EHR usability and quality assurance: do the Feds understand what is at stake?

So, 2011 is the year the checks for EHR get issued. The IT industry seems to me to be adopting a bit of a wait-and-see attitude about the Federal push to implement and integrate EHR, possibly because the standards for “meaningful use” are only now being rolled out. This is such heavily bureaucratized terrain; not every vendor wants to mess with it. A certain Zen-like patience is required for this market, what with business rules, such as they are, based on the sometimes inscrutable calculations of public-sector analysts and specialists who issue Federal guidelines. I used to work as an analyst for a Health IT company, tracking  state compliance to the Federal Medicare data transaction standards, and every time a bureaucrat put me on hold, one more little part of my youth expired, joylessly.

But after all the regulations and rules have been parsed, the rubber must hit the road. Whether doctors and nurses and admins can use the EHR systems being implemented remains the $100 Billion question, no?

From the January 18 PC World:

Dr. Tom Handler, a radiologist and analyst for the research firm Gartner, said one of the main barriers to adoption, “valid or not,” are concerns about the productivity and usability of EHR systems. Many physicians also believe that the data collected by the government through EHR reporting criteria will be used to decrease Medicare and Medicaid reimbursements, Handler said.

“Ultimately, what I hear doctors saying is, ‘Let me get this straight. You want me to spend money to put in a system that will be harder to use and slow me down, so I will earn less money, and that the end result is that someone else makes more money,” Handler said. “If you phrase it that way, it’s not illogical to see why they don’t want to do it.”

E-prescribing is another example. “Docs say, ‘I didn’t go to medical school to become a data entry clerk so Walgreens could hire one less pharmacy tech to enter the system.’”

Handler said current meaningful use criteria also doesn’t take aim with incentives that address what physicians consider some of the most critical reforms needed in healthcare today.

For example, Handler said, a computer-based patient record system can catch duplicate patient test orders, but the current meaningful use incentives don’t penalize physicians for ordering duplicate tests.

Ultimately, it’s the patient — the insurance company and then society — that pays for the duplicate test, and yet, its the physician who’ll have to foot the cost for the system that can prevent the duplicate tests, he said.

Dr. Harry Greenspun, chief medical information officer for Dell and a member of the Healthcare Information and Management Systems Society (HIMMSS), said resistance to EHR adoption can be as simple as a physician not wanting to add steps to a process that has worked for decades.

“It’s really easy to write a prescription; you just jot it down on note paper. On a computer screen it can take a lot longer,” he said. “If you go have to through a check list or a menu-driven program, it can be clunky, and a barrier to adoption.”

“On the other hand,” he continued, “If I can share [radiological] images, pull data from other systems, write a prescription all from one screen … and get valid prescription alerts and find out about public health threats, then the value is obvious.”

Everyone wants doctors and other medical professionals to interact with systems that are as intuitive as possible. The Feds know that usability is make-or-break, and they are developing appropriate usability and quality assurance standards…one hopes. But this is a non-trivial business folks, and there are issues lurking under the surface that give me pause. For instance, there is the crucial distinction between usability and learnability that Andrew Dillon highlights (scroll down to comments):

Distinguish between usability and learnability. Most usability tests are short run tests of people’s initial reactions to a technology. This privileges the earliest phases of human reactions, the making sense of something new. This is important but it is not the full story. I have shown repeatedly in my own work that people’s later reactions take time to emerge and often run counter to their initial ones.

Are your eyes glazing over with this inside-baseball arcana yet? Are you thinking, we pay good money so those nerds with advanced degrees in cognitive psychology or human factors have to worry about this kind of hair-splitting, not us. THAT’S THE WRONG ATTITUDE. Too-big-to-fail projects can fail, and with as much money is at stake with EHR, failure can mean the entire universe is sucked into a fiscal black hole.

Oh, and people can die if we don’t get it right.

a year later, the details of “meaningful use” are coming into focus

Almost one year ago, the President signed the HITECH Act: “Health Information Technology for Economic and Clinical Health” as part of ARRA, the “American Recovery and Reinvestment Act.” This part of the stimulus bill is intended to incentivize the migration away from legacy paper health records and non-standard health records towards electronic health records (EHRs), via incentive payments to physicians of up to $44,000, starting next year.

Since the passage of ARRA, there has been much speculation and some tentative analysis of how the criteria for “meaningful use” of EHR/EMR will play out. With the recent announcements by the Feds, the details are at last becoming more-or-less apparent. There is still the period of review and input from stakeholders and the public, so there may be some changes, but at this point the basic operational definitions can be characterized. My friends at Software Advice.com put together a very useful summary and representation of how the suits at CMS and ONC are making sense of the “meaningful use” provision:

“In the table below, we’ve combined the meaningful use objectives for both eligible professionals (physicians) and hospitals for the Stage 1 adoption year, the required EHR technology criteria to accomplish those objectives and what criteria the government will use to measure meaningful use.

CMS defines “meaningful use” as using an EHR for the objectives listed in the first column. The objectives fall under these general topics:

* Improving quality, safety, efficiency, care coordination, population and public health;
* Reducing health disparities;
* Engaging patients and their families; and,
* Ensuring adequate privacy and security protections for personal health information

For the first time, CMS has also outlined specific measurements for how the government will determine if an EHR is being used in a meaningful manner for the Stage 1 (2011) adoption year. Updated definitions of meaningful use for Stage 2 (2013) and Stage 3 (2015) EHR adoption periods will be released in the year before those periods begin.

This table outlines what Stage 1 objectives define meaningful use, what software features are necessary to accomplish those objectives and what criteria the government will use to measure meaningful use. EP refers to eligible professional.

For the full article, see http://www.softwareadvice.com/articles/medical/the-stimulus-bill-and-meaningful-use-of-qualified-emrs-1031209/

Discussing ARRA’s “meaningful use” provision: how to define it?

Picking through the July print edition of Healthcare Informatics, and surfing the blog, I see the debate by analysts over what constitutes “meaningful use” of Electronic Health Records/Electronic Medical Records is reaching a crescendo.  “Meaningful use” refers to the criterion for accessing some of the massive funds allocated by the American Recovery and Reinvestment Act for development and implementation of Electronic Health Records/Electronic Medical Records. As Woodward and Bernstein (allegedly) said: “follow the money“.

There is lots of good discussion and fine-grained debate over the definitions and implications of the “meaningful use” provision at http://www.meaningfuluse.org/ . I see at Health Data Management.com a nice summary:

“The federal HIT Policy Committee has approved revised recommendations of a workgroup for an initial definition of “meaningful use” of electronic health records systems. Among the changes made in the recommendations are refinements in computerized physician order entry criteria and a shorter timeline for implementing personal health records.

The definition is important because providers must demonstrate meaningful use of EHRs to qualify for Medicare and Medicaid incentive payments starting in 2011 under the economic stimulus law. The recommendations now go to the Office of the National Coordinator for Health Information Technology and other units of the Department of Health and Human Services. HHS officials will use the recommendations for guidance as they develop rules to implement the incentive programs. A proposed rule is expected by the end of this year.

The policy committee’s Workgroup on Meaningful Use recommends that 2011 criteria apply not just to 2011, but also to a provider organization’s first adoption year. That means if a provider cannot be ready for incentive payments until 2012 or 2013, the organization still will start with 2011 criteria. In other words, 2011 criteria would be considered Adoption Year 1 criteria.

Consequently, 2013 criteria would be in effect in 2013 or in an organization’s third adoption year.

The workgroup’s adopted definition of meaningful use is a matrix of more than two dozen requirements that have been revised to some degree since it first was unveiled a month ago. The workgroup made several clarifications, particularly in the area of requirements for adoption of CPOE. But many of the details remain to be fleshed out during the administrative rules process.”

Meanwhile, over at Modern Medicine, an analyst writes:

“The first public draft of the “meaningful use” definition, the linchpin of the $44,000, five-year Medicare incentive for improving electronic health record adoption, includes too many requirements for physicians to comply by the 2011 deadline, according to a healthcare technology analyst.

“The bar has been set too high, and the recommendations put forth will be virtually impossible to implement within the aggressive time schedule of the HITECH Act,” says John Moore, managing partner of Chilmark Research of Cambridge, Massachusetts, in reference to the EHR incentive legislation. “Simply put, it appears that not enough attention was paid to the processes/workflow changes that are required as part of a successful HIT rollout to meet these recommendations.”

ARRA grants for academic health informatics programs

Houston Neal of softwareadvice.com pointed me to a timely post about upcoming funding that will be disbursed via the ARRA bill for academic health informatics programs. Remember that Congress recently allocated $51 Billion for ARRA. As a medical informatics researcher finishing a PhD, I am of course very interested!

(http://www.softwareadvice.com/medical/electronic-medical-record-software-comparison/)

“We recently called the Office of the National Coordinator for Health Information Technology (ONC) to learn more. All they could tell us is funding will be available, but the details have yet to be confirmed and set in writing. We quickly learned we were not the first people to call; many others are wondering the same things as us.

While we can only speculate about when and how much will be available, one thing is for certain: there will only be so much to go around.

Here’s what you need to know and what you need to do to be prepared.

Who is Eligible?
There are two different grant programs described in the stimulus bill. The grants are for universities that wish to:

Carry out a demonstration project to develop academic curricula integrating certified EHR technology in the clinical education of health professionals (section 3015), or;
Establish or expand medical health informatics education programs (section 3016).
The grants will be available to the following institutions of higher education:

A school of medicine, osteopathic medicine, dentistry, or pharmacy;
Graduate programs in behavioral or mental health, or any other graduate health professions school;
Graduate schools of nursing or physician assistant studies;
A consortium of two or more schools described in the lines above;
An institution with a graduate medical education program in medicine, osteopathic medicine, dentistry, pharmacy, nursing, or physician assistance studies, and’
Certification, undergraduate and masters degree programs for information technology”

Ephraim Schwartz: Financial and technology issues make Obama’s EHR push not so easy to execute

from www.infoworld.com/article/09/03/11/10FE-electronic-medical-records_1.html

Up until now, the benefits of electronic medical records that have occurred accrue to just about everybody — patients, employers, state and federal governments, and medical insurers — but the actual health care providers. Doctors get the least benefits, especially in small practice groups (those with fewer than five physicians) that make up most medical practices.

But even those who might benefit from electronic health records don’t, says Homer Chin, associate medical director for clinical information systems at Kaiser Permanente Northwest. Why? Because there is little incentive to share information, the core of an electronic health record (EHR; also called an EMR for “electronic medical record”). For example, hospitals make money by doing tests. But once EHRs are up and running, a doctor ordering a test electronically might immediately receive an alert saying the test was unnecessary because the patient had the same test or procedure at another location. “There is not much revenue and profitability in putting in an EHR. There is little financial incentive,” Chin says.

An ironic consequence of EHRs is that, by helping raise the quality of health care, they penalize doctors and other medical providers for success, says Wes Rischel, a vice president at Gartner. The bottom line: Doctors will see fewer patients.

Beyond the income factor, the high cost of EHR systems today — not only the systems, but the setup and training — also dissuades adoption by doctors, especially those in small groups. Physicians have been unwilling to invest anywhere from $20,000 to $50,000 in an EHR system where the economic benefits tend to go to someone else. Today’s EHR systems are not as easy to use as they could be, so there is a large learning curve required, Chin says: “There is something intuitive about paper chart and prescription pad.”

Recognizing these factors, the stimulus package tackles these financial challenges head on by offering money to health care providers. Hospitals submitting via EHR systems to Medicare and Medicaid will receive up to $6 million a year in additional payments for sending data electronically. This incentive will remove much of the adoption inertia seen so far, says Richard Archer, a principal in the health care IT advisory practice a KPMG.

<snip>

But now Microsoft, Google, and AOL founder Steve Case’s Revolution Health are looking at entering the health care information exchange market. All three offer individuals a personal health record, which puts the patient in control of his medical information. But the business aspect is in giving health care providers access to a person’s complete health record from a single site.

There are two major questions around the reliance on health records from these providers, say industry analysts. One is whether users will trust a for-profit organization to care for the most personal kind of information. The second is whether each of us can be trusted to manage and keep such a life-and-death record up to date or if it’s safer to leave that responsibility to organizations whose only job it is to keep the health data updated.

The prognosis for EHRs
EHR providers are, not surprisingly, bullish on the future of EHR efforts. Greg Mancusi-Ungaro, a senior director at Exigen Systems, says deploying an EHR system is just like implementing any big enterprise application, only the enterprise in this case is bigger and the stakes are higher. “The technology exists today and despite the fact that we lack some core standards, we are enabling the development of a flexible infrastructure to stay in tune with requirements. I can visualize a successful national system,” he says.

As Kaiser’s Chin points out, there is a convergence occurring around health care technology regarding how to share it and use it to assist delivery of services and treatment. But the challenge of orchestrating and satisfying so many stakeholders remains. Plus, even if the solutions are mandated rather than eventually negotiated, the task of gathering the many pieces that are still in flux, then integrating them remains a complex technical and process task.

Over time, both industry representatives and analysts expect that every U.S. citizen will have an EHR available nationwide. But to make it happen will require a great deal of cooperation, innovation, and an investment in health-oriented IT. This shift will likely start at a less ambitious level than the political rhetoric suggests, with local practitioners sharing patient information in a local health care ecosystem.

5 guiding principles for spending EHR stimulus funds wisely

John Halamka, MD,  on Making Smart Investments In Health Information Technology: Core Principles

http://content.healthaffairs.org/cgi/reprint/28/2/w385.pdf

Over the past five years, thousands of public- and private-sector employees, many volunteering their time, have worked to advance the cause of interoperable, certified, secure electronic health records. As new federal funds become available, should we invest right away or wait for technology and policy perfection? Do we leverage the accomplishments of existing national organizations, or do we start from scratch? The time to invest is now, building on the organizations we already have. To ensure wise investment, I suggest guiding principles assembled from the input of hundreds of providers, patients, payers, vendors, government employees, and standards-development organizations.

No other industry has had such a mismatch between the sophistication of the technology being introduced and the lack of technological sophistication on the part of those who are supposed to manage it. Placing servers in clinicians’ offices and expecting office staff to back up, secure, and maintain technology is likely to be expensive, frustrating, and highly risky. Investments in EHRs should focus on achieving economies of scale through the funding of regional, hospital based, or vendor-hosted “software as a service” providers that provide Web-based/remotely accessible solutions that require very minimal new technology in clinicians’ offices.

Physicians to receive incentives for EHR, penalties

from www.healthcarefinancenews.com/news/physicians-receive-incentives-ehr-use

The American Recovery and Reinvestment Act of 2009 provides financial incentives to physicians who adopt and use Electronic Health Record (EHR) technology. However, physicians who haven’t adopted certified EHR systems by 2014 will have their Medicare reimbursements reduced by up to 3 percent beginning in 2015.

The act provides $20 billion in health information technology funding, divided between $2 billion in discretionary funds and $18 billion in investments and incentives through Medicare and Medicaid, to ensure widespread adoption and use of interoperable healthcare IT systems.

“In one stroke, Congress has all but removed the biggest stumbling block to EHR adoption – cost,” said James R. Morrow, MD, a physician at North Fulton Family Medicine in Alpharetta, Ga., who was named “Physician IT Leader of the Year” by the Health Information and Management Systems Society (HIMSS). “It’s time for doctors to stop complaining about the cost of an EHR and take the ball and run with it toward the goal of better medicine with better records and information sharing across the healthcare team.”

With the stimulus, the Centers for Medicare and Medicaid Services will pay physicians $44,000 to $64,000 over five years, beginning in 2011, for deploying and using a certified EHR. The stimulus package is expected to ignite significant job growth in the information technology sector and, according to a Congressional Budget Office review, drive up to 90 percent of U.S. physicians to EHRs in the next decade.

A recent Allscripts survey of 1,888 healthcare professionals revealed that 98 percent of physician practices would take advantage of the incentives or would be closely evaluating the opportunity.

hat-tip-www.fiercehealthcare.com

Will the Obama EHR/EMR plan enable government surveillance?

from  www.amconmag.com/article/2009/mar/09/00009/

“At this point, fewer than 20 percent of the nation’s physicians have gone full-speed on computerization. Obama’s plan offers between $44,000 and $64,000 to doctors who computerize patient records and up to $11 million per hospital. “On the stick side of the equation,” the Wall Street Journal reported, “the measure includes Medicare payment penalties for physicians and hospitals that are not using electronic health records by 2014.” If records are digitized on the federal dime, it will be far easier for politicians to claim the resulting information.

But the feds have no technological silver bullet to distribute to docs across the land. David Kibbe, a top technology adviser to the American Academy of Family Physicians, warned Obama in an open letter late last year that existing medical software is often poorly designed and does a miserable job of exchanging information. Kibbe declared, “If America’s physician practices suddenly rushed to install the systems of their choice, it would only dramatically intensify the Babel that already exists.”

Marc Roberts, a Harvard professor of political economy and health policy, notes, “Many healthcare systems are now intentionally building medical record systems that are nonstandardized and noncompatible so they can own and control the data.”

In the same way that George W. Bush bragged about the percentage increase in homeownership, President Obama will be able to boast about the increase in doctors’ offices using electronic records. It didn’t seem to matter to Bush that many of the new federally subsidized homeowners went bankrupt, and it may not matter to Obama that the federally controlled health-record system is bound to be a trainwreck.”

CEO of athena Health: a Federal “Marshall Plan” for Electronic Medical Records will fail

http://histalk2.com/2008/12/22/histalk-interviews-jonathan-bush-ceo-president-and-chair-of-athenahealth/

Money quotes from Athena Health CEO:

“In life and society, the goal of government is to set the rules of the road for companies. If the government intervenes and actually becomes a participant, there’s all kinds of adverse skewing that’s going to go on.

Certainly this is a world class case in point. If we end up with a Marshall Plan for EMRs, we will subsidize the approach to this that has not worked, that is certainly, among the readers of your site, clearly known to be a failed approach. We’ll keep those established players, those dominant buffoon gigundo companies, alive a little bit longer. It really feels like subsidizing General Motors. Who else would help save America from having access to cars that nobody wants?

I really feel that way about these big EMR, clinical, software-only business model companies. Nobody wants them. They’re being told that they should have them, but in their hearts, if you look at their Id, they don’t want them.”

I don’t want the Obama investment in healthcare to end up looking like the Congressional investment in General Motors, which is to say I don’t want really, really bad, dead things that ought to die sooner to be kept alive longer by a well-meaning federal government. I want software companies to die as quickly as is humane.

If the federal government gets in there and starts handing out free subsidies, then the providers of the world have to say, “Well, gee, I know it sucks, but if it’s free, does it suck that much, or maybe I should give it one more swing?” That’s what scares me to death. That’s why the interview with Wall Street Journal and with Fox and anybody else who will talk to me, including you. To make sure the Obama folks hear us saying, “Please don’t kill the emerging technologies by subsidizing the established and dying technologies in order to have something to do.”

Q-Is the track record of doctors and hospitals who have already implemented the available technology good enough that we should be subsidizing more of the same?

The hyperbole is almost ringing as you ask. You’re the ultimate insider and I know that you know that the answer is no.

The folks who have installed this stuff are experiencing negative ROI. That’s why the RAND Institute came out with the study that showed that it’s 19% slower to have an EMR. There’s no pay-for-performance revenue to cover that 19% slowness. None of the supply chain is connected to EMRs, so all the laboratories and specialists and X-ray machines and PET scanners and mammogram machines aren’t connected to EMRs. There’s an incremental administrative cost in keeping the EMR current by typing results into the chart from these other sources of medical information.

Everybody knows in their heart of hearts that without a massive increase in pay-for-performance … it’s not really even performance at this point, it’s really pay-for-data … without a massive increase in pay-for-data in hopes that will prime the pump and we’ll figure out how the data maps to performance later. I’m sitting here looking at a row of plastic white yachts in Boca Raton and I’m thinking, “What is the definition of a yacht? A hole in the water into which one pours money.” I think of EMRs a lot like that … data yachts.