We're on the "Eve of Destruction"

In the song We're on the Eve of Destruction, singer Barry McGuire laments the end of western civilization due to endless worldwide strife in the 1960-1970's.  In the article The Awful (and not so creative) Destruction of Medicine, a similar argument is made for the end of private practice medicine in the United States.

The author of the article states that only 30% of physicians remain in private practice and that the "Marcus Welby Era" is long deceased.  The endless new government mandates are eliminating the private practitioner.

The physician is now part of interchangeable puzzle where everyone especially the payers have a say in the patient care and reimbursement.  The physician is no longer the centerpiece of healthcare.  The article makes a strong case that the modern day era of medicine from 1960-present is essentially over and rapidly changing.

What's a classically trained physician to do???

The best solution is to view the rapid change and chaos as an opportunity rather than a huge negative.  Realize that before Medicare started paying physicians in the 1960s that medical care was totally different.  Periods end and new approaches need to be analyzed and taken advantage of.

Potential Solutions:

1. Take some business classes or get an MBA
2. Attend some coding and reimbursement classes
3. Analyze and embrace your technology
4. The age of automatic physician entitlement is over.  This doesn't mean it still cannot be fulfilling and financially sustainable.
5. Your Medical degree is a ticket to multiple opportunities
6. Attend a meaningful use lecture or two
7. Understand that the accountable care organization (ACO) is code for 21- 1st century HMO.
8. Rethink your hiring practices.  Get professional consultations to get improved financial situations.  Hire consultants not employees.
9. Pick software that pays for itself downstream.
10. Learn the new rules and adapt
11. Realize to succeed you will need the proper software, highly trained medical assistants, and possibly voice activated technology such as Dragon to make one complete medical technology unit.

The future is still bright for the agile and well informed.  Make your theme song, The Future's so Bright, I Gotta Wear Shades.

Technological Age Appropiate Software

Modern communication has evolved exponentially in the last few years.  The  new technology does incredible things and dramatically changed behaviors.  It is rare to see a young person today walking down the street without a "smartphone" held in an outstretched arm.

When people of my era got a "new toy", we may have read the directions.  My children say, "play with it and figure it out".  This is not an easy solution to people who think, "if I press the wrong button, I will destroy the software and or hardware".

Software and hardware developers should remember that they should provide a product that is appropriate to the technological level of the user.

My smartphone has a multitude of tasks that it can accomplish, but I will never even look at or explore by myself.  The manufacturers should remember to develop a tiered approach to their products.

Certain companies have accomplished this.  Dragon voice activated technology can be used by the most and least sophisticated user.  When utilizing Dragon in an electronic health(care) record, you can use all the widgets or just dictate correcting mistakes with the mouse and or keyboard.  Just using the old-fashioned non-video games technique only costs a few more seconds without fat-finger syndrome!

When creating a software product or website, do not assume that everybody understands programming convention or standards.  Provide simple guides and avoid the right-click solution.  Most people over 50 do not know what a right click is.

At my age, I would welcome the dreaded chip in the brain, so I could keep up.  Until that becomes a reality, realize that the only people that can afford most of these toys are chronologically old, but technologically young.

Could Your Electronic Health Record Function Without Workarounds?

The Electronic Health Record is a complex tool that hopefully improves communication, fix the legibility issue, and decrease medical errors.  However, the "Devil is always in the details".

Wikipedia states a workaround is a bypass of a recognized problem in a system.  A workaround is typically a temporary fix that implies a genuine solution to the problem is needed.  But workarounds are frequently as creative as true solutions, involving outside the box thinking in their creation.

Computer software that causes a computer to perform useful tasks beyond running the computer itself is called Application software, program, or app.

A GUI widget or control is an element of a Graphical user interface- GUI that displays information arrangement changeable by the user, such as a window or text box.  The defining characteristic of a widget is to provide a single interaction point for the direct manipulation of a given kind of data.

A true test of your EHR is:

1. How many workarounds, apps and widgets are necessary additions to make the program usable?
2. Are these add-ons value added or desperately needed to succeed?

These include some of the following resources: Scribes, Physician Assistants, Nurse Practitioners, Medical Assistants, Voice activated technology, Cut and paste, Macros, Typing courses, Artificial intelligence, Warnings, Error notifications, etc.

Some of these additions can add major value superimposed on an efficient, walk-up usable computer program.  The problem is they are necessary at great cost to survive the electronic world.

Decrease the # of Clicks and Improve Navigation

At the present time, the number of clicks necessary to fill out a chart is endlessly time consuming and non-productive.  The cost per click is now being calculated (see my prior blog) and quantified.  The work flow is slowed down and there is a real-not imagined- price to pay.

 

One solution is to create an auto-flow sequence that is tunable by site or provider and that comfortably guides the clinician from one area of the chart to another in a logical-customary- sequence.  If an out of sequence entry is desired, this should be easily accomplished.  A system with automatic guidance will eliminate the need to figure out where should one go next, especially if one is interrupted.  When it is acknowledged that one area is complete, it then moves to the next area when documentation is continued or resumed.  Once the area is completed, the list shrinks.  Your favorite click might be auto-sequenced.

 

An example sequence could be...

• Vital signs
• Triage sheet
• Past medical history
• Nursing notes
• History and PE in logical order
• Medical decision making
• CPOE
• Lab and x-ray results
• Clinical course
• Final diagnosis
• Disposition
• e-Prescribing
• Patient education
• Follow-up
• Review nursing notes
• Sign the chart

Navigation would be significantly simplified.  The provider can always go to any area directly and in any order.  Nursing notes might be reviewed, if easily accessible.  Training would be simplified and hopefully stress-reduced.

Is Your Electronic Health Record Hazardous to Your Patient's Health?

The Electronic Health Record has the potential of better care through improved legibility, warnings about allergies and drug interactions, improved communication to all providers, artificial intelligence for diagnosis and treatment, e-prescribing with accurate dosages, and improved patient education.

However, as usual the "devil is in the details", which may provide risks to the provider and the patient.

1. Choice of EHR- through meaningful use certification, imposed one-size fits all "enterprise" systems, minimal provider input, and the use of the EHR to attempt to control behavior, collect data, and solve institutional problems- the overall benefits have been neutralized.
2. Implementation- There are multiple articles written on early, middle, and late implementation issues.  Early issues include training, forcing the provider to adapt to the system rather then the rational opposite.  Training teaches you how the software program operates, but does not deal with the actual flow of patient care in the facility.  CPOE is a good example of making the most expensive person in the room a "data technician".
3. CPOE- It was implemented to control costs, decrease errors, and reduce over-ordering of tests.  There is no proof available yet.  However, most CPOE systems lead to more tests, more cook-book treatments and more expense.
4. When the provider is new to the system- lack of intuitiveness of the software, mistakes can easily be made.  A locum tenems provider require training prior to working their first shift!
5. Navigation- Many difficulties exist such as can't find the nursing notes, access old records, access important messages sent to patient, and how to discharge a patient.  Many of these tasks require multiple steps to accomplish something that should be easy and straight-forward.
6. Cooke-cutter charts- The charting output looks the same for every patient due to the use of macros, cut and pasting, and the number of clicks.  The chart becomes disorganized and does not reflect the true problem or treatment plan.
7. Patient Education- the over kill of information that the patient will not read or understand if they do!
8. Pediatric Prescriptions- The difficulty of the overly complex formula that requires a provider to process in a way they were never educated.
9. Artificial Intelligence- Warning fatigue leads to the provider ignoring things that could be significant.
10. Encounter Summaries - Sending a document to a referral provider is complex and over loaded with data that it is hard for the referral provider to determine what has already been done.  Depending on the output, the key information is not always obvious.

Many of the issues listed above force providers to hire scribes and more support personal meanwhile limiting contact with the patient.  They are busy swimming in the overwhelming paperwork!

 

EHR 2.0 will hopefully solve a lot of these issues, but the key is a USER-FRIENDLY version that is viewed as an asset not an obstacle.  Understanding work-flow by the computer developers and eliminating government mandated data collection are excellent first steps!

The Appeal of a Failed EHR Incentive Audit

Interesting industry news update from EMR Advocate Jim Tate!

Appealing an Adverse EHR Incentive Audit

by Jim Tate
Twitter: @JimTate

The letter the hospital received said it all, “Based on our desk review of the supporting documentation furnished by the facility, we have determined that Hospital X has not met the meaningful use criteria………….Since your facility did not meet the meaningful use criteria, the EHR incentive payment will be recouped. You will receive a demand for  your total Medicare EHR incentive payment shortly from the EHR HITECH Incentive Payment Center.”
If that doesn’t get your attention, nothing else will. I wouldn’t want to be the one that received the email and have to be the one to show it to the hospital CEO or Board. I would imagine the CFO also would not be too pleased. It sounds so final, “did not meet the meaningful use criteria” and “will receive a demand for  your total Medicare EHR incentive payment shortly”. I guess that is why it is call Final Determination. It sounds like a death sentence. But it doesn’t have to be.
I was contacted by the hospital the week after they received notification they had failed their EHR incentive audit and to expect a demand letter for a seven figure recoupment. They only failed one meaningful use measure, and it wasn’t the infamous Security Risk Analysis. If I had been on board earlier I could have perhaps helped with documentation and clarification that would have met the expectations of the auditor. It is hard to go back and reconstruct what happened during the 2011 attestation. Staff changes and memory fades. By the time I knew anything the audit was failed and they were behind the eight ball. Not a good place to be.
I was raised in the red clay of Georgia and my Aunt Betty was always saying, “Thank my lucky stars”. It was always “lucky stars” this and “luck stars” that. Well, I can tell you, when I heard about the appeals process for failed EHR Incentive audits the first thing I thought was, “Thank my luck stars”. We were told we were the first hospital that took a failed audit decision to the appeal level. That’s right, we were #001. We worked through the appeal process by providing additional clarifying documentation and participating in a number of conference calls. I felt we received a fair and transparent hearing. Last week the hospital received an email stating, “….we are reversing the adverse audit determination”. Now that is one email I bet everyone was glad to share. Thank their lucky stars. I hope you have a few of those lucky stars in your sky if you need them.
Having to go the appeal route is a bad sign. It means you have not met expectations and without some additional viewpoints or personnel a reversal is unlikely. For all providers, and especially for hospitals where so much is at stake, if the EHR incentive audit process is not going smoothly you simply must seek expert guidance on the process and requirements.

Jim Tate is founder of EMR Advocate and a nationally recognized expert on certified EHR technology, meaningful use and the EHR Incentive audit process. Contact him at jimtate@emradvocate.com.

http://myemail.constantcontact.com/News-Digest-for-July-9--2013--The-Appeal-of-a-Failed-EHR-Incentive-Audit.html?soid=1102564327964&aid=I0X4P4Xt73U

Migration Issues

 



They are various types of migrations.  We are going to focus on data and system migrations- both have many complex issues.

• Data migration- the process of transferring data between storage types, formats or computer systems.
• System migration - the tasks involved when moving data and applications from current hardware to new hardware.

A new complexity has been added to the Electronic Health Record when practices, hospitals, departments and urgent cares either transition from paper to electronic and/or change products or vendors.  The reason for change include:

1. Adoption of an enterprise system that co-opts prior vendors.
2. Adopting a product for meaningful use funds and/or e-Prescribing.
3. General discontent for the present system.
4. Lack of support from prior vendor.
5. New products have "wow-factors" the save FTEs.
6. New ownership wants to consolidate their practice to one format, etc.

When purchasing a new Electronic Health record, it is incumbent that the "migration" to the new format is planned and supported by the vendor.  These include interfaces to capture old data, scanning solutions, 24/7 support, and a firm understanding by the new provider of the various complexities.

Avoid "re-inventing the wheel" by having these discussions with all parties to provide a smooth transition.  Do not suffer from inertia- the tendency of a body to maintain its state of rest unless acted upon by an external force.  Making changes to improve productivity, work-flow are always in your best interest.

What Will the Future EDs & Urgent Cares Look Like? --- The Remote Controlled Practice

The Big Bang Theory

The future of medicine is in a state of flux due to politics, economics, demographics, provider shortages, and consumer activism. The paradigm will need to shift to accommodate the seemingly endless demand on the healthcare industry. Expectations (realistic or not) of quality, efficient care will drive the shifting process.

I expect to see a new process similar to the one below:

1. The basic face-to-face to provider will be a “physician extender.”
2. This extender will be supervised by a “physician advisor.”
3. The physician advisor will be on location in high volume, high acuity facility.
4. The physician advisor will interact with the extender from this remote location via electronic devices for multiple urgent care practices simultaneously. On the “Big Bang Theory” television show Sheldon created a portable extension of himself through technology. Perhaps physicians will find a way to be in two places at once…
5. Consultants will be available through Skype, telemedicine, Ipad’s facetime and other such technology. Through this technology physicians can interactive with both the patient and the physician extender. A “Flow Facilitator” will be watching all the data streams and communicate with the local provider determining what to do next to achieve maximal efficiency.
6.  Artificial intelligence from EHR to take symptom complexes and PMH to assess risk of that particular patient's visit (maybe 15 years away.)
7. EHR becoming user friendly rather than onerous.
8. Patients carrying their entire medical history on their personal device.

Consumer demand will dictate a flow of patients into the system. The majority will rely on classic medical care; however, a large segment of the population will adopt an anti-technology “Luddite” approach in response to the all the available technology. They will resort to massive increases in alternative medicines.

Regardless of the quality of the care in this remote model, the “Human Touch” will always be needed to inspire confidence in the patient.