Current Affairs

Although the behavior of one EHR vendor was wrong, more serious problems are inflicted by government-run EHR certification criteria

This week eClinicalWorks resolved a lawsuit by agreeing to pay $155 million for falsely claiming it met Meaningful Use (MU) EHR certification criteria.   Although the alleged behavior of eClinicalWorks was wrong, we have much more serious problems inflicted by the government-run EHR certification criteria.  

The business of EHR vendors is to gain clients and earn profits.  Developing innovative tools that help physicians care for patients should be the primary focus of their business.  Instead, vendors are held hostage to government-run certification criteria that are constantly changing and sometimes ambiguous.  While I do not condone the apparent behavior of eClinicalWorks, I am much more concerned about the  certification processes that led to this situation.   

The certification process evolved out of the 2009 HITECH Act that promoted the use of EHR technologies by offering incentive payments to hospitals and physicians who successfully adopted and used EHRs.   This resulted in an unprecedented rush of business for EHR vendors.  While EHR vendors began ramping up resources to meet the demands of the sales cycle and EHR implementations, they were also hit with government-imposed EHR certification criteria--criteria that are still changing frequently and sometimes are ambiguous.  This exponential increase in EHR client demands along with rapidly changing certification criteria crushed EHR vendor resource availability.  This constraint on resources forced them to focus on developing and testing EHR products to meet the specific certification criteria required by the government.  In my opinion, the unintended consequence of overwhelmed EHR vendors is that they then did not have available resources to focus more on:

  1. Improving usability
  2. Identifying and managing patient safety risks inherent to EHR use
  3. Developing innovative tools and functions that actually improve how physicians care for patients 

As a result, EHRs were developed to meet MU EHR certification criteria, but failed to improve poor usability.  EHR products could meet certification criteria, yet fail to adequately address patient safety risks associated with implementation and use.  And the constraint on EHR vendor resource availability remains an impediment to the development of innovative tools and functionalities that EHR vendors really should be focusing on today.

Physicians do benefit from EHR certification by reducing risk during the EHR selection process.  That is why the Certification Commission for Health Information Technology (CCHIT) was created in 2006 as an independent, not-for-profit group.  CCHIT certification was based on a consensus of stakeholders who determined core functionalities that a basic EHR should provide.  I participated in that effort, albeit in a brief, very small way (providing some input on pediatric core criteria).  I recall we were careful to avoid requirements that could hinder EHR product innovation.  CCHIT ceased operations in 2014 after the government created the MU EHR Certification program.  

CCHIT certification was much less prescriptive than what the government imposes today.  Less prescriptive EHR certification was, in retrospect, the right approach to take.  And we did it without government involvement.  Government works at its own hindered pace, and that pace is much slower than what an unencumbered EHR market could accomplish.  I think the government needs to get out of the EHR certification business.   But whether government remains involved or not, the EHR certification process needs to learn from CCHIT and rely more heavily on building consensus of physician stakeholders.  We will do what is best for our patients.    

So, this week one vendor was called out by the government for false claims regarding EHR certification.  But that one vendor is really not the problem.  The real problem is that the development of all EHR products has been, and still is, impeded by the government's EHR certification program.  

Matt Murray, MD

cook children's health care system


Here we go again, forcing physicians to use technology that is not yet mature

Here we go again, forcing physicians to use technology that is not yet mature.  Texas House Bill 2743, if adopted, would require physicians in Texas to use electronic prescribing (e-prescribing) for controlled substances.   

While I agree with the goal (physician adoption of e-prescribing for controlled substances), the proposed tactic imposes requirements on the wrong stakeholder.  If e-prescribing tools and associated work flows were intuitive, effective, seamless and safe, then there would be no need to require physicians to use e-prescribing.  Physicians naturally gravitate toward technologies that are easy-to-use, safe and effective or time-saving.  I don't see many physicians writing checks now that debit cards are easy to use nearly everywhere we go.  The adoption of robotic surgery and MRI scans come to mind as well.

So to reach the desired goal, should not the state representatives instead require e-prescribing vendors to bring mature, useful products to the market?   Should we not require NCPDP, the organization that develops standards for script transmissions, to more rapidly develop standards needed to close gaps in current functionality and usefulness?  

My ER patients rarely prefer a written paper prescription.  But sometimes the patient wants a paper Rx because they just came from out-of-town, or they want to shop around for a 24-hour pharmacy in the middle of the night, or for other occasional, sometimes unusual reasons.  One of my patients preferred a written prescription because she liked how prescription paper smelled.  You might successfully guess the category of medication she received.  

It is rarely in the best interest of  my patients for me to write a prescription rather than to e-prescribe one.  Unless my e-prescribing system is down, or my patient tells me they prefer a paper prescription.  Or if I'm prescribing a narcotic, because my EHR vendor has not yet enabled my e-prescribing system to do so.  In my case it will take a major upgrade to get that done.  And I have not yet gone to a Federally-approved credential service provider (CSP) or certification authority (CA) to be "identity-proofed" so that I can obtain a two-factor authentication credential or digital certificate which is required to use e-prescribing for controlled substances.  I'll go through that hassle when my vendor enables the controlled substance e-prescribing tool.  And that upgrade will cost my organization a lot to implement.  

In the doctor's real world e-prescribing tools are not easy-to-use, intuitive or hassle-free.  Instead they are cumbersome and remain prone to some easily-preventable medication errors. In the real world of the pharmacist, it is not efficient to manually transcribe  into their own system the e-prescription information I sent.  They might have to use two screens to accomplish that task, or they might print my e-prescription and then transcribe it into their system.  That printer is likely to be in the far corner of the room.

 So in the real world Texas House Bill 2743 makes little sense.  I urge our state representatives to focus their tactics on the real problem--immature e-prescribing tools and processes.   Stop imposing unnecessary risks on physicians and patient care.  

Matt Murray, M.D.                                                                                                                                                                 cook childrens 


Increasingly hazardous healthcare environment should urge Congress to create a National Health IT Safety Center

Discharge instructions for a child’s insulin dose were correctly entered into the electronic health record (EHR), but when the mother received the printed instructions there was a decimal point error resulting in a 10-times dosing error.  This error was fortunately noticed by the bedside nurse and corrected manually.  I reported this near-miss to the EHR vendor and they corrected the technical problem.  However, when I asked vendor representatives whether or not this problem was being corrected with other physician clients across the country, they informed  me that no other client had reported such a problem. 

This is analogous to a situation where an airbag explodes and sends shrapnel into your face.  You might ask the automaker whether this is a problem with their other vehicles.  They might tell you that they are not aware of others having the same problem.  However, in the transportation industry they are required to report safety incidents and near-misses.  These reports are collected, aggregated and analyzed by the National Transportation Safety Board (NTSB).  If NTSB notices a trend in airbag-induced shrapnel injuries, they will initiate an investigation.  When NTSB discovers a problem with a specific airbag that is used across multiple types of automobiles, not just the type you purchased in your own state, then they are authorized by Congress to make safety recommendations to help ensure the risk is appropriately managed across the industry.

This insulin dosing incident is one of many health IT-related patient safety risks I have encountered and resolved in collaboration with an EHR vendor.  When my experience is extrapolated to the experiences of all physicians and EHR vendors, the scope of health IT-related patient safety risks can be seen as immense.  But unlike the safety of interstate commerce produced by the auto industry that is overseen by the NTSB, the safety of interstate commerce produced by EHR vendors has no cohesive oversight mechanism.  

The lack of oversight for health IT-related patient safety incidents and near-misses creates a hazardous patient care environment that I believe is urgent for Congress to address. The threat is increasing because the Meaningful Use Program (MU) has led to an exponential increase in the use of EHRs and other technology.   As a result, physicians are assuming a higher level of risk and accountability for computer programs, networks and infrastructures that are increasingly used as tools to generate patient care actions and facilitate medical decisions.  Although health IT-related patient safety risks would best managed through a shared accountability between physicians and EHR vendors, the vendors are not currently held accountable for patient safety.  Furthermore, the aggressive MU timelines have required EHR vendors to make rapid changes to EHRs without sufficient time to align changes with efficient physician workflows or to improve the flow of data between systems.  As a result, EHRs are increasingly plagued by poor usability problems and  lack of interoperability between EHR systems--both of which are patient safety risks that physicians commonly encounter.

So it is time to urge Congress to create a National Health IT Safety Center that can implement an effective EHR safety program designed to reduce EHR-related patient safety risks.  Within this concept EHR vendors could be required to report patient safety incidents and near-misses to the Health IT Safety Center similar to how transportation safety incidents must be reported to the National Transportation Safety Board.   The Health IT Safety Center could collect, aggregate and analyze reported data.   It could have power to investigate incidents involving patient harm and require EHR vendors to make appropriate changes.  It could monitor near-misses to identify trends and risks.  It could coordinate with other agencies to develop and broadly disseminate educational information and tools that mitigate identified patient safety risks related to technology use.  

I also envision that this resolution would lead to an entity that has the authority and influence to drive improvements in EHR usability and

 
 

interoperability, which are the two most significant impediments to effective and meaningful use of electronic medical records.   

 .

 

  

Improved Physician Practice Preparedness To Recover from EMR Downtime and Other Technology Risks is Needed

It should not take 3 weeks to restore an EMR system.  

I was not surprised when one of my colleagues told me his EMR unexpectedly "went down", as there are many threats to hardware and software--wind, fire, water, construction equipment, human error and cyber crimes to name a few.  It was the rest of his story that was so disheartening.  As he recalled the struggles that his group endured for three weeks, his facial expression contorted into what I can best describe as that of "helpless resignation".   The complexities of technology had held him and his group hostage for three weeks.   At the time of our initial discussion he was still in the "grieving" stage, so I felt it to be too early to engage in a healthy discussion about IT risk management.   He needed to vent.   I needed to listen.  

And this story exemplifies what drives me to spend time collaborating with the Texas Medical Association (TMA) and others to raise physician awareness about the safe use of EMRs.   I do not have data, but my gut tells me that the majority of physician practices underestimate how vulnerable they are to EMR threats, especially small physician practices who lack internal IT expertise.  Perhaps the recent rise in ransomware attacks will actually be beneficial.  A ransomware attack on a physician office in South Texas earlier this year has led the TMA to increase communications to physicians about the threat of ransomware and other cyber attacks.    

Until recently the focus of preventive strategies against cyber attacks has been to ensure that the privacy and confidentiality of electronic medical records (EMRs) are maintained.   HIPAA stuff.   And this is understandable since privacy breaches are expensive for a practice to manage, and such breaches have the potential to financially hurt patients if their data is used maliciously.  But ransomware attacks are different because they make a physician's EMR unusable until a ransom is paid (or the EMR is otherwise restored).  Unlike privacy breaches, ransomware attacks are disruptive to the daily operations of the practice.  It is a disruption that impairs the ability to take care of patients who are in the office as well as those who call the office.  At the end of the day the physician is left struggling to take care of patients who are sick without access to information that is really needed.  This is a "new normal" that should brightly illuminate the need for improved disaster recovery preparedness and IT risk management for physician practices.    

There are ways to reduce the threat of ransomware attacks and other health IT risks.  A thorough security risk analysis can identify weaknesses that could be targeted by cyber criminals.  Steps can then be taken to reduce the chances of being victimized.  Establishing a habit of continually identifying and managing these technical risks will further reduce the chances of an EMR shutdown.  

But one of the major obstacles is that physicians generally do not have the knowledge, expertise and time to do this themselves.  Another obstacle is that security risk analyses tools are designed primarily for large healthcare systems and do not translate well onto a small physician practice.  That is why the TMA's ad hoc Health IT Committee is currently collaborating with a vendor, a state agency and one small physician practice to hone down a security risk planning tool into something that would be feasible and effective for small physician practices to adopt.  For now physicians have to rely on consultants or train/hire IT staff to identify and manage technology security risks.

Nevertheless, no system can be 100% "downtime-proofed".  So even if a physician practice adopts best practices for security risk management, they must be prepared for a disaster to strike at any time.  After a disaster strikes, maintaining the ability to effectively care for patients must be the first priority.  I have coined the term, "clinical continuity planning", to characterize this planning.  I base the term on a similar commonly used term, "business continuity planning", which is the plan businesses develop to maintain daily operations during technology downtimes and disasters.  A physician office certainly is a business and should have a business continuity plan to maintain economic viability during disasters.  But the life-and-death nature of patient care is so unique that I believe a clinical continuity plan should be developed by each practice and be considered as the first priority in disaster planning.  Business continuity is integrated with clinical continuity and is also vital to the physician practice, but it should be considered as a lower priority.  In the real world this means that when weaknesses in security and downtime planning are identified, clinical continuity weaknesses should be addressed before business continuity weaknesses are addressed.  
 
The most effective protection against a ransomware attack and other types of "downtime" is to have a complete back up of EMR data and an ability to quickly restore the EMR system.  If the practice can do that, they may not have to pay a ransom, and the impact on patient care can be minimized if the back up and restore tools/processes are effective.  
 
With the rise of ransomware attacks I believe the primary focus of health IT risk management for physician practices should be to ensure an acceptable degree of clinical continuity can be maintained during EMR downtimes.  Secondarily, the practice should understand the tools and processes that are in place to back up and restore the EMR in the event of a disaster.  And to make sure they get tested.    The first time a physician discovers that it will take 3 weeks to restore their EMR should not be after a real disaster strikes.   
 
 
mattmurraycook children's
 mgg
 

Cultural Change at CMS is Needed to Mend Adversarial Relationship With Physicians

CMS has issued a request for information (RFI) and invited comments on the implementation of the Merit-Based Incentive Payment System (MIPS) as introduced in the MACRA legislation that repealed SGR last April.   The legislated "composite performance score" upon which "adjustments" to physician payments will be made under MIPS consists of four categories:  Quality, Resource Use, Clinical Practice Improvement Activities and Meaningful Use of CEHRT.   Comments are being sought on many topics, including certification of EHRs, technology standards, accountability for data integrity, management of "virtual groups"  and, yes, Meaningful Use (MU).

I have three overarching comments:

1.  Adversarial relationship with physicians:  Right now government programs such as MU and PQRS are generally viewed by physicians as requirements only, not as elements of best practices that lead to quality care.  I think it is vital to change this adversarial perception.  This will involve a cultural change at CMS.  Perhaps the most important tactical change to pursue is moving away from rewarding/penalizing the achievement of specific targets, and moving toward innovative programs that reward practices for making incremental improvements in quality care.

2.   Inhibition of Innovation:  Physicians support technology innovations developing in the consumer marketplace that have the potential to improve quality of care and lower healthcare costs.   While government regulations have the potential to catalyze innovations in the consumer marketplace, they also have the potential to inhibit innovation.    Regulations that strive for high-level outcomes are generally more likely to catalyze innovation, while regulations that impose specific limits or require specific actions, mechanisms and processes are more likely to inhibit inhibition.   I believe the Meaningful Use regulations have inhibited innovation--EHR vendors have been scrambling to meet specific requirements imposed by the regulations with no evidence that these requirements would result in higher quality of care or lower costs.    To change this, we need CMS to mindfully develop government regulations that maintain a high-level focus on the achievement of quality care outcomes while avoiding the development of limitations or specific requirements, methods and processes that discourage innovation. 

3.    Fair and ethical use of quality metrics for reimbursement:   The AMA has published guidelines on the Fair and Ethical Use of Quality Metrics.    The guidelines advocate for rewarding physician practices that make incremental improvements in quality care rather than rewarding/penalizing the achievement of specific levels of performance.   Although my opposition to the use of quality metrics to impose financial penalties is aligned with these guidelines, I concede that it is difficult for a value-based model of reimbursement to completely avoid penalties.    My alternative suggestion is for CMS to incorporate tiered levels of "performance achievement" instead of the "all-or-none" requirements put in place for the MU program.  Tiered levels of achievement, with lower levels of achievement designed to avoid certain penalties and higher levels designed to provide additional rewards, will help avoid the "drop-out" rate that the MU program has experienced after Stage 1 as the levels of expected performance were increased.  Many physicians just gave up.  Even though they could achieve all but one of the requirements, that one requirement eliminated the possibility of receiving any credit.  

I  would be interested in hearing your thoughts on the implementation of MIPS by CMS.


Keys to Gain Value from EHR Implementation and Use

Many physicians who use an electronic health record (EHR) are having difficulty realizing value in their investment.   A recent KLAS survey found that more than one out of every four physician practices are so dissatisfied with their EHR that they are considering replacing it.    Although many physician practices have earned a financial award by using an EHR to achieve “meaningful use”,  data is lacking on whether or not such efforts actually improve patient outcomes.  

I believe, anecdotally, that I practice higher quality medicine when using an EHR.    But I am a pediatric emergency medicine physician using a hospital EHR to document patient encounters in a children's hospital's emergency department, not a physician in private practice.  On the other hand, my past experience as a a Chief Medical Information Officer (CMIO) and Chief Information Officer (CIO) for my pediatric healthcare system provided opportunities to visit many private physician offices using a variety of ambulatory EHRs and to visit with many EHR vendors.  I met many physicians  who were happy with their EHRs and see the value.  Others I met were unhappy and see no value in their EHR.  Perhaps my most eye-opening experience came when I visited with a group of unhappy physicians who were using the same EHR as some happy physicians I had met one week earlier.   So what gives?

The answer is simple, but the explanation is complex.  

The simple answer is that the value gained from an EHR is dependent on how effectively it is implemented and used.   When well-implemented and well-used, an EHR provides clinical and financial value.   When poorly-implemented and poorly-used, EHRs detract from patient care and are a financial drain.  

The complex explanation might best be explained using examples.  So, based on my past visits with physicians who use various EHRs and on other personal research, I have created an outline of what I think are the key factors that allow physicians to gain value from their EHR.  I am in the process of writing a series of blogs with case studies to help explain each of these factors.  Stay tuned! 

Keys to Gain Value

 

cook children's

 

Dr. Matt Murray

Cook Children's


Failure to Address Physician ICD-10 Concerns, Misalignment of Federal Health IT Priorities are Strategic Blunders

Texas Representative Ted Poe has introduced H.R. 2126, the Cutting Costly Codes Act of 2015.   This legislation would prohibit the federal government from requiring physician offices to comply with the proposed transition to ICD-10 codes. “The new ICD-10 codes will not make one patient healthier," Representative Poe said.    "What it will do is put an unnecessary strain on the medical community who should be focused on treating patients, not implementing a whole new bureaucratic language.”  He has clearly listened to the Texas Medical Association (TMA) which has consistently advocated for postponement of ICD-10 on behalf of 48,000 physician members.  

I am one of those Texas physicians who is thankful that a congressman has listened to us.  If this bill were passed it would postpone ICD-10 and call for the GAO to study the issue, but it does not propose any solutions.  Although I am in favor of this bill, I agree with the cry of many healthcare stakeholders that we need a solution to move away from the antiquated ICD-9 codes.  It seems likely that a bill that does not propose an alternative solution will have difficulty getting passed.  

I am hopeful, though, that debate about this bill might illuminate two major flaws in national health IT strategic planning.  The current ICD-X strategy which includes no roadmap to ICD-11 will set up the U.S. healthcare industry for strife and conflict in the 2020s when we see the rest of the world leveraging integration between ICD-11 and SNOMED to improve quality of care and control costs while we struggle to gain value from what will then be an antiquated ICD-10 coding system.  

The first flaw is the lack of a strategic plan or roadmap at a national level for ICD-X conversions.  For example, there is no mention of ICD-10 or ICD-11 planning in ONC's Federal Health IT Strategic Plan 2015-2020.    It is difficult to trust a strategic plan that fails to account for the tremendous burden that an ICD-10 and/or ICD-11 conversion brings to the healthcare industry.  The ICD-10 tactical delays can be directly attributed to conflicting strategic national healthcare priorities which resulted in an overlap of  initiatives at the local level--eRx requirements, Red Flag Rules, HITECH/HIPAA, Meaningful Use stages, PQRS, ambulatory EMR purchases/implementations/upgrades/updates and other healthcare regulations--and created unreasonable, concurrent burdens on physicians.   Tactical delays like this can be avoided through more effective strategic planning at the national level.  

It is particularly disconcerting that there is no national roadmap to ICD-11.  As I previously wrote, the U.S. is planning to achieve a short-term tactical goal of replacing antiquated ICD-9 codes while the rest of the world is closing in on their long-term strategic goal of implementing ICD-11.   Informatics experts are in agreement that ICD-11 is superior to ICD-10 and is much more integrated with SNOMED codes.   In the 2020s I believe we will see the rest of the world successfully leveraging the benefits of ICD-11 and its tight integration with SNOMED to improve quality of care and control costs, while the U.S. is struggling to gain value from what will by then be antiquated ICD-10 codes.  Cries for ICD-11 will crescendo, with most cries coming from those who do not see patients everyday.  Without an ICD-11 roadmap, we will be destined for the same predicament, only this time struggling with a short-term tactical goal to replace last century’s ICD-10 codes with no strategic plan in place to align that burdensome effort with other healthcare priorities.    

The second flaw is the lack of an effective process during ICD-X conversion planning to identify and address the concerns of grass root physicians who see patients every day.   Failing to address physician concerns prior to developing the ICD-10 solution to the replacement of ICD-9 was a strategic blunder. Perhaps the most significant physician concern is the tremendous burden placed on physician practices by the ICD-10 conversion.   Optimal planning on how to replace antiquated ICD-9 codes really should include discussions on how we might best reduce or avoid that burden.   At the very least, we should discuss how best to reduce that burden in the future, because physicians see ICD-11 coming around the corner.  

For example, we should discuss the possibility of converting from use of ICD-9 or ICD-10 to use of SNOMED codes in physician practices.  Physicians would not have to learn new ICD-X codes each time administrators decide a conversion is necessary.  Use of SNOMED codes mapped to ICD-X codes would be less disruptive to physician work flow and be more cost effective for physician practices as compared to complying with future ICD-X conversion mandates.  

The analysis on how best to resolve the ICD-9 problem should address physician concerns and result in a strategic plan that is determined to have the highest potential to improve healthcare quality at the lowest cost.  So what are some attributes of the optimal strategic planning effort?   It would be included in ONC's federal  health IT strategic plan.  It would include a national roadmap to ICD-11.   It would include a comparative analysis of the cost/benefits of completing a conversion of ICD-10 versus a direct conversion from ICD-9 to ICD-11.    It would include an analysis of  the potential to replace ICD-9 or ICD-10 codes in physician practices with SNOMED codes.   And it would include a process to identify and address the concerns of physician practices throughout the planning stages.

Dr. Matt Murray

Cook Children's


Physicians Must Level the Slippery Slope of Quality Metrics

I am concerned about the slippery slope of quality metrics that ACOs, private payors and CMS are stepping further down into.  My primary concern is that decisions being made by payors on the use of quality metrics are too often resulting in unfair or unethical use of quality metrics.   It is critical for community physicians to engage with these entities now to level the slope and establish a more optimal precedent for the future use of quality metrics.

Several years ago I participated in the Texas Medical Association's (TMA) launch of their Health Care Quality Council.  One of Council’s primary interests has been the issues inherent to pay-for-performance programs and the use of quality metrics by payors.   Some of these issues overlap onto the TMA's ad hoc Health IT Committee that I serve on as well.    Physicians in Texas have reported to these committees about unfair and unethical applications of quality metrics such as failure to consider risk adjustments for severity-of-illness or for important socioeconomic factors.   Many physicians are concerned  that they are getting overwhelmed by requests for different sets of quality metrics from different private payors as well as from CMS.   They are also frustrated by the variable, non-standardized methods by which each payor requires the physician's data to be formatted and/or submitted.

Based on my experience with these TMA committees, I have no confidence in the ability of insurance companies or ACOs to develop and use quality metrics in a fair and ethical manner without intimate involvement of working physicians from the community served by the ACOs/payors.    

There are guiding principles available regarding the fair and ethical use of quality metrics from the TMA and the AMA.     Physicians should actively engage with their ACOs and payors to ensure that these guiding principles are adhered to as quality metrics are developed.

 

 fort worthcook children's, athenahealth, meditech


Mandating Physicians to Use SNOMED codes Has Higher Potential to Improve Healthcare Than ICD-10 Mandate

I have consistently advocated for skipping ICD-10 and initiating an unprecedented effort to accelerate the development of ICD-11-CM.  Although I still believe this strategy to be the one best aligned with quality care, I fear that the sunken ICD-10 costs are now so large that skipping ICD-10 is unpalatable for most organizations, even for some physicians, and is politically perilous.  Since we must do something, I have been thinking more about the proposal to replace ICD-9 with SNOMED in physician practices.  Leveraging SNOMED to improve care, lower costs and remove physician practices from the ICD conversion melees should be a serious national conversation at this point.  
 
After several delays CMS has established October 1, 2015 as the new implementation date for the replacement of ICD-9 code sets used by medical coders and billers to report healthcare diagnoses and procedures with ICD-10 codes   But another postponement remains a possibility--especially when one considers the unclear reasons for action taken by Congress earlier this year to call off the 2014 implementation.  ICD conversion delays are costly to the healthcare industry and action should be taken to address the impediments that increase the risk of such delays.   One of the major impediments to address is the adverse impact ICD conversions have on individual physician practices.    
 
So let's jump out of the box of conventional charged impulses propagating across our cerebrums (thinking) to consider how to make ICD-10 optional for physician practices while still achieving our goal of dispensing with obsolete ICD-9 code sets.  One alternative is to mandate physicians replace ICD-9 codes sets with SNOMED code sets and require EHRs to incorporate translator technology that converts SNOMED to ICD codes in the background.  Since it would not be practicable to expect EHR vendors to incorporate the translator technology into their products by October 1, 2015, there would need to be an interim period where physician practices are exempt from the requirement to use ICD-10 codes sets until their EHR incorporates the translator technology.    This alternative mandate allows the ICD-10 conversion to proceed for the rest of the healthcare industry including any physician practices who see value in completing their conversion.  This mandate would reduce the current and future adverse impacts that ICD conversions have on physician practices, has higher potential to improve care, is more cost effective, helps EHRs be more user-friendly to physicians and mitigates the risk of further delays to ICD-10 as well as future ICD-X conversions.
 
I would anticipate a two-year transitional period where the ICD-10 conversion would be optional for physician practices based on an assumption that EHR vendors will need until 2017 to upgrade their products.  
 
Some opposition among physicians is likely to be encountered due to their lack of familiarity with SNOMED as well as questions about how this alternative strategy adds value to patient care.   I base that on the responses I heard from some respected colleagues at this weekend's Texas Medical Association meeting.  The unfamiliarity issue can be addressed by pointing out that many of us are already using SNOMED, but that we just do not know it.  CMS mandates that the problem lists in EHRs use SNOMED codes, so when one selects "Exercise-induced asthma" from a pick list of problems in their certified EHR, they are actually using SNOMED. 
 
More difficult to articulate to physicians is how this proposal to convert from using ICD-9 to SNOMED codes in our EHRs would improve healthcare, how it would improve their work flow and how this is more cost effective for physicians as compared to complying with the current mandate.  So I have developed the following bullet list to use when describing this to my colleagues:
 
  • Informatics experts are in agreement that ICD-9 is obsolete, and that although ICD-10 has potential to improve healthcare, ICD-11 and SNOMED have higher potential to improve healthcare. 
  • SNOMED, which is interwoven in ICD-11's development, is inherently compatible with ICD-11 and is already required by CMS to be incorporated into certified EHRs for Problem Lists--thus, mandating use of SNOMED is not really new to physicians and will not result in an added cost to physicians
  • EHRs can be built with technology that automatically converts SNOMED codes into ICD codes--thus, mandating use of SNOMED is agnostic to the version of ICD-X being used; the cost to physicians of using the translating technology is very small as compared to the cost of finishing the conversion to ICD-10 and then converting to ICD-11 in the next 15 years.
  • After we convert to ICD-10 in 2015, discussions about implementing ICD-11 will ensue; since ICD-10 is over 20 years old and is less sophisticated than ICD-11, it will become apparent rather quickly that we need to convert to ICD-11 as soon as possible in order to improve healthcare (i.e. today's argument about ICD-9)
  • It takes the U.S. 7-10 years to refine the international version of ICD codes into the U.S. version we use--since the ICD-11 international version is expected to be completed in 2017, the earliest conversion to ICD-11 in the U.S. would be 2024 unless an unprecedented effort to accelerate development took place
  • In any case, converting to ICD-10 in 2015 will result in two ICD conversions in physician practices over the next 15 years.  The proposed alternative strategy to convert physicians one time from ICD-9 to SNOMED results in just one conversion with all future ICD conversions occurring in the background without significant impact on physician practices--thus, mandating the use of SNOMED to replace ICD-9  would be a significant cost savings to physicians.
  • SNOMED codes have been developed for the purpose of clinical input; ICD codes are developed for important administrative and financial output purposes-- thus, use of SNOMED codes for input will improve physician work flow because SNOMED is more intuitive to use for physicians to describe clinical encounters; this also preserves the use of ICD code sets for the important administrative and financial functions that our healthcare system currently depends on.
I believe that if CMS is going to maintain their mandate to move off of ICD-9, then we should move on to an available coding system that has the most potential to improve healthcare at the lowest cost:
 
  • Informatics experts agree that ICD-11 is more sophisticated and has more potential to improve healthcare than ICD-10, but the earliest that a US version of ICD-11 could be available is 2024 unless an unprecedented effort to accelerate development occurs
  • On the other hand, SNOMED is already incorporated in EHRs and being used by physicians
Thus, I believe the mandate to convert off of ICD-9 is more likely to improve healthcare, improve physician work flow and impose the lowest costs if we make the 2015 conversion to ICD-10 optional for physician practices and mandate physicians start using SNOMED (with the translator technology incorporated in EHRs) in 2017.    There will inevitably be tactical challenges involving diverse groups of healthcare stakeholders to work on, but if we remain aligned to the goal of improving quality care, I am confident we will find mutually agreeable solutions. 
 
cook children's healthcare system

Health IT-related patient safety risks should inspire Congress to create a national patient safety board

The idea’s time has come. The U.S. healthcare system needs a national, independent entity empowered by Congress to oversee health IT patient safety. Now.

In today's world a health IT-related patient safety issue that is identified by a physician practice or hospital is investigated and managed in a nontransparent manner by the individual provider and the EHR vendor.  

Although the issue may be escalated to a local accountable care organization (ACO) or patient safety organization (PSO) that providers are increasingly becoming associated with, neither the issue nor the results of the investigation are reported to a statewide or national oversight entity. The patient safety data is therefore not collected, aggregated and analyzed at a state or national level. Without such oversight we are missing out on the opportunity to identify known avoidable health IT risks to patient safety and failing to disseminate knowledge on how to manage those risks. For example, if an issue is resolved at the physician practice between the physicians and EHR vendor but is not addressed at other practices that use the same EHR, then patients at those other practices remain at risk. 

I have observed EHR vendors tune in to patient safety issues more keenly in the past decade and sometimes make more visible efforts to ensure identified issues are addressed with all customers and not just the ones who report issues. And let's be clear that a majority of EHR-related patient safety risks are related to how an EHR product is being used or implemented by their clients and not due to inherent technical flaws with the vendor's product. Nevertheless, patient safety should be viewed as a shared responsibility between the physicians, their practices or organizations and the health IT vendors. Identifying and managing patient safety risks is done most effectively when all cooperate in a team effort.

In Texas there had been discussions within the Texas Medical Association about establishing a central, statewide EHR patient safety entity to monitor and manage health IT-related patient safety issues. The data would be rolled up from hospitals, physician practices and patient safety organizations across the state for aggregation and analysis. However, it became evident during those discussions that it would be feasible and much more beneficial to establish governance at a national level.

So why does this need to be a new, independent national agency charged by Congress to oversee health IT patient safety? 

Today there are many government agencies and private entities that I believe could and should contribute to patient safety surveillance and improvements, but none have the expertise, assets and time that are necessary to coordinate a national effort. In addition to the complexity involved with collecting and analyzing data from hundreds of institutions and PSOs, there are hundreds of unrelated EHR vendor products being used. There is not yet any available registry of health IT products, many of which are subdivided into multiple versions that sometimes vary widely in their available functionality. As a result, I strongly agree with the observations and recommendations described in an article by Singh, Classen and Sittig (J Patient Saf, Dec 2011; 7(4): 169-174) calling for a national patient safety board that is an independent government agency structured similarly to the National Transportation Safety Board. This entity would be charged by Congress to oversee HIT patient safety and coordinate with other agencies who can contribute to improvement in patient safety such as the Office of the National Coordinator, the Federal Drug Administration, the National Institute of Standards and Technology, the Agency for Healthcare Research and Quality, the Center for Medicare and Medicaid Services, the National Quality Forum, local patient safety organizations, local healthcare organizations who collect patient safety data, other local EHR patient safety reporting entities and industrial (EHR and HIT) trade associations. All of these entities need to function in a cooperative fashion in order to effectively identify and manage health IT-related patient safety risks.

The recent health IT report from the Food and Drug Administration Safety Innovation Act (FDASIA Health IT Report) proposes a framework to improve health IT-related safety risks including a proposed National Patient Safety Center. 

I am concerned, however, that the proposal does not appear to provide this entity with enough authority to get the job done effectively. A national patient safety entity must have the authority to not only monitor activity and provide learning opportunities for vendors and providers, but also to regulate activities, investigate events, ensure issue resolution and require compliance. I do not see enough "teeth" given to the entity proposed by the FDASIA report. 

The primary focus of a national Health IT Patient Safety Center should be on the dedicated surveillance of HIT-related safety risks and to promote learning from identified issues, potential adverse events (“close calls”) and adverse events. But it must also have the authority to effectively manage identified risks and ensure compliance with best practices for health IT patient safety.