When you have a totally paper system for complex issues like health care you are bound to have inefficiencies and errors. Some of these errors can be significant. Others are minor. One area that has been a source of problems is medication prescribing and distribution. Over the years problems with errors in medication dosage or type, problems with adverse effects due to mixing of different types of medications, and problems recalling patients on medications that have been discontinued due to problems have plagued the industry. The reasons for this are numerous. First, we as a people take more medications. Most of the elderly population takes multiple medications. Patients aren’t always compliant with providing physicians the correct information on what medications they are taking. When the government announced it was going to help Medicare Patients pay for medication treatment through the Part D Program they realized that this would be a tremendous burden due to the fact that it was a paper program. The administration of this program in a paper world would cost a fortune so they established a program called e prescribing and developed a series of standards so that they could move the electronic prescribing of medication to the main stream. Everyone has to be e prescribing by 2013 or they start getting money deducted from their Medicare Reimbursement (disincentive program). Let’s look at the prescribing in the paper world. I will break it up into two areas: a) prescribing and b) refilling. In the paper world it works like this.
Paper Prescribing:
1. Doctor sees a patient and gets basic information
2. Doctor diagnoses patient
3. Doctor prescribes a medication he thinks is the most appropriate
4. Doctor either writes it out or has the nurse write it out on a prescription pad
5. Doctor signs the prescription and it is given to the patient
6. Doctor bills for an office visit.
7. If the medication chosen is on the list that the insurance pays for (formulary) the pharmacy fills the prescription
8. If the medication is not on formulary, the pharmacy calls or faxes a note saying that this drug is not on the formulary. They may offer one on the formulary for the doctor to approve or ask the doctor for another one.
9. Doctor or nurse needs to update the record to indicate the drug change.
Telephone Refills
1. Patient calls or Pharmacy calls to ask for a refill a patient.
2. Nurse reviews these calls and may go through a protocol to determine that there are no problems or side effects occurring.
3. If the protocol is satisfied the nurse on behalf of the physician will call the pharmacy and approve the refill.
4. If the protocol is not satisfied then the nurse will contact the physician and appropriate changes in the medication will occur or the patient will be requested to come into the office for a visit.
5. The physician is not allowed to charge if the patient does not come to the office
When we first did a time analysis for doing refills in our office, we discovered that we did about 250 refills per day. It took about 8 steps including answering the phone, sending the call to a nurse or voice mail machine, the nurse would have the medical record pulled, review the record, call the patient, go through the protocol, call the pharmacy, update the chart in writing, send the chart back to the medical records department and they had to put it in a bin and then file it back to the records stack. This process costs about $8 and the provider can’t charge for it.
Below are the problems with the above methods in the eyes of the regulators.
1. Medications are sometime being prescribed without knowledge of other medications the patient is taking. If the doctor could be connected in real time to the pharmacy, we would know all the medications or if the physician could keep an electronic running record of all medications and which ones the patient came off of and why, there would be fewer complications. To address that, e prescribing demands connections to the pharmacy and drug-to-drug interaction being formed.
2. Some people may be allergic to certain things in medications. So it would be best if the physician had a running list of allergies that were updated regularly on the patient.
3. Sometimes the drugs or the instructions are not legible, so by making them pick these from standard tables and making sure medications are coded specifically for dosage we can prevent errors.
4. If the physician is connected to a live database that tracks all insurance plans and what they allow for their drug of choice, the doctor can pick the right medication based on what the insurance company will pay for. This is subtle action but also very profound. The reason payers have different formularies and that these formularies change on a regular basis has nothing at all to do with the quality of the medication and everything to do with the cost of the medication to the insurance company.
5. This brings us to the next problem. Medications can cost a lot of money and if we provide the doctor with how much the medications cost he might choose a lower cost medication for the patient so we need to put that in the requirements as well.
Okay so the new e prescribing steps would be:
Electronic Prescribing:
1. Doctor sees a patient and gets basic information
2. Doctor diagnoses patient
3. Doctor prescribes a medication he thinks is the most appropriate $
4. Doctor checks for drug-to-drug interaction in live feed $
5. Doctor checks for allergy medication interaction in live feed $
6. Doctor checks to see if the medication is on the insurance formulary $
7. Doctor checks to see how much the medication costs this week $
8. Doctor sends the prescription that is finally approved to the pharmacy clearinghouse to send to the individual pharmacy electronically $
9. Doctor bills for an office visit.
10. Doctor must assign a “G code” which is a new billing code to the episode so that Medicare knows that e prescribing was used.
11. Only the licensed dispenser (the doctor) can electronically transmit a prescription.
The $ signs means the doctor has to pay for to meet this requirement. In short the physician cost goes up in e prescribing and so does his workload--he needs to do more and the nurse does less.
New standards coming out in April include the pharmacy sending back a report to the doctor to tell him if the patient actually picked up the medication so that the doctor can chase down the patient if they are not complying to find out why. This requirement will undoubtedly be another post in the future.
Electronic Refill
Currently the provider does not get credit for doing over the phone e prescribing and many pharmacies do not yet have the ability to send electronic refill requests, so more than likely providers who do e prescribing will begin to force their patients to get an office visit to get a refill (that way the doctor get credit and he can actually recoup some of his money) I see standing refills being given for 6 months to the patient and then the patient will be asked to return to the office for another refill. The days of just calling in to renew your medications will probably go away.
Prior to e prescribing our customers did not pay anything to write or refill prescriptions in our system. Since e prescribing requires real time or near real time information, physicians now have to pay a monthly subscription fee which is an added expense that wasn’t there last year.
Again, I believe in drug checking and allergy checking and all the things we are striving to accomplish with e prescribing; however, we have to acknowledge that increasing the cost of treating patients, reducing the fees we pay physicians to treat patients, and setting up rules where physicians have to do more work and their supporting staff is restricted from helping the physician, is not a way to encourage EMR adoption.
Monday, February 23, 2009
Friday, February 20, 2009
7. Allow important third party health care entities to be exempt from EMR rules
There are many rules being promulgated to insure that EMR’s are safe vehicles. The first set of rules to have a major impact on health information systems in recent years was the Health Insurance Portability Act (HIPAA). As it relates to EMR’s, HIPAA requires providers to transmit their billing information in a specific format. The format, ANSI, was a complete and utter change from the existing format which took many years to develop. The rules originally stated for all providers, payers, and clearinghouses were mandated in 2002 to convert to the new standard and all electronic transactions were to be governed by this rule. I will spare you the details. First, only the providers and CMS are forced to this. Commercial payers and clearinghouses have various loopholes and exclusions. It is so bad that I now have more interfaces to various payers for our clients then ever before and providers are still bound to do whatever the payers want if they expect to get paid. I will give you an example of how bad this is. CMS was bound by Congress not to accept paper claims after a certain date. There are times when the primary insurance for an elderly person is not Medicare but another commercial payer. Once the commercial payer pays their portion, Medicare becomes what they call the secondary payer and they are to pay the remainder. However, the secondary payer, in this case Medicare, cannot accept paper claims. However, the primary payer will not send back the proper information electronically to the provider or does not send any electronic information--they only take paper. The provider had no way of creating an electronic secondary payment in their information system because they did not get the electronic information back correctly from the commercial payer (the commercial payer was exempt from doing this). Medicare commissioned someone to create a software program that allowed payers to manually put in the information so it would create an electronic secondary claim to be sent from Medicare.
To make matters worse in some cases Providers had their claims denied (they did not receive payment until they could submit these claims electronically) As a result, the provider had to purchase a system to create electronic claims but still had to manually create these claims because they could not get electronic claims information back properly from the commercial payers. My company had to recreate this software inside our program so that we could make it more efficient for customers to create these claims. This is one of many issues. HIPAA regulations also require providers to have security policy and procedures in place to insure that only the appropriate personnel have access to medical records and confidentiality requirements to make sure information is released only to the people the patient wants. However, releasing the information for treatment purposes or to insurance companies as it relates to a specific charge for services is exempt.
Most recently providers have been asked to start using e prescribing. They are being awarded 2% more in their Medicare fees if they use an e prescribing package. Most of these packages cost physicians more money and certainly more time to use than simply writing a prescription on a prescription pad. Under e prescribing, before they give you medication they are suppose to check how much the medication costs (they have to pay for a feed to a database that updates this information in real time), they have to check to see if the patient is eligible for a medication benefit (they have to pay for a feed to connect to payer plans to see if the patient has a prescription benefit), they have to be able to check to see if the medication they are prescribing is paid for by the patient’s plan (formulary check) (again they have to pay for a feed to a database that will keep this information up to date in real time), and they have to be able to send the prescription in a standard format that has been approved by the government to the pharmacies (they pay for a clearinghouse to send these transactions to all the different pharmacies that are in the area); otherwise, they would have to develop interfaces to all of them. Here’s the catch. Insurance companies are getting a fee from the government to administer the part D program and Pharmacies are getting fees from the insurance companies to distribute the medications, but until recently they have been exempt from having to do e prescribing.
Recently, the government has seen this as such a problem (physicians have tried to comply but they are having many problems because the infrastructure for the pharmacies is not ready) that they are mandating that by April of 2009 that insurance companies who manage a Part D Program have to comply with the same standards which they are forcing on physicians; however, the kicker is that it is still a voluntary program for Pharmacies. However, if the doctor does not use e prescribing and just prints the prescription on paper and gives to the patient they don’t have to abide by these rules until 2013 when they begin losing money for not doing it (disincentive program). Oh, by the way, when was the last time you were charged when you called the doctor’s office to ask for a refill? Never! They don’t receive any additional money to prescribe your medication. Don’t be surprised the next time you call your physician for a refill that they say you must come in to the office and see the physician or nurse first. That way the physician can at least charge you an office visit so that they can pay for e prescribing module. How is this going to reduce the cost of medicine?
I have explained the federal requirements, but it doesn’t stop there. States can make up their own rules regarding e prescribing and I know of one state where they think the federal requirements are not restrictive or strong enough and they have created their own certification process. Each vendor has to certify in that State if they want to offer e prescribing to their customers. Their standards make it even less efficient for the provider and more costly as compared to the Federal standards. To make matters worse, The Federal Trade Commission has now issued new rules and regulations called “Red Flags” that apply to any organization (that allows customers or patients to pay over time), including your doctor’s office, to put in an anti identity theft program. One way around this is to make the patient pay all their fees at the time of service.
In summary, any new electronic record mandates need to be thought through at the physician practice level. In the past these new initiatives have gone through expert committees and vendor groups for comments. Unfortunately, these expert groups have good lobbyists and they are stakeholders with something to lose or gain. Hardly any of them have practice medicine and some of them have implemented a EMR in a physician practice. The one group that we never get much comment from, usually because they don’t have the time to even look at the regulations let alone take the time out of their practice to meet on the topics is the physicians or their staff. I could fill several pages with details on these and other regulations that are being required and expected of physicians who have EMR’s. Again, I don’t see these as encouraging EMR adoption but rather discouraging adoption.
You might think that I am anti-standards and anti-regulations. It might even surprise you that I was among the first 7 vendors who joined to form the certification committee. What happened? The results so far has produced more restrictions, higher cost, and greater barriers to entry. In short EMR adoption has not increased. The two things that will increase adoption of EMR’s are simply lower the cost of entry and create products that make the physician workflow more efficient. For physician efficiency means doing more with the same or less resources (they make more money) or they make the same amount of money in less time (they go home early)
To make matters worse in some cases Providers had their claims denied (they did not receive payment until they could submit these claims electronically) As a result, the provider had to purchase a system to create electronic claims but still had to manually create these claims because they could not get electronic claims information back properly from the commercial payers. My company had to recreate this software inside our program so that we could make it more efficient for customers to create these claims. This is one of many issues. HIPAA regulations also require providers to have security policy and procedures in place to insure that only the appropriate personnel have access to medical records and confidentiality requirements to make sure information is released only to the people the patient wants. However, releasing the information for treatment purposes or to insurance companies as it relates to a specific charge for services is exempt.
Most recently providers have been asked to start using e prescribing. They are being awarded 2% more in their Medicare fees if they use an e prescribing package. Most of these packages cost physicians more money and certainly more time to use than simply writing a prescription on a prescription pad. Under e prescribing, before they give you medication they are suppose to check how much the medication costs (they have to pay for a feed to a database that updates this information in real time), they have to check to see if the patient is eligible for a medication benefit (they have to pay for a feed to connect to payer plans to see if the patient has a prescription benefit), they have to be able to check to see if the medication they are prescribing is paid for by the patient’s plan (formulary check) (again they have to pay for a feed to a database that will keep this information up to date in real time), and they have to be able to send the prescription in a standard format that has been approved by the government to the pharmacies (they pay for a clearinghouse to send these transactions to all the different pharmacies that are in the area); otherwise, they would have to develop interfaces to all of them. Here’s the catch. Insurance companies are getting a fee from the government to administer the part D program and Pharmacies are getting fees from the insurance companies to distribute the medications, but until recently they have been exempt from having to do e prescribing.
Recently, the government has seen this as such a problem (physicians have tried to comply but they are having many problems because the infrastructure for the pharmacies is not ready) that they are mandating that by April of 2009 that insurance companies who manage a Part D Program have to comply with the same standards which they are forcing on physicians; however, the kicker is that it is still a voluntary program for Pharmacies. However, if the doctor does not use e prescribing and just prints the prescription on paper and gives to the patient they don’t have to abide by these rules until 2013 when they begin losing money for not doing it (disincentive program). Oh, by the way, when was the last time you were charged when you called the doctor’s office to ask for a refill? Never! They don’t receive any additional money to prescribe your medication. Don’t be surprised the next time you call your physician for a refill that they say you must come in to the office and see the physician or nurse first. That way the physician can at least charge you an office visit so that they can pay for e prescribing module. How is this going to reduce the cost of medicine?
I have explained the federal requirements, but it doesn’t stop there. States can make up their own rules regarding e prescribing and I know of one state where they think the federal requirements are not restrictive or strong enough and they have created their own certification process. Each vendor has to certify in that State if they want to offer e prescribing to their customers. Their standards make it even less efficient for the provider and more costly as compared to the Federal standards. To make matters worse, The Federal Trade Commission has now issued new rules and regulations called “Red Flags” that apply to any organization (that allows customers or patients to pay over time), including your doctor’s office, to put in an anti identity theft program. One way around this is to make the patient pay all their fees at the time of service.
In summary, any new electronic record mandates need to be thought through at the physician practice level. In the past these new initiatives have gone through expert committees and vendor groups for comments. Unfortunately, these expert groups have good lobbyists and they are stakeholders with something to lose or gain. Hardly any of them have practice medicine and some of them have implemented a EMR in a physician practice. The one group that we never get much comment from, usually because they don’t have the time to even look at the regulations let alone take the time out of their practice to meet on the topics is the physicians or their staff. I could fill several pages with details on these and other regulations that are being required and expected of physicians who have EMR’s. Again, I don’t see these as encouraging EMR adoption but rather discouraging adoption.
You might think that I am anti-standards and anti-regulations. It might even surprise you that I was among the first 7 vendors who joined to form the certification committee. What happened? The results so far has produced more restrictions, higher cost, and greater barriers to entry. In short EMR adoption has not increased. The two things that will increase adoption of EMR’s are simply lower the cost of entry and create products that make the physician workflow more efficient. For physician efficiency means doing more with the same or less resources (they make more money) or they make the same amount of money in less time (they go home early)
Thursday, February 19, 2009
8. Create regulations that encourage the disparity of clinical data.
Data, data, everyone wants data. It is hard to keep track of all the Health Care Data people want. CMS wants good billing data to make sure they are only paying for the services that they contracted to pay and only for those patients who really need it. They also want to make sure that basic treatment protocols are followed to insure that patients get proper care so they developed a Pay for Performance under the alphabet soup of PQRI to provide incentive to physicians who report treating certain diagnostic clusters in a predefined manner. Commercial payers want to make sure they are only paying for services which they are contracted to pay (not necessarily the same as CMS) and only when they need to. In addition, they too are beginning to develop their own Pay for Performance based programs and as one has come to expect their measures are not the same as CMS’s measures. Patients would like their own data so that they can review it and make sure it is correct and control where it goes.
I work in the area of Cardiology and the following is what is before us. The American College of Cardiology has an IC3 quality improvement program and they would like to set up an outpatient registry for cardiology patients to improve overall all quality by data analysis. ACC has a certification program that requires vendors to ask specific questions in the EMR, provide specific answers to those questions, and require specific methods for extracting that data on a regular basis and send it to them. The American Heart Association has also recently proposed a set of data standards that they would like cardiologists to follow which is approved by a national quality initiative program called NCQA. CMS (Medicare as mentioned earlier) has the PQRI program that pays providers 2% more than the fee schedule to participate. You must remember though that this 2% increase is on top of whatever decrease they decide to give providers. Third party payers have created their own unique quality program that will either be based on an incentive plan such as CMS or a disincentive plan (you get your fees reduced). States are getting into the act and some of them provide report cards on providers and practices based on data they require from the providers. The provider is being asked to spend his (or his staff time) time providing specific data to specific groups on specific topics at his own expense. Everyone has a stake in this data, and no one can agree on one set of standards. They do however, agree that provider should bear the financial burden to provide the data. It is no wonder that even if a provider wants to purchase an EMR he resents it because more often then not it will be used to benefit all these other groups that he sees as doing nothing but making his practice of medicine more difficult while reducing his fees to do so.
Providers end up seeing these initiatives as either barriers to care and financially costly or they see them as a way to get some of their income back. Those initiatives that provide an incentive they jump on, right? Wrong. When provided an incentive to do this extra work, only 25% of our network participated in it even though we built a module for them to do it and provided it to them at no additional cost above their support payments. Why? Because they are tired of doing more work and as one physician stated, “The amount of time this takes me I could see two more patients a day. If I see two more patients per day I make significantly more than 2%.” The bottom line is I don’t see this improving care or encouraging EMR’s. If you want EMR adoption, than pay an incentive for owning one. Once you have people on it, you can move to improving quality.
I work in the area of Cardiology and the following is what is before us. The American College of Cardiology has an IC3 quality improvement program and they would like to set up an outpatient registry for cardiology patients to improve overall all quality by data analysis. ACC has a certification program that requires vendors to ask specific questions in the EMR, provide specific answers to those questions, and require specific methods for extracting that data on a regular basis and send it to them. The American Heart Association has also recently proposed a set of data standards that they would like cardiologists to follow which is approved by a national quality initiative program called NCQA. CMS (Medicare as mentioned earlier) has the PQRI program that pays providers 2% more than the fee schedule to participate. You must remember though that this 2% increase is on top of whatever decrease they decide to give providers. Third party payers have created their own unique quality program that will either be based on an incentive plan such as CMS or a disincentive plan (you get your fees reduced). States are getting into the act and some of them provide report cards on providers and practices based on data they require from the providers. The provider is being asked to spend his (or his staff time) time providing specific data to specific groups on specific topics at his own expense. Everyone has a stake in this data, and no one can agree on one set of standards. They do however, agree that provider should bear the financial burden to provide the data. It is no wonder that even if a provider wants to purchase an EMR he resents it because more often then not it will be used to benefit all these other groups that he sees as doing nothing but making his practice of medicine more difficult while reducing his fees to do so.
Providers end up seeing these initiatives as either barriers to care and financially costly or they see them as a way to get some of their income back. Those initiatives that provide an incentive they jump on, right? Wrong. When provided an incentive to do this extra work, only 25% of our network participated in it even though we built a module for them to do it and provided it to them at no additional cost above their support payments. Why? Because they are tired of doing more work and as one physician stated, “The amount of time this takes me I could see two more patients a day. If I see two more patients per day I make significantly more than 2%.” The bottom line is I don’t see this improving care or encouraging EMR’s. If you want EMR adoption, than pay an incentive for owning one. Once you have people on it, you can move to improving quality.
Wednesday, February 18, 2009
9 Encourage a Community Based Model for EHR adoption
9. Encourage a community based model where one institution purchases EHR capability then sells it or leases it to private physicians.
This is my most controversial reason for slowing down the EHR adoption. It flies in the face of what the industry and government want to do. This is their thinking. Just take the numbers first; there are about 700,000 private practice physicians out in the real world and only 25% or less have full functioning EMR’s. One of the major reasons is cost. How are they supposed to pay for the EMR? What is the Return on Investment? Let’s do a little math. Let’s say that the efficiency a primary care physician receives from the EMR allows him to see two more patients per day. (Some physicians will tell you they will see less with an EMR.) Based on my experience over the past 10 years, two additional patients per day is not unreasonable. They might net an additional $35 for those two patients when their expenses are taken out. There are 21 working days in a month and if you allow for one month of vacation you end up with an additional $8,820 per year or $35 times 21 which is $735 per month times 11 months. Most experts state that information technology systems need to be refreshed every three years because of technology changes. Thus, $8,085 over three years is $24,255. Again, current data suggest that installing a new EMR system will cost $40,000 to $60,000 per physician. There you have it in a nutshell. Most primary physicians cannot see how they can get their return on investment and as a result adoption has been very slow. Thus, the single reason for non adoption is the primary care physician does not see additional value for their money. Thus, we have to use ASP or pay as you go software as service approaches or community based models to reduce the cost so that Physicians can support these systems because in the end the community and the government benefit more from these systems than do the doctors. (This is how the physician thinks)
Now, here is my thinking. First, of the 700,000 private practice physicians approximately 300,000 are specialists (Cardiologist, Pulmonologist, Oncologist, etc.). They do not net $35 for two additional patients; they net closer to $350 or more for two additional patients. That is ten times more than a Primary Care physician and the cost per doctor to install an EMR stays the same; thus, they can make money putting in these systems. Second, what health care institutions are based in the community and able to purchase large volumes? If you said hospitals, you would be correct. Hospitals are feudal systems. They are almost like large malls. Each department has its own budget, own leadership, and make its own decisions. It is not unusual for a hospital to have multiple health care information systems that do similar things but for different people and very few of these systems talk to one another. Furthermore, I have not gone to one hospital yet that has been overstaffed as it relates to Information Technology support personnel. Many of them are outsourcing to reduce the cost. How are they going to provide a complete integrated EMR and business solution to hundreds of physicians all of whom are independent and want the system set up uniquely for their practice? They are going to try to do it as simply and cheaply as they can regardless of whether it works for all the physicians or not. They are most concerned with the physicians that provide them referrals into the hospital. Third, many physicians may have relationships with multiple hospitals. If they choose one over the other what does that mean for their patient care, the ability to use hospital facilities, and the like? The complexities in hospital settings and thinking through choosing a health care solution for multiple specialties and primary care programs are enormous. The hospital has an agenda that goes beyond individual practices. Hospitals are trying to fill their beds. They are looking for partners who are going to fill their beds. The government recently changed the Stark Law. The Stark Law was developed to reduce the ability for institutions like hospitals to provide incentives to physicians so that they send patients to their hospital (it has some other rules as well and other goals but this is the one we are concerned about here). The changes allow the hospital to provide money to purchase software and services to help physicians embrace Information Technology (It is called a “safe harbor” in legal terms.). However, to everyone’s dismay hospitals are not taking advantage of this new “Safe Harbor” because they find it better to control the whole show and are purchasing physician practices themselves. There is more economic gain for both the physicians and the hospital if the hospital purchases the physician practice because under the rules hospitals get paid more than a physician office for the same service. So, if the hospital purchases the physician practice, the physician can do the same work on the same patient in the same office and get up to 20% more for doing it. Everyone wins (sort of, but that’s another blog for the future). Think of the hospital like a battleship and a private practice like a water ski boat. Hospitals takes longer to select products, have more variables to consider, have more people that need to make the decision, and take much longer to prepare, test and deploy products. If you plan to get adoption in 10 years, it won’t be via a hospital solution. We have customers that are owned by hospitals and on average it costs us 25 – 30% more to support them which will ultimately mean the cost for our goods and services will be higher for them and they are 6 months to 2 years behind our other customers in keeping up with upgrades because of the systems and requirements put on these customers by the hospital owner. There is no way you can get wholesale and quick implementation of EMR’s via large institutions. Practices are quicker to make a decision, they know what they want, they are the most familiar with their needs and 50% of a successful implementation requires understanding and supporting the workflow of the individual practice being converted to an electronic medical record. This knowledge goes into selecting a product. If some Hospital CIO and team are making this decision, they typically do it with a very select committee of “favored providers” (the one’s that send them the most patients).
This is my most controversial reason for slowing down the EHR adoption. It flies in the face of what the industry and government want to do. This is their thinking. Just take the numbers first; there are about 700,000 private practice physicians out in the real world and only 25% or less have full functioning EMR’s. One of the major reasons is cost. How are they supposed to pay for the EMR? What is the Return on Investment? Let’s do a little math. Let’s say that the efficiency a primary care physician receives from the EMR allows him to see two more patients per day. (Some physicians will tell you they will see less with an EMR.) Based on my experience over the past 10 years, two additional patients per day is not unreasonable. They might net an additional $35 for those two patients when their expenses are taken out. There are 21 working days in a month and if you allow for one month of vacation you end up with an additional $8,820 per year or $35 times 21 which is $735 per month times 11 months. Most experts state that information technology systems need to be refreshed every three years because of technology changes. Thus, $8,085 over three years is $24,255. Again, current data suggest that installing a new EMR system will cost $40,000 to $60,000 per physician. There you have it in a nutshell. Most primary physicians cannot see how they can get their return on investment and as a result adoption has been very slow. Thus, the single reason for non adoption is the primary care physician does not see additional value for their money. Thus, we have to use ASP or pay as you go software as service approaches or community based models to reduce the cost so that Physicians can support these systems because in the end the community and the government benefit more from these systems than do the doctors. (This is how the physician thinks)
Now, here is my thinking. First, of the 700,000 private practice physicians approximately 300,000 are specialists (Cardiologist, Pulmonologist, Oncologist, etc.). They do not net $35 for two additional patients; they net closer to $350 or more for two additional patients. That is ten times more than a Primary Care physician and the cost per doctor to install an EMR stays the same; thus, they can make money putting in these systems. Second, what health care institutions are based in the community and able to purchase large volumes? If you said hospitals, you would be correct. Hospitals are feudal systems. They are almost like large malls. Each department has its own budget, own leadership, and make its own decisions. It is not unusual for a hospital to have multiple health care information systems that do similar things but for different people and very few of these systems talk to one another. Furthermore, I have not gone to one hospital yet that has been overstaffed as it relates to Information Technology support personnel. Many of them are outsourcing to reduce the cost. How are they going to provide a complete integrated EMR and business solution to hundreds of physicians all of whom are independent and want the system set up uniquely for their practice? They are going to try to do it as simply and cheaply as they can regardless of whether it works for all the physicians or not. They are most concerned with the physicians that provide them referrals into the hospital. Third, many physicians may have relationships with multiple hospitals. If they choose one over the other what does that mean for their patient care, the ability to use hospital facilities, and the like? The complexities in hospital settings and thinking through choosing a health care solution for multiple specialties and primary care programs are enormous. The hospital has an agenda that goes beyond individual practices. Hospitals are trying to fill their beds. They are looking for partners who are going to fill their beds. The government recently changed the Stark Law. The Stark Law was developed to reduce the ability for institutions like hospitals to provide incentives to physicians so that they send patients to their hospital (it has some other rules as well and other goals but this is the one we are concerned about here). The changes allow the hospital to provide money to purchase software and services to help physicians embrace Information Technology (It is called a “safe harbor” in legal terms.). However, to everyone’s dismay hospitals are not taking advantage of this new “Safe Harbor” because they find it better to control the whole show and are purchasing physician practices themselves. There is more economic gain for both the physicians and the hospital if the hospital purchases the physician practice because under the rules hospitals get paid more than a physician office for the same service. So, if the hospital purchases the physician practice, the physician can do the same work on the same patient in the same office and get up to 20% more for doing it. Everyone wins (sort of, but that’s another blog for the future). Think of the hospital like a battleship and a private practice like a water ski boat. Hospitals takes longer to select products, have more variables to consider, have more people that need to make the decision, and take much longer to prepare, test and deploy products. If you plan to get adoption in 10 years, it won’t be via a hospital solution. We have customers that are owned by hospitals and on average it costs us 25 – 30% more to support them which will ultimately mean the cost for our goods and services will be higher for them and they are 6 months to 2 years behind our other customers in keeping up with upgrades because of the systems and requirements put on these customers by the hospital owner. There is no way you can get wholesale and quick implementation of EMR’s via large institutions. Practices are quicker to make a decision, they know what they want, they are the most familiar with their needs and 50% of a successful implementation requires understanding and supporting the workflow of the individual practice being converted to an electronic medical record. This knowledge goes into selecting a product. If some Hospital CIO and team are making this decision, they typically do it with a very select committee of “favored providers” (the one’s that send them the most patients).
Monday, February 16, 2009
10. Universal Medical Identification Number -
No American wants to be assigned a unique personal Identification number. George Orwell's Big Brother still looms large. Identity theft is the worry of the day. The Federal Trade Commission just mandated a new set of requirements under the name of "Red Flags" to help prevent identity theft. Every American is mandated to have a social security number for tax purposes. So in fact everyone has a unique number, however, the law clearly states that this number can not and should not be used outside of the IRS to identify a person.
We all know that many institutions including, banks, credit cards, insurance, State Government etc, etc. ask for and use our Social Security Number to identify us. Although it is truly against the law to do so and you as a person can refuse to provide your SS NO and should not be denied services if you do so.
What does this have to do with EHR adoption? Because there is no official identification number unique to every person in the United States there is no unique that can be used to identify patients. Usually patients will go to multiple physicians and be seen at multiple institutions over their life time. There is no way to transfer records from one facility to another reliably.
Typically, a patient who is being referred by their primary care physician to a specialist will have their records sent to the specialist. This most often occurs by having the primary care employees select pages from the patient's chart that are relevant to the question at hand and faxing the pages hopefully with the patient's name on every page, along with their date of birth and possibly their address to the specialist's office. The fax pages come in among all the other Fax's being sent at the same time. The paper then gets routed to the medical records department and put in an "In Box" to be collated and alphabetized. Once this occurs some medical record clerk will then look at the name and DOB and see if there is already a medical record for you. Heaven forbid that you are named John Smith or some common name for your community because that means there are several medical records that end up with your information (only one of which is the correct one). With no unique number the medical records staff has to "eye ball" each patient record to make sure they pick the correct one. In an electronic world this is no easier. There needs to be special programs that do the job of the medical record's personnel and try to match name, DOB, address to find the correct person. Now lets suppose that one physician spell your name Robert and the other physician you have known for years and he spells your name Bob (well you can imagine the problem).
How are we suppose to move medical information between providers and between facilities in a quick and cost efficient manner with out a unique number to make sure we are correct. We can't. Because there are no unique number the interface cost 10 times what it should cost. One simple interface to one other system can cost a provider $5,000 or more. Now here is the kicker. Currently, your physician has to pay the cost out of his own pocket if he wants an electronic interface. He gets no money from anyone to do it or he can use the old fashion way of faxing the information for the cost of a telephone line. What would you do? Once a provider goes to a EHR he must take into consideration how this will change his overall work flow and cost of doing business. I will come back to interfaces in later blogs there are a whole host of other problems that make these costly propositions and I will speak to some of them.
We all know that many institutions including, banks, credit cards, insurance, State Government etc, etc. ask for and use our Social Security Number to identify us. Although it is truly against the law to do so and you as a person can refuse to provide your SS NO and should not be denied services if you do so.
What does this have to do with EHR adoption? Because there is no official identification number unique to every person in the United States there is no unique that can be used to identify patients. Usually patients will go to multiple physicians and be seen at multiple institutions over their life time. There is no way to transfer records from one facility to another reliably.
Typically, a patient who is being referred by their primary care physician to a specialist will have their records sent to the specialist. This most often occurs by having the primary care employees select pages from the patient's chart that are relevant to the question at hand and faxing the pages hopefully with the patient's name on every page, along with their date of birth and possibly their address to the specialist's office. The fax pages come in among all the other Fax's being sent at the same time. The paper then gets routed to the medical records department and put in an "In Box" to be collated and alphabetized. Once this occurs some medical record clerk will then look at the name and DOB and see if there is already a medical record for you. Heaven forbid that you are named John Smith or some common name for your community because that means there are several medical records that end up with your information (only one of which is the correct one). With no unique number the medical records staff has to "eye ball" each patient record to make sure they pick the correct one. In an electronic world this is no easier. There needs to be special programs that do the job of the medical record's personnel and try to match name, DOB, address to find the correct person. Now lets suppose that one physician spell your name Robert and the other physician you have known for years and he spells your name Bob (well you can imagine the problem).
How are we suppose to move medical information between providers and between facilities in a quick and cost efficient manner with out a unique number to make sure we are correct. We can't. Because there are no unique number the interface cost 10 times what it should cost. One simple interface to one other system can cost a provider $5,000 or more. Now here is the kicker. Currently, your physician has to pay the cost out of his own pocket if he wants an electronic interface. He gets no money from anyone to do it or he can use the old fashion way of faxing the information for the cost of a telephone line. What would you do? Once a provider goes to a EHR he must take into consideration how this will change his overall work flow and cost of doing business. I will come back to interfaces in later blogs there are a whole host of other problems that make these costly propositions and I will speak to some of them.
Friday, February 13, 2009
How to prevent the adoption of Electronic Health Records
10. Do not allow for a universal Medical Identification number
9. Encourage a community based model where one institution purchases and EHR capability then sells it or leases it to private physicians
8. Create regulations that encourage the disparity of clinical data.
7. Allow important third party health care entities (i.e., insurance payers, pharmacies, manage care providers, clearings houses etc.) to be exempt from the government regulations that physicians are forced to abide by.
6. Create Electronic Medical Record Regulations design to correct all the problems with health care financing and clinical treatment.
5. Spend the money from the new stimulus package for a National Health Care Network and Health Care Exchanges and not Electronic Medical Record Systems
4. Create standards that make the system cost more to purchase and more difficult to use
3. Create a one size fits all EMR system
2. Create the Electronic Medical Record system so that it is so complicated that it takes years to achieve full integration to the practice.
1. Expect the Physician to shoulder the financial burden of paying for the EMR.
Monday, February 9, 2009
Electronic Health Record Adoption
Electronic Health Record Adoption
About the Blogger In the spirit of full disclosure, I thought I would provide some background on myself. I am the CEO of a Health Care Information company that specializes in automating the work flow of physician offices. My company has been in business for over 10 years so I am not new to the business of providing Electronic Medical Records and integration digital solutions. Our company was one of the founding members of what is now CCHIT which is the certification body that certifies Electronic Health Records (EHR), so I am quite familiar with the process of certification. Prior to this endeavor, I was an administrator of a very large specialty medicine program in the Midwest with over 70 physicians and 28 locations. The product my company sells was built originally to reduce the problems and errors we had in the large medical enterprise and to provide efficiencies so that we could meet the regulations mandated upon us while still seeing patients in an effective manner. My education includes degrees in business, a Ph.D. in psychology, and a Post Doctorate in Health Psychology. Finally, I have Dyslexia which causes me to misspell words or use the wrong tenses at times. I usually have my secretary fix those little problems, but since I am doing this on my own you may have to deal with some of these errors.
I would like to provide some definitions for terms. This way at least I know what I mean and whoever else reads this blog will have some anchors to understand my perspective.
EMR - Electronic Medical Record - This is a digital collection of information about a patient that is specific to their treatment by a single provider or a medical facility. The real issue here is that this system is for the provider of health care--not the patient. It may focus on only one aspect of the patient’s health. If you have a primary care physician that uses an electronic medical record system, the only information that is in that system is the information that he or she will put in on your behalf. If you also have a Cardiologist who you see, they also may have an electronic medical record and in all likelihood it will contain some of the information that your Primary Care Provider has as well as information that the Cardiologist decides is important. Thus, all the info in the primary care doctor’s record may not be in the Cardiologist’s record or vice verse.
EHR - Electronic Health Record - This is a digital collection of "ALL" of a patient’s medical information in one cohesive digital medical record. To my knowledge, this is a very rare animal indeed. I don't know of any that exist with the possible exception of the VA or some Managed Care systems and even then it would mean that someone has access to the entire record. Every vendor of health care information claims they have an EHR the certification committee certifies; however, in truth most of what gets sold and implemented are EMR's.
PHR - Personal Health Record - This is something that has been near and dear to my heart for a while, but I see it getting bastardized into something that will be more for the providers and less for the patient. The idea is that the patient can have a digital copy of their medical record--if not the whole historical record, the most current and relevant record. This digital record would be stored on some media (we use a wallet size CD, some others use the Internet, USB drives, Smart Cards, etc). The idea is to have some portable media that allows the patient to bring the information to other providers and give them access to them. Standards are being developed for this type of health care exchange of information. An example would be that a health care provider would send the patient to a specialist and send specific information regarding the patient that they would need to treat or assess the patient in an agreed upon format.
RHIO - Regional Health Care Information Organizations - Regional data storage centers that house PHR's or segments of the patient records (i.e., laboratory results, etc.). Not many of these really exist and they seem ill defined. Some look to be data warehouses, some want to be IT service providers, some want to be IT distribution centers.
NHIN - National Health Information Network - This would be the mother load. It has been talked about in terms of a National Data Center where all patient information for all of the United States citizenry would be housed. Google, Microsoft, etc would love to house this data. Another approach would be a Health care Exchange system that would tie all the RHIO's together and let individuals who have the proper security search patient information.
HIPAA –Health Insurance Portability Act - A collection of rules and regulations mandated by the Federal Government but with very little funding to monitor compliance. This act governs the ability to maintain health insurance as you move from one job to another. For purposes of this blog, it speaks to specific rules and regulations for submitting medical claims to third party payers as well as Medicare. It also contains standards and rules for electronic health records, including security rules, confidentiality and privacy policy and procedures.
EDI – Electronic Data interchange – This is the electronic submission of charges and remittance for clinical service rendered to patients. Again, the specific format is governed by HIPAA but the only groups that have to adhere to these standards are the physicians and health care providers who submit the charges and Medicare. Medicaid and Commercial Payers don’t have to follow the standards; they can change it to suit themselves. Thus, the standard is not so much a standard.
CCHIT - This is a certification group that was established by Health information Vendors and HIMSS, a trade association. Once established, it became an entity of its own and was given credibility and authority by the National Office of Health Technology to certify Electronic Health Records. This group is essentially deciding what features and functions will be required for EHR's to be certified. The government has already changed some legislation so that certain payments and or tax benefits can only be applied to products that are certified.
CMS - is the newer acronym for Medicare and Medicaid programs. It is the official government organizational unit responsible for Medicare and Medicaid.
Payers - This term represents all commercial insurance companies who hold health insurance policies and create the rules for what medical services are covered under their plan and what providers will be paid for their services.
eRx - This is a new acronym and it represents the new electronic prescribing programs. The government has requested that as many prescriptions as possible being written for the new part D Medicare program be delivered electronically. This is being required to cut the cost of the Part D program, and provide better quality care. I will be talking about this in the near future. This is actually, in my opinion, a prime example of why we are not getting broad adoption of the EMR's.
Private Practice - Most of the physicians that the government and payers want on EMR's do not work for hospitals or other government agencies; they work in private practice groups of between 2 and 10 physicians. There are nearly 700,000 of these physicians and less than 20% of them have full blown EMR's and digitize the medical records of a patient. The two biggest reasons for them not buying EMR's are: 1) They cost money and their fees from Medicare and Payers are continuing to be reduced over the years. 2) In most cases the EMR's provided to them are so generic (one EMR for all physicians regardless of specialty) that they do not create enough efficiencies in their practice to offset the costs. I will be discussing this as well in future blogs.
Hospital Based Practice - These are physician practices which are owned by a hospital. This is a growing trend especially as it relates to specialty medicine. The reason for this recently is economics. While provider fees continue to be reduced (doctors have no lobby group of substance), hospital fees have stayed strong and in many cases increased (they have a much better lobby group). Therefore, if a physician becomes an employee of the hospital he can do the same procedure on the same patient in the same facility as he did when he was in private practice and sometimes get 20 to 30% more cash for doing it. This is not a bad way to increase revenue, especially when you factor in that health insurance costs are drastically reduced (one of the highest expenses of employee benefits) by joining a hospital's plan with a larger employee pool and reduced overall risk.
Interoperability - This will become more and more important and I will spend considerable time on this subject in my blog over the coming weeks. This term defines the ability for health information systems to: share information between them, connect to other systems seamlessly, and to allow data from different sources, created with different applications, with different database structures, and different formats to be brought together in one location for viewing by a health care provider. Currently, this is very expensive to do and requires a level of standardization that just isn't there.
Okay, I think this is enough to digest today. I promise that I will try to keep future blogs a little shorter and to the point. Again, the purpose is to discuss the reasons why EMR adoption is slow to non existent. Using an old business psychology technique, I will first start off with how we can produce an environment that discourages adoption and then we will move to things we might be able to do to increase adoption of EMR's.
About the Blogger In the spirit of full disclosure, I thought I would provide some background on myself. I am the CEO of a Health Care Information company that specializes in automating the work flow of physician offices. My company has been in business for over 10 years so I am not new to the business of providing Electronic Medical Records and integration digital solutions. Our company was one of the founding members of what is now CCHIT which is the certification body that certifies Electronic Health Records (EHR), so I am quite familiar with the process of certification. Prior to this endeavor, I was an administrator of a very large specialty medicine program in the Midwest with over 70 physicians and 28 locations. The product my company sells was built originally to reduce the problems and errors we had in the large medical enterprise and to provide efficiencies so that we could meet the regulations mandated upon us while still seeing patients in an effective manner. My education includes degrees in business, a Ph.D. in psychology, and a Post Doctorate in Health Psychology. Finally, I have Dyslexia which causes me to misspell words or use the wrong tenses at times. I usually have my secretary fix those little problems, but since I am doing this on my own you may have to deal with some of these errors.
I would like to provide some definitions for terms. This way at least I know what I mean and whoever else reads this blog will have some anchors to understand my perspective.
EMR - Electronic Medical Record - This is a digital collection of information about a patient that is specific to their treatment by a single provider or a medical facility. The real issue here is that this system is for the provider of health care--not the patient. It may focus on only one aspect of the patient’s health. If you have a primary care physician that uses an electronic medical record system, the only information that is in that system is the information that he or she will put in on your behalf. If you also have a Cardiologist who you see, they also may have an electronic medical record and in all likelihood it will contain some of the information that your Primary Care Provider has as well as information that the Cardiologist decides is important. Thus, all the info in the primary care doctor’s record may not be in the Cardiologist’s record or vice verse.
EHR - Electronic Health Record - This is a digital collection of "ALL" of a patient’s medical information in one cohesive digital medical record. To my knowledge, this is a very rare animal indeed. I don't know of any that exist with the possible exception of the VA or some Managed Care systems and even then it would mean that someone has access to the entire record. Every vendor of health care information claims they have an EHR the certification committee certifies; however, in truth most of what gets sold and implemented are EMR's.
PHR - Personal Health Record - This is something that has been near and dear to my heart for a while, but I see it getting bastardized into something that will be more for the providers and less for the patient. The idea is that the patient can have a digital copy of their medical record--if not the whole historical record, the most current and relevant record. This digital record would be stored on some media (we use a wallet size CD, some others use the Internet, USB drives, Smart Cards, etc). The idea is to have some portable media that allows the patient to bring the information to other providers and give them access to them. Standards are being developed for this type of health care exchange of information. An example would be that a health care provider would send the patient to a specialist and send specific information regarding the patient that they would need to treat or assess the patient in an agreed upon format.
RHIO - Regional Health Care Information Organizations - Regional data storage centers that house PHR's or segments of the patient records (i.e., laboratory results, etc.). Not many of these really exist and they seem ill defined. Some look to be data warehouses, some want to be IT service providers, some want to be IT distribution centers.
NHIN - National Health Information Network - This would be the mother load. It has been talked about in terms of a National Data Center where all patient information for all of the United States citizenry would be housed. Google, Microsoft, etc would love to house this data. Another approach would be a Health care Exchange system that would tie all the RHIO's together and let individuals who have the proper security search patient information.
HIPAA –Health Insurance Portability Act - A collection of rules and regulations mandated by the Federal Government but with very little funding to monitor compliance. This act governs the ability to maintain health insurance as you move from one job to another. For purposes of this blog, it speaks to specific rules and regulations for submitting medical claims to third party payers as well as Medicare. It also contains standards and rules for electronic health records, including security rules, confidentiality and privacy policy and procedures.
EDI – Electronic Data interchange – This is the electronic submission of charges and remittance for clinical service rendered to patients. Again, the specific format is governed by HIPAA but the only groups that have to adhere to these standards are the physicians and health care providers who submit the charges and Medicare. Medicaid and Commercial Payers don’t have to follow the standards; they can change it to suit themselves. Thus, the standard is not so much a standard.
CCHIT - This is a certification group that was established by Health information Vendors and HIMSS, a trade association. Once established, it became an entity of its own and was given credibility and authority by the National Office of Health Technology to certify Electronic Health Records. This group is essentially deciding what features and functions will be required for EHR's to be certified. The government has already changed some legislation so that certain payments and or tax benefits can only be applied to products that are certified.
CMS - is the newer acronym for Medicare and Medicaid programs. It is the official government organizational unit responsible for Medicare and Medicaid.
Payers - This term represents all commercial insurance companies who hold health insurance policies and create the rules for what medical services are covered under their plan and what providers will be paid for their services.
eRx - This is a new acronym and it represents the new electronic prescribing programs. The government has requested that as many prescriptions as possible being written for the new part D Medicare program be delivered electronically. This is being required to cut the cost of the Part D program, and provide better quality care. I will be talking about this in the near future. This is actually, in my opinion, a prime example of why we are not getting broad adoption of the EMR's.
Private Practice - Most of the physicians that the government and payers want on EMR's do not work for hospitals or other government agencies; they work in private practice groups of between 2 and 10 physicians. There are nearly 700,000 of these physicians and less than 20% of them have full blown EMR's and digitize the medical records of a patient. The two biggest reasons for them not buying EMR's are: 1) They cost money and their fees from Medicare and Payers are continuing to be reduced over the years. 2) In most cases the EMR's provided to them are so generic (one EMR for all physicians regardless of specialty) that they do not create enough efficiencies in their practice to offset the costs. I will be discussing this as well in future blogs.
Hospital Based Practice - These are physician practices which are owned by a hospital. This is a growing trend especially as it relates to specialty medicine. The reason for this recently is economics. While provider fees continue to be reduced (doctors have no lobby group of substance), hospital fees have stayed strong and in many cases increased (they have a much better lobby group). Therefore, if a physician becomes an employee of the hospital he can do the same procedure on the same patient in the same facility as he did when he was in private practice and sometimes get 20 to 30% more cash for doing it. This is not a bad way to increase revenue, especially when you factor in that health insurance costs are drastically reduced (one of the highest expenses of employee benefits) by joining a hospital's plan with a larger employee pool and reduced overall risk.
Interoperability - This will become more and more important and I will spend considerable time on this subject in my blog over the coming weeks. This term defines the ability for health information systems to: share information between them, connect to other systems seamlessly, and to allow data from different sources, created with different applications, with different database structures, and different formats to be brought together in one location for viewing by a health care provider. Currently, this is very expensive to do and requires a level of standardization that just isn't there.
Okay, I think this is enough to digest today. I promise that I will try to keep future blogs a little shorter and to the point. Again, the purpose is to discuss the reasons why EMR adoption is slow to non existent. Using an old business psychology technique, I will first start off with how we can produce an environment that discourages adoption and then we will move to things we might be able to do to increase adoption of EMR's.
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