Probably unintentionally, it seems like various HHS branches are playing good cop-bad cop right now.

I’m in Ojai, Calif., right now (please don’t hate me because of it) for the annual Association of Medical Directors of Information Systems (AMDIS) Physician-Computer Connection meeting, a gathering of chief medical information officers and others in the field of what AMDIS likes to call applied medical informatics. That contrasts with the American Medical Informatics Association (AMIA), which tends to draw more from the academic side.

The Office of the National Coordinator for Health Information Technology (ONC) apparently is the good cop. National health IT coordinator Dr. Farzad Mostashari was unable to make it out here from Washington, but he addressed the gathering by telephone. Unfortunately, he called into a cell phone hooked up to the PA system in a room already suffering from poor cellular coverage, so some of his words were clipped. But a few things were clear.

Mostashari indicated that he was in favor of delaying the start of Stage 2 of “meaningful use” to 2014, even for those who meet Stage 1 requirements this year. That’s the recommendation that the Health IT Policy Committee made to him a couple of weeks ago. Furthermore, if CMS approves the delay—CMS is producing and administering the EMR incentive program—Mostashari said that providers will be able to earn three years of Medicare and/or Medicaid bonus payments, not just two years’ worth, prior to the start of Stage 2.

That, not surprisingly, elicited some smiles and nodding from attendees. Mostashari, himself a medical informatics veteran with a primary care and public-health slant, played to the crowd by pointing out how health IT is accelerating real reform of American healthcare—not just an expansion of insurance coverage that to me is just throwing more money at a broken system. “We’re moving away from the fee-for-service model comfortably faster than we had anticipated,” he said.

Meanwhile, CMS came off looking like the bad guy, at least in contrast to ONC.

The agency already is taking a lot of heat from many parts of the healthcare world, which has heaped tons of criticism on the proposed Accountable Care Organizations rule. Just after Mostashari’s session, Ethan Moore, a health IT and HITECH Act specialist at CMS, hosted an update on the Medicare and Medicaid agency’s efforts in health IT, which included two other CMS technical specialists calling in on the phone.

One of the callers delivered a disheartening message to the 200 or so informaticists present: the Oct. 1, 2013, deadline to convert to ICD-10 coding is “firm.” That may not have surprised anyone, but it certainly seemed disappointing, given that there’s probably going to be more time available to achieve later stages of meaningful use.

Moore also showed slides that walked through the online application for attesting to meaningful use. Moore was an engaging speaker, albeit not as enthusiastic as Mostashari, but a lot of eyes still glazed over. Blame it either on the relatively early hour if you want, but I think it had more to do with the bureaucratic nature of the process. I suppose there isn’t much anyone can do about that. If there is, I’d love to know exactly what.

This is the second in a series of EMR and EHR interviews that will be done on EMR and HIPAA and EMR and EHR. The full EMR interview with Dr. Muir can be found on the new EHR and EMR interviews website. The following is a summary of that interview written by Kathy Bongiovi.

If you’re a doctor, nurse, practice manager, EHR consultant, CEO or executive of an EHR vendor, etc with EMR experience that’s interested in being interviewed, let us know on our http://www.emrandehr.com/contact-us/“>Contact Us page.

Dr. Peter Muir of Springfield Center for Family Medicine was interviewed recently concerning his acquisition of the maximum Medicare Incentive for showing Meaningful Use of a Certified EHR. The Ohio based primary care practice has been using NextGen Ambulatory since 2003 and NextGen Management since 2006.

Dr. Muir stated that their practice chose NextGen EHR because the company focused on clinical offices. Dr. Muir and NextGen EHR share the philosophy of always searching for ways to improve the product. Dr. Muir not only believes in this philosophy but also attended a development think tank along these lines at NextGen’s headquarters. He was also drawn to NextGen because he wanted the capability of customizing his templates.

Having demographics, scheduling, clinical and billing information all on one database has had a huge impact on Muir’s practice. He feels that having a centralized database “makes reporting much easier and more comprehensive than those EHRs with separate databases or separate vendors”. The doctor admitted the conversion from paper charts to EHR was stressful for the first year but well worth it in the long run.

Since Muir’s office has been using EHRs (since 2003), there have been relatively few changes needed for Meaningful Use and any required upgrades to the system came as part of the standard NextGen maintenance fees. There was data that had to be added which was not normally collected by his practice as it had little relevance to his patients but from the patients’ perspective, there was no change in the attention patients received from Springfield Center.

The family practitioner Muir credits the CMS web site and NextGen Healthcare for not only the upgrades to their EHR software but also for their pathway documents and webinars which helped them show meaningful use. He also credits GBS of Youngstown, Ohio (his NextGen vendor for hardware, software) who also helped them implement security upgrades in 2010 in anticipation of the process.

Additionally, being a part of the ONC Meaningful Use Vanguard Program was a benefit to Dr. Muir because “it provides recognition which may allow a greater input in system design and operation.” Muir is concerned, though, that the Program’s flow of information may be difficult if multiple database silos remain in service and a lack of standardization isn’t addressed.

Especially with respect to Meaningful Use Stages 2 and 3, the doctor believes it is critical to have professional health providers utilizing some form of regional system – versus individual systems – in order to have a seamless flow of information. Muir has begun such a system within his own state of Ohio.

The doctor was intricately involved in starting CCHIE (Collaborating Communities Health Information Exchange) in Springfield, Ohio. CCHIE chose HealthBridge as their data engine and together they have partnered with other healthcare providers to provide electronic access to patients’ lab and radiology results as well as to admissions, discharges and transfer information. They have added regions in Southern Indiana and two regions in Northern Kentucky.

Dr. Muir’s advice to fellow doctors is that unless they are planning to retire within the next couple of years they should not delay in the implementation of an EHR. The longer they wait, the more difficult and time consuming the transition will be because, with time, the activities of daily practice will be much broader and more demanding. Additionally, he suggests providers select a system that does not just meet Meaningful Use requirements. His advice is to “select a system that assists you in providing better medical care”.

Read the full transcript of Dr. Muir’s interview.

As much as I’d like to visit DC (I’ve never been), I wasn’t able to make it out there to attend the NIST workshop on EHR usability. However, Carl Bergman from EHR Selector did make it to the event and sent the following notes on EHR usability according to NIST.  Most of the speakers name link to their slides in PDF format.

National Institute of Standard and Technology’s Workshop on EHR Usability

This week I went to a NIST workshop examining the state of EHR usability. The workshop was at its administrative headquarters, a large 60s building on its sprawling Gaithersburg, MD campus about 20 miles outside Washington.

You might wonder what NIST is doing in the EHR business? I certainly did. NIST’s mission is to promote commerce and technical innovation including methods to determine, independently, the safety and security of a broad range of technologies including software. (It’s part of the Department of Commerce.) Since WW II, this has involved looking at the human factors involved in operation of every thing from nuclear plants to robotics. Interestingly, it’s not a regulatory agency, such as, the FDA or FCC. NIST’s standards work is through consensus building among manufacturers, consumers, regulators, etc.

The workshop, attended by about 200 persons, had two parts:

•      A review of the state of EHR usability studies by academics, practioners and system administrators and,

•      Introduction of NIST’s draft for a usability standard.

Part I. EHR Usability Today. There were many speakers, here’re the ones that had the most new information for me:

•      Mat Quinn of NIST covered its approach and work with ONC on the issue. Notably, NIST has published several documents in the area such as, NIST Guide to the Processes Approach for Improving the Usability of Electronic Health Records, (NISTIR 7741) which promotes a user centric approach to design and development.

•      I was really taken by Muhammad Walji’s study using a unified framework for EHR testing. The study compared user experience with the VA’s Vista program and a prototype system. It looked at:

o   What percent of an operation was substantive and what was overhead?

o   How long it took users to reach various performance levels.

o   How much memorization tasks took.

o   How many steps tasks required.

o   Error and recovery occurrence.

o   Time to complete defined tasks.

The study then applied its findings to rework the EHRs’ structure and workflow showing potential time and effort savings.

•      Anjum Chagpar of Toronto’s University Health Network. A human factors manager for this large healthcare network, she discussed the problems of integrating various vendor products into their system and their approach to usability and user satisfaction.

•      Buckminster Fuller famously declared, “I am a verb.” Dr. Lyle Berkowitz may not be a verb, but he is at least a gerund. His presentation swiftly covered several topics from HIMSS’ EHR Usability Task Force to usability definitions to stakeholder roles, and applying metrics to see how much of the problem was the system and how much the user.

•      The VA’s Dr. Jorge Ferrer provided several key references on usability studies.

Part II. NIST’s Proposed Protocol. If the first part took a broad and free ranging approach to usability, NIST’s staff approach was more focused. After an outline of the study’s setting and approach, the study director, Lana Lowery, outlined the protocol’s goal: prevention of unacceptable medical errors. These include errors of both omission and commission, for example:

•      Writing an order for the wrong patient.

•      Prescribing the wrong dosage.

•      Omitted information causing an error.

•      Critical delays in delivery due to system design errors.

•      Errors due to incorrect sequencing of actions.

Next, came examples of EHRs allowing errors. Unfortunately, several of the examples weren’t well thought out. For example, a patient ID error showed two patient records on the screen. One had the first patient’s x-ray, but the second patient’s name. Most likely, this would be a database problem or an x-ray production error not an EHR problem.

Robert Schumacher of User Centric, outlined how the protocol would be tested. For example, review and update of a problem list or replacement of one medication with another. The plan included testing several of ONC’s meaningful use functions that had usability factors.

Part III. Workshop Reactions. The workshop finally broke into two discussion groups: one for the draft protocol and the other on consensus building. In both cases, the discussion quickly went off script. Participants were quick to criticize the staff’s error oriented protocol as too narrow. Why, for example, did the protocol focus on internal EHR processes to the exclusion of workflow generated errors?

I understand NIST has a high interest in eliminating catastrophic errors, but I think there is not enough solid evidence on the kind and extent of the problem. No one discounts the need to prevent catastrophic errors, however, much of the EHR error focus is due to anecdotal reports of computer prescribing errors. From what I read, many of these reports are both old and recycled. Does anyone know the actual extent of major errors?

The FDA has developed several systems for dealing with medical device errors. These now include the software that the devices use. Even if the FDA does not regulate EHRs, it may step up its efforts to record important errors. I’d sure like to know FDA’s findings before I started an effort to shape EHRs.

This is not to say that safety is not important in EHRs, obviously the types of errors that are outlined by the staff are major. However, I think there are three points that are missing in the NIST approach:

•      Design for Success. You can’t design for failure. You have to design for success. The object of EHRs, as with any system, must be to accomplish certain ends. If you loose sight of that, you may not make mistakes, but you also will fail your objective.

•      Risk Analysis. Risk analysis measures the impact on a given population of an action, its potential and costs broadly defined. It also specifies mitigation efforts. I’d be far more comfortable about the protocol if there were a risk analysis behind it.

•      Error Handling. There should be more thought to error handling. For example, when the stall warning alarm goes off on a plane, it doesn’t grab the stick and take control. It’s a warning, just that. Physicians should be warned if they are about to prescribe beyond the recommended dose, but they may have good clinical reason to do it.

NIST put on a worthwhile workshop. My guess is that the draft protocol is not going to survive without modifications that take into account a broader range of usability issues and approaches.

Yesterday on EMR News, we posted about the first case I’ve seen where someone has collected EHR stimulus money after attesting to meaningful use.

It’s the day many have been waiting for. The first checks arrive for those showing meaningful use of a certified EHR (Medicaid had sent some EHR Stimulus checks previously). Yes, the government really is going to pay out the money. Yes, people really are getting paid. In fact, it seems that they’ve pretty much stuck to their schedule for meaningful use stage 1 and paying out the first EHR stimulus checks. Props to the people at CMS and ONC for being able to stick to that schedule (even if meaningful use stage 2 might be delayed).

I do have to say that an electronic bank transfer isn’t nearly as exciting as a check in the mail. Plus, a picture of someone checking their online banking isn’t as compelling as a picture of someone with a check. So, technology has hurt the visible image that would illustrate this occasion. However, the “shovel ready” ARRA stimulus money has started to flow (sorry I had to point out the irony of “shovel ready” or lack therof).

Since seeing the news, I’ve wondered whether the cash flowing will have the impact on doctors that one would expect. Will doctors start saying, “I want to get my EMR stimulus check!”? Certainly the cash has just started flowing and so we can’t fully assess the impact of these first checks. However, I personally think that the cash flowing will provide little momentum to EHR adoption.

First, from those I interact with, there aren’t that many fence sitters. Most have already decided to do EMR or not to do EMR. The flow of money would be great to get the fence sitters off the fence, but I don’t believe it’s strong enough to get those against EMR to finally go for it.

Second, the lack of certainty around meaningful use stage 2 and 3 is a major concern. Most people aren’t and shouldn’t be concerned with the payments for meaningful use stage 1 (unlike PQRI incentives). Why should they be? After all, it’s a self attestation process for meaningful use stage 1. Check the right check boxes and give them the right numbers and you get paid. However, the same certainty isn’t available around MU stage 2 and 3. We don’t know how it will be measured nor what it will include.

Third, it takes real time for the word of mouth discussions between doctors to disperse in the medical community. Will the message of stimulus money get out quickly enough for it to matter to most doctors who are mostly against an EHR?

It’s great to see the EHR stimulus money flowing. We’re still in a wonderful EHR and healthcare IT bubble that will continue for at least another couple years. However, EHR incentive money flowing isn’t going to contribute much to that bubble.

In probably the biggest news of the day at HIMSS, we got the following tweet spreading quickly through the Twittersphere:

RT @afbmet Chuck Friedman from #ONC just announced that “usability WILL be in Stage 2 of #meaningfuluse at the #Usability Symposium #himss11

February 20, 2011 9:23 am via HootSuiteReplyRetweetFavorite

@techguy

John Lynn

There you have it. Word out of ONC is that meaningful use stage 2 will include some form of EHR usability. How that will be, I don’t think even ONC knows. Although, I’m sure they’ll consider looking at the EHR usability that’s already in CCHIT.

What I don’t understand is why they would do this. First, it should be part of the EHR certification and not meaningful use (maybe it was a mistweet). Why would ONC want to measure an EHR’s usability during meaningful use? That’s too late, no? Although, maybe it’s just ONC trying to collect data for other doctors that will select an EHR later? I don’t understand it.

Plus, let’s look at the EHR usability that’s been done by CCHIT. Has it really improved the usability of EHR systems?

I asked someone at HIMSS this question, and they said something like, “Of course not.”

We all want the EHR software to be usable. I just don’t understand how ONC adding it to meaningful use stage 2 will help achieve that goal.

EMRandHIPAA.com’s HIMSS11 coverage is sponsored by Practice Fusion, provider of the free, web-based Electronic Medical Records (EMR) system used by over 70,000 healthcare providers in the US.

Looks like the people at HHS and ONC have been working hard. On Monday this week they published the Permanent EHR Certification Program Final rule. You can find the press release about the Permanent EHR Certification final rule on my new EMR News website (if you have other EMR news, please let me know).

You can download the full Permanent EHR Certification final rule here (Warning: PDF). Although, I must admit that I found the permanent certification fact sheet very interesting. Here’s my summary:
*Testing and certification is expected to begin under the permanent certification program on January 1, 2012 (with an exception if it’s not ready)
*NIST (through its NVLAP) will continue with accrediting organization to test EHR and to work with ONC to create test tools and procedures
*A new ONC-Approved Accreditor of ONC-AA will be chosen every 3 years
*All ONC-ATCB (those bodies certified under the temporary) must apply to be ONC-ATB (permanent certification bodies)
*ONC-ACB have to renew every 3 years
*Gap Certification will be available for future EHR certification criteria.

The most interesting part to me was that ONC will be selecting an ONC-AA (Approved Accreditor) through a competitive bid process. So, they’re going to accredit an accreditor to accredit the certifiers? I think you get the gist. I can see how ONC saves so much by only having to have to deal with one ONC-AA and not the 6 ONC-ATCB (that was in the sarcasm font if you couldn’t tell).

It does make sense to have a gap certification so that EMR vendors that are already certified don’t have to certify against all the criteria every time. I guess in theory changes an EHR vendor has made could have caused issues with their previous functions, but that’s pretty rare. Especially since their users will need it to be able to show meaningful use (which is why EHR certification has little meaning beyond it being required for EHR incentive money).

Whether you agree or disagree with EHR certification (I think you know where I stand), you have to give ONC credit for pushing out the EHR certification program so that there are plenty of certified EHR software out there to choose from. Looks like they’re well on their way to implementing the permanent EHR certification as well.

In the weirdest news I’ve seen in a while, SureScripts has become an ONC-ATCB. Here’s the details from Health Data Management:

In a Dec. 23 announcement, the Office for the National Coordinator for Health IT said that Arlington, Va.-based Surescripts can verify that e-prescribing, privacy and security modules meet the standards laid out in the meaningful use requirements. Surescripts is the sixth authorizer to be approved by ONCHIT, but it’s the only one with limited certification abilities—the five others have ONCHIT’s blessing to certify Complete EHRs and EHR modules.

Doesn’t this scream conflict of interest? They run a nationwide e-Prescribing network, and yet they can certify ePrescribing for ONC. I guess you could make the argument that they know ePrescribing well and so they are qualified to do it. Although, it is just weird and awkward to consider them as an ATCB. I wonder which ePrescribing companies will actually use them. Why did SureScripts even go to the effort to become an ATCB?

I guess I should have assumed that people would start posing this question. Turns out Jeff Rowe at HITECH Watch (part of Healthcare IT News) has posted the question about delaying the HITECH incentives twice in a week.

I guess it’s a reasonable question to be asked, but my emphatic answer to the question is NO!

It took us plenty long enough to get to this point. The wait for the details of meaningful use and certified EHR was a long enough wait that absolutely slowed the adoption of EMR software. There are http://www.emrandhipaa.com/wiki/EMR_and_EHR_Matrix“>300-400 EHR companies just waiting for this EHR incentive program to get going. That’s a lot of companies to hold hostage while the government tries to “make meaningful use better.”

Plus, you can quite easily argue that more time won’t actually make meaningful use substantially better. In fact, it seems reasonable to argue that more time could actually make meaningful use much uglier and discouraging for those interested in implementing an EMR.

It is also worth mentioning that there’s kind of a built in year of waiting as is. You get paid the same amount of money whether you show meaningful use starting in 2011 or 2012. The amount is the same and the meaningful use requirements are the same.

Plus, meaningful use stage 1 is already pretty generic when it comes to the reasons Jeff offers for delaying in the above article. Meaningful Use stage 2 is where ONC and CMS should focus on adding in requirements that will help us get closer to the exchange of patient data. Trying to go in and mess with meaningful use stage 1 is a mistake. Not just because the hour is near, but also because it would provide little benefit.

The article linked above had an interesting poll related to this. However, it requires registration and so there had only been one response. Hopefully this poll will get a little bit better response:

I figured it was about time for me to do a post updating one of my top posts from 2009. This was a post I posted on February 19, 2009. It was REALLY early on in our understanding of the HITECH act and EMR stimulus incentive program. In the post, I predicted the Big Winners of the Obama EHR stimulus program. Let’s take a look at this list, see if anything’s changed and look at new additions to the list.

First, I loved the premise of my original post that with the government spending $36 billion (in the previous post the estimate was $20 billion) there have to be some people who dramatically benefit from the spending.

Here’s a look at my original list of Big Winners and my thoughts today:

• EHR Vendors – In the short term I think that EHR vendors have taken a real hit. While we waited for the government to define meaningful use and certified EHR there was a dramatic slow down in EHR adoption. Now that we’re coming out of that funk I can see a lot of excitement and energy out of the EHR vendors. I predict this HIMSS is going to be absolutely electric. It’s easy to note that interest in EHR software has increased thanks to the stimulus money. This interest is going to spill over to every EHR vendor out there. Some will do better than others, but all will start seeing some sales now. Long term, those that provide the best service to these initial adopters (or cash out first) will be the long term big winners.
• Health Care IT Consultants (ohhh…maybe I should become one) – First, I’m not likely to become a consultant any more than I am now. This blogging gig is far too good. Although, I’ll keep that in my back pocket. Me aside, the good healthcare IT consultants I know have a lot of work. Some have changed their names to meaningful use consultants or EHR certification consultants, but overall they’re doing well. A bunch are also working at RECs which doesn’t seem like a bad gig at all (as long as they meet their targets).
• Existing EHR Users – I still see them winning. The doctors I know with an EHR are loving the idea of the EHR stimulus. First, it doesn’t matter too much to them if they get it or not. Second, they see it as something that likely won’t take that much effort beyond what they’re doing now. We’ll see if they change their minds once they get into the nitty gritty details of meaningful use. They might find changes for meaningful use harder than they think.
• CCHIT (if they get chosen) – Well, CCHIT wasn’t chosen. Although, CCHIT made a really smart move to do the Preliminary ARRA certification as a way to basically lock in most of the top EMR vendors to their EHR certification. I guess I don’t see CCHIT as the big winner, but still a winner. EHR certification is still a requirement and will be for a while to come, so they still are in business. They just finally have some competition.
• Hospital Systems – There’s just far too much money available for them to ignore the EMR stimulus. Not to mention the penalties are meaningful at the scale they have. I guess I can see this going both ways. Those hospital systems with great leaders and effective organizations are going to do very well. Those with less effective leaders and poorly run organizations are going to have issues.
• Health and Human Services (HHS) – Maybe I should have said ONC or the healthcare IT portion of HHS. It’s an exciting time for healthcare and I think Blumenthal has worked hard to do things right. It is government work, but I applaud what seems to be some real sincere effort.
• Obama’s HIT Donors – I’ll leave this one alone.

Now for a quick look at the other winners that I might not have considered almost 2 years ago:

• IT Companies – I’m not sure why I didn’t consider this, but I’m amazed at how many IT companies out there are helping with EMR implementations and their businesses are benefiting from the EMR stimulus.
• HIE – It’s a bit early to tell exactly how this is all going to play out, but the EMR stimulus and meaningful use requirements have extended the life of a bunch of HIE companies. Not to mention many have been acquired because of all the activity. It’s a good time to be an HIE company.
• Trade Organizations – I think many organizations have seen all this buzz around EMR as a great opportunity for them to expand their services. It’s amazing how many different trade organizations have gotten their hands into the EMR world.
• EMR Bloggers – Let’s just say, the EMR stimulus money has worked for my family. I’m thankful for that!

I’m sure there are probably others I’m forgetting. I tried to convince myself that doctors and patients should make this list, but couldn’t find a way to do it. Certainly some doctors and patients are going to receive the benefits, but I fear that many practices are going to select the “Jabba the Hutt EMR software” that is large, powerful and difficult to use and regret it. I hope I’m proven wrong.

Neil Versel at Fierce EMR recently did a post talking about the meaningful use exceptions that are available for specialists. In it he quotes David Blumenthal, national health IT coordinator, and Dr. Derek Robinson, medical director for HHS Region V. They provide an example of an exception to the meaningful use criteria that a specialist might be able to use:

For example, three of the “core” measures of meaningful use that all providers must be able report on are blood pressure levels, whether patients over 13 use tobacco products and adult weight screening. “You may say that one of these or all three of these may not be part of your scope of practice,” Robinson said, amednews reports. It is possible to report zero as both the denominator and numerator for the quality measure if that specific item is outside a physician’s scope of practice.

This is what I was talking about in my last post about the EHR Stimulus money for dentists. No doubt there are a whole lot of specialties that will want to be granted these types of exceptions. It will be interesting to see what the exact process is for being granted the exception. I also won’t be surprised if we see some EMR vendors (specialty specific EMR vendors in particular) helping their doctors apply for these exceptions.

The only problem with the exception is for those specialists where the denominator is not 0, but it’s a very small number. I seem to remember a pediatric orthopedic surgeon saying that he only wrote prescriptions a few times a week. Learning and implementing an ePrescribing system for a couple scripts a week isn’t going to be very fun.