Meaningful Mess?

Since first announcing that Meaningful Use (MU) would go the way of dinosaurs in January of 2016, CMS has been less than forthcoming in defining what the world might look like for hospitals after MU. While the MACRA program has begun to define how clinicians will be paid, hospitals remain in limbo with CMS stating that they should expect changes, but with a lack of clarity about what they will be.

In a recent article on healthcareit.com titled “Is CMS Looking to Replace Meaningful Use for Hospitals?”, Mike Miliard asks the question that is on everyone’s mind but that CMS has yet to give clear guidance to.

An internet search for articles on the future of Meaningful Use turns up only a few that have been written since January of 2016, when CMS first announced sweeping changes in MU. One exception is an April article on the Federation of American Hospitals website titled “MACRA Proposed Rule Lacks Meaningful Use Flexibility for Hospitals” – See more at: http://fah.org/blog/macra-proposed-rule-lacks-meaningful-use-flexibility-for-hospitals#sthash.1MDZtnai.dpuf

This article includes the following:

‘CMS’s proposed rule would provide regulatory relief to eligible physicians under the MU program, by offering them greater simplification and flexibility using the “Advancing Care Information” criteria, which is the new name for EHR use for physicians. Unfortunately, the rule fails to give hospitals the same relief. Hospitals must meet compliance thresholds with an “all or nothing” approach for MU criteria, which is too demanding and unnecessary.’

It has been widely acknowledged that many hospitals failed to achieve MU Stage 2 and others struggled to do so at the expense of patient care. While we wait for a road map, Congress has started to get into the act with proposed legislation that would ease the requirements of physicians but it may be too little too late. In a July 10th article, Congresswoman Rene Ellmers was reported to say that ‘Many physicians have told her they would rather take the 2% penalty for failing to comply with Meaningful Use than to meet the requirements’. Wanda Filer, MD, FAAFP, President of the American Academy of Family Physicians, also has heard physicians say they may pay the penalty or apply for a hardship waiver to avoid the penalty.

Another concern that Meaningful Use has raised is the lack of innovation that would make EHR systems easier to use, more interoperable, and more adaptable to hospital and clinic environments. With EHR vendors and hospitals spending so much time on MU and being limited to the structure of MU testing, the industry has often failed to deliver on the promise of EHR to make hospitals more efficient.

Let’s hope that CMS can get their act together to settle on a future road map instead of putting band aids on Meaningful Use that don’t deal with the underlying problems.

A Picture is Worth 1,000 Words

Many patient conditions are difficult to describe accurately but can easily be captured by a digital photo. While most hospital EMRs will accept photo files, the process can be very cumbersome. A digital camera has to be found, the picture taken, then uploaded to the hospital EMR system through a PC. This not only takes time and multiple devices but potentially leaves images on unsecured devices.

In a much more efficient approach, HarmoniMD, an EMR developed by EHRI Inc., uses tablets to access patient charts and can take photos directly into the patient chart without storing an image on an unsecured medium. This system also displays all of the prior photos for the patient, which makes taking a series of photos to represent the healing process much easier and more reliable.

Being able to view photos of patient conditions on the same device that contains the patient chart is also very helpful to physicians, nurses and patients alike. As the healing process progresses, documenting the progress on a daily basis will give the clinical team a much better view than having to read through many paragraphs of text. Photos can also alert the team to setbacks or deterioration much faster than having to interpret nurse or physician notes.

Explaining to patients how their care is progressing can be made much easier if they are able to see the progress visually. This is especially true for injuries, wounds and surgeries that the patient can’t see as in the case of wounds on the back or buttocks. Allowing patients to view their condition and progress can also be useful and is generally reassuring.

Tablets have excellent auto focus cameras and can take photos in low light conditions that might otherwise be challenging. Most tablets will focus as close as 2-3 inches from the subject and once the image is captured it can be expanded to show even more detail than would be available to the naked eye. In this respect, they take the place of a magnifying glass to allow finer details to be viewed.

When an image is captured, it should be reviewed before saving to the patient chart to make sure that it is in good focus and displays the condition clearly. Placing a disposable ruler next to the area to be captured will make comparison easier and more accurate. Lighting can also make a difference in the quality of the image and a series taken over a number of days or weeks is best done with consistent lighting.

Sonoma West Medical Center in Sebastopol, California uses bedside photos to track wound care and post-surgical healing by taking photos every time dressings are replaced, both before and after the process is complete. This documents not only the patient’s condition but also the treatment that was done. The 7 inch Lenovo tablets that nurses carry is ideal for this process and obviate the need for cameras and uploading of images.

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When in Doubt, Scan It

Whenever we visit the grocery store, we hear the constant beep of scanners from the checkout counter. In our travels in the developing world, and even in many US hospitals, we find very little scanning being used.

A recent visit to a small hospital in Guyana was instructive of the digital divide between healthcare and the rest of the world. On our way, we stopped into a small grocery store close to the hospital to buy a few things and the beep of scanners was immediately apparent in an efficiently organized but small space.

When we got to the hospital, we toured the materials room and were immediately aware of the turmoil. On the ward, we reviewed the workflow and found the unfortunately common and cumbersome processes of inventory management and charge capture that define many hospitals.

In our discussions with hospital administrators, we pointed out that the local grocery is able to utilize modern technology to streamline their process and that hospitals certainly should be able to as well. But it was soon clear that the tools to do so were not available at the time, at least in an affordable platform.

Since then, some newer technologies have changed this equation, the most notable of which is the ability to scan barcodes from mobile devices like cell phones and tablets. These inexpensive tools use a different technology than the grocery store scanner by capturing frames of a streaming video, which are then mapped by software to determine if a barcode is present and what type it is. While this process can be somewhat slower than a laser-based scanner since the camera has to focus and potentially capture multiple images before identifying a barcode, the difference in timing is not usually noticeable.

Once captured,SwmKim the barcode can be processed by whatever application is currently running on the mobile device. Barcodes can be placed on supplies, medical equipment, inventory locations, bins, medications and rooms as well as patient cards and wristbands. Patient cards can be used in the admitting areas of the hospital and wristbands once patients are admitted.

With consumables that are charged to the patient, a barcode reader can be used at a desktop computer or a tablet computer can be used at the bedside. This can greatly improve charge capture and inventory control in any hospital. An often overlooked use of barcodes is the coding of medical equipment that is used to treat patients during procedures. Attaching a barcode to equipment will make the capture of this information much easier.

 

Medical Necessity in the ER

Of all the criteria for a receiving a payment by Medicare, MACRA requirement to establish medical necessity seems to generate the most questions and discussion. With the introduction of ICD10 and the added complexity of coding for medical conditions, the debate over what constitutes medical necessity and how it should be documented runs high. Discussions with ER physicians indicate that there is continued confusion about documenting medical necessity when ordering diagnostic testing and that hospital practices may have not caught up with CMS regulations.

However, the confusion extends far beyond Medicare since insurers have been anxious to deny services based on medical necessity and the courts have been inconsistent in their definition. Hospital practices are not consistent either. As one physician recently asked ‘We don’t have to provide a reason for placing orders in other hospitals so why do we have to do it here?’

What came out of discussions with ER physicians is that they were used to providing medical necessity documentation after the fact or in many cases having someone else provide coding of the diagnostic process from their notes. While Medicare includes the concept that medical necessity might reasonably be ‘inferred’ from the documentation this will likely not be a standard to count on in a Medicare audit.

What might help this debate is building a documentation path to the final diagnosis in the patient problem list. This concept rests on an understanding that ICD10 includes not only diagnosis of medical conditions but also complaints and indications. For example, R10.10 Upper Abdominal Pain, unspecified is not a final diagnosis, but is a starting point for diagnostic tests that can lead to a final diagnosis and that supports medical necessity for initial tests. Adding this problem to the patient’s problem list before ordering tests documents the reasons for certain tests. However, the tests must be appropriate to the problem to be ‘medically necessary’ from Medicare’s point of view.

If, on the other hand, no ICD10 codes are provided when diagnostic orders are placed, there is the potential that some might be disallowed when the final diagnosis is the only item in the problem list. If, for example, a patient presents with upper abdominal pain and tests are ordered to determine the root cause but only the final diagnosis of gallstone is entered into the patient chart, some of the tests might not be appropriate to a gallstone diagnosis and could be disallowed in an audit.

While Medicare has not been enforcing medical necessity aggressively in the past, this is clearly an area where Medicare as well as insurers see an opportunity to save big money. Unfortunately, Medicare works by disallowing charges in an audit rather than denying payment initially so hospitals can be hit with a big bill years afterward. In a recent case, a hospital in California was charged $2.2M for cardiac diagnostic procedures that were not considered medically necessary.

In a related issue, there is a common misunderstanding that only physicians can document ICD10 codes. While this will be true of diagnoses of medical conditions, documenting the reason for a patient visit will commonly be done by admitting staff or nurses in the ER. For this purpose, having a cheat sheet of the ICD10 codes that reflect patient complaints can be an important tool in the ER admitting process. While some might argue that the reason for visit be a text field that allows for open-ended text, ICD10 codes are available for most (if not all) reasons for patient ER visits, so ICD10 should be used.

This starts the ball rolling for physicians by documenting the initial complaint the patient presents with, which will be followed by more detailed problems and diagnosis as the patient’s condition is identified in more detail. It will also provide documentation of medical necessity as the patient’s care is started.

 

Digital Health Technology

Order Sets on Steroids

Building and maintaining physician order sets can be one of the most important steps a hospital can take in making the use of EMR systems more efficient and creating a culture of structured care. In his book The Checklist Manifesto, Atul Gawande makes a clear case for the use of checklists in all aspects of healthcare. But checklists alone can create an additional burden to the already busy hospital physician if they are not connected to the process of physician ordering.

The art of building appropriate levels of structure and details into an Electronic Clinical Document (ECD) involves a multidisciplinary approach that includes workflow, activity and interface design as well as deciding what to include and exclude from a clinical perspective. While we might at first believe that clinicians should be the sole arbiters of ECDs, it turns out that people with user graphic and interface design should also be a part of the design team. Clinical educators should also weigh in because the point of order sets, nursing forms, and other clinical documents is not just to capture data but also to teach best practices.

HarmoniMD, EHRI’s hospital EMR system, includes a unique system for creating and storing Electronic Clinical Documents that can also serve as physician order sets. These documents are built in an XML format, which describes each discrete element of the form as an XML element. When the document is saved, the data entered is inserted into the XML document and the XML document is saved in its entirety as an XML field in the patient’s chart. In this way, each ECD can be displayed in its original format without versioning issues yet the data elements within the document can be reported on as discrete elements.

Newer features of this system greatly enhance the physician ordering process by making orders a single click process and pre-selecting orders where appropriate. In this way, a hospital can have pre-defined order sets that include pre-selected orders as defaults. For example, a General Admit order set can have PRN medications for bowel care pre-selected so the physicians do not have to choose these items every time they use the order set. Of course, they can deselect items and add items not on the order set (if this is consistent with hospital policy).

With order sets, checklists, and other clinical documentation design overseen by a multi-disciplinary team, documentation can become more efficient and accurate over time as workflows and ECDs are perfected. The Checklist Manifesto gives clear insight into the application of structure to the clinical care process and is a must read for anyone working in the modern hospital environment. Gawande points out that hospitals are often far behind other industries in perfecting the process of healthcare delivery with the emphasis often placed on documentation for billing and legal requirements rather than improving care.

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When Everything Falls Apart

In recent news articles, the fragility of hospital EMR platforms has been illustrated by the interruption of access to the EMR and the resulting loss of information to clinical workers. In at least one case, the hospital was without access for a number of days, creating havoc and closing vital services. The backup plan in these cases is to go to paper forms but this means there is no access to existing information in many cases and the hospital is often thrown into chaos.

While we might all wish that these were isolated incidents, the reality is that hospital EMRs normally rely on the hospital’s internal network to be reliable. The network in turn relies on the IT staff to maintain the many complex elements of the system without making any major mistakes. While these systems will have some level of redundancy, at least for data storage devices, the networks themselves can be affected by a number of factors including hacking and sabotage that will take them off line. Recent news articles have also profiled hospitals that have been invaded by ransomware resulting in days to get back online and a cost of thousands of dollars to cure.

Cloud-based EMR vendors such as E-Health Records International, Inc., replicate databases across multiple data centers and leverage the cell phone network for alternate access. Because the cell system tends to be very robust even when there are power interruptions and landline problems, this provides a real-time backup that will bridge over problems with a hospital’s internal systems. As a mission-critical application, having redundancies at all levels of operations is the key to maintaining 100% up time and utilizing the cell network (which itself has many redundancies built in) is a way to do this.

In some of the Gulf Coast areas, backup systems also include satellite internet connectivity to allow connection during periods when local internet connections are not available. Satellite connections prove to be very reliable and can be a good backup for other internet connections.

Database replication in the cloud, such as with Amazon Web Services, can also serve to bridge when local systems fail. When internal systems fail, which they ultimately will, having options that continue access to patient data can be critical to keeping a hospital functioning. Reverting to paper should be the last resort after all other options are exhausted.

 

Digital Health Technology

David and Goliath

In his seminal book on disruptive technology, David and Goliath, business guru Malcom Gladwell points out that Goliath didn’t have a chance against David who was wielding a technology that was a precursor to modern warfare where killing could be done at a distance. While the sling was not a new technology, having been invented sometime in the Neolithic period, its art was highly developed by biblical times and David had the advantages of being mobile and able to fire repeatedly at Goliath who could not get within range to inflict damage on David.

Gladwell goes on to illustrate that technologies bring down giants on a regular basis these days and that the Goliaths of the world should be very wary of the disruption that is constantly bubbling up around them. A Sebastopol startup, EHRI Inc., is positioning itself to take on the Goliaths of the hospital Electronic Medical Record (EMR) business with a disruptive mobile technology that emulates David’s sling.

‘The hospital EMR space is dominated by complex, expensive software systems that run on costly hardware and are generally very cumbersome to use. Surveys show that 94% of nurses dislike the EMR systems they are forced to use and hospitals are often paying as much as $100,000 per licensed bed for these systems, not counting hardware and implementation costs. In contrast, ‘we have developed cloud-based systems that run on inexpensive mobile devices and are easily adaptable to any hospital’s workflow’ according to Nick Smith, CEO of EHRI.

Smith likens EHRI’s position to Quickbooks and Salesforce which took over the market for small business accounting and customer resource management from companies with expensive server-based software systems. ‘We are small and nimble and are offering solutions for hospitals that are much more affordable and easier to use.’

The company recently implemented HarmoniMD at Sonoma West Medical Center in Sebastopol, a recently reopened hospital that was formerly Palm Drive Hospital. ‘One of the primary reasons Palm Drive failed was the attempt to implement one of the Goliath EMR systems’ says Dan Smith (no relation to Nick), board chair of Sonoma West Medical Center and a founder of EHRI. ‘The implementation alone cost $1.2M in consulting fees on top of software and hardware. After all of this, the hospital was not able to obtain certification for Stage 2 of meaningful use and therefore lost $800,000 in possible rewards.’

HarmoniMD is currently being installed in Kenya and Tanzania and the company is in discussions for implementations in other countries in Africa and Asia. ‘Our mission is to improve world health with affordable mobile cloud computing’ Nick Smith says. ‘Basically, our goal is to provide a full Electronic Medical Record system cheaper than the paper that is currently still in use in the developing world.’

At Kilimanjaro Christian Medical Center in Tanzania, HarmoniMD is being implemented in this 500-bed hospital and a new cancer center which will open in September. ‘This is a big hospital so implementation has to be done in stages, but the hospital’s IT team is now fully in charge of the process. Duke University has assisted with the implementation and is helping the hospital manage their networks.’

In Kenya, Matata Nursing Hospital, a 120-bed facility, is well on their way to a full implementation of HarmoniMD after a single visit from an EHRI trainer. ‘These implementations show that HarmoniMD is very adaptable and can be implemented at minimal cost while providing a full feature set for a hospital. We are now ready to take on the Goliaths with our sling of agile mobile could computing.’

While EHRI is making a big boast, the EHRI team have been successful in providing disruptive technologies to other industries including The Master Builder, which became a dominant player in the construction industry under Dan Smith. By taking on the mini-computer systems that previously dominated construction management and providing software on Apple and PC computers, Smith was able to create a nationwide market for The Master Builder.

‘Whenever a market is dominated by overpriced dinosaurs, someone will come along and take them out’ says Nick ‘and we intend to be David, not Goliath.

 

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Will Hospital-Acquired Infections Kill Your EMR?

Recent reports of hospitals infected with computer viruses have IT managers very worried as well they should be. EMR systems typically run over the same networks as other hospital functions, often leaving the door open to malware and viruses. In two recent examples, hospitals were crippled by what is known as ransomware.

Often emanating from Eastern Europe, ransomware hackers infiltrate a network and install software that locks access to data files. They then demand a ‘ransom’ to free up the files. Often, this is paid because other options are limited. Unfortunately, malware of this type has a lot of opportunity to infiltrate a hospital system with the large number of people on a network, the regular turnover of staff and systems that are in use 24/7.

Even the most secure systems are subject to misuse by employees and can become infected relatively easily. While we might want to blame digital intrusion on the system administrators, the most common methodology to gain entrance into a network is phishing. Phishing uses deception to get users to give up user names and passwords or download malware and is now rampant on the internet.

While we might assume that all of our employees are very savvy about phishing, likely many are not, especially because phishing has become very sophisticated. Here is an example: You get an email from FedEx that a package could not be delivered to you. This email looks like the real deal. It has the FedEx logo and the return address is something like FedExDelivery. You click on the link in the email to verify your information and the phishing software now has important information about you.

Other phishing examples are emails that pretend to be someone you know or a business that you work with. Another favorite is to offer something free like free access to an E-Book. All you have to do is set up a password to the site. You might be surprised at how many people will use the same password they use at work, giving away their login information.

So what is your hospital’s plan for protecting your EMR and for data recovery if it is hacked? Most facilities will say that they have redundant drives and redundant servers with regular backups but this has not always proven reliable. And paying a billion dollars to Epic doesn’t ensure 100% up time, as Sutter Hospital learned a few years back.

While no one can claim that their system can’t be hacked in a world where humans are involved, there are many steps that can be taken to improve your odds. These include replicating data in more than one location, hosting in secure data centers, having more than one path to data centers, and using mobile devices that are less prone to malware. Having replication in multiple locations and alternate access through satellite or cell connections can be a critical piece in assuring reliability in the face of hacking.

 

Digital Health Technology

EMR in Africa and Beyond

The US market for hospital EMR systems has primarily been driven by the 36 billion dollars of the HITECH meaningful use program but what is going to drive the transformation from paper to full EMRs in the developing world? The answer is simple, Return on Investment (ROI). Actually, the US market would have been a lot better off if it had been driven by ROI and not taxpayer money, because hospital executives would have made more sustainable choices.

To attain ROI in the developing world means that EMR systems will have to be CTP (cheaper than paper). Those of us who have experienced the US market will find it hard to believe that an EMR can be cheaper than paper, especially where wages are so low that pushing paper around does not cost much.

Will the Epics, Cerners, and Meditechs of the world jump into these markets? Not too likely as their products and services sell at a premium, are expensive to implement, and run on costly hardware. It will take an innovative approach to get buy-in from developing world hospitals and at least one company, EHRI in Sebastopol, California is marching down that road.

HarmoniMD, EHRI’s hospital EMR, is designed to be CTP (cheaper than paper) according to Nick Smith, Founder and CEO. To accomplish this, the system is built to run on inexpensive mobile devices like the 7” Lenovo tablet, can be run as a cloud- hosted or local system, and is provided as Software As A Service (SAAS) based on the hospital volume of patient visits.

To accommodate physicians who need access to patient information from outside the hospital facility, HarmoniMD runs on cell phones over the cell network. This is critical for the developing world where internet connections on land lines are not as reliable as the cell networks.

Nick is quoted as saying, ‘We traveled to many countries and visited a lot of hospitals to understand how to build a system that could meet their needs. HarmoniMD is the culmination of five years of work and is ready for prime time. We know that we can add bottom line results for pretty much any hospital in the world while giving them a fully featured EMR.’

To learn more, go to: about.harmonimd.com

 

Digital Health Technology

Meaningful Use Has Cost Taxpayers 34.7 Billion Dollars, Was it Worth it?

According to a recent article by John Lynn, founder of HealthCareScene, “CMS has put out the latest data on meaningful use participation and payments. They broke the Medicare dollars out by meaningful use Stage 1 and Stage 2. Meaningful use Stage 1 cost nearly $20 billion. Meaningful use Stage 2 cost $3.4 billion. The amounts were less for Stage 2, but that’s still a massive drop off (and indicates that many hospitals failed to attain Stage 2).

Less than half of eligible providers participated in Stage 2 that participated in Stage 1 (308k compared to 145k). Participating hospitals dropped from 4600 hospitals to 3096. This illustrates well what we’ve been saying for a while as far as hospitals still largely participating in meaningful use and most doctors choosing not to participate. Also interesting to note is that at its peak, meaningful use was paying about $10 billion per year. In 2015, they spent $2.8 billion.”

What does this all mean? First and foremost, that the gravy train for EMR companies has come to an end. The billions of dollars that tax payers have delivered to Epic, Cerner, Meditech and others will no longer be pouring into their bank accounts. It also means that hospitals will no longer be getting big rewards to cover their costs for bloated IT budgets and will have to find money to cover the high cost of maintaining these systems on their own.

So have taxpayers gotten a good deal for their 34.7 billion or did meaningful use create an inflated market for hospital EMR systems that did not deliver a return on investment? There is a lot of evidence for the latter. Without the 34.7 billion, hospitals would never have paid the inflated prices for software and implementations that EMR companies demanded. Only the feds (and the EMR lobbyists) could come up with a scheme to waste that much money in such a short period of time.

A common joke at the height of the gravy train flow was that you could get a job as an EMR implementer if you could spell EMR. A review of the billings by EMR companies to hospitals bears this out. On top of high-priced consulting fees are airfare, hotels, meals, car rental, and other costs often far in excess of the cost of the software itself. Would hospitals have agreed to this if they had to cough up all the money themselves? Not likely.

And now, many are saddled with cumbersome and expensive systems that are difficult to manage or unreliable. A recent lawsuit by PinnacleHealth, a three-hospital system based in Harrisburg, PA, claimed that Siemens software, (which was purchased by Cerner,) was defective; this was in turn met with a countersuit by Cerner of $20 million for unpaid services from February of 2015 to the present. $20 million for a year and 4 months use of software? As my uncle Charlie would say, ‘You gotta be kidding!’

The hospital EMR market is about to go through a major shakeout as hospital executives are forced to cut costs and find more efficient systems to replace the dinosaurs they inherited from meaningful use. Innovation is sorely needed in the EMR market and disruptive systems that are cloud-based, offer much lower costs, easier implementation and more intuitive interfaces on mobile devices will run away with the market just as they have in other industries.

The show is about to begin…

 

Digital Health Technology