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June 22, 2017

Godfather of the Structured Medical Record Dies

Filed under: Data standards,EMRs,Medical Records — HankMayers @ 12:27 pm

For anyone who has worked to improve the understand-ability and availability of medical records, their godfather was always Dr. Larry Weed. Well, with his passing at 93, he now becomes our ‘patron saint.’ He died on June 3rd in Underhill, Vermont.

His passion for understandable (even helpful!) medical records has saved untold millions of patients over the years. He was truly a trailblazer, and will be missed.

May 25, 2017

Medicare Bundled Payments Starting to Get Push-back?

Filed under: CMS,Incentive Payment Programs — HankMayers @ 4:00 pm

HealthAffairs Blog published, on May 9th, an article on the “fatal flaws” inherent in the Medicare bundled payment (BPCI) program. See:

http://healthaffairs.org/blog/2017/05/09/medicares-bundled-payment-programs-suffer-from-fatal-flaws-but-there-is-a-logical-alternative/

Their concerns are as follows:

  • Their specified bundles are currently focused exclusively on in-patient care
  • Bundles lack factoring in consideration of patient severity
  • Encouraging hospitalizations for acute exacerbations of chronic conditions that could be otherwise adequately treated in non-inpatient settings
  • Quality measure reporting is just reporting – no performance thresholds on which to measure payment incentives
  • The quality targets are designed to move with trends, but the delays in notice can take up to 6 months so providers are not sure of the targets that their care will be judged against while care is actually delivered

One senses that there is a desire to have physicians be more in the driver seat on defining and controlling the encounters and the resulting quality. Indeed, HealthAffairs goes on to cite the recent recommendations of the Physician-Focused Payment Model Technical Advisory Committee (PTAC). Their recommendations apparently support an “episode of care model” developed by the American College of Physicians. Those recommendations include the following elements not currently in the BPCI

  1. Adjustments for patient severity
  2. Outcomes reflects gains and losses
  3. Physicians can self-assemble the best possible teams to manage a patient’s condition, illness, or injury
  4. Encouragement of teamwork across all involved physician disciplines
  5. Encourages physicians to find the most efficient and effective course of treatment and service setting for the patient

These are important factors that need to be properly incorporated into bundled payments. Of particular concern going forward, is that modifications need to be made, many along the above lines. However, the present administration in Washington has a penchant for declaring anything that preceded them as garbage. Hopefully, less polemically-oriented leaders will prevail, and an “improving/amending” approach will be adopted to make these changes.

We don’t need more confusion and discord in healthcare. We need continuing improvement.

January 9, 2016

Turning to the Problems Inherent in Getting to the Right Diagnosis

Late in 2015, the National Academy of Medicine (formerly, the Institute of Medicine a/k/a the IOM) generated an important follow-up report to their earlier To Err is Human: Building a Safer Health System.  Their 2015 report is entitled Improving Diagnosis in Health Care. The report starts out acknowledging that, in spite of its importance to the value of care, the diagnostic process remains a rarely studied subject.

Errors in diagnoses remains a significant problem. The report cited some study data that concluded:

  • Diagnosis errors contribute to around 10% of all deaths
  • 17% of adverse events in a hospital setting had diagnosis errors
  • An analysis of malpractice claims indicated that diagnosis errors were the leading type of paid claim

As significant as this problem is, the authors, Erin P. Balogh, et. al., found that there was limited research on this topic. The authors identified 3 themes that repeat in their findings on what inhibits study in this area of medical practice. Those themes are

  1. Data is sparse
    1. Few reliable measures exist
    2. Errors are identified only in retrospect
  2. Patients play a big role in the diagnosis, and often are not adequately factored in
  3. Reaching a diagnosis is typically a collaborative process, and support for such collaboration remains a challenge in healthcare

The study produced the following 8 goals that they believe can lead to improvement in the diagnosis process and reduce diagnostic errors.

  1. Facilitate more effective teamwork in the diagnostic process among health careprofessionals, patients, and their families
  2. Enhance health care professional education and training in the diagnostic process
  3. Ensure that health information technologies support patients and health care professionals in the diagnostic process
  4. Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice
  5. Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance
  6. Develop a reporting environment and medical liability system that facilitates improved diagnosis by learning from diagnostic errors and near misses
  7. Design a payment and care delivery environment that supports the diagnostic process
  8. Provide dedicated funding for research on the diagnostic process and diagnostic errors

What I find especially encouraging is that these goals reveal the systemic nature of the challenge in improving diagnoses. We need to make progress on a number of fronts. Like so much in the health care system, the challenges flow from the fact that healthcare is a team sport. And, as the first goal makes clear, central to the team is the (engaged) patient.

In all settings, the bedrock for effective team work is participant engagement and respect, backed up by effective communications. While not listed as a goal, the study rightly touches on the need for healthcare entities to become continuously learning organizations. Being able to learn from one’s mistakes, in healthcare, requires overcoming cultural barriers, achieving some simultaneous changes in how liability is addressed, and understanding what it means to be accountable in our complex healthcare system.

Not surprisingly, Goal number 3, Ensure that health information technologies support patients and health care professionals in the diagnostic process, clearly asserts that HIT must play a significant role. In addition, closer examination of the report details on Goals 1, 2, 4, 5, 6, and 7 reveals the need for new or enhanced HIT applications to meet those goals as well. Some examples of those related HIT applications or enhancements are [I acknowledge having elaborated on a few of these items to make them a bit clearer]:

  • Technologies (Portals/PHRs) that allow patients (1) to contribute valuable input to diagnoses, and (2) enable patients to provide feedback on diagnoses
  • Technologies that enable close collaboration amongst practitioners – electronic data exchange and interoperability were mentioned as an exceptionally high priority within the HIT realm
  • Within the educational/training settings, a need to include HIT applications that are typically used to support diagnosis within the live clinical setting
  • Move on from the present focus of EHR clinical documentation, which is mostly data that supports billing, to presenting and recording data that supports the diagnosis process
  • EHRs, Radiological, and Laboratory applications all must do a better job at focusing on the diagnosis process and providing better capabilities for tracking the evolution of a patient diagnosis and incorporating second opinions.
  • PHRs can play a stronger role in engaging the patient in the diagnosis process. The report also touched on the emerging opportunities and special challenges in incorporating mHealth-based data.
  • Radiological and Laboratory applications need good access to clinical information that resides in EHRs
  • Identification and tracking of performance measures specific to the diagnostic process
  • Expand the concept of entity-specific, and national, registries for never events to include diagnostic errors. Envision applications that can systematically gather relevant clinical data on diagnoses from clinical & other applications so to enable systematic analysis, feedback, and workflow improvement for the diagnosis process
  • Improved patient access to clinical documentation for the purpose of identifying and correcting diagnosis errors
  • More consistent use of human factors engineering and ergonomics to identify application design flaws that actually are contributing to diagnosis errors
  • Systematically leveraging and communicating the knowledge of the professional liability insurance carriers regarding diagnosis errors

I believe that the National Academy of Medicine with its Improving Diagnosis in Health Care report has done a good job of helping all of us think about the web of HIT applications and how it can be enhanced to improve one of the most important tasks in healthcare – getting the right diagnosis for a patient as quickly as possible. It will take years of effort, moving on multiple fronts. The good news is that what is being recommended is not blue sky, just very complicated.

A worthy challenge indeed.

Cheers

April 10, 2015

Standards-Based Interoperability Is Finally Being Candidly Addressed

Filed under: CHERT,Data standards,EHR Record Portability,EMRs,HIEs,Interoperability — HankMayers @ 9:29 pm

It appears that National Coordinator DeSilva has laid down the gauntlet over the obstacles that the software industry has often (tho not universally) placed in the way of true, open standards, interoperability. In the ONC’s own words from their report to Congress, Health Information Blocking:
“While many stakeholders are committed to achieving this vision, current economic and market conditions create business incentives for some persons and entities to exercise control over electronic health information in ways that unreasonably limit its availability and use. Indeed, complaints and other evidence described in this report suggest that some persons and entities are interfering with the exchange or use of electronic health information in ways that frustrate the goals of the HITECH Act and undermine broader health care reforms. These concerns likely will become more pronounced as both expectations and the technological capabilities for electronic health information exchange continue to evolve and mature.”

And the former Coordinator Mostashari tweeted substantial agreement later today when he said:
“The second interoperability challenge that is really top of mind for these practices, in many cases, that they have spent years inputting data in to the systems that they have paid for, and now, to get their own data out of these systems, they are having to pay the vendor $5,000 to $10,000 for an interface. We’re covering that cost, but it’s outrageous. What we really want is basically the CCDA that they, for certification purposes, are supposed to be producing anyway.”

It has generally been understood that leadership has been quiet on this major problem because of its complexity, and the need for the solutions industry to truly get behind electronic medical records. Well, after $28 billion in EHR Incentive Funds (and untold billions by others to address electronic records needs for sectors of healthcare that were not eligible for HITECH funds), it is safe to assert that the market is no longer in its infancy. There are important elements in the healthcare information highway that must no longer be ignored, and agnostic interoperability is one of them.

This is precisely the thrust of the remarkable letter of January 21, 2015 wherein 22 medical specialty boards and the AMA said enough was enough to the National Coordinator and the Secretary of HHS. One of their major complaints was the absence of any meaningful (my intentional wording) agnostic interoperability readily available by federally certified medical records systems.

The S&I Wiki and HL7 have made great progress in providing agnostic interoperability concepts and standards. We now need the political will and the sense of common purpose to designate those standards that the industry must use to gain CHERT (now, HIT Certification Program) certification on the matter of interoperability. While there is still ways to go to reach our ultimate interoperability goal(s), we can set a starting point with what we have now, and incrementally reach where we need to be.

This is one of those areas where we must place aside our national zest for competition, and cooperatively build that which we all must ultimately share.

I am going to be very interested in the buzz at HIMSS15 in Chicago next week.

Comments, anyone?
Cheers

December 14, 2014

Time To Review Important ONC Report

Filed under: Interoperability,Meaningful Use — HankMayers @ 6:36 pm

The Office of the National Coordinator for Health Information Technology (USDHHS) has just released their 5 year strategic plan. This is especially important as it is being touted as containing the answer to 2 significant current questions for HIT nationally.

– How will the sectors of healthcare that were left out of the HITECH Act be included?

– What is going to be the approach used to end the persisting difficulties in achieving interoperability?

This latest report can be obtained at the following URL:

http://www.healthit.gov/sites/default/files/federal-healthIT-strategic-plan-2014.pdf

March 31, 2014

The NIST Folks Chime-In on EHR Workflow and Usability

Filed under: CMS,EHR Incentive,Meaningful Use — Tags: , , — HankMayers @ 10:27 am

The National Institute of Standards and Technology (NIST) was directed by Congress to work with the ONC on the CHERT certification process as well as generally advise on the EHR effort. Given their background on the application of advanced technology, it is good to hear from them. Their findings reinforce much of what EHR implementers experience every day. One only hopes that the ONC can help champion this work in some fashion, and that the vendor community does not miss these considerations as they scramble to meet 2014 and 2015 CHERT changes.

While it is great to have the NIST credibility behind this topic, I have only one beef with their work; An organization with as broad a scope as they have, isn’t it about time that this analysis include a strong focus on mid-levels and other practitioners, who also must make considerable use of the EHR? With the advent of the PCMH, the significance of their use of the EHR is continuing to rise, and how the EHR enhances the staff integration of knowledge and activity is a key consideration.

If the NIST folks elect to perform a similar analysis of the INPATIENT world (which I hope they do), nurses, techs, and other classes of patient-serving folks are heavy users of EHRs in their own right.

One final observation: CMS’ ambulatory workflow in their DOCIT effort should have been included in the NIST research.

Thoughts anyone??

March 22, 2014

Federal HIT Policy Committee Advises that MU3 Objectives Be Reduced By 8

Filed under: EHR Incentive,EMRs,Meaningful Use — HankMayers @ 8:15 pm

At its March 11, 2014, the HIT Policy Committee to the ONC recommended that the number of objectives for Stage 3 be reduced by nine (9). The objectives that they believe should be removed include the following:
• Reminders via patient preference
• Handling patient requests for amendments to their record
• eMARs
• Automated Case Reports for the CDC
• Medication Adherence- tracking what is actually administered
• Syndromic Surveillance by EPs
• Access to Images
• Recording Family History

These changes leave the following as recommended Stage 3 MU Objectives:

Improving Quality of Care & Safety
1. Clinical Decision Support
2. Order Tracking
3. Demographics/patient information
4. Care planning – advance directive
5. Electronic Notes
6. Hospital labs
7. Unique device identifiers

Engaging Patients & Families in Their Care
8. View, download, and transmit records
9. Patient generated health data
10. Secure messaging
11. Visit summary/clinical summary
12. Patient Education

Improving Care Coordination
13. Summary of Care at transitions
14. Notifications
15. Medication Reconciliation

Improving Population & Public Health
16. Immunization history
17. Registries
18. Electronic lab reporting
19. Hospital syndromic surveillance

Next step: ONC final decision-making and the Publication of final NPR

September 25, 2013

The Road to Value-Based Purchasing in Healthcare is Emerging

Filed under: Uncategorized — HankMayers @ 3:35 pm

In my conversations with practitioners and administrators, one common refrain is serious doubt that the change from fee for service (FFS) to value-based purchasing (VBP) can be achieved. Indeed, I have to acknowledge that I have seen many a good big idea get lost in the details. And make no mistake; This is a VERY big idea.

Fundamentally, the current quality reporting/incentive programs must ultimately morph into vehicles that can enable VBP. And one of our practical problems is that there are quite a few different quality reporting programs at the federal level, and others within the private payer realm, that must come together, or at least be similar enough to avoid unacceptable increases in administrative burden and related cost increases.

After listening to a CMS information session on the Value-Based Payment Modifier (VBPM) program yesterday, I can say that significant progress is being made. Furthermore, I can add that the VBPM is a logically-incremental program designed to move us down the road.

Key themes undergirding the VBPM program include:
…….Based on existing NQF quality measures (process and outcomes)
……….Special subset of 17 measures are available from the following domains, consistent with current national quality goals:
…………clinical care
…………patient experience
…………population/community health
…………patient safety
…………care coordination
…………efficiency
…….Cost measures focus on (1) COPD, (2) heart failure, (3) CAD, and (4) diabetes
…….Various existing electronic reporting methods for quality measures all remain valid, including the EHR Incentive and the PQRS Incentive
…….The VBPM program factors for the complexity or clinical risk levels of the mix of the practitioner’s Medicare patients (a very important achievement)
…….A single reporting method for physician groups that elect this option
…….Can satisfy CMS requirement for quality reporting to avoid the start of penalties in 2015 for non-reporters
…….Successful VBPM reporters not only avoid the 2015 penalties, but may qualify for incentive payment premiums (up to 2%) if their quality and cost performance exceed the national mean for similar care and circumstances
………..If enrolled for the incentive, practitioners are also accepting the potential of a deduction (“shared savings/risk”) of up to -1% if their performance is well below the national mean for similar care and circumstances
…….There are a variety of detailed claims and patient reports that a practitioner can use to see how CMS arrived at the scores that a provider has/will achieve

Another part of the VBPM program is that it provides reports with analyses for current FFS practitioners, that are in groups (a TIN registered with CMS) of 25 or more physicians, which they can examine to see, from current claims data, how they might fare if they were to enroll in the VBPM and elected for the incentive payment. This is very helpful, and is the result of a lot input from physician groups.

This is a critical but complex topic, and I encourage my readers to go to the following CMS website to get more information.

    http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html

This is a very important topic that all of us need to (1) understand at a basic level, and (2) monitor as we go down this road, as it surely will evolve.

July 9, 2013

The EHR Auditors Are Coming??

Filed under: CMS,EHR Audits,EHR Incentive,HIPAA,Meaningful Use — HankMayers @ 11:15 am

Some of you may have heard that the CMS EHR Incentive program (for both Medicaid and Medicare) has begun the process of conducting audits of providers who have applied for, or have received their EHR incentive payment. There has been a lot of chatter as of late on this event, and not all of it accurate.

I can share with you the following facts and feedback that we are getting from CMS, HIMSS, and those being audited.

1. This does not represent some kind of negative political turn of events for the program. Yes there has been a number of congressional hearings on how the incentive program is doing. But these audits were always part of the regulations on the incentive program.

2. All providers are not being audited. Generally, the selections are made on a random basis

3. It is true that some providers are being audited before they receive their incentive. This is the case for providers seeking a Medicaid incentive. These pre-payment audits are apparently only focused on validating that the applicant has met the minimum threshold of Medicaid or “needy” patients (20%+ for pediatricians, or 30%+ for all other practitioners).

4. Medicare audits are conducted subsequent to the provider receiving his/her/its incentive payment.

5. One of the complicating factors is that the auditors’ requests are not consistent, but are changing, as the CMS auditing contractor, Figliozzi, gets clarifications from CMS on the way the regulations should be interpreted.

6. Your audit will require that you provide documentation to validate the data that you submitted in your attestation to CMS or your state Medicaid agency. The best strategy is to use the exact documents you used to construct your attestation – just like you would with your tax return. This would include:

a. Reports and/or screen shots from your EHR containing the data you submitted
b. If your attestation was for implementing, not using, your EHR (Medicaid only), the best proof is a confirmation letter from your vendor that their product was fully installed and available to you for implementation.

c. Copies of any patient lists you generated

d. Copy of your Risk Audit
……………1. Remember that it is possible that you could ALSO get selected for a HIPAA Security & Privacy Audit.
………………….This is an entirely unrelated audit process
……………2. Your EHR Risk Audit requires that you follow the HIPAA guidelines
………………….The HIPAA Audit will require that you ALSO be implementing remediation efforts on discovered short-falls in your current security & privacy practices
……………………….The EHR regulations do NOT require (at the present) that you be engaged in remediation efforts

7. If you fail the audit, you will be directed to refund your incentive back to CMS

8. There is a formal appeal process that is part of the EHR audit program.

9. CMS has published the following document on this audit program: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/EHR_Audit_Overview_FactSheet.pdf

We are very interested in learning more from healthcare entities on their experiences with these audits. Please share your experiences by commenting on this blog.

April 10, 2013

CMS Releases Final Electronic Clinical Quality Measures [eCQMs] for 2014

Filed under: EHR Incentive,EMRs,Meaningful Use,PQRI — HankMayers @ 7:52 pm

After much input from a wide array of stakeholders, CMS has just released the final regulation on the eCQMs that will be acceptable for meeting Meaningful Use at Stage 2 of the EHR Incentive program. The measures can be obtained at:

http://cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/eCQM_Library.html

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