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EHR Vendors Need to Expand Their Definition of Customer Service

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Living in Las Vegas I likely have a skewed idea of what customer service means. In the tech world, we have Zappos headquarters in downtown Las Vegas. Most of you are likely familiar with Zappos unique approach to customer service. They really have taken customer service to the next level and created an entire company culture around the customer service they provide. The same could be said for the experience that the various casinos on the strip offer their customers. They do a really amazing job at most casinos providing an amazing customer service experience.

With this background, I find it really smart of Kareo to open an office in Las Vegas. Although, that’s not really the point of this post. Instead, I want to focus on the idea that most EHR vendors need expand their idea of customer service.

As I look at the world of EHR customer service I see so many organization lacking. Certainly we see examples of terrible EHR customer service that include calling into a call center in another country where the person doesn’t speak English and has no power to actually solve a user’s problems (Disclaimer: I don’t have a problem with call centers in other countries if they are well trained and can actually solve problems). Of course, the same thing can apply to a call center in the US who can’t solve the users’ actual problems. Both are terrible customer service and a problem in the industry. However, there’s a far more painful problem that I don’t think most EHR vendors consider a part of their customer service plan and 99% of EHR vendors have done terrible at this.

Adding new features and accommodating an EHR user’s feature request is just as much a part of the EHR customer service experience as the person who answers the phone. I can assure you that every EHR vendor out there would get rated an F the past few years when it comes to this form of EHR customer service. Why do I know this? I know this because every EHR vendor has been focused on meaningful use that they haven’t had the time to add any meaningful EHR user feature requests and features outside of meaningful use.

This isn’t EHR vendors’ fault. The end users have required it and EHR vendors have had to spend the time doing it. However, EHR customer service has suffered as a consequence. Don’t believe me. Look through all the EHR press releases that have been released over the past couple years. Find me the plethora of press releases that talk about the innovations that EHR vendors have created for their end users that aren’t related to meaningful use. I get the press releases and they’re MIA.

That’s not to say that EHR vendors have done nothing for end users. They’ve made some incremental progress on a few things, but meaningful use has zapped their development time. Stage 2 was even worse. I look forward to the new day where EHR vendors can focus on great customer service and EHR features and not just MU.

July 21, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 14 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

EHR Incentive Market Share Charts Worth A Thousand Words

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One thing I really love about the government lately is their goal to be as transparent as possible. Certainly they still have a ways to go, but I think healthcare has done some significant things when it comes to transparency into the government health programs. A great example of this is the Health IT Dashboard which has all of the data for the various health IT programs.

I don’t want to steal Carl Bergman’s thunder, because he’s already posted some really interesting Hospital EHR market share data and his previous EHR market share data. Plus, he’s planning to dive into the meaningful use market share data next. I love the approach of multiple sources when it comes to evaluating EHR market share and so I look forward to his analysis of EHR incentive market share against the EHR adoption market share from Definitive Healthcare and SK&A.

Until then, I thought I’d give you a taste of the EHR vendor participation in the EHR incentive program. This data comes from the ONC dashboards listed above and are put into some really nice snapshots of the data by ONC.

First up is the data for EHR vendor attestations by eligible professionals (ie. ambulatory doctors):
EHR Incentive Market Share - Eligible Professionals

And the EHR vendor attestations by hospitals:
EHR Incentive Market Share - Hospitals

It’s worth noting that the above data is just the EHR incentive money data. No doubt the actual EHR adoption data would have a few differences and include some companies in specialties that don’t qualify for EHR incentive money. Not to mention specialty specific EHR vendors who likely don’t make the chart even if they dominate their specialty. These charts do serve as an interesting proxy for EHR market share that’s worthy of discussion even if it doesn’t paint the full picture. Plus, even more important will be to watch the change in these numbers over time.

With that disclaimer, we could analyze this data a lot of ways. I’ll just offer a few interesting insights I noticed. First, 711 vendors have been used in the ambulatory EHR incentive program. That’s a lot of vendors. Only 78 of those 711 supply secondary EHRs as opposed to the primary EHR. 452 EHR vendors supply a primary EHR to less than 100 eligible professionals. 200 EHR vendors supply a primary EHR to fewer than 10 eligible professionals. These observations and a comparison of the ambulatory versus hospital EHR incentive charts’ “Other Vendors” shows how fragmented the ambulatory EHR market share is right now.

I was also intrigued that Mitochon Systems, Inc. was on the list even though they shut down their Free EHR software in May 2013. They had white labeled their EHR software to a number of other companies and so it will be interesting to see how that number evolves. I assume they sold the software to those companies, but I hadn’t heard an update.

On the hospital side of things, MEDITECH certainly doesn’t get the credit they deserve for the size of their install base. The same goes for CPSI, MEDHOST and Healthland. I think their problem is that people only want to read about the Mayo, Cleveland Clinic, and Kaiser’s of the world and so the articles about Billings Montana Hospital (I made that hospital up) rarely happen. I should find more ways to solve that since the small hospital market is huge.

I do wish that there was a way to divide the ambulatory chart into hospital owned ambulatory practices and independent ambulatory practices. That would paint an even clearer picture of that market.

What do you think of these charts? What can we learn from them?

July 8, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 14 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Eyes Wide Shut – Patient Engagement Pitfalls Prior to Meaningful Use Reporting Period

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July 1, 2015 – the start of the Meaningful Use Stage 1 Year 2 reporting period for the hospital facilities within this provider integrated delivery network (IDN). The day the 50% online access measure gets real. The day the inpatient summary CCDA MUST be made available online within 36 hours of discharge. The day we must overcome a steady 65% patient portal decline rate.

A quick recap for those who haven’t followed this series (and refresher for those who have): this IDN has multiple hospital facilities, primary care, and specialty practices, on disparate EMRs, all connecting to an HIE and one enterprise patient portal. There are 8 primary EMRs and more than 20 distinct patient identification (MRN) pools. And many entities within this IDN are attempting to attest to Meaningful Use Stage 2 this year.

For the purposes of this post, I’m ignoring CMS and the ONC’s new proposed rule that would, if adopted, allow entities to attest to Meaningful Use Stage 1 OR 2 measures, using 2011 OR 2014 CEHRT (or some combination thereof). Even if the proposed rule were sensible, it came too late for the hospitals which must start their reporting period in the third calendar quarter of 2014 in order to complete before the start of the fiscal year on October 1. For this IDN, the proposed rule isn’t changing anything.

Believe me, I would have welcomed change.

The purpose of the so-called “patient engagement” core measures is just that: engage patients in their healthcare, and liberate the data so that patients are empowered to have meaningful conversations with their providers, and to make informed health decisions. The intent is a good one. The result of releasing the EMR’s compilation of chart data to recently-discharged patients may not be.

I answered the phone on a Saturday, while standing in the middle of a shopping mall with my 12 year-old daughter, to discover a distraught man and one of my help desk representatives on the line. The man’s wife had been recently released from the hospital; they had been provided patient portal access to receive and review her records, and they were bewildered by the information given. The medications listed on the document were not the same as those his wife regularly takes, the lab section did not have any context provided for why the tests were ordered or what the results mean, there were a number of lab results missing that he knew had been performed, and the problems list did not seem to have any correlation to the diagnoses provided for the encounter.

Just the kind of call an IT geek wants to receive.

How do you explain to an 84 year-old man that his wife’s inpatient summary record contains only a snapshot of the information that was captured during that specific hospital encounter, by resources at each point in the patient experience, with widely-varied roles and educational backgrounds, with varied attention to detail, and only a vague awareness of how that information would then be pulled together and presented by technology that was built to meet the bare minimum standards for perfect-world test scenarios required by government mandates?

How do you tell him that the lab results are only what was available at time of discharge, not the pathology reports that had to be sent out for analysis and would not come back in time to meet the 36-hour deadline?

How do you tell him that the reasons there are so many discrepancies between what he sees on the document and what is available on the full chart are data entry errors, new workflow processes that have not yet been widely adopted by each member of the care team, and technical differences between EMRs in the interpretation of the IHE’s XML standards for how these CCDA documents were to be created?

EMR vendors have responded to that last question with, “If you use our tethered portal, you won’t have that problem. Our portal can present the data from our CCDA just fine.” But this doesn’t take into account the patient experience. As a consumer, I ask you: would you use online banking if you had to sign on to a different website, with a different username and password, for each account within the same bank? Why should it be acceptable for managing health information online to be less convenient than managing financial information?

How do hospital clinical and IT staff navigate this increasingly-frequent scenario that is occurring: explaining the data that patients now see?

I’m working hard to establish a clear delineation between answering technical and clinical questions, because I am not – by any stretch of the imagination – a clinician. I can explain deviations in the records presentation, I can explain the data that is and is not available – and why (which is NOT generally well-received), and I can explain the logical processes for patients to get their clinical questions answered.

Solving the other half of this equation – clinicians who understand the technical nuances which have become patient-facing, and who incorporate that knowledge into regular patient engagement to insure patients understand the limitations of their newly-liberated data – proves more challenging. In order to engage patients in the way the CMS Meaningful Use program mandates, have we effectively created a new hybrid role requirement for our healthcare providers?

And what fresh new hell have we created for some patients who seek wisdom from all this information they’ve been given?

Caveat – if you’re reading this, it’s likely you’re not the kind of patient who needs much explaining. You’re likely to do your own research on the data that’s presented on your CCDA outputs, and you have the context of the entire Meaningful Use initiative to understand why information is presented the way it is. But think – can your grandma read it and understand it on HER own?

June 30, 2014 I Written By

Mandi Bishop is a healthcare IT consultant and a hardcore data geek with a Master's in English and a passion for big data analytics, who fell in love with her PCjr at 9 when she learned to program in BASIC. Individual accountability zealot, patient engagement advocate, innovation lover and ceaseless dreamer. Relentless in pursuit of answers to the question: "How do we GET there from here?" More byte-sized commentary on Twitter: @MandiBPro.

Patient Engagement vs. Patient Education: What’s the Difference?

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The following is a guest blog post by Jamie Verkamp, Chief Speaking Officer at (e)Merge.
Jamie Verkamp
Healthcare organizations often see attesting to the Measures included in Meaningful Use Stage 2 as a burdensome checklist which results in a massive resource drain in exchange for inadequate financial compensation. MU Stage 2 Measure 7 is one such oft-maligned requirement for attestation. This Measure requires that online access to records is provided to 50% of patients and that 5% of patients execute the viewing, download, or transmission of their online health information.  Organizations should not see Measures regarding patient engagement as intimidating or inconvenient. Instead, these Measures seeking to improve patient engagement should be seen as an opportunity to create more loyal, involved, and empowered patients.  The importance of engaging our patients in their own health shows itself in current statistics relating to personal health.  According to a study by TeleVox, roughly 83% of Americans don’t follow treatment plans as prescribed by their physicians.  Adding to that, 42% of Americans feel they would be more likely to follow their care plan if they received some form of motivation to participate.  By giving patients a channel to monitor and participate in their own health, organizations can develop a more educated population capable of producing greater outcomes.

Understanding the reasoning behind the Measures driving patient engagement is the first step; now, we must educate our patient population on the value of logging in and connecting with their information. While the frequency of patients physically visiting their provider’s office is somewhat inconsistent, this is often the most successful way to encourage electronic patient access. Patient facing staff members should be well educated on electronic patient access and be prepared to answer questions as they arise. Physically walking patients through the engagement process of maneuvering their electronic access, or providing video tutorials with simple instructions in the office lobby can increase patient engagement substantially. Consider setting up a station in the waiting room to allow patients to sign up for the service, thus solving the issue of forgotten motivation.

However, organizations must seek to include in their engagement plan the younger and healthier population who may not enter the physical office space outside of unforeseen emergency visits or more often than their annual checkup requires. Looking online to relate with these patients can be beneficial, as this has been found to be where this demographic spends the majority of their time and communication engaging with brands and services.  Providing information and education on an organization’s website, Facebook, Twitter, or even YouTube page through video promotion can assist in sparking an interest with this patient population.  Many times, those likely to engage in a patient engagement offering remain unaware of its availability due to a lack of communication from the healthcare organization.  From the practice standpoint, we must understand our work is not done once the portal is merely completed; rather this is when the real challenge presents itself.

In today’s society, consumers are bombarded with promotional emails and routinely asked for their contact information so further communication can be established.  With this in mind, consumers are more cautious as to what and how much information they provide to companies.  Unfortunately, for the healthcare industry, this includes a cautious nature toward information shared with healthcare organizations.   With this barrier in place, administrators must actively engage with their patients to educate them on the benefits of becoming involved in electronically managing their care.  Before consumers choose to willingly hand over their personal contact information, they will likely need to understand the reasons for doing so and what advantages they will receive.

Convenience has become one of the most desired aspects of communication and buying behaviors in consumers today.  As a society, we have adopted a “need it now” expectation.  With the ease portable technology has brought to our information search, patients and consumers count on service when they desire it.   This is especially true when it comes to customer service; consumers are becoming less patient and beginning to expect service when they desire.  In a recent study, it was found businesses offering a “Live Chat” option online saw a 15% increase in conversions. Explaining to patients the ease of communication with physicians and key staff members through the portal can be a helpful start in creating buy in.  Communication via the portal includes direct messaging, appointment reminders, and more. Informing patients of potential time saving factors in appointments down the road and quicker access to lab results can also establish and pique interest.  In many instances, finding the optimal moment to address the patient portal can create successful outcomes.  Patients burdened by numerous prescription refill requirements or those frustrated with waiting in line to pay a bill can be directed back to the convenience of a patient portal to handle all of these items at their own computer at home.

As a whole, those looking to meet this Stage 2 requirement must focus their attention on creating personalized communication with patients.  Standardized information will not entice patients and may easily be looked over.  Begin to examine which staff members may be the best fit for providing patient education and focus on educating patients on what they will get out of participating, not just simply meeting your Measure 7 requirements.   Potential touch points can be found within your signage, billing communications, appointment reminders and especially on your practice website and social sites.

According to HealthIT.gov, Meaningful Use Stage 3 will continue with the goal of driving patient engagement and improving outcomes.  This will include, “patient access to self-management tools”. The options for healthcare organizations are clear:

1. An organization can meet the bare minimum for the Stage 2 requirements using a patchwork of initiatives which produce minimally satisfying results while have no significant effect on the patient experience. Then repeat the entire process for the applicable Measures in Stage 3.

2. An organization can have a well-articulated and executable plan. In doing so, the practice, hospital or healthcare organization can commit to utilizing technology for the optimization of patient care, get a full return on investment from the Patient Portal, and simultaneously grow their business through the competitive advantage of a successful online presence. Initiating this push now will further develop readiness for Stage 3 as the implementation date approaches and with productive workflows in place, administrators can free themselves to focus on other Measures for attestation.

So which option will your organization choose? It’s not going to be easy, but change seldom is. Every industry experiences social and digital evolution, now it is healthcare’s turn.

About Jamie Verkamp
This article is a result of a partnership between (e)Merge, a medical growth consulting firm and DataFile Technologies, an outsourced medical records management and compliance company. Jamie Verkamp leads (e)Merge as Managing Partner and Chief Speaking Officer, she works shoulder to shoulder with medical professionals the healthcare industry to improve the patient experience and see measurable growth in clients‘ customer service efforts, referral volumes and bottom lines. DataFile Technologies is led by Janine Akers, CEO. DataFile’s passion for compliance allows them to be thought leaders in HIPAA interpretation while executing innovative medical records workflow solutions on behalf of their clients. Our companies produce white papers, speaking engagements, and videos to keep health professionals up to date on the latest industry topics.

June 3, 2014 I Written By

Lack of Rec Support Cause of Meaningful Use Stage 2 Slowdown?

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By now, I imagine that most of you have read about the meaningful use stage 2 delay and EHR certification flexibility. The details and interpretation are still going on, but it’s a big change to the current meaningful use program. Although, the biggest question I hear asked is if the change leaves enough time for organizations to change course. I think the rule has to be open for 60 days of comment before it becomes final. We’ll see if that leaves people enough time.

We’ll see if this change will provide some relief to a meaningful use program that I described as on the ropes. In response to that post, Deborah Sherl, BSN, RN, CHTS, CHPS, made an interesting comment on a possible cause of the meaningful use stage 2

@ John Lynn…. of course I am slightly biased on the topic of the rapid response & deployment of Stage 1 vs Stage 2. A great amount of Stage 1 success was ushered in with the amazing assistance of professional consultants across the country for those EPs & EHs that were willing to use us…. and we were called the Regional Extension Centers Health IT workforce.

Now that the federal grant is done (Feb.2014) Stage 2 implementations are possibly stalled not only by overburdened EMR vendors, but lack of project management forces that were provided by the RECS. Many RECs have built sustainable business models but are no longer “free” services as was perceived while under the HITECH grant.

I find this a very interesting hypothesis. I’m not sure that it accurately reflects why many organizations chose not to attest to MU stage 2, but it certainly didn’t help things. In fact, it adds one more log to the already burning fire. Think about what happens with MU stage 2. We’re going to pay them less incentive money, require them to do substantially more, and oh yeah…those “free” REC support resources are now gone too. Plus, your EHR vendor may or may not be ready either.

I think the changes to the EHR Certification requirements and delay of meaningful use stage 2 are good. Although, I’m hoping this is just the start of HHS blowing up meaningful use and making it dramatically simpler and more meaningful.

May 21, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 14 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Healthcare Risks, Privacy Risks, and Blowing Up MU

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All of healthcare has risks. The key is getting a good grasp of all the risks. Are we doing that really well in healthcare IT and EHR?


I repeatedly find that most people are happy to give up some privacy risk for the potential for better health. This increases even more when someone is seriously sick. Privacy becomes even less important to them.


I always love to see tweets from someone I’ve never met or heard of tweeting out my articles. Tim did a good job summarizing my post about blowing up meaningful use. The post has gotten some good traction and a great discussion. I’m sure that they won’t take my exact approach, but I hope that it will help push ONC to move MU in a direction of extreme simplification.

May 18, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 14 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Will Meaningful Use Be Used by Payers?

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I was on a call recently with someone who started to state that it was inevitable that the payers would start requiring doctors be meaningful users of a certified EHR. I wouldn’t say that it’s 100% sure that payers won’t adopt meaningful use, but I think it’s far from a forgone conclusion that they’ll jump on the meaningful use bandwagon as well.

Before I get into some of the various rationale for why they will or won’t, I’d love to see what you think in the poll embedded beloww:

Those who think that payers will start requiring meaningful use if you want the highest reimbursement rate usually point to the fact that the payers have often followed whatever Medicare is doing. This is true and so it is possible that they’ll piggyback the meaningful use train.

Those who say they won’t do it will say that meaningful use doesn’t really align with what the payers want to accomplish. There are elements that interest them, but it goes too far in many areas.

I’d say that most payers will probably not hop on the meaningful use bandwagon. However, I’m sure that they’ll let Medicare take the lumps while they sit back and watch how doctors react to meaningful use. If a large portion of doctors opt out of meaningful use, then I can’t imagine payers hopping on that train and making all of those doctors angry. I see payers just sitting back and watching how MU plays out before making any firm decisions.

In the end, I think payers will adopt something that may include some elements of MU that align with their business interests. I’ll just be very surprised if they just take MU on in its current state.

What do you think?

May 15, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 14 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Your EHR Vendor Isn’t Certified – How Should You Approach MU Stage 2?

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A recent study conducted by Wells Fargo Securities stated “Over 700 EHR vendors had solutions certified for Stage 1, but at this point about 40 have been certified for Stage 2. While there is still time, we believe 300-500 vendors will ultimately disappear from the government program.”

We talked about the possibility of many EHR vendors not being 2014 certified in our interview with John Squire. This is a real possibility for many EHR vendors. It will be interesting to see which ones choose not to tell their customers that they won’t be ready until it’s too late to switch EHR. I think that will say something about the company.

Allscripts has put out a whitepaper that looks at some of the meaningful use stage 2 challenges and what you should do to make sure you’re ready.

  • Where to begin with Meaningful Use Stage 2
  • The new requirements for Stage 2 attestation
  • Technology upgrade and replacement considerations
  • Meaningful Use reporting
  • Transitioning to population health management

I find the idea of using MU stage 2 as a way to get ready for population health pretty interesting. I know this is a challenge when an organization is overwhelmed by the day to day life of someone in healthcare.

Considering the abysmal meaningful use stage 2 numbers that were released, it seems that many organizations could benefit from some meaningful use stage 2 help this whitepaper provides. I’d be interested to hear if people think that MU stage 2 does help their organization move towards population health management. Is that a reasonable goal you can work on as you work on MU stage 2? Reminds me of those who are doing CDI (clinical documentation improvement) projects alongside their ICD-10 work.

May 12, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 14 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Surviving 2014: The Toughest Year in Healthcare

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The following is a guest blog post by Ben Quirk, CEO of Quirk Healthcare Solutions.
Ben Quirk
How bad is 2014 for the healthcare industry? We’ve all read about ICD-10, EHR incentives, Medicare cuts, and the Affordable Care Act. But the most telling moment for me occurred during this year’s HIMSS conference in Orlando. There was quite a bit of B2B enthusiasm, but among the civilians it was mostly a lot of stunned looks and talk about how to get through the year. Here are some of my observations:

ICD-10. CMS has made it abundantly clear there will be no further delays to the October 1 deadline for ICD-10 implementation. This is possibly the most significant change to the healthcare industry in 35 years, affecting claims payment/billing systems, clearinghouses, and private and public software applications. Anyone who provides or receives healthcare in the US will be touched by this in some way.

In a recent poll of healthcare providers conducted by KPMG, less than half of the respondents said they had performed basic testing on ICD-10, and only a third had completed comprehensive tests. Moreover, about 3 out of 4 said they did not plan to conduct tests of any kind with entities outside their organizations.

Incorrect claims denial will be the most likely result. CMS will not process ICD-9 Medicare/Medicaid claims after October 1, and there is a high potential for faulty ICD-10 coding or bad mapping to ICD-9 codes. Error rates of 6 to 10 percent are anticipated, compared to an average of 3 percent under ICD-9. ICD-10 will result in a 100 to 200 percent increase in denial rates, with a related increase in receivable days of 20 to 40 percent. Cash flow problems could extend up to two years following implementation. This will be a costly issue for providers, and a very visible issue for patients.

We advise our clients to be proactive in their financial planning. This should include preparation for delayed claims adjudication and payments, adjustments to cash reserves, or even arranging for a new/increased line of credit. Having sufficient cash on hand to cover overhead during the final quarter of 2014 could be very important, as could future reserves to cover up to six months of payment delays. Companies not in a position to set aside reserves should consider working with lenders now before any issues arise.

Meaningful Use. As with ICD-10, CMS has stated there will be no delays to MU deadlines in 2014. That means providers who have never attested must do so by September 30, or else be subject to penalties in the form of Medicare payment adjustments starting in 2015. Providers who have attested in the past will have a bit longer (until December 31), but the penalties are the same.

There is much dissatisfaction with the government’s “all or nothing” approach to MU, where even the slightest misstep can invalidate an otherwise accurate attestation. While the ONC has proposed a more lenient model for EHR certification in coming years, everything will be measured against a hard deadline in 2014.  CMS is offering some mitigation through hardship exemptions, based on rules that are somewhat broad at this point. Providers should consider applying for an exemption if no other options are available.

We advise against taking shortcuts or rushing to beat the clock on MU. Up to ten percent of eligible professionals and hospitals will be subject to audit, and large hospitals may have millions of dollars at stake. Being prepared for an audit means more than just making sure an attestation is iron-clad; internal workflow and communication are also important. A mishandled audit notification can result in a late response and automatic failure.  Data security should also not be overlooked. Medical groups have failed audits due to lapsed security risk assessments as required under HIPAA.

Medicare Payment Cuts. Medicare Sustainable Growth Rate (SGR) cuts continue to hover over Medicare providers. Enacted by Congress in 1997, the SGR was intended to control costs by cutting reimbursements to providers based on prior year expenditures. But every year costs continue to rise, as do ever-worse SGR cuts (almost 24% in 2015). And every year Congress prevents the cuts via so-called “doc fix” legislation.

In early 2014 there was surprising bi-partisan agreement on a permanent doc fix, whereby Medicare reimbursements would be based on quality measures rather than overall expenditures. However, the legislation was derailed by linking it to a delay of the ACA’s individual mandate. As of mid-March there is still no permanent or temporary solution. Congress will almost certainly intervene to prevent SGR cuts, but by how much is uncertain.

The ACA. As the cost of insurance has increased over the past decade, high-deductible plans have become more and more common. Due to the Affordable Care Act, this trend has become the norm. Media outlets focus on the impact to consumers, and argue about whether more “skin in the game” leads to better choices or less care. What we’re hearing from the front lines is much more concrete: high deductibles are having a negative impact on revenues.

Very few people understand their liabilities under a typical health insurance plan. Last year George Loewenstein, a health-care economist with Carnegie Mellon University, published a survey showing that only 14 percent of respondents understood the basics of traditional insurance policies. At the same time, hospitals report that about 25 percent of bad debt originates from patients who are currently insured. With millions of new enrollees in high-deductible plans and an ongoing economic slump, the situation can only get worse.

The ACA had a further impact by reducing the amount of Disproportionate Share Hospital (DSH) charity funds available, based on a projected increase in insurance coverage.  But with some states not participating in Medicaid expansion, combined with an increase in patients lacking the knowledge or resources to manage large medical expenditures, the reduction in funds comes at exactly the wrong time.

Providers can cope by adjusting revenue cycle processes. For example, new programs should focus on estimating patient liabilities pre-arrival, educating the patient at check-in, and instituting proactive billing/collection at the point of service. In general, providers must pay more attention to the self-pay process, focusing on patient education and offering transparent, easy-to-use billing and payment methods.

Value Modifier. This program has not been a worry for most providers thus far. Not because it won’t have an impact on revenue, but because they don’t know about it. A little-known provision of the ACA, the Value-Based Payment Modifier mandates adjustments to Medicare reimbursement based on quality and cost measures. The program is being phased in, and so far has applied only to group practices of 100 or more Eligible Professionals (EPs). In 2014, smaller groups of 10 or more EPs will be subject to the legislation. These groups must apply and report to the program by October 1. Otherwise, they will be subject to a 2 percent cut in Medicare reimbursements starting in 2016.

One of the most important aspects of the program is its definition of “eligible professional” when defining the size of a group practice. For the purposes of Value Modifier, eligible professionals include not only physicians but also practitioners and therapists. That means that a practice with 8 physicians, a nurse practitioner, and a physical therapist would qualify as a practice with 10 EPs.

Value Modifier is part of the growing trend toward quality-based reimbursement. Even commercial payers are considering some version of the program. The scoring calculations are complex and poorly understood, so we advise clients to get up-to-speed as soon as possible. Groups with high quality and low cost will receive incentives rather than cuts, with additional upward adjustment for services to high-risk beneficiaries. Groups that are not paying attention may be surprised by an additional hit to revenue in 2016. In addition, quality scores will eventually be published to the general public on the Medicare.gov Physician Compare website.  Sub-par or missing scores could have a negative financial impact on a practice.

Conclusion

These are only the most high-profile impacts to the healthcare industry during the current year. Much else flows from them: changes to workflow, to computer systems, to financial expectations. Tremendous pressures are coming to bear within a limited timeframe.  We’re seeing an industry in the midst of tectonic change, with 2014 as the fault line. It’s unclear whether these disruptions will be for better or worse. But there certainly will be winners and losers, and those who plan ahead are most likely to survive.

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Ben Quirk is CEO of Quirk Healthcare Solutions, a consulting firm specializing in EHR strategic management, workflow optimization, systems development, and training. The company’s clients have enjoyed remarkable success, including award of the Medicare Advantage 5-star rating. Quirk Healthcare presents a weekly webinar series, Insights, to inform clients and the general public about government programs and industry trends. Mr. Quirk is also Executive Director of the Quirk Healthcare Foundation, a learning institution which fosters innovation in the healthcare industry.

March 26, 2014 I Written By

Eyes Wide Shut: Meaningful Use Stage 2 Incentive Program Hardships

Written by:

In my January update on Meaningful Use Stage 2 readiness, I painted a dismal picture of a large IDN’s journey towards attestation, and expressed concern for patient safety resulting from the rush to implement and adopt what equates to, at best, beta-release health IT. Given the resounding cries for help from the healthcare provider community, including this February 2014 letter to HHS Secretary Kathleen Sebelius, I know my experience isn’t unique. So, when rumors ran rampant at HIMSS 2014 that CMS and the ONC would make a Meaningful Use announcement, I was hopeful that relief may be in sight.

Like AHA , I was disappointed in CMS Administrator Marilyn Tavenner’s announcement. The new Stage 2 hardship exemptions will now include an explicit criteria for “difficulty implementing 2014-certified EHR technology” – a claim which will be evaluated on a case-by-case basis, and may result in a delay of the penalty phase of the Stage 2 mandate. But it does nothing to extend the incentive phase of Stage 2 – without which, many healthcare providers would not have budgeted for participation in the program, at all, including the IDN profiled in this series. So how does this help providers like mine?

Quick update on my IDN’s progress towards Stage 2 attestation, with $MM in target incentive dollars at stake. We must meet ALL measures; there is no opportunity to defer one. The Transition of Care (both populating it appropriately, and transmitting it via Direct) is the primary point of concern.

The hospital EHR is ready to generate and transmit both Inpatient Summary and Transition of Care C-CDAs. The workflow to populate the ToC required data elements adds more than 4 minutes to the depart process, which will cause operational impacts. None of the ambulatory providers in the IDN have Direct, yet; there is no one available to receive an electronic ToC. Skilled resources to implement Direct with the EHR upgrades are not available until 6-12 weeks after each upgrade is complete.

None of the 3 remaining in-scope ambulatory EHRs have successfully completed their 2014 software upgrades. 2 of the 3 haven’t started their upgrades. 1 has not provided a DATE for the upgrade.

None of the ambulatory EHRs comes with a Clinical Summary C-CDA configured out-of-the-box. 1 creates a provider-facing Transition of Care C-CDA, but does not produce the patient-facing Clinical Summary. (How did this product become CEHRT for 2014 measures?) Once the C-CDA is configured, each EHR requires its own systems integrator to develop the interface to send the clinical document to an external system.

Consultant costs continue to mount, as each new wrinkle arises. And with each wrinkle, the ability to meet the incentive program deadlines, safely, diminishes.

Playing devil’s advocate, I’d say the IDN should have negotiated its vendor contracts to include penalty clauses sufficient to cover the losses of a missed incentive program deadline – or, worst case scenario, to cover the cost of a rip-and-replace should the EHR vendor not acquire certification, or have certification revoked. The terms and conditions should have covered every nuance of the functionality required for Stage 2 measures.

But wait, CMS is still clarifying its Stage 2 measures via FAQs. Can’t expect a vendor to build software to specifications that weren’t explicitly defined, or to sign a contract that requires adherence to unknown criteria.

So, what COULD CMS and the ONC do about it? How about finalizing your requirements BEFORE issuing measures and certification criteria? Since that ship’s already sailed, change the CEHRT certification process.

1. Require vendors to submit heuristics on both initial implementation and upgrades, indicating the typical timeline from kick-off to go-live, number of internal and external resources (i.e., third-party systems integrators), and cost.
2. Require vendors to submit customer-base profile detailing known customers planning to implement and/or upgrade within calendar year. AND require implementation/upgrade planning to incorporate 3 months of QA time post-implementation/upgrade, prior to go-live with real patients.
3. Require vendors to submit human resource strategy, and hiring and training program explicitly defined to support the customer-base profile submitted, with the typical timeframes and project resource/cost profiles submitted.
4. Require vendor products to be self-contained to achieve certification – meaning, no additional third-party purchase (software or professional services) would be necessary in order to implement and/or upgrade to the certified version and have all CMS-required functionality.
5. Require vendor products to prove the CEHRT-baseline functionality is available as configurable OOTB, not only available via customization. SHOW ME THE C-CDA, with all required data elements populated via workflow in the UI, not via some developer on the back-end in a carefully-orchestrated test patient demo script.
6. Require vendor products adhere to an SLA for max number of clicks required to execute the task. It is not Meaningful Use if it’s prohibitively challenging to access and use in a clinical setting.

Finally, CMS could redefine the incentive program parameters to include scenarios like mine. Despite the heroic efforts being made across the enterprise, this IDN is not likely to make it, with the fault squarely on the CEHRT vendors’ inability to deliver fully-functional products in a timely manner with skilled resources available to support the installation, configuration, and deployment. Morale will significantly decline, next year’s budget will be short the $MM that was slated for further health IT improvements, and the likelihood that it will continue with Stage 3 becomes negligible. Vendor lawsuits may ensue, and the incentive dollar targets may be recouped, but the cost incurred by the organization, its clinicians, and its patients is irrecoverable.

Consider applying the hardship exemption deadline extension to the incentive program participants.

March 5, 2014 I Written By

Mandi Bishop is a healthcare IT consultant and a hardcore data geek with a Master's in English and a passion for big data analytics, who fell in love with her PCjr at 9 when she learned to program in BASIC. Individual accountability zealot, patient engagement advocate, innovation lover and ceaseless dreamer. Relentless in pursuit of answers to the question: "How do we GET there from here?" More byte-sized commentary on Twitter: @MandiBPro.