Communique from the Beach - by Jim Tate EMR Advocate

EMR Advocate Newsletter

by Jim Tate

August 2013

 

Communique from the Beach

Summer is almost gone. My kids start school next week. Time for one last trip to the beach. "The windy beach, far from the twisted reach of crazy sorrow" as Dylan proclaimed. Even here, beneath the diamond skies of Coral Bay on St. John Island, I am not beyond emails informing me of the latest developments pertinent to CMS EHR Incentive audits. 

In between snorkel trips to Trunk Bay and Salt Pond Beach I find disturbing emails lurking through my inbox. Of course, there are the standard inquiries I've received from eligible professionals who are being audited and don't stand the slightest chance of passing an audit. There is the dermatologist who swears he was told there was no minimum number of patients he had to document in his ONC certified EHR to receive an $18,000 incentive in 2011. He received the infamous "audit engagement letter" letter last week. I asked him how many patients he saw during his 2011 meaningful use period and he answered, "Hundreds". I asked him how many patients did he record in his EHR? "Six" was the reply. My advice? Do not pass Go, do not go through the audit, do not appeal. Pay the money back and go and sin no more. Those are the easy, black and white answers. However, I have also be running across some issues with those touchy nuances pertaining to the often foggy "public health" measures.

The Public Health (PH) measures have been slightly off the radar as they swish and sway down there in the Menu Measures for Eligible Professionals (EP) and Eligible Hospitals (EHs). Such Menu Measures as Immunizations, Syndromic Surveillance, and Reportable Lab Resultscontinue to confuse and confound. Wouldn't it be nice to pick one, claim an exclusion, and then be rid of it hopefully for all time? Just throw it over the fence and forget about it. These PH measures and the attestation strategies employed by both EPs and EHs are now starting to bear bitter fruit. I am working with a number of providers undergoing audits for their 2011 attestation in which the core area of concern is focused on the PH measures. Often the person that planned and carried out the 2011 attestations has moved on and there is no paper trail to document the logic behind the decisions as to which Menu Measures were chosen. If that wasn't enough, a thorough audit will want documented proof supporting an exclusion claim. You say your state was unable in 2011 to receive immunizations electronically? Fine, provide that documentation to your auditor and move on. If you can't, well you can see why this is a sticky area. For an EP this could be the tipping point between keeping or giving back that long gone $18,000 incentive. For an EH the stakes are much, much higher. We are talking millions here.

  

I'm thinking there were a lot of attestations that were just thrown together in 2011. There was so much money on the table. I can imagine the pressure that came from those at The Top to "Get those incentives!" Who wouldn't want to make the boss happy with the news that the attestation was successful and the check was on its way? Tell the CEO, the CFO, and the Board, "It's all good". I haven't talked to too many of those happy folks. The ones that contact me are the ones who are undergoing an audit or have failed one. The ones that are trying to piece together the what, how, and why that occurred two years ago. They ones sent in with mop and bucket to clean up the mess. Contact me here if you need help. Audit and appeal resources can be found here.

Webinar: Meaningful Use, Audits, and Behavioral Health 

I'll be joining Mary Givens on September 12, 2013 at 2 PM EDT for a  

Meaningful Use Audit webinar designed specifically for the Behavioral Health Eligible Professional. Register for free here and send in questions ahead of time and we'll try and cover them.

 

http://www.hitechanswers.net/about/our-experts/emr-advocate/

 

 

 

 

Ditch, Switch and Migrate!

This article has many interesting statistics on the demand of the provider to find an EHR that works for them.  When and if you switch-we advise you have a "Migration Plan" carefully created with your new vendor to avoid starting from ground zero. 

 

EHR users ditching systems, trading up - Dissatisfaction with current EHR systems have many providers turning to new vendors 

Erin McCann is Associate Editor at Healthcare IT News. She covers physician practices, ambulatory care and social media in healthcare. Follow Erin on Twitter @EMcCannHITN

2013 has been billed as the year of EHR dissatisfaction, with up to 23 percent of physician practices reporting they were trading in their current EHR system for a new brand altogether, and, according to a new Black Book Rankings report, there were only a handful of vendors that came out on top. 

 

The survey finds that providers switching to new EHR systems were turning to Practice Fusion, Care360 Quest, Vitera, Cerner, Greenway, ChartLogic, GE Healthcare and athenahealth — all vendors who have risen to the top of the replacement market satisfaction polls, officials note.  

 

"Regularly, at least two of these eight vendors were on the short lists of 88 percent of the current replacement market buyers surveyed," said Doug Brown, managing Partner of Black Book, in a news release. 

Seven others — Allscripts, AmazingCharts, eClinicalWorks, Kareo, McKesson and NextGen — also received top rankings in six of seven 2013 Black Book client experience surveys, Black Book officials note. 

 

"EHR system shifters now position to reallocate more than $5 billion in sales as the unstable vendor marketplace begins to get agitated," said Doug Brown, managing partner of Black Book, in a news release. 

 

Eighty-one percent of survey respondents who indicated they were ditching their current systems said they were on track to replace their EHR within the next year; some 11 percent said they were unsure, according to the report. 

 

The study is a follow-up assessment on the status of electronic health record users, all of which indicated deal-breaking dissatisfaction with the current vendors.

 

EHR users polled in the original survey had cited numerous cases of software vendors underperforming enough to lose crucial market share, with vendor solutions often struggling to keep up.

 

Most concerning to current EHR users were unmet requests for sophisticated interfaces with other practice programs, complex connectivity and networking schemes, pacing with accountable care progresses and the rapid EHR adoption of mobile devices, the original survey found.

 

Out of those EHR users considering a system switch, 80 percent said the solution does not meet the practices' individual needs; 79 percent indicated that the medical practice had not adequately assessed the group's needs before choosing the EHR; 77 percent of respondents cited solution design as ill-fitted for their medical practice or specialty; and 44 percent said vendors have been unresponsive to requests. 

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 There a Place for Paper Documentation?

The first question is whether any urgent care, medical office, and/or emergency department can really survive totally without paper.  Second question is whether the documentation portion of the medical record can still be done on paper, and whether it could then serve to support patient care in a manner equally, or perhaps more, effectively than electronic documentation.  These are complex questions, but many are coming to realize that paper may still have a role in modern medicine.

In practices or institutions not quite ready for a full-blown electronic health record, paper can be a very effective part of the workflow.  Well-structured paper charting,  integrated with modest and simple electronic tools (scanning, e-prescribing, patient education and follow-up) can be a beneficial and legitimate solution to the EHR documentation quagmire.

Some benefits-

1. Predicable provider acceptance and willingness to cooperate- this is a key component for the success of any clinical system.
2. Storing and retrieving patient records becomes simple by scanning all documents to the patient database.
3. Prescriptions are quick, managed, and legible.
4. Patient education and follow-up instructions are legible and rapidly produced.
5. The need for provider-financed documentation assistants- scribes- virtually disappears, saving $$$!
6. Template documentation facilitates completeness, and is valuable for medical-legal and financial reasons.  Free-handwriting should be used only to supplement a template, but not to document the entire encounter.
7. The costs of paper solutions are historically much less than those of EHR implementation and maintenance.

Negatives do exist-

1. Legibility issues
2. Potential losses of meaningful use stimulus money.  However, meaningful use criteria is a constantly moving target that many- despite huge expenses for EHR systems- have not received.
3. Decreased ability to extract data.
4. Common traditional complaints about paper templates- legibility ad difficulty obtaining a representative narrative.

Paper documentation can be realistic for practices that can structure themselves to be partially electronic.  If you are so inclined, choose a product that has a good database, a scanning solution, and well-written templates.  You may want to implement a system that uses voice-activated EHR technology for certain type of cases.  When the next- future - quantum advance in EHR technology is available to clinicians, it may - if simple and easy to use- actually take us beyond paper.  At the moment, however; that future isn't here yet.

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

Computer Failures

Steps to take when your computers and/or Internet fails.

 

1. Relax!
2. Check the power source.
3. Reboot the computer.
4. Call the "Help Desk"????
5. Have a back-up plan in place for charting, ordering, prescribing, and discharging patients.  Avoid re-inventing the wheel each time there is an outage.
6. Install a back-up computer system with paper charts that can be scanned in later.
7. If forced to input data in the Electronic record later, make sure to note the circumstance of late entries.
8. Use the "Russian Space Utensil" aka a Pencil- works in zero gravity.
9. Use a reliable back-up company to store all your data.
10. If using your own server, have a contingency plan with redundancy.
11. Cloud hosting should keep you protected.
12. Hand write prescriptions- there is a pad laying around somewhere.

 

Bottom line - Plan Ahead - It is inevitable!!