Digitized Medicine

Healthcare Industry's Triple Strand of DNA: health IT, payment reform and patient empowerment

Earlier this month I used a genetics anology to describe the amazing progress with electronic health record (EHR) usage by physicians over the past two years (see Progress being made to splice information technology into the healthcare industry's genome in Texas).   Facilitating this progress are the EHR Incentive Program and other federal health IT initiatives that the Office of the National Coordinator for Health IT (ONC) oversees. 

Last Thursday the National Coordinator of ONC, Dr. Farzad Mostashari, took my genetics analogy one step further in his keynote speech at the HIMSS12 Annual  Conference for health IT in Las Vegas.   And I have to admit that he improved upon it.  I guess that's why he's in Washington D.C. and I'm not. 

Dr. Mostashari warned the 36,000  conference attendees that along with this continued progress there are two other societal trends to align health IT with.   He advocated for "twisting health IT to create a triple strand of DNA" with payment reform and patient empowerment. 

Health IT, payment reform and patient empowerment.  The triple strand of DNA to splice into the healthcare industry.  I like that. 

Payment reform is seriously needed to align incentives with the provision of quality care in an efficient manner.   Right now I am basically paid to "encounter" patients and to do procedures.       Although I am personally motivated to provide high quality care, the incentives are oddly there for physicians to "see more" and "do more" rather than to "see it done best".     In addition, my documentation is based on meeting reimbursement rules to make sure I get paid rather than being based on communicating a clear picture of my findings and care plan.   I absorb the extra time it takes to do both.

Consequently it is no surprise that for decades EHR vendors developed products based on episodic care.    Physician's sought out products that would help them document and get paid for patient encounters.  Documentation templates and charge capture functionalities were developed to maximize chances for reimbursement.    

The potential for EHRs to improve quality and chronic disease management is just now starting to be realized.    The ONC's health IT initiatives enacted by CMS under the HITECH portion of the 2009 Recovery Act are providing the push.   But as payment reform proceeds, whether it be value-based purchasing, accountable care or some other program, EHR vendors will be incentivized even more to shift development efforts into chronic disease management and clinical decision support that are a basis for improving patient care. 

And the third strand of DNA to splice into the healthcare industry, patient empowerment, is indeed an active and growing societal influence.  But I will have to blog about that another day...

Bipartisan Health IT Support and ARRA Insulate EHR Incentive Funds From Budget Cuts

A physician colleague recently asked me why I am confident that CMS will not cut off EHR incentive funding in the future.   This question is important to him and other physicians who plan to qualify for up to $44,000 in CMS incentive payments by achieving the meaningful use of EHRs.   They fear that the dragging economy and political discord will result in budget reductions that will cut this and other important health IT funding programs.    What I see, though, is a decade-long track record of bipartisan support for health IT initiatives and a 2009 federal law that requires CMS to provide funding for the EHR incentives and other health IT programs.

In his 2004 State of the Union speech President Bush envisioned the adoption of EHRs for all Americans by 2014.   Since then bipartisan support at both the state and federal levels for health IT initiatives toward the achievement of that vision has held strong.   At the federal level CMS  not only established a new office in 2004 to support health IT, the Office of the National Coordinator of Health IT (ONC) but has also increased funds to support ONC initiatives which promote the adoption and use of EHRs.  CMS works collaboratively with ONC and has consistently shown an understanding that the broad adoption and effective use of EHRs are necessary to better manage spiraling healthcare costs.   CMS understands that the data captured by EHRs is superior to claims-based data when attempting to analyze quality and establish benchmarks.    Physicians have long complained that claims-based data is incomplete and does not fairly demonstrate the quality of care they provide.     EHRs must be broadly adopted in order to capture accurate and meaningful data that can then be used to improve quality or save costs.  

It is important to recognize that CMS is required to provide EHR incentives to physicians by law.   Specifically, the $800 billion American Recovery and Reinvestment Act (ARRA) of 2009, commonly refered to as the Stimulus Bill, allocates over $36 billion to health IT programs through the Health Information Technology for Economic and Clinical Health (HITECH) Act.   This funding includes an estimated $34 billion for the Medicare and Medicaid EHR Incentive Program and over $300 million to support state-wide health information exchange efforts.

In order to cut funding for EHR incentives, this means that bipartisan support would have to be garnered in the House and Senate to rescind ARRA or part of ARRA.   The intent of ARRA  initiatives is to stimulate economic activity and produce jobs.   In the current economic environment it would seem very risky, perhaps even foolish, for a politician to drum up support for new legislation that eliminates economic stimulus activity, especially if that activity is already producing jobs.

So, is the EHR Incentive Program stimulating the economy and producing good jobs?   I am not an economic expert, but from what I see around me the answer is clearly, "yes".    I see job openings in the local paper for healthcare system IT analysts and other staff, I speak with IT consultants most of whom are actively seeking personnel, I hear about physician offices investing into the economy $10,000-$70,000/doctor to implement EHRs or upgrade other office technologies, I read about physicians receiving $44,000 federal incentive payments and about hospitals receiving larger amounts, some of which is surely returned into local economies.  The graph below is a composite view of the 3-year stock performance of the health IT sector since 2009.   EHR vendors and other health IT companies appear to be thriving well since ARRA was passed despite the depressed economy.

I suspect that several years from now when experts analyze the impact of the $800 billion stimulus package, the puny $36 billion provided to health IT initiatives through the HITECH portion of ARRA will go down as perhaps the most bang for the buck in terms of stimulating the economy.  

The EHR incentive funds appeared to be well insultated from budget cuts for these same reasons. 

Texas Medical Association video provides in-depth look at meaningful use, how RECs can help physicians

This video does a good job of describing Meaningful Use, the electronic health record (EHR) incentive program and how the four regional extension centers (RECs) in Texas leverage federal grants to subsidize services for physicians that help them select/implement or upgrade an EHR, and then use their EHR to improve quality of care and meet the Meaningful Use requirements.  

The four RECs in Texas currently charge primary care physicians only $300 for consulting services valued at $5,000.  These services include:

o    Select and implement a certified EHR (or upgrade your current EHR to a certified version)

o    Optimize your practice workflow,

o    Achieve meaningful use,

o    Qualify for EHR incentives, and

o    Obtain CME credit hours      

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Twitter Chats and Physicians (#eRx630)

Today I (as @drmattmurray) and @TexMed moderated our first Twitter Chat that focused on the topic of e-prescribing. To participate in a Twitter Chat a physician must have a Twitter account and must know the date, time and Twitter hashtag for the Twitter Chat.  In our case the hashtag-- #eRx630--refers to e-prescribing and the date, June 30th, by which time physicians must meet the CMS requirements regarding the use e-prescribing. Physicians who fail to use a qualified e-prescribing system or certified EHR to enter at least 10 e-prescriptions during eligible Medicare encounters will incur a 1% penalty on 2012 Medicare claims.    On the other hand, those who meet this requirement are eligible for a 1% bonus. 

Despite the high importance of this subject matter, there were not any other physicians participating on this particular Twitter Chat.   At least none that we heard from.   It was lonely.  

However, we considered this to be an experiment and a chance to experience what it is like to actually moderate a Twitter Chat.    Without a lot of participating "chit-chat", it was difficult to coordinate questions and answers with my friends @TexMed and @TexMedHIT.     We basically asked each other questions or even asked ourselves for our own answers.  I think we did get out some excellent information, but this would have been more valuable with some active back-and-forth dialogue.   Again, though, the purpose of this venture was to dip our toes in the water to see how this type of format could be used in the future. 

Twitter Chat among physicians will certainly have challenges, but I think it will find it's place as a useful mode of communication for specific purposes and in certain situations.  The format will need to be refined, and this means we will have to try it (like today!), experiment with it, refine it and keep doing that PDSA thing to it (Plan-Do-Study-Act).   Eventually it will find a place where it serves as an effective way to communicate some things.     I already have found Twitter useful at large medical conferences that use a hashtag to communicate real-time information.    It is a matter of finding the right niches. 

One of the useful aspects of a Twitter Chat is that a transcript can be created of the entire conversation.  This means that you don't have to be "online" and engaged in the Twitter stream for the entire duration of the chat.   Since most physicians are hard pressed to find an un-interrupted hour, they would find it very helpful to be able to access and peruse the transcript at their leisure.

Here is a transcript of today's Twitter Chat #eRx630:

 
 
 
 
 
 
 
 
 

Help Available For Small Physician Practices to Overcome Technology Challenges

American Medical Association (AMA) President, Cecil B. Wilson, M.D., said in an AMA Commentary this week, "Physicians should take the time to explore their practice needs, assess their practice's readiness to adopt health IT and select the right system for the practice --and its patients".    This is wise advice that I wholeheartedly agree with.

I also agree that the successful adoption and meaningful use of electronic health records (EHRs) impose many new challenges onto physician practices and that overcoming these barriers is especially difficult for physicians in small practices or solo practices that are constrained by limited resources.   My only disappointment with Dr. Wilson's message to physicians is that it failed to highlight how Regional Extension Centers (RECs) can be leveraged by physicians to address these issues with EHR adoption and use.

The HITECH portion of the 2009 Reinvestment Act (ARRA) included over $677 million in grant funds to establish RECs across the nation to cover every geographic region.   The purpose of each REC is to provide consulting services to physicians that help them overcome many of the described barriers to the adoption and use of EHRs.   It is important for physicians to know that the RECs receive federal subsidies specifically based on and proportionate to the number of primary care physicians in solo or small group practices (<10 physicians) that they successfully help adopt, implement and meaningfully use an EHR.  In other words, RECs are financially dependent on providing effective health IT consulting services to a segment of physicians who have the greatest need for such services.

In Texas there are four RECs including the North Texas REC (NTREC) for which I volunteer time as Board Chairman.    Other Texas physicians volunteer their time to comprise 50% of the governing boards for each of the four RECs.   Our goal is to ensure that our RECs are physician-friendly and remained focused on providing high quality services that meet the technology needs of small physician practices in each region.   Texas RECs collaborated with each other to create a common business plan that leverages the federal subsidies to charge Texas physicians a token fee of $300 for IT consulting services worth over $5,000.    

NTREC will receive 100% of their allotted subsidies if we successfully help 1,500 physicians adopt EHRs and achieve meaningful use.   Since last October more than 500 North Texas physicians have enrolled for NTREC services; over half of them have already successfully implemented an EHR and are now working on the achieving meaningful use of their investment.

My hope is that physicians in other states will emulate our efforts by actively engaging in the governance of their region's RECs to ensure that they are physician-centric and remain focused on addressing the unmet needs of the small physician practices.

 

Comparison of Web-based vs. Traditional EHRs For Physician Offices

An ambulatory electronic health record (EHR) can be provided to the physician practice through one of two different models:    

1. Web-based-- also referred to as a "hosted EHR" or the "ASP Model" where the physician accesses the EHR through an Internet connection
2. Client-Server (C/S)--  the traditional model where the EHR server may physically resides in the  physician's office

Both models are considered to be acceptable, but each has inherent pros and cons to consider.   The traditional model of choice has been the “client-server” model.   In this model the EMR software is installed on a server that is typically located in the physician’s office.  The physician and staff access the EMR through computer devices that are connected to the server through a local area network (LAN) set up in the office.  The computers may be connected wirelessly to the network if desired.   This model has a few similarities to loading Quicken on your home computer and then using Quicken to pay bills online: 

1. After loading Quicken onto your computer you will periodically be advised by Quicken to take "updates" to fix known "bugs" in the software.  Similarly, you will load the EHR software onto the server in your office and physically download any updates to fix "bugs" that the vendor discovers and fixes.     
2. Microsoft periodically advises you to take security updates on your home computer.  Similarly, the EHR server will need to take periodic updates from Microsoft.
3. You may later decide to upgrade Quicken to its latest version, and then purchase and install the Quicken upgrade on your computer.  Similarly, you will want to upgrade your EHR software periodically, usually every 12-18 months.
4. You may decide in the future to purchase a new home computer that is faster;  you will have to then load the Quicken software onto that new computer and transfer all of your old Quicken data to the new computer.  Similarly, you will need to periodically replace the EHR server with a newer one that is faster, stronger and/or meets future recommended requirements of the EHR software.  And make sure your data gets transferred as well.

The web-based model is gaining popularity.  In this model the EHR software is located on a server at a remote location designated and hosted by the EHR vendor.  The physician and staff access the EHR through the Internet on computer devices in the office.  This is analogous to online banking that you access on your home computer and use to pay your bills online (instead of using Quicken).  Using this analogy: 

1.  You will not physically have to take updates because the bank will update the software themselves
2.  Microsoft will not ask you to take Microsoft security updates to the online banking server because the bank hosts the server and will do that themselves
3. When there is an upgrade to the online banking software, you do not have to purchase and physically load that software on your computer because the bank does that on their server that you are simply accessing.
4. If the online banking server is too slow you will not have to purchase a new server, the bank will do that (if enough customers complain)...and they will migrate your data over to that new server)

Here is a comparison chart for these two EHR models:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Personally, the business side of me is strongly averse to allowing a 3^rd party vendor to take care of the “heart and soul” of my practice (i.e. the revenue dollars and the clinical data).   Hence, in private practice I would strongly favor keeping the server in-house.     However, the clinic I currently work at is a small part of a large academic institution.   For our ambulatory EMR I am leaning toward recommending a web-based model.  The presence of an institutional IT Department whose primary purpose is to support the education of thousands of students, not to understand and dedicate the resources needed to provide a high level of clinical IT support required for a clinician using an EHR.  And I know who is most likely to get trumped down the road when conflicting priorities arise!

Why should primary care physicians enroll for Regional Extension Center services?

Why should primary care physicians sign up for REC services?   What are the unique selling points and assistance they will receive as compared to other consultant organizations?  

These are excellent questions I am hearing from physicians in Texas regarding the four RECs that cover our entire state.  The RECs are subsidized by the federal government through the Health Information Technology for Economic and Clinical Health (HITECH) Act which appropriated $640 million in REC grant funds to create 62 RECs across the nation, including the four in Texas. 

Primary care physicians in Texas should use REC services because they will receive a steep discount for high quality services that are provided through a trustworthy, physician-centric organization that was specifically created to meet the technological needs of physicians in their region.

In Texas the four RECs have collaborated to develop a shared business plan that leverages the federal subsidies to provide onsite technical consulting for a token fee of $300.    For this $300 enrollment fee Texas physicians receive over $5,000 in consulting services which include:

• EHR implementation and project management;
• HIT education and training; 
• Vendor selection and financial consultation; 
• Practice and workflow redesign; 
• Privacy and security compliance education; 
• Meaningful use analysis, tracking, and monitoring; 
• Assistance in meeting meaningful use requirements for CMS incentives; 
• Collaboration with state and national health information exchange (HIE); 
• Ongoing technical assistance; and 
• Opportunities for CME credit hours

In addition to this steeply discounted enrollment fee, the Texas Medical Association (TMA) works closely with the RECs to help ensure that the RECs are physician-centric and focused on meeting physician needs.    Physicians hold 50% of the seats on each REC's governing board as a result of the TMA’s early efforts.

Another unique selling point is that the REC technical consultants are specifically focused on, and experienced with, the small physician practice.    Other IT consultants naturally give priority to large practices or healthcare systems where they get large amounts of money from a small number of contracts.    The REC consultants, on the other hand, only get a small amount of money per contract, but they get a large number of them.    This business strategy allows them to become more experienced with and more focused on the small practice.    The REC administrative staffs enable this strategy by facilitating the enrollment of a large number of physicians and by using the REC federal grant funds to offer physicians the steep discount.

The four RECs in Texas are:

• Gulf Coast Regional Extension Center (GCREC)
• CentrEast Regional Extension Center (CEREC)
• North Texas Regional Extension Center (NTREC)
• Texas Tech University Health Science Center

North Texas Regional Extension Center's Successful Start and Current Activities

Today, while wearing my hat as the Board Chairman of the North Texas Regional Extension Center, I am writing a message primarily to my colleagues who practice medicine across North Texas.   I am sharing this message through my blog, however,  because others may be interested to see and hear what is happening at the grassroots level of local and regional health IT initiatives:

 

  
 February 2, 2011

To my physician colleagues across North Texas,

On behalf of the volunteer physician board members of the North Texas Regional Extension Center (NTREC), I am writing to inform you that registration for the federal electronic health record (EHR) incentive program has begun and that the money is already flowing.   In January, for example, two Oklahoma physicians at the Gastorf Family Clinic of Durant, OK, received $21,250 each for having implemented a certified EHR.   If you are considering making the jump to an EHR, or if you already use one, you may become eligible for EHR incentives up to $44,000 under Medicare or $63,750 under Medicaid by meeting “meaningful use” requirements.

NTREC receives federal grant funds for providing on-site technical consulting to enrolled physicians who are selecting, implementing or using an EHR.   This federal subsidy allows NTREC to charge primary care physicians only $300 for consulting services valued at $5,000.  

NTREC is focused on helping you:

• Select and implement a certified EHR (or upgrade your current EHR to a certified version),
• Optimize your practice workflow,
• Achieve meaningful use,
• Qualify for EHR incentives, and
• Obtain CME credit hours along the way

I am happy to report that NTREC services were successfully launched four months ago.   Since then, 289 physicians have enrolled for services and another 370 physicians have enrollment contracts in progress.   Our goal is to provide services to more than 1,500 physicians in North Texas by the end of 2011.   Our operational plans will enable us to scale physician services to even higher levels if needed to meet physician demand.  

The federal EHR incentive program and these discounted NTREC consulting services are unprecedented and genuine.   Please call NTREC to enroll and set an appointment for on-site consulting at (469) 648-5140 or by visiting  www.ntrec.org.   The NTREC’s dedicated team of experts will be considerate of your valuable time and show you how they can help you identify and meet your unique needs.

If you have questions, please don’t hesitate to contact me.

 

Sincerely,

 Matt Murray, M.D.

Brown Lupton Health Center

Texas Christian University

 

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For Meaningful Use Payment: Goin' to the CHPL, Gonna Get a "CMS EHR ID"

Use of certified electronic health record (EHR) technology is a core requirement for physicians and hospitals to become “meaningful users” and to be eligible for payments under the Medicare or Medicaid EHR incentive programs.    Operationally, CMS requires providers who apply for these payments to submit the "CMS EHR ID" that their certified EHR technology is assigned.   Physicians and hospitals will benefit from an awareness of several issues revolving around EHR certification and on this CMS EHR ID, especially when "goin' to the CHPL" as noted below.

Awareness Issue #1:  The Office of the National Coordinator for Health Information Technology (ONC) in 2010 established a temporary certification program for EHR products.    A permanent certification program, which builds upon the current temporary program, is expected to be ready to launch by the end of 2011.   This program uses ONC-Authorized Testing and Certification Bodies to test and certify EHR products.   The list of certified EHRs is updated as new products are certified and posted on the Certified HIT Product List (CHPL) website.    CHPL is maintained by ONC and is the sole, designated authoritative list of currently certified EHR products.  

Awareness Issue #2:    ONC certification is different from that provided by the Certification Commission for Health Information Technology (CCHIT).    CCHIT certification is based on more comprehensive criteria.    CCHIT certification continues to be an important resource for those who are in the process of selecting an EMR because of this more comprehensive testing.    ONC certification testing, on the other hand, is specifically based on the CMS Meaningful Use criteria. 

Awareness Issue #3:   EHR products are tested and certified by ONC as either a Complete EHR or a Modular EHR.   A Complete EHR product is defined as an EHR product that meets all of the certification criteria for meaningful use.  A Modular EHR product is defined as an EHR product that meets at least one but not all meaningful use criteria.

Awareness Issue #4:   When a physician or hospital apply for their incentive payment they are asked to submit to CMS the "CMS EHR ID" that is assigned to their EHR product(s).  The CHPL website is the only place where this ID number can be found.  

Awareness Issue #5:    When looking for this CMS EHR ID number, it is helpful to know that this is not the same number ONC provides the EHR vendors when they are certified.    This is because some providers may decide to use a modular approach and combine Modular EHR products from different vendors in order to achieve meaningful use (i.e. a basic EMR without e-prescribing from one vendor and an e-prescribing module from another).  

Awareness Issue #5:   As the website works today, the CMS EHR ID can only be found on the "Grocery Cart" page and only after the <Get CMS EHR ID> button is activated.    One first selects their EHR product(s), puts them in their "Grocery Cart" and then goes to their <Grocery Cart> page.    The button becomes available when one has either:

• selected a certified Complete EHR product

                                     or

• selected a set of certified Modular EHR products that meet all of the certification criteria      

It interesting and helpful that CHPL provides real-time feedback when selecting a set of Modular EHRs.  Once all of the criteria are met, the <Get CMS EHR ID> button becomes available.  

Awareness Issue #6:    Regarding the modular option, the CMS certification process does not include integrated testing of all the possible permutations of Modular EHR sets that can be selected.    So even though a set of Modular EHR products may produce a CMS EHR ID on the CHPL website, this does not mean that the selected set of products were tested as an integrated unit.   This does mean that the physician or hospital who is in the EHR selection process should not depend on the CMS EHR ID to determine whether the selected products can be interfaced or work together.     Due diligence will still be needed to ensure all of the selected Modular EHR products are compatible.   

In other words, if you're goin' to the CHPL and gonna' get an CMS EHR ID, it's best to know your EHR partners well before purchasing and implementing them!

Crossing the Quality Synapse: Interoperability is the Neurotransmitter Propagating 21st Century Healthcare

Yesterday at the 2010 ONC Grantee Meeting in Washington, D.C  I was invigorated by the optimistic energy, realistic networking and paucity of pessimism from over 1,000 participating grantees whose collective repository of health IT knowledge is astounding.   And it got me thinking, maybe the Institute of Medicine (IOM) got it wrong and that it is not actually a chasm...maybe we are...crossing the quality synapse?

Imagine for a moment that electronic health information is a charged impulse using health IT neuronal circuitry to propagate 21st century healthcare.  This neuronal circuit provides the infrastructure needed to enable charged impulses of the right information on the right patients to be sent or received wherever it is needed, whenever it is needed.  However, as we physicians know, the neuronal circuit is made up of many individual neurons that are not physically connected to one another.  Each neuron can individually propagate a charged impulse along its long, tubular-shaped axon, but the axon ends blindly at its terminal end.  Between it and the next neuron there is a space, called the synapse, across which the electrical impulse cannot travel.  This constraint prevents an individual neuron from transmitting the electronic impulse to its final destination.  On the other hand, an absence of such constraints and uncontrolled releases of electrical charges between the neurons of our brain would result in seizures.   So, some type of trusted intermediary is needed to enable the neurons to talk with one another in a standard and controlled manner...to be an interoperable neural circuit that coordinates and directs the traffic of electrical charges to their permitted destinations.     

In medicine we recognize the complexity of this synapse.  Although we have learned much about it, we remain humbled by what we do not yet know.  What we do know is that at the "receiving" end of a neuron there are tiny tentacles, or dendrites, that stick out into the synapse toward the "sending" neuron's axonal terminal.  When the charged impulse reaches the axon terminal, the action potential stimulates the chemical release of neurotransmitters from the terminal into the synapse.    The neurotransmitters physically travel across the synapse to the dendrites.  At that point the neurotransmitters become a catalyst for the transformation of the chemical process back into an electrical one.  The new electrical impulse travels from the dendrite into the neuronal axon and propagates down to the next synapse, where interoperability will again have to occur. 

Health IT interoperability is the 21st century neurotransmitter that is catalyzing the transformation of the healthcare system.  Without interoperability we know that electronic health information is severely devalued as it remains trapped in individual silos, just as an an absence of neurotransmitters would limit electrical impulses to a single neuron. 

Concurrent with ongoing neuroscience research on the complex synaptic neurotransmitters, medical researchers used what we already knew to initiate trials and studies in an effort to improve psychiatric care.  Breakthrough research demonstrated that a synaptic deficiency of one of the neurotransmitters in our brains, serotonin, can cause depression.  Through additional trials and experience we then discovered that SSRI medications, which elevate serotonin levels by inhibiting their "reuptake" in the synapses after being released, are useful when treating people with depression and other mood disorders.   Similarly, a deficient level of interoperability between EMRs depresses our ability to transform our healthcare system.  We need to use what we already know about interoperability to initiate trials and studies in an effort to raise our interoperability to optimal levels that will propel our healthcare system into the 21st century.