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Sunday, September 30, 2012

Au revoir, FY 2012. Bonjour FY2013

Five weeks and a day to election day (It's Oct. 1st Eastern time as I write this). We could be in for some huge changes. Or not.


The Conservative Case for Obamacare
September 29, 2012

...The core drivers of the health care act are market principles formulated by conservative economists, designed to correct structural flaws in our health insurance system — principles originally embraced by Republicans as a market alternative to the Clinton plan in the early 1990s. The president’s program extends the current health care system — mostly employer-based coverage, administered by commercial health insurers, with care delivered by fee-for-service doctors and hospitals — by removing the biggest obstacles to that system’s functioning like a competitive marketplace.

Chief among these obstacles are market limitations imposed by the problematic nature of health insurance, which requires that younger, healthier people subsidize older, sicker ones. Because such participation is often expensive and always voluntary, millions have simply opted out, a risky bet emboldened by the 24/7 presence of the heavily subsidized emergency room down the street. The health care law forcibly repatriates these gamblers, along with those who cannot afford to participate in a market that ultimately cross-subsidizes their medical misfortunes anyway, when they get sick and show up in that E.R. And it outlaws discrimination against those who want to participate but cannot because of their medical histories. Put aside the considerable legislative detritus of the act, and its aim is clear: to rationalize a dysfunctional health insurance marketplace.

This explains why the health insurance industry has been quietly supporting the plan all along. It levels the playing field and expands the potential market by tens of millions of new customers...

Read the entire piece (link in the title). "The health care law forcibly repatriates these gamblers..." Love that line. JD rocks. Recall "Free Riders"?


An excellent blog post.
What’s the Business Plan for Serving the Poor?
(From the American Hospital Association’s H&HN Daily, September 25, 2012)

Doing more with less. Doing the most for the least.

Seems like the biggest magic trick ever. It’s invisible, people don’t seem to even notice you’re doing it. You do it every day. And every day it gets harder to pull it off. It’s called “serving the underserved.” Helping the poorest, the least reimbursable, the homeless, the undocumented, often the least educated, least compliant, most addicted. Doing it with fewer resources year over year. Doing it in a climate in which the elderly, the poor, even the children of the poor have increasingly become political and cultural punching bags — with you and your institution caught in the middle.

Despite the reform, the tide of the helpless will continue to grow, and the resources to help them will shrink. How will you manage it? You cannot manage the future of your institution without a good answer to that question.

There is an answer, but it doesn’t lie in cutting back, in spreading the same resources more and more thinly. The answer lies in changing the question from How do I scrape by one more year? to How do I own this? How do we get really good at this? What would it look like if we were to become best in the world at this? How do we “make a living” at this?

The answers are paradoxes, but they are happening now. Let’s talk...

Nice. I heard this while in the car.


The light and smells in places like hospitals can often depress us. And, our favorite room at home keeps us sane. But why? Immunologist Esther Sternberg explains the scientific research revealing how physical spaces create stress and make us sick — and how good design can trigger our "brain’s internal pharmacies" and help heal us.

From the transcript:
Ms. Tippett: Gosh. And so you make this observation in your more recent work that physicians and nurses know that a patient's sudden interest in external things is the first sign that healing has begun. And you ask, do our surroundings in turn have an effect on us? And you're part of these new encounters between neuroscience and other kinds of scientists and architecture and people involved in all kinds of spaces, from how hospitals are designed to civic spaces to contemplative spaces. So there's a drama unfolding. There's a cast of characters and there's this whole new body of knowledge. It's really exciting. And one of the milestones in this story that you've talked about is Roger Ulrich's study called "The View from a Window" study of 1984, which was the beginning of one of these pieces of this new puzzle of what you now call environmental psychology.

Ms. Sternberg: Right. Well, so Roger Ulrich is an environmental psychologist who took advantage of a naturalistic experiment, if you will, where in patients were admitted to a ward for gallbladder surgery. Back in those days, you actually stayed in hospital for a number of days after you had gallbladder surgery. And some of them randomly were assigned to beds with a view of a brick wall and others had a view of a grove of trees. And he simply took the clinical data and measured how much pain medication these patients needed during their recovery, how long they had to stay in hospital, in other words, how quickly they healed, the number of negative nurse's notes where they were complaining or had pain or such, and he controlled for everything: age, sex, you know, med — other medication use, other disease use. And all of these patients were taken care of by the same doctors and nurses. So it was an extraordinarily well-controlled study. And even with all these controls where the single variable that differed between patients was the view out the window, what he found was that the patients with a view of a grove of trees left hospital on average a day sooner, needed less pain medication, and had fewer negative nurse's notes than patients who had a view of a brick wall.

Ms. Tippett
: So interesting, yeah.

Ms. Sternberg: Well, and one of the scientists that we interviewed, Irving Biederman, has a great quote where he says, you know, obviously, looking at a view does something positive to the brain. And his hypothesis is that endorphins are released in that part of the brain that recognizes a beautiful or preferred view. And he said, why else would we pay hundreds of dollars more for a hotel room with a beautiful view?

Ms. Tippett
: Right.

Ms. Sternberg: You know, that really tells you that people are willing to put money out to pay for a view.

Ms. Tippett: Yeah, but we don't think of it in terms of this is good for us. We don't even think it that through that much. We just know that's what we want. So let's talk about some different kinds of experiences that, again, we have and maybe things we kind of know without processing. I mean, so I think most people or certainly many people would agree that being in a place of beautiful nature is somehow nourishing, uplifting. You know, people would use different words. That it feels good and is good for us and we often know that we're restored afterwards. So what do you know — what do we know now about what is happening in us physiologically in those experiences?...
Nice interview. About 51 minutes long.

Brings to mind "God's Hotel," which I reviewed some time back.

Also brings to mind the emerging discipline of "Evidence Based Design."

Yeah, I know...

I downloaded two of Dr. Sternberg's Kindle edition books for study.


Just what I need; something else to keep up with. Ahh.h.h...


Health IT firm’s platform for lets nurses use text messages to manage work flow
September 27, 2012 1:39 pm by Stephanie Baum

As the trend of providers adopting smartphones begins to pick up, a health IT and communication company’s platform for iPhones hopes to reduce medical errors by clinical care team members. The Sarasota, Florida company has raised $6 million in a series B round, according to a Form D document filed with the U.S. Securities and Exchange Commission.

Voalte CEO Robert Campbell told MedCity News the investment raised from strategic corporate investors would help the company scale up to meet demand.

“We set out to address [hospitals'] critical communication needs. Traditionally, hospitals are equipped with antiquated communication systems. Even if hospitals are already using smartphones, getting signals can be a big impediment as many medical devices can create electromagnetic interference.”

The platform relies on the providers Wi-Fi system, so Voalte works with companies to update provider’s Wi-Fi coverage. Its platforms for iPhones and iPads and desk-based computers help members of the clinical care team communicate with each other. The smartphone platform integrates phone calls, alarms and alerts. It shows users which clinical care team members are available...

Interesting. Anything that improves work flow is always of interest to me. This vendor has a nice blog here. I'll certainly look at this more closely.

More to come.


Tomorrow. Last Call.

I should also note that two core "attestation" measures,  -- "Drug-Drug/Allergy Interactions," and "Clinical Decision Support  (CDS)" -- have to be enabled for the entire 90-day period. Same for menu set measure "Enable Drug Formulary Functionality."

This question arose among staff at our weekly REC meeting yesterday, and later during the HITRC Adoption and Implementation CoP "Burning Issues" conference call, wherein they decided to forward the question on to the Meaningful Use CoP. 

We've been so focused here in Vegas on helping getting our high maintenance clinics' numerator/denominator measures up to snuff (along with the onerous and unloved Core 15 "PHI Security Risk Analysis and Mitigation") that some of us (mea culpa inclusive) have failed to remember and emphasize that. I've always asked to see if the functionalities cited were "turned on," but have not verified that they were so for the entire period (and, from system to system, userid date-time stamp audit log information availability may be problematic).

David from our SLC REC staff set us straight on that point. Wyatt from SLC also rightly observed that, absent such a requirement, EPs could enable the functionalities in question on Day 89 and "attest," contravening the intent of the measures (though, why they would choose to do that given the ease of setup escapes me).

Verbatim, from the CMS guidance detail:
Core Set Items
  • Clinical Decision Support: Eligible professionals (EPs) must attest YES to having implemented one clinical decision support rule for the length of the reporting period to meet the measure.
  • Implement drug-drug and drug-allergy interaction checks. The EP has enabled this functionality for the entire EHR reporting period.
Menu Set Item
  • Implement drug formulary checks: The EP has enabled this functionality and has access to at least one internal or external formulary for the entire EHR reporting period.  Exclusion: Any EP who writes fewer than 100 prescriptions during the EHR reporting period.
Being Wrong. It sux.

More to come...

Friday, September 28, 2012

Time to play nice

I saw your latest blog post, including the piece about ARCH-IT.  It's nice to know that others are paying attention to what we've been doing, even if it isn't evident on our website. Much as I would like to report more website progress--as well as a launch date--that would be premature.  Suffice it to say that we are working on it, but our other work has been somewhat more urgent.  And yes, due to your prodding, we are making our website development a much higher priority.

In other news, I am pleased to report that our membership continues to grow.  We now have more than 20% of RECs as members, and we are actively in discussions with a number of others.  But perhaps more importantly, we have had a host of fruitful meetings with members of congress to educate them about the good work that REC programs are doing.  For example, over the summer I met with staffers from two senate offices, and just this week I met with committee and legislative staff serving the Energy and Commerce's Subcommittee on Health. It was a great meeting, and they are pleased to hear both about ARCH-IT and what RECs are doing in districts around the country.

At ARCH-IT, we have mostly been focused on member recruitment and on government relations, with a growing focus on program development.  We are exploring a number of initiatives to bring RECs with similar revenue generation models together, as well as to leverage the REC purchasing power on behalf of RECs.  Given the heterogeneous nature of REC programs, we're focusing the business opportunities, not on a total business model.  Sustainability is THE hot button issue right now.  We hope to make a program announcement in the coming weeks which I hope you'll attend.

Of course, you should know that, unlike the RECs, ARCH-IT didn't even start with seed funding, so we're not only doing this with limited staff, but with limited funds, too.  I realize this is all chicken and egg kind of stuff, but given that we have only existed since April, I'm pleased with our progress, even if I'm not yet satisfied with the results.  Your involvement and your clear web savvy would be a huge help, if you're willing to lend us a hand. 

Again, I want to thank you for keeping us honest with regard to our website development, but I assure you that a lack of reported activity via the website is not the same as no activity.

Should you have any questions, please don't hesitate to reach out to me.  I can be contacted as noted below, and would welcome an opportunity to talk to Healthinsight about joining ARCH-IT.

I look forward to speaking to you soon.



David M. Bergman
Executive Director
Association of Regional Centers for Health Information Technology

Hi, David

I pay attention to everything HIT, every day.

I will post this on my blog -- with your permission, -- and I will quit cracking on you. Thanks for not taking personal offense. I bet I've irritated some of your startup participants. But, we're all after the same goals, and I always have taken pains to not call anyone out by name.

And, yes, you can count on me to help. I offered that at the outset, I believe, and never heard a word in response. I believe my reaction at the time was "I guess I'm just too radioactive."  :)

BTW- Health 2.0 granted me a press pass for the San Francisco conference Oct 7th to 10th, so I'll be there soaking it all in.

Amid distractions...

BTW, my Congressman is Joe Heck. I've talked with one of his staffers (nice young man) about the reported pending House Energy & Commerce Committee hearings on the Meaningful Use program. From the looks of the website, it seems like of their content was written by Sean Hannity's writers. Garishly hostile. So, I would expect that any Meaningful Use hearing would largely be an accusatory star chamber exercise via which to bash HHS/CMS/ONC.

I offered to come on my own dime and testify re my in-the-trenches POV. I rather doubt they'll take me up on it. Nothing's scheduled yet, anyway. They may have bigger fish to fry right now.

Good to hear from you.




Well, my apologies for not taking you up on your offer a little sooner--I'd love your help.

Can we set up some time to talk next week?  Thank you!

Yes, you should feel free to post this--I wrote it with that in mind.

I'm aware of the MU hearing, but was told that it wasn't scheduled yet.  I was also told that we (Arch-it) would be a great addition. I'll keep you posted on any developments on that front.

Thanks again for your prodding!


How about 9 Pacific next Tuesday, Oct 2nd? (noon your time) I can call you.

My Mondays are always hell, meetings all day.


Sorry, Bobby.  I can't do Tuesday.  How about Thursday?  Say 10:00 AM PDT? 



OK. Want me to call you?


Sure. Thanks,


It's all good.


I'm not the only wiseass out there in Snarkland:

Blog: An empty-chair conversation with Eric Holder on EHRs
Here’s a conversation somebody should have had with an empty chair.

Let’s pretend the chair is U.S. Attorney General Eric Holder.

“You know, Mr. Holder, we pay doctors as if they're sewing shirtwaists in some sweatshop loft in New York's garment district in the 19th century. If they whip in some more-elaborate stitching, so to speak, we try to keep track of that and pay them a little more, but basically, we just pay them like pieceworkers.

“So, Mr. Holder, work with me on this analogy.

“Let's suppose, instead of making them sew (i.e., treat patients) the old-fashioned way, whipping in stitches (I mean documenting their work) with needle (pen) in hand, let's make them all get pedal-powered sewing machines (by that, of course, I mean electronic health-record systems).

“Old ways die hard, Mr. Holder, and the best of these machines are, admittedly, kinda clunky, but still, I think we can sell the docs on switching over to them by explaining that once they buy and install the machines and once they figure out how to use them, they should be able to crank out in a given day a lot more shirtwaists (by that, I mean patient visits).

“But this is the real selling point, Mr. Holder. With the machines, the docs' production of the more-difficult, intricately stitched shirtwaists (the more thoroughly evaluated patients) will jump. That'll be good for the patients and docs, particularly if we don't change the piece rate.

"So, the sales staffs of the machine vendors will sell the docs on the machines by saying they're gonna make a lot more money. It's brilliant.

“We can try this first as a pilot, Mr. Holder. Then, we'll toss in a few billion bucks for down payments on new machines. We'll get all that money back and more through the docs' increased productivity.

“But wait, just thinking out loud here: Won't we have to pay the docs more? Because once they get handy with these machines, they'll produce more, especially the higher-cost stuff.

“What's that, Mr. Holder? You've got an idea? Cut the docs' piece rate, right?



“Accuse the docs of fraud?


“You're kidding, right?

“You'll come off like Claude Raines in Casablanca.

“Didn't we just tell the docs to use the machines?

“And what if this all comes down in an election year?

“OK, so you figure, it's a big country, someone will have to be using the machines up against the chalk lines. Right, and then you say, 'I'm shocked, shocked!' Just like Claude Raines. We'll have a couple of show trials and the docs will dial it down on their own.


“Do you really think it will work?

“Nah, me neither.”


Can't have enough visual analogies. Let's say you start in the lower left, at "8 o'clock a.m.," and then go around in circles every day (often shutting of the lights and going home by 7 pm if you're lucky).


Uplift Medical, P.C. (Uplift) failed to provide forty-one individuals with timely access to their medical records and failed to cooperate with an HHS investigation of complaints regarding the company's noncompliance with HIPAA. Uplift argued that the medical records were not available because they were being used in a criminal hearing. As a result, HHS proposed a $4,351,600 penalty. Seems reasonable? Uplift did not request a hearing to challenge the penalty which was subsequently imposed by HHS.

Surprisingly, Uplift was no more cooperative in paying the fine than in cooperating with the investigation. As a result, HHS filed a complaint against Uplift and its owners to collect the penalty, alleging that Uplift continued operating after its corporate charter had been forfeited. HHS contended, and the court agreed, that Uplift had become a de facto partnership and its owners were therefore liable for the HIPAA civil money penalties as de facto partners. The court also held that the owners were barred from challenging the penalty for failure to exhaust their administrative remedies, by requesting a hearing and by the doctrine of res judicata.
Interesting (PDF).

Tuesday, September 25, 2012

The 2014 CEHRT 3rd Wave

So, after work tonight I downloaded and combined the draft NIST 2014 CEHRT stds to date in Adobe Acrobat, "waves 1 through 3" (nearly 300 pgs).

After which I keyword-searched the following:
  • usability;
  • ease of use;
  • efficiency; and
  • workflow.
"Usability"? Nada. Zilch.
"ease of use"? Nada. Zilch.

"efficiency"? Maybe 8 references, all unrelated to "usability."
"workflow"? 13 or so, all also unrelated to "usability."

2014 Edition Test Procedure for §170.314.a.16
Electronic medication administration record – inpatient setting only For Public Comment, September 21, 2012

The Tester shall use and apply the provided test data during the test, without exception, unless one of the following conditions exists:
  • The tester determines that the Vendor-selected message format requires some modification to the test data.
  • The Tester determines that the Vendor product is sufficiently specialized that the provided test data needs to be modified in order to conduct an adequate test. Having made the determination that some modification to the provided test data is necessary, the Tester shall record the modifications made as part of the test documentation.
  • The Tester determines that changes to the test data will improve the efficiency of the testing process; primarily through using consistent demographic data throughout the testing workflow. The Tester shall ensure that the functional and interoperable requirements identified in the criterion can be adequately evaluated for conformance and that the test data provides a comparable level of robustness.
CMS/ONC/NIST have effectively just punted on the "usability" thing this time around.

"Stop it! This is Hard!"

BTW: I found this repetitive statement equally revealing:
Any departure from the provided test data shall strictly focus on meeting the basic capabilities required of EHR technology relative to the certification criterion rather than exercising the full breadth/depth of capability that installed EHR technology might be expected to support.
Emphasis mine. I keep having that Clinic Monkey Moment.

So, here's the logic: EHR "usability" will flow naturally as a byproduct of vendors having a "QMS" in place (Quality Management System). I guess they'd intended to promulgate one, but, well...

From the 2014 CEHRT Final Rule (pdf):
We have adopted a certification criterion that accounts for the fact that we did not publish the quality management document as we had proposed. The certification criterion we have adopted is more general and provides more flexibility. The certification criterion expresses that for each capability an EHR technology includes and for which that capability's certification is sought, the use of a QMS in the development, testing, implementation and maintenance of that capability must be identified. Unlike our proposal, any QMS may be used to meet this certification criterion and even an indication that no QMS was used for particular capabilities for which certification is requested is permitted. The commenter who stated that they are implementing the FDA’s Quality System (QS) regulations (for example, under the MDDS rule) would – by definition – be meeting this certification criterion so long as they cite their compliance with FDA’s QS regulations for certification. Given this flexibility, we cannot foresee any reason why this certification criterion cannot be satisfied nor do we believe that it will be a significant burden to indicate the QMS used (or not used) in the development of capabilities for which certification is sought.

We understand that some EHR technology developers have several teams who work on different functional components of EHR technology. In the case where the whole development organization uses the same QMS (or not at all) across all teams, then this certification criterion may be met with one report. Where there is variability across teams, the EHR technology developer will need to indicate the individual QMS’ followed for the applicable certification criteria for which the EHR technology is submitted for certification.

We encourage EHR technology developers to choose an established QMS, but developers are not required to do so, and may use either a modified version of an established QMS, or an entirely “home grown” QMS. We also clarify that we have no expectation that there will be detailed documentation of historical QMS or their absence. As specified above, we believe that the documentation of the current status of QMS in an EHR technology development organization is sufficient.
[pp 106-107]
Emphases mine.

I have searched my PDF Waves 1 through 3 NIST stds repeatedly. Neither the acronym "QMS" nor the phrase "quality management" appear anywhere therein. I guess NIST didn't get The Memo.

Maybe I'm missing something. I again reviewed ARRA/HITECH itself (pdf):

Subtitle A—Promotion of Health Information Technology


The Public Health Service Act (42 U.S.C. 201 et seq.) is amended by adding at the end the following:

42 USC 300jj.    ‘‘SEC. 3000. DEFINITIONS.

‘‘In this title: ‘‘(1) CERTIFIED EHR TECHNOLOGY.—The term ‘certified EHR
technology’ means a qualified electronic health record that is certified pursuant to section 3001(c)(5) as meeting standards adopted under section 3004 that are applicable to the type of record involved (as determined by the Secretary, such as an ambulatory electronic health record for office-based physicians or an inpatient hospital electronic health record for hospitals)...
Again, emphasis mine. So, it's within the purview of HHS to set forth the specs of certification -- inclusive of requiring vendor documentation (or not) of an operative QMS. Well, I guess they're not exceeding their regulatory Brief.

Quite the contrary.

BTW, I'm not the only crank here.

EHR Certification 2014—Darwinian Implications?

The final EHR certification criteria for 2014 were released a few weeks ago, and I am surprised by how many of the more forward-thinking proposals made it into the final set.  The proposed criteria, released in March, contained suggestions that I thought were good ideas (e.g., usability testing, price transparency, and data portability requirements), but which seemed unlikely to survive the comment period.   I was shocked to see they made the cut!  Since these criteria affect how products are developed and sold, they may very well change the dynamics of the EHR market by helping some vendors and hastening the demise of others.  Their impact on the EHR market could be huge!  Let’s take a closer look at the three with greatest potential impact.

Usability Testing
This was the biggest surprise.  I thought usability testing would become part of certification, but not for the 2014 cycle. According to comments received by the ONC, EHR buyers liked the idea–vendors, not so much...

EHR usability rises to the forefront
September 27, 2012 | Bernie Monegain - Editor

Interview excerpt, Robert Tennant, senior policy advisor for the Medical Group Management Association:
Q. Is it a good idea to have usability as one of the measures for EHR certification?

A. I really think it’s a good step for ONC [the Office of the National Coordinator for Health IT] to start pushing the vendors toward more user-friendly systems, because if they’re not easy to use, it slows the clinician down, which we certainly don’t want to happen. It can frustrate them. It could lead to errors, and not taking full advantage of what these systems offer the clinician. User friendliness is especially important for what I would call the next wave of clinicians to adopt EHRs. The first wave, many of them had the systems in place, [and] a lot of them were technology-savvy. Now we’re trying to get at those physicians that aren’t necessarily technology-savvy. It’s absolutely critical that the interface be very friendly. Again, that’s going to increase the adoption rate among physician practices.

Q. Why has usability not been a consideration from the get-go?

A. We've been pushing the idea of usability for a long time. I was involved in the formation of CCHIT, the Certification Commission for Health Information Technology, which one of the six ATCBs now authorized to certify these products. I remember in the early days of CCHIT, I kept saying, "You know it’s not good enough just to test the functionality. If it takes a thousand keystrokes to get to something, well, it’s not very user friendly." The pushback came from two sides. One was from CCHIT, saying, "Well I don't know if we can test that. It’s difficult; it’s subjective." And the vendors themselves were leery about including usability in the testing criteria. We continued to harp on it over the years, and finally CCHIT added it to their test script. They have a whole protocol now in place to test it. My understanding is the product is assigned a rating from 1 to 5 in terms of its usability.


Implementation of a health IT product is one of the most challenging and time- consuming stages of the health IT life cycle. A database of user experience, including identification of new safety risks, would provide organizations with suggestions for ways to improve the efficiency, effectiveness, and safety of implementation. These organizations will benefit from lessons learned by similar health care organizations about how to improve the performance and safety of their existing systems. The information may include ideas on effective product upgrade practices or applications, safety risks associated with a specific vendor’s product, warnings about data entry combinations that could result in erroneous clinical orders, or suggestions for ways to enhance user training.

Health professionals responsible for setting up and managing clinical information ex- change will benefit from data on user experiences. The integration of health IT products with other clinical IT products (e.g., picture archiving and communications systems, pharmacy systems) and devices is complex and requires a significant amount of upfront configuration to en- sure that data are not lost or corrupted along any phase of the information exchange. A user experience database will help identify integration-related problems to avoid.

Health care organizations should also find comparative user experiences useful for workflow redesigns and new personnel infrastructures needed in a health IT–enabled health care system. In addition, organizations need to plan for the appropriate time and approaches to decommission an existing system. This can be facilitated through review of reports submitted by other health care organizations at similar stages of their health IT products’ life cycles. Many of these organizations will likely be working on the process of replacing their products with new products and should have information to share about what has worked well for them and what problems they encountered during the transition.

Ideally, this information could be parsed so that consumers of the data could easily find information relevant to their particular questions or contexts. In addition, an open and transparent approach to sharing user experience could create organic learning communities among different categories of professionals within the health care industry.
What's not to love there?
Multi-Modal Approach to Characterizing and Comparing User Experiences

No single measure can meet all needs for comparative user experiences. Different audiences—clinicians, vendors, implementers (e.g., chief medical informatics officer [CMIO]), organizational decision makers (e.g., board of directors)—will have different needs. Furthermore, no single measure can fully capture the strengths and weakness of a particular health IT product. Thus, multiple modalities of acquiring and reporting user experiences are recommended, including

  • in vitro “flight simulator” laboratory evaluation of test scenarios; 
  • in vivo point-of-use reporting; 
  • data mining of use patterns; 
  • third party–administered user surveys;
  • direct user-to-public reporting; and 
  • a formalized system of hazards reporting (see Table 1).
Some modalities will have more scientific rigor, such as formal surveys and “flight simulator” lab testing, while other modalities will be less scientific, but will provide an opportunity for input from a large number of users and hold the potential for discovery of unanticipated user experiences...
Stipulated. Nice report (PDF). Read the whole thing.
At present, some vendors prohibit users from sharing screenshots and otherwise effectively communicating with others about a problem with an EHR. There is currently no place for health IT users to share publicly the experiences they have had with their health IT products. However, even if a place were designated and developed a following, its use would be limited because of contractual prohibitions on sharing screenshots.
A voluntary multi-modal, multi-stakeholder approach to health IT safety reporting and communication may deter a more heavy-handed approach to regulating health IT vendors. Regulation by the Food and Drug Administration is a serious possibility on the horizon if improve-ment in health IT safety and usability is not achieved through a voluntary process...
The goal of collecting and publicly reporting user experiences is to improve products across the industry and promote safety. After a decade of development and experience, EHRs and other health IT products have not advanced sufficiently; nor have they been adopted widely and enthusiastically, in step with other consumer products such as smartphones and iPads. Some have referred to this as a market failure (Mandl and Kohane, 2012). With EHRs, unlike other consumer product areas, there has been little opportunity for cross-vendor comparison, which has stifled the evolution of this technology.

We believe that the development of meaningful metrics of comparative user experiences in domains such as cognitive workload, accuracy of decision making, time required to perform tasks, and implementation experience will support the purchaser in making wise decisions when choosing a health IT product, and will simultaneously provide the vendor community with incentives to improve products.
Finally, we believe that public reporting of user experiences, in a variety of forums, is essential to leveraging the power of the user and purchaser to affect change.
More thoughts on this shortly.


My Fetch FTP upgrade.

One, two, done, use...


Lucie wandered into my life in 1999, a red chow-huskie mix stray (one of my 3 rescue dogs and 1 rescue cat). She died slowly and peacefully in my arms last night. I shot that pic in the back yard earlier this year. I am heartbroken. It was a long night.

U Cal Davis HIE developments

California Health eQuality (CHeQ)

On May 16,2012, the California Health and Human Services Agency announced that IPHI had been selected to implement California's Health Information Exchange (HIE) programs under the State’s Cooperative Grant Agreement with the federal Office of the National Coordinator for Health Information Technology (ONC).

The administrative transition from Cal eConnect to IPHI is now complete; we appreciate your patience as we build out the California Health eQuality (CHeQ) website. In the interim, information on the status of funding opportunities begun during the transition is now available; new opportunities will be posted in the near future...


I relentlessly search out HIT related stuff every day and night. I should legally change my name to "Boolean Substring()"

I've increasingly noted, with a bit of frustration and irritation, that when I search out items via Google some of the top responses are links to my own REC blog!

Sept 28th update:

The comments section of this post just in oughta be interesting.


More to come...

Saturday, September 22, 2012

Weekend Updates

My quick Photoshop response to the "VDT' push. Shot the USB drive on my kitchen counter, imported it, and did the overlays. Plenty to say about this concept coming up. Some of you might recall the quickie iMovie/YouTube I did a while back.

And, yeah, I know, a PHR <--> Patient Portal is the significantly better way to go long-term, but, whatever works, and flash drives are way more convenient than burning stuff to CDs.

UPDATE: Quick news item:

10 EHR Vendors Pledge Patient Records Access Within Months
Joseph Goedert, SEP 21, 2012 11:51am ET

The Office of the National Coordinator for Health Information Technology recently challenged electronic health records vendors to have their systems support patients viewing, downloading and transmitting their health information by the 2013 HIMSS Conference in March.

View/download/transmit is an EHR functional requirement under Stage 2 of the meaningful use program. Four vendors initially took the pledge and the count now is up to 10. They are: Alere Wellogic, Allscripts, athenahealth, AZZLY, Cerner, eClinicalWorks, Greenway Medical Technologies, Intellicure, NextGen and SOAPware.

Vendors taking the challenge can Tweet their pledge to #VDTnow.


Again, After October 3rd, there will be some criteria regarding which you will be unable to make up any ground (i.e., once the doc has closed the note, she can't go back in and change any encounter-related data, including those needed for MU attestation).

On the Medicare side, having to attest in 2013 (no, it does not traverse the calendar year) will cost you $5,000 per EP, $3,000 of that in year one.


First three weeks of September are cookin'. I don't pay a whole lot of attention to my traffic numbers, as this is a non-commercial personal blog I use just to reflect upon my interests since I began my REC work. But, I gotta say, this is pretty nice to see. Probably has something to do with my getting the HIMSS12 and Health 2.0 Conference press passes.

If you're attending and have any topics/views you'd like to have me write about, give me an email shout and we'll hook up. BobbyG "at" BGladd "dot" com. Also, tweet me, @BobbyGvegas

This is pretty curious, my top traffic countries:

Norway? Norway?

Tusen takk, mine norske venner, og si hei til Ole Børud for meg!


Saw this linked in a tweet. Jeez...
Medicare Bills Rise as Records Turn Electronic

When the federal government began providing billions of dollars in incentives to push hospitals and physicians to use electronic medical and billing records, the goal was not only to improve efficiency and patient safety, but also to reduce health care costs.

But, in reality, the move to electronic health records may be contributing to billions of dollars in higher costs for Medicare, private insurers and patients by making it easier for hospitals and physicians to bill more for their services, whether or not they provide additional care.

Hospitals received $1 billion more in Medicare reimbursements in 2010 than they did five years earlier, at least in part by changing the billing codes they assign to patients in emergency rooms, according to a New York Times analysis of Medicare data from the American Hospital Directory. Regulators say physicians have changed the way they bill for office visits similarly, increasing their payments by billions of dollars as well.

The most aggressive billing — by just 1,700 of the more than 440,000 doctors in the country — cost Medicare as much as $100 million in 2010 alone, federal regulators said in a recent report, noting that the largest share of those doctors specialized in family practice, internal medicine and emergency care...
Over all, hospitals that received government incentives to adopt electronic records showed a 47 percent rise in Medicare payments at higher levels from 2006 to 2010, the latest year for which data are available, compared with a 32 percent rise in hospitals that have not received any government incentives, according to the analysis by The Times.

The higher coding has captured the attention of federal and state regulators and private insurers like Aetna and Cigna. This spring, the Office of Inspector General for the federal Health and Human Services Department warned that the coding of evaluation services had been “vulnerable to fraud and abuse.”

Some experts blame a substantial share of the higher payments on the increasingly widespread use of electronic health record systems. Some of these programs can automatically generate detailed patient histories, or allow doctors to cut and paste the same examination findings for multiple patients — a practice called cloning — with the click of a button or the swipe of a finger on an iPad, making it appear that the physicians conducted more thorough exams than, perhaps, they did.

Critics say the abuses are widespread. “It’s like doping and bicycling,” said Dr. Donald W. Simborg, who was the chairman of federal panels examining the potential for fraud with electronic systems. “Everybody knows it’s going on.”...

Many hospitals and doctors say that the new systems allow them to better document the care they provide, justifying the higher payments they are receiving. Many doctors and hospitals were actually underbilling before they began keeping electronic records, said Dr. David J. Brailer, an early federal proponent of digitizing records and an official in the George W. Bush administration. But Dr. Brailer, who invests in health care companies, acknowledged that the use of electronic records “makes it faster and easier to be fraudulent.”

Both the Bush and Obama administrations have encouraged electronic records, arguing that they help doctors track patient care. When used properly, the records can help avoid duplicate tests and remind doctors about a possible diagnosis or treatment they had not considered. As part of the economic stimulus program in 2009, the Obama administration put into effect a Bush-era incentive program that provides tens of billions of dollars for physicians and hospitals that make the switch...

Some contractors handling Medicare claims have already alerted doctors to their concerns about billing practices. One contractor, National Government Services, recently warned doctors that it would refuse to pay them if they submitted “cloned documentation,” while another, TrailBlazer Health Enterprises, found that 45 out of 100 claims from Texas and Oklahoma emergency-department doctors were paid in error. “Patterns of overcoding E.D. services were found with template-generated records,” it said.

The Office of Inspector General is studying the link between electronic records and billing...
Wow. Read the entire article, along with the 140+ comments (linked in the title). The touting of HIT is not going to get any easier. Add to the foregoing the pending conversion to ICD-10... May we live in interesting times.

We were cheerleading the notion of legit and defensible "upcoding" via EHRs all the way back during the DOQ-IT program (all part of the endless "ROI" pitch). I knew back then it was only a matter of time before there'd be major pushback on the payor side.

Expect the claims adjudication fighting to get ever more intense.


Center investigation suggests costs from upcoding and other abuses likely top $11 billion
by Fred Schulte
Thousands of doctors and other medical professionals have steadily billed higher rates for treating elderly patients on Medicare over the last decade — adding $11 billion or more to their fees and signaling a possible rise in medical billing abuse, an investigation by the Center for Public Integrity has found.

Medical groups argue that the fee hikes are justified because treating seniors has grown more complex and time-consuming, both due to new technology and declining health status. The rise in fees may also be a reaction, they say, to years of under-charging, and reflect more accurate billing. The fees are based on a system of billing codes that is structured to make higher payments for treatments that take more time and effort...

Among the investigation’s key findings:
  • Doctors steadily billed Medicare for longer and more complex office visits between 2001 and the end of the decade even though there’s little hard evidence they spent more time with patients or that their patients were sicker and required more complicated — and time-consuming — care.  The higher codes for routine office visits alone cost taxpayers an estimated $6.6 billion over the decade.
  • More than 7,500 physicians billed the two top paying codes for three out of four office visits in 2008, a sharp rise from the numbers of doctors who did so at the start of the decade. Officials said such changes in billing can signal overcharges occurring on a broad scale. Medical groups deny that.
  • The most lucrative codes are billed two to three times more often in some cities than in others, costly variations government officials said they could not explain or justify. In some instances, higher billing rates appear to be associated with the burgeoning use of electronic medical records and billing software.
  • Medicare administrators have struggled for more than a decade to crack down on medical coding errors and abuses, often in the face of opposition from medical groups including the American Medical Association, which helped design, and now controls the codes. Whether they make honest mistakes or engage in willful misconduct, there’s little chance doctors who pad their charges will face any serious penalties.
...Medicare officials deny the AMA and other medical groups have outsized influence over the payment system. But they concede that the system has been left in place for years because they could not reach an agreement on ways to improve it.

Most patients have no idea doctor pay scales exist because Medicare and other insurers don’t typically help people decipher them. As owner of the copyrights on the codes and their definitions, the AMA controls their publication and aggressively enforces its copyright.

Princeton University Professor Uwe E. Reinhardt, a prominent health care economist, said government officials could have paid the AMA a lump sum to develop the codes, simplified them and retained their ownership for taxpayers. Doing so would have opened up the process to public scrutiny and given patients a better understanding of health care finances. Other critics note that millions of seniors might help the government check on the veracity of medical bills if they knew the lingo and how to crack the codes.

“I wish I had some way to check up on the billing process,” said Judy Ryden, a retired community college teacher who is on Medicare and lives in Grants Pass, Ore. “Unless I had a degree in medical coding I have no idea what all that means. I can’t tell whether a charge is legitimate or not,” she said...
Again, read all of this. I found it here on THCB: Kill The Codes. Excerpt:
...Not long ago I asked readers what my time is worth on a per-hour basis.  Collectively and independently, they settled on a number of about $500/hr (see the comments).  Now look for a moment at what Medicare pays, even at its highest level of billing for a physician’s time for evlauation and management of a medical problem: for 40 minutes of a physician’s time, it’s $140 (or $210/hr) before taxes.  Again, we see another disconnect as to how doctors are valued in our current system.

Doctors are working long hours to collect these fairly low fees from Medicare while jumping more hoops than ever to do so.  They have become pseudo-experts at the coding game, trying to get as much money for their extra efforts as legally possible.  But these fees paid by Medicare do not cover payments for time spent on phone calls, e-mails, and working insurance denials.   These services are still considered by our system as gratis. To partially counteract this coding problem, doctors realized (and the government insisted) that doctors use electronic medical records.

But when independent doctors set out to implement these records they quickly discovered that the expense and long-term maintenance costs of local office-based EMRs could not compete with more sophisticated systems already in use by their neighboring large health care systems.  Because of ever-increasing cost-of-living and overhead costs, not to mention the threats of large fee cuts, doctors have migrated to large health systems faster than ever.  With the fancier electronic record at those systems (streamlined for billing, collections, and marketing) fields required for higher billing codes (but not always material to the problem at hand) are completed in less time.  So are doctors really the problem?

It depends on who’s looking.  Since every medical test and order is tied to a doctor’s name, then of course it looks like doctors are the problem.  And yet it’s the government who has mandated the codes, the requirements for chart completion, and the electronic records to which our electronic signatures are attached...


And, Mr. No Life is digging into May 2011 update of DURSA. Pretty interesting, actually. My recommendation to HealtHIE Nevada brass is that we leverage the experiences of those who've already gone down this path. No sense re-inventing wheels. HIPAA (and related) compliance gets you a good bit of the way to being a successful DURSA signer, but there are also a lot of technical testing specs to engage and document to demonstrate Trusted Secure Messaging.

Consistent weaknesses in sections of the Millenium clinical information System (CIS) are revealed in the combined study of the ERD, logical schema and the data tables. PK values are not always defined unambiguously at the design level and data tables reveal inconsistencies in declarations and data validation. There is evidence that keys are managed by software within the application rather than by the in-built functions available in the database management system leading to less confidence in data integrity.

Health reform is pressuring hospitals, health systems, and physician groups to demonstrate value, not just generate volume and that IT improvement has to be seen as part of that drive. To meet this challenge, all members of the care team will need to break down silos and collaborate more closely than ever before. Building trust with IT services is essential, but at the same time this will not occur without IT staff becoming committed to primarily clinical objectives. Success will require the enthusiastic engagement of physicians through the use of sophisticated CIS in quality improvement — and not just on isolated projects. This next level of interdependence and collaboration — known as clinical integration — is vital to any enterprise seeking improved quality, patient safety, and value. This study analyses the deployment of Firstnet in Emergency Departments from the viewpoints of ED Directors, systems analysts and software engineers and observes that the support needed by the EDs comes up well short of what is needed and that the shortfall is attributable to both the Health Support Services of NSW Health and the technology itself. If this situation is not rectified then the promise of the gains of the IT Age for clinical care will be well and truly squandered.

This document consists of a study, in 9 sections, into the deployment of the Firstnet software in the Departments of Emergency Medicine in New South Wales, Australia. The first section was published in October 2009 and later reissued in November 2009 (Part 1). Seven sections (Parts 2-8) cover work completed in the second half of 2010 and are published here. The ninth and final section captures the context in which this study was completed. It is a summary of five years research into the design and construction of clinical information systems and was published as a conference paper in November 2010.

The titles of the 9 sections are: 
  1. A Critical Essay on the Deployment of an ED Clinical Information System ‐ Systemic Failure or Bad Luck? 
  2. Discussions with ED Directors: Are we on the right track? 
  3. Discussions with Software Performance Experts. 
  4. Conceptual Data Modeling. 
  5. Database Relational Schema and Data Tables. 
  6. Coalescing the Analyses of the ER Diagrams, Relational Schemata and Data Tables. 
  7. The Integrated Assessment.
  8. Future HIT Regulation Proposals.
  9. Ockham’s Razor of Design: An Heuristic for Guiding Design and Development of a Clinical Information Systems Generator.
This kind of stuff is red meat for people like me.

I've post all of the unzipped PDF sections here.  

"PK values are not always defined unambiguously at the design level and data tables reveal inconsistencies in declarations and data validation."

Ya think?

(btw, "PK" means "Primary Key," a continuing bane of tight software development.)

It's not pretty. e.g.,

Compilation of Weaknesses
A complete study of each table and our observations about their weaknesses are presented in Appendix 1. A compilation of the principal weaknesses identified in the available schema and data tables has been collated in Table 2. The results show that there is no schema or table without a weakness of some kind. The most persistent weaknesses across the data set are non-integer PKs and non-declared FKs. Issues that would represent the highest risk for user sites would be: doubtful PKs, misnamed PKs, and overloading attributes as these potentially can interfere with more fundamental aspects of data management and hence veracity. Other weaknesses if they create disturbance to data will tend to be isolated to single items such as a single patient or pharmacy record.

Weaknesses in CIS implementation suggest a lack of attention to detail, particularly specific testing to validate schema designs and index/FK and PK selection. If the yellow key icon is truly an FK indicator then the apparent use of FKs for creating indices rather than their purpose of maintaining referential integrity is a misapplication of this functionality.
Identified weaknesses could reasonably be expected to produce faulty processing of user data manifesting as problems such as, missing parts of patient records, missing information about pharmacy products. Particularly, these occurrences will appear occasionally without any apparent systematic behaviour as they will not be triggered by each and every patient record but rather only where a particular record uses a combination of information that requires the correct data relationships. Hence any one clinical user will observe a fault on occasions so far apart in time they will not connect a set of failings as being related to an underlying systematic weakness.

That last paragraph is very important. Complete Part 5 PDF document here. Pretty cool; full of tables and screen shots of the various schema relational dictionary tables.

I know just a thing or two about RDBMS architecture, dated as my experience may be in some ways. While data types and functionalities have changed and grown (along with code bloat), the core, necessary logical / linkage concepts have not.

I can't believe we're still extending so much scut-work effort on de-duping stuff in our Microsoft CRM at the office.


Margalit never disappoints.
The health care crowd is abuzz with The New York Times revelation that Medicare billing rates seem to have increased by billions of dollars in parallel with increased adoption of EHR technologies for both hospitals and ambulatory services. The culprit for this unexpected increase is the measly E&M code. Evaluation and Management (E&M) is the portion of a medical visit where the doctor listens to your description of the problem, takes a history of previous medical issues, inquires about relatives that suffered from various ailments, asks about social habits and circumstances, lets you describe your symptoms as they affect your various body parts, examines your persona and proceeds with diagnosing and treating the condition that brought you to his/her office or hospital.

The more thorough this evaluation and management activity was, and the more complicated your problem is, and the more diagnostic tests are reviewed, and the more counseling the doctor gives you, the more money Medicare and all other insurers will pay your doctor. Makes perfect sense, doesn’t it?...

...There are ... administrative functions embedded in larger EHRs that allow those who employ physicians to ensure that the docs click on all the necessary things to ensure optimal billing and payment. It is very easy to be critical of clinicians in these scenarios, but let’s remember that if Medicare wouldn’t have defined the value of a doctor visit to be proportional to the amount of text generated during the visit, none of this would have happened.

So the “unintended consequences” of pushing physicians to use EHRs seem to consist of doctors actually using EHRs, as effectively as possible, to document all the little details Medicare wants to see. This can only surprise people who had no clue what EHRs are, how they work, and how they are used in everyday practice, which did not (does not) prevent said people from proclaiming themselves as health care experts, best suited to set the national agenda for EHR design and adoption.

It'll be interesting to read the comments in response to her post as they accrue.


Payers are making mistakes on roughly 1-in-5 claims they receive. Even the most meticulous coding can't protect your practice from payer errors. (Read more here.)

Those mistakes are wasting an estimated $17 billion annually in needless administrative cost -- not to mention delaying payments for your practice. It seems that payers are making it almost impossible for you to get promptly paid in full.

Who has the time and resources to compare each payment, denial and underpayment with changing rules and contracted rates to ensure complete compensation?

With CareCloud Concierge, you do. Our comprehensive revenue cycle management service features:

  • Automated claims-contract reconciliation
  • Proactive compliance
  • Daily aging of receivables
  • Instant rules updates
  • Highly effective internal controls
  • Vigorous denial management protocols
  • Expert support and guidance
Take the headache out of getting paid with CareCloud Concierge.
An obvious marketing response to the recent stories of upcoding and other billing controversies. I now have a REC client using CareCloud. They recently dropped Alteer, in the wake of persistent, maddeningly poor support, and migrated over. I'll be paying a Meaningful Use support visit to them this week to assess how well things are progressing.


That's funny. Sort of.

More to come...