Athena Health CEO Jonathan Bush on the RECs

Courtesy of EHR Bloggers:

Jonathan Bush, Chairman and CEO of AthenaHealth discussed his opinion of the Regional Extension Centers (RECs). During the quarterly earnings call, Mr. Bush was asked how the REC strategy could be improved. He replied, "A bullet. Give the money back. Quick bullet, they won’t even know. There’s no one in the office, so there’s no one to even take the boxes out."

Whatever. I can find nothing in the press where he expanded on those remarks. Tasteless cheap joke metaphorical allusion to firearms violence aside, it'd be nice to know precisely what is his beef with the RECs. One might also be forgiven for wondering what proportion of his company's recent dramatic revenue growth emanates from the incentives comprising the ARRA/HITECH Act under which we work.

This (below), from the "news" column on the Athena website is pretty interesting.

From the recent CalHIPSO press release:

Jonathan Bush, Chairman and CEO of athenahealth said, “Many California physicians find themselves in the exact same situation as physicians all across this country, trying to adapt to a world where electronic health records are becoming a necessity – but this change isn’t easy. The good news for California doctors is they’ve got a great organization in CalHIPSO to turn to for support and we look forward to bringing our deep understanding of the benefits cloud-based EHR services can bring to a host of new physicians and helping them receive financial reimbursements for embracing the future of healthcare.”

So, you'll extoll your involvement with RECs where it suits you, while otherwise trashing us?

Mr. Bush interviewed on EHRtv at HIMSS 2009, asked about the impact of the ARRA/HITECH Act:

[0:40] “Part of me is ecstatic because, why not have more ‘schtimulus,’ and, part of me is, like, well, now we’re gonna ‘schtimulate’ all these losers, and, so, why couldn’t we just let them die, and we’ll just do it ourselves?”

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MAY 8TH UPDATES: SOME ACCOUNTABILITY ITEMS

Now that Meaningful Use Attestation is underway, we might make note of some accountabiity provisions. First, the anticipated CMS audits:

Any provider attesting to receive an EHR incentive payment for either the Medicare EHR Incentive Program or the Medicaid EHR Incentive Program potentially may be subject to an audit. Here's what you need to know to make sure you're prepared:

Overview of the CMS EHR Incentive Programs Audits

• All providers attesting to receive an EHR incentive payment for either Medicare or Medicaid EHR Incentive Programs should retain ALL relevant supporting documentation (in either paper or electronic format used in the completion of the Attestation Module responses). Documentation to support the attestation should be retained for six years post-attestation. Documentation to support payment calculations (such as cost report data) should continue to follow the current documentation retention processes.
• CMS, and its contractors, will perform audits on Medicare and dually-eligible (Medicare and Medicaid) providers.
• States, and their contractors, will perform audits on Medicaid providers.
• CMS and states will also manage appeals processes.

Preparing for an Audit

• To ensure you are prepared for a potential audit, save the supporting electronic or paper documentation that support your attestation. Also save the documentation to support your Clinical Quality Measures (CQMs). Hospitals should also maintain documentation to support their payment calculations.
• Upon audit, the documentation will be used to validate that the provider accurately attested and submitted CQMs, as well as to verify that the incentive payment was accurate.

Details of the Audits

• There are numerous pre-payment edit checks built into the EHR Incentive Programs' systems to detect inaccuracies in eligibility, reporting and payment.
• Post-payment audits will also be completed during the course of the EHR Incentive Programs.
• If, based on an audit, a provider is found to not be eligible for an EHR incentive payment, the payment will be recouped.
• CMS will be implementing an appeals process for eligible professionals, eligible hospitals and critical access hospitals that participate in the Medicare EHR Incentive Program. More information about this process will be posted to the CMS Web site soon.
• States will implement appeals processes for the Medicaid EHR Incentive Program. For more information about these appeals, please contact your State Medicaid Agency.
  
  

In a nation where crooks routinely scam everyone from 9/11 victims to Katrina and tornado survivors, it would not surprise me one whit to see completely fake providers and clinics try to cash in on Meaningful Use. Now would it surprise me for some providers to fake some of their attestation data. One hopes that the audit program will have teeth.

THE OIG

I find this one particularly interesting. It appeared originally in the April 2011 edition of the "Liability and the Lab" column at mlo-online.com.

Q: What is the Office of the Inspector General’s (OIG) role in electronic health records (EHR)?

A: The OIG recently released its Recovery Act Implementation Overview and Work Plan (Plan) for 2011. A significant portion of the Plan items relate to healthcare information technology (HIT), including meaningful use. With regard to HIT generally, the OIG seems especially concerned with information security. The meaningful use incentive program contemplates a large outlay of government funds to eligible professionals and hospitals who have met technically exacting criteria regarding the implementation and use of varied HIT. The OIG intends to monitor this program closely. In total, the Plan includes a half dozen different items related to meaningful use. The OIG intends to:

• review the ONC’s oversight of the ATCBs to ensure that the ATCBs have properly reviewed and tested the security features of EHR products put forth for certification (this review will include a review of some EHRs that have already received certification);
• determine whether Centers for Medicare & Medicaid Services’ (CMS) HIT system enhancements include the standards adopted by the Department of Health and Human Services (HHS) and provide sufficient security for sensitive personal information;
• assess CMS’ compliance with the current Breach Notification Rule (which is described at http://tiny.cc/r3606) and CMS’ response to breaches;
• identify incentive-program payments made in error and review CMS’ response to identified erroneous payments;
• determine the progress states have made toward CMS approval for incentive payment plans and determine when states intend to make Medicaid incentive payments available to program participants;
• review states’ IT controls for capturing meaningful use data and track payments made; and
• determine whether states’ initial plans for incentive payment processes and incentive payments eventually claimed were both in accordance with Recovery Act requirements.

As part of the meaningful use program, the Office of the National Coordinator for Health Information Technology (ONC) sets standards for the certification of EHR systems and modules. Providers may only receive incentive payments where they use meaningful use-certified EHR technology. Final testing of EHRs and final determinations of certification status is made by Authorized Testing and Certification Bodies (ATCBs) named by the ONC. With regard to the ONC, the OIG intends to:

• review the ONC’s oversight of the ATCBs to ensure that the ATCBs have properly reviewed and tested the security features of EHR products put forth for certification (this review will include a review of some EHRs that have already received certification);
• determine whether the ONC’s process to develop HIT-related standards properly considered security concerns; and
• determine whether the federal Regional Extension Centers are providing IT security support to healthcare providers.
  

Finally, the OIG Plan included as an independent work item examination of providers’ compliance with HIPAA and Recovery Act requirements and the HHS Office of Civil Rights’ (OCR) compliance with the enforcement responsibilities authorized by the Recovery Act. The OIG’s plan to review the certification of certain EHR technologies raises the question of whether a negative review could result in the “de-certification” of previously certified EHR technologies that providers have already implemented. In addition, the OIG’s plan to review the enforcement activities of the OCR should remind all healthcare providers that properly executed and implemented HIPAA policies, procedures, and training must remain a foremost compliance concern.

Potential for "decertification" of CHPL certified EHR products? Wow. That should be interesting. Equally bracing is their intent to assess "whether the federal Regional Extension Centers are providing IT security support to healthcare providers," something regarding which we had better pay close attention, given the resource-intensive nature of this aspect of MU and the potential to simply pay it lip service.

RECs are to be performance-evaluated by ONC early next year in mid-contract reviews independent of this OIG thing, so, we'd better all be up to speed across the board.
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SOME NOTES FROM THE FRAY

As the CHPL certified versions of EHRs get rolled out, we are increasingly out in offices walking through the Meaningful Use criteria workflows with our REC client providers. Much of what we see is a bit disturbing. A number of these platforms simply do not capture MU data correctly and report out readily, and vendors are often just deploying the upgrades without any relevant MU training. Relatedly, there are reports of increasing vendor support bottlenecks and testiness, with providers having to "open a support ticket" on the phone to get a single question answered.

I have sometimes gone to vendors' Facebook pages to pose questions, in attempts to end-run support queues on behalf of my clients. For instance, on of my co-workers came back from a visit to report that eClinicalWorks does not enable its users to picks just any 90-day attestation period (as is their right under the terms of the federal program).

Following this exchange I posted one more follow-up question asking for confirmation that eCW does not provide for ad hoc MU report period queries.

They deleted it.

It's gonna be a long summer.

MEANINGFUL USE ATTESTATION PROGRESS UPDATE

There isn't one. After CMS reported 150 attestations on Day One (April 18th), there has been virtual silence regarding aggregate attestations to date. What are we to make of that? It'd be illuminating to know the vendor mix, outpatient EPs-vs-hospitals relative proportions, daily trend, and aggregate dollar amounts thus far.

UPDATE:

Well, I made email contact at CMS, and they answered the question:

"As required by the American Recovery and Reinvestment Act of 2009, CMS will post the names, business addresses and business phone numbers of all Medicare eligible professionals, eligible hospitals, and critical access hospitals that receive EHR incentive payments. It is expected that the 2011 report will be posted on the CMS website in May 2012 There is no such requirement for CMS to publish information on eligible professionals and hospitals receiving Medicaid EHR incentive payments, although individual states may opt to do so."

Not what I'd wanted to hear.

A year? Moreover, what would be helpful to the RECs in particular would be an early tally of which CHPL certified EHRs were "ready for prime time" straight away, as inferred by early attestations.
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"COGNITIVE TRAPS"

As I've mentioned before, one of my favorite blog hangs is that of Science Based Medicine. Today's article by Harriet Hall, "Cognitive Traps," is really very nice. It addresses some of the cognitive liabilities regarding which "experts" such as physicians may be vulnerable, notwithstanding that they'd likely be overwhelmingly loathe to admit it.

Even more fascinating than the essay itself is one of the comments:

Ed Whitney on 10 May 2011 at 1:46 pm

Some of these cognitive biases in medicine are associated with deeper biases induced by the socialization of physicians. “You’re a doctor; do something” bias permeates the entire health care system, leading to many kinds of overtreatment. The need to act comes first; the rationale for acting comes later.

George Bernard Shaw nailed it 100 years ago in “The Doctor’s Dilemma.” Cutler Walpole is a surgeon who has a single explanation for everything: “Ninety-five per cent of the human race suffer from chronic blood-poisoning, and die of it. It’s as simple as A.B.C. Your nuciform sac is full of decaying matter—undigested food and waste products—rank ptomaines. Now you take my advice, Ridgeon. Let me cut it out for you. You’ll be another man afterwards.”

Confirmation bias appears to be part of human nature. There is strong statistical evidence that there is no such thing as a hot hand in basketball, but just try to watch the NBA playoffs and deny that players are hot or not in particular games.

There is an article in the current “Behavioral and Brain Sciences,” whose abstract is [here]. This article is likely to become widely quoted and cited. The authors propose that the function of reason is primarily argumentative rather than cognitive; we reason in order to be able to persuade others of our intuitively arrived at opinions rather than to arrive at truth. A preliminary copy of the entire paper is [here PDF].

If reason’s function is primarily social, then it requires considerable effort to adapt it to a different purpose, namely sitting alone and using it to arrive at a position which may contradict our own intuitions and argumentative preferences. Medical schools would have to teach students to transcend their own human nature, and this would entail instruction at a higher logical level than is used in preparing them to pass the standardized tests upon which their fate so often depends.

Wow. Read the entire paper. It is rather exhaustively documented. Much to consider. I have to add that to my research stash.

A couple of Money Quotes from pages 51 and 53 of the paper:

Some of the evidence reviewed here shows not only that reasoning falls short of reliably delivering rational beliefs and rational decisions, but also that in a variety of cases, it may even be detrimental to rationality. Reasoning can lead to poor outcomes not because humans are bad at it but because they systematically look for arguments to justify their beliefs or their actions. The argumentative theory however puts such well-known demonstrations of ‘irrationality’ in a novel perspective. Human reasoning is not a profoundly flawed general mechanism; it is a remarkably efficient specialized device adapted to a certain type of social and cognitive interaction at which it excels...

...one might be tempted to point out that, after all, reasoning is responsible for some of the greatest achievements of human thought in the epistemic and moral domains. This is undeniably true, but the achievements involved are all collective and result from interactions over many generations (on the importance of social interactions for creativity, including scientific creativity see (Csikszentmihalyi & Sawyer, 1995; K. Dunbar, 1997; John-Steiner, 2000; T. Okada & Simon, 1997). The whole scientific enterprise has always been structured around groups, from the Lincean Academy down to the Large Hadron Collider. In the moral domain, moral achievements such as the abolition of slavery are the outcome of intense public arguments. We have pointed out that, in group settings, reasoning biases can become a positive force, and contribute to a kind of division of cognitive labour. Still, to excel in such groups it may be necessary to anticipate how one’s own arguments might be evaluated by others, and to adjust these arguments accordingly. Showing one’s ability to anticipate objections may be a valuable culturally acquired skill, as in medieval disputationes (see Novaes, 2005). By anticipating objections, one may even be able to recognize flaws in one’s own hypotheses and go on to revise them. We have suggested that this depends on a painstakingly acquired ability to exert some limited control over one's own biases. Even among scientists, this ability may be uncommon, but those who have it may have a great influence on the development of scientific ideas. It would be a mistake, however, to treat their highly visible, almost freakish, contributions as paradigmatic examples of human reasoning. In most discussions, rather than looking for flaws in our own arguments, it is easier to let the other person find them, and only then adjust our arguments if necessary...

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Apropos of the topic of reasoning, rationality, cognitive liabilities, and wrongness, some observations of "Being Wrong" author Kathryn Schulz, during a TED talk:

So let me tell you a story. A couple of years ago, a woman comes into Beth Israel Deaconess medical center for a surgery. Beth Israel's in Boston. It's the teaching hospital for Harvard -- one of the best hospitals in the country. So this woman comes in and she's taken into the operating room. She's anesthetized, the surgeon does his thing -- stitches her back up, sends her out to the recovery room. Everything seems to have gone fine. And she wakes up, and she looks down at herself, and she says, "Why is the wrong side of my body in bandages?" Well the wrong side of her body is in bandages because the surgeon has performed a major operation on her left leg instead of her right one. When the vice president for health care quality at Beth Israel spoke about this incident, he said something very interesting. He said, "For whatever reason, the surgeon simply felt that he was on the correct side of the patient." The point of this story is that trusting too much in the feeling of being on the correct side of anything can be very dangerous.

This internal sense of rightness that we all experience so often is not a reliable guide to what is actually going on in the external world. And when we act like it is, and we stop entertaining the possibility that we could be wrong, well that's when we end up doing things like dumping 200 million gallons of oil into the Gulf of Mexico, or torpedoing the global economy. So this is a huge practical problem. But it's also a huge social problem.

Think for a moment about what it means to feel right. It means that you think that your beliefs just perfectly reflect reality. And when you feel that way, you've got a problem to solve, which is, how are you going to explain all of those people who disagree with you? It turns out, most of us explain those people the same way, by resorting to a series of unfortunate assumptions. The first thing we usually do when someone disagrees with us is we just assume they're ignorant. They don't have access to the same information that we do, and when we generously share that information with them, they're going to see the light and come on over to our team. When that doesn't work, when it turns out those people have all the same facts that we do and they still disagree with us, then we move on to a second assumption, which is that they're idiots. They have all the right pieces of the puzzle, and they are too moronic to put them together correctly. And when that doesn't work, when it turns out that people who disagree with us have all the same facts we do and are actually pretty smart, then we move on to a third assumption: they know the truth, and they are deliberately distorting it for their own malevolent purposes. So this is a catastrophe.

This attachment to our own rightness keeps us from preventing mistakes when we absolutely need to and causes us to treat each other terribly. But to me, what's most baffling and most tragic about this is that it misses the whole point of being human. It's like we want to imagine that our minds are just these perfectly translucent windows and we just gaze out of them and describe the world as it unfolds. And we want everybody else to gaze out of the same window and see the exact same thing. That is not true, and if it were, life would be incredibly boring. The miracle of your mind isn't that you can see the world as it is. It's that you can see the world as it isn't. We can remember the past, and we can think about the future, and we can imagine what it's like to be some other person in some other place. And we all do this a little differently, which is why we can all look up at the same night sky and see this and also this and also this. And yeah, it is also why we get things wrong.

1,200 years before Descartes said his famous thing about "I think therefore I am," this guy, St. Augustine, sat down and wrote "fallor ergo sum" --"I err therefore I am." Augustine understood that our capacity to screw up, it's not some kind of embarrassing defect in the human system, something we can eradicate or overcome. It's totally fundamental to who we are. Because, unlike God, we don't really know what's going on out there. And unlike all of the other animals, we are obsessed with trying to figure it out. To me, this obsession is the source and root of all of our productivity and creativity.

Highly recommended book, btw.

These items give me pause for even more cautionary reflection on my REC work. We pretty much take it as a given that more effective/extensive and more efficient capture and reporting of clinical patient data via HIT will inexorably improve patient care across time -- that caregivers will, in the aggregate, make objectively better decisions leading to improved outcomes in the wake of ready access to more voluminous and finer-grained "evidence."

The truth may in fact be considerably more complex. Below, yet another good read on the topic:

...Dr Groopman explores both rational and irrational factors that bear on medical decision making; he explains in detail where and how misdiagnosis can occur. A snap judgment that leads to a right decision can just as easily lead to a wrong one. A prior experience can influence a current case. Rapport with a patient or lack thereof can affect a potential diagnosis.

In the hurly burly of everyday medicine, the Socratic principle of well thought-out diagnosis often gives way to what Dr Groopman and others have called “pattern recognition.” This quick gestalt is often subtly influenced by one of several premises: availability—the reach for the most plausible explanation; commission bias—the need to do something; confirmation bias—the selective use of information supporting what one expects to find; attribution errors—the use of stereotypes that then bias decision making; and diagnosis momentum—where a diagnosis is accepted as definitive despite contrary or incomplete data...

BTW: Another favorite quote of mine:

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More to come...