Rethinking the Decision to Replace Your EHR

Small and medium sized physician groups are faced with an overwhelming number of EHR solutions.
There are several groups for medical practice defined by their size and history of EHR usage. Large medical clinics and integrated health systems  have adequate HIT resources to study this question. Unfortunately small practices do not have adequate HIT resources, and must outsource this to a consultant or their software vendor.

About ten years ago the impetus for EHR Early adopters jumped on the  train purchasing early software/hardware configurations.  At the time cloud computing was a little known option.  Most EHR providers did not offer that solution.  Providers were suspicious about data stored offsite (and with good reason as experience has shown.)

Changing to a new EHR system is becoming a more common choice, but is it always the right one? Beyond the question of whether a new system will deliver actual improvements, practice leaders must consider two other key factors – cost and time – before making a switch. Moving to a new EHR system may be far more expensive than optimizing your current system, and finding and implementing a suitable vendor may take up to two years. Instead of investing time and money in a new EHR system that may or may not offer better performance, organizations should make sure that they maximize the value of their current system. This session will provide guidance on determining whether optimizing an existing EHR or pursuing a replacement system is right for your practice.

MGMA 2014 Annual Conference session

This session will provide you with the knowledge to:

• Articulate the impact of EHR system replacement
• Assess the viability of exiting EHRs
• Identify options for optimizing existing EHRs

Practice needs for EHR evalutation into replacement or upgrade of present EMR. Thesee fall into several categories

1. None. These practices rely upon paper-based records
2. Adopting early word processing EHR for making records more legible. These systems may or may not interface with a practice management system
3. Early  EHR. These often combine practice management, billing, and electronic medical records
most of these are not interoperable for exchange of data between disparate EHRs.  These systems did not have standards from ONCHIT since they were in the earliest phase of development.  While ONCHIT led the effort to standardize and harmonize systems the task was left to providers and new organizations, some local, some regional and some state-wide.  In additioin to the multiplicity of organizations, they were often in competition with each other as to who would gain the most market-share. Organizations would appear and disappear according to how long their government grants lasted. This was due to a lack of sustainable business models.
3.Mid-term EHRs have a variety of advances, which may or may not include meaningful use stage I, stage II or stage III. The deadlines for  adoption include reward incentives for adoption within a  certain time period and penalties for non-compliance with the mandate.
4. Late term adopters. This group may be in the best position and may not need to  convert to a newer EHR.  (a sub-category also includes those with more recent EHRs which can be upgraded according to the individual vendor and the cost of such upgrades.

Perhaps those in the best category are those whose EHR is cloud-based. Cloud based applications can be updated instantly for thousands of users at the same time, very cost effectively.

So the answer is:

Early EHR...........replace
Mid term EHR......depends upon cost of upgrade
Late Client server application .......dependent upon extent of revision required, and how it affects user functionalitiy.

Cloud based.......vendor upgrades the software.

ICD 10 Getting Ready for October 1, 2015

Much confusion and hand wringing are occurring in regard to the deadline for ICD 10.  CMS, providers and organized medicine (American Medical Association) AMA  The AMA has asked for postponement previously.

Past deadlines were as early as October 2013, followed by a CMS reversal postponing the date to October 1, 2014

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The latest date posted by CMS is October 1, 2015. Despite some success in Congress repealing the SGR (sustainable growth reduction), CMS remains adamant about the date.

Congress intervened to delay the original date of October 14, 2015.  CMS was adamant about keeping October 1, 2014, as the compliance date. However, Congress passed H.R. 4302, "Protecting Access to Medicare Act of 2014" in March. The bill included this statement:

• The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD–10 code sets as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002 of title 45, Code of Federal Regulations.

President Obama signed the bill into law April 1 and as a result, HHS was forced to move the ICD-10 implementation date.

HHS first stated October 1, 2015, as the new implementation date in the IPPS proposed rule, released April 30. In several places in the proposed rule, HHS referred to October 1, 2015, as the ICD-10 implementation date.  One day later, CMS issued this statement:

• On April 1, 2014, the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. No. 113-93) was enacted, which said that the Secretary may not adopt ICD-10 prior to October 1, 2015. Accordingly, the U.S. Department of Health and Human Services expects to release an interim final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning October 1, 2015. The rule will also require HIPAA covered entities to continue to use ICD-9-CM through September 30, 2015.
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Focus on Technology: Preparing your practice for ICD-10




Latest from the AMA


The AMA appears to carry little influence with congress. The AMA is considered a 'special interest group" and is placed in the special category of most lobbyists. The AMA also carries less and less influence with members, a shrinking minority of physicians (unfortunately) Most of the time decisions are diluted by the very hierarchical structure of AMA governance. Compromise at the top waters down whatever the strong intent of the membership.  The AMA is better at publishing educational material and/or selling insurance as a front-man for a number of insurers. Today's world of Internet communication, openness and transparency leaves open to question, why go to AMA meetings, and why aren't they carried online via webinars and/or YouTube videos ? The AMA is fossilized.




ICD-10: AMA Considers Grace Period to 'Save Docs'

AMA | ICD10 Watch

Coalition for ICD-10 Responds to AMA President Dr. Robert ..

AMA explains silence on ICD-10 delay |

AMA | ICD10 Watch

Remote Patient Monitoring

Telemedicine,  remote patient monitoring  go hand in hand in the world of HIT.  Telemedicine although becoming more commonplace faces some serious legal hurdles from the Federal Trade Commission and the Food and Drug Administration as well as established regulatory state medical boards.  However the battle is on and the current focus on cost containment, improving outcomes coupled with reducing hospital admissions will most likely overcome these obstacles.

Remote monitoring has been made possible by advances in wireless technology. Monitoring vital signs from a patient at home reduces the necessity of a hospitalization or a stay in a SNF. It will take some effort to make this sea-change to make it a standard of care.

The  following seminar hopes to address these issues.



The Remote Monitoring, Implementation and Data Integration Summit 2015 Los Angeles California will be held 23-24 June 2015.

"With the US health care system transitioning from a volume to value model, it is a critical time for health care providers to re-evaluate and evolve their services to ensure they meet new model quotas. With new model requirements, health care providers must improve the quality of care, with the goal of dramatically reducing readmission rates, or face penalties.

Of course, one of the key and most revolutionary opportunities for cutting costs and improving the care of the chronically ill to reduce readmission rates is Remote Patient Monitoring (RPM). Set to transform the way patients are cared for in the years ahead, it is forecasted not only to save long term costs within healthcare institutions, but also to save the US government a staggering $700 Billion in health care costs over the next 15-20 years.

As with all disruptive technologies however, there are significant barriers to implementation of RPM which need to be overcome in order to realize the full benefits. US health systems therefore need to know:"

What Are The Top 3 Barriers To Implementation? Cost; trained staff to utilize the home monitoring equipment, data, and communication; patient/ caregiver adherence. Legal, regulatory, equality of care, lack of standardization and security Connectivity on the patient side (need adequate internet to send data)

What Is The Largest Barrier Preventing Insurance Providers From Reimbursing RPM? Reimbursement for RPM is an innovative concept and the biggest barrier is having programs in place to manage populations. Effective RPM can’t be put in place / approved on individuals: it must be looked at for groups of the population to be most effective.

Key Topic Areas Presented By Leading Healthcare Providers Include:

• MEASURING THE VALUE OF RPM: Examining the correlation between remote patient monitoring and reduced readmission rates to quantify return on investment

• CONDITION-SPECIFIC CASE STUDIES: Reviewing the latest disease-specific RPM case studies to identify where the most immediate opportunities lie for improving care to the chronically ill

• REIMBURSEMENT: Investigating the case for and against reimbursement from the insurance perspective to determine payer support for RPM - Private VS Medicare

• CRITERIA FOR A SUCCESSFUL RPM PROGRAM: Identifying implementation criteria to ensure RPM programs successfully reduce readmission rates while mitigating financial risk

• PATIENT BUY-IN: Identifying barriers to patient buy-in and devising actionable plans to maximize RPM reach and adoption

• DATA TRANSMISSION & REPORTING - DEVICES: Scrutinizing RPM data gathering and selection technologies to identify which can deliver the quality of data necessary for a responsive program

• INTEGRATION OF TECHNOLOGIES: Scrutinizing the integratability of RPM technologies and data gathering devices to determine which can be seamlessly synthesized with existing systems

• OVERCOMING TECHNICAL BARRIERS TO ADOPTION: Identifying strategies for overcoming home bandwidth limitations and data security risk to drive RPM adoption.     The meeting will bring together key industry players and health professionals

What to Do If an Insurer Profiles You as a High Utilizer

The Letter Every Doctor Dreads

One of the most important lessons Ruth Williams, MD, has learned about the practice of ophthalmology in recent years is to open her mail.

Throwing away what looks like junk can mean missing important news—like the fact that a major health plan is offering incentives to steer patients away from your practice. "The physicians don't even know this is happening because the information comes in a preprinted envelope," says Dr Williams.

Dr Williams, president of the Wheaton Eye Clinic in Wheaton, Illinois, says every physician in the practice recently received such a letter from UnitedHealthcare. It stated the physicians did not meet the "cost and quality designation," Dr Williams says.

As a consequence, the insurer was charging higher copayments for patients of the Wheaton Eye Clinic ophthalmologists than it was charging for some other ophthalmologists in the area.

Such letters are arriving at the offices of physicians throughout the United States. Many have already had the experience of being removed from a patient's network. In these cases, the patients must pay higher out-of-network costs to continue to see them.

Now some insurers are using cost and quality data to sort physicianswithin networks into tiers with different copayments and deductibles.

Although insurance companies have been "economically profiling" physicians in similar ways for at least 20 years, the practice has accelerated with the implementation of the Affordable Care Act, according to William L. Rich III, MD, medical director of health policy at the American Academy of Ophthalmology (AAO). "It's really exploded in about the past 5 years," he says.

Table. Sample Tiers and Rates for UnitedHealthcare's North Shore-Long Island Jewish Hospital Advantage Plan^[1]

Tier	Primary Care Physician Copayment	Specialist Copayment	In-Network Coinsurance	In-Network Maximum Out of Pocket Cost	Emergency Department Copayment
Tier 1	$30	$250	10%	$1000	$200
Tier 2	$100	$500	30%	$2000	$200

These amounts are very significant.

In an email, Aetna spokesperson Sherry Sanderford says that her company assigns ophthalmologists and other physicians in its Performance Network to tiers on the basis of the hospitals they use. If the ophthalmologists don't use hospitals much, or they use tier-1 hospitals, they are sorted into tier 1. If they use tier-2 hospitals, they are sorted into tier 2 themselves.

Besides cost efficiency, Sanderford says, Aetna rates hospitals on the basis of adverse events; 30-day hospital readmissions; average length of stay compared with expected averages; data from the Centers for Medicare & Medicaid Services (CMS); and "cost efficiency" compared with other hospitals in that market.

Your rating may not only depend upon your specialty, but according to the hospital rating you use. If your hospital has a tier 2 or 3 rating you will also.  Some ophthalmology subspecialists admit more frequently (retina) because their patients are much more ill.

Most private insurance companies provide little public information about the software they use, and in general how they profile physicians. Representatives of UnitedHealthcare, the Blue Cross and Blue Shield Association, and America's Health Insurance Plans did not return phone calls. Queries to four other plans went unanswered.

So despite promises of patient-centered health care, openness and transparency are moot.

Accurate measures of cost-effectiveness can help individual ophthalmologists control their costs, he says. "There are people who do too many tests," he says. "They're going to get caught up in this web. I don't have a problem with that."

He does have a problem with data that don't capture the reality of the physicians' practices. Simplistic measures of cost punish subspecialists in particular, whose costs are higher because their patients have more complex conditions requiring more treatment. "They lump bad apples doing too many tests and good docs doing the right thing into the same basket and whack them," says Dr Rich.

That happened to three pediatric ophthalmology subspecialists at Northern Virginia Ophthalmology in Falls Church, Virginia, where Dr Rich is the senior partner, he says. "Cataract surgery in a baby is much more expensive than in an adult because it must be done in a hospital with specialized anesthesia" An insurer threw all three physicians out of a plan, claiming that their cataract costs were too high.

Being Profiled as a High Utilizer

Many private insurers use third-party "episode grouper" software that aggregates data from pharmacies and outpatient and inpatient care, then compares costs of treating episodes of illness among physicians, Dr Williams says. In theory, the software also incorporates information about the quality of care, but in reality insurers don't collect much quality data beyond patient satisfaction surveys, Dr Williams says.

"One of the challenges we all have as providers is that nothing, absolutely nothing, is communicated prior to the patient visit,"

What to Do if You're Unfairly Profiled

Physicians don't have to take their designations lying down, says consultant Reed Tinsley. "You appeal it," he says. "You sit down and say, 'Tell me how you graded me, and I want to see the data you used,' and compare. Insurance companies make mistakes, like anybody else." 

The trend is also likely to continue because payers see economic profiling of physicians as a successful experiment overall. "If you're a business, you're going to want to save money on your costs, so you're going to want your employees to have skin in the game when they decide to do a test or something," says Dr Rich. "The aggressive tiering of physicians and increased deductibles and copays are the reasons for the lowering of healthcare inflation since 2005."

Although physician profiling isn't likely to go away, it may become more sophisticated, says Dr Rich. Under a congressional mandate to develop its own episode grouper software, CMS is working to create algorithms that accurately link quality and cost data, he says. "They are struggling to do it right."

The agency has a long way to go, in his opinion. "The risk-adjustment factors they use have nothing to do with many subspecialties, each with it's own grouping of high cost diseases," 

Numerous specialty societies are developing registries on diseases with itemized costs, length and complexity of disease for payers to cmpare with provider costs.