As guest and panelist of the Business Law Section of the American Bar Association on April 14, 2011, I had the privilege of participating in a lively discussion.  The session entitled: “Healthcare Reform and the Cost of EHR” included the following highlights from my presentation that I would like to share.

For medical practices of all sizes the journey of incremental change in the context of healthcare reform and electronic health records (EHR) has only begun to take shape.  New business models for delivering medical care and reporting for patient outcomes and predictive models are goals that have both short and long-term implications.  First, new business models of care are a conversation for many practices as they determine how to navigate the possibilities of collaboration with consideration for the competitive landscape as well.  Second, reporting for patient outcomes and predictive models are being facilitated to some extent by the Centers for Medicare and Medicaid Services (CMS’) EHR Meaningful Use stage 1 criteria for structured data.  However, a robust realization of an enhanced patient experience will be driven by both collaboration strategies and knowledge management among a variety of providers. 

The commitment for all concerned in the delivery of healthcare demands a culture of both proactive behaviors and change management.  Although many of the changes are incremental, as with the adoption and use of EHR and their ongoing enhancements, the rate of change is rapid.  The rate of change will continue to have an impact on privacy and security of information within the healthcare industry and therefore must be a consistent part of the business strategy, technology strategy, and codes of conduct.  Consider the impact that an EHR vendor can have on a medical practice with regard to business strategy, delivering care on a daily basis, business risk, and cash flow. 

At least for some medical providers, challenge may also bring opportunity.  Healthcare reform, with its many uncertainties, will certainly have an impact on the importance of knowing the cost to provide every service and then measuring reimbursements for care.  The question many will have to ask is:  How do I develop and sustain a competitive advantage in a climate of capitated payments?  Answers to this question include factors such as:  finding a niche, productivity of people, appropriateness of EHR (and other technologies) for the business purpose, integration, and vendor accountability.  Collaboration of both people and technology must displace the climate of fragmentation within the delivery of medical care in many ways to realize the benefits of improved patient care while controlling costs. 

Here is a link to the full presentation:  Healthcare Information Technology: Collaboration, Competition & Outcomes

Trying to see the bright side of an incomplete scenario can be helpful in some cases.  However, in the case of your EHR system, you’ll very likely find the full glass more palatable than the one that’s half-full.  The Office of the National Coordinator for Health Information Technology is the source to find all of the EHR systems (http://onc-chpl.force.com/ehrcert/CHPLHome) that are certified in accordance with the Stage 1 criteria for EHR “Meaningful Use”.  One key distinction and therefore a necessary question in the EHR selection process though has to do with classification of certification being “modular” or “complete”. 

The short answer to this question is that “modular” certification means that the vendor has only demonstrated capabilities for a portion of the standard criteria necessary to put the medical practice into a position to gather and report on all of the appropriate data to qualify for the stimulus funds from the Centers for Medicare and Medicaid (CMS).  The implication for a medical practice that chooses a “modular EHR” is that they will likely have to purchase another EHR system.  The second EHR system from another vendor would have to be one that includes at least the remaining criteria that the first EHR vendor of choice has chosen to disregard at this time. 

The key is to ask a lot of questions of any EHR vendor, and that includes their business strategy too.  One great question in this context is:  “Why did you choose to pursue a modular EHR certification?” 

For more thoughts on this topic, here is a link to an earlier post on needs assessments for the medical practice:

http://www.waident.com/component/content/article/50-robert.green/460-why-a-needs-assessment-is-critical-for-emr

In the context of one of my earlier blog postings about the EMR needs assessment (http://www.waident.com/blog/viewpost/460) I wanted to take a moment to reiterate the need for a process both in EMR selection and in ongoing use.  Rather than thinking about how to convert a paper process into an electronic one, think about process improvements instead.  Setting goals for how the EMR system can provide more timely information, including alerts for the physician and other staff, will be a meaningful step towards recognizing value with your EMR system.  The key being not to overlook anyone in your process, as everyone has some impact on the medical practice workflow.

Here is an interesting article that provides some insight on how physicians are using EMR’s in the context of meaningful use:

Meaningful Metrics: The Patient Experience & the Baseline

I have talked with many physicians and practice managers in small and midsized practices across specialties about their thoughts and concerns on the path to EHR selection, implementation and meaningful use.  Some of these conversations steer toward waiting to see what their affiliated hospital will do.  While alignment with the affiliated hospital is certainly an important aspect of the EHR for the medical practice, the ongoing concern must be continuous process improvement within the practice.  Meaningful use can be part of the even bigger picture of your practice.  This is not only a change from paper to electronic but also provides more sophisticated and timely information.  The challenge many times is getting buy-in to the idea that everyone will be creating a new process and it does not happen overnight or even after a 3-day “go-live” with the EHR system.  The bottom line is that if everyone in the medical practice buys-in to defining and developing the new process within the EHR, there can be real benefits to making this leap.  If you have ongoing concerns about achieving meaningful use within the practice, here is an interesting article on the concerns that CIO’s of the hospitals have in this process:

Survey: 80% of CIO’s concerned about meeting Meaningful Use standards in time

With the ongoing interest in achieving “meaningful use” with EHR systems – here is a link to the new CMS (Centers for Medicare and Medicaid Services) resources website for EHR Incentives Programs:

http://www.cms.gov/EHRIncentivePrograms/

I have long been an advocate for considering the business process as a whole to identify opportunities for improvement and to establish a business case.  I have talked with physicians and practice managers who share the opinion that the goal of the practice is to get the doctor in front of as many patients as possible every day.  However, it is interesting how sometimes the other aspects of the operation in the practice can diminish that concerted effort when it comes to the bottom line in the financial statements every month. 

A real pain point within the operations I hear about time and again is collections.  After all, it is money that the physicians should have earned by providing care.  But what happens when people in the practice think more like individuals than as a whole practice?  The answer is that gaps develop and grow between people and their processes.  Technology, such as an EHR system, can be a great tool for creating efficiencies within the practice.  But those efficiencies are only as strong as your underlying processes for delivering care, managing collections, and every other aspect of the practice. 

One key point that we consistently talk about with our clients involves the alignment of their technology with the strategy of the practice.  The key here is that the strategy must be in place and everyone has to buy-in for best practices to evolve.  Consistently measuring your process through key performance indicator reports will then facilitate improvements.  Technology can help people become more efficient, but it’s only as good as the underlying processes.  We provide our clients with a variety of performance reports for their technology.  Further, we make time to discuss this information and the implications with them as well.  What makes this work is a shared vision and commitment between our clients and us. 

Here is an interesting article from someone I know and trust, Rosemarie Nelson, regarding the big picture view of collections for your practice:

How Big Is Your Collections Gap?

In my conversations regarding technology with healthcare professionals, privacy and security throughout the business/clinical process is a common source of pain.  After all, whether a medical practice is well into the use of an EHR or at some stage of selection/implementation, the business process is critical to determining how effective technology will be as a tool for everyone.  Each person in the practice has important responsibilities to fulfill and that, in many cases, requires access to patient records in some level of detail.  Having a concise technology management and use policy can go a long way in the development of best practices within the practice for concerns such as privacy and security because technology does have implications on both your people and processes.  The point is that whatever your process is today, using an EHR can be a great tool when it is surrounded by sound technology management policies for the practice.  What’s more, this is an ongoing process with much iteration.

Here are some interesting statistics regarding breaches of healthcare data and other personal information:

P2P Networks a Treasure Trove of Leaked Health Care Data, Study Finds

I have been having more conversations every month about the use and value of social networking sites for interacting with patients.  One of the concerns that I hear  time and again from healthcare professionals is apprehension regarding protecting patient privacy.  While privacy is always important, there are real benefits to being able to share insight with patients in an asynchronous environment. 

Consider the implications of using a social site as a resource tool for the physician to share with patients whenever they choose to view it – especially when the office is closed.   Telemedicine is a term that for some remains obscure in application within the physician-patient interaction.  I use my blog posts to share information with the people who I know and trust in healthcare.  Some people have even asked me why I share so much information.  The answer is that behind the scenes it’s actually a two-way street among my healthcare peers, clients and me and it makes all of us better off. 

Below is a link to an interesting article which gives examples of using social networks like Facebook and Twitter to interact with patients.  Whether or not you agree with this type of exchange with health information I think you’ll at least find this thought provoking:

E-Health and Web 2.0:  The Doctor will Tweet You Now

Have you been through some EMR demos lately?  I’ve been working with practices in various stages of EMR selection and use and one of the common themes that I’ve noticed is “buyer’s remorse”.  With all of the hype associated with the HITECH stimulus, it seems an interesting climate has developed – vendors talk about their CCHIT certification and then you should just buy their stuff.  Since many physicians would qualify for this incentive, assuming they have all the pieces in place for meaningful use, it’s just a matter of making the purchase of an EMR system and paving the road to receive those annual incentive dollars. 

But with so many EMR vendors out there, how can a practice make a commitment to buy and implement?  The answer may seem a bit counterintuitive at first, but these vendors should be qualifying for your business through a needs assessment of your practice.  Now you may be asking:  What about the demo?  The key here is that a demo is important, but it’s a later step in the process of evaluating these vendors.  The first step is to define from your current process what you expect the EMR system to do for every aspect of your practice and every step of your process.  Don’t be afraid to put the onus on these EMR vendors to qualify for your business before you invite them for that visit to your office.  By defining your specific expectations up front, you’ll find that you are much more likely to know what to expect when you begin implementation and are on the road to qualifying for that great incentive.

We feel that the needs assessment process is often ignored, but is extremely important in helping acquire the best EMR system for our clients. Because of this, we work closely with our clients to develop a robust needs assessment and have even created a template to be used to help the process be as painless as possible. We understand that our clients are busy, but they are the only ones who can specify in detail their business process and needs. Together we can set the expectations with the needs assessment and facilitate a confident selection process.  Going forward, we allow the practice to focus on their patients rather than worrying about their technology.

I recently read an interesting article about a business which sold an aging copier. The firm that acquired the copier took the hard drive out and could see all of their copy and print jobs. This is not a place you want to be – handing over a lot of patient information to someone who happened to get your old copier.  Most copiers have a hard drive with significant memory and that memory includes complete images of copies and prints made from the copier.  We just completed the exercise of clearing the hard drive on an outgoing copier for one of our clients.  There are real implications for all this data being stored – consider the implications of an outside party seeing every copy you’ve ever made. 

HIPAA is an acronym that can cause healthcare professionals to lose sleep for a number of reasons.  This image storage over the life of the machine should cause concern – but you don’t have to lose sleep with the right procedure in place.  The data that is stored on these hard drives can be easily retrieved and viewed.  Make sure you consider this in your risk assessment of privacy and security policies in your office environment and don’t get rid of that copier until you’ve managed for this issue. 

Here is a good CBS News video about this situation which has been receiving more and more coverage recently:

Copy Machines, a Security Risk?