts 1.8 million patients worldwide will receive RPM, compared with just 308,000 patients that received these services in 2012, of which 220,000 were from the US.  Yes, the US is leading the way in telehealth. I expect this to continue!

You can look at various factors for telehealth adoption, in addition to the formation of MBANS, as I’ve written previously.  First, with the introduction of Obamacare, payers will be looking for ways to cut costs, while providing services to a new population of patients.  As reported by the Wall Street Journal recently, Wellpoint plans to offer e-visits for all patients using webcams, tablets, and smartphones.  Secondly, this is driven by large employers wanting to cut their own healthcare costs, and increase employee/patient compliance.  Companies like Home Depot and Westinghouse are including telehealth in their employee health plans. As pointed out in the WSJ article, 39% of large employers are also considering similar benefits. Forcing payers like UnitedHealth and Aetna to offer these services to a limited number of employers.  Third, telehealth will help ease the shortage of primary care physicians.  Telehealth is perfect for minor conditions like colds, sinus and ear infections, and other non-acute events.  Lastly, I believe as EHR adoption increases, it will provide a platform for telehealth services.  EHR vendors, themselves, will start introducing telehealth services as add-on modules.  As physicians and hospitals increase their comfort level with technology (i.e. their EHR), so will they with telehealth.

February 4, 2013  12:24 PM

Apps for self diagnosis: A fear to patient care!

Posted by: AllinHIT
PHR, PHRs and patient engagement, self diagnosis

Some years ago, while I was a consultant for Quest Diagnostics, I remember talking to various physician groups about utilizing Google Health’s PHR.

The ROI argument centered around the idea that the program would reduce patient phone calls and staff call backs, increase patient engagement, and could increase business (if you are an OBGYN, reporting normal paps via the PHR is a selling point). Quest had the ability to automatically send normal lab results to the PHR, or a physician could control the release of results.

Regardless of any selling point, it was completely overshadowed by one concern: a patient self-diagnosing results. Fast forward to now, where patients frequently Google any and all symptoms, conditions, and lab result analytics, and it seems the physician fears were warranted.  It has officially been proven that medical apps can be more of a danger in self-diagnosing!

The University of Pittsburgh Medical Center recently evaluated four medical smartphone apps developed to evaluate whether skin moles were cancerous.  The study, published in JAMA Dermatology a few weeks ago, had dismal results.  The best performing app was 98% accurate, however the other three were found to perform far worse than imagined by the participating dermatologists.  Why did the best performing app do so well, while the other three didn’t? That was my immediate question.  Then after reading more of the study, my answer came.  It was because the best app involved doctors forwarding the skin mole images to their peers for review!

This study is a perfect example of how using ONLY apps for self diagnosis is a danger to patients.  Patients must realize these tools are not for determining conditions, nor any routine of care.  However, the onus should not be only on the patient.  The company developing the app should always include a disclaimer to be acknowledged by the user prior to use and again, when reporting the results! This is being done on most apps already. However, I think the message should be stronger and re-enforced through its use.

Lastly — I hate to say it –but the app world needs some monitoring for accuracy, such as only becoming available on the market  if they meet a minimum gauge (e.g. 80% accuracy).  Without this accuracy model, apps diagnosing something as serious as cancer will continue to scare physicians, and worse, negatively effect patient care!

January 23, 2013  7:13 PM

Genetic PHI needs protection

Posted by: AllinHIT
Genetic PHI, gPHI, Human Genome Project, Privacy and security

Hospitals, business associates, covered entities and the rest of us in the industry are quite aware of the record-breaking year of PHI breaches, with the HIPAA security rule defining what constitutes a “breach.”

What might not be so familiar  is the breach vulnerability of a special kind of PHI: Genetic PHI, which I will subsequently refer to as gPHI. As a layman, I will define gPHI as a patient’s genetic map containing genetic markers and chromosomes which define who you are. Truly, it’s your DNA!

DNA and genetic information are vital for researchers.  New, more effective drugs and personalized medicine are all possible by understanding both one’s DNA and DNA group (African American, Indian, Anglo, etc.). Projects like the Human Genome Project  and the 1000 Genomes Project were highly successful and will lead to many of the aforementioned advances.

We all know about the many genealogy websites (e.g. that provide tools to research lineage and family history. As reported by The Wall Street Journal on Jan. 18, researchers were able to identify participants in genetic studies – when they were supposed to be anonymous! With no malice at heart, the researches wanted to display the vulnerability of gPHI using public genealogy websites. If a public website contains Y chromosome data and the surname of males, then those chromosomes can be easily matched with participants in the studies. I repeat, this feat only requires knowing one male chromosome and a surname.  What’s more, researches can use those little bits of information to find relatives.

The good news, bad news about this?  The good news: this gPHI “breach” can only be performed by researches with special skills. The bad news: there are a plethora of these sites for researchers, easing the opportunity for gPHI breaches.

What makes gPHI so special and necessitates a new frontier of protection? This data can be used to determine disease predispositions, family history, and, if accessed by  insurers, employers, sperm banks, and others, to discriminate! In 2007, this fact was not overlooked by the Honorable Louise Slaughter, U.S. House representative from New York.  She introduced the Genetic Information Nondiscriminatory Act (GINA), which was signed into law in 2008 . GINA provides federal protection from discrimination in health insurance and employment based on one’s genetic map.

So GINA does provide some protection, and that is great. However, it does not stop researchers from genetic matching in order to identify donors.

Considering some of the sites containing this information is public, it complicates the task of protecting gPHI. David Altshuler, co-chair of the 1000 Genome Project, warned his participants and donors in 2008 that he would take all the necessary precautions to keep them anonymous. But with new technological advances, it very well be possible one day to identify them. I think that day has arrived!

Read more about genetic analysis. 

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