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Eyes Wide Shut – January, 2014 Meaningful Use Stage 2 Readiness Reality Check

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Happy New Year?

As I begin the 2014 Meaningful Use measures readiness assessment and vendor cat-herding exercises, I’m reflecting on this portion of CMS’s Director of E-Health Standards and Services, Robert Tagalicod and the ONC’s Acting National Coordinator Jacob Reider’s statement regarding the Meaningful Use timeline modification: “The goal of this change is two-fold: first, to allow CMS and ONC to focus efforts on the successful implementation of the enhanced patient engagement, interoperability and health information exchange requirements in Stage 2.” (Previously published on EMRandHIPAA.com.)

I call BS.

If the “goal” is a “successful implementation”, then CMS failed miserably by not addressing the START of the quarterly attestation period for Stage 2, which is still required in 2014. CMS and the ONC need more time to successfully implement the measures, and they are bureaucratic agencies that don’t directly deal with patient medical care. Why wasn’t the additional time required to truly succeed at this monumental task extended to the healthcare provider organizations? Because the agencies want to save face, and avoid litigation from early adopters who may be already beginning their 2014 attestation period amidst heroic back-breaking efforts?

Here’s a reality check for what a large IDN might be going through in early January, in preparation for the start of the 2014 quarterly attestation period. Assume this particular IDN’s hospitals’ fiscal year runs October-September, so you MUST begin your attestation period on July 1. You have 6 months.

As of December 31, 2013, only 4 of the 8 EMRs in your environment completed their 2014 CEHRT certification.

Each of those 4 EMRs has a different schedule to implement the upgrade to the certified edition, with staggered delivery dates from March to July. The hospital EMR is not scheduled to receive its certified-edition upgrade until April. You pray that THIS implementation is the exception to your extensive experience with EMR vendor target timelines extending 6-8 weeks beyond initial dates.

The EMR upgrades do not include the Direct module configuration, and the vendor’s Direct module resources are not available until 6-9 weeks after the baseline upgrade implementation – if they have knowledgeable resources, at all. Your hospital EMR vendor can’t articulate the technical infrastructure required to implement and support its own Direct module. Several vendors indicate that the Direct module configuration will have to be negotiated with a third-party. Your clinicians don’t know what Direct is. Your IT staff doesn’t know how to register with a HISP. Your EMR vendor doesn’t support a central Direct address directory or a lookup function, so you contemplate typing classes for your HIM and clinical staff.

The number of active patient problems requiring manual SNOMED remediation exceeds 60,000 records in your hospital EMR. You form a clinical committee to address, but they’re estimating it will take 6 months of review to complete. You’re contemplating de-activating all problems older than a certain date, which would whittle down the number and shorten the timeframe to complete – but would eliminate chronic conditions.

There are still nagging questions regarding CMS interpretation of the measures, so you ask for clarification, and you wait. And wait. And wait. The answers impact the business rules required for attestation reporting, and you know you need any help you can get in whittling down the denominator values. Do deceased patients count in the view/download/transmit denominator? If records access is prohibited by state/federal law, does that encounter count in the view/download/transmit denominator?

Consultant costs skyrocket as you struggle to find qualified SME resources to blaze a trail for your internal staff. Their 60-to-90-day assessments inevitably end with recommendations for “proof of concept” and “pilot” approaches to each of the 2014 measures, which don’t take into account the reality of the EMR upgrade timelines and the looming attestation start date. Following their recommendations would delay your attestation start by 9-12 months. So, your internal staff trudges forward without expert leadership, and you throw the latest PowerPoint deck from “Health IT Professionals-R-Us” on the pile.

Who needs testing, when you can go live with unproven technology the day it’s available in order to meet an arbitrary deadline? Healthcare.gov did it – look what a success that turned out to be!

But wait, this is real clinical data, generated by real-world clinical workflows, being used to treat real patients, by real healthcare providers. By refusing to address the start of the 2014 attestation period, CMS and the ONC are effectively using these patients and providers as lab rats.

I did not give permission to be part of this experiment.

January 13, 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.

ROI for EMR: Does It Even Make Sense Now?

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There’s a new data point to add to the debate over EMR return on investment.

Norton Healthcare Inc. in Louisville, Ky., has experienced a $12 million increase in federal reimbursement since it started using Epic, Louisville Business First reported. The health system, which operates five hospitals and a network of outpatient sites, is three years into a five-year, $200 million implementation.

Sounds like the beginning of some pretty good ROI. Or does it?

It’s hard to say.

ROI for records systems is notoriously hard to pin down. The word is that many hospitals don’t even try. And they might be onto something.

A revenue boost is a good sign. It’s often a result of improved coding and lower claims denial rates, as Colin Konschak of health care consulting firm Divurgent and Garrett Blair of Norfolk, Va.-based health system Sentara Healthcare recently wrote. And of course, there are the federal incentives for using an EMR — for hospitals, as much as $11 million over four years.

There’s also the rise in productivity that EMRs are expected to cause. At first, an EMR can slow down clinicians’ workflow and cost them and their organization money. But in time, the system could increase productivity.

But revenue is only part of the equation. Cost savings are the more important — and harder to calculate — factor.

Here are a few ways, as described by Konschak and Blair, that EMRs can help hospitals to save:

  • Less need for transcription.

  • Reduced use of staff time for copying and filing.

  • Reduced — often by 50-70 percent — use of preprinted forms.

  • Potentially lower malpractice premiums because of more complete documentation.

Many other potential benefits are probably real but are even less straightforward to measure. Features such as clinical decision support and electronic medical administration records, for example, could lead to reductions in medical errors — the types of mistakes the federal government no longer pays for. But measuring the money you saved from the errors you didn’t make is fairly abstract.

Many hospitals do little if anything to measure the return on their EMR investment, according to a study released by Beacon Partners last year. Healthcare Scene’s John Lynn wrote a few months ago that CIOs likely view the systems as a “necessary requirement of being a hospital today,” somewhat like cleaning supplies. So they don’t see the need to measure ROI.

To me, the “investment” part of ROI suggests that you have a choice. You put money into something now with the hope — but no guarantee — of a payoff later.

Building an imaging center on the edge of town or buying a surgical robot would probably be considered investments. Maintaining your buildings or upgrading your phones would not.

Doing something the government is making you do is not an investment. Given the reimbursement penalties that will eventually kick in for organizations that stick with paper, it’s hard to imagine that many hospital executives see EMR adoption as a matter choice.

The idea of ROI for EMR is probably outdated, a holdover from the days when having a system was optional. Hospital leaders are shopping for EMRs with an eye toward getting the best value for their money — just the way they shop for cleaning supplies, furniture or legal services.

You could say that as a society we’ve invested in the idea of EMRs and that we’re hoping for a payoff in terms of better outcomes and lower costs. But that doesn’t predict much about whether any particular hospital or doctor will see a dollar-and-cents ROI.

At Norton in Louisville, it sounds like they’re happy just to be recovering some of what they’re spending.

“It really does improve the continuity of care,” Norton’s chief medical officer, Dr. Steve Heilman, told Business First.

For now, it sounds like Norton is on track.

(Note: I work for Business First as a freelancer but didn’t write the story linked here.)

December 20, 2013 I Written By

James Ritchie is a freelance writer with a focus on health care. His experience includes eight years as a staff writer with the Cincinnati Business Courier, part of the American City Business Journals network. Twitter @HCwriterJames.

It’s Not The Health IT You Choose, But The Way You Talk About It

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With system upgrades taking shape across the country, IT is no longer just another another department in the hospital. More than ever, it’s integral to how healthcare organizations work and get paid.

But you don’t always see this shifting landscape reflected in hospitals’ leadership structures or practices.

That’s unfortunate. Getting the most out of  the billions being spent on health IT will require clear vision and skillful communication at the top levels, according to a December article in the Journal of the American Health Information Management Association.

Doctors, nurses and other team members “must understand the nature of the changes—what the result of the changes will be, how their roles and work will be different, and why change is important,” author Tiankai Wang wrote.

Thoughtful language can go a long way toward minimizing staff resistance and making an implementation successful, explained Wang, a professor of health information management at Texas State University.

Leaders should practice “framing” by promoting the benefits of the technology, such as improved outcomes, lower costs and greater efficiency, Wang wrote. They should also use “rhetorical crafting” by using stories, analogies and other devices to make their message resonate.

Rhetorical crafting, according to Wang, “leverages a ‘show, don’t tell’ approach to frame leaders’ message in a form that will connect more easily with staff and help them to embrace the possibilities of the coming change.”

He also advises using words such as “we” and “should” rather than “you” and “must” when talking about IT changes.

At a more fundamental level, though, IT leadership isn’t always valued in healthcare to the extent that other roles are. In 2013, average total cash compensation for chief information officers was eighth-highest of all hospital titles at about $316,000, Modern Healthcare reported.

And despite the growing importance of health IT, it’s also uncommon for hospital CIOs to be promoted to the roles of chief operating officer, president or CEO.

It does happen, though, as David Raths wrote in Healthcare Informatics. In perhaps the best known example, Cincinnati-based Mercy Health, which operates several hospitals, earlier this year named Yousuf Ahmad, who had previously served as CIO, to the chief executive role. Ahmad had also held other management roles, including president of the system’s physician group.

It’s likely a sign of the front-and-center role that IT is now taking at healthcare organizations everywhere.

December 13, 2013 I Written By

James Ritchie is a freelance writer with a focus on health care. His experience includes eight years as a staff writer with the Cincinnati Business Courier, part of the American City Business Journals network. Twitter @HCwriterJames.

Outfitting for the ICD-10 Voyage – Breakaway Thinking

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The following is a guest blog post by Laura Speek from The Breakaway Group (A Xerox Company) and Honora Roberts from Xerox. Check out all of the blog posts in the Breakaway Thinking series.
ICD-10 Boat
These are challenging times for healthcare providers in every imaginable vessel – and the whitewater ride is not over yet. Just around the bend looms the transition to ICD-10, scheduled for October 1, 2014. Most providers know the wisest course is to start preparing now, yet few have dared to navigate these uncharted waters.

For many, a major problem is not knowing where to start. Others may be suffering from protracted procrastination. And still others may be well on the road to ruin via the path of good intentions.

An effective way to put some wind in your ICD-10 sails is to get real about the serious costs of noncompliance. After October 1, 2014, claims must be submitted using ICD-10 coding to be eligible for reimbursement. In other words, if you don’t bill with ICD-10 codes, you simply won’t get paid. And that’s the cold, hard truth.

The transition to ICD-10 will affect every facet of healthcare, but it begins with understanding the basic differences between ICD-9 and ICD-10. First and foremost, ICD-10 is not just a simple expansion of ICD-9. There is no reliable one-to-one mapping system. Some ICD-9 codes equate to multiple ICD-10 codes, while some do not correspond to any.

ICD-10 codes include much greater specificity; care providers must document etiology, laterality, exact anatomical site, and other information. Patient encounter documentation must include proper detail to enable coders to locate the correct ICD-10 diagnosis and procedure codes. Physicians and mid-level providers should begin to assess their documentation today to identify where ICD-10 coding requirements are already being met and where improvement is needed.

Because clinical documentation is at the core of every patient encounter, it must be complete, precise, and accurately reflect the scope of care and services provided. Assuring depth and consistency of documentation represents a challenge for many organizations.

ICD-10 encompasses a huge increase in accessible codes. The ICD-10-CM diagnostic code set, used in all healthcare settings, increases from roughly 13,000 to 68,000 codes. The ICD-10-PCS procedural code set, used within inpatient settings only, expands from roughly 3,000 to 87,000 codes. It should be noted that ambulatory settings will continue to use CPT (Current Procedural Terminology) procedural codes.

Given this massive growth in coding scope, the importance of detailed clinical documentation becomes even more pronounced. Physicians and other healthcare providers typically are not trained to develop proper documentation skills in medical school or residency; nurse practitioners (NPs) and physician assistants (PAs) generally do not receive such training during graduate school or clinical rotations. Hospitals and healthcare systems need to compensate for this training deficiency by instituting educational programs and tools that align healthcare providers with proper documentation practices to clear the decks for successful transition to ICD-10.

ICD-10 requires physicians, NPs, and PAs to thoroughly document each and every patient encounter to a much greater level of specificity than is needed in ICD-9. Nonspecific or incomplete documentation within ICD-10 will cause delays, claim denials, cash-flow interruptions, and inaccurate quality reporting. Definition and terminology changes inherent in ICD-10, particularly for surgical procedures, will also require focused education and training.

At the end of the day, providers aren’t coders. They are far less concerned with ICD-10 codes than they are with improving quality of care. This is where ICD-10 can be viewed as a welcoming beacon on a rocky shore. It gives healthcare providers an incentive to establish a clinical documentation improvement (CDI) program. In fact, implementing and sustaining an effective CDI initiative should be a top priority for all healthcare organizations preparing for ICD-10. For those with no CDI program in place, the time to begin is now. Consider improved clinical documentation as essential equipment for maneuvering through the twists, turns, and churns that accompany the voyage to ICD-10.

Honora Roberts - Xerox
Honora Roberts is Vice President of Healthcare Provider Services at Xerox.

Laura Speek  - The Breakaway Group
Laura Speek is a Learning and Development Specialist at The Breakaway Group (a Xerox company).

Xerox is a sponsor of the Breakaway Thinking series of blog posts.

November 19, 2013 I Written By

CA EMR Adoption Up, But Other Health IT Use Is Behind

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While California providers are stepping up their use of EMRs, they’re still behind on some other measures of health IT adoption, according to a new report by the California HealthCare Foundation.

First, the positives. California physicians who use EMRs grew from 37 percent in 2008 to 59 percent in 2013. The report also concluded that 50 percent of California hospitals used EMRs in 2012, compared with 13 percent in 2007, and that 65 percent of community health centers used EMRs in 2011, compared with 3 percent in 2005.

All that being said, California providers are behind when it comes to Meaningful Use. While 58 percent of them said in 2012 that they planned to participate in Meaningful Use, only 30 percent of California providers with EMRs had a system that met all of the program’s 12 objectives, notes iHealthBeat.

What’s more, California hospitals’ use of clinical support systems fell from 77 percent in 2010 to 71 percent in 2012, a pretty low number given that the national average of 97 percent use of such tools. Also, the state ranks 49th in the country for e-prescribing rates.

The researchers also note that providers seem less interested in health IT than consumers. The 57 percent of state residents who had access to their EMRs  used them to view their health records, e-mail physicians and schedule care appointments, iHealthBeat reported.

All told, the report comes as something of a surprise, given that over time, California has traditionally been at the leading edge of many healthcare industry trends. And it suggests that many California providers are missing out on increasingly well-documented opportunities to improve productivity. So let’s hope that traditionally cutting-edge providers take the nudge provided by this report seriously.

November 18, 2013 I Written By

Katherine Rourke is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

Factors that Influence Healthcare Information Technology Adoption – Breakaway Thinking

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The following is a guest blog post by Laura Speek, learning and development specialist at The Breakaway Group, a Xerox company. Check out all of the blog posts in the Breakaway Thinking series.
Laura Speek  - The Breakaway Group
Healthcare organizations of nearly every variety are heavily involved in analyzing a smorgasbord of choices in electronic health record (EHR) technology. While some care providers still face the challenge of transitioning from paper to digital records, others are already moving to next-generation electronic systems.

Clearly, the cornerstone benefit of EHRs is improved patient care. However, that objective is best achieved when healthcare organizations look beyond software implementation (the installation phase) and orchestrate true technology adoption (overall integration for clinical benefit).

Consider the analogy of a wedding and a marriage. Software implementation is a momentous, finite event, similar to a wedding ceremony, that marks the beginning of a long-term partnership. The ensuing marriage demands that couples work diligently to learn how to live together in a way that is harmonious and meaningful. True technology adoption requires an extended commitment, comparable to a marriage. Over time, the organization coordinates efforts to seamlessly integrate a software system into daily workflows, procedures, and processes. The result is an enduring, measurably beneficial marriage with technology.

The Breakaway Group (TBG) is a company that works in healthcare and has conducted extensive research to identify elements of successful EHR adoption. Studies have shown that certain strategies can significantly contribute to the integration process. Referred to as the “four corners of adoption,” here are our research-based recommendations for successful EHR conversion.

Four Corners of Technology Adoption
The Breakaway Group Four Corners of Technology

Engaged Leadership: Leaders must possess the insight, will, and ability to direct and inspire teams throughout the adoption process. Engaged leadership begins with communication of a common vision and purpose that permeates the organization from the top down. Informed and enthusiastic healthcare leaders set the tone for creating a culture of adoption, which research has proven is vital for successful EHR integration.

Speed to Proficiency: TBG’s research indicates that targeted, streamlined education can significantly reduce training time and associated costs, while rapidly building user proficiency and confidence. The goal of developing proficiency to perform common daily tasks – as opposed to requiring mastery of multitudinous software bells and whistles – can be achieved in very short order. Brief, role- and scenario-based online courses that are relevant, self-paced, and accessible on demand appeal strongly to adult learners. Motivated learners generally complete assigned courses, score well on review tests, and rapidly assimilate new technology into routine workflows.

E-learning is a financially attractive alternative to instructor-led education. However, some healthcare organizations supplement online courses with carefully developed in-person instruction about unique or complex workflows that are not well suited to electronic formats. Our research confirms the effectiveness and efficiency of a “blended” educational approach that combines digital and personal delivery systems.

Performance Metrics: Positive change nearly always emanates from constructive, quantitative examination. In other words, “what is measured will improve.” Studies prove that rigorously tracking and analyzing performance metrics can uncover opportunities for adjustments that substantially bolster technology integration. The key is to establish reliable systems for collecting performance metrics early enough to yield meaningful results and to prescriptively analyze that data on a regular basis.

Adoption Sustainment: True EHR adoption requires a plan for accommodating software updates, new medical discoveries, and changes in workflows – a process referred to as “optimization.” Optimization addresses post-implementation issues involving best practices, workflows, and related educational revisions. This key adoption element requires continuous effort, examination, and the willingness to make mid-course adjustments to fine-tune the relationship between an organization and its technology.

The Breakaway Method™

TBG’s intensive research led to the publication of Beyond Implementation: A Prescription for Lasting EMR Adoption, a book that has inspired many hospitals to re-examine their approach to technology integration. Careful analysis of our research data led to the development of The Breakaway Method™, a comprehensive EHR-adoption solution. To date, our methodology has helped nearly 1,000,000 healthcare staff members rapidly embrace new HIT software. Our method reliably accelerates bona fide adoption while minimizing organizational stress and disruption.

In the course of working with hundreds of medical organizations, using EHR systems from vendors of all varieties, we have acquired valuable insights. TBG has identified some common HIT adoption issues and helped clients envision and implement successful resolution strategies. Over the coming months, we have the opportunity to share our experience, observations, and recommendations concerning adoption challenges successfully met by different types of care providers. Stay tuned.

Laura Speek is a learning and development specialist at The Breakaway Group, a Xerox company. She can be reached at: laura.speek@xerox.com. To learn more about TBG, go to: http://www.thebreakawaygroup.com.

Xerox is a sponsor of the Breakaway Thinking series of blog posts.

October 16, 2013 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 – Inflicting Agile On The Waterfall World of Healthcare

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In a recent hangout with John Lynn discussing Healthcare Big Data and Meaningful Use Challenges, he asked me why incorporating more agile development practices into healthcare software and business practice is so hard. In my fumbling attempt to articulate a pithy answer, and I bumbled into an insight: health IT mandates are inflicting agile methodology onto the waterfall world of healthcare, and demanding adoption at an unprecedented pace. It’s creating an uncomfortable, and in many ways untenable, situation for the healthcare system as a whole.

For quick reference, here’s a diagram explaining the difference between the traditional waterfall approach to software development, and the newer agile methodology.

waterfall_v_agile

What immediately jumped out at me about this visualization of waterfall versus agile: doesn’t this inverse-triangle comparison look a bit like a diagram of the “flipped clinic”? “Flip the clinic”, as defined by the Robert J. Woods Foundation project, has become a rallying cry to reinvent the patient-provider interaction, empowering patients and providers to increase the value of each encounter through technology-enabled improved engagement opportunities.

flip_clinic

This “flipping” approach is considered a disruptive concept, with great power to accelerate insights and empower patients. However, currently, it is far from mainstream, and likely to take a decade or more to enjoy widespread adoption.

Health IT mandates are, effectively, demanding that healthcare “flip the systems”: move from a conservative, quality-deliverable “plan-driven” model to an aggressive, loosely-defined-deliverable “vale-driven” model – on an ambitiously aggressive schedule, on a massive scale.

As an industry, healthcare follows a very slow progression through the Waterfall development cycle. A commonly-cited statistic states that it takes 17 years for a single clinical discovery to become commonly applied practice. In the beginning, there is an idea with fixed requirements: a specific clinical trial is designed, with narrowly-defined scope to control variables and insure the highest quality results. The results of the trial are analyzed, published, considered for expansion. Patents are pursued. FDA approval is obtained. Over a decade later, the discovery makes its way into accepted treatment protocols, and eventually becomes part of the attending’s lecture to residents on rounds.

Contrast that slow progress through development and adoption with what’s happening under ACA, specifically with Meaningful Use objectives.

cms_mu_timeline

Now, if it takes 17 years for a clinical discovery to make it to mainstream practice, and that specific type of clinical function is what the healthcare industry is designed to DO, does anyone else see anything wrong with the schedule presented here? Notice there are only 11 years on that timeline, from inception of the certification program to the last year to receive an incentive payment? Only 5 years between program inception and penalties for non-conformance?

Another key differentiator between Agile and Waterfall: the criticality of quality. Quality is defined as “conformance to requirements”. Because Waterfall methodology places emphasis on explicitly-defined requirements, it also demands high-quality deliverables; there is traceability between each requirement and the specific feature/function that is designed to meet that need. Agile methodology places emphasis on flexible deliverables, as requirements are not clearly defined prior to starting work; the scope of the feature/functions that will be delivered varies, according to the results of the development effort and the time left to execute.

In one of my first posts on EMRandHIPAA.com, “Yes, Healthcare IT Adoption is Expensive AND Painful”, I ranted:

Haven’t we all heard the adage, “You can only have things done two of three ways: fast, cheap, or well”? Considering that the “thing” we’re trying to do is revolutionize the healthcare industry, the effects of which may be felt in each and every one of our lives at some point, don’t you want to include “well” as the bare minimum of what is required? After all, this is YOUR electronic health record, YOUR data, YOUR treatment plan and effectiveness measurements. So, what’s the other way we want this “thing” done: fast or cheap?

Now that I’ve spent more time working in the trenches with clinicians, detailing the operational challenges they’re facing with the rate of change the health IT mandates are demanding they absorb, I’ve come to the conclusion that I was wrong.

Health IT adoption must ONLY be done well. No other constraint matters.

Quality is of the utmost importance. Arbitrary deadlines are only increasing the cost required to implement half-baked product and process solutions that meet only the bare minimum “letter of the law” stipulations of the mandates.

The current focus on adopting health IT fast is only incenting corner-cutting measures from both IT vendors and healthcare providers. As a patient, I’m not ready to sign off on User Acceptance Testing of the nationwide implementation of Meaningful Use.

October 8, 2013 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.

Eyes Wide Shut – Managing Multi-EMR Meaningful Use Stage 2 Is Hard

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Most discussions on Meaningful Use (MU) seem to focus on a single healthcare provider organization (acute or ambulatory), with a single EMR, and a single Medical Record Number (MRN) pool generating unique patient identifiers. Even in that context, the complaints of the difficulties of successfully implementing the technology and obtaining the objectives are deafening. How daunting might those challenges seem, multiplied across a large integrated delivery network (IDN), attempting to make enterprise-wide technology and operational process decisions, in alignment with MU incentive objectives?

Imagine you are an IDN with 9 hospital facilities, sharing a single EMR. You also have 67 ambulatory practices, with 7 additional EMRs. You’ve made the progressive choice to implement a private health information exchange (HIE) to make clinical summary data available throughout the IDN, creating a patient-centric environment conducive to improved care coordination. To properly engage patients across the IDN and give them the best user experience possible, you’ve purchased an enterprise portal product that is not tethered to an EMR, and instead sources from the HIE. And because you’ve factored the MU incentive dollars into the budget which enabled these purchasing decisions, there is no choice but to achieve the core and select menu measures for 2014.

It is now October 2013. The first quarter you’ve chosen to gather Stage 2 attestation data starts on April 1, 2014. All your technology and process changes must be ready by the data capture start date, in order to have the best opportunity to achieve the objectives. Once data capture begins, you have 90 days to “check the box” for each MU measure.

Tech check: are all the EMRs in your IDN considered Certified Electronic Health Records Technology (CEHRT) for the 2014 measures?

Your acute EMR is currently 2 versions behind the newly-released MU 2014-certified version; it is scheduled to complete the upgrade in November 2013. Your highest-volume ambulatory EMR is also 2 versions behind the 2014-certified version, and it cannot be upgraded until March 2014 due to vendor resource constraints. Your cardiology EMR cannot be upgraded until June due to significant workflow differences between versions, impacting those providers still completing Stage 1 attestation. One of your EMRs cannot give you a certification date for its 2014 edition, and cannot provide an implementation date for the certified version. The enterprise portal product has been 2014-certified as a modular EMR, but the upgrade to the certified version is not available until February 2014.

Clearly, your timeline to successfully test and implement the multitude of EMR upgrades required prior to your attestation date is at risk.

Each EMR might be certified, but will it be able to meet the measures out of the box?

Once upgraded to the 2014 version, your acute EMR must generate Summary of Care C-CDA documents and transmit them to an external provider, via the Direct transfer protocol. Your ambulatory EMRs must generate Transition of Care C-CDA documents and use the same Direct protocol to transmit. But did you purchase the Direct module when you signed your EMR contract, or maintenance agreement?

Did you check to see whether the Direct module that has been certified with the EMR is also an accredited member of DirectTrust?

Did you know that some EMRs have Direct modules that can ONLY transmit data to DirectTrust-accredited modules?

You determine your acute EMR will only send to EMRs with DirectTrust-accredited modules, and that you only have a single ambulatory EMR meeting this criteria. That ambulatory EMR is not the primary target for post-acute care referral.

You have no control over the EMRs of providers outside the IDN, who represent more than 20% of your specialist referrals.

Your 10% electronic submission of Summary of Care C-CDA documents via Direct protocol measure is at risk.

Is your organization prepared to manage the changes required to support the 2014 measures?

This is a triple-legged stool consideration: people, process, and technology must all align for change to be effective. To identify the process changes required, and the people needed to support those processes, you must understand the technology that will be driving this change. Of all the EMRs in your organization, only 2 have provided product specifications, release notes, and user guides for their 2014-certified editions.

Requests for documentation about UI, data, or workflow changes in the 2014 versions are met with vague responses, “We will ask product management and get back to you on that.” Without information on the workflow changes, you cannot identify process changes. Without process change recognition, you cannot properly identify people required to execute the processes. You are left completely in the dark until such time as the vendors see fit to release not only the product, but the documentation supporting the product.

Clearly, your enterprise program for Meaningful Use Stage 2 health IT implementation and adoption is at risk.

What is the likelihood that your Meaningful Use Stage 2 attestation will be a successful endeavor for the enterprise?

As a program manager, I would put this effort in flaming red status, due to the multitude of risks and external dependencies over which the IDN organization has zero control. I’d apply that same stoplight scorecard rating to the MU Stage 2 initiative. There is simply too much risk and too many variables outside the provider’s control to execute this plan effectively, without incurring negative impacts to patient care.

The ONC never said Meaningful Use would be easy, but does it have to be this hard?

October 2, 2013 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.

Eyes Wide Shut – Teaching to the Meaningful Use Stage 2 Test

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According to Twitter analytics, one of my more engaging tweets recently stated that Meaningful Use is stifling innovation by requiring that health IT vendors and healthcare providers employ very specific tactics to capture and report on clinical data capture and interoperability standards compliance – ostensibly to engage and empower the patient, and improve coordination of care between providers. Of course, I said it much more succinctly than that. In effect, conforming to the Meaningful Use Stage 2 attestation measures is akin to “teaching to the test”:

Here’s a real-world example of what it means to “teach to the test” of Meaningful Use. In order to qualify for CMS incentive dollars, Meaningful Use Stage 2 Year 1 patient engagement measures must be met, with auditable data captured, in a 90-day contiguous period in 2014. An eligible provider (EP) must demonstrate that 50% of all patients with encounters during that time period have online access to their clinical summary within 4 days of the data becoming available to the provider. 5% of those patients must access the clinical information within the 90 days, and 5% of those patients must leverage secure messaging to communicate relevant health information with the provider. Finally, the MU-certified EMR must proffer patient-specific education materials for 10% of the patients seen during that time.

What I believe the ONC had in mind when they crafted these measures: engaged patients who will log in to their portal after each encounter, review the findings and lab results to assess their own progress and outcomes, read or listen to the condition-specific educational materials provided that resonate with them, and ask more meaningful questions of their providers as a result of this new-found, data-enabled empowerment. That is why they categorize these measures as “patient engagement”, right?

Wrong. This is what “patient engagement” looks like, from the EMR implementation, Meaningful Use-consultant, EP business process standpoint.

First, establish the bare minimum thresholds for meeting the measures. If the EP saw 1000 patients during the same 3-month period the previous year, your denominator is 1000; calculate the numerator for each measure based on that. So, we need 500 patients to have access to their clinical data online; 50 patients must access their information; 50 patients must communicate with their provider via secure messaging; 100 patient encounters must prompt specific educational opportunities.

To meet the 500 patients with online access to their clinical data, patient portal software is preloaded with patient demographic accounts, based on the registration data already available in the EMR. An enrollment request is emailed to the patient or authorized representative (assuming an email address is available in their demographic information). The EMR captures the event of sending this email, which contains the information about how to enroll and access the patient’s medical records via the portal. This measure is met, without the patient acknowledging the portal’s existing, and without any direct communication between provider and patient.

The medical records view and secure messaging measures can be met simultaneously, in a matter of days, by planning to add a few extra minutes to each encounter for 50 patients’ worth of appointments. The EMR has already triggered an email with portal enrollment information to each of the patients in the waiting room on a given day. As the medical assistant (MA) is taking vital stats, she asks whether the patient has enrolled in the portal. It’s likely the patient has not; the MA hands the patient a tablet and has him log in to his email, and walks him through the portal enrollment and initial login process. Once logged in, the MA directs the patient to click the link to view his medical record. That click is recorded, and the “view” measure is met; whether a CCD or C-CCD is actually displayed is irrelevant to the attestation data capture.

Having demonstrated how a patient can view his record, the MA then asks the patient to go into the portal’s message center, to send a test communication to the provider. The patient completes the required fields, and the MA prompts him with a generic health-related question to type into the body of the message. Once the patient hits “Send”, the event is recorded, and the “secure messaging” measure is met.

For all patients, whether portal-users or not, a new process begins when the MA finishes, the provider enters the room and begins her evaluation of each of the 100 patients required to meet the education measure. As the patient talks, the provider is clicking through EMR workflow screens, recording the encounter data. The EMR occasionally prompts with a dialogue box indicating educational materials are available for patients with this diagnosis code, or this lab result. Each dialogue box prompt is recorded by the EMR; the “patient-specific education” measure is met, whether the provider acts on the prompt and discusses or distributes the educational information or not.

To put it simply: the patient never has to log in to a portal to meet the 50% online availability requirement, they don’t have to actually view their records to meet the 5% view requirement, they don’t have to have an actual message exchange with their provider to meet the 5% communication requirement, and they don’t have to receive any tailored materials to meet the 10% education requirement. Once those clicks have been recorded, the actions never have to be repeated; meaningful and ongoing patient engagement is not needed to meet the attestation requirements and receive the incentive dollars.

In a previous post, I introduced my interpretation of the difference between the spirit and letter of the Meaningful Use “law”. By teaching to the test, we’re addressing the letter of the law, only, in its narrowest interpretation. When will we incent vendors and providers to go above and beyond and find ways to truly engage patients in meaningful ways, empowering them with accurate, timely data access and tools to analyze it?

September 30, 2013 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.

Eyes Wide Shut – Is This Meaningful Use?

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Again and again, I find myself expounding upon the need to differentiate between the “letter of the law” and the “spirit of the law” of Meaningful Use Stage 2. I believe whole-heartedly in the transformative power of health IT, and support the future vision of the Meaningful Use objectives of patient empowerment and nationwide standards for records transmission and interoperability. The spirit of the “law” is a revolutionary movement towards a technology-enabled, patient-centric healthcare system, where clinical data can be shared and consumed instantly, whenever patient desires or requires it.

The letter of the “law” is daunting, and its implementation could be seen as not only counter-revolutionary, but detrimental to the very patient population it is designed to engage and empower.

Consider this acute care scenario:

You’re a hospital healthcare provider, discharging a patient, in compliance with the patient-specific education and Summary of Care measures. You log in to your EMR, complete the discharge instructions in the correlated workflow, print the discharge summary and any condition-specific educational information for the patient, revisit their room to insure that they can review the instructions and ask any questions, and you’re on to assessing the condition of the next patient in need of care. Right?

How many times did you have to close the “patient-specific education” suggestion windows that popped up, alerting you to available materials for download, keyed off diagnosis codes or lab results?

How many minutes did you spend looking for the HISP address of the patient’s cardiologist, so you could transmit the Summary of Care document to them via the Direct module of your EMR? How many clicks did you have to use to FIND the Direct module in your EMR? And how many minutes did you spend cursing the ONC for requiring Direct for Summary of Care transmission for 10% of your discharged patient population when the cardiologist’s address was rejected by the Direct module, giving you a message that the receiver is not DirectTrust-accredited?

How much time did the discharge process take you before your facility decided to attest to Meaningful Use Stage 2? How much time does it take you now?
Consider this ambulatory care scenario:

You’re support staff for a general practitioner, who is deploying a patient portal in support of patient engagement measures. At check-in (or check-out), you provide the patients with the URL for enrollment and access, give them information on the benefits of having their medical records available electronically, encourage them to communicate electronically with their provider with questions or concerns, and you send them on their empowered and engaged way.

How many minutes did you spend validating each portal account owner’s identity once their enrollment request came? How many minutes did you spend validating the relationship of the portal account owner to each of the patients he/she requests to associate with the account? How did you document the due diligence done to insure no medical records are improperly released per HIPAA and other federal guidelines, as in the case of custodial disputes, behavioral health patients, or emancipated minors?

How many minutes did you spend walking patients through the enrollment, login, medical records view, and secure message functions? How much time did you spend answering questions from patients about the portal, rather than the health concerns that prompted the visit?

How much time did the check-out process take before your GP decided to attest to Meaningful Use Stage 2? How much time does it take you now?

In both of these scenarios, did you or the patient see any measurable difference in care as a result of the EMR’s new functionality?

Now, consider the aggregate of these scenarios over an entire day – dozens of encounters, dozens of clicks, dozens of minutes spent engaging the EMR to record requisite “clicks” for attestation numerator reporting, rather than engaging the patient.

Is this meaningful use of a healthcare provider’s time and energy? Is this meaningful use of health IT, meeting very specific targets to obtain finite objectives rather than enabling innovation and deriving best practice long-term solutions?

Is this what the ONC intended?

September 25, 2013 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.