A recent comment from Jim Hook from The Fox Group had a nice checklist of items that doctors and practice managers could start doing to make sure that their EMR implementation is ready to meet the meaningful use standards. This isn’t an exhaustive list, but I thought was a good list for those providers wanting to being their preparation for showing meaningful use and obtaining the EMR stimulus money.

Everyone should keep in mind that there are no systems “Certified” at this point.

Here are some things to check as you get ready to claim your incentives for EHR Meaningful Use under the HITECH Act. This information is based on (EPs) qualifying for the Medicare incentives.

1) Start talking to your vendor about their plans to submit their EHR software for certification as “Certified EHR Technology”. The system does not have to be certified as of January 1, but it does need to be certified by the end of the 90-day period you are using to attest to your EHR Meaningful Use.

2) Keep in mind that if you are using a stand-alone EMR product with an existing legacy practice management (PM) system, the system needs to be Certified EHR Technology also. This is because some of the functions of a certified system, such as recording patient demographics electronically, are most likely functions of your PM system, not the EMR product. So talk to that vendor, too.

3) Verify that any eligible provider attesting to meeting EHR Meaningful Use objectives provides 10% or more of his/her Medicare services in an outpatient setting (not inpatient or in a hospital ED). CMS will look at the percent of services rendered in an outpatient setting for the fiscal year ending 09/30/2010 to determine the IP/OP percentages. Your EHR healthcare consultant must be qualified to do the analytical and reporting work in preparing the self-attestation report, based on the current fiscal year and the individual EHR Meaningful Use objectives in place, starting January 2011.

4) Make sure all eligible providers you are planning to certify for EHR Meaningful Use have an NPI number and are enrolled in PECOS.

5) For EPs in group practices, confirm the tax Id number – group or personal – of each provider for payment of the incentive amount. Payments can be made to either number.

6) CMS will be establishing an Internet-based enrollment process for EPs planning to apply for incentive payments. Keep checking this site for the Registration process, and enroll when it is available.

7) As soon as you start the clock on your 90-day period, make sure you are meeting all the EHR Meaningful Use objectives applicable to your practice, and, for objectives with numerical thresholds, that you are attaining the levels specified. If your EHR system is Certified EHR Technology, it should be capable of supporting all Stage 1 Meaningful Use objectives.

8) Monitor the CMS website on EHR Incentive Programs to determine the format of the attestation for 2011. And keep in mind that accuracy is paramount; attesting to EHR Meaningful Use is making a claim to a Federal program. And the penalties for false claims are significant!

Attestations can be completed as early as April, 2011, and CMS has stated payments will be made in May. For EPs seeking incentive payments under the Medicaid / Medical program, visit the CMS website for further information.

In response to my previous EMR and ICD-10 posts, an EMR vendor recently sent me how they plan to address the transition from ICD-9 to ICD-10. Here’s their plan:

1. We are going to have both the ICD-9 and ICD-10 codes reside in the same file in our application. This will allow the charge entry people to enter either code. There will be a field in the ICD-9 that will map to a single ICD-10.
2. We will provide a report to each doctor showing them the frequency of the ICD-9 codes they used over a period of time that they can specify. This report will show the available ICD-10 codes. The doctor can study it, start to change, or ignore it.
3. The staff can opt to let the software map one ICD-10 to the ICD-9 or manually enter the code of their choice.
4. Our electronic claims software will have a flag per insurance carrier indicating whether or not it will accept ICD-10. For those that will, we will map the ICD-9 to the 10 and send that code. If no map identified, we will generate an error edit.
5. At some point down the road, we will use the information collected from billing to update the doctor’s preferred list of dx codes in the EMR.
6. We will have to augment customized programs at each client site that may be doing reports based on ICD-9.

Seems like we’re just about out of the daze that is the mammoth meaningful use final rule (yes, I know that other rules are even bigger, but it’s still mammoth). I thought it would be interesting to ask what’s the part of meaningful use that’s most concerning. Just so we’re not always pessimistic, I’ll follow up this post next week with one asking people to share the most exciting part of meaningful use. Both answers should be interesting.

While I don’t want to bias your comments, I will say that the thing that concerns me most about meaningful use is physicians going deep into debt for an EMR system they barely want in the hopes of EMR stimulus money and then end up with no stimulus money.

The first concern with this is those physicians that think they have to go into deep debt in order to fund an EMR. In most cases, this can generally be avoided. There may be some debt involved, but it should be pretty minimal and the return on the investment should be understood from the beginning and should not include the EMR stimulus. Unfortunately, I fear that many won’t heed this advice.

Add on the past experience with government handouts and I can see many appropriately disgruntled providers who get left holding the bag which includes no stimulus money.

Ok, your turn. What concerns you about meaningful use?

I’m really glad that the chorus of people singing the tune I’ve been singing is starting to swell. Here’s some comments from Barbara Hales of The Write Treatment talking about the right way to implement an EMR and the problems with the EMR stimulus carrot approach:

I agree with you that EMRs should be implemented because it is the right thing to do,not because of the incentives. The government incentive is a dangling carrot.

Money promised for implementation comes by way of increased Medicare and Medicaid reimbursements by 1-2% from each claim. Talks of slashing Medicare reimbursements by 21% came soon after. So after investing money and time in a system, you are going to get….what was that?

This was considered by the government when they issued the proposal that rather than getting money, reimbursements would be taken away as a penalty for failure to comply as of 2014.

Clever. Not only will they not have to dish out much money, now they will be getting money ( in the sense that services will not cost as much)

Now consider the physicians that do not have a large percentage of patients that participate in theses Medicare and Medicaid programs. They too, will not be seeing any government subsidy for implementation.

Yes, get the system because of increased efficiency or because you can achieve more with it, like any piece of medical equipment. If it is for the subsidy, don’t hold your breath!

Nicely said Barbara!!

P.S. I think the thing that EMR and HIPAA needs is a pretty face like Barbara’s to put on the site. They have some over on the Healthcare blog and HISTalk has Inga. Maybe a pretty female face is what’s really missing from EMR and HIPAA.

I’ve been meaning to write a post linking to BobbyG’s blog for a while and just never got around to it. If you follow the comments on here, you’ll have seen many of BobbyG’s comments as well. The thing that first struck me about Bobby was his sincere and thoughtful comments on the challenges that the RECs face. Here’s some of his thoughts on REC Challenges:

• Critics bemoan a lack of prior HIT deployment and QI experience among some REC awardees (as well as the heterogeneity of business models);
• While 60 REC contracts have thus far been awarded, with the newly chartered RECs frantically ramping up to meet the rather compressed Stage One Meaningful Use incentive payment timelines, both the requisite Meaningful Use reporting criteria and the EHR (Electronic Health Record) certification regulations remain unresolved at this writing. The cart is seriously out in front of the horses in many respects;
• The anticipated huge and short time-frame new demand for HIT installs may well overwhelm the capacity of HIT vendors, resulting in lengthy, problematic implementation queues (not to mention a severe shortage of qualified installation, training, and support personnel);
• Notwithstanding that HHS is spending hundreds of millions of dollars on REC contracts, physicians and hospitals are not required to engage REC services in order to qualify for federal incentive payments. Consequently, RECs are having to spend significant time and money hawking their services (the polite term being “enrollment.” I did not know when I signed on that I would be required to do what amounts to hastily and minimally trained cold-call sales). Moreover, REC services are not fully subsidized, the upshot of which is often skeptical ”we’ll pass” pushback, especially in light of the hyperbolic claims of virtually all major EHR vendors “guaranteeing” that their products will get the provider to MU (with the glossed-over disclaimer, well down in the fine print”When Used As Directed”);
  • At this writing, the aggregate Final Rule for MU criteria is still under HHS consideration, with myriad professional stakeholder groups arguing for relaxation of both the compressed compliance timelines and the all-or-nothing approach, countered by a broad array of equally vocal consumer/patient advocacy organizations arguing for MU criteria adoption “as-is” as set forth in the Interim Final Rule.

    I would have added another MU criterion: requireworking with the RECs as a condition of incentive money eligibility;

• The relatively sparse per-provider federal REC funding may force the RECs to focus simply on assisting their client physicians with hitting the MU criteria in pursuit of the incentive reimbursements — to the practical exclusion of broader and more sustainable, internalized quality improvement efforts;
• There is to be a “Health IT Research Center” funded by HHS and intended to “gather relevant information on effective practices from a wide variety of sources across the country and help the Regional Extension Centers (RECs) collaborate with one another and with relevant stakeholders to identify and share best practices in EHR adoption, effective use, and provider support. The HITRC will build a virtual community of shared learning to advance best practices that support providers’ adoption and meaningful use of EHRs.”

  It is not even slated to be up and running until FY2012.

I think most of these points hit the nail on the head. RECs are in for some major challenges. It will be interesting to watch those that creatively confront those challenges and those that fold under the pressure of it all. I still stand by my opinion that they could be a tremendous force for good or bad. Considering there are so many RECs all over the US, I’m sure we’ll have plenty of both types.

It’s always interesting to talk with someone about the permissions they should set in their EMR. Pretty much every EMR that has any footprint has a broad set of permissions available to restrict the access of your end users. It can often be a pretty significant task to set all of these permissions. Thankfully, it’s a project that you do once and then don’t have to go again (except for maybe some minor changes). Also, many EMR vendors have good templates for giving you a starting point for permissions.

What usually happens is that users end up with ALL sorts of restrictions on user accounts. I can’t say this is such a bad thing. Users should only have access to the information and features they need for the job. However, in the application of this rule, people almost always go overboard. Shortly after an implementation, the permissions are eventually opened up.

Since this is bound to happen, it’s important to make this part of the EMR implementation plan. Don’t make your nursing staff beg you for access to something. Give them a way to ask for access without making them feel like they are doing something they shouldn’t. Instead, encourage them to ask you for access to things that would make their life easier. That doesn’t mean that you’ll always give access, but from what I’ve seen, most people don’t want more access than what they need.

Remember that the rule is that people should only have access to the information that they need. If they’re asking for access to certain information to make their (and often your) life easier, then they probably do need it and should have access.

I’ve heard this mentioned a few times, but in all my posts I don’t think I’d ever mentioned it myself. But it’s very true that EMR is the Physician equivalent of an ERP (Enterprise Resource Planning). Wikipedia describes an ERP as such:

Enterprise resource planning (ERP) is an integrated computer-based system used to manage internal and external resources including tangible assets, financial resources, materials, and human resources. It is a software architecture whose purpose is to facilitate the flow of information between all business functions inside the boundaries of the organization and manage the connections to outside stakeholders. Built on a centralized database and normally utilizing a common computing platform, ERP systems consolidate all business operations into a uniform and enterprise wide system environment.

Basically, it’s consolidating all of your IT software in one package. However, the real key is that by implementing this broad variety of packages you’re affecting almost every part of the organization. This is why I think the comparison of EMR software with an ERP is so interesting. An EMR has the same impact on the entire organization as the ERP does in a business.

As an aside, it is also interesting to note that ERP’s have been slow to be implemented in small business and have been most popular in very large companies. So, I think it’s interesting to see that we’ve seen a somewhat similar thing happen in healthcare. Most large hospital organizations have an EMR (at least in some state) and the smaller clinics have been more resistant to implementing an EMR.

The question then is what are the lessons we can learn from ERP implementations that we can apply to EMR implementations? Turns out that they’re things that I’ve talked about over and over.

1. Get Leadership Buy-In – An ERP is doomed to failure without a strong leadership that drives the ERP initiative. Since it affects every level of the organization it takes a strong leader to implement the changes and bring everyone together. The same is true for EMR.
2. Find Great Support – When you implement an ERP, you have to create a huge budget for customizations. In fact, one of your biggest expenses will be the consulting help you need to customize the ERP to meet your organization goals and policies. The consultants you bring to help you are critical to the quality of the implementation. EMR and IT consultants can have the same impact during an EMR implementation. Every EMR needs some level of customization for your clinic and a consultant well versed in your product can be a great boon.
3. Consider Implementation Phases – An ERP never goes live all at once. They ALWAYS do it in phases. This could be a great lesson for EMR implementations. Don’t bite off more than you can chew when you’re implementing. For example, in one implementation I did we just started with entering the diagnosis and charges into the EMR. Then, shortly after that we implemented the rest of the charting in the EMR. You can’t implement EVERY EMR feature from day one. So, phased EMR implementations are a good idea.
4. Include Staff in Selection Process – I was working at a large university and was asked to participate in a presentation by each of the ERP vendors. I felt very empowered to be part of the selection process. The challenge is that you can’t be fake about this. Don’t invite people to the meeting and then not listen to them. Otherwise, it will have the opposite impact from what you want. Really listen to people’s feedback and make sure they know you heard what they said and took it into serious consideration. Turns out that this involvement also helps with the buy-in mentioned above.

I’m sure there are many more. Feel free to add some in the comments. Much can be learned from other industries that can be applied nicely in healthcare. We’re not as unique as we’d like to think we are.

In a recent EMR webninar I attended, I heard some really good counsel that was worth sharing here on my blog:

Limit EMR Investment Appropriately, but Don’t Skimp

When people go into an EMR implementation I’ve seen all sorts of approaches. I’ve seen the phenomenally cheap to the no limits buying. Both of those are recipes for failure.

The problem with the phenomenally cheap is that you’re going to end up not investing in the IT products and software that will make a huge difference in your EMR implementation. For example, you might buy a cheap scanner which 2 months later you realize was a horrible idea since you’ve literally burnt through the scanner and it no longer works. Instead, if you’d spent money on the right scanner (which do feel expensive), you wouldn’t have to worry about getting another scanner for 5-10 years (if even then). (See my EMR scanner suggestions on this page.)

That’s just one example. There are many more. Interestingly, the opposite seems to happen when it comes to EMR software. Doctors will spend insane amounts of money on EMR software. I can’t figure out if doctors just don’t realize that there’s a number of very reasonably priced EMR software out there or if they just think that the more they pay for an EMR the more they’re getting.

I guess you could make the case that when you pay more for an EMR you are getting a more robust software platform. In some cases this is absolutely the case. The problem for small practices is that they don’t need or want a more robust platform. In fact, they end up buying this really robust EMR software platform which is so robust that they don’t have the time, money, or energy that’s required to configure the millions of available options and customizations that would make the software great for their clinic. This leaves them with a generally unusable EMR software and an unhappy user of EMR software.

There’s dozens of other examples where doctors need to find the balance between limiting their EMR investment, but not skimping. This is the art of an EMR selection and implementation.

I’ve come across a number of websites and people who’ve made the assertion that with the short time frames for meaningful use, a SaaS EHR is the only option to be able to meet the meaningful use requirements in a timely manner. Let’s see if I can do my part to clarify this idea which isn’t completely accurate.

First, there is still plenty of time for a clinic to implement an EMR of any type and get EMR stimulus money. At some point this might change, but at this point we are still far enough out that time is not an issue. Although, I’ll admit that it would be helpful if CMS and HHS would finally get some EHR software certified and provide some practical meaningful use details. Of course, these details shouldn’t be stopping doctors from evaluating and planning for their EMR implementation.

Second, it is worth acknowledging that in general a clinical practice can implement an EMR faster if it’s a SaaS EMR and not a client server EMR. The time for the server to be shipped to your office alone just takes time not to mention getting an IT person or your EMR vendor to install the server in your office. However, if you need more computers and a laptop to be able to use your SaaS EMR, you’re going to be waiting for computers to arrive anyway. Generally though, SaaS EMR is faster to implement than client server.

Of course, this doesn’t mean that you can’t quickly implement a client server based EMR. For example, I implemented a local doctors office in a week from when the server arrived. It was an incredibly fast implementation. Other than ordering time (which they had to order workstations also), it was as fast as any SaaS EMR implementation. So, it’s certainly possible. You just better make sure you have the right IT people supporting your implementation.

My point in this post is that it’s mistaken to say that SaaS EMR is the only option that’s fast enough to implement in time for meaningful use. Many of the client server EMR companies out there have really streamlined the process for installing a server in a clinic. Although, this is not true for all of them. So, it’s a question worthy of asking any EMR company if you’re looking at compacted time lines.

At least for now, it’s a mistake to rule out a great client server EMR just based on the meaningful use time line. We’ll leave the other arguments for ruling out a client server EMR in favor of a SaaS EMR for another post.

If you’ve read this blog for a while you know that I love to compare EMR implementation to other parts of life. It’s always amazing to me how similar other parts of life are to EMR selection and implementation. In case, you’re a newer reader, go and read my posts comparing EMR to Marriage (also talks about divorcing your EMR), EMR implementation to Pregnancy, and Marrying an EMR for Money (VERY important with all this EMR stimulus money). A presentation on comparing EMR to life would be a fun presentation to give, but I digress.

The other day I came across a comparison that will be familiar to all types of people, but doctors will be acutely aware of this comparison (even more so than I). EMR implementation is very much like weight loss. Yes, that’s right. Weight Loss!

Think about it, there are a lot of similarities. Most patients that need to lose weight know that they need to lose weight. Deep down they really know they need to lose weight, but a part of them is still trying to argue that they don’t need to lose weight. A part of them still kind of wonders, “what’s so wrong with being overweight?” Sounds like many doctors looking at an EMR implementation. They know deep down that they need to implement an EMR. However, they just keep asking themselves “Why can’t I just keep using paper charts?”

No doubt many older people that are overweight have basically given up the fight to lose weight. They figure that they’re older and they have no need for weight loss anymore. Sound a bit like older doctors and how they approach EMR?

Of course, the most interesting comparison between weight loss and EMR implementation comes when applied to the actual implementation itself. Weight loss requires a huge change in someone’s life. Thus, it usually requires a lot of “hand holding” and reminders about the value of losing weight. They’ll often lose motivation and need someone to pick them up and help them continue to make the changes in their life so they can lose weight.

No doubt implementing an EMR requires change. Weight loss is about changing habits. EMR implementations are about changing habits too. Often they are habits which were instilled many years ago during medical school. I don’t have to describe why changing habits are hard (although, here’s a couple change pictures to illustrate what I mean). That’s why so many people have a challenge losing weight and why so many people have avoided implementing an EMR.

Yes, and most EMR implementations require a certain amount of hand holding along the way. That’s more a feature of change than anything else. The real question a clinic should be asking themselves is who will be doing the hand holding. The answer might surprise you when you find out that it will likely not be one person, but many.