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.

Thursday, September 18, 2014

Negative Practice Reviews on the Internet

Formerly physicians would receive negative reviews or 'bad press' in a local newspaper as a result of a malpractice case, deserved or not. The negative information is difficult to counter even if disputed. False reports were subject to libel complaints.  Individual bad feelings or complaints about a physician would be disregarded in the noise of other news.

However today a poor review or even less than a ***** (five star) rating on websites such as Health Grades, Vitals,  Rate MDs,  ZocDoc, and can be devastating to a practice.  WebMD offers an analysis of Doctor Rating Sites.

About 40 to 50 online sites -- such as Healthgrades, and Vitals -- allow patients to rate or write reviews of their physicians.

The visual appearance of a web page often has more authority than the printed content, when a user is searching for physicians and their ratings:   For Example:

Physician                      Satisfaction Score

Dr Good                          ******
Dr Soso                            ***
Dr. Who                          -------
Dr. Uhoh                          *
Dr. Missing
Dr. Maybe                       **

Let's hope it is not something like this:

Early on these services were very questionable, but some have improved.   Some are even 'respectable' and now have a mechanism for building their ratings, and sources.  An algorithm for **** power appears to have developed.

iHealthbeat offers how physicians can take a proactive approach to online rating websites. However, the devil is in the details and can take a considerable investment of time and alteration of practice routines.

Once upon a time physicians were unaware of these 'consumer oriented websites". Some did not even know they existed, however they are now or should be uppermost in any practice administrator or physicians mind set.  Even one negative review, or the absence of any reviews or a missing listing on a search engine such as Google,  Yahoo or  Yelp can be disastrous and result in a patient's bypassing your services. It is mandatory that administrators and/or physicians routinely monitor these websites, and have a consistent proactive approach to building reputation.  It is not expensive but does require a professional plan. It can be done internally, however there are marketing services that can incorporate into your overall marketing plans.

Any administrator can easily search any of those search engines to find ratings, or where your practice shows up on 1 or page 1000.  Few patient and consumer searches go beyond page 2, and page 1 is best.

Unfortunately the internet and social media are growing and changing on an almost daily basis. New social media sites appear, and grow rapidly, even in their content. What at one moment appears to be a simple social media site morphs into Google pages, Google local, Facebook pages and rating capabilities.  The source of virtually all of the ratings is from users and not accredited or credible.

Patients and/or consumers go first to Google when looking for services, even if it is a friend referral, and yes even if it is your 'plan provider book', online or printed.  No longer do patients call the medical society, which is usually way behind on information about their physician membership.

The opposite is also true. Physicians look up medical information as well as information about their patients on Google.

Find out more specifics and dowloand:

White papers:  pdf file  if you cannot open the pdf file download word file

Monday, September 15, 2014

Is he the Steve Jobs for Health Care or a super-rich hypomanic snake oil salesman?

His reputation precedes him, he has had some failures but also manages to turn lemons into lemonade, one foot in the Venture Capital arena, the other in a 'gestalt' of health innovation and organizational abilities.  Forbes Magazine featured him as the icon of "The Manhattan Project". They titled the article,

Medicine's Manhattan Project: Can The World's Richest Doctor Fix Health Care?

His biography, and resume demonstrate an outstanding presence, and personal charm, daring to go 'where no man has gone before'.  His accomplishments are diverse, especially manipulating his financial treasure to march forward on his mission of disrupting medicine with innovative ideas, merging new tools together.  Many have and are trying to accomplish this same goal. Perhaps he has become more visible due to his extroversion and lack of fear from the establishment, since he is independent of grant funds private or public. He is a quiet speaker and refrains from bold and embellished ideas.
Will he be another icon of Disruptive Men in Medicine ?

Before                                                                                                        After

Read, and judge for yourself.