A poll on adoption of EHR’s

We are at the stage now where Federal writ must be interpreted and scrutinized by those planning budgets and personnel decisions. Institutions and organizations such as Regional Extension Centers face serious financial and logistical challenges concerning EHR’s. While these challenges certainly present opportunities for those of us in the healthcare informatics/healthcare IT world, the history of implementing complex upgrades to institutions that must provide mission-critical services during the upgrade is daunting. Healthcare CIO’s and CTO’s and directors must proceed with caution as the Feds operationalize the logistics of the ARRA EHR meaningful use provisions.

Houston Neal from www.softwareadvice.com/ passed along a note that they are running a poll on an important issue concerning the adoption of EHR’s and how the Feds are structuring incentives to do so.

One of the major components of the the American Recovery and Reinvestment Act of 2009 (ARRA) was the allocation of $19 billion to jump start the adoption of electronic health records (EHRs). One of the major uses of those funds was the establishment of Regional Extension Centers (RECs) to support EHR adoption by primary care physicians.

The entity spearheading this effort, the Office of the National Coordinator for Health IT (ONC), is specifically charged with helping 100,000 priority primary care providers become “meaningful users” of EHRs in 24 months. Eight months have passed since the ONC began funding RECs, and we’re skeptical that they will deliver.

Don’t get us wrong. We’re big advocates of EHRs. We’re glad to see such an energized EHR market. We’re just skeptical that throwing money at the problem will lead to efficient and successful adoption of this important technology.

In our opinion, there are five fundamental flaws with RECs:

1 Doctor’s aren’t moving as fast as the money is flowing
2 The market already delivers on what RECs promise
3 “Preferred vendor lists” limit choice and free markets
4 RECs won’t get doctors to “meaningful use” fast enough
5 The REC model leads to under-staffed, ephemeral entities“

What do you think about how electronic health records (EHRs) will be imlemented in the key category of Regional Extension Centers ? Take the poll at : http://www.softwareadvice.com/articles/medical/five-reasons-we-think-recs-are-reckless-1092310/#survey#ixzz10rpWUNdV

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.”

Uwe E. Reinhardt: healthcare comparative effectiveness analysis and cost-effectiveness analysis

from http://economix.blogs.nytimes.com/2009/03/13/cost-effectiveness-analysis-and-us-health-care/

With so much brouhaha over what should be thought of as basic operations research for health care, it may be well to explore what “comparative effectiveness analysis” is, and how it is related to what is known as “cost-effectiveness analysis.”

The sketch below describes the basic structure of “comparative effectiveness analysis.”

It is assumed that researchers compare two therapies aimed at the same medical condition. The researchers try to determine which of these therapies can be judged “better” in terms of the positive and negative consequences associated with them. In principle, the clinical practice guidelines promulgated by medical specialty societies to help physicians with their daily treatment decisions should be based on this type of carefully structured comparative effectiveness research.

Source: Uwe Reinhardt A diagram of comparative effectiveness analysis.

Alas, in practice most of the currently promulgated guidelines lack that kind of rigorous scientific foundation. For example, as the science reporter Ronald Winslow recently reported in The Wall Street Journal “just 11 percent of more than 2,700 recommendations approved by cardiologists for treating heart patients are supported by high-quality scientific testing, according to new research.”

That circumstance alone justifies spending billions more than we traditionally have on operations research for an industry that now absorbs $2.5 trillion or close to 17 percent of our gross domestic product. Why anyone would oppose that kind of research challenges one’s imagination.

Early drafts of the economic stimulus bill, however, referred not only to “comparative effectiveness research,” which keeps the analysis strictly in the clinical realm, but also to “comparative cost-effectiveness analysis,” which brings economics into the inquiry. That analysis seeks to establish which of several alternative therapeutic strategies capable of achieving a given therapeutic goal is the least-cost strategy. It seems a sensible form of inquiry in a nation that is dismayed over the rising cost of its health care.

Indeed, in recent years most industrialized nations have begun to subject clinical practices in their health systems to this type of analysis, as have private insurers in the United States (see, for example, the American Journal of Managed Care).

In Congress, however, the word “cost” in this connection remains anathema. This is despite the fact that that same Congress rings its hands in despair over the millions of American families priced out by the ever-rising cost of health care, and over the bigger chunk of the federal budget taken up by Medicare and Medicare.

So, in the end, the offensive term “cost-effectiveness analysis” was stricken from the bill.

The opposition to cost-effectiveness analysis in health care comes from two distinct groups that work closely together and reinforce one another.

The first group includes individuals or enterprises that book other people’s health-care spending as their own health-care income.

The manufacturers of pharmaceutical and biotechnology products or of medical devices are often found in that group, even though in some instances the greater economic transparency provided by cost-effectiveness analysis might help them market their health products or health services. Also in this group are physicians who thrive economically from highly resource-intensive medical treatments, even if some of its components are of only marginal clinical benefit.

The second group among the opponents of cost-effectiveness analysis includes individuals who sincerely believe that health and life are “priceless” — for them, cost should never be allowed to enter clinical decisions. It is an utterly romantic notion and, if I may say so, also an utterly a silly one. No society could ever act consistently on such a credo.

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

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.

political debates on “comparative effectiveness research” of medicine and treatments

The New York Times is reporting on an emerging political debate tied up with the February 2009 stimulus bill about comparative effectiveness research of medicine and treatments:

www.nytimes.com/2009/02/16/health/policy/16health.html?hp

“The $787 billion economic stimulus bill approved by Congress will, for the first time, provide substantial amounts of money for the federal government to compare the effectiveness of different treatments for the same illness.

Under the legislation, researchers will receive $1.1 billion to compare drugs, medical devices, surgery and other ways of treating specific conditions. The bill creates a council of up to 15 federal employees to coordinate the research and to advise President Obama and Congress on how to spend the money.

The program responds to a growing concern that doctors have little or no solid evidence of the value of many treatments. Supporters of the research hope it will eventually save money by discouraging the use of costly, ineffective treatments.

The soaring cost of health care is widely seen as a problem for the economy. Spending on health care totaled $2.2 trillion, or 16 percent of the nation’s gross domestic product, in 2007, and the Congressional Budget Office estimates that, without any changes in federal law, it will rise to 25 percent of the G.D.P. in 2025.

Dr. Elliott S. Fisher of Dartmouth Medical School said the federal effort would help researchers try to answer questions like these:

Is it better to treat severe neck pain with surgery or a combination of physical therapy, exercise and medications? What is the best combination of “talk therapy” and prescription drugs to treat mild depression?

How do drugs and “watchful waiting” compare with surgery as a treatment for leg pain that results from blockage of the arteries in the lower legs? Is it better to treat chronic heart failure by medications alone or by drugs and home monitoring of a patient’s blood pressure and weight?

For nearly a decade, economists and health policy experts have been debating the merits of research that directly tackles such questions. Britain, France and other countries have bodies that assess health technologies and compare the effectiveness, and sometimes the cost, of different treatments “