Patient Doctor Relationship
It seems like this topic keeps coming up in my online and social media reading. Basically, the discussion usually centers around the role the patient plays in healthcare. Many people like to discuss what has been called the ePatient. I instead want to talk about the motivations of patients and their ability to influence the healthcare system.

Patients in healthcare are unlike “customers” in many other industries. I can’t think of a single patient that wants to go and see a doctor. Ok, maybe they like the doctor and they want to get whatever’s ailing them fixed, but to a person I’m sure we’d say that going to the doctor is the last place we want to be. It’s not like going shopping for a new pair of shoes. There’s nothing you get to take home from the doctor. Well, at least nothing that you really want to take home.

Plus, healthcare is an interesting thing, because often it’s not clear if you should go to the doctor or not. If my A/C is broken, then it’s quite clear that I need to call an A/C repairman. Seeing a doctor is quite different since it’s a fine line between when you need to go and see the doctor versus when your body will heal on its own. I think we’ve all hated the doctor visit where they check you out and basically say there’s nothing they can do for you. Well, other than send you the bill for your visit. I guess that’s the cost of the peace of mind that you get from the visit (I know I’ve done that with my kids a few times).

Please don’t take this as me knocking doctors or the healthcare profession. They provide an absolutely essential and critical role in our lives. Without great doctors many of us wouldn’t be here today. My point in this post is that the patient doctor relationship is quite different than the customer business relationship that we’re use to seeing.

Online Patient Portals
Take for example the online patient portal. Many people love to go on Amazon.com (or insert your preferred shopping site) and browse through all the various things they could buy. We all know people who spend hours shopping. I don’t think I’ve ever heard someone say that they wanted to spend hours browsing through their patient portal. You know, someone who just couldn’t wait to see what great healthcare services their doctor could provide them.

The only partial exception to the above reasoning is possibly the chronic patient. If I’m a diabetic patient, then I am going to have an ongoing dialogue with my care provider and the services they provide. I’m going to be interested in monitoring and tracking my care in collaboration with the treatments that my doctor provides.

Is there a reason why we don’t want this kind of interaction for our general healthcare?

Regular Online Interaction with Doctors
Why shouldn’t I go online on a regular basis so that my doctor can assist me in total wellness even when I’m a healthy patient? The difference here of course lies in doctors treating symptoms and illness as opposed to a very different form of care: wellness. To be honest, I’m not sure I’ve seen any doctors who treat healthy patients. Sure, some doctors do provide some pro-active wellness information during a sick visit to the doctor. Regular physicals are the closest we come to doctors treating healthy patients, but how many health people get those? It feels counter intuitive that we would go and see a doctor when we’re healthy or appear to be healthy. However, maybe that’s the shift our healthcare system needs.

Reimbursement Model Challenge
One real challenge with what I just described is the reimbursement model we have in healthcare. We’ve incentivized treatment of sickness and illness. We haven’t (yet?) incentivized treatment of healthy patients and promotion of wellness. This sounds a bit like the ACO discussion that’s become so popular these days. I’ll be interested to see how these incentives play out. Word on the street is the train has left the building and reimbursement is going to be tied to healthcare outcomes in the future.

Healthy Patient Motivation
Unfortunately, another major challenge I see is that healthy patients aren’t really motivated by wellness initiatives. I’m sure that there are people that understand this phenomenon a lot better than I. Although, I think it’s abundantly illustrated when you talk to someone who’s getting older and starting to lose their health.

It seems particularly poignant for highly successful people that start to get older. How many times have we heard during Oprah or a Barbara Walters interview someone talk about being willing to give up all their riches and fame to just have their health (and they often throw family in there too)? All the time! The problem is that it takes old age or some other health incident for people to make healthy living and wellness an important part of their life. Which begs the question of whether even a change in the reimbursement model for healthcare will get unmotivated people to visit their doctors and be “treated” even when they’re a healthy patient.

Gamification of Healthcare
One idea that I find incredibly intriguing is the idea of gamification of healthcare and wellness. The basic concept behind gamification is to create incentives for people to do the behaviors you want them to do. I believe Foursquare was one of the first applications to do this. They would give you electronic badges and crown you as mayor as you did certain things on their mobile app. It was (and still is) amazing to see what people will do for a little electronic badge and the electronic title of mayor (Turns out this works in the offline world as well. There’s a reason boy scouts give out badges, beads and pins.). The question is how can we apply rewards systems to incentivize healthy behavior and wellness?

To be completely honest, I don’t think I’ve seen anyone crack the gamification code in healthcare. Although, I think the concept is just beginning. I predict in the next couple years that we’re going to see some amazing mobile and web applications that really drastically impact our motivation to healthy living.

The closest I’ve seen so far has been something like the Nike+ device and website. It’s a simple device that tracks your running habits either in a watch, iPod or even in your shoe. Then, that device uploads your running data to a website where you can create and track your running progress. It also provides a social experience, but that’s a topic for another day.

I actually find these tracking device/website combinations (see the FitBit and DigiFit as other examples) to be some of the most interesting things happening when it comes to pro active treating of healthy patients. A while back I predicted a whole plethora of medical tracking devices are going to hit the market. This is happening and will continue for many years to come. I heard one guy interviewed who talked about one day (many years from now) having little mini processors attached to every nerve or blood cell in our body. Ok, that’s kind of creepy to think about, but personal monitoring of our body is a burgeoning field in healthcare.

Crunching All the Personal Healthcare Device Data
The question once we’re monitoring all of these various vital signs and health information is what are we going to do with that information. Is it reasonable to think that we’ll be able to use computers to crunch through all the data and provide a self service analysis of all the data collected? Yes, Watson did some amazing things on Jeopardy, but I think we’re far away from the day when this type of self service crunching of all the medical data we collect will be possible.

Yes, that means we’re still going to need doctors and other healthcare professionals who help us analyze the data that we’re collecting and dealing with the health issues that are related to that data. In fact, I predict a whole new breed of doctor will come together that will be specialized at analyzing this data and treating even the healthy patients.

Future Healthy Patient Doctor Relationship
This all comes full circle when you go back to the start of this discussion: the doctor patient relationship. How are doctors going to see all this health information we’re collecting? Where are we going to have these healthy patient interactions with doctors? I predict that it will be through patient portals that are connected to a physician’s EHR.

I and every blogger I’ve ever known has been a stats junkie. We’re addicted to checking our stats. There’s no reason we wouldn’t be just as addicted to checking our health stats on a patient portal. The problem is that the patient portals I’ve seen aren’t there yet. Plus, most doctors aren’t yet ready for this type of healthy patient interaction around such a large set of data. Although, I predict we’ll get there and it will change the doctor patient relationship forever.

Meaningful Use Menu Measure: At least 10% of all unique patients seen by the eligible professional (EP) are provided timely (available to the patient within 4 business days) electronic access to their health information.

This is a third meaningful use measure related to providing patients with access to their health information. Meaningful Use Mondays has already addressed the two core measures—clinical summary and electronic copy of health information—“timely access” is a menu measure.

 The requirements are as follows:

• The measure includes a provision for EPs to claim an exclusion, but I don’t believe that many will qualify for this exclusion. They would have to attest that they “neither order nor create lab tests or information that would be contained in the problem list, medication list, medication allergy list, etc.”—a fact that would make meeting the core meaningful use measures quite unlikely.
• Access to patient information must be provided online, via a portal or a personal health record (PHR)—in contrast to the other two patient-related, access-to-information measures, which allow the use of various types of electronic media and/or paper.
• The denominator is “all unique patients seen during the reporting period.” Therefore, in order for that patient to be counted in the numerator, every time any piece of clinical information that can reside in the EHR is added to the patient’s chart, the portal must be updated within 4 days of the EP’s receipt of that information.
• This measure assesses the availability of timely access. It does not matter—for meaningful use purposes—whether patients request, or ever access, the information.

A challenge associated with this measure is securing patient consent to have clinical information posted on an online portal and then getting a sufficient number of patients to register. Because it is a menu measure, EPs can choose to omit this measure in Stage 1, and it appears—from my conversations with providers and with CMS—that many are planning to do just that!

Lynn Scheps is Vice President, Government Affairs at EHR vendor SRSsoft. In this role, Lynn has been a Voice of Physicians and SRSsoft users in Washington during the formulation of the meaningful use criteria. Lynn is currently working to assist SRSsoft users interested in showing meaningful use and receiving the EHR incentive money. Check out Lynn’s previous Meaningful Use Monday posts.

In kind of ironic timing, the news was recently reported of a patient talking to lawyers about a possible lawsuit against a doctor who sent her protected health information (PHI) to his home email in an un-encrypted format. The irony is that for the past week, my post on Email not being HIPAA secure has been having a really good discussion happening in the comments about these very issues (you should go read through the comments, they’re very interesting).

One interesting part of the above news story is that it didn’t even include the most common personal information used for identity theft. Certainly a person’s name and medical information should be kept private as well and could have consequences related to its release on the internet. However, it definitely doesn’t bring out the privacy critics like a breach of financial related info would bring.

While I personally hate lawsuits, a part of me kind of hopes that this or some other lawsuit happens related to email and PHI. Not because I like lawsuits or I want someone to be held responsible. Mostly because we could use some legal precedent to better enable those who want to use technology like email. Until the precedence is set (or a more specific law), I think that many people are just too afraid to use email for any sort of health care related communication.

In the comments I mentioned above, someone even commented about them wanting a doctor who would let them waive their right to privacy in the name of convenience. Basically, they would rather use email to communicate even PHI at the risk of someone seeing their health information so that they can use communication tools like email in their healthcare. I bet there are a lot more people who would opt in for this also. The problem is that the law is such that I don’t know many doctors who are willing to take the risk even if the patient gives them permission.

The best alternative right now is the patient portal where a patient receives an email saying something has been added or updated on the portal and invites them to login to the private secured portal to see the PHI or other health information. Not perfect and not that broadly adopted.

Lots of other issues related to email with doctors, but at least resolving the privacy and security ones would allow us to focus on those other issues.

An interesting discussion happened in the comments about HIPAA secure fax services in regards to the security of email. Being a tech person who formerly managed a few different corporate email systems, sometimes I forget that many people don’t understand some of the details about the security (or lack of security) that’s provided by email.

The short story is: Email is NOT HIPAA Secure (at least in 99% of cases)

There is a way to encrypt email sent between 2 email systems, but so far a standard and mechanism for encryption between all the vast number of email providers has not been established. I won’t go into the details of why this is the case (cost of encryption, standards for encryption, etc), but suffice it to say that almost none of the email systems send encrypted email that would satisfy the HIPAA requirements.

In fact, most times when an EMR, PHR or other patient portal wants to send a secure email/message to someone they send an email which contains a link to an encrypted website that has a unique login. The reason they do this is because there’s no recognized and adopted standard for encryption of email. However, presenting Protected Health Information (PHI) through an encrypted webpage where someone has a unique login is HIPAA compliant and doesn’t require the receiving email system to understand the encryption. It’s a pain, but it’s the reality of privacy of health information right now.

One of the major reasons that many people think that email is secured is that a number of email providers (Gmail being the most famous for this) turned on encryption for all of their users. The misunderstanding is that this encryption is just for users logging in to check, read and send their email. It does not encrypt the email as it it sent from Gmail to the destination email system. Aleks, from Sfax described it similar to a postcard. It’s open where anyone listening can see what’s in the email with no traces left behind.

The only security email partially offers in this manner is the volume of emails that are sent. There’s such a huge volume of useless emails that there’s some security by obscurity benefits. Although, that security doesn’t meet well with the HIPAA requirements. Plus, remember that one thing that computers are great at doing is crunching large amounts of data.

One minor exception that I might make is that if you’re sending email in an internal email system, then it’s possible to set up email encryption. This is possible because you control the email system for the sender and the receiver and so there are ways to do this. However, I know very few people that have actually set this arrangement up. Probably because if they are on your internal email system they usually have access to your EMR and all the PHI can remain in the EMR instead of your email system.

Now many have said that you shouldn’t use the free email providers like Gmail. After reading this it should be clear. You shouldn’t use ANY email provider for sending PHI. So, whether you use Gmail or some other free email provider it shouldn’t matter since I’m sure you won’t be sending any PHI through email any more.

Of course, I’d recommend you use the free Google Apps version of Gmail since DrSmith@yourpractice.com is so much more professional than DrSmith985373@gmail.com. Although, that’s kind of a topic for a different discussion.

In response to my previous post about possibly creating an EMR pricing comparison website, I got a really interesting set of comments from a CPA who’s been assisting their clients in their EMR selection process. You might laugh at the idea of a CPA participating in the EMR selection process. Interestingly, the CPA that I use has also been asked by their clients about the EMR stimulus money and so they were grateful they could ask me some questions.

This aside, I found this person’s comments interesting. I think they also illustrate some of the challenges in EMR pricing and some of the thirst for EMR pricing also. I removed some identifying information and some other comments about EMR and HIPAA. Otherwise, the comments are in tact.

I have been pondering trying to do some sort of price comparison myself, and you’re right, they all differ so it’s tough to just do one basic comparison chart. I’ve seen already how some have things all bundled (ie.Athena, and others do it in separate modules can add on – ie. Greenway)

I have featured remote demo’s for clients to listen/view through our firm so they can avoid the vendor pressure… I thought I would try to get info on others for comparison purposes, but in keeping with the theme… it is just not that easy.

There are a few challenging items for comparison purposes, one of them being support and related costs.
The support/training is many times where the wheels fall off the well-intentioned EMR wagons.
You just don’t seem to get an answer or know the true support/training costs until you have already tied the knot with your new EMR system. If you could get more comparative info on that aspect, that would be very helpful – or better yet, come up with an EMR Pre-Nup.

Another toughy is the interfacing costs
From what I hear a [EMR Vendor] system may charge $30k to interface with another EMR vendor.
The vendors call that “not playing nicely”.
So tack on another layer of subjective complexity to your pricing project.

And yet another cost factor I’ve noticed is what EMR system an affiliated hospital is getting preferred pricing on. There is a hospital by us in an arrangement with [EMR Vendor], and of course advising the outside practice physicians to use the same. I am not to thrilled with this idea, I think there are better products that are not spread so thin in so many markets.

I mention the patient portal separately below as some of my clients don’t seem quite ready for that yet.
They view it as another task and feel could attack it once get the EMR running smoothly.
I know they need it for MU [Stage 1 doesn't require this, but future stages probably will], but they seem to want that a little later than sooner.

In any case, I think some possible approaches for a comparative pricing schematic would be to have different scenarios:
a) 1-5 Docs & Midlevel providers /Web Hosted/ EMR only/ PM Interface/ No Patient Portal
b) 1-5 Docs & Midlevel providers /Web Hosted/ EMR only/ PM Interface/ With Patient Portal
c) 1-5 Docs & Midlevel providers /Web Hosted/ EMR & PM Bundled/ No Patient Portal
d) 1-5 Docs & Midlevel providers /Web Hosted/ EMR & PM Bundled/ With Patient Portal
e) 1-5 Docs & Midlevel providers /Web Hosted/ EMR & PM Bundled/ With Revenue Cycle Mgt/ With Patient Portal

Many of you know I’m all about keeping things simple, effective and useful. It’s better to have something simple that does a killer job at what it does than to have something so complex that no one uses it. In fact, that’s really the basis of my simple plan for meaningful use. Of course, this can often be confused as not valuing other items. However, that’s just not the case. You just start with reasonable goals and do amazing things with it. Then, you expand once you’ve conquered something simple, but I digress. The point is that I really enjoy seeing simple systems that just flat out work.

That’s why I was intrigued by an email I received from a reader about their system called ePatientHistory. I think it can best be described as a simple patient portal that tries to do 2 things really well: online patient registration and online patient payments.

I should make a disclaimer that I haven’t used this service other than the demos on their website. However, I really like some of the concepts and I wish more EMR companies would try to create something simple and effective that focus on small goals as opposed to trying to cure the whole world with a patient portal that is so complex no one uses it (man I’m in a ranting mood today). Let’s talk about each function which they call ePatientHistory and ePatientPayments.

ePatientHistory – Online Patient Registration
I tested the demo for this and it was a little buggy and not as intuitive as I would have liked it to be. For example, it didn’t have the standard * next to all the required fields and the pop up that was shown for the required fields didn’t make much since to me. A small thing that makes a big difference. Maybe this just wasn’t shown in the demo, but it would have been nice to had nested questions that were only shown if I’m female for example. That way I can skip the pap smear questions and go straight to the testicular self exam ones.

Also, it was awkward to have to register and then choose the form I want to fill out. Ideally the doctors office could just send me an email that has basically registered me into the system. The email would include a link which I click and get taken to a step by step webpage of what the doctor’s office wants me to do for my appointment. Then, I can’t screw it up as a patient. After I’ve filled out the important paperwork, then let me see the full login and the other features that I may want to use.

Of course, when you’re dealing with a standalone portal like this, the question really is how are you going to get the information out of the system. This system seems to offer a CSV file which can then be imported into an EMR. Ideally, I’d like this company to show me a list of EMR companies that support this type of import. I know that all of them could since CSV is pretty standard, but how many would and if they do would that data be inserted into your EMR in a useful way? Of course, many might just want the health history form to be a nice PDF file that they can upload to their EMR. However, it’s just sad to lose all that data in a PDF file.

The cost structure for this service is interesting. Basically it’s $695 up front and $39.95 per month for hosting. Seems a little pricey to me, but if they can make sales that’s a really good business model to have. You get the up front money and a residual income.

ePatientPayments – Online Patient Payment
This is an interesting module since it’s basic idea is to collect payments. Although, one good part of this system is that it will collect payments over time according to a payment plan. I think this can be really useful in collecting harder to collect accounts. Plus, it can be scheduled to be done automatically thanks to the power of Paypal.

Similar to the other description above, I’m not sure how the patient will know how much to pay. I didn’t see anywhere in the admin that seemed like a place that someone in a clinic could notify someone that they have a bill to pay and come to this portal to pay it. That would be nice functionality. Although, it would be really sweet functionality if it was tied to the EMR where the actual charges arrive. Of course, this is the challenge of using a system that’s not connected to your EMR.

The cost for this is similar to the other one with $395-495 a month up front and then $29.95 per month for hosting. One thing it doesn’t say is how the charges that Paypal charges will be handled. I’m guessing they pass those on to you the end user as well. Paypal is an amazing platform and great for developers since it costs nothing to get started and use it. However, Paypal instead gets paid on the back end with the highest percentage fees of any other credit card processor. I imagine ePatientPayments will want to switch to something other than Paypal as they grow. The savings of using another credit card processor over PayPal will basically pay for the ePatientPayments and then some.

Conclusion
I think we’re going to see a lot more little services like this pop up. I think a number of them could be very beneficial if they’re integrated or used alongside a great EMR. The other good part is that it seems like using stand alone services like this one will still allow you to be considered a “certified EHR” and possibly receive some of the $36 billion of EMR stimulus money.

Read more…

I’ve been following the Google Health announcements for quite a while now and today Google Health finally went live.

It’s been a long time coming and so it will be interesting to finally take a look under the hood. I haven’t personally had enough time to do a full analysis of Google Health myself, but techcrunch posted the announcement live and an initial review.

I think that techcrunch summed up a major part of Google Health and its meaning for EHR software in the following:

Google is planning to open up APIs to Google health to make it easy for other partners to tap into its health platform. And make no mistake about it. That is what this is: a platform. Health apps anyone?

Sure does make for some interesting thinking about how an EMR or EHR could integrate with Google Health. Depending on how my next couple days go, I may see if Google Health has given any sort of specifications for importing a patient record into Google Health from an EMR or EHR software program. In my previous posts it was said to use some form of CCR to integrate Google Health with EMR and EHR software. I hope this is the case. If it is, I think I’ll try to be the first to integrate Google Health with my EMR. I don’t think most of it would be that difficult.

Recently I’ve been reading a fair amount about the movement that many are calling Health 2.0. I think the most simple description of Health 2.0 is applying many of the Web 2.0 concepts to health care. My question is whether EMR fits into Health 2.0. My personal feeling is that most of them don’t. Most Web 2.0 projects are consumer facing projects that allow people to interact, collaborate and participate in the process. EMR software is more about facilitating a doctor’s charting.

Certainly you could make a good case that a patient portal or EHR is more Health 2.0. In fact, that really seems to cut to the heart of Health 2.0. Creating a powerful interface between doctors and patients so that patients are a part of the process. However, I think that most EMR in their current state don’t benefit from this type of interaction.

Of course, this begs the question of whether an EMR should have this type of interaction. My short answer is that it should, but until the payment systems catch up with the technology that creates these interactions we won’t see broad Health 2.0 application to EMR software.

I’ve been looking through my statistics lately (which I actually do most days) and it seems like most people aren’t searching for EMR anymore. It seems like there is a shift going on in people’s minds that they are now starting to search for EHR as opposed to EMR. There’s a whole discussion on wikipedia about whether the Electronic Medical Record (EMR) and Electronic Health Record (EHR) articles should be merged.

In my book they are pretty much the same in most people’s minds. Sure, some people like to argue that EHR has features that reach out to patients and allow patients to enter medical data, but most EMRs have those type of features anyway. I prefer to look at it as an EMR with a patient portal. However, the in thing to do seems to be to call a company’s EMR an EHR. The fact is that most people that have an EMR have a number of patient facing portions of their EMR. Does that make them all an EHR?

Regardless, I’m just wondering if one day I’m going to need to rename my blog to EHR and HIPAA. I’ve kind of grown fond of EMR and HIPAA, but I’m definitely not oblivious to the fact that people are starting to seach for EHR and not EMR. Renaming my blog might be a great thing to help with getting better google searches on the subject. Yes, I do enjoy having a lot of traffic to my blog. It makes me happy to think that people read my stuff and that I’m participating in at least some small way to shape the evolution of EMRs EHRs.