Access Controls – Check all user accounts for strong passwords.  Make sure your data is protected with file and sharing permissions.  Make sure your staff has access based on the “need to know” concept. 

 Network Security – Make sure you have a firewall on each computer as well as between your network and the internet.  Configure your firewall to deny all connections unless you explicitly approve them.  Make sure your wireless network is protected with maximum strength encryption. 

 Malware Protection – Make sure your computers have anti-virus and anti-adware and spyware software.  Make sure all your machines stay current with Windows updates. 

 Backups and Storage – Make sure you have local and offsite backups.  They should be protected with encryption, file permissions, and other controls.  Also consider purchasing battery backups for your computers and networking gear.  

 Physical Security – Make sure to secure your office against fire and theft by keeping your doors locked and installing security and sprinkler systems.

 Staff Habits – Train your staff to be aware of fraudulent emails, instant messages, and never to give their password out to anyone. 

Identify potential threats – Threats are forces that will exploit your vulnerabilities, and they can be difficult to determine.  Threats can be broken down into four categories:  natural, human, software, and environmental. 

 Natural - Natural threats are things like floods, earthquakes, tornados, and hurricanes.  Unfortunately there is nothing you can do to prevent them.   Adequate offsite backups will reduce the risk posed by these threats.

 Human – Human threats are most commonly your own employees.  They may accidentally delete your data or break your computer systems.  Employees may also maliciously destroy or steal your data or computer systems.  Ex-employees, hackers, patients, and pretty much anyone else could be a potential threat.  Luckily fixing the vulnerabilities listed above will drastically reduce the risk posed by human threats. 

Software - Software threats consists of viruses, worms, Trojan horses, adware, spyware, and any other malicious software.  Adequate anti-virus, anti-spyware and strong firewalls will all but eliminate the risk posed by these threats. 

Environmental – Environmental threats include fire and power outages.  Like natural threats, there is little you can do to prevent these threats.  Making sure your sprinklers, smoke detectors, and fire extinguishers work can help mitigate the risk.  Consider also that most damage from a fire occurs from water sprinkler systems and the fire department.  You may choose to cover your computers with tarps when the fire alarm goes off.  Installing battery backups will help minimize the risk of data loss from power outages. 

Identifying vulnerabilities and threats is key to performing a risk analysis, which you need to do periodically to comply with HIPAA.  Vulnerabilities are the most important.  They affect your computer systems, and luckily there are many controls you can use to fix them.  Threats are almost always outside of your control, and they can be difficult to identify.  Keep these basic vulnerability and threat categories in mind when you begin your risk analysis.

Join us next week for a basic how-to guide for conducting your risk analysis.   
 
Ryan Ricks
Security Officer
www.xlemr.com
 

The PHR hype is in full swing, and it will likely take a decade minimum for a majority of patients to have PHRs. I doubt most people will even look at their PHR even if they have one. Progressive insurers like Aetna offer members a pre-populated PHR based on claims data. In the long term, this will help Aetna improve care, reduce errors and lower costs. Follow the money and one will see the adoption path PHRs follow.

As with all technologies, the question of standards is arising with PHRs. AHIP has taken a good first step in creating a standard that is expected to be ready by December of ‘08. The standard includes data set and portability requirements to take into consideration a person’s change in employers and health plans.

Some payors like Medical Mutual of Ohio and Anthem BCBS have PHRs that align with the AHIP standard. Time will tell how PHRs are accepted by consumers. Nationally, CCHIT, the Certification Commission for Health Information Technology, will be certifying personal health records (PHRs) next year. Criteria will be proposed in April, 2009, along with a comment period. Certification will officially start in July 2009.

CCHIT’s certification of EMRs met with mixed reactions early on, with smaller vendors crying foul over the $20,000 fee. Since then, it’s become a somewhat important stamp of approval in large enterprise purchasing decisions. This will likely happen with PHR certification as well.

Locally here in Massachusetts Blue Cross Blue Shield of Massachusetts partnered with Google Health to enable members to import their claims data into their Google Health profile. BCBSMA says that members with Google Health PHRs will be able to share data with healthcare providers who currently don’t have access to their data. Also, they can download medical records and prescription history from other connected providers.
_________________________________________________________________________________________________

By Shawn Whalen, SVP & Director, Healthcare IT Practice, Schwartz Communications

Saint Raphael Health System, which championed the grant application, is hosting the technology that will facilitate data sharing across the exchange. Ultimately, the network will touch 22 counties and approximately 800,000 patients in the greater New Haven area. Saint Raphael will serve as the cornerstone of the initiative, establishing a community pilot for a larger, statewide effort that is already underway via eHealth Connecticut.

From the beginning, it was clear that long-term success would depend upon the initiative’s ability to overcome several key challenges, most dominantly a low adoption of electronic health records (EHRs) among the physician groups that are expected to participate in the HIE. The majority of the state’s physicians groups are small and independent; none of the approximately 30-40 small practices impacted by the HIE had EHRs before the beginning of the project, and less than 10 percent of healthcare delivery organizations in the New Haven region have true electronic medical records systems.

The work done by Saint Raphael Health System and its partners leading up to the successful grant application, in particular identifying existing and prospective resources to strengthen the reach and effectiveness of the area’s commitment to health information exchange, is an excellent demonstration of the best practice recommendations conveyed in previous chapters of the “Best Practices Guide to Community Health Information Exchange.”

Assessing the Environment

New Haven’s initiative began by assessing the environment that accounts for political, social and economic interests within the community the data sharing initiative will serve. The goal of this exercise was to both gain a comprehensive understanding of the stakeholder, participant and community resources that can be available to the HIE and to understand the community’s topography to ensure that those resources could be leveraged to the benefit of all stakeholders.

Conducting an assessment to better-understand the environment is important to establishing the community links necessary to move the initiative forward. An environmental assessment also allows identification of the most effective incentives for winning over opponents and keeping stakeholders involved and active.

This is critical because fighting or ignoring the political, social and economic pressures and priorities that characterize the community environment is very likely to result in a failure to fully leverage available resources to the long-term detriment of the initiative.

When properly conducted, the environmental assessment will lead to the accommodation of stakeholder concerns and values, which is key to aligning and maximizing existing and prospective resources, strengthening consensus and finding the focus necessary to move the message from “do you want to do this” to “it’s clear you need to get on-board.”

In a nutshell, environmental scanning assesses the internal strengths and weaknesses of an organization in relation to the external opportunities and threats it faces. For an HIE, typical focal points for the scan are competition, technology, regulatory activity and the economy.

The general steps for conducting an environmental scan are:

• Identify the purpose, participants and time commitments
• Carry out the scanning activities
• Analyze and interpret the strategic importance of issues and trends
• Select issues and trends for further action
• Report and disseminate the results

In New Haven, securing the participation of key stakeholders in the community such as Yale-New Haven Hospital (YNHH), Fair Haven Community Health Center and Hill Health Center within the health information exchange is an excellent example of the importance of continuous environmental scanning to an initiative’s ability to fully understand the strengths and needs of the community’s key players, thus making it possible to focus on the most important battles first.

Due to the competitive relationship between Saint Raphael and Yale-New Haven Hospital, participation by the latter was not something the initiative’s leadership expected to happen. However, as the interest of other HIE stakeholders began to strengthen Saint Raphael was asked a lot about YNHH’s participation as was YNHH asked about their interest and participation in the HIE and suddenly the community collaboration and sharing opportunity expanded.

Working together and sharing among competitors is difficult but possible especially if one is listening and looking for opportunities to open discussions and engage in collaboration. Because ongoing environmental scanning was a HIE priority, the initiative leadership quickly became aware of other key stakeholder’s unexpected interest and was able to work with these organizations to overcome the barriers. This was accomplished in large part through the establishment of a neutral foundation that removes proprietary interests so that the main focus can be on improving relations between the regional competitors. This, in turn, encourages their ongoing support of and participation in the initiative.

Targeted Value Creation

Another important strategy in New Haven was to maximize its available resources and follow up the environmental assessment with targeted value creation designed to broaden its pool of participants-a process that will continue throughout the life of the initiative.

During the assessment one of the lessons learned was that maintaining the engagement and participation of provider stakeholders would require that the initiative find ways to create immediate value. Because physicians are a population not always known for their patience, it was important to show value from day one, which for New Haven meant starting on the hospital side with the electronic exchange of lab results.

At the same time, however, project leaders were aware that the focus could not be so narrow as to slow momentum in other areas the initiative had established as priorities with physicians and other provider stakeholders.

As noted in the results from a roundtable discussion convened by the National Institute for Health Care Management Foundation: “The tension between creating short-term and long-term value through HIE is another dimension to stakeholder value clash. RHIO functions that provide short-term return on investment (ROI) through administrative data exchange and improved results delivery may be of greater value to some stakeholders than long-term quality improvement through enhanced outcomes, patient safety, and even expanded access to care. Balancing this tension among different stakeholders to ultimately benefit all stakeholders is key to broad stakeholder participation.”

For example, regardless of the speed and volume at which lab results are exchanged, if physician participants use the local patient clinical information look-up tool in the beginning phases and are unable to find patient records several times in a row, they will fail to see the value of continuing their participation in the HIE. Focusing only on long-term goals and not building incremental value in the minds of the stakeholders will weaken the initiative’s ability to achieve its objectives of connecting the entire provider community.

The solution for New Haven was to handle the organizational efforts in a way that balanced the interests of all the subsets of the provider stakeholder group. At the same time, it was important to establish stakeholder values that allow for future growth. The key here was to align incentives in a way that ensured broad acceptance and long-term support.

New Haven also continues to review its community values to address current and future shifts in stakeholder priorities. This is critical, because community values do not always mesh with stakeholder values, in particular as they pertain to the HIE’s ability to generate revenues.

Health plans and employers are often hesitant to invest in clinical information exchange projects in any significant capacity without seeing reductions in waste through the elimination of duplicative therapies or testing. Further, even purchaser-driven initiatives have struggled to engage providers without the ability to show how the HIE will enhance the practice at the point of care through improved access to hospital and imaging data and administrative savings. Notes Bruce Bradley, director of healthcare strategy and public policy at General Motors: “We struggle a lot with the value proposition because we’re often asked to make investments in our communities, particularly in this area. A way to think about it that resonates with purchasers, in particular manufacturing-type purchasers, is the whole concept of waste. What can [HIEs] do about waste?”

Tapping into Best Practices

New Haven has made a concerted effort to take advantage of the experiences of other communities that have gone through the process of establishing a working health information exchange initiative. The best practices that have emerged from these previous efforts will continue to be an essential external resource as the initiative continues moving forward toward its objectives.

Lessons learned from other sites have provided New Haven with a set of guidelines for navigating issues and for developing viable alternative solutions when roadblocks have been raised. Among the external resources the initiative’s leadership has tapped include sessions on HIE and regional health information organization (RHIO) development and management at key trade conferences such as the Healthcare Information and Management Systems Society (HIMSS), as well as other communities that utilize the same software applications as New Haven and other vendor application user groups.

These conversations are invaluable for the ideas and solutions they generate, as long as they pass the “pressure test” with the initiative’s knowledge of the community it is designed to serve.

Another strategy developed based on these best practices, one New Haven found to be particularly advantageous, is to bring in a neutral facilitator with a deep understanding of the national HIE landscape and expertise gained from working with other initiatives to help keep the process moving forward. Dialogues with other communities made it clear that New Haven needed someone that did not have a stake in the community and with no “skin in the game” to step in when progress stalled and to diffuse potentially disruptive situations quickly and effectively.

Early on New Haven worked with SMC Partners, LLC, a consulting company who has been working with the e-health Connecticut’s board to drive the adoption of HIE’s across Connecticut, to bring impartiality to the collaboration discussions. This proved to be a valuable relationship in the early stages as it provided insight into what other connected communities were doing.

Staying Alert to Opportunities

Long-term success for New Haven will come from its leadership’s ability to utilize the resources at hand, and a commitment to continue assessing the environment to identify and capitalize on opportunities and resources that present themselves in the future.

These may come from inside the initiative, from within the community, or from outside organizations or stakeholders that perhaps were not present in the early days of New Haven’s formation. The key is to be aware of any changes in the political, social and economic environment of the community and to seek ways to continuously expand and strengthen stakeholder participation and value.

Best Practices Guide

The Center for Community Health Leadership^TM, an organization sponsored by Misys Healthcare Systems to facilitate the development of health information pathways by building connected communities, created a thought leadership series focused on encouraging collaboration and providing the guidance necessary to build successful, sustainable community HIE. 

To help community health professionals make HIE a reality, the Center developed guidelines for the creation of a community-based data exchange. Each success factor represents a pivotal point on the path to achieving community-wide information exchange. The Best Practices for Community Health Information Exchange presents success factors, offering prescriptive guidance to carry communities and all represented parties (hospital-based physicians and caregivers, community clinicians, home health organizations and most importantly, community residents) along that path.

To download a free full-version of The Best Practices for Community Health Information Exchange, visit http://www.misyscenter.com/Best+Practices.htm.

______________________________________________________________________________________________
By: Gary Davidson
CIO of the Hospital of Saint Raphael

Works Cited

Abels, Eileen. “Why Is Environmental Scanning Important?” Bulletin of the American Society for Information Science and Technology. Feb/March 2002. Vol. 28, No. 3.

Available at http://www.asis.org/Bulletin/Mar-02/abels.html

Enrado, Patty. “New Haven Lands Grant to Link Healthcare Data.” Healthcare IT News. February 1, 2007.

Available at http://www.healthcareitnews.com/story.cms?id=6397

Malepati, Sarath; Kushner, Kathryn; Lee, Jason S.. “RHIOs and the Value Proposition: Value Is in the Eye of the Beholder.” Journal of AHIMA 78, no.3 (March 2007): 24-29. Available online at:http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_033607.hcspdDocName=bok1_033607#participants

Section 164.308(a)(1) requires covered entities to “conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of EPHI held by the covered entity.”  In this statement:

“EPHI” stands for Electronic Personal Health Information.  This includes all medical information related to patients in your care.   

“Vulnerabilities” are weaknesses in the way your system handles information.   This can mean anything from inadequate physical security at your office (such as locks and alarms), to employing out-of-date software, to failing to employ the security features included in your software (not creating passwords, etc.).

Threats are forces that will exploit vulnerabilities.  This can mean people, such as disgruntled employees, burglars and hackers, or it can mean things like fires, floods, earthquakes and tornadoes. 

“Risk”, therefore, is a calculation of two things:  first, the probability that a given threat will exploit vulnerabilities in your system, and second, an estimate of how much damage would be caused by that exploitation.  Risk is hard to assess; the factors involved are often subjective.  Just because an event has a low probability level doesn’t mean it can’t or won’t happen…and highly probable events with risk assigned might not impact your system security at all.

For instance:  a viral infection on a computer in your system is highly probable, but the likelihood that the infection would lead to a system failure or security breach is small…therefore it would be considered a low-risk scenario.   If a burglar, however, were to break into your office and steal all of your equipment, there is a 100% chance that your data will become unavailable to you and a good chance it may end up in malicious hands.  Even if the crime rate is low in your neighborhood, this would be considered a high-risk scenario.

No matter what your assessment finds, when you address the vulnerabilities of your system and (where possible) eliminate threats, you reduce your overall risk levels- this is the best way to ensure you’ll be in compliance with the Rule. 

Join us next week for some tips on how to conduct your risk analysis. 

Ryan Ricks
Security Officer
ryan.ricks@xlemr.com
www.xlemr.com

1.  Make sure they have a good general reputation.  Ask for references and follow up.  Search the internet for feedback from their customers.  Have they delivered on their promises?  Check with watchdog and consumer protection groups.   Have they been accused of unscrupulous practices? 

2.  Read the contract.  Look for hidden fees.  What will they charge for product support?  Do they offer a maintenance plan?  Is there a warranty?

3. Find out how they handle version upgrades.  Are upgrades free?  If not, do they intend to support older versions of their product?  For how long? 

4.  Are they prepared to customize?  Will you have to change your business model to fit the needs of their product?  Do they expect you to pay for features you don’t want?*

*Very few EMR providers offer totally customizable products.  Click <a href=”http://www.xlemr.com/faq.html” target=”_blank”>here</a> to read more about customization.

Most EMR providers are legitimate and reliable, but there are exceptions.  Don’t be afraid to ask questions.  If what you learn makes you feel uneasy, or if the provider won’t give you straight answers, move on and don’t look back.   More on shopping in future articles!

Examples: Aetna is making PHRs powered by ActiveHealth Management available to their 15 million members. In Massachusetts, the Blue Cross Blue Shield Foundation awarded $50 million to almost 100 small and medium sized medical practices for EMRs. Stark Law reform will help accelerate these efforts.

Business interests continue to come together to encourage reform. This month two more coalitions have formed.  The Business Roundtable has joined the AARP and the Service Employees International Union to campaign Congress for better legislation for healthcare and retirement issues.  A second expansive group unites the U.S. Chamber of Commerce, insurance companies, and advocacy groups including Families USA.

High on the agenda is healthcare for the uninsured. One in six Americans doesn’t have health insurance.  Not all of these are poor - according to the Census Bureau, 70% live in a family with one worker, and a fifth are in families with household incomes above $40,000. The problem is many small and medium sized employers are doing away with healthcare benefits due to cost, or passing along the prohibitive cost to employees.

States have lost patience with Federal inaction and Massachusetts, Vermont, Maine, California and most recently Pennsylvania have moved forward with their own universal healthcare plans.  Most big insurers, facing dwindling medical plan enrollment, favor such state plans.

It will be interesting to see if more coalitions have deeper impact. Leapfrog Group has had limited success. A more receptive Democrat administration will likely help.

_________________________________________________________________________________________________

By Shawn Whalen, SVP & Director, Healthcare IT Practice, Schwartz Communications

When integrated into an electronic health record (EHR) system, evidence driven decision support is presented to the physician at the point of thought, providing crucial evidence-based literature that promotes timely and informed medical decision making. Further integration with a single platform solution that includes an electronic prescribing module provides the physician with objective, medication therapy decision support at the point of prescribing.

Integrated seamlessly into a practice’s EHR, e-prescribing provides additional information, including the cost, efficacy and adverse effects of various medication-based therapeutic alternatives to help the physician make the best prescribing decisions.

Three published estimates suggest that physicians are directing 80% of the spending in our $2 trillion health care market.  Yet if you consider the information that we physicians bring to these spending decisions, frankly, it is primitive and pathetic.  Imagine physicians as purchasing agents with $2 million annual budgetary authority.  Studies show that we physicians don’t know how much the drugs and diagnostic tests that we order cost, and we lack comparative information about their effectiveness and adverse effects.  Furthermore, our compensation is largely disconnected from the quality and cost-effectiveness of our performance.  Is it any wonder that the U.S. has the most expensive health care in the world, while perennially ranking near the bottom of industrialized countries in metrics like healthy life expectancy? 

Health information technologies, especially EHR systems, are often promoted as the solution to much of what ails our health care system. The implementation of technology has become a powerful political issue, but in such a fractured healthcare system, adoption remains a constant struggle for small and medium-sized practices.

Evidence-based medicine promises to displace Authority Based Medicine, wherein practicing clinicians simply followed the recommendations of expert thought leaders in the healthcare community.  These thought leaders were usually identified by their affiliation with distinguished academic medical centers with successful college football programs. 

The actual practice of EBM requires clinicians to formulate carefully structured questions about clinical problems in specific patients, and to then perform medical literature searches to find valid randomized controlled clinical trials containing individuals who are representative of the patient being treated.  This is a time-consuming process that demands up to one hour per question.

If the true practice of EBM takes too long and is not compatible with having a financially viable medical practice, and if most physicians lack expertise in critical analysis of sophisticated medical studies, then what can dedicated physicians do to improve the quality and cost-effectiveness of their care? 

Answering the Adoption Question

The answer is advanced tools and economic incentives that together optimize health care outcomes for patients.  The state-of-the-art in evidence-based medical practice involves the integration of context-specific rules-based clinical decision support messages into electronic health records.[i] 

On the technology side, advanced EBM tools need to follow and intuitively present medical evidence in the traditional four-step organization. This is aggregation of relevant medical studies, synthesis of such data including reviews, synopses of key studies and systematic reviews, and summaries of the relevant synopses. 

Clinical decision support systems use rules behind the scenes to link relevant messages about patient care to patients who met the characteristics of the rule.  Simply presenting guidelines with no validation, or offering links to online textbooks is unlikely to improve healthcare outcomes.

For example, in 2004, Michael Fischer and Jerry Avorn published a study which showed that if all Americans aged 65 and older who had high blood pressure were treated with the drugs that the best evidence proved to be most appropriate, we would save $1.2 billion in annual drug costs.  There would also be enormous additional savings due to fewer heart attacks, strokes and heart failure.

But 2005 HEDIS pay-for-performance (P4P) measures reward the lowering of blood pressure without distinguishing whether this happens with a calcium channel blocker that may worsen the patient’s five-year mortality, an expensive new drug with no five-year outcomes data, or with a thiazide diuretic that clearly improves five-year mortality.

Not only is simply supporting P4P guidelines inadequate, but many EHR vendors don’t even support guidelines in the work flow in the first place.  It is rare for electronic health record companies to truly integrate evidence-based context-specific decision support information into the work flow of busy clinicians.  EHR vendors will be reluctant to invest in building the decision support needed to improve the quality and cost of care unless the market demands it because higher reimbursement rewards it.

Thus the incentive carrot is as important as the technology. In England, the contract between the General Practitioners and the National Health Service has 18% of the physicians’ annual income at risk-dependent on their performance against 146 quality measures.  In contrast, here in the U.S., physicians are lucky if even 2 or 3% of their income depends on their performance against quality measures.  In America, pay-for-performance is a plastic carrot: it looks appetizing, but when you bite into it, there is little satisfaction.  Like the Soviet Union in the 1970s, doctors will continue to pretend to perform in the clinical outcomes arena as long as the health care system pretends to pay them for outcomes. 

Why should we have to pay physicians more to perform well?  Isn’t this their job?   In fact, one might object to the thesis that physicians need incentives-that they are mercenaries and not missionaries.  The reality is that physicians need incentives to be able to afford the software, hardware and implementation costs of electronic health records.  Primary care physicians practice under surprisingly severe economic pressures-many are struggling for financial survival.   

Between 1995 and 2003, family physicians increased their billable productivity by 35% but received an 18% inflation-adjusted reduction in average income.  Meanwhile, the number of American-trained physicians choosing careers in family medicine declined by 50%.  And Medicare projects physician payment cuts of about 35% between now and 2015, while physician costs are expected to escalate by another 20%. 

Payers are reluctant to offer generous payment for performance bonuses.  Payers generally struggle with the “free rider” problem.  Physicians tend to treat all patients in their practices the same.  If one payer with a 20% market share finances an effective incentive program for evidence-based care, then most of the benefits will actually accrue to the sponsoring payer’s competitors.  The IHA program in California is a notable exception insofar as multiple payers cooperated to overcome the free rider problem.  Nonetheless, this multipayer coalition has grossly underfunded the bonuses.  They typically amount to only a 1 to 2% of a physician’s income.  Experts estimate that such bonuses should be in the 5 to 10% of income range to be effective.[ii]   Some of the Hawaii Medical Service Association’s performance-based bonuses reach into this range, but HMSA has an 80% market share, and Hawaii enjoys an aberrantly strong sense of community that is lacking in the mainland.  HMSA is the exception that proves the rule.

Many primary care doctors are likely unaware of the most powerful financial incentive for EHR adoption, which also indirectly rewards evidence-based fiscally responsible care: CMS’ Medicare Advantage HMO plans.  About 20% of Medicare recipients receive their care in these plans.  They are funded through a prospectively risk-adjusted compensation formula, wherein the revenues that physicians receive for each patient in one year are determined by the severity of illness that they documented through their diagnosis coding for each patient during the previous year.  In brief, doctors using an EHR with sophisticated Medicare HCC coding support may code more thoroughly and accurately, generating up to 30% more revenue than doctors who lack EHRs and do not pay attention to their diagnosis coding practices.  The insurance company administering the Medicare Advantage plan often has a risk-sharing contractual agreement with physicians for a substantial percentage of this incremental revenue.   Ironically, this powerful P4P program costs CMS nothing, since is a zero sum game; the risk adjustment model is rebalanced every 12 months.  Doctors who code poorly and are paid poorly fund the incremental revenue for doctors who code well.

Employers are becoming increasingly interested in P4P programs; however, most businesses need to see a strong case before engaging in these programs on a large scale.  One promising incentive for evidence-based care is the Bridges to Excellence (B2E) program.  This program is offered in collaboration with the National Business Coalition on Health, NCQA, and Leapfrog.

The B2E program encourages physicians and physician practices to deliver safer, more effective and more efficient care by giving them financial and other incentives to do so.  Thousands of physicians currently participate in the Physician Office Link, Diabetes Care Link, Cardiac Care Link and Spine Care Link programs.  Because of the extensive reporting requirements, purchasers and their employees have the information they need to make better health care decisions while also obtaining cost-effective care. 

The American Board of Internal Medicine, with support from B2E, is developing a new program called the Comprehensive Care Practice Improvement Module.  This initiative will allow as many as 180,000 internists seeking to maintain ABIM board certification to send performance data collected through that process to B2E and eventually to other payers.  Under this new partnership with ABIM, participating internists will qualify for maintenance of board certification, continuing medical education credits, and bonus payments under B2E’s new Internal Medicine Care Link program.[iii]

EBM Benefits - More Than Anecdotal

An EBM approach to care has clear benefits in quality of care, reduction of medical errors and cost savings. In peer-reviewed studies published in the Annals of Family Medicine and the Journal of Managed Care Pharmacy, an e-prescribing clinical decision support solution showed a significant impact on the cost and quality of patient care. The studies demonstrated a 12 percent savings in the costs of new prescriptions and refills, compared to contemporaneous control groups. The participating payer, Affinity Health Systems, enjoyed ongoing savings of $1,270 per doctor per month, relative to the contemporaneous control group, in pharmacy costs. In fact, there was remarkable consistency among the largest groups using the software.  Their generic prescribing rates had all climbed to about 75%. 

Another third-party study, performed in Maine by Anthem, found a savings of $3.55 per prescription, or some $470 per physician per month. Because Anthem was the payer for approximately 30% of patients in Maine, the total savings for all payers could be estimated to be more than $1,500 per physician per month in just one quarter.

Clinical decision support integrated with evidence driven data can make major impacts of patient safety. Take for example what happened at Esse Health, a 60-doctor medical practice in St. Louis, Missouri. The FDA often approves drugs that are appropriate for a small number of patients. Then, as we all know, direct-to-consumer advertising creates outsized demand for the medication. Earlier this decade, the majority of prescriptions in the U.S. (61 percent) for nonsteroid anti-inflammatory drugs (NSAIDS) were for the newer COX-2 inhibitors such as Vioxx and Bextra.

Using its e-prescribing software, Esse Health had been messaging its patients and physician-customers about the risks and limitations of these drugs since the CLASS and VIGOR studies came out in 2000.  The group then tracked the prescribing patterns of doctors using the EBM clinical decision support software and found that 25% of all prescriptions for NSAIDs were for COX-2 inhibitors. 

In September 2004, Vioxx was withdrawn from the market after studies showed the medication quadrupled the risk of heart attacks. In April 2005, Bextra was withdrawn from the market because it doubled the risk of heart attacks and strokes. Many e-prescribing companies took pride in being able to rapidly notify physicians when these drugs were withdrawn from the market and/or enable them to quickly message their patients to stop taking these medications.

While both these items are good things, Esse Health felt they were taking things a step further by scouring the medical evidence and seamlessly incorporating it into physician workflow at the point of medical decision making.  Esse was ahead of the FDA in limiting the exposure of their patients to these risky drugs.  The physician group knew that incorporating clinical decision support at the point of thought could make a measurable impact on patient safety.

Considering that 70% of U.S. healthcare is delivered by small and medium-sized practices, To realize rapid adoption of EBM, clinical decision support solutions should ideally be tailored to small and medium-sized practices, considering that 70% of U.S. healthcare is delivered by these groups. This means several things: eliminating the cost barrier; ensuring that workflow is not disrupted by infusing EBM into the workflow; making evaluation transparent, Web-based and convenient; and achieving rapid and non-disruptive implementation.

Clinical decision support with EBM is a critical factor in the success of Regional Health Information Networks as well as a larger National Health Information Infrastructure. Physicians prepared and supported in this manner can shift their focus from reacting to acute illness toward using data to proactively manage patients with chronic disease, as well as populations with specific diseases. More aggressive reimbursement reform that rewards fiscally responsible, high quality, evidence based care will save money for payers, representing a win-win proposition for physicians, payer and patients. 

References:

R. Brian Haynes.   ”Of studies, syntheses, synopses, summaries and systems: the “5S” evolution of information services for evidence-based healthcare decisions.” Evid. Based Med. 2006;11;162-164

Laura Landro, “To Get Doctors to Do Better,Health Plans Try Cash Bonuses”  Wall Street Journal, September 17, 2004 http://www.bridgestoexcellence.org/programs/upcoming.mspx  (Accessed August 18, 2007).

Although highly sensitive to the cost of transitioning to a paperless office, many physicians lack the time or inclination to focus heavily on business matters. This is especially true in primary care, where dwindling reimbursements threaten livelihood and the main factor in the success of a medical practice is volume. Docs must work at a rapid fire pace all day, every day, there is little time for much else^1,2.

On the other hand, when IT professionals talk about security with their customers, they are decidedly not talking about finances, simply because they’re in business to turn a profit.  Historically, high cost of entry, ongoing maintenance costs, and hidden fees ensure that they will and that financial security for their customers is not the top priority¹.

EMRs have largely failed in delivering on the promise of increased revenue, and are instead a major and disruptive investment with a shaky return. The decision-making process for small independent physicians involves the threat not only of dollars up front but an immediate loss of revenue as productivity suffers.  This results in a hit to the financial security of the practice and the physicians’ own pocketbook.

EMR ROI calculators tout both savings and increased revenue.  And, supporting anecdotal incidents exist regarding practices that were able to:

…replace the chart room with an exam room for a new    partner

…save money on error reduction and nurse time e-prescribing

…reduce headcount by automating eligibility and billing functions

But, these stories are subjective… and for every positive tale, there are numerous laments about lost time and productivity and even adding staff for IT needs where headcount reduction is not plausible or desirable.

All of this results in the fact that “primary care practices are declining in number, suffering financial strangulation and sliding into irrelevancy”. In fact, in “7 Guidelines for Saving Primary Care” four of physician and financial expert, Ken Zonies’ seven guidelines involve finances and IT ². 

1.  Increase Pay
2.  Teach Basic Finance
3.  Forgive Loans
4. Reduce Bureaucratic Hassles
5. Revise Approach to IT
6. Tort Reform
7.  Renew Respect

Outside the scope of medical care, when technology is done right, costs decrease.. This is due to competition and the race to develop and deliver a superior product. Doctor’s have the right to expect this of office technology as well. Therefore, financial security for physicians need not focus on some clever derivative of cost savings…it just needs to cost less. 

Financial security also means the elimination of financial risk.  Large up-front capital investments, far in advance of any real ROI do not eliminate risk.  A typical physician’s office is ill-prepared to support and maintain large scale hardware and software purchases and this lack of IT knowledge only adds risk for physicians and opportunity for IT firms.  Hiring IT support staff to run a thousand dollar investment when your business is diagnosis and treatment does not eliminate risk and may add to responsibilities outside the scope of care.

There are, however, means for physicians to reduce their financial risk in regards to practice technology:

• o Pay for only the services you need
• o Reuse existing PC and networking equipment
• o Use a firm that offers monthly subscription pricing and eliminates up front investment
• o Outsource IT management and maintenance - look for a firm that employs state-of-the-art data facilities with highly trained professionals to support your IT needs, not a half-time person fussing over a server in a closet at the back of your office.
• o Outsource patient record storage and backup - this huge and real elimination of risk particularly in light of recent and increasingly common natural disasters.
• o Realize economies of scale…every provider receives the exact same quality of service as the largest of groups

Finally, whether you are in primary care or specialty care, look for an IT provider that truly embodies the seventh and possibly most important tenet above.  Respect for health care providers.  In IT, service is key.

_________________________________________________________________________________________________

Rich Steinle, CEO  of Practice IT

Rich Steinle’s article is published in EHR Scope Spring 2008 Volume 5 publication.  To view his article and references, please visit www.ehrscope.com/magazine

References

1. AC Group. 2007 PMS/EHR Functionality Ratings. http://www.acgroup.org November 2007.
2. Zonies, Ken. “7 Ways to Save Primary Care”. The Physician Executive. pg 18-22, Jan/Feb 2008.

Are you thinking of taking the plunge and instituting an Electronic Health Record in your practice?  Before you do, consider web-based software as an alternative to the traditional on premises software.  Many other industries have accepted Software as a Service (SaaS) as a viable alternative to on premises software with leading software applications like Salesforce.com and Oracle Small Business.  With some new introductions to the market, there are now systems that will certainly pique your interest.  All that is required to get up and get going is a broadband Internet connection, a workstation or tablet and  a web browser.

Why Go Web-Native.   Generally web native software can be delivered more affordably in a subscription model, rather than a one time license purchase.  Because you are essentially “turning the software on” that is already running, vendors can price their software at a reduced costs.  Implementation costs can also be reduced as there is no on-site software or data sets to install.

Centralization of computer system functions also offers a big advantage to the end-user.  Updates, maintenance, network security, and backups all happen centrally.  These are all functions that are hidden costs for on-premises software.  Moreover, it is difficult for the small practice to maintain and afford an infrastructure to perform these functions professionally.   This centralization of computer services also enables centralization of other functions such as billing, scheduling and transcription services.

Your data is also always available to you wherever you have an Internet connection.  So if you are in the hospital, home at night, or away on vacation, all you need is an Internet connection to view or monitor what is going on in your office.  Having your records always available also can save on the cost of chart-pulls and the expense of faxing records between offices.

Finally, connectivity is another advantage to using a web-based platform.  If the platform you select is connected to reference labs, clearinghouses, pharmacies and hospitals - these are connections that you do not need to individually maintain yourself.  The cost and work associated with maintaining these connections is centralized and relieves the practice of establishing and then maintaining all these connections.  As connectivity becomes more important in Health IT, this becomes a big differentiator.

What are the Risks.  There is a natural concern about not having your data sit on your own servers in your own office.  Although your data remains yours, you are relying upon your service provider to perform reliable backup and continuous service.  Most software providers can do a better job of maintaining your data better than the small practice, but physically having on site servers may be an issue for some practices.  Also, many of these software services are relatively new to the market.  This leaves some room for uncertainty about the quality of the products.  Independent certifications such as CCHIT (Certification Commission for Health Information Technology) can help relieve physician concerns about the levels of functionality and security contained within a product.  CCHIT certified web-native products include Waiting Room Solutions 3.0 (www.waitingroomsolutions.com), WebChart 4.23 (www.mieweb.com), CureMD 9.0 (www.curemd.com), athenaClinical 0.15 (www.athenahealth.com), and OfficeEMR 2007. You can use CCHIT certification as a starting point, however there are other non-CCHIT certified products that also may suit your needs.

Other risks associated with a web-based platform include system speed.  Most systems, if optimized should perform with the same speed and functionality as on-premises software.  However, you will need adequate bandwidth at your office and workstations that have sufficient chip-speed and RAM. With new technologies such as AJAX, web native software can do everything and respond as quickly as on-premises client-server software. 

Is the Software as a Service better for some practices than others?  The software as a service model may hold particular appeal for the small practice of 1-5 physicians.  Most small practices do not have the financial resources to afford expensive license fees of on-premises software.  Moreover, the cost of updates and service for on-premises software may be in the same range as the subscription cost for SaaS web-based software.  Also practices that are just starting up and looking for a complete solution, but do not want to spend a lot of money would fit well with a SaaS vendor.

Is now the right time?  With the low barrier to entry in terms of cost and features, there could not be a better time to try a web-based solution.  Most of these systems are compatible with multiple forms of data entry such as templates, voice recognition, key board and handwriting recognition.  Some will also offer a limited free trial.  With the advantages growing it might just be the right time to get connected.

Dr. Gordon’s article is published in EHR Scope Fall 2007 Volume 4 publication.  To view his article please visit www.ehrscope.com/magazine

           Perhaps you have heard some of the nightmare stories about EMR implementations. You have certainly heard about the disasters and train wrecks. It seems the negative gets the most press.

In reality, however, thousands of EMR installations have been successful and are providing increased productivity and revenue to physicians’ practices. So it is of critical importance that we identify the necessary factors for a successful EMR implementation. 

Obviously, each EMR vendor will promise their product is the best solution and their team the best. But if we take a step backward, we can identify the characteristics of a successful and effective EMR implementation.

• 1) Speed - If you are constantly waiting for your vendors’ response, or for an answer to a configuration question, you cannot be productive. Therefore it is critical that both your vendor, and their product, can move quickly. However, keep in mind that during an implementation, your vendor will also need your attention - Vendors can only move as quickly as your participation allows. So although up front some time is required, your continuous involvement will ensure that the implementation will move along quickly.
• 2) Quality - Every EMR requires considerable customization to effectively serve the specific needs of each practice. Because each office sees “quality” and “need-to-haves” differently, you will need to articulate clearly to your vendor what is critical to you and your practice. Frequently physicians become frustrated when they don’t like how the EMR operates, but do not clearly define exactly what has to be changed to make it acceptable for them. The better you can communicate your needs to your vendor, the higher the quality of the customized result.

•3)      Cost - Often physicians are frustrated because the price quote they receive differs from the actual cost of implementation. Although vendors can do their best to estimate what an implementation will cost, there are too many variables (Scope Creep) at a practice that may affect the actual price. Actual implementation costs are most often affected by unforeseen complications such as faulty or imperfect wiring, networking gear, internet connections, and the quality of existing computers and their software and security configurations. Once a vendor gets onsite, the true nature and scope of the needed customization will become clear, and is often more extensive than the physician communicated or understood. Vendors also must estimate training costs, but more extended training may be necessary based on the skills and participation of those in the office. Although costs are a painful reality, it is important that a physician focus more on the return than the cost. A truly effective EMR will not cost you anything in the long run - by lowering the cost per encounter, and increasing your revenue per encounter your profitability should improve. See Sidebar to calculate how much you can save.

• 4) Participation - The real implementation killer, unfortunately, is generally the office’s unwillingness to participate. If anyone in a practice actively or passively refuses to participate in the EMR implementation, it is quite possible that the entire EMR implementation is destined to failure. Very often, those who are afraid of change and resistant to “fix what isn’t broken” can be a hindrance in the implementation. This feeling can be avoided but you must identify the “non-believers” and work with them through their fears. They simply need to understand how this implementation will make their jobs easier!

Critical Success Factors

• 1) Attitude - Like all things in life, a positive attitude is required for success. Check in regularly with your staff and your vendor during the implementation process. A great question is to ask them to rate the progress on a scale of 1 to 10. If your vendor says 10 and your staff says 3, there is a breakdown in the process, and an issue that needs to be addressed.
• 2) Implementation Team - Your vendor is only as good as their most recent implementation experiences. Ask your vendor to provide you a few names of physicians who are currently in the implementation process. Call them, and ask how well the implementation is going. Not all implementation teams are created equal. You may choose to postpone your implementation until your chosen vendor, and the best team, is available.
• 3) Technical Competence - Each implementation team will have technical competence that varies by experience and talent. There will likely be a mix of novice and experts on your team. This is normal; all vendors are continually adding new quality people to be trained for successful implementations. If a team member is causing concern and you feel the implementation is in jeopardy, just raise your concerns to the vendors’ organization.
• 4) Planning and Project Management - Coordination, communication, and performance all must be actively managed throughout the implementation project. The expense of project management may seem unnecessary, but having a competent project manager will contribute more to your success than nearly anything else. Without a competent project manager overseeing all aspects of the implementation, your transition is likely to be more complicated, unnecessarily time consuming and certainly more costly.

Off the Rails? Indications of an Implementation Gone Wrong -

• 1) Ask your Staff - Your staff will be the ones using this solution every day - ask them how they think things are going. If you hear low scores and low confidence, dig deeper. If the problem lies in fear or misunderstanding, it is important to reiterate the purpose of the implementation - to make the office more productive, and their work easier and less time consuming. If it is simply not working, the vendor should be called in to discuss solutions.
• 2) No Visible Progress on the Priorities - Insist on weekly project meetings. Issues should be discussed and agreements made on what is to be accomplished in the ensuing week. Careful notes of agreed upon deliverables should be taken and reviewed each week. If critical things slip more than 2 or 3 weeks, your concern is merited.
• 3) Accountability and Attention - It is vital that a project manager or team leader be identified. This person is one you can call at a moments notice to discuss concerns, issues, or progress. A qualified project manager will communicate with you promptly and courteously as to status and current progress. If no one person is willing to take full accountability for your project, your project is likely “off the rails”…or soon will be.

How do you define success?  Be SMART and define your measures.

• 1) Specific - Be specific about your measure and define it clearly. Example “We need to chart and bill all encounters in 5 minutes or less”
• 2) Measurable - Have the ability to measure the quantifiable value of each measure. Example “Today we did 45 encounters in 7hrs and 45 minutes, that’s 10minutes per encounter”
• 3) Attainable - Each measure must be attainable, setting expectations that cannot be met is counter-productive. Be willing to set aggressive goals - but they must also be attainable. Example “5 minute averages is reasonable but we should expect 10minutes on comprehensive physicals”
• 4) Reproducible - One shot goals are often achievable in special conditions, but long term goals must be something you can reproduce with good results over the long term. Example: “We can easily achieve 5 minute encounters on Wednesdays before 8am but on Fridays the system slows to about 11 minutes per encounter.”
• 5) Timely - Make sure each goal is time bound. Delays will occur, and should be expected to a point; but it is important to identify a desired goal time, as well as a deadline which must be met or the measure is disqualified. Example “We have been working on achieving 5 minute encounter averages for about 6 months now, how much longer will this take?”

In summary, an implementation is a partnership between your team (staff) and your vendors team.

Your vendor needs you for their success, and you need them to successfully implement your EMR.  Be flexible and understanding throughout the process. Your vendor cannot perform their desired function if your office resents them being there; by the same token your vendor needs to be sensitive to the ongoing business of the practice, and the discomfort a complete change of procedure can bring.  As a team, you and your vendor are asking an entire operation to change their habits and mindset - a challenge in any environment. But with partnership and teamwork, your EMR implementation will be successful. And that is good for everyone.

SIDEBAR

Determining Savings - Average Cost per Encounter / Average Revenue per Encounter. 

Establish a Base-Line - Ascertain Total Gross Revenue, Total Expenses and Total Claims filed for the previous year. 

Divide Expenses by Encounters to determine Average Cost per Encounter

Divide Revenue by Encounters to determine Average Revenue per Encounter

These numbers will vary greatly from practice to practice. It is very important is to determine your baseline numbers, then track your progress weekly to measure your success.