Studies are revealing nothing new, time to focus on adoption!

For the past five years, I have written about, spoke on and advocated for the implementation of electronic prescribing software and electronic health records (EHRs). Labor costs concerning pharmacy phone calls and refill requests, the many downsides to fax, and overall increased efficiencies afforded by implementation are all great ROI variables making eRx worthwhile to implement. Heck, I always held that poorly written prescriptions causing deaths due to adverse events were alone enough of a reason to adopt! 

But despite my advocancy for eRx, I have also been realistic about the challenges—workflow, managing both paper and electronic refills temporarily, eRx to mail-order pharmacies, dosage manufacturer changes, etc.  However, I understand that these issues are resolved with workflow changes, and are also vendor and software specific.  Hence, its really about making the right decision (for example, using an application that sends data electronically to a desired PBM), implementing workflow changes, making sure software parameters are set correctly and receiving the proper training.  

All of these facts were recently brought to light in yet another eRx study, published online in the Journal of the American Medical Informatics Association.  The study, commissioned by HHS, revealed nothing new to what has been known for years, and I thought about how we as an industry need to stop the “studying” of ACOs, eRx, EHRs, etc., and go with my bottom line theory and just get it done!

For the past year, I’ve read many headlines confirming the effectiveness of health IT, EHRs, and eRx.  Headlines like “PCMH proves to improve those with chronic diseases”, “Coordinated care increases patient compliance”, and “EHR’s increase office efficiencies”.  These headlines, created by investing millions in research, are getting old. It’s time to “move the cheese” to adoption! 

The dollars dedicated to more studies simply to prove what is inevitable is on the verge of overkill.  It’s time to dedicate dollars to physician and patient education.  Billboard awareness campaigns, physician community education programs (on PHRs, EHRs, MU and HIE), online campaigns, and other community outreach efforts are all examples of activities where resources should be allocated instead.  Let’s get out of this “study after study” phase and really begin focusing our efforts on moving the pendulum towards adoption!

Reading tea leaves on the Health IT train!

For the record, I do not practice tasseography!  However, I do consider myself, as I put it, a “bottom line theorist”.  As a bottom line theorist, lets say I’m using “reading the tea leaves”, as synonym for the “acknowledging the obvious”.  Let me explain further. I am not specially trained in the practice and interpretation of divinatory skills, but the tea leaves are quite clear to me, the Health IT train has left the station.  The train will not, cannot, be stopped, as it needs to correlate to the rest of the electronic world. This is a bottom line theory, a theory whose results are inevitable, obviously going one way or another.  The “its not a matter of if, but when” cliche supports my bottom line theory, and I’m sure we all can agree the cliche also pertains to our industry. Matter of fact, we would also agree the Health IT train is not slowing down, but speeding up! 

This bottom line theory, the reading of the tea leaves, were two of my thoughts reflecting on a recently attended meeting and reading some recent surveys by Wolters Kluwer Health and Manhattan Research (subject of a forth-coming blog).  During the meeting, we had discussions on EHR’s ROI, adoption barriers, HIE’s, quality of care, privacy/breaches, HITECH, ACO’s, all great topics.  However, I was thinking its time to shift towards implementation and the “how to” versus the “should I” pertaining to technologies. Hence, I reminded these industry physicians, technologists, and other stakeholders in delivering care, to think past all the studies, surveys, and discussions.  Let’s read the tea leaves, and talk about moving this Health IT train.  I drew comparisons to the adoption of of PMS’s in the 80’s.  The concerns going from paper billing to EDI, were the same as today.  PMS adoption was slow, the concerns the same as today.  Cost, ROI, workflow changes, training, penalties (the stick), were barriers to entry.  Yet, physician adoption experienced a hockey stick effect, once CMS required it for Medicare billing! Additionally, scheduling patient appointments, managing collections, reconciling claims remittance, and automating reminders, had a positive effect on practices.    

Today, ask any physician or hospital, if they will go back to a front-end paper system for their practice or a hospital’s paper patient registration system, and paper billing (Not an exact comparison with hospitals, but you get my drift!).  What do you think the answer will be?  How will the pendulum sway towards physicians’ opinion on EHR’s 10 years from now?  How about consumer acceptance?  Do you think Gen X’ers and younger physicians, will be more comfortable, with electronic PHI, PHR’s, mobile health, analytics, EHR’s in waiting rooms, Kiosks, etc.?  Matter of fact, will they not require it?  Do you think privacy will more or less of a concern? (like they got privacy now with Facebook, four square, etc)?  The answers to all these questions are a matter of reading the obvious tea leaves.  What do you think?

Limiting EHR risk is great, but can I get a discount?

I will never forget a discussion I had with a physician about using the e-prescribe “refill status” to monitor medication compliance with her chronic disease patient population.  The doctor made it clear that she did not want this feature “turned on” with the practice’s existing e-prescribing module.  I asked the doctor “why?” and was told that having this information, and not addressing it when a patient is non-compliant, could negatively impact them during a lawsuit. 

It was the first time I asked myself, “does technology increase the risk of lawsuits, or does technology help guard against it?”  Although I can debate whether it does, doesn’t, or that it does both, I would rather consider the discussion to be moot.  However, it was “top of mind” for some caregivers, so it deserved debating.  And now, with the new legislation proposed by Representative Tom Marino (R-Pa.), maybe this will be a moot point!  The legislation can possibly save liability insurers alot of money!  However, wouldn’t it be nice if EHR use not only limited lawsuits, but also it lowered premiums for the physicians?   

Rep. Tom Marino (R-Pa.) has introduced, The Safeguarding Access for Every Medicare Patient Act , which would grant some legal protection to CMS providers if an adverse event occurs, as a result of EHR errors.  The Act would also allow for these errors to be reported without retaliation and places time limits on the filing of lawsuits.  We all know that EHR adoption and usage will eventually be an analytic data trove for developing care plans, benchmarks, and possibly new rountines of care.  The benefits to patient care can be enormous, so physicians should be able to utilize these systems, and that analytic data without fearing legal backlash. 

Not only should physicians avoid legal backlash for using these systems, they should get a discount on their liability insurance for doing so!  If using these systems are going to limit lawsuits, insurers and other tort reform advocates will be elated.  However, where is the financial benefit for the physician?  As I have said in a previous blog, I propose insurers give a discount to physicians for using EHR’s, it only makes sense considering this Safeguard !

The ONC, a proven listener in HITECH Affordable Care Acts

From final regulations on Meaningful Use stage 1, to the most recent ACO rules, the ONC has shown that they are listening, reading, and putting thoughts to the industry comments.  The recent rule changes to the Shared Savings ACO program, are being applauded by the American Hospital Association, AARP, the AMA, and many physician groups.  The new and final rule, truly has addressed many of the barriers to entry, which existed in the preliminary rule. The most favorite changes are the obvious, Changing the risk burden in Track 1, eliminating the two-sided model of savings and losses in the third year, allowing for “first dollar” sharing after minimium savings are reached, and reducing the number of quality measures.  These changes were expected, but its the several small changes, which received my attention.

The stated inclusion of FQHC’s (Federally Qualified Health Centers) and RHC (Rural Health Clinics) as ACO qualified entities, is welcome news to those delivering care in those communities.  I am also hopeful  the adoption of telehealth technologies will increase, due to its effectiveness in reducing hospitalizations, increasing compliance, and in delivery care.  Although the EHR physician use requirement of 50% has been eliminated, the role of EHR and other technologies, is crucial for success.  This is especially true looking at year 3 and beyond, regardless of a chosen track. 

Another related item is ONC’s test creation, Advance Payment ACO Model.  This is a program that will provide up-front funding to IPA’s, and rural providers, for developing an ACO model.  This is a loan program, funded to the tune of $170 million, hence monies will be repaid (I am trying to find out if monies will be deducted from shared savings). I also suspect this was birthed from their Innovation Center.

Lastly, they changed the rule that marketing materials have to be approved by CMS/ONC.  Instead, they will provide the language to be used, allowing for ACO entities to market much faster to the Medicare population.  Since this is a voluntary program, recruiting of patients is important and CMS approval for marketing materials would of been a clog in the wheel. I thank the ONC, not only for not being a clog in the ACO wheel, but for giving it an engine, moving us to a value purchasing model alot faster!

Jobs’ innovations, a profound effect on health IT adoption

I, like millions of others across this world today, am sadden and shaken with the passing of Steve Jobs, a man who literally has changed the world. There are many accomplishments of this “world changing” figure, from the creation of the PC to the launching of iPads, with such products having a true, positive effect on the everyday lives of humans, from the home to the workplace and literally everywhere in between. The way we listen to music, buy music, talk, text, research, and pretty much do anything technology related has been forever changed due to this one man.  And an argument can be made that the industry on which he has had the most effect, besides the PC industry, is health care. 

The iPhone and iPad have had a profound effect on the use of technology in many industries, and health care is certainly no exception.  The iPhone and iPad have made physicians more comfortable with technology (there is definitely a “cool” factor), and has given them ancilliary tools (apps) that lower the cost and increase the quality of care.  Here in Florida, there is a childrens hospital that uses the app Medical Video to explain MRIs and other procedures to children using an interactive game.  The iPad even has an eco-friendliness aspect to it, reducing paper by providing health information electronically, such as medical procedures and textbooks,  and prescription information on a PDR (which also reduces the cost of paper and ink, and saves time).

Most recently, I’ve heard of a physician using the RemoteScan app to scan charts for storing inactive patient information.  The iPad has also been used in the sterile environment of surgery. By using a “frog” skin cover during sterilization, surgeons are able to access information at their fingertips.  The uses and number of apps are seemingly infinite and are continuing to multiply.  Matter of fact, I am very comfortable saying that physicians 50 years from now will benefit from the accomplishments of Steve Jobs and Apple.   

Apple’s famous commericial, and one of Steve’s mantra’s, challenged us to “think different”.  Steve understood that “thinking different” gives one the opportunity to change the world.  Forever touched by this man, I plan on doing exactly that, and I challenge you to do the same. Maybe together, thinking different, we all collectively can effect healthcare delivery, outcomes, and quality.  Like Steve Jobs, I want to give consumers (patients) something they didn’t know they needed, until it’s created. Thanks, Steve, for setting this example and may you rest in peace.

My AAFP conference discussion on rural health

During the the rural health discussion at the AAFP conference, as moderator, I focused on two areas: The  common barriers, and the role that technology can play in addressing these barriers, while also providing quality care to an underserved, rural population. The group, small but passionate, were a diverse set of physicians representing rurals areas in various sections of the US, Canada, and even Nigeria.  Some were operating existing rural telehealth programs, while others were providing clinical services in communities lacking in care.  Some were searching for answers on how to simply deliver services.  Regardless of the background or situation, the challenges discussed were related to “access of care”, and the answers all mapped back to the technology solutions.

The group was quick to point out “access to care” as the biggest challenge in rural health, and within most critical access hospitals.  The interesting point about access is its diverse meaning among the various, and geographically different, rural areas.  “Access” to some communities related to lack of transportation, needed to help transfer the underserved population to much needed medical facilities in the city.  They associated transportation with compliance, managing chronic conditions, and in being able to provide basic care.  Another’s view of access was in regards to having a lack of access to specialists, versus basic, primary care. Consultations for chronic diseases, CHF, and anything neurological are common gaps in service within these communities and must be addressed in order to improve population health.

The challenges, though great, are not insurmountable.  The group agreed that the telehealth umbrella — which includes telemedicine, tele-monitoring / remote patient monitoring, and tele-trauma — contains solutions which effectively address most of these challenges.  Transportation issues, a lack of specialists, and access to care all can be solved by creating telehealth programs. It was not a surprise that some of the physicians were implementing these programs already, but want to actively expand their services.  So, it was quite disappointing that even among this group, there was a lack of knowledge on the various CMS pilots and the various grants available for such programs.  The USDA Distance Learning and Telemedicine Program, Beacon communities funding, and even President Obama’s new Jobs Act, has funding for implementing telehealth.

Of course, I was more than happy to educate the group on the various efforts and online resources containing information on funding telehealth programs.  I’ve pledged to learn and listen to those on the front lines of providing care in rural areas and to educate when possible on telehealth.  Hopefully, by learning and educating, I can become a better advocate for change.  I thank the AAFP rural health table top participants for allowing me to do both.

AAFP discussion on ACO’s, has questions, fears, but opportunity.

Yesterday, while attending the AAFP Scientific Asssembly in Orlando, I haphazardly, and happily, assisted in leading a table top discussion on Accountable Care Organizations (ACOs). After probing and discussing this topic with physicians, I recognized their need for understanding the opportunity for primary physicians, the two versions of the Shared Savings Program, and most of all, an increase in their participation for the regulation and structure of ACOs.

I attended the session in order to learn and gauge physicians’ levels of understanding pertaining to ACOs, and contribute to their knowledge of the subject.  What first surprised me was the “baker’s dozen” that attended.  I expected more of a turn-out, as did others, because of the role this model presents for the primary family physician (your PCPs).  The second surprise was that the discussion lacked a formal AAFP moderator! Again, considering the impact of this model, I expected more focus and resources dedicated to the subject. These surprises led me to believe, there should be a greater effort toward educating physicians on the impact that ACOs can have on revenue, and in some cases, losses (three year threshold rule in the Medicare ACO Shared Savings model). Education will then translate to greater participation, not only in ACO discussions, but in lobbying efforts of various organizations, like the AAFP, AMA, and the NMA. 

It was well noted by myself and a mixture of physicians, like Rishi N Sud with the Union Medical Center, that opportunities exist for physicians to form ACOs.  Union Medical, based in Chicago, is a staff model HMO with a functioning, effective PCHM, well poised in creating an ACO.  This, and an IPA structure, presents opportunities for physicians to collaboratively provide quality care while increasing their revenue with Shared Savings. With an ever-changing and debated Medicare SGR, this could be a welcome offset! 

Of course, there were many questions concerning ACOs various structures, needs, and challenges, as well.  It was suggested that ACO’s boards of directors include the voice of the primary physician. And the mere definition of an ACO was questioned, as well, where we all gave our general, layman’s terms definitions.  As a health IT guy, I discussed the necessary role of EHRs, telehealth, and sharing PHI (protected health information). I also noted technology’s role with the various Beacon Communities, using it for coordination of care, disease management, and remote services (telehealth).  Hospitals dominanting the space and payors’ ACO pilots and activities were other concerns expressed. 

Despite the challenges and questions, however, the opportunity to coordinate all aspects of care in the ACO model excited the group the most.  It was almost as if the primary physician will have a reprieve of importance, equal to specialists, in delivering patient care.  I hope they’re right!

New AAFP EHR survey a revealing trove of information

The AAFP’s EHR User Satisfaction Survey has served as an accurate barometer of physician EHR users satisfaction with their EHR systems.  The survey, recently published in the July/August 2011 issue of American Academy of Family Physicians’ Family Practice Management magazine, is a treasure trove of information, and is useful to both users and vendors!

The results of the survey, based on a response from 2,719 family physicians, should be analyzed by both EHR vendors, and physicians buying EHR’s.  Vendors will learn about user’s perception on areas for product improvement, product comparisons, and market positioning.  For example, the survey publishes a table of EHR Rankings on 17 different “dimensions” or features. The table shows, and the survey reports, Allscripts MyWay and Medinotes didn’t fare as well as other EHR’s popular in the 1 -10 physician space. This table also identifies vendor strengths and weaknesses, giving the vendor a development blueprint, and the buyers a peer review of each product.

Another “must review” is the “Response Spectrum” tables, a series of detailed responses to specific questions about usability, specifics work task ease of use, and if the users feels the EHR contributes to the quality of patient care. After reviewing this, you will find that Amazing Charts ranks number 1in the usability category, and McKesson’s Horizon, is at the other end of the spectrum.  This is revealing information for those technologically challenged physicians, and to McKesson developers to work on the user friendliness of their product.

Last, but not least, is the revealing EHR vendors, have work to do in the areas of implementation, training and support.  The survey revealed the lowest satisfaction rate was in EHR vendor support and training. Only 39% of users were satisfied or very satisfied in this area, 31% were dissatisfied or very dissatisfied, and 25% were neutral. This dismal rating of support and training, directly correlates to the surveys low overall satisfaction of 49%.  Support and training, an implementation variable, must be improved by vendors, in order to increase adoption.  Horror implementation stories are still an impediment to adoption, and vendors need to take notice.  I know that Allscripts, has recognized this and are on a national employment tour, looking for people to employ to address their backlog of implementations, and to increase support personnel. I hope that other major, ATCB certified vendors, are doing the same.

Venture Capital in health IT, alive and well, especially in Austin.

The health care IT software and services market is projected to grow approximately 25% per year, till 2014.  While this growth is due to many factors, the primary credit can be attributed to the HITECH Act and its numerous technology initiatives.

HITECH has shifted the industry to a quality based model, which can be seen in the advancement of ACOs and a shared savings model.  It has fueled a vibrant mobile health market, which is expected to reach over $2 billion by the end of 2011.  All of this has also created an increase in new, innovative start-ups, and their availability in accessing venture capital.  Creating a hot bed of exciting new firms with high paying jobs, and available start-up capital, Austin, Texas is a shining example of an area whose health care IT scene has been impacted by HITECH.

The IBM Entreprenuer SmartCamp in Austin, an IBM Global Entrepreneur initiative, brings new technologies to market faster by creating an incubating system of matching start-ups to VC firms and angel investors. This competition also rewards the best start-ups with mentoring and consulting services, a critical tool in growing start-ups successfully.  Though based in Austin, the SmartCamp is open to all firms in the US, though it’s no surprise that Austin firms are well represented in the competition.

Austin based DxUpClose, who developed an electronic sensor that screens bacterial infections (big hospital play), and Tactical Information Systems, who developed a product called WanderID, a biometric fingerprinting identification system for patients unable to speak, are two of the finalists in the competition.  (I have to also give a “shout out” to a similar company I work with, BioSig-ID.  They received VC dollars from the State of Texas VC fund!).

On August 25th, 2011, Morgenthaler Ventures, a VC firm based in Menlo Park, CA, was named the top 11 finalists in their nationwide contest for seed and Series-A funding.  Finalists will present in front of leading VC firms and angel investors.  They received ” a tremedous response, showing health IT as sexy, as social media and games”, according to the Rebecca Lynn, partner at Morgenthaler Ventures and head of the firm’s health IT investing team.  She went on to say, “We received 117 applications that reflect how entrepreneurs are ‘thinking big.’ They are building powerful applications and services on top of today’s Web, mobile, social media, and cloud-based infrastructures to transform our healthcare system.”

Venture capital is alive and well in health care IT, and it is a welcome sign in the mist of this economic downturn.  The creation of jobs and new and exciting technologies in health IT will continue, thanks to the many funding initiatives.  This investment is smart and timely, so lets just hope adoption of these technologies continues to grow along with the investments!

Unencrypted thumbs….are really dumb!

This week Australia selected Accenture as a prime contractor, and selected some subcontractors, including Oracle and Orion Health, to develop Australia’s “Personally Controlled Electronic Health Record” or PCEHR.  This PHR product will allow Australia’s 22 million citizens access their medical records, manual entering of  PHI, and the record will contain information on access with audit trails. 

After reading about this effort, I was then reminded about one of my tweets last week declaring “unencrypted thumbs are dumb”, which I tweeted after hearing about the recent notification breach at St. Francis.  Just by definition of this blog’s title, “unencrypted thumbs are dumb”, most will agree with that as a statement.  However, due to the recent breaches involving thumbs, I thought a recap of these incidents can serve as another warning to hospitals and physicians. 

St. Francis hospital, located in Wilmington, Delaware, notified over 400 maternity patients that their PHI from a prenatal study 10 years ago was breached. A physician, who was involved with the study, discovered the breach after receiving a lost thumb drive in the mail from a stranger.  This thumb drive had unencrypted PHI on it, hence, had a high probability of being compromised.  Gladly, the information did not contain some personal, vital information like social security numbers, addresses, and phone numbers.  However, it was a violation that is well within the “Harm Threshold” as part of HIPAA. This mishap, due to a physcian losing an unencrypted thumb drive, pales in comparison to what happened with St. Barabas hospital system in New Jersey last summer. 

Over 3600 patient’s information was breached when an employee of KPMG, the large consulting firm, lost an unencrypted thumb drive belonging to St. Barabas. Besides the sheer volume of patients involved, and the fact that a vendor created the breach, what makes this more shameful, or I should say dumb, is not reporting the breach during the 60-day period as required.  Additionally, and how’s this for irony, KPMG received a contract with HHS/Office of Civil Rights, to perform HIPAA privacy and security compliance audits!

From these two recent examples, the message should be clear.  Encrypt your thumb drives, if you are going to us them for PHI. There is a bunch of software one can be purchased that automatically encrypts files being transferred from hospital computers to a thumb drive. The cost of purchasing this software is minimal compared to the cost of a breach.  This is why I say ” unencrypted thumbs are just plain dumb”!