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An EHR is like a good pair of shoes – you want them to fit right or you are going to feel the pain. And let’s face it, selecting the right electronic health record (EHR) for your practice is not an easy task – particularly for practitioners who may not have IT expertise. Plus, there are more than 400 providers of EHR/EMR products on the market today. It’s important to exercise caution and perform a thorough due diligence, but where should you start?

Nuesoft Technologies believes we have an amazing product that will truly improve your practice’s efficiencies and profitability, but we only want you to buy our software if it’s the “right fit” for you. We’ve got the insight of nearly 20 years of experience in the field of health information technology. But don’t just take our word for it. We encourage you to follow the suggested outline provided by Dr. Robert Lamberts in the Nov. 2009 issue of Physician’s Practice magazine. Lamberts successfully implemented an EHR in his office. Although he recognizes the fears and concerns of his peers, he also describes the positive impact the software has had on his practice.

Lamberts’ recommends that those considering purchasing an EHR start by first identifying any broken processes in their practice. What causes the most frustration to staff? To patients? Where is the most time wasted? Where is the greatest exposure to malpractice risks? Where is your office losing money? Improperly coded claims? Under-billing? Low volume? Over-staffing? Look at the whole practice – front and back office, not just at the providers.

Next, Lamberts recommends that you visualize what your “fixed” processes would look like. This is where you will develop your shopping list for that perfect pair of shoes! So what were your “fixes”? Never needing to search for lost charts – with an EHR, your charts are always a click away. Answering telephone inquiries – with charts immediately available, response times are much quicker. Improperly coded claims causing a delay in payment – with claim scrubbing capabilities you can get paid more quickly.

Now you are ready to start approaching vendors and looking for the practice management and EHR solution that best fits the needs of your practice. If the vendor does not suit you, cross them off your list and continue to the next vendor. And don’t forget to demo the software. Have a vendor representative walk you through how the software works, and ask lots of questions! Once you have a shortlist of vendors, consider the following and make your decision.

1. What is involved in product implementation?
2. Is the implementation process disruptive to your day-to-day operations?
3. What kind of training is available?
4. What is the response time if you have problems next week or next year?
5. How long has the company been around?
6. What are the hardware requirements – will it require you to buy new systems?
7. Who is responsible for data back-ups?
8. How will the data be securely stored to protect your patients’ privacy?
9. How often will the software/hardware need to be upgraded and what will this cost?
10. Is the solution scalable as your practice grows?

By now, you have a couple of vendors who are standing out from the rest. You like their graphic user interface, the functionality meets the needs of your practice and you are starting to get excited about how the new practice management and EHR solution can help your practice. Now it’s time to get references and ask your peers what they think about the software. Here are some questions you can ask:

1. How smooth was the implementation?
2. How well was training conducted?
3. What do you like best about the software?
4. What do you like least about the software?

Hopefully this has helped to further narrow your selection. The last bit of advice that Lamberts provides is to look at the purchase as a chance to improve your practice rather than an unwelcome expense. Remember that you get what you pay for and you shouldn’t waste your time on products that don’t meet the needs you identified at the beginning of the process. Focusing on cost first could rule out some of the best products and minimize your chance to find the best solution that maximizes your potential gains – giving you a shoe that just doesn’t fit.

Reference Link:
http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1425.htm

Source: November 2009 issue of Physicians Practice.

With public attention on the ARRA stimulus funds in recent months, physicians have been feeling the pressure to adopt electronic health records. The vision is that in the next couple of years, the technology will be advanced enough to exchange health data freely between systems. Yet there is some skepticism from many in the health care industry that the lack of infrastructure and data sharing standards means that the day of sharing patient records between providers, labs and hospitals is a lot further off than the current administration is hoping.

The announcement last week therefore that Florida will be putting Medicaid patient histories online was a welcome indication that other stakeholders are willing to get involved to put the necessary health data infrastructure in place. If practices know that payers and government agencies are invested in coordinating these efforts (and actions speak louder than words here), it will reassure physicians that they won’t be left alone to arrange dozens of interfaces with a myriad of other systems. If other states adopt Florida’s example, it would almost certainly speed health IT adoption by the smaller players that are currently ambivalent about making such a large investment in a technology that is still young. In fact, the inability of some smaller practices to afford EHRs at all has been another issue that has troubled advocates of health care technology. The Medical Group Management Association (MGMA) voiced the concern back in July that those practices without the purchasing power of larger medical groups would in effect be penalized for their inability to show meaningful use. This stumbling block to widespread EHR adoption may soon be removed if Senator Kerry’s proposed legislation to make smaller practices eligible for business loans to buy health IT is passed.

There is still a long way to go, but perhaps these and other measures will give physicians  confidence that the current path of health care enhances the chance that they will spend more time treating patients and less time tracking down information.

The “red flags” rule is now scheduled to take effect on June 1, 2010, after another delay announced earlier this week by the Federal Trade Commission as it considers new legislation that would exempt small businesses, including medical practices, from compliance. The rule mandates the creation of identity theft prevention programs, and will apply to any organization that can be considered a creditor with “covered” accounts (i.e.-commercial accounts that involve multiple transactions). Most providers, many medical billing companies and some health plans are expected to comply.

The American Medical Association, American Academy of Family Physicians and other industry groups have weighed in against the rule, on the basis that physicians do not meet the definition of creditors. A completely sensible argument. But medical practices need to proactively engage in some agreed-upon set of identity theft prevention practices. It’s in the best interest of consumers, not to mention practice owners, who’ll otherwise pay the price through legal costs, or through the provision of services for which they would never collect payment. Incidences of medical identity theft are increasing – enough to raise the gander of the government, which commissioned a study to assess and evaluate the scope of the problem. And smaller medical practices (which account for nearly 80 percent  of all U.S. practices) may be more vulnerable, as thieves could perceive them to be lower risk targets based on the assumption that they lack the sophisticated security procedures of hospitals or larger health care organizations.

Despite the widespread outcry from industry groups, the actual impact on a practice for complying with the red flags rule may be minimal. The new rule would simply buttress state privacy laws that already require health care organizations to respond to breaches of certain patient information. In addition, there is a great deal of overlap between the proposed FTC regulations and HIPAA, which applies to medical practices or other entities that are conducting electronic transactions.

Medical practices concerned about compliance can learn more at: http://www.ftc.gov/bcp/edu/pubs/articles/art11.shtm or http://www.ama-assn.org/ama1/pub/upload/mm/368/red-flags-rule-edu.pdf.

Drs. Kibbe and Klepper this week posted a characteristically thoughtful post on The Health Care Blog concerning the uncertainty surrounding EHR adoption and its role n health care reform. Their argument: that physicians do not know what level of Medicare reimbursement to expect next year as the SGR, which calculates Medicare reimbursement rates in an eccentric way, was not part of the package that was voted on earlier this month. Additionally, critical terms for ARRA incentive payments such as “meaningful use” and “certified EHR” have yet to be defined, plus there is a general lack of confidence about whether adopting an EHR is going to bring a sustainable return on investment, no doubt partially due to the still-evolving technology and the much publicized challenges of creating a nationwide system that is truly interoperable.

Their post was not anti-EHR exactly; more of a jumping-off point for a discussion about whether these factors can be corrected and what the major industry players should do, given the environment. Kibbe and Klepper are right on the money in their description of the current climate, but what they fail to note is that this confusion and uncertainty is short-term and is likely to be resolved (for the most part) in a matter of months. While it is regrettable that Medicare reimbursement is up in the air at the same time as some important definitions upon which ARRA incentives rely, let’s not forget that these definitions should all be hammered out by the second quarter of 2010.

Whether you see an intrinsic value in EHRs, interoperability is really the facet of health IT that will make them almost indisputably worth using, bringing better quality of care to the nation at the very least, with or without the cost savings for physicians that many say will also follow. Yes, interoperability is a big challenge, but there are a lot of parties invested in making it happen, from the government to hospitals to vendors such as GE, who this week announced they were launching technology to aid with setting up health information exchanges. This is encouraging because if interoperability is an issue attractive to businesses, progress is likely to be a lot quicker .Added to this, the price of EHRs is almost certainly going to decrease, driven by software as a service (SaaS) vendors, who can offer a lower-cost, lower-risk option to smaller practices. This will in turn aid interoperability, because these Internet-based solutions tend to be designed using data standards such as XML, and it will also help confidence in the security of EHRs.

In short, now may indeed be, as Kibbe and Klepper say, an uncertain time for physicians; but big changes are difficult to bring about without such a period of flux. While it may mean in the short term that physicians are slower to adopt EHR technology, there are too many players involved with too much invested for things to simply revert to the paper-based status quo. When the dust settles, we can only hope the nation’s health care will be the better for it.

The exchange of lab data is included in the draft of the meaningful use criteria, but as the HIT Policy Committee workgroup heard on Tuesday, exchange of data between laboratories and electronic health record systems in practices and hospitals will be a challenge to implement on a large scale for two main reasons. One is the lack of standards – there are not even standard naming conventions for orders, let alone existing standards for data exchange. And the second reason is that varying state laws will hamper direct access to test results. Some states only permit laboratories to release results to the physician or other person that ordered the test, meaning that if a patient is referred to a specialist, the specialist would have to access the test results via the other physician rather than directly from the laboratory.

Without data standards, interfaces between lab systems and EHRs are a long way from “plug and play”, as one of the professionals that testified before the committee explained. Planning, coding and testing means most interfaces cost about $5,000 and take about three months to complete – which makes them resource- and cost-prohibitive for the smaller hospital and independent labs that actually perform the majority of lab tests in the U.S. Even if the EHR vendors foot the bill (and they often do), without proper IT resources on the lab company’s side, it can be a slow process, particularly if this same process has to happen dozens of times with each different EHR vendor.

The Policy Committee has yet to release its recommendations, but summaries of the meeting seem to point to one common-sense conclusion – that standards are required before exchange of lab data can feasibly be considered part of the definition of meaningful use. This probably comes as no surprise to most in the industry, particularly the HIT Standards Committee, which has previously met on this very subject and whose Co-Chair, Dr. Halamka, has already suggested a set of suitable standards for lab data exchange.  However, the other part of the knotty problem; how to reconcile differing privacy requirements between states, is a legal headache that may prove harder to resolve. As interoperability in health care is explored in greater depth and we move into an era in which data-sharing across state and national borders becomes ever more common, expect this issue to become an ongoing part of the dialogue.

As previously discussed on this blog, one of the biggest hurdles to making health IT fully interoperable is that it increases the chance of massive scale privacy breaches due to some systems being less secure than others. In the Health Information Technology for Economic and Clinical Health (HITECH) Act, Congress inserted a clause requiring that in the event of a breach, all persons whose health information was compromised must be notified. Under the regulations, not only would the care provider be required to notify their patients; a breach by the EHR vendor in turn must also be communicated to the care provider. This creates an incentive for the vendor and provider alike to ensure the highest levels of security are maintained, and ultimately should lead to vendors making their systems more secure to ensure they remain competitive in the marketplace, as the security of an EHR may now be a deciding factor in a practice’s purchase. Additionally, knowing that these safeguards exist should bolster public trust in health care technology, a necessary step given the widespread consumer concern about losing control over the privacy of personal information.

Some members of Congress were therefore concerned to read that the Breach Notification Interim Final Rule modified the legislation’s original requirement with the addition of a “harm standard”. As they wrote in their letter to Secretary Sebelius last week:

“If the breaching entity decides there is no significant risk of financial, reputational or other harm to the individual, that provider or health insurer never has to notify their patients that their sensitive health information was used or disclosed in violation of the federal privacy rule.”

Their argument is threefold; first that “risk of harm” is extremely subjective and requires self-regulation, second that it will aid consumers to make informed decisions about a health care entity based on its breach record, and third that enforcement will be simpler if the rules stay black and white.

There is another side to the argument, of course; outlined with some clarity on this health care law blog. In brief, it suggests that some of the “real world” breaches that would occur would be insignificant and relate to individual records (such as a nurse accessing the wrong patient record accidentally, seeing that it was the wrong one and closing it again immediately) and that because of how frequently this is likely to occur, it would be overly burdensome to require mandatory notification in all instances.

The question is really whether incentivizing the tightening of security standards outweighs the interests of providers, many of whom are already struggling to implement health care IT effectively in their practices. When the 60-day public comment period expires toward the end of this month, the Department of Health and Human Services will have the unenviable task of deciding between these competing priorities.

As the health care community watches the EHR meaningful use criteria take shape under the American Reinvestment and Recovery Act (ARRA), some may be wondering whether the push for more interoperable health IT systems will truly improve care and reduce costs. Skeptics might find an example of success from an unlikely source: the government.

The Federal Health Architecture, which coordinates federal efforts for national healthcare IT initiatives under the Office of the National Coordinator (ONC) for Health Information Technology, kicked off in March 2008 with a goal to achieve interoperability in government health IT operations. On board are 20 federal health agencies and 16 private sector entities that are all able to securely exchange electronic health data through the National Health Information Network ‘s CONNECT software, which is available to all states through an open source platform. Results from pilot users are starting to come in, and they look promising.

The Social Security Agency was one of the first to begin using the CONNECT network, through a partnership with Virginia’s Regional Health Information Organization, MedVirginia. Initial data has shown decreased time to determine benefits eligibility (weeks to days), faster decisions on outstanding claims, and significantly reduced administrative work and costs.

The SSA/MedVirginia partnership, and FHA in general, offer a microcosm of what health care IT might be like if HHS succeeds in its vision under the ARRA to consolidate all information exchanges relevant to electronic patient records. Currently, the Health IT Policy Committee is requiring that by 2011 EHRs include seven electronic data exchanges; including e-prescribing, lab results, clinical data summaries from provider to provider, biosurveillance, immunization registries, public health and quality measurement.

While these attempts to facilitate shared, structured data exchange may still fall short when it comes to standardizing workflow within a practice (see Nuesoft blog post highlighting the impact of technology standards on practices), the government through its efforts is giving health care a needed push down the path toward interoperability, and thus improving continuity of care and communication among providers

If asked to name an initiative funded by the American Recovery and Reinvestment Act (ARRA) that will make a difference to health care in the United States, chances are the EHR adoption incentives would probably be the first to spring to mind. There is, though, a less obvious but potentially important answer: the broadband initiatives.

These initiatives, like the EHR incentives, are similarly aimed to use technology to provide public benefit; their goal to “accelerate broadband deployment in unserved, underserved, and rural areas” will have a positive impact on a wide range of businesses and individuals alike. Health care providers and patients in particular will be poised to reap great benefits from improving the technology infrastructure. It will mean that practices will have a wider choice of electronic health record systems and can consider Application Service Provider (ASP) solutions that require Internet connectivity (a particular boon for smaller practices who struggle to afford the large upfront costs for a client-server-based system) and it will also have an impact on telemedicine, which has been growing in popularity over the last few years.

Telemedicine is particularly valuable for rural areas where there is a low density population spread over hundreds of miles; traditionally, such communities are difficult to serve effectively. As well as two-way video conferencing, telemedicine also includes remote monitoring and could even extend to surgeons performing operations from miles away using remote-controlled robots. These technologies can increase patient access to care in a variety of situations. On top of benefitting rural communities, they could allow patients to be monitored after they return home from surgery or allow specialists to offer services to a much wider geographic area. However, current barriers to adoption not only include lack of access to a high-speed Internet connection, but also the lack of payer consistency in reimbursement for these services. Currently, Medicaid covers certain telemedicine services in just 27 states, and private payers up until now have also had a spotty reimbursement record. Other potential issues include state-based licensure limits, an absence of clearly defined privacy standards relating to telemedicine as well as concerns about how it might increase liability suits. Nevertheless, access to broadband across the United States is a positive step toward harnessing available technology that could improve patient outcomes in a way that would have been unimaginable 50 years ago.

You can read more about the broadband initiatives and access materials relating to its impact on health care here.

An article by Neil Versel published in CMIO magazine this month provides a great breakdown of what meaningful use is, why it has become part of the criteria for receiving stimulus funds, and what practices and hospitals need to do about it – right now.

In a nutshell, meaningful use is important because the government is not interested in providers going electronic as an end in itself; the whole point is to foster better ways to share information, thus bringing down costs and improving quality of care by making each patient visit less about gathering pieces of the puzzle and more about effective diagnosis and treatment.

The trouble is, providers are facing a dilemma. If they don’t choose and implement an EHR soon, the chance of them meeting all the criteria for meaningful use is slim, especially for smaller physician practices who can’t afford to have a member of staff devoted to EHR implementation. Added to that, if they wait too long, they will have to meet the more stringent set of 2013 meaningful use criteria straight off the bat, somewhat like going from zero to 60 in under five seconds. However, the meaningful use requirements have not yet been finalized and probably won’t be until at least the beginning of 2010 – and the problems caused by rushing out and choosing an EHR without proper research could far eclipse the benefits gained from adopting one.

One survey from the EMR Straight Talk Blog seems to show an inverse correlation between reading the meaningful use requirements and wanting to benefit from the government’s program, indicating that as physicians find out how much will need to change before they can meet the requirements, they are deciding to simply ignore the juicy carrot of stimulus incentives in favor of sticking to their existing plans (or lack of them) for EHR adoption.

Will this picture change over the next few months? As organizations such as the Medical Group Management Association (MGMA) weigh in about the burden that these requirements will put on the average small practice, it is possible that the Office of the National Coordinator (ONC) will reissue a final set of meaningful use requirements that are less off-putting to the group that will ultimately cause the success or failure of this initiative – the physicians themselves.

With Emdeon last month announcing the launch of its initial public offering, there has been increased scrutiny on the role of clearinghouses in the health care industry. Providers rely on clearinghouses rather than submitting their claims direct to payers due to complex (and to a provider, often seemingly arbitrary) stipulations that differ between each payer. If the government is considering trimming the fat from health care costs as part of health care reform, it may well make sense to eliminate “middle-men” companies and instead implement clear nationwide standards that payers are not at liberty to change. In this way, a provider filing a claim to Medicare in Georgia would require a CMS 1500 form filled out to exactly the same specifications to Blue Cross Blue Shield in Kentucky, say.

Creating such standards would reduce cost and would also likely increase reimbursement for providers, who even with clearinghouses can often suffer through cycles of  rejected and resubmitted claims. Until the time such standards are implemented across the board, however, clearinghouses do provide a simpler way of checking patients’ eligibility for benefits, catching many errors on claims before they are submitted, and likely speeding up reimbursement and increasing efficiency for physician practices across the board.

The respectable performance so far of Emdeon’s IPO says it all: in an ideal world, clearinghouses may not be needed, but in a country where there are numerous other industry reforms at the head of the line, investors don’t need to worry that Emdeon or its competitors are going to be redundant any time soon.