Guest post by Matthew Douglass, co-founder, SVP Customer Experience, Practice Fusion
In part 1 of this series, we reviewed the history of digital health tools and discussed why they are not yet fully satisfying the needs of many physicians.
If you think of the U.S. healthcare system as a vast nationwide transportation network, current electronic health record (EHR) functionality is the basic highway infrastructure. The American Recovery and Reinvestment Act of 2009 provided the incentives for those highways to be built and put in place the structure for ONC-certified EHRs to define the rules of the road via regulatory standards. The roads are now mostly in place: certified EHRs all offer roughly the same base functionality for use by physicians, store clinical information in standardized ways, and have the capabilities to securely communicate with each other.
Sixty-seven percent of medical practices in the U.S. are now using EHRs to run all or part of their daily operations. Patients’ vital signs are stored as discrete values for each visit. Encrypted messages between physicians and their staff are transmitted reliably. Chart notes are being digitally documented and can be shared confidentially with patients. Physicians that have chosen cloud-based EHRs can securely prescribe and refill medications from the convenience of their mobile phones.
Despite having this digital highway system in place, we haven’t yet reached a destination where use of EHRs achieves better patient outcomes or improved clinical experiences. Physicians want more from digital tools than simply receiving, storing, and displaying data values about each patient visit. Rather than devoting too much of their already limited time to data entry and retrieval, physicians want to provide the best patient care possible, and they expect technology to help them achieve this goal.
There is such a thing as too much data, which physicians are reminded of each time they open a digital chart. Clinicians very often are left swimming in more data than they can adequately process, which can erode the crucial patient-provider human relationship.
To address data overload and dehumanization challenges, software partners must go back to the drawing board and visualize dramatic innovations that can be built on top of the nationwide EHR foundation. Significant cognitive overhead is required to distill hundreds of disparate pieces of clinical data into a salient picture of an individual’s overall health. The vast amount of data now available in a patient’s chart is quite often far more than any medical professional, no matter how clinically experienced, can consistently and reliably assimilate.
Physicians and their staff need intuitive technology to be their always-available, intelligent assistant, from start to finish during a patient’s visit.
When a patient’s record is displayed on the computer screen, physicians shouldn’t have to dig for relevant information about that visit. Instead, the EHR should be able to display the pertinent clinical data and health insights for the physician to review and assess a patient’s health condition more quickly and effectively. For example, lab values and vital signs relevant to that patient’s chief complaint are likely already stored as discrete values in the patient’s chart. An EHR that learns along with the physician’s workflow preferences should display only the most relevant data through easily digestible visualizations.
Guest post by Matthew Douglass, co-founder and SVP of Customer Experience, Practice Fusion.
Despite enjoying broad technological advances in their medical practices over the past decade, many physicians still find little pleasure in having to use electronic health records (EHRs). Reasons for low satisfaction run the gamut, from a litany of potentially distracting alerts to overwhelming features that are difficult to learn. This flagging usability, combined with the growing burden of data entry and documentation, impedes physician satisfaction.
Physicians do not begin their careers in medicine so they can spend a majority of their time wrestling with technology. A recent study found that physicians spend three times as many hours working on computers as they do providing direct patient care. It is no wonder that physicians are reporting record levels of burnout and deep job dissatisfaction.
There are practical workarounds to the challenges of using EHRs, such as programs pairing physicians with scribes that are pre-med students who assist those physicians or plugging in additional technologies that reduce direct documentation overhead. However, these practical workarounds mask the root problem rather than address it; EHRs have yet to provide consistently actionable insights that will help to dramatically improve clinical outcomes.
When a physician opens a patient record in her EHR today, she is probably no better equipped than if she were to open that patient’s paper record 10 years ago. All the data points she might ever need are available for her to sift through, but where is the insight? How is she supposed to interpret clinical meaning in individual pieces of data scattered throughout her patient’s history? How is the EHR assisting her in making better, more informed care and treatment decisions for her patients’ lives that she has been entrusted with improving?
EHRs were originally created as a digital recreation of the physical paper chart that accompanied a physician into the exam room during every patient visit. Vital sign collection sheets were recreated as vital sign fields on the screen. SOAP notes that physicians judiciously completed with pen and paper after every patient visit became digital SOAP note fields in the EHR that still have to be typed by the physician or a physician’s representative at the end of every patient visit. Billing one-pagers with pre-printed ICD and procedure codes have been replaced with nearly identical digital superbills containing point-and-click picklists of diagnoses and procedures.
Although we have created a digital system, the healthcare industry lingers in an analog world: Everything still operates like paper.
In the early 20th century, Henry Ford envisioned a future where transportation was dramatically better than what the main transportation technology of the time (i.e., horses) could provide. Confronted with this problem, he didn’t try to re-engineer horses to run 10 times faster. Thankfully, he set his sights on an entirely different and improved solution, experimented with a few ideas, and succeeded in completely altering the future of human transportation by introducing the first mass-produced automobile.
EHR vendors have a similar opportunity today, as they imagine the future of digital health technology that will be highly usable and incredibly helpful for physicians. Fortunately, EHRs are now broadly distributed enough that there is a solid foundation in place on which to build . Now that the vast majority of patient clinical information lives in a digitized form, we can look to the future and ask a novel, crucial question: How can this rich repository of clinical data evolve into upgraded tools that can be used to broadly improve patient health and physician satisfaction?
To best answer these questions, EHR vendors need to reevaluate the specific assistance that physicians can garner from digital health tools. First, clinicians and their staff must be intimately involved in the functionality discovery process in partnership with EHR vendors. This research can then be converted into success metrics and key questions that clinicians and vendors’ product teams utilize as benchmarks for measuring overall successful implementation.
Am I happier as a clinician because of this functionality?
Am I able to devote more or less time to focusing on my patient because of this functionality?
Overall, did this functionality save or cost my practice time and money?
Are my patients healthier and more satisfied with the service my practice provides them?
Further, as physicians are evaluating which digital health technology vendors to partner with in their practice, there are a few advantageous traits they should consider. EHR vendors that operate in a secure cloud offer distinct advantages because they can roll out frequent updates that do not interfere with a practice’s day-to-day operations. If a bug or usability issue does arise, the problem most often can be addressed quickly and without interruption.
Guest post by Richard Loomis, chief medical officer and VP of informatics, Practice Fusion.
In 2016 the healthcare industry made a number of meaningful strides on the move to value-based care, culminating in October with CMS issuing the final rule for the Quality Payment Program (QPP). As the largest program of its kind, the QPP will replace existing programs such as meaningful use and PQRS and fundamentally change the way providers receive payment for patients with Medicare Part B coverage.
In 2017, this focus on value will begin to shift to the vast value found in restoring the provider-patient relationship that drives individualized care and best outcomes. Healthcare isn’t ultimately about quality programs, big data or population health management — it’s about improving our shared human experience and to live happier, longer, more fulfilling lives. The healthcare industry will start restoring this humanity by unwinding the complexity of care delivery and supporting individualized care through a number of new and exciting ways in the new year. Below are five themes we’re predicting to see in 2017:
The year of EHR usability: EHR usability will become a critical success factor for providers as the burden of quality reporting continues to grow in an increasingly fee-for-value world. Practices already spend $40,000 per doctor per year — $15.4 billion nationwide — on collecting and reporting information about their care to Medicare, payers and others. These costs will increase in 2017 and disproportionately affect small practices. It will be financially impossible to practice medicine without a user-friendly EHR. Given this emphasis in usability, more EHRs will turn to offering cloud-based solutions to stay relevant and cost-effective.
Real world evidence comes of age: Real world evidence (RWE) will increasingly be used to support FDA approval for marketing new drugs, leading to further investigation through one or more RWE studies. Although randomized clinical trials continue to be the gold standard for establishing efficacy and safety, they may not reflect typical patient care or day-to-day experiences. RWE studies can include larger sample sizes and a greater breadth of patient demographics and clinical circumstances, which can help supplement the data derived from clinical trials. The FDA has already signaled their interest in RWE, and in 2017 we will begin to see it come to fruition.
Small practices recognized for their oversized role: Small independent practices are a cornerstone of the healthcare ecosystem: Independent solo and small practices are shown to have a lower average cost per patient, with fewer preventable hospital admissions, and a lower readmission rate among their patient populations. For CMS to drive additional value through the QPP, they will start to recognize and support small practices in 2017.
Guest post by Richard Loomis, MD, chief medical officer and VP of informatics, Practice Fusion.
If you bill Medicare, changes are coming in 2017 that may affect your reimbursements. Existing programs such as the electronic health record (EHR) Incentive Program (meaningful use) and the Physician Quality Reporting System (PQRS) are being replaced by a new payment system called the Quality Payment Program (QPP), which is a complex, multi-track program that will adjust payments from -9 percent to +37 percent by 2022. The Centers for Medicare & Medicaid Services (CMS) recently released the final rule that will implement the QPP as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
While the 2,300-page final rule outlining the new program is complex, successful participation in 2017 doesn’t have to be. Here are some tips on how to participate in the QPP starting January 1, 2017 to minimize the risk of any negative adjustment to your Medicare Part B payments beginning in 2019.
Step 1: Check if you qualify to participate
CMS has expanded the range of clinicians able to participate in the QPP compared to Meaningful Use (MU). Eligible clinicians now include physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists. However, you’re excluded from participating in 2017 if:
You’re a clinician enrolling in Medicare for the first time. You’re exempt from reporting on measures and activities for the Merit-Based Incentive Payment System (MIPS) until the 2018 performance year.
Your practice meets the low-volume threshold. This means your Medicare Part B allowed charges ? $30,000 OR you see ? 100 patients covered by Medicare Part B during the 2017 calendar year.
Step 2: Choose your participation track
Although the QPP will begin January 1, 2017, there will be a ramp-up period with less financial risk for eligible clinicians in at least the first two years of the program. CMS designated 2017 as a transition year to help providers get started in either of the two participation tracks: MIPS or the Advanced Alternative Payment Models (Advanced APMs).
MIPS streamlines current Medicare value and quality program measures — PQRS, Value Modifier (VM) Program and MU — into a single MIPS composite performance score that will be used to adjust payments. All eligible clinicians who are not participating in an Advanced APM should report under MIPS in 2017. Conversely, you’re not required to participate in MIPS if you’re participating in an eligible Advanced APM, as described below. Some APMs, by virtue of their structure, are not considered Advanced APMs by CMS. If you participate in an APM that doesn’t qualify as an Advanced APM, it will increase your favorable scoring under the MIPS participation track.
APMs are new approaches to paying for medical care through Medicare that provide incentive payments to support high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. The main difference between the MIPS and Advanced APM programs are that Advanced APMs require practices to take on more financial and technological risks.
They receive a five percent lump sum bonus payments for the years 2019-2024.
They will receive a higher fee schedule update for 2026 and onward.
It’s important to note that if you stop participating in an Advanced APM during 2017, you should make sure you’ve seen enough patients or received enough payments through an Advanced APM to qualify for the five percent bonus. If you haven’t met these thresholds, you may need to participate in MIPS reporting to avoid a negative payment adjustment.
How many doctors have you seen in your lifetime? Don’t know or remember? You’re not alone – the average American patient will see nearly 19 different doctors during their lifetime. Nineteen different offices. Nineteen different medical charts. Nineteen different phone numbers. Nineteen different calls to track down your records. Now, can you even remember your last five doctors?
The future: Imagine this, you visit your doctor – or any doctor for that matter – and they quickly pull up your medical history. Vaccinations when you were a child? Check. Currently on a hypertensive medication? Check. Pre-disposed to a medical condition? Yep, that’s in there, too. No more arriving 20 minutes early to the doctors’ office to fill out the industry-average seven pages of paper forms. Your records – past and present – are already being reviewed by your trusted provider.
Beyond the sheer convenience, the accuracy and completeness of having your entire medical history available at the fingertips of your provider can impact your well-being and scope of care. Can you accurately remember all procedures you’ve had? And when? Or all the medications you’ve ever taken? With dates? Imagine if you were a senior. Not just daunting, but nearly impossible. Instead of going over just snippets of what you actually remember, your doctor is empowered to holistically review your entire medical history with the potential to make more informed decisions about your health.
Seem like a pipedream? If you were to ask a mere decade ago, most would have agreed. As recently as 2007, 88 percent of physicians were still charting on paper. And those physicians on an EHR system – who were paying a premium – were almost exclusively using a localized, server based platform with no connectivity. For cost perspective, according to HealthIT.gov, the average upfront cost of implementing an EHR is $33,000 per provider plus an on-going fee of $4,000 yearly, a cost-prohibitive amount for most private practices.
Fast forward to 2009 and the passage of the HITECH Act which provided billions of dollars of incentives for providers to implement an electronic health record. In addition to the incentives, new vendors appeared on the market who provided electronic health record platforms completely free-of-charge, allowing providers to reinvest the incentives in their practice as additional staff, new equipment, etc.
In this series, we are featuring some of the thousands of vendors who will be participating in the HIMSS15 conference and trade show. Through it, we hope to offer readers a closer look at some of the solution providers who will either be in attendance – with a booth showcasing and displaying key products and offerings – or that will have a presence of some kind at the show – key executives in attendance or presenting, for example.
Hopefully this series will give you a bit more useful information about the companies that help make this event, and the industry as a whole, so exciting.
Facilitating more than five million patient visits every month, Practice Fusion’s platform is the new gold standard for ambulatory EHR technology. We can support your organization’s goals for risk adjustment, accurate coding and coordinated care management—in real time and at scale. We also partner to support clinical programs in collaboration with our physicians to improve outcomes for patients at the population level. Finally, our connectivity services provide a single point of connection to our ecosystem of over 112,000 health care professionals nationwide.
Practice Fusion is the #1 cloud-based electronic health record (EHR) platform for doctors and patients, with a mission of connecting doctors, patients and data to drive better health and save lives. A driving force in modernizing American health care, Practice Fusion is used by a community of more than 112,000 active medical professionals with over 100 million patient records under management. In 2014, Practice Fusion’s EHR facilitated more than 56 million patient visits (approximately 6% of all ambulatory visits in the US) and is the fastest growing EHR in the US.
Founded in San Francisco in 2005 and bootstrapped in a Starbucks, Practice Fusion has grown dramatically, building the largest physician-patient community in the U.S.
Services and Products Offered
Clinical data exchange, HCC code assist, digital care management
Interesting insight below from Practice Fusion about meaningful use stage 2 adoption trends, specifically state-by-state rates of effective EHR adoption. Am I surprised that large states like California and New York lag behind the rest of the country in EHR adoption progress? For some reason, I’m not really.
What surprises me here is that my native state of South Dakota leads every state in the country in the adoption of EHRs with Minnesota, Wisconsin, Iowa and North Dakota all making the top 10.
I’m also surprised that no other state really comes close to So. Dak. Minnesota, the next closest state in level of adoption is a full 10 percent behind.
Nevertheless, what does this suggest about rural healthcare facilities? Do they need the money more than their urban counterparts? Does the technology make it easier for them to practice with such a dispersed population or are they just able to make the move more quickly because they are smaller, more agile facilities?
The last reason is less likely. I’d think it’s a combination of the first two points I make, and that they fee the technology makes it easier to communicate and track patient outcomes across their respective geographies.
I’d love your thoughts.
The second chart below tells which organizations are implementing specifically. It’s no surprise to me that family practice has a healthy lead.
Dr. Lucy Hornstein, solo practitioner at Valley Forge Family Practice in Phoenixville, Penn., was not a proponent of electronic health records. An active physician blogger and published writer, she spent quite a few of her words on the technology’s uselessness.
They were expensive, overly complicated and tough to use and provided little return on the investment for users. Besides, most physicians, in her opinion, only implemented them because of meaningful use and the federal incentives they received for using them.
Paper, she had long decided, was good enough for her and during the first 21 years of practice in her own practice, she had no plans to change. It was only after the loss of one of her two staff members that she soon realized that she’d have to re-hire just to maintain her practice at its current load. However, that wasn’t an option for her. Neither, she thought, was adding an EHR to handle the management of the records because other than her perception of the technology, the self-described “dinosaur” didn’t have the budget for such an endeavor. She had zero for such technology.
Even if she had a change of heart and adopted the technology, she had not seen one system that was not cumbersome, not hard to use, intuitive to maneuver and or that offered her the option to meet the needs of her small practice while running the business efficiently.
Dan Rodriques, CEO of Kareo, discusses entrepreneurism, healthcare IT innovation, Kareo’s move into electronic health records and the EHR hangover.
As an entrepreneur, what is your approach to leading and driving innovation?
I have always been driven, and I knew I wanted to be an entrepreneur from a young age. Each of the three companies I have started came about for the same reason. I saw a problem and I wanted to fix it. I am a problem solver at heart and that is what drives innovation for me. I launched my first company, Scour, an Internet search engine, when I was 21. At that time, there wasn’t a way to search the web for multimedia content (photos, music, and video) and we developed Scour in response to that need. I had to learn about running a company on the job. I took what I learned with me on my next endeavor, which was a consulting firm. Each client brought a unique challenge with them and we developed technology solutions to the complex problems within their businesses. It was there that I started with a client in the healthcare industry. As I worked with that client, I began to see all the challenges facing healthcare and particularly small medical practices. This was the birth of Kareo.
In a recent conversation with Steve Ferguson, vice president of Hello Health, he described how the company is identifying new revenue sources for practices while working to engage patients. Even though the company’s business model is one that sets it apart and helps it rival other free EHRs, like Practice Fusion, I left the conversation with him wondering why more venodrs weren’t trying the same thing as Hello Health: trying something no one in the market is trying to see, if by change, a little innovation helps pump some life into the HIT market.
Along the same lines, myself and thousands of others in HIT have wondered why systems are not interoperable and, for the most part, operate in silos that are unable to communicate with competing systems.
Certainly, there’s a case to be made for vendors protecting their footprints, and for growing them. In doing so, they like to keep their secrets close; it’s the a business environment after all and despite the number of conversations taking place by their PR folks, improving patient health outcomes comes in only second (or third) to making money.
However, let’s move closer to my point. Given the recent rumors that Cerner and McKesson are working on a joint agreement to enable cross-vendor, national health information exchange, I’m wondering: Why don’t other vendors partner now and begin to build interoperable systems.
According to the rumors, the deal, if completed, could shift the entire interoperable landscape for hospitals, physicians and patients. It would position Cerner, which has more EHR users, and McKesson, which has a strong HIE product in RelayHealth with a loyal user base, to take on Epic Systems, a leading EHR vendor.
An announcement is expected at HIMSS13.
Here’s why this is important news: Interoperability mandates are coming. Like most things, it’s really just a matter of time. Systems will be forced to communicate with other, competing systems. They should already. It’s actually a bit shocking that given the levels of reporting required of care givers, the push for access to information through initiatives like Blue Button and patient’s access to information through mobile technology that there’s not more openness in the market.
The Cerner/McKesson news is incredibly refreshing and worth a look. Two major competitors may be realizing that by partnering they’ll be better able to take on each company’s biggest competitor: Epic.
Imagine connected systems exchanging data. The thought alone would be marketable across several sectors of the healthcare landscape and the move worthy of reams of coverage, which would lead to great brand awareness for each and the change to do what all EHR companies aim for: To create thought leaders; to stand out; to set the market on its heels.
If nothing else the partner vendors would stand ahead of the pack when future interoperability mandates are enacted and will be seen as experts in the exchange game. Tongue and cheek aside, the idea really is a good one and with no one currently doing it, it’s a great opportunity for a couple of HIT companies to actually move change forward and create an environment where information can be easily exchanged across practices, across specialties and across borders.
Then, perhaps, we’ll see a real commitment to improved patient health outcomes rather than them simply trying to improve bottom lines.