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Adelphi U ad spreads health reform fallacy

The following ad has popped up several times on my mobile Facebook app recently:

Adelphi Facebook ad
That’s from Adelphi University in Garden City, N.Y., and the first sentence of that ad is absolutely false, not to mention poorly written. There is no government mandate for any healthcare facility to go paperless at all, much less by 2015.

As people in health IT and in healthcare management probably know, the federal Meaningful Use EHR incentive program calls for Medicare penalties starting next year for any provider that hasn’t achieved at least Stage 1 of Meaningful Use. But that’s not a mandate; hospitals and other providers still have the option of participating. Those who don’t see Medicare patients don’t face penalties anyway.

Even those that are able to meet all the Meaningful Use requirements still don’t have to be paperless, at least not according to the Stage 1 and Stage 2 rules. Nor have I seen any evidence that Stage 3 would contain such language, and even if it does, that phase does not start until 2017.

There are plenty of reasons why those who start work on a master’s in health informatics this year will be very much in demand next year. Why does Adelphi need to mislead people in an apparent attempt to create demand for its program?

June 29, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

Video: Aneesh Chopra on ‘The Daily Show’ for a long interview

Everybody else has the news about CMS offering leniency with Stage 2 Meaningful Use, letting providers use EHRs with 2011 certification to meet Stage 2 standards because so few vendors have been certified to the 2014 standards previously required for Stage 2. I won’t rehash here.

I will, however, share the very extended interview Jon Stewart had last night with former White House CTO — and, before that, HHS CTO — Aneesh Chopra on “The Daily Show.” Stewart is a comedian with a known liberal bias, but he is not a bad interviewer when dealing with a serious subject.

Stewart has been hammering the VA over its backlog of new registrations, and stepped it up in the wake of the recent revelation that VA bureaucrats in Phoenix were gaming the system to make it look like waits weren’t as bad as they really were. He’s also criticized the federal government for failing to link medical records between the Military Health System and the VA — you know, what we in health IT call interoperability. (In Part 4, Chopra discusses lack of interoperability in the broader healthcare sense.)

I found out about Chopra’s appearance last night shortly before the show aired. Unfortunately, we were having heavy rain at the time, and my satellite TV got knocked out, so I missed it. It’s OK, because the Chopra interview was long — more than 22 minutes — and the version that was on TV is heavily edited. Here’s the full interview of the “Indian Clooney,” as Stewart called Chopra, from the show’s Web site.

Part 1  (4:41)

 

Part 2 (7:27)

 

Part 3 (5:19)

Part 4 (5:35)

 

May 21, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

APSO vs. SOAP, continued

A couple weeks ago, I had a story in Healthcare IT News about the growing use of the “APSO” notes for documenting patient encounters. APSO flips around the traditional SOAP format (subjective, objective, assessment, plan), ostensibly making it easier to view progress notes in electronic health records.

As I reported, APSO is in wide use at University of Colorado Health and at Lucile Packard Children’s Hospital in Palo Alto, Calif. Baystate Health in Springfield, Mass., found that hospitalists focused most of their attention on the “impression and plan” sections of patient records, essentially the AP part of APSO/SOAP. Physicians at Epic Systems, according to University of Colorado’s Dr. C.T. Lin, are recommending APSO as a best practice.

Yet, the inventor of the SOAP note, Dr. Larry Weed, still believes his format is superior. You saw his comments in the Healthcare IT News story. But every time I have the privilege of speaking to the nonogenarian Renaissance man, he always has more to say than I can fit into the average article. I often can’t keep up in my note taking, but, fortunately, in this case, Weed and his son/occasional co-author Lincoln, took the time to put their thoughts in writing for me.

I left most of their comments out of the story due to space limitations. I don’t have that problem here, so I present their entire statement to me:

The following represents our collective thoughts, including references to relevant portions of Medicine in Denial [their 2012 book].

The supposed advantage of the APSO alternative — that it begins with the physician’s assessment rather than data — is actually a failing. This sequence tends to make the note provider-centered rather than patient-centered, and judgment-based rather than evidence-based.  In contrast, beginning the progress note with data disciplines the provider’s assessment. The provider must think in terms of specific data, specific problems on the problem list to which the data relate, and the interrelationship of each problem to the other problems on the list. Moreover, it’s important to begin the progress note with subjective (symptomatic) data from the patient rather than so-called “objective” data,  As Medicine in Denial states (p. 168):
“… progress notes should begin with subjective data, because progress should be assessed from the patient’s point of view.  Practitioners should be alert to discrepancies between subjective and objective data (for example, where the patient does not feel better when lab results show improvement). These discrepancies may signal an error in data or misstatement of the patient’s problem.”
In short, provider thinking can be disciplined with problem-oriented SOAP notes as a standard of care. Yet, regulators and academics who are in a position to act on this issue have shied away from the whole notion of standards of care for organizing data in medical records. See our comments on ONC’s Stage 2 regs and our comments on the PCAST Report.
The need for standards of care in medical records goes far beyond the SOAP vs. APSO issue in progress notes. In fact, that issue is secondary. Two more fundamental issues for medical records are the following:
  1.  Determining initial inputs to the record. Initial inputs are determined by selection of data needed for the patient’s problem situation, and once the data are collected, analysis of the results.  Both selection and analysis are fatally compromised when determined by the physician’s clinical judgment. External standards and tools, based on a combinatorial standard of care, must govern the selection and analysis. Once that happens, then judgments of patient and practitioners (not just physicians) may supplement the combinatorial minimum standard.  See Medicine in Denial, pp. 53-61, 69-79, 136-37, 145-52.
  2.  Organizing the medical record around the problem list. Once initial data are collected and a complete problem list is defined, then care plans, orders, and progress notes should be problem-oriented, that is, labeled by the problem(s) to which they relate on the problem list. This disciplined practice is essential to justifying provider actions in terms of defined patient needs. Yet this practice is not followed or enforced with consistency. Indeed, some EHR systems do not even enable electronic links between the problem list and care plans, orders and progress notes. See Medicine in Denial, pp. 134-35, 144, 159-60, 166-67.
Like so much else in medicine, medical record practices are a Tower of Babel. Medicine need standards of care for managing clinical information (knowledge and data) no less than the domain of commerce needs accounting standards for managing financial information. This failing is a primary root cause of the health care system’s failures of quality and economy.

For that matter, Lin had more to say than what you saw in the story. He discussed the supposed importance of the subjective and objective elements. “That’s true in cases where there is diagnostic uncertainty,” Lin said. But he added that those components are still there for reference, jut not up front.

Lin called SOAP “a phenomenal innovation,” but suggested that EHR complexity sometimes makes it difficult to find the assessment and plan. For example, he said that a non-Epic EHR in the emergency department at UC Health has as many as 17 different screens for progress notes. “At least with APSO, you would collect the assessment or plan in the first half,” Lin said.

Because SOAP is so entrenched, Lin ran into much resistance when he proposed switching to APSO at 40 affiliated practices. He, of course, heard the tired, “But we’ve always done it this way” defense.

“I learned myself about culture change very acutely,” Lin said. “I was literally shouted out of the room by our physician leadership.” He had neglected to prepare the heads of various departments and clinics for the change in advance of the meeting where he announced the plan.

He subsequently had to have individual conversations with all 40 practice directors. And then Lin dropped a great quote from none other than Niccolo Machiavelli (speaking of Renaissance men): “Those who benefited from the old order will resist change very fiercely.”

Yes, that’s absolutely perfect for an industry as resistant to change as healthcare. But is APSO superior to SOAP? I’d love to hear your thoughts.

May 20, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

IBM acquiring Epic or Cerner? I dunno

The “unconfirmed rumor of a huge acquisition” that HIStalk (a.k.a. the National Inquirer of health IT) tweeted about on Wednesday apparently is that IBM was going to acquire Epic Systems. Mr. HIStalk on Thursday expressed some reservations.

 

 

So am I. The announcement was supposed to happen Friday morning, which is right now (10 am EDT as I write this). IBM is in the Eastern time zone and Epic is in the Central time zone; for that matter, Cerner also is on Central time, and when you think “huge” in health IT, really only Epic and Cerner come to mind. If there were to be an announcement not involving anyone on the west coast, it probably would have happened already.

In any case, I’m told that IBM has been rather quiet with analysts of late. I actually haven’t been able to find the ages of Epic honchos Judy Faulkner and Carl Dvorak, but they’ve been at this for some 35 years. Cerner CEO Neal Patterson is 65 and has an ownership interest in the Sporting KC soccer team. He’s also been in the health IT business for 35 years.You’d think any or all of the three have to be thinking of retirement, or, in Patterson’s case, moving on to the hobby of running a pro sports franchise. Except that Faulkner seems to love what she does.

Cerner’s stock price has dipped a bit in the last couple of months, but it has risen by 259 percent in the past five years, according to Yahoo! Finance. It still seems as if the health IT business has plenty of room to grow, especially among the biggest players, who promise to be the biggest beneficiaries of consolidation on the lower end of the market.

Until I hear something more substantive, I am not buying the IBM-Epic rumor. IBM-Cerner seems a tad more likely, but I still need to hear more.

May 2, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

Docs, stop whining, start e-prescribing

The whining is getting old.

Per Surescripts, in 2012, the latest year for which statistics are available, about 69 percent of physicians nationwide used e-prescribing technology in one way or another, and 44 percent of all prescriptions written nationwide were routed electronically. (That report came out in early May 2013, so expect some new numbers soon.) Both are up substantially from the previous year, probably due in no small part to the Meaningful Use EHR incentive program, which does require a minimal level of e-prescribing.

But what about the holdouts? A recent article in the journal Perspectives in Health Information Management found that cost remains the No. 1 reason why physicians still haven’t ditched the paper prescription pad in favor of electronic prescribing.

“While e-prescribing offers many benefits, not all providers have been excited about implementing e-prescribing systems. A major barrier, reported by more than 80 percent of primary care physicians, has been lack of financial support. New technology requires training and information technology support for installation and upkeep. A practice must take these costs into account when deciding whether to implement an e-prescribing system and also when choosing a stand-alone system or one that is integrated into an EHR system. According to the Health Resources and Services Administration, in a 2007 study the total cost of implementing an e-prescribing system was found to be $42,332, with annual costs after implementation of about $14,725 per year, for a practice of 10 full-time equivalent psychiatrists,” the authors reported.

Yes, but the paper also says this: “E-prescribing improves the efficiency of the prescribing process. Though the actual entering of a new prescription takes about 20 seconds longer per patient than writing a prescription, this time is offset by the time saved because of the fact that less clarification is needed for electronic prescriptions. Prescribers spent more time on the computer, on average an extra 6 minutes per prescriber per day or an increase of 20 seconds per patient when seeing 20 patients per day. If implemented correctly, e-prescribing should cause little disruption in the workflow of ambulatory care settings.”

In other words, those resisting the switch are being penny-wise and pound-foolish.

Besides, e-prescribing systems don’t have to cost that much. In fact, they don’t have to cost anything. Allscripts offers a free, standalone e-prescribing system online, while PracticeFusion, DrChrono and Kareo have e-prescribing modules in their free EHRs. A startup named ScriptPad has an e-prescribing app for Apple iOS that’s free to prescribers; transaction fees get billed to pharmacies. I can’t vouch for the efficacy of any of this software, but cost doesn’t have to be an issue.

I think the real problem here is intransigence. Some doctors simply don’t want to get with the times, and the only losers are patients.

April 24, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

Athenahealth-EHRA news significant only that it shakes up the status quo

By now, you’ve likely heard the news that Athenahealth has decided to quit the HIMSS EHR Association. As Athenahealth’s Dan Haley put it in a blog post: “At the end of the day, athenahealth left the EHRA because we never really belonged there in the first place. The EHRA was founded in 2004 by a group of EHR software vendors. Today, a decade into the age of cloud technology, the EHRA is still dominated and governed by a group of EHR software vendors.”

Athenahealth long has billed itself as a services company, not a software vendor, going so far as to hold a jazz funeral for the “death of software” at HIMSS13 in New Orleans. Athenahealth didn’t join the EHRA until 2011 anyway. It sounded like a bad fit.

I contacted Athenahealth, and was told that the company remains “fully committed” to the CommonWell Health Alliance, a coalition of health IT companies — also including Allscripts, Cerner, CPSI, Greenway Health, McKesson and Sunquest Information Systems — that came together for the stated purpose of “developing, deploying and promoting interoperability for the common good.” (There’s also the unstated purpose of fighting the dominance of Epic Systems.)

Athenahealth is staying on the interoperability path, but as is befitting the corporate culture, is going rogue when it comes to EHRs. It’s not the first time. It won’t be the last time, because it’s not like most of the other vendors/service providers, if for no other reason than CEO Jonathan Bush doesn’t fit the buttoned-down model of an executive. For that matter, neither did his co-founder, Todd Park, whom I often called an “anti-bureaucrat” during his time with the federal government. Park’s brother, Ed, is COO of Athenahealth, and also has unconventional tendencies.

I can relate to this mentality in a way. I quit the Association of Health Care Journalists years ago because it didn’t feel like a good fit for me. That group tried to include health IT in its programming, but it really was an organization for consumer and scientific reporters, not those of us in the business and trade press. Eight years later, I still don’t think the national media are doing such a great job covering health policy or explaining the nuances of this complicated industry. And, as I’ve said many times before about healthcare, the status quo is unacceptable.

 

April 23, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

Despite scandal, TMIT is still operating

You’ve no doubt hear about the kickback scandal involving CareFusion and Charles R. Denham, MD, founder of the Texas Medical Institute of Technology (TMIT). I wrote a piece about it in the context of Meaningful Use for Healthcare IT News this month, since Denham co-chaired the steering committee of the National Quality Forum’s Safe Practices for Better Healthcare program during the time CareFusion allegedly paid Denham $11.6 million to promote its products.

CMS, of course, has, to date, based Meaningful Use quality measures on NQF recommendations.

Denham has become a pariah of sorts in patient-safety circles since the U.S. Department of Justice announced a $40.1 million settlement with CareFusion in January. Yet, believe it or not, TMIT is still in business. The organization’s Web site is functional; in fact, the “about” page prominently features a video with Denham. And the TMIT Twitter account is activem, promoting a webinar as recently as yesterday.

 


Perry Bechtle, D.O., is a neuroanesthesiologist at Mayo Clinic in Jacksonville, Fla., and a former U.S. Navy flight surgeon. I want to believe that his credentials are impeccable, but it’s hard to take TMIT seriously these days in the absence of a major house-cleaning. Interestingly, the last academic article Denham wrote before the scandal broke was in the December 2013 issue of the Journal of Patient Safety. It’s entitled, “Safe Use of Electronic Health Records and Health Information Technology Systems: Trust But Verify,” and co-authors include heavyweights such as David Classen, M.D., and David Bates, M.D.

How are we supposed to trust an organization that itself was wrapped up in such a serious breach of trust?

April 18, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

About those Obamacare numbers and the ICD-10 delay

While I’ve been busy writing a couple of stories on different topics, you’ve probably heard two pieces of news that will affect healthcare providers nationwide: the close of the first open enrollment period for Patient Protection and Affordable Care Act insurance exchanges and the Congressional “fix” (read “Band-Aid”) to the Medicare sustainable growth rate that statutorily delays the ICD-10 compliance deadline for another year, until October 2015.

The White House yesterday reported that 7.1 million people had signed up for health insurance through healthcare.gov or state-run exchanges, barely exceeding the Congressional Budget Office’s projection of 7 million. Independent tracking site ACAsignups.net says it’s more like 7.08 million, but still just above the goal. That site also tallies the following sign-ups as a result of the ACA:

  • 6.37 million – 12.45 million in private “qualified health plans” (plans that meet ACA standards) via private exchanges, insurance agents or direct purchases from insurers, including deductions for the estimated 3.7 million whose “noncompliant” policies were canceled;
  • 4.71 million – 6.49 million through Medicaid/Children’s Health Insurance Program expansions;
  • 2.5 million – 3.1 million “sub-26ers,” young adults whom the ACA allows to stay on their parents’ health insurance until age 26; and
  • 1.8 million “woodworkers,” those who came out of the woodwork because they did not know before the Obamacare enrollment push that they were eligible for Medicaid or CHIP.

ACAsignups.net places the total range at 14.6 million – 22.1 million as of March 31, not counting the healthcare.gov numbers, though my math puts it at 15.38 million – 22.06 million. Add in the healthcare.gov sign-ups and you get about 22.5 million to nearly 29 million newly insured people. However — and this is a big however — we do not know how many of the beneficiaries are newly insured and how many were replacing previous coverage.

Personally, I bought a high-deductible, ACA-qualified health plan through an independent agent to replace a rather restrictive high-deductible plan that was grandfathered in, and should save about $70-$80 a month on premiums starting in May. The new insurer rejected me several years ago due to a pre-existing condition; the ACA assures that I can’t be denied for that reason anymore. I imagine there are millions in the same boat as I am.

The U.S. Census Bureau placed the number of uninsured for 2012 at about 48 million, or 15.7 percent of the population. (The same year, 198.8 million had private insurance.) Until we see new figures for uninsured Americans, we will still just have “gross” statistics, not a net figure to show if the insurance part of the ACA is working.

By the way, the ACA is about much more than insurance coverage, despite what the national media have focused on. I encourage you to read up on this before you say Obamacare is saving or ruining our country.

Now, as for the temporary SGR fix, the ICD-10 delay kind of came out of nowhere last week when it got slipped into the House version of the legislation, but the Senate adopted the same language — reportedly without debating ICD-10 at all — and President Obama today signed it into law. I’ve said before that ICD-10 and other transactional elements of healthcare stopped mattering to me as I watched my dad being mistreated in a hospital due to broken clinical processes in his last month of life. I still think this way. However, this sneaky move shows that the AMA, AHA and other groups more intent of protecting the status quo than fixing healthcare still have enormous sway in Washington.

It makes me wonder whether lobbyists haven’t already started pushing hard for Congress to delay the Medicare penalties for not achieving Meaningful Use that are due to kick in next year. Actually, I don’t wonder. I’m sure it’s happening.

All delaying real reform of a broken industry does is prolong the agony, and ensure that millions more people will be affected by errors and neglect in institutions that are supposed to “do no harm.” The status quo is not acceptable.

 

April 2, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

Patient safety update

I’m passionate about patient safety. I’m happy to report a couple of things that aren’t exactly breaking news, but still worth bringing to your attention.

First off, there is a fairly new peer-reviewed journal called Diagnosis, and it’s about exactly what the title suggests. The first, quarterly issue, from German academic publisher De Gruyter (North American headquarters are in Boston), came out in January, so the second issue should be published soon. The online version is open access. That means it’s free. (A print subscription is $645 a year.)

A highlight of the premiere issue is a submission from the legendary Dr. Larry Weed and his son, Lincoln Weed, discussing diagnostic failure and how to prevent it. “Diagnostic failure is not a mystery. Its root cause is misplaced dependence on the clinical judgments of expert physicians,” they begin. The answer? Clearly defined standards of care and wider use of clinical decision support tools. It’s not anything new. Larry Weed has been advocating this for a good 50 years and saying that the unaided human mind is fallible for probably 60 years. Yet, medicine still largely relies on physicians’ memory, experience and recall ability at the point of care.

This doesn’t mean evidence-based medicine ,which is based on probabilities. Probabilities are fine when the patient has a common condition. They’re useless for outliers. No, Weed has long said that IT systems should help with diagnosis by “coupling” knowledge to the patient’s particular problem, and this starts with taking a complete history.

Weed, of course, created the SOAP (subjective, objective, assessment, plan). I recently talked to a CMIO who is advocating flipping that around a bit  into an “APSO” (assessment, plan, subjective, objective), which he said works better with electronic records. I’ll have more on that in an upcoming article for a paying client, and I’ll probably want to dive into that again in the near future.

For those who still believe American healthcare is safe, effective and efficient, ProPublica worked with PBS Frontline and marketing firm Ocupop last year to produce a video “slideshow” called “Hazardous Hospitals.” It’s worth a view for healthcare industry insiders, and definitely merits sharing with laypeople. I recommend that you share it. Please. Do it. Now. I’m serious. Patient safety is a problem that doesn’t get enough attention. :)

 

March 25, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

Video: Farzad Mostashari on patient engagement, ‘physician ACOs’

As I alluded to earlier, I was leaving the press room one afternoon at HIMSS14, and there I see former national health IT coordinator Dr. Farzad Mostashari hanging around Gregg Masters and Dr. Pat Salber of Health Innovation Media. It turns out, Masters and Salber had just pulled Mostashari aside to do an interview on video, but they didn’t have anyone to interview him on camera, so they asked me right there on the spot to be the interviewer. Here is the result.

Mostashari, now a visiting fellow at the Engelberg Center for Health Care Reform at the Brookings Institute in Washington, discussed how the years of searching for a business model to coordinate care and engage patients is finally starting to pay off. Always the champion of the little guy in healthcare, Mostashari also brought up the notion of physician-led ACOs, or, as he called it, the “Davids going up against the Goliaths.”

 

I had pretty much no preparation for this interview. It probably shows. I still think it worked out well.

Here’s a link to Salber’s post about the interview because I don’t want to steal page views. :)

March 14, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.