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Wednesday, July 31, 2013

Meaningful Use Payments Update

$15.5 Billion paid out to date. Not much of an increase over the May numbers. To be expected, I guess.

More reporting:

Eight out of 10 eligible hospitals and 58% of eligible physicians and other medical professionals have received payments totaling $15.5 billion under the federal electronic health record incentive payment program, according to the latest CMS data.

Through June, 4,024 hospitals have shared nearly $9.2 billion dollars to adopt, implement, upgrade and/or meaningfully use certified EHRs under the Medicaid and Medicare EHR incentive payment programs created by the American Recovery and Reinvestment Act of 2009.

In addition, 305,778 physicians and other eligible professionals have been paid more than $6.3 billion under the Recovery Act’s Medicaid, Medicare and Medicare Advantage EHR incentive payment programs, the CMS report said.

There are 4,477 hospitals that have registered for the programs, which leave just 11% of the 5,011 eligible hospitals that have not registered. Meanwhile, 400,960 physicians and EPs have registered, which leaves 24% of the estimated 527,200 eligible physicians and other EPs that have not registered.
"4,024 hospitals have shared nearly $9.2 billion dollars to adopt, implement, upgrade and/or meaningfully use certified EHRs"

Note the weasely boolean "or." "AIU" (Adopt, Implement, or Upgrade to an ONC CHPL Certified EHR system) has been viewed by many skeptics as the "free money" part of the MU program -- a year one "baby steps" initiative for the more marginal Medicaid cohort. On the ambulatory side, if, say, you're a Medicaid Peds or OB provider, sign up for the "free" Practice Fusion and collect $21,250 year one AIU money per doc just for attesting "AIU"
-- without having to meet or exceed the MU Stage 1 criteria (and, notably, without having to comply with that pesky and onerous Core 15 ePHI Security measure set forth in 45 CFR 164.308 et seq).

Well, how are the RECs stacking up? From data I downloaded into Excel off the snazzy ONC Regional Extension Center Dashboard. M1 = you signed up an EP or EH, M2 = they began using an ONC Certified EHR, and M3 means they successfully attested and got paid.

Raw ordinal ranked data are only marginally useful. A variety of weightings would be needed (e.g., outlay per M3, total #of EPs in the state vis those who signed up for REC, REC time in the program, etc) to make better sense of these (and maybe they're mining this stuff internally at ONC, but they aren't publishing any findings publicly). For starters, these are state based data, and a number of REC contracts are multi-state / territory (e.g., two RECs in PA, Several in CA, Qualis covers WA and ID, and tight-lipped Hawaii has to deal with the far-flung Pacific Islands territories). 

My own REC exemplifies the problem. The high and mighty Health IT-leading Utah is #5; its bordering red-headed stepchild anarchic Nevada is 50th (49th, discounting DC) -- but, they are the same HealthInsight REC contract. But Utah, home to Intermountain Healthcare (IHC), is a largely homogenous state that has been an aggregate "early adopter" of HIT going all the way back to DOQ-IT and before. Nevada, on the other hand, is Ground-Zero of the late 2000's financial meltdown and foreclosure crisis.

I'm sure it cheeses certain Utah HealthInsight management to no end that Nevada is "dragging us down" (there's some vestigial QIO chafing there; NV was acquired by UT just prior to my first QIO tenure in 1993). Were one to pool UT and NV REC performance data into one REC contract look, HealthInsight would be solidly and unremarkably mid-pack in a raw data ordinal ranking.


I had no idea about Robert Downey Jr's vocal chops.

More to come...

Sunday, July 28, 2013

An EPIC Tale. Portending an EPIC Fail?

One of my compadres sent me this link the other day.


In the Boston marketplace, Partners Healthcare is is replacing 30 years of self developed software with Epic. Boston Medical Center is replacing Eclipsys (Allscripts) with Epic. Lahey Clinic is replacing Meditech/Allscripts with Epic. Cambridge Health Alliance and Atrius already run Epic. Rumors abound that others are in Eastern Massachusetts are considering Epic. Why has Epic gained such momentum over the past few years?

Watching the implementations around me, here are a few observations:

1. Epic sells software, but more importantly it has perfected a methodology to gain clinician buy in to adopt a single configuration of a single product. Although there are a few clinician CIOs, most IT senior management teams have difficulty motivating clinicians to standardize work.  Epic's project methodology establishes the governance, the processes, and the staffing to accomplish what many administrations cannot do on their own.

2. Epic eases the burden of demand management. Every day, clinicians ask me for innovations because they know our self-built, cloud hosted, mobile friendly core clinical systems are limited only by our imagination. Further, they know that we integrate department specific niche applications very well, so best of breed or best of suite is still a possibility. Demand for automation is infinite but supply is always limited.   My governance committees balance requests with scope, time, and resources. It takes a great deal of effort and political capital. With Epic, demand is more easily managed by noting that desired features and functions depend on Epic's release schedule. It's not under IT control. 

3. It's a safe bet for Meaningful Use Stage 2. Epic has a strong track record of providing products and the change management required to help hospital and professionals achieve meaningful use. There's no meaningful use certification or meaningful use related product functionality risk.

4. No one got fired by buying Epic. At the moment, buying Epic is the popular thing to do. Just as the axiom of purchasing agents made IBM a safe selection, the brand awareness of Epic has made it a safe choice for hospital senior management. It does rely on 1990's era client server technology delivered via terminal services that require significant staffing to support, but purchasers overlook this fact because Epic is seen in some markets as a competitive advantage to attract and retain doctors.

5. Most significantly, the industry pendulum has swung from best of breed/deep clinical functionality to the need for integration. Certainly Epic has many features and overall is a good product. It has few competitors, although Meditech and Cerner may provide a lower total cost of ownership which can be a deciding factor for some customers. There are niche products that provide superior features for a department or specific workflow. However, many hospital senior managers see that Accountable Care/global capitated risk depends upon maintaining continuous wellness not  treating episodic illness, so a fully integrated record for all aspects of a patient care at all sites seems desirable. In my experience, hospitals are now willing to give up functionality so that they can achieve the integration they believe is needed for care management and population health...
I have to say that, given that my particular REC project turf was almost exclusively small doc shop outpatient EPs, I've never gotten to kick the Epic tires or even watch it in action. It may be a perfectly fine, usable, featiure-rich project with great vendor support behind it for all I know.

Critics are not difficult to unearth, though. Foremost among the high-profile target is the Epic CEO herself, an Uber-geek straight out of Central Casting, but all the more notable for her gender.

An Interview With The Most Powerful Woman In Health Care
Zina Moukheiber, Forbes Contributor

Judy Faulkner might not be a household name yet, but in the health care industry, she’s simply known as Judy. She is the founder and chief executive officer of Epic Systems, a privately-held $1.5 billion (2012 revenue) company that sells electronic health records—a position that makes her one of the few self-made women on the Forbes billionaires list. Her customers are top medical centers, such as Cleveland Clinic, Geisinger Health System, and Johns Hopkins. She wields enormous influence. Almost half of the U.S. population will have its medical information stored in Epic digital records when hospitals finish installing them.

Faulkner, rarely, if ever, grants interviews. A year ago when I profiled her, she refused to speak. Because Epic shuns publicity and press releases, it is perceived as aloof; and criticism leveled at Epic regarding its business strategy is rarely challenged by the company. In a phone interview from Epic’s seat in Verona, Wisconsin, Faulkner acknowledged that.

Forbes: A year ago, you declined to be interviewed, what made you decide to talk now?

Faulkner: I’m recognizing that when we were small, we could stay under the radar, but now it’s harder. I get so many requests for interviews. If I talk to everyone, we can’t do our job with our customers and work on our software. It would be hard to stay focused.

I was an undergrad math major, and a grad student in computer science. I’m hugely introverted, not atypical of math majors. It’s not something I love [being in the public eye]; it’s a personality thing. I like to go around, and people not knowing who I am. I like to keep some privacy, be a normal person.

Forbes: With success comes visibility, plus you’re a woman who’s a computer scientist, who coded the original software for Epic. It makes for a good story.

Faulkner: If you line up the CEOs of major [electronic health record] companies, the CHEESI group–I came up with that to remember them all: Cerner CERN -1.97%, HBOC (now McKesson MCK +5.29%), Eclipsys (now Allscripts), Epic, Siemens , IDX (now part of General Electric GE -0.16%), what’s the primary difference? It’s funny, visually I’m the one woman, but I’m the only one with a technical background. That’s the main difference.

Forbes: Many things are said about Epic by competitors, but also by customers. One of them is that Epic is a closed system: it’s difficult to exchange patient information with other electronic health records; it’s hard for third-party vendors to integrate with Epic, and the technology is old. Is this totally wrong?
Read on...

The hits just keep on coming.
Judy Faulkner: Criticism that Epic system stymies interoperability 'unfair'
May 17, 2013 | By Dan Bowman
Responding to criticisms that Epic's electronic health record systems are closed and, thus, difficult to integrate with third-party vendors, CEO Judy Faulkner, in a rare interview granted to Forbes, called such accusations "totally wrong."

In fact, Faulkner referred to Epic as "the most open system I know," saying it's designed as a database management system.

"Database management systems need to allow their users to mold it to what they need," Faulkner told Forbes. "We interface with speech recognition, imaging, medical devices, lab, patient education content, user authentication and hundreds of different vendor systems."
Faulkner said claims that the company does not value interoperability are "unfair," adding that Epic systems were interoperable before government regulation came into play.

She also took a jab at the recently formed CommonWell Health Alliance in the Forbes interview.

Faulkner raised concerns about CommonWell at a Health IT Policy Committee meeting last month, saying that not initially being invited to be part of the alliance caused her to have doubts about its motives.

"What is it?" Faulkner, a policy committee member, asked rhetorically at the meeting. "Is it a competitive business? Is it a service? Will it be favoring those who started it and using those who did not start it as the means to feed the business? What components of business will be in it? Will it sell the data? Will there be patents?"...
Faulkner referred to Epic as "the most open system I know," saying it's designed as a database management system. "Database management systems need to allow their users to mold it to what they need."

OK, so, does this mean you'll share your RDBMS database dictionary with everyone?

Didn't think so.

Interesting Forbes article comment here in the wake of "Who Says Chief Information Officers Can't Lose By Choosing Epic?"
John Stokes: I think you are only beginning to scratch the surface of the difficulties providers and institutions face with regards to making a rational, informed decision about EHRs, and about the true, long-term total cost of ownership.

For any new EHR installation there is at least some form of “double hit”: The product cost and the lost productivity cost.

In contrast to the comment above that “there are literally thousands of other causes of decreased revenue immediately following ANY [EHR] implementation”, Epic stands out as the only EHR for which there is now a track record of failing hospitals immediately following their EHR implementation. A mere coincidence? No. It is because Epic’s execution and business strategy imposes and requires new, permanent, and massive increase in the fixed cost of operations of the organizations that they partner with. These are simply not sustainable. What are two of these “hits”?

The Epic product cost: The software and licensing is only a small part of this. The major costs come is in the massive time and funds spent on training, support, configuration, updates, and salaries of a large number of new full-time staff that the institution has to hire permanently (50 new FTE for a small hospital; 150+ new FTE for a large academic institution). At 100k with benefits, that is 5 to 15 million a year in new fixed operational costs.

The Epic productivity cost: No other EHR other than Epic requires 18 to 24 hours of full-time training for highly educated physicians to become ‘basic’ end users. This is a huge loss of time (two to four days) that physicians are not compensated, nor taking care of patients. As the prior commenter stated “Any responsible EMR vendor will suggest a lighter schedule in the first few weeks of a new system to allow staff to get acclimated”. To be precise, Epic recommends a 50% reduction in clinical workload during this “acclimation”, and then recommends a 25% reduction for at least several more weeks. Epic states that providers should be back to their baseline productivity after six months to one year. However, the reality is that after a year of using Epic, most physicians never recover their full level of efficiency, and are experiencing at least a 10% productivity hit. What are the financial costs of this?

A typical physician will see 40 to 50 patients a day, or 5-6 per hour in clinic. That leaves about ten minutes per patient for an entire encounter, including history, examination, prescription writing, and counseling the patient (including the new Meaningful Use required data entry requirements, etc.). So even as little as one or two minutes more per patient adds up quickly – lengthening the workday by one to two hours. With a loss of productivity of only one hour per day (above) at $100 per visit, that represents six patients, or $600 /day. At that rate the physician is losing $10k/month. Multiply that by the number of physicians working in your practice group or community hospital and you get millions in losses each month.

This loss of physician time may also be measured as an opportunity cost of seeing an additional five to ten patients per day. With all of the strains on the healthcare system, a shortage of primary care doctors (made acutely worse by an influx of 38 million newly ‘insured’ patients entering the system under the ACA) – can we really afford to waste the most valuable and essential asset of the entire healthcare system: physicians’ time?

Note that most of the 5800 hospitals in the US are not large, well endowed academic medical centers with both alumni and government giving billions to prop them up. Epic’s market is only those hospitals with at least 100 million to spend, which is some 200+ hospitals in the US. The remaining 5500 hospitals? They run on a razor thin margin of 1-2%, and where a few million here or there is enough to put them deep into the red. Epic is very selective in picking clients only that fit their one and only criteria: deep pockets.

It would be convenient to dismiss Epic’s role in the financial demise of a growing list of hospitals in the United States. Unfortunately, these are not coincidences. This is a real and consistent pattern, and correlates the physicians comments and surveys on usability. [Ignore the trade association surveys sponsored by the vendors under HIMSS and KLAS - these are meaningless technical specifications and laundry lists of features].

The arguments that Epic provides for failure is that is was ultimately the end-users fault. Yes, those stubborn, unteachable doctors who went through 24 years of formal education – through college, graduate, and postgraduate study and training – who happily use their smartphone, tablet, and laptop to do manage virtually every aspect of their life on the web. But we can’t get those doctors to learn how to use a 1992 vintage thick client with nested dropdown menus seven layers deep. Will Epic lead the way and take usability seriously? Or it will it continue to be a risk to the financial health of the institutions it is supposedly helping?

We live in dangerous times in HIT. In a few years, when the $27 billion subsidy program for EHRs dries up and the mad gold rush for EHR implementation is over – it will expose many more hospitals that over-extended themselves with their choice of Epic. I must concur with Ryan Champlin. That is a dangerous choice.

John Stokes: After reading my followup post here comparing the cost of two statewide hospital networks (Maine with Epic at $366 million; West Viginia with VistA at $8 million) there must be some fundamental reason that CIOs are willing to spend thirty times more for a product than another product.

Is Epic actually “better” than any other EHR? What do the end users have to say about Epic?

This survey on usability is directly from physicians (not via a vendor-sponsored surveys such as KLAS or HIMSS that emphasize vendor attributes such as ease of implementation, or length of feature lists).

These are ordered from lowest to highest rating.

EHR Overall Usability Rating (number of raters)

AHLTA 2.64 (49)
Siemens Soarian 2.73 (15)
Cerner 2.93
GE Centricity Enterprise 2.96 (57)
McKesson 3.1 (88)
Allscripts 3.06 (3)
Meditech 3.08
Partners Healthcare 3.34 (25)
EpicCare 3.51 (148)
Greenway 3.83 (69)
VistA: 4.06 (124)

This survey shows that usability of EHRs has gotten *worse* since Meaningful Use regulations came into effect in 2010. One factor may be that EHR vendors have focused their development efforts to satisfy these requirements rather than the requirements of their end users.

Note also that survey results of VistA were mostly from the VA, where they are using a non-Meaningful Use certified EHR. It appears that while commercial EHRs devote their energy to winning the buzzword compliance awards from KLAS, VistA remains steadfast on its commitment to its physicians.

Now, to your question. VistA is the #1 ranked EHR and more cost effective by a factor of twentyfold.

I can only guess that the reason CIO’s choose any system over VistA:

(1) lack of information: the VA does not have a marketing department
and get and and publicize its system.
(2) lack of vision: an institution does not see the value in open-source, in taking ownership of their own intellectual property and information infrastructure, in building internal capacity to support this, and in supportin their own user-driven innovation. They would rather outsource this to a proprietary vendor.
(3) lack of name brand recognition: The CIO does not want to get blamed for a failure, so chooses a big name company. (This is obviously untrue: how can you say the VA and its 1400 clinics and hospitals running VistA is not a large enterprise)
(4) lack of clinical and technical expertise: The CIO does not have the combined technical and clinical knowledge to appropriately assess EHRs, and therefore has to depend on superficial demos, marketing materials, word of mouth, or responses to RFI (which are simply marketing brochures, sans slick pictures).

Again, these are only guesses, but based on many observations. 
Whatever one thinks of this commenter's views, they comprise a refreshing, considered respite from the endless onslaught of bumper sticker quality anti-Health IT naysayers.

Epic's "Usability" assessment in the America EHR survey.

Interesting. a 4.01 high for "Document a progress note for each encounter."

You have to register an account with American EHR (free) to get at the full report for all surveyed systems.


Why Epic's market dominance could stifle EHR and health IT innovation
Brandon Glenn

Epic has attracted several notable critics, who warn that its market dominance could have harmful effects on the future of health information technology, EHRs and even patient care. Worse, these critics warn, Epic has achieved much of its market dominance on the backs of taxpayers.

Epic is the nearly undisputed king of the electronic health records world.
About 40% of the U.S. population has its medical information stored in an Epic electronic health record (EHR), and the company often sits atop research firm KLAS' rankings of best-available EHR systems.

Epic has plenty of big-name clients who've spent tons of money installing its expensive systems: $700 million from Duke University Health System; $700 million from Boston's Partners Healthcare; $150 million from the University of California, San Francisco; and $80 million from Dartmouth-Hitchcock Medical Center in New Hampshire, Forbes reported last year.

So it's not surprising that such a high-profile company has attracted several notable critics, who warn that its market dominance could have harmful effects on the future of health information technology, EHRs and even patient care. Worse, these critics warn, Epic has achieved much of its market dominance on the backs of taxpayers - courtesy of $35 billion in federal subsidies paid to hospitals and doctors to purchase EHR systems...

Aside from the taxpayer subsidies Epic has indirectly received, what really rankles the company's critics is Epic's lack of interoperability with other EHR systems, meaning that's it's a "closed" system that doesn't share patient data particularly well with doctors or hospitals who don't use Epic's software.

"If Epic (already based on an antiquated technology -- MUMPS) decides to maintain an essentially closed system, and to drive all innovation internally, this could prove stultifying, limiting the development of novel ideas, and forcing the many high-profile adopters of Epic to accept stagnation or pay the staggering costs of switching," wrote physician-scientist David Shaywitz in Forbes.

In other words, the "closed" nature of Epic's systems - coupled with its dominant market position - could mean that Epic ends up setting the defacto standards for EHR systems, effectively stifling innovations that its competitors might develop in the EHR market. That, in turn, could lead to Epic's big hospital customers - and those hospitals' patients - being frozen out from advances in EHR technology. ..

Then there's the question of to what extent American taxpayers are helping to subsidize Epic's market grab, courtesy of EHR incentive payments outlined in the Obama administration's 2009 stimulus bill. It's not a coincidence that the privately held company's sales have been skyrocketing in recent years, up to $1.2 billion in 2011, double what they were four years prior, according to Forbes.

It's also no coincidence that Epic and other major EHR players lobbied the federal government hard for the subsidies, and those companies "have reaped enormous awards because of the legislation they pushed for," The New York Times reported earlier this year.

Executives at smaller EHR companies say the legislation cemented the established companies' leading positions in the field, making it difficult for others to break into the business and innovate, according to The Times...
??? Ya think? I don't think Judy does.
Helping enrich Faulkner is ... a piece of government legislation [Meaningful Use] that subsidizes the adoption of electronic medical records, by paying millions to qualifying hospitals... Faulkner is also the only head of a company to sit on a government-appointed policy committee that makes recommendations on standards for the exchange of patient information.
- Epic Systems Tough Billionaire


Google "Epic EHR." Here are the first, above-the-fold responses I got.

Gotta love it. Paying for positioning. I bet Judy Faulkner could care less about all these ankle biters.

Below, gotta love this stuff as well (rolls eyes).


New on SBM
[T]he new CAM buzzword these days to explain why quackery “works” is epigenetics. Basically, whenever a proponent of alternative medicine uses the word “epigenetics” or “quantum” to explain why an alternative medicine treatment “works,” what he really means is, “It’s magic.” This is a near-universal truth, and even the most superficial probing of such justifications will virtually always reveal magical thinking combined with an utter ignorance of the science of quantum mechanics or epigenetics.

More to come...

Wednesday, July 24, 2013

Delay Stage 2?

That seems to be the consensus of testimony before the Senate Finance Committee this morning (I'm watching and listening live).

Senator Hatch Statement:
...I am most interested in hearing the thoughts of today’s witnesses about the timing of the various stages of Meaningful Use, and the requirements involved. Let me be clear, I think we need to hold people’s feet to the fire so that we continue to make strides in delivering high quality care.

If that means making requirements more stringent, then let’s have that conversation. However, as I said to our witnesses last week, we have to give organizations enough time to acquire certified technologies and appropriately train staff to use them.

Ignoring the question of whether providers have the ability to keep up will only hurt the

This transformation won’t happen overnight. But, having the right timelines in place is nothing short of a necessity for success.

Providers cannot afford to waste resources on systems that quickly become out of date as CMS and ONC change requirements over time. And vendors should be afforded very clear instructions as to what is expected as part of a certified system...
Witness Dr. Glaser advocates for making an additional year before Stage 2 optional, i.e., those who need it, take it; those who don't, commence to Stage 2 in 2014. Witness Mr. Fattig advocates three years in each stage.

Discussion comments consensus: "Interoperability" and "patient engagement" are the "most important elements of Stage 2.

11:55 EDT update: Witness Statements (PDFs) have been posted.

11:59: Hearing adjourned. Wow, that was quick. Not much new here.

From Witness Marchibroda's prepared statement:
The U.S. health care system is undergoing significant change, brought about by concerns related to rising health care costs, uneven quality, and eroding coverage. Delivery system and payment reforms which promise to improve both the quality and cost-effectiveness of care are rapidly emerging with leadership by the federal government, states, and the private sector. Such reforms cannot be successful without a strong health information foundation which health IT provides.
 That observation has not changed materially in a decade.

...As we discussed at last week’s hearing, just implementing technology is not the goal. Technology must be used to actually improve health care.

Vendors need to create the right software so that when doctors run quality reports, they get accurate results. If the software isn’t written correctly, it may not recognize drug allergies or dangerous interactions.

Vendors must also create systems that talk to each other, even when those systems are not part of the same network.

Medicare and Medicaid can play a role. Their payment policies can create the right incentives for providers to use health I.T. and for vendors to improve quality.

When it comes to I.T., the vision is there. But as our witnesses today know, it’s the execution that matters. So let us ensure that our health I.T. vision is being executed in a way that lowers costs and improves care for all Americans.


apropos of the foregoing.

Congressional EHR interest brings both opportunity and risk
July 25, 2013 | By Marla Durben Hirsch, FierceEMR
Look at at all of the attention that congress is lavishing on electronic health records.

More than 30 bills aimed directly at EHR use have been introduced since the new session began in January. They cover a lot of ground, including bills to:

Ease the pain of the Meaningful Use program by creating two new exceptions and softening other requirements

  • Expand the Meaningful Use incentive program to safety net clinics
  • Impose strict time limits on interoperability of EHR data between the U.S. Department of Defense (DoD) and the U.S. Department of Veterans Affairs (VA)
  • Increase congressional scrutiny of the DoD/VA joint EHR
  • Exclude pathologists from the Meaningful Use program (HR 1309)
  • Create a prize program for the development of an iEHR (HR 2055)
  • Extend Meaningful Use eligibility to some physician assistants (HR 1790)
  • Use EHRs as part of coverage of voluntary advance care planning (HR 1173)
  • Use EHRs when caring for newborns (HR 1281), mothers and babies (S 425)
  • Provide loan guarantees for small providers who wish to purchase health IT (HR 28)
  • In addition, while not a proposed bill, you've got lawmakers asking the U.S. Department of Health & Human Services Office of Inspector General to extend the legal protections allowing EHR donation programs, which otherwise would sunset at the end of this year.
And this doesn't even count the ongoing attention being given to the beleaguered Meaningful Use Incentive Program, with Republication lawmakers calling for a reboot, freeze or a pause of the initiative...
...this uptick in congressional interest is not without its risks.

For one, not everyone may be in favor of this increase in governmental interest in EHRs. It's one thing to suggest that pathologists be excluded from the Meaningful Use requirements. It's another to require DoD and VA get its iEHR act together in only one year; they've been trying for years to accomplish that. Simply telling them to speed it up might not be that effective.

There's also a risk that the subject will become even more partisan. I hope we don't start seeing repeated votes to repeal the Meaningful Use program, the way the House continues to vote to repeal the Affordable Care Act.  

At the same time, perhaps this is a great opportunity for congress to step in take some positive steps to improve EHR use...
Color me skeptical on Marla's last speculation.


Only ~ half would still choose Medicine as a career?

More to come...

Monday, July 22, 2013

"20%" MU dropout rate? "17% dropout rate"?
"To clearly address the meaningful use dropout rate and ensure the ongoing success of meaningful use, the government must reduce the program’s complexity.

My last EMR Straight Talk post, which addressed the alarming 17% meaningful use dropout rate, generated many comments and resulted in several subsequent media interviews. While CMS has acknowledged the facts regarding this program failure, it does not acknowledge the gravity of the implications for the future of the program. According to a Bloomberg News article, CMS attributes the fallout to many of the same reasons that I have identified from the outset—program complexity, lack of fit with specialty practices, cost, dissatisfaction with EHRs, and inability to meet the meaningful use requirements...
"...[P]hysicians have been quite outspoken about their concerns from the beginning, expressing their perception of the program as overly burdensome, wasteful, and distracting from their mission to provide that care. Now, the evidence is in—they are not just speaking, but they are walking. Clearly, to ensure the ongoing success of meaningful use, the government must fundamentally reduce the program’s complexity.

Recall from my July 8th post "Whither/Wither Meaningful Use."
Meaningful Use program loses 20% of attesting docs
July 8, 2013 | By Marla Durben Hirsch

The dropout rate for Meaningful Use has "soared" in the second year of the program, with a whopping 21 percent of family physicians who attested in 2011 failing to do so in 2012, according to a recent article in AAFP News Now, a publication of the American Academy of Family Physicians.

AAFP reports that in reviewing Centers for Medicare & Medicaid Services attestation statistics, 23,636 family physicians became first-time attesters in 2012, a 180 percent increase from 2011. But of the 11,578 family physicians who attested in 2011, only 9,188 stuck with the program and attested in 2012.

The overall dropout rate among all physician specialties was 20 percent...
Oh, well. What's a ~18% relative reporting disparity among friends?

The Holy EHR Wars.
...A few years ago ... there were dozens of EMR vendors trying to sell software to physicians and hospitals, and like every vendor of any product, they were actively and creatively marketing their wares. Save time and money was a common marketing slogan. EMR websites were sporting all sorts of fancy calculators comparing the costs of doing business on paper to doing business on a computer. The costs of new charts, dividers, paper, ink cartridges, each chart pull, forms, printing paper, etc. were carefully added and compared to the almost zero cost of using software instead. Some fancier calculators even factored in the rent for the additional space needed for chart racks. There were estimates of the number of FTEs that could be let go, or used for worthier causes, and the number of additional patients you can see, if you just buy this or that EMR. Some vendors went as far as advertising better care for patients, with advanced features like automated lab results, pre-built clinical templates and clinical decision support. Folks were kicking tires, shopping around and buying when convinced by ads, sales guys and gals, or even a special discount for the month of August. It was a market, like selling beer, or cars.

But then something strange happened. The United States Government became a believer in the EMR vendors’ marketing slogans. Health care was expensive and not as good or as accessible as it could be, and the EMR vendors promise of saving time and money while providing better care was the perfect solution, particularly since nobody else had anything to offer. Thus the Promise of Technology was born with a silver spoon in its mouth, and was immediately and extensively showered with millions and billions of incentives and resources. The messages on EMR vendors’ websites changed practically overnight from preaching to the infidels to preaching to the choir. Get your incentives, guaranteed, or your money back, was the new slogan. It wasn’t like selling beer anymore. It became missionary work. And, like all great mythological promises, the religion based on the Promise of Technology developed its high-priests, prophets, masses of passive followers, skeptics, and blasphemous heathens destined for martyrdom. The Holy Wars are now in full swing...



Tomorrow. I'm going to try to watch it live.

More to come...

Thursday, July 18, 2013

"RECs are well positioned to continue to assist providers with the full implementation of the EHR Incentive Programs..."

Well positioned

From Dr. Mostashari's Senate Finance Committee hearing testimony yesterday (pdf).

Seriously? It will be interesting to see what remains of the RECs at the end of February, 2014 when the last little dribs of Stage 1 REC funding finally run out (all we were funded for). Farzad loves to allude to the venerable Agricultural Extension Centers by way of warm and fuzzy REC analogy. They are still around today, authorized by Congress via the Smith-Lever Act.

Of 1914.


Consider, above, just the Medicare EP (ambulatory) side of things. If you attested in 2011, again on 2012, and will attest for 2013 (all Stage 1), you will have gotten 86.4% of the incentive funds (assuming you had sufficient Part-B for the max each year). If you began attestation in 2012 and attest for 2013, you'll have gotten 68% of the money.

You will have to update to a Stage 2 certified EHR release ($$$) for 2014. There will only be $6,000 of remaining incentive money potential for the remaining two years (and you'll be coping with ICD-10 and more stringent HIPAA compliance -- not to mention the sequester cuts, which have already adversely impacted the program). See my July 8th post on other aspects of the "Withering of Meaningful Use."

And, you'll be paying fee-for-service for Stage 2 help, whether it comes from the Surviving Sons of REC or from commercial consultants.

What's not to love?

BTW, Dr. Mostashari's live testimony doesn't match up verbatim with his submitted statement. Not even close. There's video of the hearing. Worth watching.

They will have another next week in which vendors will testify. I wonder whether the ever-entertaining Jonathan Bush will be on hand for the festivities.

John Thune bandied the "REBOOT" report about, and Senator Hatch called for "hitting the Pause Button."

I don't see much coming of any of this, beyond the usual handwringing. While the House would certainly vote to defund the remainder of HITECH (if they could sandwich it in between the 40th and 41st poignant votes to Repeal ObamaCare), I rather doubt the Senate can and will muster the requisite 60 votes via which to cut off funding. Meaningful Use incentive funds are not subject to annual appropriations bills, IIRC.

We'll see.


This is interesting.

Master of Science in Healthcare Quality, Safety & Information Technology
Health care quality, safety and information technology program graduates will be prepared to assume leadership roles in the development, design, implementation, evaluation and sustainability of improvements in performance outcomes. In addition, these individuals may assume key roles in education, research, and public policy. Some of these roles may include directors of quality departments or other leadership roles in quality organizations, research and development scientists, health information management or privacy and security specialists.

Loyola University Chicago graduates receiving a transformative education as engaged scholars will be prepared to transform health care. Health care industry sectors demanding QSIT professionals:

  • Provider organizations, including hospitals, outpatient facilities, home health organizations, and integrated delivery systems
  • Quality, safety and information technology vendors, including product development and management firms (e.g., electronic medical record suppliers) as well as education and support firms
  • Governmental health care agencies, such as Centers for Medicare & Medicaid Services (CMS), Health & Human Services (HHS), or Office of the National Coordinator for Health Information Technology (ONC)
  • Public/private organizations focused on quality improvement in health care, such as the Joint Commission (JC), National Quality Forum (NQF) or National Committee for Quality Assurance (NCQA)
  • Professional provider organizations, such as the American Medical Association (AMA) or American Nurses Association (ANA)
  • Universities, including research and education roles
  • Consulting firms
  • Health insurance organizations
  • Health policy research firms and think tanks
  • Community-based advocacy and service organizations
 Upon completion of the QSIT degree, the student will be prepared to:
  • Synthesize key concepts in quality, patient safety and healthcare information technology and management in health care organizations
  • Apply principles and tools from quality, safety, informatics and information technology and measurement science to problem solving and performance measurement in health care organizations
  • Formulate ethical and socially just solutions to the quality and safety problems confronting health care organizations
  • Assume leadership roles within health care systems to promote quality, safety and the use of health information technology
I'm gonna submit an "information request," even though I know it means I will likely be henceforth endlessly badgered via email and phone by some "Admissions Counselor" -- a.k.a. outsourced call center employee reading a script and fishing for a credit card. Unless I've missed something, I don't see any info on their site regarding cost.

I had a transient lapse in judgment a couple of years ago and clicked on a Facebook ad for the "Master of Science in Law" program at Champlain College in Vermont. At the time I was eyeball deep in jousting with our HIE lawyers regarding HIPAA and Nevada SB43 privacy and consent policy stipulations. as a staff member of our "cross-functional privacy and security task force. I'm too old to go to law school, and I don't have a spare hundred grand strewn about. Would a 2nd Masters, a Master's in Law get me any traction with attorneys who always just roll their eyes and pat you on the head with their patronizing 'you just don't understand Legislative Construction' thought bubble blow-off?

I decided not. And, the relatively low MSL admissions requirements comprised a yellow flag.

Two years later, they're still on my case. "Admissions Counselors." Right.

More from Loyola QSIT...
The MS degree in QSIT is planned as a two-year, 36 credit hour, cohort, on-line program with two-day immersion to take place during each of the Spring and Fall semesters. Cohorts will be admitted in the Fall semester. With its holistic and inter-professional approach, the QSIT degree program will integrate a variety of core competencies, including: measurement science, outcomes management, ethics, information systems, research methods and leadership.

Interprofessional concepts will be infused into both immersion and course activities. Five principal members of the QSIT faculty are registered to attend the May 2013 IPEC Interprofessional Faculty Development Institute for Quality & Patient Safety. The IPEC Institute is an opportunity for our faculty team to create an implementable plan for interprofessional curricular design in support of the new QSIT program.

Immersion experiences will be carefully planned to fully complement coursework. During the immersions, Loyola faculty from nursing, medicine, public health and the Graduate School, as well as Loyola and Trinity clinical and administrative leaders will be invited to present short seminars on current relevant topics in quality, patient safety and health information management.

An integral component of the immersion weekends will be experience in the Clinical Simulation Learning Laboratory (CSLL). Through the use of case scenarios, QSIT students will have the opportunity to enhance their technical, communication, critical thinking and decision-making skills as they face simulated quality, safety and information technology challenges. The use of roles, clinical scenarios, faculty feedback and debriefing contribute to a rich and life-like interprofessional learning environment in the CSLL.

Immersion experiences will combine socialization and learning activities designed to develop a community of scholars and leaders as well as provide opportunity for rooting of social justice values to the pursuit of health care quality and safety.

Structure of Each Proposed Focus

The QSIT degree will offer only one focus. Students will individualize their programs through the inclusion of selected Specialty course options based on previous experience, coursework, and career goals, and in consultation with the Graduate Program Director.

The 36-credit Master of Science Degree in Healthcare Quality, Safety, and Information Technology (QSIT) is organized around five Core courses (15 credits), three Advanced Core courses (9 credits), three Specialty courses (9 credits), and one Capstone course (3 credits). Insituations where students have had equivalent courses, a maximum of six credit hours may be transferred in and applied toward the MS degreeIn all cases, students must complete a total of 36 credit hours to fulfill the coursework degree requirements, with a minimum of 30 credits taken through Loyola University Chicago.
I note the absence of any overt Statistics courses in the curriculum (though they do allude to "measurement science"). This is probably a good thing, given the miserable way Stats is typically taught at the undergrad level (I will always be grateful that I came to stats via the UTK Philosophy Department's "Inductive Logic" and "Philosophy of Science" courses). You can take the gamut of conventional univariate stats, bivariates/multivariates, correlation and regression, analysis of variance, and sampling methods and emerge with your cluelessness intact.

From my bank credit risk modeling days, in my blog post "Tranche Warfare":
...I once interviewed a pleasant young hire prospect (playing house "liberal-arts-guy" dumb), a woman with a Master's degree in Statistics (University of Denver). Offhandedly, I asked her to explain to me, in plain plebian English, the concept of "Standard Deviation."

She couldn't do it. She haltingly gave me all the Stats textbook jargon: "Root Mean Squared (RMS) Deviation," the "Square Root of The Mean Squared Deviation, corrected for degrees of freedom" blah, blah, blah...

I dropped the line of questioning.

OK. The Standard Deviation is simply the "average" or "expected" variation around an "average." You calculate an arithmetic average. Unless each value is identical, there is variability. The Standard Deviation -- beneath the hood of all the Scary Greek Shit -- is simply the amount of variation to "expect," "on average."

We hired her anyway. It wasn't my call. She lasted about 3 months, did a few banal yet aesthetically pleasing Excel sheet graphs and Powerpoint assemblages, and then moved on to inflict her thoroughly academically pedigree'd ignorance elsewhere.

Perhaps stuff like this will suffice for QSIT students:
Outcomes Performance Management Methods CMAN 440 (3 credits). This course focuses on methods, techniques and tools employed in outcomes performance management and patient safety. Emphasis is on: application of quality improvement, evidence-based practice and safety approaches; strengths, limitations, purposes and appropriate uses for accepted performance measurement and decision support methods, effective use of statistical process control, variance analysis, guidelines, protocols, root cause analysis, failure mode and effects analysis and other measurement tools and methods; design, implementation and evaluation of performance management programs...
Maybe. Looks promising. I encourage people to look into it.

I think my time, though, may be better spent reviewing and renewing my CQE and studying up for and taking and passing the IAPP CIPP/US exam (I'm an IAPP member in addition to my HIMSS and ASQ memberships).


The Feds' curriculum consortium put a lot of work into this. Now available for public download distribution, free (warning: huge zip files).
Component 1
Introduction to Healthcare and Public Health in the US
This component is a survey of how healthcare and public health are organized and services delivered in the US. It covers public policy, relevant organizations and their interrelationships, professional roles, legal and regulatory issues, and payment systems. It also addresses health reform initiatives in the US.

Component 2
The Culture of Healthcare
For individuals not familiar with healthcare, this course addresses job expectations in healthcare settings. It will discuss how care is organized inside a practice setting, privacy laws, and professional and ethical issues encountered in the workplace.

Component 3
Terminology in Health Care and Public Health Settings
Explanation of specific terminology used by workers in health care and public health. Note that this is NOT a course in data representation or standards.

Component 4
Introduction to Information and Computer Science
For students without an IT background, this Component provides a basic overview of computer architecture; data organization, representation and structure; structure of programming languages; networking and data communication. It also includes basic terminology of computing.

Component 5
History of Health Information Technology in the U.S.
This component traces the development of IT systems in health care and public health, beginning with the experiments of the 1950s and 1960s and culminating in the HITECH act, including the introduction of the concept of “meaningful use” of electronic health records.

Component 6
Health Management Information Systems
A “theory” component, specific to health care and public health applications. Introduction to health IT standards, health-related data structures, software applications; enterprise architecture in health care and public health organizations.

Component 7
Working with Health IT Systems
This is a laboratory component. Students will work with simulated systems or real systems with simulated data. As they play the role of practitioners using these systems, they will learn what is happening “under the hood.” They will experience threats to security and appreciate the need for standards, high levels of usability, and how errors can occur. Materials must support hands-on experience in computer labs and on-site in health organizations.

Component 8
Installation and Maintenance of Health IT Systems
This component covers fundamentals of selection, installation and maintenance of typical Electronic Health Records (EHR) systems. Students will be introduced to the principles underlying system configuration including basic hardware and software components, principles of system selection, planning, testing, troubleshooting, and final deployment. System security and procedures will also be introduced in this component.

Component 9
Networking and Health Information Exchange
This unit will address the OSI, including the purpose and content of each of its seven layers: physical, data link, network, transport, session, presentation, and application. Products, processes, protocols and tools at each level will be explained. This unit will also focus on the flow of data through the models as data is transmitted and receive by end devices.

Component 10
Fundamentals of Health Workflow Process Analysis & Redesign
This component covers fundamentals of health workflow process analysis and redesign as a necessary component of complete practice automation. Process validation and change management are also covered.

Component 11
Configuring Electronic Health Records
This component provides a practical experience with a laboratory component (utilizing the VistA for Education program) that will address approaches to assessing, selecting, and configuring EHRs to meet the specific needs of customers and end-users.

Component 12
Quality Improvement
Quality Improvement introduces the concepts of health IT and practice workflow redesign as instruments of quality improvement. It addresses establishing a culture that supports increased quality and safety. It also discusses approaches to assessing patient safety issues and implementing quality management and reporting through electronic systems.

Component 13
Public Health IT
For individuals specifically contemplating careers in public health agencies, an overview of specialized public health applications such as registries, epidemiological databases, biosurveillance, and situational awareness and emergency response. Includes information exchange issues specific to public health.

Component 14
Special Topics Course on Vendor-Specific Systems
Provides an overview of the most popular vendor systems highlighting the features of each as they would relate to practical deployments, and noting differences between the systems.

Component 15
Usability and Human Factors
Discussion of rapid prototyping, user-centered design and evaluation, usability; understanding effects of new technology and workflow on downstream processes; facilitation of a unit-wide focus group or simulation.

Component 16
Professionalism/Customer Service in the Health Environment
This component develops the skills necessary to communicate effectively across the full range of roles that will be encountered in healthcare and public health settings.

Component 17
Working in Teams
An experiential course that helps trainees become “team players” by understanding their roles, the importance of communication, and group cohesion.

Component 18
Planning, Management and Leadership for Health IT
This component targets those preparing for leadership roles, principles of leadership and effective management of teams. Emphasis on the leadership modes and styles best suited to IT deployment.

Component 19
Introduction to Project Management
An understanding of project management tools and techniques that results in the ability to create and follow a project management plan.

Component 20
Training and Instructional Design
Overview of learning management systems, instructional design software tools, teaching techniques and strategies, evaluation of learner competencies, maintenance of training records, and measurement of training program effectiveness.

Component 0
Version 3.0 Change Documents
These documents provide information about general changes that occurred across all 20 Components as well as information about changes by Component and Unit.

More to come...

Monday, July 15, 2013

The Progress Principle and Meaningful "Use"

My wife turned me on to this book. She participates in a "book club" at work wherein they read and discuss selected works of interest.
2008, Google accomplished a rare feat among companies in any industry. Perched in Fortune magazine’s lofty ranks of the top five most admired companies in America, Google also ranked among the top five of the magazine’s best companies to work for. Millions of people around the world used Google’s search engine daily, and ad revenues streamed in at an astonishing rate. The company’s Mountain View, California, headquarters took on almost mythical status, tempting many business observers to assume that lavish perks led to employees’ outstanding performance. 

Media accounts made the ten-year-old Internet powerhouse seem like an employees’ paradise, albeit one that relied on fabulous wealth. World-class chefs served up three free meals a day in several cafés spread across the two dozen buildings of the Google campus. Hourly shuttles with Wi-Fi access transported employees, free of charge, between Mountain View and San Francisco. Ping-pong games enlivened workdays, dogs tagged by their owners’ sides, and the free state-of-the-art gym never closed. How could other companies possibly aspire to this double nirvana of business success and employee delight? Our research shows how. And the secret is not free food or athletic facilities. The secret is creating the conditions for great inner work life—the conditions that foster positive emotions, strong internal motivation, and favorable perceptions of colleagues and the work itself. Great inner work life is about the work, not the accoutrements. It starts with giving people something meaningful to accomplish, like Google’s mission “to organize the world’s information and make it universally accessible and useful.” It requires giving clear goals, autonomy, help, and resources—what people need to make real progress in their daily work. And it depends on showing respect for ideas and the people who create them. 
As Google founders Larry Page and Sergey Brin said during the company’s magical early years, “Talented people are attracted to Google because we empower them to change the world; Google has large computational resources and distribution that enables individuals to make a difference. Our main benefit is a workplace with important projects, where employees can contribute and grow.”1 In other words, the secret to amazing performance is empowering talented people to succeed at meaningful work. [emphasis mine]
Meaningful work, not "use."

More shortly. I'm traveling this week and my internet connectivity is maddeningly sketchy at times.


Monday morning Google scan...

Like retail, financial services, music, travel and a range of other industries before it, healthcare is becoming a digital business, and that means providers should benchmark their online engagement against other industries'. Healthcare providers will face these questions: How come a retailer such as Amazon or Apple can remember I bought an Ace of Bass recording the last time I visited, but the people who help keep me alive or healthy have to ask about my allergies every time I show up at the doctor's office? Why can I book a flight, hotel and car from three different companies on one website but not schedule doctor appointments online and see all of my upcoming medical visits in one place?
Indeed. From "Why Health IT Must Work More Like Amazon."

As we delved deeper, we realized that we could unravel the mystery of what really affects workplace creativity only by understanding the human stories behind inner work life: what happens to people’s thoughts, feelings, and drives as they try to solve complex problems inside companies?

...To get answers, we opened a window onto the thoughts, feelings, and motivations of people as they did their work every day. We spent years looking through that window, discovering the rich, complex world of inner work life, how it fluctuates as events at work change, and how it influences performance every day.

Inner work life discoveries
  • Inner work life is a rich, multifaceted phenomenon. 
  • Inner work life influences people’s performance on four dimensions: creativity, productivity, work commitment, and collegiality. We call this the inner work life effect. 
  • Inner work life matters for companies because, no matter how brilliant a company’s strategy might be, the strategy’s execution depends on great performance by people inside the organization. Inner work life is profoundly influenced by events occurring every day at work. 
  • Inner work life matters deeply to employees. 
A testament to this is the extraordinary participation of the volunteers in our research, who completed the diary form day after day, for no more compensation than the insight they would gain into themselves, their work, and their team’s work. In addition to revealing how much inner work life matters to employees—and thus to companies—our research turned up another, deeper layer of meaning, concerning events that are part of every workday
  • Three types of events—what we call the key three—stand out as particularly potent forces supporting inner work life, in this order: progress in meaningful work; catalysts (events that directly help project work); and nourishers (interpersonal events that uplift the people doing the work). 
  • The primacy of progress among the key three influences on inner work life is what we call the progress principle: of all the positive events that influence inner work life, the single most powerful is progress in meaningful work. 
  • The negative forms—or absence of—the key three events powerfully undermine inner work life: setbacks in the work; inhibitors (events that directly hinder project work); and toxins (interpersonal events that undermine the people doing the work). 
  • Negative events are more powerful than positive events, all else being equal. 
  • Even seemingly mundane events—such as small wins and minor setbacks—can exert potent influence on inner work life.
From the highest-level executive offices and meeting rooms to the lowest-level cubicles and research labs of every company, events play out every day that shape inner work life, steer performance, and set the course of the organization...
...Inner work life is the mostly invisible part of each individual’s experience—the thoughts, feelings, and drives triggered by the events of the workday. Each person has a private inner work life, but when people go through the same events at the same time, they often have extremely similar private experiences. Over days, weeks, and months, if the same sorts of events keep happening in a group or an organization, those similar experiences can combine to become a formidable force—even if each event, by itself, seems trivial. “The Power of Small Wins (and Losses)” reveals the surprising strength of apparently trivial events...
As I progress, I will connect the dots here back to Lean thinking. This is good stuff. Where can we link "Meaningful Use" to "Meaningful Work"? To what extent can we link "Meaningful Work" in health care to "Meaningful Outcomes" for patients? To what extent can Lean principles and tactics leverage all of the foregoing?


Lawmakers Reintroduce Bill To Expand Meaningful Use Eligibility
Tuesday, July 16, 2013

Last week, lawmakers reintroduced legislation (HR 2676; S 1286) in the House and Senate that would expand meaningful use incentive payments to certain safety-net providers and clinics that currently do not qualify for the Medicaid electronic health record incentive program, EHR Intelligence reports...

According to EHR Intelligence, the legislation has just a 4% chance of passing the committee and a 1% chance of being enacted...
Meaningful Use doldrums days.

More to come...