As you know, the Centers for Medicare & Medicaid Services (CMS) issued final requirements for meaningful use stage 2 on August 23. Since then, it’s clearly been one of the most discussed topics in healthcare technology circles, perhaps this site aside.
While the dust finally settles, the nuances of the regulation are being turned over and devoured. Providers and practice leaders are examining the 17 core (required) measures and wondering which of the three menu items will allow them the clearest path to overcome the hurdles of stage 2.
Successfully meeting the meaningful use measures aside, for me the meaningful use exceptions for noncompliance are what stand out here.
Let’s have a look.
CMS established hardship exceptions to the penalties practices and providers will face for noncompliance of meaningful use. Exemptions are available for physicians who:
Have insufficient Internet access for any 90-day continuous period between Jan. 1, 2013, and July 1, 2014.
Are new to Medicare.
Encounter extreme circumstances outside the physicians’ control, such as practices closing, natural disasters, EHR vendors going out of business and similar scenarios.
Practice in multiple locations and have a lack of control over the availability of EHR systems.
Have a lack of face-to-face visits or other patient interactions, or the need to provide follow-up care.
I’d love to know your favorite exception. Feel free to let me know in the comment section below. What caught my eye, though, is the third exception. Specifically: “EHR vendors going out of business.”
Perhaps I’m giving this single point more importance than it deserves, but I find this to be wonderful foresight on the part of CMS. Kind of like the nation’s forefathers providing exceptions to the success of the United States; a caveat to hedge against the Constitution’ failure.
Here, tucked in with acts of God and insufficient Internet access, CMS ensures that physicians need not worry about their EHR vendor putting plywood over the windows in the middle of your attestation process.
Clearly, contraction in the vendor market is going to happen. It’s a matter of time. Those of us in the vendor space have speculated on this very fact for several years. Analysts have provided their opinions and they agree, as do my counterparts.
Perhaps the next year won’t bring a dramatic change to the EHR vendor landscape, but we all know it is coming. The fact is, there’s just not enough physicians and care providers to support between 400 and 600 vendors.
Stage 2 is most likely going to prove too complex for many of the smaller shops. Those without a tool that’s robust enough to make the meaningful use push or companies without a sizable enough footprint to be an attractive acquisition target are going to fold. Their clients may expect them to weather the storm, but a ship without a sail is nothing more than a lost vessel without direction.
So, with all the other exceptions that can cause a set back, and given the level of commitment required to meet stage 2, the easiest exception to avoid may in fact be making a vendor switch now. Given the set backs a vendor collapse could cause your practice, I might prefer taking my chances with an act of God because at least I might be able to pray my way out of it.
When looking forward, it sometimes helps to look back; sometimes.
Though the past is not always an indicator of things to come, sometimes we’re able to find a little guidance in the hindsight.
Much is being written by folks like myself in response to HIMSS asking the question of where Health IT is going to be a year from now, on the anniversary of second annual National Health IT Week.
Unlike several of my counterparts — perhaps I’ll be considered less of a forward thinker because of it — but instead of fast forwarding one year, I’d like to go back one year to formulate a response.
In May 2011, I had the pleasure of helping draft a column for my then boss for Imaging Economics magazine. The piece, one of my favorites, seemed to strike a chord, even if just with my office colleagues.
Nevertheless, this piece essentially answers the very question asked by HIMSS, a year before the asking.
And so, as we wrote back then, I’ll begin here again, with an encore of the piece as a response.
“Here’s how I see it: Healthcare is a world of major transition. Like life, there is some unpredictability, and most likely, there always will be.”
We continue: “Yet, during this time – call it one of change, progress, upheaval — we must continue focusing on creating a more mobile and connected place in which physicians and their patients share tools. We need to encourage a greater, more vested conversation, where health information exchanges and practice and patient portals are used, secure messaging and 24-hour access to records and patient data for the patient and their physician.”
This observation, according to my best estimate, couldn’t be any timelier.
We continue again:
“I see a healthcare environment that mirrors the rest of the world. Where, as a patient, I can see my labs at 3 a.m., can query my doctor and request refills; if I’m up for it, pay bills anywhere there’s a connection. I see this as accepted and practiced, in the practice of medicine. Always. Any time. Now.”
Perhaps we’re there now; perhaps not. Regardless, we’re talking about it and, given another year, I might be able to more profoundly announce, “Always. Any time. Now!”
If I remember correctly, in helping write this next section I spoke for myself: “But, here’s what I know: Patients are demanding greater ownership of their care and records (I was). They (I) want the always, any time, now. I also know that physicians – along with constant pressure of requirements and reform – need solutions they can trust; technology tools that are intuitive that help them provide the highest quality of care, all while meeting their patients’ needs.”
It seems nothing has changed in more than a year. I suspect little will change in another. Reform continues as we move past Stage 1 and into Stage 2, which are more rigorous than their predecessors. It will consume hours of healthcare professionals’ time. They will toil and try, and try and toil.
Despite the continuing and conflicting headlines, patients do want to get more involved in their care, but they need a reason to buy in; and physicians need tools that are going to improve their lives. They need more efficiency, more powerful and intuitive solutions. They need to start responding to survey that asks “What is the best system to use?” rather than “What is the least complex system to try to operate?”
Let me jump ahead now. “Physicians realize their sway within the healthcare market, both as practitioners and consumers, and they realize – like their patients — how technological connections enhance their experiences in other areas of their lives (read: paying bills online, online banking, booking appointments with the DMV through a website, purchasing movie tickets through a phone, etc.). This understanding of using technology as a tool is helping them improve and streamline their practices and, ultimately (for the better), engage their patients in care. “
Finally, here we get to the heart of the matter: “Technology by itself won’t improve patient care. Physicians know this – we all know this – and physicians play the key role in providing higher quality of patient care, but using technology as a tool to improve care improves outcomes, according to the physicians and patients I speak with. And, to me, that means improved outcomes equates to improved quality of care.”
“So, it makes sense that the practice of medicine is changing with technology, which calls for an adjustment of its perceptions in the space.”
And, to the tune of Paul Harvey, here’s the rest of the story:
“Because, as more attention flows into the market – with reform and regulation – it’s time to decide where the future of healthcare is going to be. Connection and interoperable features that drive ownership of patient care may be rooted in the patient-centered medical home and accountable-care organizations, but for that, more needs to be done. We have to be able to share data – again, that’s where connectivity comes in — and we’ll have to be able to move records quickly and efficiently, all while trying to remove the shackles from providers attempting to do what they sought the schooling and expertise for: To practice medicine.”
“All of this begins with the electronic record – other tools are essential, too, including patient portals; physician referring portals with the ability for images and notes to be accessed from anywhere there’s a connection; labs; refills and appointments through one interface, a seamless integration between practitioner and patient – is where I think we need to be, so we can move forward with the rest of the marketplace (meaning: banks, media and communication segments). With the value perceived in being able to share and communicate endlessly and with ease socially, we have to reach these heights in the practice of medicine.”
“Technology helps make lives better. Though, as noted above, technology doesn’t make doctors (or people of all kinds, for that matter) better, it just makes it easier for them to do their jobs (and live their lives). It won’t happen overnight, but I can see even better healthcare attained.”
And so, the encore performance may actually be a sign of things to come.
Dr. David DeShan leads a global healthcare mission from Moscow. Because of his work with Agape Unlimited, he supports thousands of poor and under served Russians while maintaining a full-time practice in Midland, Texas. Agape is a medical mission serving thousands of people
Dr. DeShan’s medical mission, through Agape Unlimited, provides everything to its patients for free. There’s no cost for the consultation, for medication or for the glasses received. Because of the care provided for the folks in the rural areas, sometimes this is the only medical treatment they’ll receive for years. Word of mouth spreads and people come for miles. In one instance, a group of patients rode on a reindeer-pulled sleigh for more than 24 hours for a visit with an Agape physician.
Agape Expedition Life
Each expedition outside of Moscow has its own set of challenges depending on where the group of volunteers is going and the time of year, but each has several things in common. First, the expeditions to the remote areas are all two weeks long, primarily because there is a tremendous amount of travel involved. From the U.S. to Moscow takes between 20 and 24 hours then there is the travel to region where the work is done, which can take between 24 and 36 hours by train. Once the crew reaches the region, there is often another eight to 10 hours of travel by vehicle to get to the area where they will work. This is typically a large village in the region where they stay with a host family.
Once they reach the area they’ll be working in, each day the crew goes out to different villages for anywhere from one to three days. This is where the work of seeing patients begins.
Each team consists of four to six people and is a combination of Russians and foreigners, with a doctor, translator and others who fit people for eyeglasses, take vital signs, do basic lab work and patient education. Often they arrive in the morning and work late into the night as they attempt to see everyone who comes for a visit.
When they arrive in the tundra or taiga, little clinic areas are set up in any area that can accommodate volunteers – in churches, homes or government-owned buildings.
Often, the temperatures are extreme and basic comforts are a luxury. Roads are few, the people are scattered and the towns are made up of 19th century-like structures.
The medicine that is dispensed is the most readily available to those living in the area, making it easier for people to acquire drugs once the team of doctors has left.
For those treating patients in Moscow, they travel to various sites throughout the massive city, caring for the sick and poor. The story is much the same here as it is in the countryside: far too many people need care for anyone to provide in their lifetimes.
“Because of the lack of care and education about personal health, the results, in many cases for patients, are not good. Ailments of all types are seen, and too many of the devastating kind seem to appear,” DeShan said. “We’ve seen men in their 40s who have had a stroke.”
Home on the Range
Back in Texas, most of his patients have been very supportive of Dr. Deshan’s global work.
“When this all started, the big concern I had was if I was going to have any patients left,” he said. “I’ve lost a few, but gained more. They and my partners are very supportive.”
Midland Women’s Clinic office manager Marge Bossler never thought DeShan was going to be able to connect to the EHR from Moscow to make his global pursuits a viable reality. “It’s really quite amazing how he can work, respond to emergencies and attend to the needs of his patients from half a world away,” Bossler said.
“In many ways, when he’s in Moscow, it’s as if he’s only in another area of the building, not in another area of the world. He responds to alerts and takes action for his patients as needed. He’s totally aware of what’s happening back home, and gives his recommendations when required,” she said.
“Now when he leaves, there’s no hopeless feeling that he won’t be reachable,” she added. “The EHR made this possible. This approach gives him the capability to do what he feels he needs to do to answer his calling. Besides, there’s nothing he can’t do from there that he can’t do from his office.”
Where Agape Goes
To the Tundra:
In Russia’s northernmost zone is a treeless, marshy plain. The journey takes days. First, volunteers travel by jet to the region and then use 6×6 Russian trucks to travel up to 24 hours across the Tundra. There are no roads. Sometimes progress can only be measured in inches. They continue by snowmobile to the teepees where the local people live. Once there, they provide medications, medical consultations, health kits and eyeglasses that are often lifesaving for the Nenet people.
To the Taiga:
The world’s largest forest is an area about the size of the United States and spans 11 times zones across Northern Russia. Here in the Taiga, people are extremely distant from the rest of the world, both geographically and communicatively, and some still speak their own ethnic language.
To Southern Siberia:
Deep in the mountains of Southern Siberia, most people are shepherds who tend sheep and goats in these vast valleys. The closest medical help for them is often a three-day trip away, with much of the traveling done on rut filled dirt roads.
Agape Unlimited opened Medical Center Agape in Moscow in 2004, the first Christian Family Practice clinic in Russia. Since 2004, Medical Center Agape has grown to a staff of more than 50 and seeks to provide quality compassionate Christ-centered care to the people of Moscow, to send medical teams to the remote rural areas of Russia, and to provide free medical care to the poor and destitute of Moscow.
In 2007, Medical Center Agape began working in cooperation with several of the leading medical universities and residency training programs in the Moscow area. Agape asked, “How can we help?” They answered that they wanted the mission to teach their doctors to be compassionate. Through this arena, Apage’s goal is to grow a new generation of Russian medical personnel who can continue the work initially started by Agape.
Currently, there are more than 400 written invitations to come and serve in different parts of Russia, some of them are as far as 11 time zones away.
The program is open to doctors, dentists, nurses, dental hygienists, chiropractors, med-techs, residents, interns and even medical students who are in their clinical clerkship years.
Want to Help?
Agape Unlimited is always seeking volunteers to serve in clinics throughout Moscow and to travel on medical expeditions to rural areas of Russia. One- and two-week slots are available.
The cost for the two-week program in Moscow is $2,200 per person or $1,500 for a one-week program. The cost of going on one of the remote expeditions is $3,000 per person. The programs begin on Saturdays. An initial deposit of $1,000 is required to reserve your space in the program, and the balance is due eight weeks before departure.
What is Covered:
Airport pickup and return
A clean bed at the guest flat with bathroom, shower, and kitchen
Public transportation around Moscow
Medical translators for the clinic, medical university, and medical expedition
A medical expedition to a poor region near Moscow
Sightseeing, translators, and touring on the weekends to selected spots (Red Square, Christ the Saviour Cathedral, Ismaylovo market for souvenirs, Mega Mall, underground metro station tour, Arbat Street, Botanical Gardens, and church on Sundays).
One Texas physician leads a global healthcare mission from Moscow, supporting thousands of poor and underserved Russians, while maintaining a full-time practice in Midland, Texas.
Part 1 of a two-part series.
For more than 10 years, Dr. David DeShan has been traveling between Midland, Texas, and Moscow, Russia. DeShan is a physician and a missionary — serving patients at Midland Women’s Clinic in Texas and providing needed prescriptions, exams or treatment to hundreds of indigenous Russians.
The contrasts between the two worlds in which DeShan lives are stark. Here in the United States, he’s connected to his patients through electronic health records and secure web-based practice portals that allow him to communicate, share records and provide consultative services. Likewise, his patients can connect with him through any web-enabled device from anywhere in the world where there’s an Internet connection. His practice, which is building a new state-of-the art clinic, provides 21st century medical care.
In Russia, he is the president of Agape Unlimited, an international Christian medical mission program. Through Agape he visits people that are often secluded in very remote villages far removed from first-world creature comforts. Sometimes, as part of his medical mission work, he travels days into the lost wilderness of one of the world’s most vast and remote regions.
Four to five times a year he ventures outside of Midland, Texas, for up to four weeks on each trip. The majority of his travels are to Moscow where he oversees the nonprofit and its network of clinics. His involvement with Agape includes both the oversight of the organization in addition to traveling to the countryside to administer medical care. Despite being half way across the world he is able to effectively take care of his patients and colleagues in Texas.
In 2002, when Dr. Deshan first started his missionary work in Russia, he was completely detached from his practice in Texas. Needing to reach his patients, he eventually secured a satellite phone. Today, with the help of his EHR, he is fully connected irrespective of his location. Dr. Deshan has access to patient charts and tracks their progress remotely. Occasionally, he will use the information from the EHR and Skype his clients if a face-to-face conversation is warranted. Either way, when he returns to his patients in Texas, he never misses a step.
“None of what I’m now able to do through the ministry and the practice would have been possible without our EHR,” Dr. DeShan said recently. “I run the ministry over there, provide medical education over there, conduct outreach in Siberia and bring doctors here to the U.S. to train. The EHR really allows me to stay connected, in a fashion not available just a few years ago. It’s nice to have the opportunity to live in two worlds at the same time, and the EHR technology really makes it possible.”
Empowering an impassioned dream
Being a full-time physician and president of Agape is highly demanding and Dr. Deshan works up to 90 hours a week.
He has been on 14 expeditions into central Siberia and has made another 16 trips to Russia working in Moscow for a total of 30 trips since 2002. Outside of the expeditions to the countryside he does not practice medicine in Russia. “My role with our organization is to administer, encourage and enable our Russia staff to do the work and to invite others to join us,” DeShan said. “I have also been spending more time in medical education working with the medical schools and hospitals in Russia.”
Healthcare is different there than in the United States, as would be expected. The system is more socialized and less open compared to the U.S. Technology is also limited and use of such tools like EHRs are minimal. In fact, DeShan says there are just a few EHR-like systems in place in Moscow at elite practices.
Each workday, he logs in remotely to his EHR, reviews the pap smears, lab work and patient calls that need his response. His nurse highlights any abnormal mammograms and scans them into the system for his review, and he reviews the physician assistant encounters with his patients. The only things remaining when he gets back home is to go through the mail and review the bone density exams and normal mammograms, usually taking about 30 minutes.
“The EHR is truly what enables me to work in Russia yet still stay caught up. Since I can do this from Russia, it greatly reduces the burden on my partners and most of my patients really don’t miss me while I am gone because everything is still answered in a very timely fashion,” DeShan said.
From Midland to Moscow
DeShan said he’s always been drawn to serving his faith through medicine.
“I’ve always been very interested in Christian outreach, and I see medicine as a tool to this end. I wanted to find an organization for Christian doctors and I went to Russia once and kind of got hooked. I just felt like I was supposed to do more. It called to me,” he said.
He leads a handful of international volunteers from Germany, Canada and the U.S. and a staff of 10 in Russia working on the ministry and 40 working at Agape’s clinic. About 50 serve on expeditions each year. Despite resources, these folks see more than 365,000 patients a year at the group’s clinical network throughout Moscow and provide more than 2,000 pairs of eyeglasses to people throughout the country. Outside Moscow, more than 70,000 consultations have been given since DeShan became involved with the mission.
Though Russia is considered a first-world country, more than 75 percent of its rural residents don’t have plumbing. Without running water, medical infrastructure is not just impossible, it is a wishful hope.
“There’s a tremendous need for care, especially in rural areas out there, for medicine, and things like glasses,” he said.
What is Agape Unlimited?
Agape goes where no others go, taking action to improve the health of people who may have never seen a physician. This takes the organization to remote areas in Siberia and beyond, as well as to Moscow, meeting the needs of the medically underserved in the capital city, DeShan said.
Since 1993, Agape has been providing medicine, medical consultations and assistance to those who have little or no access to medical care in Russia. Agape sends teams to areas where the need for medical help is urgent , focusing on both the most remote and isolated people in the Arctic and Siberia, as well as the poor and overlooked in rural and urban areas,.
Agape’s medical expeditions always work in conjunction with a church within the region; this way the work continues in the community after the medical missionaries leave.
Agape provides everything to its patients for free. There’s no cost for the consultation, for medication or for the glasses received. Because of the care provided for the folks in the rural areas, sometimes this is the only medical treatment they’ll receive for years. Word of mouth spreads and people come for miles. In one instance, a group of patients rode on a reindeer-pulled sleigh for more than 24 hours for a visit with an Agape physician.
For more about Agape Unlimited, visit www.agaperu.org.
For example, video tape and video stores are virtually gone already. Watches, paper maps and newspaper classifieds are on their way out; and perhaps newspapers, too.
Wired phones are hard to find (though my children will probably see a land line in my house because of their benefit in hurricanes and other natural disasters.)
Printed encyclopedias (some of the last were printed this year) and, likewise, encyclopedia salesmen are history. Printed phones books I still get, and use, but they will one day stop coming to the door; CDs, film and fax machines are all but obsolete, though, there are still enterprises trying to make their livings peddling their wares to help organizations send secure faxes.
I don’t consider myself to be old by any means; just part of a transitional generation. I remember paying $1 for a gallon of gasoline and I remember protestors picketing gas stations in Southern California when the prices topped $1.50 a gallon.
I was introduced to the web via dial-up Internet and wondered when its value would be achieved, as it was difficult to imagine a life lived through the web one AOL minute after another.
Now, the Internet is considered one of the most innovative advancements of all time. Healthcare, and nearly every other business sector, will never be what it once was because the technology allows for continuous advancement and the development of tools like EHRs, patient portals, HIEs and mobile devices.
Why all the reminiscing, then, about all of the gadgets that my children will never know?
Simple. My primary care physician uses paper charts. She has no plans to change and is unapologetic about it. Her patients sometimes ask her why and she shrugs it off like it’s not important, an overly hyped issue. One that she’d rather not discuss and one she might wish went away.
The wall of charts behind the reception desk is a symbol of her success. They represent patients she’s treated, conditions faced by the people she cares about, meetings with those of us she’s counseled. Perhaps that wall of record is her trophy case, a testament to her professionalism, outstanding demeanor and nature, and the trust she’s earned with all of us.
She doesn’t want to be forced into any kind of decision that affects her business – that’s how she sees her practice, as a business — even if she’s ultimately penalized because of it.
Though she’s got the paper to sift, she claims to be organized and just as efficient as any machine could make her. The notes enclosed are her own and won’t be shared with anyone. The only incentive for paper these days is the recycle bin.
But, she carries on. For now.
In the end, though, she’ll probably close shop, shred the records and move on to retirement if her decision not to implement an electronic health record means she can’t continue to do what she loves – practice medicine and provide care.
She has that luxury. She’s of a certain age. She remembers things that many of us have never experienced. She grew her business on typewriters, dial telephones and paper records.
And soon, she will become one more thing my children will never know.
In an effort that could revitalize the EHR space (at least the mainstream market), the Veterans Affairs Department’s classic and still heavily used VistA (Veterans Health Information Systems and Technology Architecture) system is getting the open source EHR treatment.
In a move that is revolutionizing other technology sectors — like manufacturing, gaming and the device world and because of the success of such sites as Kickstarter (I know because I represent clients in this space and have seen their success first hand), which is a haven for open source projects, allowing volunteer programmers who are passionate about code and perhaps even passionate about healthcare, is really a pretty swell idea.
From the VA’s perspective, how else could it possibly bring a beleaguered and somewhat bemoaned product like VistA to the modern area after more than 30 years in use? Certainly, the government didn’t seem to have the funds or the necessary experience to overhaul the system by itself.
According to Rick Baker, chief information officer for the VA, even though there is a contract with a firm to make changes to VistA’s code to make it less complex and more readable, the open source community will be involved directly, day to day, with the EHR’s refresh.
The success of involving the open source community in healthcare, and in the development and maintenance of EHRs, is showcased at Oroville Hospital in Northern California, which recently passed on some of the mainstream vendors like McKesson and Meditech for a personalized, customer version of its.
Leaders at the hospital wanted the flexibility to make changes to its EHR system, and they wanted to ensure they received the attention they felt they deserved from their vendor of choice. Ultimately, they wanted total control over the hospital’s electronic health record.
The best solution to the problem for the hospital? Build its own EHR.
In addition to gaining every advantage over the creation and implementation of the home-grown system, Oroville Hospital plans to save a bunch of money by not purchasing a commercial system even though it is building a complete EHR soup to nuts.
The hospital chose to build the system with the help of the same open source folks who are working on the VistA system; the same folks the VA is using to update VistA. Once done, Oroville Hospital’s EHR was even certified for meaningful use and the hospital received more than $5 million in meaningful use incentives.
What all of this seems to suggest is that custom solutions are viable options in a sea of corporate technology offerings. With open source now breaching the professional world of electronic health records, this may only just be beginning of a wave of technology innovation, especially as hospitals and practices seek more efficient solutions and more control of their EHR technology.
Given the time, patience and buy in of leaders, healthcare facilities may be closer to independence than we’re used to in the regulated and oversight-driven world that has become healthcare.
Patients are not the only ones who will become more engaged as mobile devices continue to infiltrate healthcare; physicians, too, are reaping the so-called rewards.
As the debate continues to rage about the efficiencies created when EHRs are used in a practice setting, there seems to be little argument as to whether tablet PCs, smart phones and even applications like Skype actually improve the business of communication and interaction with patients and their physician partners and physicians with their colleagues.
A physician whom I very much respect, Dr. David DeShan, is one such physician who communicates with patients and colleagues via Skype from his mission outpost in Moscow, Russia.
Spending weeks at a time in Russia each year, he also maintains his status as a partner and practicing physician at a growing OBGYN clinic in Midland, Texas. As an early adopter of the virtual visit, DeShan is able to maintain contact with his patients if they need a consult, and he’s also able to maintain his connection to his practice so he can check labs, review diagnosis and provide counsel to his practice mates should they request it.
By his own admission, he works a full-time practice schedule from abroad in addition to his full schedule as the leader of a major international mission. By partnering Skype and his EHR, DeShan is essentially a full-time practicing physician without a need to be restricted by the brick and mortar location of his practice. At the same time, he’s able to dedicate himself to his medical mission work in Russia and serve individuals throughout the world’s largest country in places that would never receive even the most primitive of care without him and his network of medical volunteers.
But, I digress. I’ll save DeShan’s story for another day.
The point I’m trying to make is in support of CDW Healthcare’s article “Momentum Surges for mHealth,” which cites a recent IDC Health Insights observation that shows clinicians use more than six mobile devices in the care setting each day.
Accordingly, as the mobile world continues to open new opportunities in all aspects of life, physicians, like all of us, know that they will come to rely more on these devices to practice, communicate and collaborate.
Clinicians and practice leaders continue to embrace the devices in the care setting, and they expect practices to allow them in their work. When technology delivers upon its promise and actually makes life easier, it is obviously going to be supported and used, like DeShan has done with Skype.
The technology helps him bridge gaps and essentially eliminate a half-the-world-away gap between himself and his practice. But, in some places, there are policies in place to inhibit this type of care offering. (Policies in opposition to this type of approach should be considered archaic and simply regrettable.)
The CDW piece goes on to state that according to a University of Chicago School Medicine study, providing tablet PCs to residents actually reduced patient wait times in hospitals. Likewise, the study found that the same residents did not have to look for an open computer for medical charting and actually allowed the residents to spend more time with patients.
Novel concept. Technology working as promised. Not so unbelievable when spelled out so clearly as this.
As I said, mobile health will continue to grow in popularity. If internal policies are not supported and encouraged, you’ll quickly find yourself in a BYOD environment, which is not such a bad thing.
In fact, if it develops or if you’re unable to support your own internal mobile device initiative, set some rules and let it bloom.
According to CDW, “You need to establish and enforce policies for mobile users including setting up passwords, separating personal from corporate data on devices … and you need to educate users on how to securely use mobile devices.”
When managing a population that’s more likely to use or own a mobile device like a tablet PC than the rest of the consumer population, the infiltration is well underway so it’s time to begin reaping your mobile rewards.
In continuing a series based on HealthIT.gov’s “How to Implement an EHR,” now seems like an appropriate time to seek additional insight into how to prioritize your implementation plan and identify critical tasks to perform when putting your system in place.
As the HIT world continues to reel from continuous change – meaningful use stage 2, ICD-10 postponement and mobile health among the biggies – like any commercial market, there’s bound to be some constant ebbs and flows.
Selecting, and changing, an EHR are bound to happen no matter what else is going on in the market. So, though much of the market may be focused on regulation and reform related to EHRs, there are still practices who haven’t yet implemented, and there are practices that are looking to get out of their current solutions.
According to the Office of the National Coordinator (ONC), “Building an EHR implementation plan becomes critical for identifying the right tasks to perform, the order of those tasks and clear communication of tasks to the entire team involved with the change process.”
Implementing an EHR is really about implementing a change management process: new rules, new ways of doing things and new things to learn. That’s an oversimplification, but it essentially hits the mark.
Setting up an implementation plan (the plan should be in place before the implementation begins) first starts with segmenting tasks into three categories, according to ONC:
What new work tasks/process are you going to start doing?
What work tasks/process are you going to stop doing?
What work tasks/process are you going to sustain?
The three categories help determine the future work environment of the practice; how things will work after the change.
Obviously, if you are moving from an existing EHR, you’re probably going to be more familiar with how things will work once the system is in place, with a few exceptions. However, moving from paper to electronic records means there are going to be a great number of changes that, if not accounted for, may cause some initial hurdles along the way.
Your next steps should include:
Mapping your current workflow and analyzing how you get things done
Mapping how the EHR will affect your workflow, and how you hope it will enable you to perform certain tasks or functions like how you plan for them to create more efficiencies and reduce duplicate processes?
Creating a backup plan to address issues that arise during implementation. This is crucial as issues beyond your control will come up and if you’re not prepared for them, they could derail your process and set you back. Think of worst case scenarios and plan for them to happen then hope for the best. No implementation is ever the same as another; each are there own experiences.
Building a project plan to blueprint the transition then appoint a team member to manage the plan.
Identifying data that must be transferred to the EHR either from paper or from the previous EHR (charts are the most obvious example here)
Finally, find out what can be transferred to the new system like patient demographics and schedules.
Once this point has been reached, you can bring other parties into your plan, like consultants and vendors, to get the plan rolling and potentially start the implementation.
Fee, fees are everywhere, and not all EHRs are similar. But when purchasing an EHR, there’s much more to consider than just the amount of cash you’ll have to spend for the actual system you want. More than the sticker price of the system alone, you have to account for all the other functional pieces — like support, training and licensing — that need to be bolted on.
So, let’s hear it for the Maryland Health Care Commission. The Commission provides some great insight into all of the things you need to consider before making an EHR purchase and some intangibles that, when addressed, may determine your long-term happiness or misery with the tools you decide to implement.
The Commissions’ list is succinctly published by AmericanEHR Partners, which also makes a fine and sincere recommendation to take into account during the pricing of any EHR: “Price of the system alone should not be used as the primary determinant for the system, but rather one single factor to help make the decision.”
Licensing and Subscription Fees
Check to see how licensing and subscriptions work with the vendors you are shopping: Do you pay per clinician or per user, and do you pay more for more “seats” at the table if you need them? Is your payment all inclusive, meaning, are getting a fully integrated EHR with practice management system or are covering for additional features?
The Commission makes an interesting point here: Client server systems are usually licensed based upon a one-time fee with maintenance costs.
I’ll add the following: Hosted, cloud solutions are less expensive than client server to implement; typically fees are paid on a monthly retainer; and they often are less robust systems than on-site server-based counterparts.
Practicing with Your Practice Management System
If purchasing an EHR that includes and PM system, be cautious of paying extra for the practice management capabilities. With continued integration of the systems and requirements brought on by regulation, such as meaningful use, there really should not be any additional fees for the capability.
Vendors may offer a full version and a light version of PM. Make sure the light version can meet your practice’s capabilities if you decide to take that option.
It goes without saying, but make sure that the PM, like the EHR, is meaningful use compliant.
Paying forPatient Portals
According to the Commission, “Vendors may have tiered pricing for portals based upon level of functionality.”
Make sure you have an understanding the portal’s functionality, how it fits with your system and if it’s part of the EHR or an add on. It could go either way, but from experience, you’ll be paying extra for it. Don’t forget to budget for it if you plan to meet meaningful use.
Support, Training and Maintenance
No surprises here, vendor support costs vary significantly based on the level of service you need and when the support can be accessed. You’ll pay more for support at certain times like nights, weekends and holidays.
To budget for training, you have to account for the trainer’s time, travel expenses and the amount of training you want. Plus, there may be a flat fee built in to cover it with additional hours sold in blocks.
The most important thing with training is to clarify how much you’re going to get for the price paid. A word of advice: Log your own hours. Track how much you’ve actually used and compare it to the amount that you’re billed.
Another cautionary tale from the Commission is to be prepared for any training initial fees and should be priced out separately.
Finally, the maintenance. Maintenance fees are generally included as part of your software agreement. If not, proceed with caution and read the agreement carefully.
And, according to the Maryland Health Care Commission, maintenance fees for client-server systems are generally 20 percent of initial licensing and interface fees.
Hopefully, some of the preceding information helps as you price and shop for your EHR. If you have additional tips or insights, please post them in the “comment” section.
When someone says, “It’s just like riding a bike,” they typically mean that once you learn how to do a certain thing, you never forget. There’s something about the task or the ability of your body and mind to remember how to effortlessly accomplish the goal that just brings it back.
The same can be said for breathing; perhaps even driving or swimming.
Okay, point made.
But, remove the training, the time spent rehearsing or the practice attempts (you know, the fall on your head and the scars on your knees) and the whole process begins to make a lot less sense than it would had you put in the time to understand how to accomplish said task.
In fact, in the example of the bike, without the practice many never get to experience the exhilaration of reaching the peak of the hill after fiercely pumping on the pedal and finally zipping like a bullet train down the other side. In that instant of wind-rushing joy, all the hard work on the first half of the hill was worth the effort of being able to experience the second half of the hill.
I can’t imagine life without having learned how to ride a bike, or learning how to disappear into the pages of a favorite book because I knew how to read. Frankly, I can probably say the same thing about a few pieces of technology and software that I have been trained to use or that I have taught myself to use. Had I not learned how to use them properly, life wouldn’t be so rich.
Perhaps electronic health records don’t fall into the category of technology that enriches users’ lives if used properly, but there’s apparently a connection between the level of experience one has when working with the systems and the success they’ll have using them to track health outcomes and build efficient practices if they have received proper training of the systems.
According to AmericanEHR Partners, the results of a study it issued shows that user satisfaction was lower for clinicians that used an EHR but received less training than their counterparts who received more training of the systems.
Essentially, the more training and experience using the systems the more likely users are to get more out of the systems. Likewise, clinicians who received less training of the systems perceived their experiences with systems as less than positive.
According the study, five findings were discovered, none of them all that shocking, but certainly very telling.
AmericanEHR Partners found that the more training a survey respondent had with the EHR, the happier the respondent was. Secondly, three to five days of training on the EHR was typically required to achieve the highest level of satisfaction. Fewer than half of those surveyed said they received at least three days of training. The report’s other findings suggest more training leads to happier users.
In addition, according to the finding, those who had a hand in selecting the EHR were generally happier when using it than those who did not help select it.
So, there are some obvious questions here, which Steve Ferguson of Hello Health asks pointedly in his blog post on the same topic. In summary, Ferguson asks: are doctors not getting sufficient training? Why? Do vendors not offer enough training? Is it too expensive? Is the doctor at fault?
Well said; questions deserving of answers.
In some cases, though, no one is really at fault. Vendors, looking to finalize a sale add the fewest number of training hours to the deal so as not to scare new clients away. Training hours are expensive and typically not a free service provided by the vendor. The number of training hours vendors require their clients to buy have been know to cost vendors some deals. Too many training hours can cause some practice leaders to run.
In some cases, there’s often not a lot of margin in selling the EHR systems. Some vendors have even given them away to lure customers.
For vendors, the EHRs are a lot like gasoline at gas stations. The stations make next to nothing by selling the gas; it’s all the convenience store items you purchase while you’re filling up that keeps them in the cash. Same can be said for movie theaters. Theaters make little profit on the movie tickets; their dough is made selling you candies, popcorn and Cokes.
The point is that practice leaders are often scared by the often high prices of vendor’s training hours. Vendors sell systems so they can lock in lucrative annual maintenance and service agreements. They’ll forgo the training hours to close a deal to get to the monthly or annual client stipends.
Practice leaders are sometimes like moviegoers who buy the ticket, but bring their own sandwiches and sodas from home. They think they can get by on their own or will ask for free assistance from colleagues using similar systems.
In the end, it seems quite a few folks are standing around looking at the bike rather than getting on it and taking it for a spin, even though the practice and the inevitable falls is where the real value is at.