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Sunday, October 14, 2012

REC blog post 100

889 days, 100 posts. A labor of love.

Will try to wrap up my observations on my Health 2.0 SF Conference today. BTW: You might want to bookmark this as well.

Interesting tweet here.
More shortly...


The Office of Provider Adoption Support (OPAS) is responsible for helping health care providers utilize health IT effectively to improve the quality and efficiency of the care they deliver to their patients. Through the REC program, the Health IT Research Center (HITRC), and the Community College Workforce program, OPAS has developed a national network of organizations that are focused on supporting individual providers and assisting them to achieve meaningful use.

Examples of activities and processes led by OPAS include:

  • REC Program: As required by HITECH, Section 3012, ONC initiated the REC program, which offers technical assistance, guidance, and information on best practices to support and accelerate health care providers’ efforts to become meaningful users of certified EHR technology. As of December 2011, the 62 Regional Extension Centers have collectively recruited over 120,000 primary care providers and nearly 8,000 specialists to achieve meaningful use by 2014, surpassing the HHS High Priority Goal of recruiting 100,000 primary care providers to achieve meaningful use by 2014. Of the providers working with the RECs, by the end of 2011 nearly 60,000 were live on an EHR system that had e-prescribing and quality measurement functionality...
  • HITRC: As required by HITECH, OPAS established the HITRC. The office’s responsibilities include gathering relevant information on effective practices as well as helping RECs collaborate with one another and with relevant stakeholders to identify and share best practices in EHR adoption and meaningful use. The HITRC supports 14 Communities of Practice (CoPs), which focus on topics such as education and outreach, implementation and project management, workflow redesign, vendor selection and management, meaningful use, privacy and security, workforce issues, public health, etc. During the last eight months of 2011, the HITRC portal, which provides a virtual environment for collaboration amongst individuals focused on implementing and using health IT to improve health care, averaged over 40,000 hits per month. Since the launch of the HITRC Portal, more than 895 resources have been posted, including 127 articles, 17 Frequently Asked Questions, 45 reports, 531 tools, 105 trainings and 70 suggested websites. The HITRC also launched a Learning Management System (LMS) to provide on-line training to REC staff on key issues related to EHR implementation and meaningful use...
Notwithstanding the laudatory lip service, not one word asking for more REC money (PDF). They do, however, want 19 more FTE at HQ.

Note also: "...120,000 primary care providers and nearly 8,000 specialists to achieve meaningful use by 2014, surpassing the HHS High Priority Goal of recruiting 100,000 primary care providers to achieve meaningful use by 2014."

Stage 2 commences in 2014. REC money runs out in 2013, and we don't even get "Milestone" payment for anything beyond Year 1 Stage 1. While we feel obligated to be there for our REC clients who do two or three years in Stage 1 (while fielding Stage 2 queries), we don't get paid for any of that.

Kyle Murphy, writing for EHR Intelligence:

Meaningful use requires the “meaningful training” of health IT professionals, but there’s still the problem of affording these resources. Considering that the regional extension centers (RECs) created by the Office of the National Coordinator for Health Information Technology are set to expire with the close of Stage 1 Meaningful Use, it’s imperative that providers have access to reliable and affordable resources for future phases of the EHR Incentive Programs.

RECs are busily burrowing about trying to develop "sustainability" models in the face of this void, but I rather doubt that the efforts will support more than a fraction of existing FTE, as providers experience significantly increased compliance complexity, concomitant with declining incentive reimbursements.

J.D. Kleinke joked to me, deadpan, "don't worry Bobby; once Mitt wins the election, he'll fund all of this stuff."



His take on Health 2.0 SF. It doesn't get any better than this. Beat me to the punch on a bunch of riffs.

  ...Among the two dozen or so people I’ve known over the years and who have yet to be paroled from health care, the consensus at 2.0 was “these are mostly good products, not companies, there is too much overlap, they have too narrow a scope of functionality, and many need to be rolled up. But a few actually have replacement revenue potential.”
As for the first part of that consensus, nothing new here. Nor anything new about the classic chicken-and-revenue problem that has hampered Health 2.0 start-ups from the start. I’m hardly the first, and surely won’t be the last, to point out the obvious: health care is not lacking for great consumer information products, services, systems, or apps; those products etc. are lacking users, adoption, exposure, traffic, critical mass, revenue. By “revenue” I mean “cash,” from paying customers, not promises, sales pipelines, booked revenue, or even signed contracts with guarantees. And I certainly don’t mean investors’ cash. I’m talking about revenue from consumers, patients, providers, or any of the myriad third parties who are spending money today – just not happily.
That is why it was gratifying to see a mushroom of people with real-world jobs at 2.0, and even more gratifying to hear several entrepreneurs make references in their presentation to the “known spend” out there in their target markets. Also good to hear many in this newest generation of entrepreneurs calling them “markets” again, not “spaces” – worn out dotcom-speak for markets without actual revenue...
“Known Spenders” might actually buy that new product because they are currently spending a non-trivial amount of their company’s money trying to solve a problem the new product solves better, faster, and cheaper. What far too many Health 2.0 entrepreneurs still apparently do not understand: the Known Spender is usually not a household, but someone housed inside a corporation – which means their pitch needs a three-way (or more) value proposition, not the simpler two-way value prop – something I learned the hard way in my time with HealthGrades, a Health 2.0 company so old it was actually a Health 1.0 company before there was such a thing...

The sad truth about so many of the great products – or glorified product ideas – that we have always seen at 2.0 is that the world has never seen anything like them. They don’t replace any “known spend.” Rather, most seek to illuminate the enormous darkness surrounding the physician/patient “visit” that has been for a century, and that remains for the foreseeable future, the epicenter of the modern health care “system.” Many other 2.0 products shed light where a different army of Suits don’t want patients to go – alternative out of network providers, newly available surgeries, more expensive doctors, clinical trials. Luckily, the sheer march of technology everywhere else in our world – and the double-edged sword of ever higher cost-sharing by patients – forces more and more of the old guard to meet the new guard halfway.

And so the 2.0 audience ages. It fills with people who can actually implement a handful of its bold product visions, and is sprinkled with a few entrepreneurs who are catching on. These exceptions to the rule are not part of the latest generation in health IT who believe, as did Healtheon and Revolution Health, “if we build it, they will come.” They are building great new products and services to replace crappy old products and processes already included in somebody’s shrinking budget...
Read all of it. Beautiful.

This is why I am a REC grunt, and JD is a famous medical economist and major league policy wonk. I have total respect for his work and insights.

I was having my Moments at Health 2.0 SF, I have to say.

Gartner circa 2009. Three years later, it still looks like Groundhog Day at times.
Cue Joe Schumpeter.

JD will be here on Wednesday, BTW.

I may try to call in.

OH, BOY...

Outlawing Templated Notes in the Electronic Health Record

It was just a matter of time until this would happen.

Buried in the middle of this New York Times article on The Ups and Downs of Electronic Medical Records is the observation that a Medicare administrative contractor dubbed National Government Services has announced that it, on behalf of CMS, will “deny payment” for medical services that are documented in an electronic health record (EHR) using “cloned documentation.”

The topic was covered more than 2 years ago. “Cloned documentation” is the widespread practice of copying, pasting past documentation in an EHR into the current encounter record to inflate the recorded patient evaluation to primarily justify a higher payment. Thanks to this OIG report, the Feds have figured out that the true value proposition for an EHR is not “meaningful use” but wasteful abuse...

The Times article has been on my review to-do list since it broke.

I commented "I wonder what the Praxis EMR people would say about this."

AmericanEHR Partners Q and A: EHR adoption trends
Patrick Ouellette, October 16, 2012


Why do providers want to move between systems?
Vendors are growing incredibly fast because there’s so much money available. It’s a bit of a distorted market right now because you have many organizations with regional extension centers (RECs) that are encouraging EHR adoption. So the vendors are drinking from the fire hose in many respects; they’ve got so much coming at them. Supporting existing clients, upgrading clients to meet Stage 1 meaningful use etc… And having more than one product is tough as well. For example, Allscripts coming out and saying that they’re going to be consolidating and will not be supporting MyWay product upgrades to Stage 2 meaningful use, there’s going to be attrition with multi-product companies.

What’s the biggest EHR challenge for healthcare providers?
Usability is a massive challenge. Just fitting it into the workflow so they can maintain their relationship between the physician and the patient and it’s supportive toward what they’re trying to do: care provision.  And just behind is the data interoperability we just talked about.

Brookstone offers some interesting insight into what providers need from EHR vs. what they’ve been able to receive so far. Vendors seem to be aware that interoperability and usability are keys to driving EHR adoption. Hopefully for providers, changes start being made to the software with their needs and meaningful use requirements in mind...



Does EHR Use Lead To Lower Or Higher Costs? An Overview

Incorrect Assumptions Lead to Incorrect Conclusions That Misinform Policy

While Democrats and Republicans may each have their own take on how best to move our country’s physicians and hospitals from paper to electronic records, there has generally been broad consensus that widespread adoption of electronic health records (EHRs) is a necessary, if as yet imperfect, step in the evolution to better, safer and more affordable care.  While there have been challenges to the logic and effects of the HITECH Act and the CMS EHR Meaningful Use Incentive Program that have catalyzed greater EHR use, stories published in in two high impact newspapers last week raised additional serious questions about the conventional wisdom that EHR use will help contain increases in health care costs.

The first, published as an op-ed piece in the Wall Street Journal, takes the position that there is no evidence from four to five decades of research that EHRs save money, and that the current policy to use financial incentives to accelerate EHR adoption is misdirected.  The second, a report published in the New York Times, does not question the rationale behind the policy; instead, it presents the startling and disturbing finding that whatever policy makers were hoping for, there is evidence that doctors and hospitals with EHRs are using them to bill for more and higher complexity services – and are thus increasing costs.  Worse, the New York Times article suggests that much of the higher billing may be due to widespread electronic ‘science fiction’ in which doctors electronically record findings without actually ascertaining them, while their EHR coding software actively encourages documentation resulting in unethically and even criminally inflated bills.

Our initial reactions to these two pieces were mixed.  On the one hand, we were troubled by the possibility that EHRs could be directly and significantly contributing to billing fraud, a criminal activity that hurts everyone.  We applauded the speed and clarity with which the US Attorney General and Health and Human Services Secretary indicated that such fraud will be vigorously pursued and prosecuted.

On the other hand, as practicing primary care physicians with longstanding informatics leadership roles and experience in our respective organizations and professional societies, we have presented and published data from our own practices showing cost savings and quality gains from EHR implementation and optimization.  We have seen EHR coding decision support software from multiple vendors designed to facilitate appropriate billing rather than fraud.  We have reviewed enough of the primary literature over many years of research and have deployed enough of it in our own practices to believe that well- designed, implemented and optimized EHR systems used by trained healthcare professionals in a “meaningful” way can support improvements in health care quality and value.

In light of our experiences, we wondered how a recent study could yield such strong and conclusive evidence that the WSJ editorialists could reasonably conclude that the “savings claimed by government agencies and vendors of health IT are little more than hype.” We were also curious to understand the  evidence base behind the claims in the NYT report that there may be a widespread problem with EHRs encouraging doctors to document work they did not do to inflate their bills, and then using their EHR coding software to discover and document in a manner that would support fraudulent billing practices.  We also were mindful about other forces unrelated to billing fraud or EHR design that drive increased physician documentation but did not see much discussion of these forces in either the WSJ or NYT stories...
I find this an important contribution to the dialogue. Highly recommended. Read all of it, all six parts. Decide for yourselves.
...We do not need any more research that concludes the obvious, that ‘EHRs in and of themselves do not make care better, safer or less costly.’ We and most others already accept this, and current EHR incentive program policies reflect a similar conclusion through their incenting of meaningful use rather than EHR implementation and adoption alone. Studies of health IT effectiveness should look at system goals and the inherent financial incentives for performing or avoiding the performance of specific services. In that context, we should then examine whether health IT has an effect on adherence to goals, costs to achieve these goals, and other objectives.It is foolish to study health IT infrastructure divorced from how it is deployed and used.
The Meaningful Use incentive program is far from perfect; we are regular commentators for proposed rule enhancements and have no shortage of opinions as to what could be improved. However, on balance we believe that the Meaningful Use program is a reasoned one that has succeeded in accelerating movement of the health IT industry in a positive direction, and moving providers toward use of steadily improving health IT that will make care better, safer, and less costly. 
I will revisit this article shortly.

More to come...

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