MediNotes to PeakPractice to MyWay to…..?

My sympathies go out to the doctors and their staffs having to endure the Allscripts MyWay sunset.  Many of you started with MediNotes and were moved to PeakPractice then MyWay when both MediNotes and PeakPractice were sunsetted.  I know your pain, I rode that train with you as your implementation consultant and project manager.  You’ve patiently endured through the 2008 sale of Bond Technologies, 2008 sale of Medinotes, 2010 sale of Eclipsys and now apparent imminent sale of Allscripts.  We’ve patiently sat by while each newly constituted company merged cultures, systems, and software platforms.  You’ve waited for them to announce their “go-forward” strategy and software.  You have put vacations on hold, quelled staff revolts, and suffered lost productivity as you have implemented your “free technology uplift” when your existing EMR was sunsetted.

So what next?  If you’re a 1-10 provider medical practice, do you stay with Allscripts or move to another vendor?

Well, that’s a difficult question, and one I don’t think can be answered yet because there are so many other unanswered questions. 

Can a privately-owned Allscripts profitably make and support a competitively priced small-practice EMR and practice management software, when they have shown they can’t do this in the past?  Or do they even want to at this point?  Or do they want to focus on the acute care and large ambulatory care market segments, but feel forced to offer their existing mid-size practice software (Allscripts Professional) to their existing small-practice customers?  What will the future pricing of Allscripts Pro look like for small practices?  Can Allscripts overcome their reputation as being more sales-focused than  development and client support focused? 

That’s lots of questions, and I don’t see any answers yet. 

From where I sit, here’s what I see.  I see an EMR/PM market which had not produced a user interface which has created a devoted following.  No MS Excel, no Word versus WordPerfect debates, no Mac versus PC enthusiasm.  I see regulatory bodies shaping functionality for the EMR/PM platforms.  I see lots of little players in a growing market, but also a market which will see slimmer margins.  I see continued mergers and acquisitions of EMR/PM vendors.  I see more hospitals and health systems subsidizing EMR/PM software for independent medical practices in the hopes of getting their ancillary business such as lab work and radiology.  I see health systems consolidating medical care in their communities.  I see health information exchanges sharing patient information to an increasingly national grid of information networks.  I see the actual EMR/PM software platform becoming less important than the pipes of information that feed it, and those pipes of information will increasingly structure the user interface.

I anticipate medical practices will very likely see their existing EMR/PM vendors be purchased in the coming few years.  And the purchase won’t be for their software, but for their installed customers.  And those customers will also have to endure a “free technology uplift”.

So, I can’t say I have an answer for you at this point.  I think much of it depends on where you’re located and what’s going on in your medical community.  I’m sure most of you have already been approached by other EMR/PM vendors.  If it were me, I’d listen to their pitch, but also remember that any EMR/PM vendor is prone to the same pressures and questions as Medinotes-Eclipsys-Allscripts.

The intersection of YouTube cats and medicine

Ok, so I’m not normally one to watch cat videos on YouTube.  But this is a touching clip of hospital staff at Seattle Children’s Hospital using Facebook and crowd sourcing to bring a young cancer patient in isolation (and missing her own cat) some happiness by creating a “cat immersion” or “virtual feline cocoon”.   Enjoy.

The Informed Patient: What’s a health information exchange and why should I care?

There has been lots of talk the past few years about the changes to healthcare and how it’s delivered.  One of the driving forces of this change has been the desire to reduce the cost of delivering healthcare services while at the same time producing better outcomes for patients.  Health information exchanges, or HIE for short, are one tool which can help drive these changes.

In its simplest form, an HIE allows your doctor to share your medical information with medical professionals  in other organizations.  Just how this is accomplished and what information is available is dependent upon how the HIE is setup.

An HIE may be structured to allow your doctor to send lab or radiology orders to a hospital, and those departments can in turn electronically send back your results when available.

It may also be set up so your doctor can send your medical information to another doctor, such as a specialist you’ll going to visit.  Your information could also be made available so in case you need to go to the emergency department those doctors can access your information even if your own doctor’s office is closed.

An HIE is accessible only by users who have been given access, and they only have access to information which their user account gives them rights to access.  For example, it is typical for emergency room physicians to have special access to records in cases of emergency.  But a physical therapist wouldn’t automatically have access to mental health information.

Information is made available to an HIE when a doctor’s electronic medical record (EMR) software is given access to the HIE.  The doctor then makes patient information available to the HIE.  Typically patients are provided with a form to sign stating whether they wish to make their information available on the HIE or not.  Depending on the state and the healthcare organization, this will take the form of an opt-in or opt-out authorization.

An HIE can be privately run, such as by a hospital, or publicly run, such as by a state.  And an HIE can be connected to another HIE.  For example, multiple hospital systems can be connected through a state-wide HIE.  Whoever is in charge, the cost of the HIE is born by that organization and it will typically charge a fee to subscribers (your doctor or hospital) to access the HIE.  Patients are not directly charged for making their information accessible to an HIE.

HIE’s can be very helpful because in the past sharing patient information between organization has been inefficient and cumbersome.  When a patient was referred to a specialist, someone had to copy the patient’s medical file and mail or courier it to the specialist.  Or someone had to take the medical file apart, fax it, then reassemble it and file it way.  It may not sound time consuming, but when this is repeated multiples times per day every day, it is time consuming and expensive.  Plus, there’s usually a time delay because the doctor must first update the medical record, and if it was done through transcription it could take days before the record could be mailed or faxed.  Additionally, sometimes radiology films and other media end up in the wrong office or not returned to the primary care physician’s office and are lost.

Finally, don’t confuse the term “health information exchange” with “health insurance exchange”.  A health insurance exchange is a place where patients can shop for health insurance.  A health information exchange is where doctors can share patient information with other doctors.

So that’s a very simple explanation of a health information exchange.  For more information I’ve provided links to additional resources below.

Wikipedia

Healthcare IT News

Healthit.gov

Medicity (HIE vendor)

dbMotion (HIE vendor)

American Medical Assocation online article

 

 

When to Join an HIE- HIStalk Advisory Panel weighs in

HIStalk.com has an interesting post where one of it's advisory panels discuss' when is the appropriate time for providers to join a health information exchange (HIE).  Here's the LINK. 

The Informed Patient: Concierge medicine explained

Ask most people what concierge medicine is, and they’ll think it’s getting a Band-Aid from the hotel concierge.  Or they think of it as personal physicians for the very wealthy.  Well, in the past that may have been true, but it’s becoming more mainstream, and more patients will need to make a decision of whether they want to use a primary care physician who has a concierge practice.  This post will explain what concierge medicine is, why it’s becoming more prevalent, and provide links for additional reading.

What is Concierge Medicine?

The basic premise of concierge medicine is that a doctor will see and manage fewer patients, but provide more personalized and thus more effective care for each patient.  For example, a family doctor may reduce their patient inventory from 2,000 to 500.  The doctor would provide his cell phone and email address to patients, and generally be more available to patients as well as provide more personalized attention to their preventative health needs.  The doctor may also be more involved in working with specialists when a patient referred to them.

Concierge physicians will typically use one of two business models, though there are variations.  In the first model, the concierge doctor will charge an annual fee to each patient, ranging from $600 to $5000, averaging out at $1,500.  The doctor will continue to accept insurance in addition to the annual fee. 

In other cases, concierge doctors will charge patients an agreed upon cash rate for their visits, and the patient is free to file their own insurance claim if they wish.  The doctor won’t file claims or accept insurance from patients.

Why is Concierge Medicine Growing?

So why is concierge medicine on the rise?  Much of it has to do with the reductions in reimbursement payments from private insurance companies and public insurance programs (i.e. Medicare) made to primary care physicians.  In order to make up for the reduced payments, these doctors must see more patients.  They will typically reduce or eliminate hospital and emergency room visits, reduce patient appointment length, and increase clinic hours.  At some point many family and internal medicine doctors end up feeling like they’re on a never ending treadmill and can’t get ahead.  They also typically complain that the need for volume reduces the time they can spend with patients on preventative health, which typically reduces the cost of healthcare.  For example, if a doctor can discuss lifestyle issues with a patient and change their behavior instead of just prescribing medication, it’s ultimately less expensive for the health care system and the patient.  So they opt for concierge medicine.

Learn More

Expect over the coming months and years to hear more about concierge medicine and its advantages and drawbacks.  To learn more, check out these links.

 

Concierge Medicine article - wikipedia.org

PBS Newshour report on Conceirge Medicine- July 2012

 Forbes.com article 2012/05/23

Chicagotribune.com article 2012-02-01

 

dailyfinance.com article 2012/04/06

Hospital and Concierge ED: HIStalk interviews Sean Kelly MD, CMO, Imprivata

Healthcare IT blog HIStalk.com recently posted an interview with Sean Kelly MD, CMO at Imprivata.  He has some interesting things to say regarding his hospital ED and concierge urgent care experiences, as well as ED technology.

Better, Worse, or Just Different?

When we’re facing change, it’s easy to assume it will be worse or better.  But what if it’s just different? 

A few years ago I was working with a group of implementation consultants (IC) who were converting customers from one electronic medical record solution (EMR) to a new one.  This group was struggling with client expectations of how the new EMR would function and it’s workflow.  These client expectations were driven by their experience with the original EMR, which in most cases was the only EMR they had worked with.  In the client’s eyes, the original EMR, with its own set of strengths and weaknesses, was the norm.  Anything else was either better, or worse.

Well, in fact the new EMR did have some weaknesses, but it also has many more strengths.  And in many instances, it was just different.  And this was where the ICs were facing struggles.  They had anticipated how to handle the weaknesses, and it was easy to trumpet the strengths.  But the “just different” stuff was often just addressed in passing.  In many cases, these differences were wrongly perceived by clients as weaknesses.

One of the first things we did was to work on the IC notions of what was better or worse, and had them start to identify the things which were just different.  We worked on removing the value statements and inferences from their vocabulary.  We worked on tools to assist then in emphasizing “just different”, such as compare and contrast scenarios for training, small tests the clients could use to compare workflow, and comparative diagrams of old and new functionality and workflows.  Once the ICs began to internalize the “just different” mentality, clients started to get it too. 

So remember, change isn’t always about better or worse, sometimes it’s just different.

Another Iowa ACO

Genesis Health System in eastern Iowa has signed on to a collaboration with Wellmark Blue Cross/Blue Shield of Iowa to form an accountable care organization (ACO).  More details HERE.  This is the second ACO in Iowa, the other being Iowa Health System senior affiliate Trinity Health Systems.

DM Register: Iowa ACO examined

Today's Des Moines Register has an interesting article on Iowa's first accountable care organization (ACO) at Ft. Dodge's Trinity Regional Medical Center.  Trinity is part of Iowa Health System.  You can find the article HERE.

The article presents an example of care provided to one cardiac patient, them explains the ACO concept.  It goes on to present arguments from both supporters and critics of the ACO concept.

Side Note: On June 1, 2012 the Des Moines Register is changing it's subscription model.  Therefore, I'm not sure if this link will be valid after that date.

Telemedicine Technology Planning Questions

Most bad technology solutions are not created by bad decisions, but by bad questions.  In this post we’ll look at questions which should be part of a telemedicine technology decision making process.  For additional background on telemedicine, please refer to my previous telemedicine posts including a telemedicine overview, terminology, and technology options.  As I've said in my earlier posts, I'm not an expert in telemedicine.  I'm just passing along what I've learned as I explore this very interesting topic.

I’m going to lay out questions and considerations which you can use to facilitate your planning process.  I hope that as you read this you’ll think of many more questions nested within each area.  And that’s really the purpose of this post, to get you thinking of the right questions. 

Before making any technology decisions, it’s important to have a defined telemedicine business case and strategic need.  Technology is the means to an end, not the end itself.  If technology is selected without a defined business case and strategic need, it increases the odds of making improper and costly technology decisions. 

Not to put too fine a point on it, but technology decisions are wrapped up in general operations decisions, which are ultimately constrained by a budget.  The budget, of course, is constrained by reimbursement, whether fee-for-service or some flavor of capitation.  So figure out how much you can receive before you commit to how much you have to spend.

Information needs

What information will be received? 

What information will be sent out?

What is the quality of the information to be received and sent? 

What is the quantity of information to be received and sent?

When is the information to be received and sent?

What is the format of the information to be received and sent?

This may seem obvious, but it’s important to define information needs.  If a provider needs patient history prior to the telemedicine encounter, there needs to be someone and some process to make that happen.  If there is need for vital sign or mental state screening during the encounter, there needs to be someone and some technology to make that happen.  Maybe it’s an inexpensive fax machine, maybe it’s and EMR, maybe it’s a full-scale integrated telemedicine cart.  Whatever it is, unless information needs are clearly defined, it’s not possible to make an informed technology assessment.

Wrapped into this discussion is sharing of patient information.  This includes considerations for EMR and HIE.  If there’s a need to send out referral letters and CCD/CCR, the system will either need to handle it or there needs to be a manual process.  Volume counts here, a couple patients per day are much different than managing the process for 15 patients per day.

At some point there must be charge capture, so that will need to be considered. How does the clinical information flow to the billing clerk or CBO?

The Who

Who is the patient population? 

Who is facilitating the encounter for the patient (patient helper)? 

Who is the provider?

It’s my hope that planners will consider patient population needs.  The environment, tools, and process should create a positive patient experience.  A repainted closet entered from a busy waiting room may not be optimal for mental health patients.  A cool room with only technology devices may not be the best setting for an elderly population.

Patient population also impacts the telemedicine setting.  Ambulatory mental health patients can go to a fixed telemedicine location.  Elder care facilities may require a cart solution.  If the telehealth equipment is to be moved between facilities, then an even more mobile solution is called for.

Regarding the patient helper, if they need to attach an ECG, take vitals, or ask screening questions, they’ll need the proper clinical credentials and training.  They’ll also need aptitude and training to operate, troubleshoot, and maintain telemedicine equipment.  Finally, working with a remote provider is different than working with one shoulder to shoulder, so the patient helper will need the appropriate skills and training to be effective.

Regarding the provider, this person will need to facilitate the technology to successfully conduct a telemedicine encounter. This includes technical skill, but also skill and training on conducting a successful remote encounter.

Where

Where is the patient location?

Where is the provider location?

Does the location have adequate Internet connectivity?

Is the equipment secure?

Does the patient encounter location provide privacy and security for patient and data?

If you’re thinking of telemedicine, you’re probably already considered the care facility or setting.  But within that facility the equipment will need to be stored and secured.  The patient encounter location will need adequate privacy and security.  There will need to be a process for handling the patient and PHI before and after the encounter.  Any patient information will need to be secured and protected, which includes all pieces and parts of the telemedicine technology solution.   After all, you don’t want unauthorized people surfing the internet or playing with a camera and come across some bit of patient PHI.

It’s also important to consider where the provider will be located.  Most of the time they may be in their practice office, but will they also be available when making rounds or when otherwise out of the office?  If so, you’ll need to address a laptop or mobile solution for the provider. 

How

How is the telemedicine encounter and related information intended to be used?

This may seem basic, but will patient visits be diagnostic, follow-up, or chronic disease maintenance?  Knowing this may steer your technology decisions.  Assessing a patient’s lightheadedness differs from discussing their hypertension plan compliance.

When

When will encounters be conducted?

Will appointments be scheduled, walk-in, or on-call?

Are the patient care site, the patient helper, and the provider available for the appropriate days and time?

Typically we think of “when” in terms of scheduling method: scheduled, walk-in or on-call.  However, telemedicine presents its own set of coordination challenges.  This may not seem like a technology issue but it is.  If the remote patient location needs to be scheduled, there needs to be a way to track that.  Same goes for the patient helper and provider.  Is there shared scheduling software?  If it’s a paper schedule (a no-tech solution), who manages the schedule and coordinates the people and locations?

Conclusion

I hope these questions have provided some insight into what it takes to plan a telemedicine technology solution.  As I said at the beginning, this was intended to prompt to you think of additional questions if you’re exploring telemedicine and telemedicine technology.  If you’d like to discuss telemedicine and technology further, please feel free to reach out to me through this blog or via email.

Straight ahead,

Bob