Monday, November 3, 2014

Grass Roots HIT in the Hospital and Clinic

Clinicians are an innovative group. From physicians, nurses, pharmacists, administrative personell, all are users of mobile apps at home and/or work.

mHealth News reports that there are some "apps that clinicians can't quit". Patients at the Hospital of the University of Pennsylvania (HUP) might wonder why their nurses are always on their smartphones — until they learn those nurses are actually sending secure messages to everyone on a patient’s care team.
It’s part of a highly successful pilot that began more than a year ago, and one that caregivers don’t ever want to see end.
What made this pilot unique is that it was grassroots-driven,” said Neha Patel, MD, one of the pilot’s developers.
Patel, an assistant professor of medicine at HUP, partnered with the information systems department at Penn Medicine to develop an mHealth strategy that would not only improve communication among a patient’s care team, but also save clinicians time.
Patel and a colleague will discuss the pilot at the upcoming mHealth Summit in December outside Washington, D.C.
For the pilot, which began in May 2013, residents, faculty physicians, pharmacists, social workers and discharge planning nurses were provided with iPhones or iTouches in four of the hospital’s departments: three general units and one surgery outfit. They used a secured-messaging mobile application called Cureatr to communicate everything but emergency messages with a patient’s entire team. As shifts changed, the phone was passed on. Communication remained fairly seamless, Patel said.
Now, nearly a year and a half after the pilot started, staff at HUP refuse to let go of their phones or Cureatr. When house staff rotate to units that don’t use the app, Patel explained, they complain that communication is “archaic.” 
It’s no wonder. A HUP time-motion study showed residents were spending about 20 percent of their day communicating with other healthcare providers, either face-to-face or on the phone
Another home-grown application, Connexus.(Connexus®, the Education Management  an app that allows providers to pull up patient data on their smartphones.

System(EMS). Connexus has been adopted by various user groups for purposes beyond the original design scope:. “Anesthesiologists, for example, are using it for pre-op evaluation, ancillary providers to follow the ‘thinking’ of the primary team, and consultants to quickly evaluate a new patient.".
The lesson is that iit does not take a million dollar investment to design HIT solutions for the hospital, or clinic. Individual initiative and grass roots trials are often more creative and functional than a poorly designed commercial medical app

Sunday, November 2, 2014

AMA Calls for Design Overhaul of Electronic Health Records to Improve Usability

Much controversy has arisen regarding the usability and loss of efficiency when electronic health records were introduced and then incentivized as a mandatory component of physician practice. Electronic records have been in existence for 15 to 20 years, however most are woefully inadequate when it comes to usability.

ref: HITECH Answers

While AMA/RAND findings show physicians generally expressed no desire to return to paper record keeping, physicians are justly concerned that cumbersome EHR technology requires too much time-consuming data entry, leaving less time for patients. Numerous other studies support these findings, including a recent survey by International Data Corporation that found 58 percent of ambulatory physicians were not satisfied with their EHR technology, “most office-based providers find themselves at lower productivity levels than before the implementation of their EHR” and that “workflow, usability, productivity, and vendor quality issues continue to drive dissatisfaction.”

When EHRs are compared to other business software, and mobile applications they deserve a "FAIL"  Physicians have been coerced (read extorted) to acquire the obsolete software by a combination of inadequate incentives // penalties, if not used and according to a format that encourages analytics.

Standards for interoperability  are in place, however adoption remains a barrier. The Office of the National Coordinator for Health Information Technology (ONCHIT) stimulated the development of such a standard for EHR to insure interoperability between disparate EHR software.  While the standard is encouraged by incentives and penalties, adoption is slowed by lack of financial models.  

Different regions of the country use different health information exchanges and some have none. In addition, even those who have formed exchanges, there may be poor participation resulting in inadequacy.   Challenges remain, including user buy-in, lack of interest and/or need. Another challenge is the financial model for sustainability. Several different models exist.

Despite numerous usability issues, physicians are mandated to use certified EHR technology to participate in the federal government’s EHR incentive programs. Unfortunately, the very incentives intended to drive widespread EHR adoption have exacerbated and, in some instances, directly caused usability issues. The AMA has called for the federal government to acknowledge the challenges physicians face and abandon the all-or-nothing approach for meeting meaningful use standards. Moreover, federal certification criteria for EHRs need to allow vendors to better focus on the clinical needs of their physician customers.

Building on its landmark study with RAND Corp. confirming that discontent with electronic health records (EHRs) is taking a significant toll on physicians, the American Medical Association (AMA) called for solutions to EHR systems that have neglected usability as a necessary feature. Responding to the urgent physician need for better designed EHR systems, the AMA released a new framework outlining eight priorities for improving EHR usability to benefit caregivers and patients.
“Physician experiences documented by the AMA and RAND demonstrate that most electronic health record systems fail to support efficient and effective clinical work,” said AMA President-elect Steven J. Stack, M.D. “This has resulted in physicians feeling increasingly demoralized by technology that interferes with their ability to provide first-rate medical care to their patients.”
“Now is the time to recognize that requiring electronic health records to be all things to all people — regulators, payers, auditors and lawyers — diminishes the ability of the technology to perform the most critical function — helping physicians care for their patients,” said Dr. Stack. “Physicians believe it is a national imperative to frame policy around the desired future capabilities of this technology and emphasize clinical care improvements as the primary focus.”

To leverage the power of EHRs for enhancing patient care, improving productivity, and reducing administrative costs, the AMA framework outlines the following usability priorities along with related challenges:
  • Enhance Physicians’ Ability to Provide High-Quality Patient Care
  • Support Team-Based Care
  • Promote Care Coordination
  • Offer Product Modularity and Configurable
  • Reduce Cognitive Workload
  • Promote Data Liquidity
  • Facilitate Digital and Mobile Patient Engagement
  • Expedite User Input into Product Design and Post-Implementation Feedback

Monday, October 13, 2014

Why the Government Prejudice regarding Specialty Electronic Medical Records

The past decade saw the development of electronic medical records, both in number and level of sophistication During this decade there was a steep learning curve by vendors with frequent and arbitrary regulations regarding EHRs.

Successfully Choosing Your EMR: 15 Crucial Decisions 

                                                                   Purchase on Amazon

EHR development has been overly influenced not by it's functionality but by parameters of HHS and CMS in regard to data structure and interoperability.

The regulations included a mandate for interoperability and items called 'meaningful use'.. The term 'meaningful use' is a misnomer.  Meaningful use in their terms only had to do with it's utility in garnering information from an EMR which may or may not be useful for it's designed purpose.

The following statement from Ophthalmology Management specifies some items:

"Switching electronic medical records (EMR) systems is a big decision, even if you feel like throwing your existing system against a wall. So don't ditch your EMR system before you download the paper that includes an eight-question assessment to help you decide - and to protect you from making the same mistake twice.  (this statement is from Ophthalmology Management and is a quote from EMA, a specialty EHR for ophthalmology.)"

In many specialties there are fields and specific information unique to that specialty. Clinical work flow must be considered, since a poorly designed software can radically alter efficiency and disrupt the clinic volume and income. Numerous studies have revealed that efficiency can be reduced for several months by a factor of 20-30%.

Medical practices chose to accept incentive payments for consenting to meet meaningful use criteria with their EHR.  This occured by an angst of 'not being left behind' despite serious reservations and advice for HHS and ONCHIT. Several deadlines have been delayed and doubts remain about the implementation of MU Stage III.

Many medical practices have invested in EHRs. Some installations were obsolete at the time of purchase.

Some medical practices decide to purchase a new system despite the added costs, preferring to write off an older system with accelerated depreciation. These decisions are supported by a record of decreased patient volume.  Most physicians report an additional hour of work each day and a reduction in patient volume.

Many physicians have expressed their extreme unhappiness with their electronic health records. Management surveys continuously confirm dissatisfaction. Despite this, EHR use has grown.  Imagine using a defective hammer to drive in a nail. Regulators have taken their eyes "off the ball" ignoring patient care, and equating paperwork with 'quality of care'.  This has become a fundamental failure of the entire American health care system.  Poor patient care can easily be disguised if all the information which is entered is designed to thwart the 'required entries' to proceed, or satisfy an algorithm for a complete medical record.

There are several certifying standards, the most onerous are those mandated by CMS and regulated by  

Adding to this frustration is that many large organizations will select a vendor whose reputation has been built upon usability for primary care and/or internal medicine/pediatrics.  Population Health has become a new 'buzzword" in the HIT workspace.  A large or medium sized multispecialty group may select a system which their specialists can not use.  Interoperability has become a deserved design requirement.

When designing or selecting an EHR, every department must have input on decision making. Some IPAs and loosely organized primary care groups have offered to 'give' an EHR to their specialists t
o encourage acceptance of a group EMR.  This in many instances has been disastrous.

Their are other choices.

1. Utilize a specialty specific EHR based upon:

     User testimonials
     Site visits
     Demonstrated user functionality and efficiency in actual operations.

2. The requirement for interoperability are clearly defined by ONCHIT which should make disparate systems interoperable.

3. The realities however are quite different from a vendor point of view, leaving users holding the proverbial 'bag'.

Does your EHR need a tweak or a trashing?

How to tell if your system is already in need of a major goose.


Need an EHR plan?

Whether it’s your practice’s first foray into EHRs or your practice is upgrading to a new version of the software or a new system, the HealthIT.govwebsite provides ophthalmology practices valuable insight. This includes these six steps:
    1. Assess your practice readiness
    2. Plan your approach
    3. Select or upgrade to a certified EHR
    4. Conduct training and implement an EHR system
    5. Achieve Meaningful Use
    6. Continue quality improvement

On the website, each step is a link that users may click on for a detailed explanation.

Saturday, September 27, 2014

Value Based Care

The concept of "value" has now firmly taken root.
These demands for greater value in the use of increasingly precious resources are producing effects across all sectors of healthcare-related products and services. For example, value-based delivery system reimbursement continues to advance and is increasingly supported by more robust measures of quality and cost-effectiveness.
Transparent reporting of performance is reaching critical mass, although not without controversy in some physician communities. Encouragingly, the "Choosing Wisely" campaign led by several medical societies, and supported by influential patient advocacy organizations, does signal recognition by clinicians that evidence-proven wasteful practices require serious attention.
Value-based reimbursement is also becoming aligned with value-based health benefits and value-based technology assessment. Taken together, these three initiatives are gaining a critical mass effect.
Value Based Care:   for  whom ?
Where is the value assigned, the provider who works tirelessly to see all his patients, finish his paperwork, save for retirement, support a family, pay health insurance premiums?
So, don't insurance companies gain with value based care, expecially if they assign the value based upon increased, or at least stable profits.
For patients it is the matter of do you know what you are buying, and how much does it cost?

If you struggle with IT, here is why you shouldn’t give up!

Why it is crucial for people who struggle with IT not to give up now. The reason is that a lot of developments coming out in the coming months and years will make the use of digital technologies very simple.
The image above is a great example demonstrating how we could use workplace desktops in the future:

The Progression of Value-Based Payment Models

Michael Kitchell: Accountable Care Organization results

By Dr. Michael Kitchell

One of the major healthcare reforms coming out of the Affordable Care Act is the promotion of the three-part aim of: 1) better experience and outcomes of care, 2) better health of the population, and 3) lower per capita costs in healthcare.
These three goals have been the guiding force for many changes in how healthcare is delivered.
One delivery system reform involves a group of physicians who are willing to be held accountable for their quality of care and their patients’ outcomes while keeping costs below a certain level.
Not all physicians are willing to be held accountable for both quality and cost, so these delivery reforms have been based on those physicians who voluntarily agree to be part of an organization that is held responsible for the value of their care.
The concept of an organization delivering higher value care has been one of the major points of emphasis in reforming health care since Dr. Donald Berwick served as the administrator of the Center for Medicare and Medicaid.
Berwick wrote the rules for Accountable Care Organizations in 2011.
The number of Medicare Accountable Care Organizations has been growing steadily since the first year of activity in 2012, and we are now hearing about the results of the second year (2013) of Medicare Accountable Care Organization performance.
Accountable Care Organizations consist of a group of primary care physicians who are often associated with hospitals and other specialty physicians.
Accountable Care Organizations are measured by their performance on quality indicators and spending for patients that are attributed to the primary care providers who are responsible for guiding most of their care.
The hospitals and doctors in an Accountable Care Organization are paid by fee for service (the traditional way) in most cases, plus a bonus if they perform well.
Patients may not even know they are in an Accountable Care Organization because the doctor or hospital is doing the service and billing just as it always has been done.
The Accountable Care Organization’s success in achieving a bonus for their better care and lower cost though depends upon exceeding certain quality standards before receiving any payment for lowering costs. The Accountable Care Organization will not receive any bonus payment unless they are high performers in 32 quality measurements.
The payment for Accountable Care Organizations is therefore based on the services they give, and the bonus or payback depends on whether the organization keeps the costs below their historical (last year’s) spending.
The Accountable Care Organizations’ strategy is to keep costs down by prevention or earlier detection of disease (such as heart disease) and managing chronic diseases (such as diabetes), keeping patients healthier and out of the hospital, which can be very expensive.
Accountable Care Organizations cannot skimp on care because they must meet higher quality standards as well as higher patient satisfaction results.
Of the 243 groups that were Medicare Accountable Care Organizations last year, 64 of them performed well enough to receive shared savings bonuses, the amount of which is half of the savings compared to their spending the year before. Those 64 Accountable Care Organizations earned a combined total of $445 million, and even with paying those bonuses, Medicare saved a total of $372 million after accounting for all the 243 Accountable Care Organizations, some of which did not have success. Only four Accountable Care Organizations had to pay back some of the money they received in 2013 because they went over the expected spending.
Though these numbers are small compared to the $500 billion Medicare spends per year, the success of these Accountable Care Organizations in bending the cost curve down instead of going up every year is encouraging.
There are now more than 360 Medicare Accountable Care Organizations. As Accountable Care Organizations improve their disease prevention and management of chronic disease there will be more savings, and patients will benefit by their physicians’ focus on keeping them healthier rather than on increasing the number of services they bill.
The concept of Accountable Care Organizations and promotion of higher value in healthcare has been so successful that many private insurers are offering Accountable Care Organization contracts for physician groups.
In Iowa, 14 large physician/hospital groups are now contracting with Wellmark for ACO payments for value.. ..

The ACO value based payment model is voluntary, and despite it's promises some have little faith in it's ability to reign in costs.  ACO may have effect, if and when it is competitive in price in the marketplace for health care.  

Will employers or health plans buy ACO providers?

Value-based payment models expected to reach tipping point by 2018, study finds

Eighty-two percent of health plans responding to a recent survey consider payment reform a ‘major priority.’ Nearly 60 percent forecast that more than half of their business will be supported by value-based payment models in the next five years. And, of those, 60 percent are at least mid-way through implementation, according to a study published May 9 by Availity, a health information network.
The Health Plan Readiness to Operationalize New Payment Models study delves into the progress of the country’s commercial health plans, as they migrate from fee-for-service to value-based models of compensating physicians, according to a news release by Availity. The study highlights the consensus among plans that information sharing with physicians must be automated – primarily in real-time – for these models to achieve success.
The transition from fee for service to a value-based payment model will be complex.
Managing value-based payment models alongside existing fee-for-service arrangements, and across numerous health plans, is creating issues that range from accurate revenue forecasting to workflow integration challenges. According to one physician practice respondent, “The administrative complexity of administering these plans is likely to be costly. The unpredictability of the revenue stream is likely going to make administering some of these plans not worth the cost.”

From volume to value: how health execs see the future of health care From Volume to Value

Mission Impossible ?

Mission Impossible is what some think about the Affordable Care Act, and it's consequences. Admittedly, unless you are an expert the law is baffling, and even more so it's implementation.

Meet Jim, the chief medical officer at a well-respected integrated delivery system. His 

meeting with the board resulted in one key directive... a Mission Possible!

Kryptiq and Case Manager present an interesting portrayal of the impossible mission.

Dr. Jim,"will you accept this mission"  Unfortunately this message will not self-destruct in ten seconds.