Providers' willingness to partner with the technology industry to explore collecting personal activity-tracking information demonstrates the value of boosting patient engagement via mobile devices.
This article appears in the July/August 2015 issue of HealthLeaders magazine.
Patient engagement remains an elusive goal for providers, but new mobile technology initiatives by Apple and others are breathing fresh life into the effort, providers say.
Patient portals still struggle to meet the 5% requirement of meaningful use stage 2.
Much of this approach currently revolves around providers engaging with mobile phone manufacturers, such as Apple, and their technology partners. Last fall, Apple rival Samsung revealed digital health partnerships with Cleveland Clinic, Humana, and Stanford University, among others. That followed Apple's initial blitz of partnerships last year with EHR publisher Epic and the Mayo Clinic. During the year following, a growing number of other healthcare providers also revealed alliances with Apple.
What all these announcements share is the willingness of providers to explore collecting personal activity–tracking information, such as number of steps taken as well as other patient-collected measurements from either mobile phones or devices connected to those phones, to boost patient engagement with their providers.
The most dramatic implementation so far of such collection is Cedars-Sinai's decision to permit up to 87,000 patients to add mobile data from six parameters to a special sequestered section of Cedars-Sinai Health System's Epic-based EHR, available through the provider's patient portal as MyCSLink.
Darren Dworkin
"We were pushing to get patients to use our EMR portal, and we've tried to take it to the next level by putting more useful information into it," says Darren Dworkin, chief information officer at Cedars-Sinai. Patients could already visit the portal and download continuity of care documents (CCDs)—essentially, their medical records. But the parameters gathered by Apple iPhones and iPads and connected devices represent the device's own measurements of the patient's steps, weight, glucose, blood pressure, saturation of peripheral oxygen, and pulse.
"We do have to begin to understand that, more and more, the patient record is going to be a shared tool," he says. "We're still in the very early stages of learning and understanding what all of that means."
So far, about 500 patients have taken up Cedars-Sinai on its offer and connected Apple's HealthKit information hub to their Cedars-Sinai health record. In addition, the health system is preparing to launch programs that, unlike the initial HealthKit integration there, will require clinicians to actively monitor the patient-provided data.
"We've been quick to point out to folks that this isn't as new as it sounds," Dworkin says. "Diabetic patients have been keeping logs of their insulin and glucometer readings for years, and they'll bring those paper logbooks in to visit with their physician and have a conversation. Some patients are better record keepers than others, and they may be tracking their weight or their blood pressure or other such things manually. This really just affords them an electronic way of replacing that paper for the patient much in the same way that we've replaced paper for the physician."
So Cedars-Sinai plans to soon launch HealthKit-based initiatives around tracking patients with congestive heart failure, diabetes, and COPD, Dworkin says.
Meanwhile, Dworkin pores over the unmonitored data coming in from the initial HealthKit rollout. "We could already see from the early data that most patients who are connecting devices are connecting fitness bands, and fitness bands are interesting. But healthcare providers have hopes that there will be a much wider array of interesting consumer-grade medical devices that will be available. Blood pressure cuffs are falling in price and becoming more prevalent. Weight scales are actually doing pretty good. I think that's our second-highest utilization.
"As more and more of these devices enter the market, and frankly, drop in cost, I think we'll see a wider adoption and use of those devices and then ultimately more linkages back." Consumers are free to discontinue using one particular kind of device and connect others, he notes.
Inevitably, the question comes up of when the health system will begin to monitor this data across all patient populations. "If you look on our website, there is actually a disclaimer that reminds patients that this isn't monitored data, much the same way that when you go into our patient portal and you type in an issue, it reminds you that if this is an emergent issue, you should dial 911," Dworkin says.
"We've been doing patient-entered information for a while, as have many, many organizations. We're certainly not the first. And all that information when entered is always understood to be not emergent, or nonmonitored information. It's really about facilitating dialogue with the clinical care team, and ultimately at the end of the day, as always is the case, we're relying on the expert clinical judgment of that care team to understand what to do with that data."
Dworkin acknowledges that Cedars-Sinai is building upon the interoperability alliance forged between Apple and Epic, as well as earlier, more pilot-oriented HealthKit deployments at Duke Medicine and Ochsner Health System. "We entered the game a little bit later than the pioneers, so we were able to take advantage of doing it in a slightly different way," he says.
Development time to integrate HealthKit into Epic at Cedars-Sinai has been measured in weeks, not months or years, Dworkin notes.
At Ochsner, Chief Clinical Transformation Officer Richard Milani, MD, heads up the 19-hospital system's care delivery redesign effort. "We have a process where we onboard individuals with heart failure once they enter the hospital," Milani says. "We phenotype them. They go home with a wireless scale that's connected to us. We're monitoring their weight and other things on a daily basis. If we start seeing changes that are probably not going in the right direction, we're in contact with them. This is seven days a week. And we've seen about a 45% reduction in readmissions over a year-and-a-half period as a result."
Such work predated Ochsner's integration of HealthKit, with weight scales directly communicating to Ochsner servers. But a new initiative to better control hypertension is based on HealthKit, and the weight scales in the previous monitoring program are also now integrated via HealthKit, Milani says. "Hypertension is the leading chronic disease on the planet, and Louisiana is the fourth worst state in the nation for prevalence," he says.
Richard Milani
One benefit of HealthKit is the reliability of Apple's hub, Milani says.
"The entities that are in this space sometimes are not recognizing that they need to make sure that their connectivity and their servers are working," he says. "That's working in the healthcare world, which means daily, hourly, as opposed to, 'It's been down for a week, oops,'—that kind of thing. HealthKit has been a solid performer and is very durable and reliable."
The monitoring programs at Ochsner are part of its new integrated practice unit care redesign, which is focused on just the desired outcomes, unlike previous, more broadly aimed medical home redesigns, Milani says. It also enables providers to collect more than three or four data points per year on patients, unlike the previous models that did not incorporate such data from HealthKit.
Traditional portals going mobile
This summer, the Centers for Medicare & Medicaid Services will issue new file rules expected to reduce the patient engagement requirement, but while the industry waits for those rules, at providers such as Advocate Health Care, recently launched patient portal initiatives are gaining momentum, and mobile hasn't even kicked into gear as expected—so far.
At Advocate Health Care, approximately 125,000 patients are now using a patient portal that launched in 2014, and it is gaining roughly 2,000 more patients per week, says John Norenberg, vice president of information systems in physician services at the 12-hospital system based in Downers Grove, Illinois. About 33% of patients invited to register for the portal ultimately join it, he adds.
Like many portals, Advocate's provides lab results, secure messaging, bill payments, and appointment scheduling, viewing, and cancellation. In addition, patients can look up information on their currently prescribed medications.
A recent upgrade also enables patients to link devices from Fitbit, Withings, and Jawbone, storing the data in a section of the portal called a health journal, to record activity, weight, and other readings such as blood pressure, Norenberg says.
"We feel good about that number," he says regarding portal users. "It's an indicator that the market is ready. We also did quite a bit of work with our clinicians and our office staffs to have them heavily promote the portal as a much more convenient way to interact with the physicians and office staff, and that seems to have helped."
John Norenberg
In just two months, the mobile version of Advocate's portal has already attracted approximately 3,200 patients, as well, as measured by Google and Apple app store downloads, Norenberg says. "We thought it would be more positive, but I guess the Chicago market is slower on the uptake with these kinds of tools than the coasts are."
Anecdotally, many patients who try the mobile portal tell Advocate providers they will rely on the app and not call the office, "because this just works," he adds.
Norenberg notes that, personally, he really doesn't like phone apps, "but I really like this one, which is weird for an IT guy. It is a massive time-saver for me."
Likewise, his own primary care physician at Advocate has come to prefer using the portal to communicate with patients—a big cultural change from a year ago, Norenberg says.
Norenberg recently visited his physician to be seen for a respiratory bug, and after being prescribed an antibiotic, the physician asked him to check in the following Monday via email. "I asked him why, and he said, 'Because it's the most efficient way for us to work with you. It's the best use of my time and the best use of your time.'
"I was shocked, because a year earlier, our doctors were kind of nervous about this thing called the portal, and now we have the doctors actively promoting it as the best way to communicate with them, so I think we're onto something."
Reprint HLR0815-9
This article appears in the July/August 2015 issue of HealthLeaders magazine.
Congress is pushing for a delay, and hospitals that can opt out of MU, are. But abandoning Meaningful Use would lead to problems with other healthcare regulations.
It is high time to consider whether the federal meaningful use program can survive.
Trouble signs are all around. But abandoning meaningful use at this juncture would lead to problems with other healthcare regulations.
Meanwhile, in Washington, D.C., elected officials continue to pound the table demanding to know where their $30 billion worth of seamless digital healthcare is, rather than the disjointed system of fractured digital care we currently have.
And finally, the American Medical Association, in a town hall on July 20, heard a torrent of complaints about EHRs. The low point had to have been the physician who wanted to return to paper.
On top of all this, the world continues to wait for CMS and ONC to drop the final rule for meaningful use stage 3. Last week, one member of Congress preemptively suggested a series of reforms for stage 3, which quickly won the endorsement of the College of Healthcare Information Management Executives (CHIME)—which I suspect had some role in helping write the legislation.
H.R. 3309, the Further Flexibility in HIT Reporting and Advancing Interoperability Act of 2015, or Flex-IT 2 Act for short, has five objectives:
Delay Stage 3 rule-making until at least 2017, either when the Merit Based Incentive Payment System (MIPS) final rules are released or at least 75% of doctors and hospitals are successful in meeting Stage 2 requirements
Harmonize reporting requirements (MU, PQRS, IQR) to remove duplicative measurement and streamline requirements from CMS
Institute a 90-day reporting period for each year, regardless of stage or program experience
Encourage interoperability among EHR systems
Expand hardship exemptions, as they are very narrowly defined under current regulations
Introduced by Rep. Renee Ellmers (R-North Carolina), Flex-IT 2 is so named because it is a successor to H.R. 5481, the original Flex-IT Act, introduced by Ellmers last fall. The legislation was effective at prodding CMS in January to announce it would introduce flexibility into the 2015 through 2017 meaningful use reporting years. And yet, as of today, that flexibility still has not been finalized, so last week CHIME also issued a call for CMS to hurry up.
"The additional time proposed by the modifications rule could help hundreds of thousands of providers meet meaningful use requirements in an effective and safe manner. However, we are just 61 days away from the end of the fiscal year, and the final quarter of 2015, yet hospitals and physicians are without the rules outlining the requirements for participation in the program this year," said Leslie Krigstein, interim vice president of public policy for CHIME, in a statement issued last Friday.
Meaningful Use + MIPS
Now here comes Flex-IT 2 to address the concerns enumerated above, and more. Krigstein tells me that the relationship between MIPS and meaningful use means that health IT stakeholders don't have much of an option other than to fix meaningful use, unless they want real chaos.
Leslie Krigstein
"The Merit Based Incentive Payment System (MIPS), which sets the new formula for physician Medicare reimbursement, includes meaningful use in its calculations, but the MIPS regulations have not been written" and no date for their release has been set, Krigstein tells me. Also, "there is confusion about how CMS will evaluate the meaningful use program changes and how the MIPS program and the MU program will be reconciled."
For instance, CMS has stated that 2019 will be the first year for MIPS. "Presumably, like meaningful use, there's a two-year look-back [for MIPS], or a year look-back, which means it would start in 2017 or 2018."
Thus, CHIME's call to press pause on stage 3 of meaningful use.
Another point both CHIME and AMA have gradually been making louder and louder: meaningful use attestation requirements are too inflexible. Krigstein also points out that MIPS scoring is expected to be on a sliding scale—25% of which will be derived from meaningful use compliance—and so it only makes sense that meaningful use adopt a sliding scale instead of the current all-or-nothing approach to penalties and what dwindling incentive payments remain.
"At this point, you would have a provider losing a full 25 points out of 100 if you are missing meaningful use by one patient, or if you fail your risk assessment," Krigstein says.
Also, if stage 3 is postponed, potentially as the MIPS rule kicks in, providers would only have to meet the stage 2 bar, instead of the much higher stage 3 bars.
It's worth remembering that EHR vendors have a ton of work to do to meet the stage 3 certification requirements. "You see a lot of the conversations about the APIs, and the new security, the compartmentalized approach to security with different modules meeting different levels of security, and all of the calls for incorporation of patient-generated data," Krigstein says. "I'm not a vendor, but I should anticipate it not being an easy lift."
The Cause for a Pause
Congress may be pivoting from its earlier table-pounding to lending a sympathetic ear. Sen. Lamar Alexander, chair of the Senate HELP Committee, which is currently holding a series of hearings on health IT, called for a stage 3 delay last month. "Especially as members head home for a recess, I would guess that we're going to start hearing that line of thinking from members of Congress more and more readily as the summer progresses," Krigstein says.
"What our CIOs and what physicians are saying is, 'We're trying, and we have the software, but we are just not able to do what CMS is asking us, because it just doesn't match the way we deliver care.' "
The risk is, if the rush to stage 3 isn't slowed, more and more healthcare providers will simply bail on the program or call for its elimination, following the lead of the children's hospitals.
"There was talk of a piece of legislation to be introduced last week that would eliminate the penalties, and that's not the right approach," Krigstein says. "Comprehensive reform is what we're looking at, and that's what we think this bill does."
One other note has to do with Flex-IT 2's expansion of hardship exemptions. The new proposed expansion would encompass providers who switch certified EHR products; provide an exemption for providers who experience a cyber-attack or other disruptive technology problems; and provide an exemption for certain physicians based on their specialty or if close to retirement.
All in all, Congress and policy makers should carefully consider these suggestions if they don't want to see meaningful use fall apart completely. And without a working meaningful use program, it seems unlikely we can leverage health IT to get to merit-based incentive payments. The issues are inextricably linked and demand immediate attention.
The widespread inability of electronic prescription services to handle order cancellations is just a point of pain for physicians. Other vexations can affect patient safety.
I recently reported on widespread grumbling at AMDIS about the fact that it is still a rare thing for physicians to be able to cancel an e-prescription order made through the nation's de facto e-prescribing service, Surescripts.
I was only able to get a brief statement from Surescripts at the conclusion of AMDIS, which mentioned "all stakeholder groups" as holding the key to solving this problem, which in the meantime, may be causing who knows how much inefficiency and waste in healthcare – and perhaps, even some harm.
Ajit Dhavle
Later, I had a chance to interview Ajit Dhavle, the vice president of clinical quality at Surescripts. I learned, to my surprise, that Surescripts has had the technical capability to move cancellation messages for five years—nearly as long as e-prescriptions have been in widespread use. Why, I had to ask, has it taken so long for the other stakeholders to get on board?
The main reason: Too many EHRs and technology vendors serving pharmacies need to certify their attempted cancellation transactions, conforming to the NCPDP 10.6 standard, with Surescripts. Some now have, and some still have not.
"The pharmacy system technology vendors are thinking, 'prescribers are not ready,'" Dhavle says. "Prescribers are thinking, pharmacies are not ready. It's a chicken and egg situation."
Industry Responses After our conversation, I made some inquiries with various EHR vendors and large pharmacy chains.
Epic officials tell me they have been able to handle cancellations since their EHR software's 2014 release.
A Cerner spokesperson says, "Cancellations are on our radar, pending final MU3 stipulations and adoption by pharmacies."
On the pharmacy side, I tried Walgreens, but did not hear back from anyone there. CVS Health is currently piloting the ability to process the cancellation of orders.
"Cancellation of electronic prescriptions is a relatively new functionality in the industry and only a few EHR systems can accommodate it at this time," says CVS spokesman Michael DeAngelis. "CVS Health has piloted the ability to accept cancellations for electronic prescriptions and our goal is to make this functionality available in all of our pharmacies in the near future. We look forward to partnering with health systems and Surescripts to make cancellation of e-prescriptions a more widespread capability in the healthcare industry over time."
During my conversation with Dhavle, when he revealed that Surescripts had solved their portion of this problem five years ago, I again referred back to the room full of annoyed CMIOs at AMDIS who nevertheless see this as Surescripts' problem. Reiterating his June statement to me, Dhavle says "We are actively engaging with all technology vendors, asking them to certify and begin communicating these messages."
I offered that if five years have passed and essentially nothing much has happened, some will question how actively this is being solved.
"Earlier on, the focus was on new electronic prescriptions and refill requests," Dhavle concedes.
And the Faxes Roll On
Another source of grumbling is the industry's continuing use of fax technology. An unnamed physician I spoke with not long ago contends that some national chain pharmacies still fax refill requests to avoid Surescripts transaction charges.
Dhavle says even if this is true, no transaction charges would be avoided, so he doesn't see the logic in such faxing. To be specific, the pharmacy incurs a transaction charge when receiving the new prescription, not when it submits the refill request to a physician, Dhavle says.
But this discussion did prompt me to do some other digging and I discovered another variable that certainly vexes physicians: timing.
According to Dhavle, "We ask prescribers to respond to all pending pharmacy refill requests in a timely manner, within 72 hours, because we are all doing this for the patient, and there is a patient waiting for their medications."
"It's not 72 hours," another source in the e-prescribing industry tells me. "For Walgreens, it's more like four hours." Apparently, Walgreens, and other pharmacies, respond sooner because they lack a level of assurance that the message they sent to Surescripts made it to the physician's office.
Again, the fault may not rest with Surescripts. Acknowledging those refill requests takes people. Algorithms alone aren't going to do it. And overworked physicians have plenty on their plates other than dealing with refill requests. I cannot speak for Walgreens, but I can understand why faxing still happens.
But the net effect of all those faxes being sent anyway is even more distraction and overload on an already overloaded system.
E-prescribing undoubtedly has been a great boon to healthcare. It is often touted as one of the true undisputed success stories of Meaningful Use.
But it's also true that e-prescribing has become very, very big business. According to a report by Persistence Market Research, the global market for e-prescribing, valued at $250 million in 2013, will reach an estimated value of $888 million by 2019, with an annual compound growth rate of 23.5%.
The cancellation scenario I came across at AMDIS now appears to be just one of a myriad of reasons we have to get e-prescribing right, especially as technology drives big profits for technology and service providers such as Surescripts.
Here's a more troubling patient safety example reported in the Philadelphia Inquirer last February:
Electronic prescribing systems currently used by doctors do not communicate discontinued medications to the pharmacy. It's a known flaw that has gone uncorrected by the industry and government since e-prescribing began. Unfortunately, rarely do patients or their doctors remember to communicate to the pharmacy that changes in medication therapy have taken place. But if the pharmacist doesn't know about changes the computer is not reset. The auto-refill system just keeps rolling along, dispensing unneeded and possibly harmful medicines.
It's discouraging sometimes to realize once again that any technology has its good and its bad side. And in healthcare, the bad side can hurt people. Apparently, at least for now, e-prescribing is no exception.
Population health leaders are divided over government actions to create interoperability—but agree that lack of data standardization hampers good analytics.
If the angst over meaningful use has taught us anything, it's that federal policy and federal money is a blunt instrument when it comes to directing the future of healthcare IT. That's why it's perilous for Congress to be acting as it is to tackle health IT's current big bugaboo, data interoperability. Leaders of the efforts to drive population health initiatives are divided on the notion.
Michael D. Robertson, MD
When I brought up this topic at the recent HealthLeaders Media Population Health Exchange, there was no shortage of opinions. The very stimulus money that is driving health IT's winds of change through healthcare is also magnifying the flaws in meaningful use that allow new information silos to arise and lead to accusations of information blocking.
Those accusations permeate the Office of National Coordinator's April report to Congress on information blocking—a report that clearly led to language in the 21st Century Cures Bill, which passed the U.S. House of Representatives this month. That bill would penalize providers who hoard information and give ONC new powers to investigate and take both punitive and corrective action against the hoarders.
But one healthcare executive's perceived hoarding may at the very same time be another executive's prudent effort to protect patient data and their own customer list from being poached by larger rivals. A third executive may simply be frustrated with the differing technology approaches and Tower of Babel that healthcare IT solutions sometimes resemble.
But listening to the assembled executives at the Population Health Exchange, I didn't hear a lot about the hoarding that has Congress and the ONC so up in arms. Instead, I heard plenty of grief about the lack of data standardization between the range of EHRs, analytical tools, and other health IT systems these executives have been purchasing.
"You've got to figure out a way to build a bridge to map those [systems] out and bring that into your data warehouse," says Michael D. Robertson, MD, chief medical officer of Covenant Health Partners in Lubbock, TX. "We've got tons of data, but [we] can't do anything with it. It's just like a room full of paper."
Robertson, like several others at the Exchange, wishes that someone with authority would intervene to enforce interoperability between different vendors' products. "There's too much money in it" for the vendors themselves to solve the problem without some prodding, he adds.
Even data originating from payers, which is essential to population health initiatives, still shows an unhelpful variability, says Richard Vaughn, MD, chief medical information officer of SSM Health Care in St. Louis, where he also serves as system vice president at SSM's Center for Clinical Excellence.
Richard Vaughn, MD
"In order for aggregated claims data to be useful, the information in a claims file must be extracted and properly loaded into our vendor's analytics data warehouse," Vaughn says. "Unfortunately, due to variation on the payer side, each claims source has to go through a mapping process to make sure the data lands in the right place in the warehouse, followed by testing and validation to prove the data is reliable.
"It is only after mapping, loading, and validation are complete that we can then use the risk models from the vendor to develop insights and actionable reports. The mapping, loading, and validation can take months, is labor-intensive, and generates significant cost to the customer."
Vaughn points hopefully to newer analytic tools that combine both claims data and clinical (EHR) data, which allows for a more robust risk model than the traditional approach using only claims data. "Again, due to EHR vendor variation, the analytics vendor must map, load, and validate each EHR source before the full power of the analytic tool can be applied, which becomes another source of cost, delay, and frustration," he says. "Imagine the efficiency we could obtain if these information sources, or at least the critical data that they contain, were all using the same approach to data structure and reliably used the same standard in the same way for every transaction."
Vaughn believes government has a role to play in sorting all this out.
"As for the proper mix of public/private involvement—as insurers continue to grow in size, healthcare organizations may struggle to impose a standard on them," he says. "This is where government may serve an important role by driving carefully designed health information standards that will improve information flow by decreasing the costly and inefficient processes currently needed to transform and merge the data."
Another Population Health Exchange participant was Scott Joslyn, CIO and senior vice president of MemorialCare Health System in Orange County, CA. "With regard to interoperability, the government has set expectations and the pace of progress through meaningful use," he says. "Still, the results have been less than satisfactory in some cases. It can be awkward. Also, the data exchanged are only a subset of the record, and it typically lacks the semantic meaning to associate like data. Still, it's a major step forward."
Back in 2008, when MemorialCare pioneered the use of Epic's Care Everywhere interoperability platform, "the ability to connect to the Epic system of another organization without intervening technology was a true advance," Joslyn says. "In their native Epic workflow, clinicians are able to examine, select, and incorporate patient data from another Epic system into the patient's record. This has proven helpful time and again for us and for many others as the Epic community has grown."
Joslyn acknowledges the concerns of Congress and others that data does not flow well among different EHR vendors. "That is true, though it is mostly a matter of being sufficiently cumbersome to impede clinician use and the requirement of having some intervening technology in place, i.e., a community HIE."
But more regulation is not the way to go, he says. "It is best that the industry address these problems, rather than through some regulatory means. The government should do more to encourage exchange through consistent, clear policy on opt-in/opt-out, for example. And, we need the data to be more complete and compatible among systems."
HL7's evolving FHIR standard shows great promise to increase the richness and compatibility of exchanged data, Joslyn adds. "While very early in the Gartner hype cycle, [FHIR] might just deliver all that is required if strongly embraced by all concerned."
While governments and groups gnash teeth and craft future policy concerning EHR usability, providers are turning to overlay software to recast EHR workflow.
This article appears in the June 2015 issue of HealthLeaders magazine.
Electronic health records are doing more than ever, but providers are challenged like never before to find ways to make them easier to work with and more productive; in short, more usable.
In January, the American Medical Association, joined by 34 other medical professional organizations including the College of Healthcare Information Management Executives, told government regulators there is an urgent need to change the current federal EHR certification program to better align end-to-end testing to focus on EHR usability, interoperability, and safety. CMS has even recommended enhanced user-centered design principles in the 2015 EHR certification criteria proposed in conjunction with meaningful use stage 3.
While governments and groups gnash teeth and craft future policy concerning EHR usability, providers are turning to overlay software—some of it powered by speech input, some of it running on simplified tablet-based desktop or mobile user interfaces—to recast EHR workflow.
Misinformation and misunderstandings surround ICD-10 as the go-live date nears. One result is that too many providers have yet to conduct testing. They should take advantage of CMS's grace period, starting now.
The announcement yesterday that the American Medical Association is now working jointly with CMS to educate its membership about ICD-10is better late than never.
Consider that, according to a survey conducted by the American Health Information Management Association (AHIMA) between May and June, the majority of providers have not yet conducted ICD-10 testing. This annual survey found that 19% of respondents do not even plan to conduct any end-to-end testing.
That is a fairly astounding finding, nearly as astounding as some of the continuing misinformation being circulated about how coding errors in ICD-10 will affect physician's payments. For some clarification on this, I again turned to AHIMA.
"ICD-10 has very little to do with physician payment," says Sue Bowman, AHIMA senior director for coding policy and compliance. "On the hospital side, it drives the DRGs and all kinds of payment issues. On the physician side, their payment rates are driven by the CPT codes."
Sue Bowman
ICD-10 diagnosis codes do determine medical necessity, and wouldn't we want those to be properly coded? I am puzzled by the continuing procession of physicians who speak of having to document their procedures in the ICD-10 procedure coding system (PCS). "It's not true that [physicians] have to document in ICD-10 PCS lingo," Bowman says. "There's actually a coding guideline that says the physicians can document their procedures the way they always have, and it's up to the hospital coder to translate the physician's description of [procedures] to ICD-10 PCS codes. But only hospitals are going to be using those codes, not physician practices."
One big irony of some recent criticism of the specificity of certain ICD-10 codes themselves, Bowman says, is that specificity was itself inserted into ICD-10 PCS by physicians, through specialty societies.
Yesterday's announcement that CMS would not deny claims for the first year of ICD-10 due to lack of specificity, along with AMA's acquiescence to working with CMS to educate its members, will immediately take the wind out of the sails of the usual movement to postpone ICD-10. In a June letter to CMS, the four largest state medical societies (California, New York, Florida, and Texas) declared ICD-10 a "looming disaster." Denied and delayed claims could bankrupt many small physician practices, the societies said.
Proposed physician relief in this letter and in H.R. 2247, the ICD-TEN Act, would have permitted claim payments and withholding of penalties despite any errors and mistakes in ICD-10-coded claims submissions for up to two years, and to withhold Recover Audit Contractor (RAC) audits related to ICD-10 coding mistakes during that period of time.
The fear was that overbroad relief could have opened the floodgates to a rash of Medicare payment fraud during such a two-year period.
Another part of H.R. 2247 would prohibit Medicare from denying claims due to "the use of an unspecified or inaccurate subcode." Bowman and the Coalition for ICD-10 (of which AHIMA is a member) point out that CMS accepts clinically accurate but less "granular" code under both ICD-9 and ICD-10. Bowman points to a CMS "Medicare Learning Network Matters" posting that acknowledges that clinicians do not know any more than a particular level of detail, which can continue to be represented by the unspecified codes.
Perhaps for all of the above reasons, the AMA has now chosen to work with CMS instead of continuing to fight the inevitable.
Finally, I continue to hear a constant refrain that ICD-10's focus on billing yields no benefits to the quality of healthcare. I asked AHIMA to weigh in on this continuing criticism.
"There's a lot of research analysis that's done based on claims data that uses that diagnosis and procedure data for a lot more ways than beyond just how that claim got paid," Bowman says, "to be able to assess difference in resource utilization, difference in outcomes for different kinds of treatment, [and resolving] patient safety issues."
Lynne Thomas Gordon
AHIMA CEO Lynne Thomas Gordon, herself a former hospital administrator, adds that ICD codes help hospitals with strategic planning, including capital construction, service line creation and termination, and quality measures. "When we move to population health and value-based purchasing, we're going to need to use these codes to say, Okay, what's going on in our population?" Gordon says. "What are we seeing with the patients that we serve? Are we seeing a lot of infection rates? I could just go on and on."
I am left wondering: if ICD-10 is so critical to quality measures, why are many other quality metrics that are not based upon ICD-10 sitting in certified EHR software? I chalk that up to something CMS, other payers, and the rest of healthcare and public health desperately need to clean up: the many overlapping and redundant quality measure reports putting a severe burden on providers of all sorts.
But main point is that, with fewer than 100 days to go until the go-live date of October 1, all providers should be testing ICD-10. If they are not, they need to get going now. Undoubtedly, those organizations with fewer resources will be the most severely challenged. They should make the most of CMS' one-year grace period and tap the additional resources now offered by AMA and CMS.
At the annual meeting of the Association of Medical Directors of Information Systems, CMIOs and their peers celebrated some victories in using technology to successfully improve healthcare, but the overall mood was somber.
I learned a lot at last week's Association of Medical Directors of Information Systems (AMDIS) Physician-Computer Connection Symposium in Ojai, CA:
Physicians are reporting there's trouble in e-prescription land
Lots of childrens' hospitals have pulled the plug on participating in Meaningful Use Stage 2 and 3
U.S. senators have copied-and-pasted a new healthcare informatics industry association report as the blueprint for a current set of hearings underway.
This annual meeting, AMDIS's 24th, brought together a room full of brilliant, connected CMIOs and equivalent executives from healthcare systems and practices around the country. While they celebrated certain victories in using technology to successfully improve healthcare, the overall mood was somber.
Richard Schreiber, MD
AMDIS members shared their frustrations with the many business and government mandates and technology challenges that often are perceived as getting in the way of improving that care.
ePrescribing Complaints The grumbling over how e-prescriptions usage is doing was among the loudest. It's getting even louder now that the Meaningful Use Stage 3 proposed rules are out, and it's clear that e-prescribing will be mandatory for all providers who don't want to be penalized in 2018—three short years from now.
The problem is that the largest provider of e-prescribing services, Surescripts, largely does not permit physicians to cancel e-prescriptions once they are transmitted. Some physicians say the issue has to do with pharmacies at the other end of the Surescripts network either not being prepared for or not wanting the burden and cost of filling those prescriptions, only to have to process a cancellation.
"This is a particularly difficult problem in teaching hospitals, where the residents might send out prescriptions, but the attending comes in the day of discharge and says, 'no I want that [other medicine], this dose and so on,'" says Richard Schreiber, MD, CMIO of Holy Spirit Hospital, now part of the Geisinger Health System. "How do you account for that?"
"Absent a requirement on the part of partners with whom we need to work, whether they're SNIFs, or pharmacies, or other practices with which we're exchanging CCDAs, without putting some requirement on them to be able to do something like accept cancellation messages within e-prescribing paradigms, then we're kind of stuck in the water," says Harris Stutman, MD, chief medical informatics officer at MemorialCare Health System in Fountain Valley, California.
During a break, I spoke with another physician who preferred not to be named, and he described a pharmacy behavior that, if true, must infuriate physicians. Initial e-prescriptions from a provider to a pharmacy typically include several refills for the patient. When the refills are depleted, in theory the patient contacts the provider and has a checkup visit or at least requests the refill be sent again to the pharmacy.
In practice, though, patients often just contact the pharmacy even when they have zero refills, expecting the pharmacy to contact the physician. But, according to this physician, even some national chain pharmacies still fax such refill requests to the physician, creating extra work for the medical staff, introducing a possibility of error as faxed information is manually entered. The physician I talked with claims that pharmacies are reverting to faxing to avoid paying a transaction fee to Surescripts.
ONC: 'No Regulatory Authority' Over Transaction Fees All of this can happen because pharmacy behavior is not regulated by ONC. Michael McCoy, MD, ONC's chief health information officer, who I interviewed earlier this month, was also at AMDIS, and says that "ONC doesn't have regulatory authority over financial impact" of the transaction charges that Surescripts collects – even though e-prescribing is rapidly becoming mandatory at all providers.
On Monday, I reached out to Surescripts to hear their perspective on all of this. Company officials were not available for interview, but did provide a statement from Ajit Dhavle, the company's vice president of clinical quality:
"A CANCEL Rx message is used by prescribers to notify the pharmacy that a previously sent prescription including any remaining prescription refills should be cancelled and not filled," Dhavle states. "This message is part of the widely implemented NCPDP SCRIPT standard, version 10.6, and is supported by Surescripts.
"However, the industrywide adoption and utilization of CANCEL Rx is very low. Surescripts continues to diligently work with all stakeholder groups to increase awareness of this message and help them implement this new functionality into their workflows. Prescribers and pharmacies should reach out to their technology vendors and request them to implement and enable this functionality within their software systems."
"Lots of finger pointing," says my unnamed physician source, upon hearing Surescript's statement. Stay tuned.
Children's Hospitals Balk on MU Stage 2 and 3 Another mini-bombshell at AMDIS was delivered by Christopher Longhurst, MD, chief medical information officer at Stanford Children's Health. "In the children's hospital community, which gets Meaningful Use funds through Medicaid, not Medicare, the bulk of our standalone children's hospitals have made the decision not to pursue Meaningful Use stage 2 and 3," Longhurst says.
"That was a conscious decision, recognizing the fact that Medicaid does not penalize us for not pursuing Meaningful Use stages. We're currently pursuing stage 1 at Packard Children's Hospital at Stanford, and having an active discussion about whether we will move forward as well. I think what that represents from my perspective is a community perspective in a very mission-driven sector of healthcare that this is not adding value to our patients or to our clinicians."
Christopher Longhurst, MD
Toward Better EHRs While attendees at the AMDIS gathering pondered the future of Meaningful Use, they also learned that the American Medical Informatics Association (AMIA) has a new-found influence over renewed Senate scrutiny of EHRs. In May, AMIA issued a five-point program for improving EHRs by 2020. The EHR 2020 Task Force Report called for simplifying and speeding documentation in EHRs, refocusing regulation, increasing transparency and streamlining EHR certification, fostering EHR innovation, and putting the patient at the center of EHR-powered care delivery.
The most important of the five aims, I believe, is increasing transparency. To be precise, researchers seeking to scrutinize the workflow of EHRs are often forbidden from taking and publishing screen shots to shed light on EHR inefficiencies. EHR vendors say this ban is to protect their intellectual property from being copied without permission.
"Sometimes you aren't sure exactly how a particular product has met the criteria," said new AMIA president Douglas Fridsma, MD, speaking at AMDIS. "Maybe the smoking cessation isn't integrated into your note, but there's another window that pops up and you have to do 12 clicks, and then you can meet the criteria. That worked for certification for Meaningful Use, but it doesn't work in the workflow. So increasing transparency says, 'let's at least get the information out there so people can make informed decisions, and if it doesn't make sense, we can say, this is how they did this.' Do people think this is a good way?"
Fridsma says Sen. Lamar Alexander, (R-TN) who chairs the Senate Committee on Health, Education, Labor and Pensions, otherwise known as the HELP Committee, quickly adopted the five aims of the EHR 2020 report and scheduled hearings on each aim.
Two such hearings have occurred so far. If, like me, you wondered where Sen. Alexander, his Republican colleagues, and Democratic committee members from across the aisle got their current bipartisan investigatory inspiration, now you know.
For patients to get the medical data they deserve in a way the HIPAA Omnibus law says they deserve it, they need to demand that providers cut the red tape. Whether they will do so remains to be seen.
When former national coordinator of healthcare IT, Farzad Mostashari MD, stood on stage at the annual HIMSS conference in April and called for a national day of action on July 4 for patients to request their medical records, headlines followed.
Farzad Mostashari, MD
But now that the headlines have died down, and the date is approaching, I wonder just how big a day it will turn out to be.
Russ Branzell, president and CEO of CHIME, expressed sympathy about patients' difficulty in obtaining their records. But CHIME still supports the gutting of Meaningful Use requirements that providers prove actual patient viewing/downloading/transmitting of their data, a decision now in ONC's hands.
"When you have it all fragmented, in multiple records without a complete record, it actually can be of little value and actually be more dangerous without having all of it combined, which is the journey we're on," Branzell told me back in April.
Even now, the national day of action isn't much to look at in the way of an organized or sponsored initiative. It is supposed to take place on July 4, but if you go looking for it on the Web, mostly it converges around some blog posts, videos, and a Twitter hashtag, #dataindependenceday.
While my sympathy lies squarely in the camp of patients getting the data they deserve in a way the HIPAA Omnibus law says they deserve, I am not certain that things will be much different on July 5.
An HIE of One
When I spoke with him last week, Mostashari downplayed what a single day of action could yield.
"There is no legitimate business policy, practice, privacy—nothing—there is no legal basis for standing in the way of that what we call an HIE of one. And the individual is the one who can break any information blockage, but they have to ask," Mostashari told me.
"That is what the day of action is, or really it's going to end up being, I think, the launch of a yearlong campaign. [It will] make it easy for people to ask and to document their experience, [and] to bear witness to what happens when you do ask. Let's fix it, and make it easy so that people can be the ones to break through the information blockage."
After five years of pushing patient engagement policy down to providers, what Mostashari refers to as "pushing rope," he admits that providers now "meet the requirements enough to get the check… but until there's a pull on the rope, it's knotted."
At too many health systems, he says, numerous barriers still exist to getting patients their health records. That's despite the fact that technically, the EHR software that providers were paid Meaningful Use incentive dollars to deploy are technically capable of serving up such data via a patient portal. Too many providers still say "you have to come down to our basement," he says. "You have to sign the form in person. You'll get [your] paper 60 days later and you have to pay $400 for it."
If enough patients asked for information in this hard-to-use and hard-to-afford form, providers would have to think differently. That's what the #dataindependenceday is supposed to be all about. "The best case is that a sharp tug on that rope can start the flywheel spinning that makes it easy for more people to ask," Mostashari says.
Russ Branzell
He says the worst outcome of the campaign could be "If this is still seen as some sort of compliance task, if we still have a culture in medicine that views patient engagement in their health as largely a nuisance."
Patient Data Hard to Gather
When I spoke at length with Branzell at HIMSS, he presented a detailed analogy about how every provider in the U.S. was on a journey to assembling a full longitudinal record on every patient, but that each provider was taking a different path toward that full record. And we are now at a point in the journey where patient data is actually harder to gather than ever before, because providers are pursuing radically divergent interoperability solutions, at least so far, to deliver that longitudinal record to the patient in one location.
I can see Branzell's point. We have $30 billion of EHR software that ostensibly meets a set of common criteria. But in practicality, what it means to a patient with several comorbidities is that getting his entire record means visiting maybe half a dozen patient portals, each of which contains a slice of his data. I can see why CHIME and others view the burden of providing and supporting these portals as busywork without much upside.
And yet, Mostashari points out that many providers have successfully implemented patient portals and easily met the Meaningful Use Stage 2 criteria of 5% of patients viewing, downloading, or transmitting a medical record or discharge report.
Technically, it can be done, and with the software that those providers were reimbursed by the government to purchase. And not every patient requires the entire longitudinal record to get value out of that download.
What it comes down to is, are the current patient engagement requirements good enough, and is Branzell's preferred ideal longitudinal record a form of perfect that patients should not have to wait for? Is perfect the enemy of the good?
Business Practices are a Barrier
The answer may lie in looking beyond the current patient engagement debate, to what Mostashari is now doing, instead of running ONC. He is co-founder and CEO of a 2014 Washington D.C. startup, Aledade, which provides software and services to help medical practices with ACOs and population health in a Medicare shared savings context. At the heart of Aledade's success is whether the very interoperability Mostashari pushed into Meaningful Use is itself successful for not.
"If [patient record] exchange does occur, you have a much better chance than you did five years ago, actually being able to do something with that data," he says. "We also have now universal protocols for how to essentially replace the fax machine, and securely push information from provider to provider. And we've seen some increase in the actual exchange of information.
"What's holding it back now are the business practices, and frankly the financial incentives, [for] healthcare providers, health systems, and EHR vendors, for either enabling or blocking the flow of that information."
Early practices using Aledade have increased the rate of wellness visits by 500% "within a matter of months," Mostashari says. "We increased fivefold the number of vaccinations."
If those practices' patients don't get as sick later, the savings ACOs are supposed to produce will be realized. That sounds like progress—good, if not perfect—progress.
Mostashari believes patient engagement is essential to the success of ACOs, a point I've been making with some regularity. Whether patients show the same passion for engagement, in numbers big enough to make providers pay attention, remains to be seen.
The federal government's chief health information officer is shaping ONC's interoperability roadmap. It's a foundational step to achieving goals such as precision medicine. But ONC's priorities don't always align with those of healthcare providers.
This week, to understand the future of population health, I turned to Dr. McCoy. Not the guy on the Starship Enterprise. This is the real-life Michael McCoy, MD, chief health information officer for the federal Office of the National Coordinator for Health Information Technology.
When I first asked McCoy for his thoughts on population health, he brought up a couple of HHS's big-think current initiatives: precision medicine and semantic interoperability. Here's a quick primer gleaned from our conversation:
Precision medicine: McCoy says it takes personalized medicine to the next level. "The precision is in informing both the caregivers and the people receiving care what really works and should work for them, given a number of factors. How much of a dose do we need to give a person to treat whatever? One dose of whatever drug probably isn't the right amount. It's either too much or too little for 95% of the people that are taking it." Likewise, the duration of drug treatment might be too short or too long. By integrating genomic data into medical records, then analyzing those records across a population, precision medicine aims to cut drug costs and optimize treatment effectiveness, McCoy says.
Semantic interoperability: "The ability to gather large amounts of good data is also predicated on having the right information about the individuals, and having it shared in a semantically interoperable way. Semantic is taking it down to the level where we mean the same thing when we say something."
Michael McCoy, MD
As an example of creating a health system with semantic interoperability, McCoy points to the different nuances of sharing information on blood pressure readings.
"It's two numbers, systolic and diastolic. So do you do that as 130 over 70 with a slash between them, or do you make that two separate fields? Oh, and by the way, was that blood pressure taken by a blood pressure cuff? Was it taken by an interarterial pressure monitoring device? Was it sitting, standing, lying, after running? Was it on a treadmill? So you have a lot more information that you can convey that just a numbers. There's metadata that goes around that."
Another example would be recording the number of cc's of blood in reporting an incident of excessive blood loss. "A 400 cc blood loss in a vaginal delivery is not excessive, but a 600 isn't for a C-section. So when we talk about these kinds of things, you have to have a contextual understanding of more than just the data that went with it."
These are the kinds of interoperability issues ONC is wrestling with in its ten-year interoperability roadmap. Since McCoy is ONC's clinical subject matter expert for interoperability, he is in the middle of shaping the roadmap.
I mentioned criticism to McCoy that I've heard widely about the precision medicine initiative—that it puts the cart before the horse, assuming the patient's longitudinal record is in place to be married with genomic data, when clearly, due to interoperability barriers, those longitudinal records just aren't ready yet.
To illustrate, I mentioned some of the results of a pre-meeting survey that HealthLeaders Media conducted of attendees of our Population Health Exchange, which takes place later this week in Carlsbad, CA. Attendees said their top challenge was inadequate or incomplete longitudinal clinical data. How useful can precision medicine be, I asked McCoy, if that remains an unsolved problem?
"It will be very challenging to make it as widespread and as desirable as we would like for an outcome," McCoy says. "It's a linchpin for having the person-centric care, so that the person at the center of that care can direct the care to the people that they want caring for them, as clinicians [and] as hospital systems."
In our survey, we also asked our attendees what their top three data-related challenges are in the next three years. Number three, behind EHR interoperability and data cleanup, was analyzing unstructured data—which has not been on ONC's radar nearly as much as making structured data interoperate.
"Clearly, there are opportunities with natural language processing and other modalities to analyze" unstructured data, McCoy says. As an example, unstructured notes containing a history of present illness or care plan can explain whether a broken arm came from a simple fall or something that an athlete just experienced while performing. "How this is best done is a moving target, and I'm not sure that ONC at this point has any better guidance on some of that than the rest of the industry does," he says.
"We talk about the learning health system as the end goal at the 10-year mark … and that is an ambitious goal," McCoy says. "I'm not suggesting that we could tomorrow have a precision medicine ubiquitous success, absent the foundations of interoperability. The first three years is all about getting interoperability and the governance for the data standards well established. That has to go in concert though with the delivery system of reform, so that we tie the incentives to alter business practices that currently are not in alignment with sharing data.
"There's no great incentive for a large hospital system that's the dominant player in a market to want to open up its data to take care of people who may also go to competing hospitals. We have much more of a cultural and business practice challenge to overcome than a technical one. Not to say that there aren't some technical issues. I do admit that we have some work to do there as well, but I think it's less a problem than the people and process and business practice issues."
Of course, progress is unevenly distributed across healthcare. Large academic institutions who are doing well with their EHRs, such as Duke, Stanford, and the Mayo Clinic, are pushing ahead on the precision medicine front, he says.
Of course, the interoperability roadmap is itself a living document for the moment. ONC is saying a new version of the roadmap will be out later this summer. Hundreds of pages of public feedback to the initial draft are available at healthit.gov. It's a lot to comb through, and after sampling it over the past few days, I can safely say Dr. McCoy will need some real luck in getting the nation to agree on a succinct set of priorities to move federally driven interoperability initiatives forward.
Dealing with the complexity and, ironically, the flexibility of the regulations is leading providers, large and small, to seek external resources.
This article first appeared in the May 2015 issue of HealthLeaders magazine.
The federal meaningful use program remains a minefield that providers are carefully stepping through to avoid losing out on incentives or being hit with the ever-increasing Centers for Medicare & Medicaid Services penalties for failing to file timely attestations of use.
In a statement in mid-February, the American Medical Association said it remained "alarmed" that three-quarters of eligible professionals still have been unable to attest to meaningful use.
"The program's one-size-fits-all approach—that has not been proven to improve quality—has made it difficult for physicians to take part," stated Steven J. Stack, MD, AMA president-elect. "In order to successfully attest, physicians must spend tens of thousands of dollars for tech support, software upgrades, interfaces, and data exchange, often on a recurring basis."
