The Office of the National Coordinator for Health Information Technology (ONC) and the Centers for Medicare & Medicaid Services (CMS) released documents detailing what physicians and hospitals must do to qualify for (EHR) incentive payments under the HITECH Act.  To qualify for incentives, physicians and hospitals must be using “certified EHR technology” in a “meaningful manner.”  These documents were released on December 30, 2009, one day before they would officially be considered late.

These documents provide a list of features physicians and hospitals need to have included  in their EHR technology and how these features are to used to meet the definition of meaningful use during the 2011 EHR adoption period.

There’s only one minor problem, there are no qualified organizations that can certify that your EMR is up to stuff including CCHIT.  That’s supposed to come later this year.  Instead of getting all puffed up about this I would say that the standard will have to be slimmed down and/or delayed, stay tuned.

Since I was in fourth grade I’ve had glasses, it general has never bothered me. When I hit my 40’s I had adjust because I had problems reading so my prescription lens became progressive lens. I never ever was tempted to switch to contact lens, seemed like much to much work and when people had problems it didn’t seem like it was worth it. So I’ve veen wearing eyeglasses for almost half a century!

But a couple of months ago I started to talk to a local New York LASEK service and it seemed like a solution because it deals with both near and far sightedness.  But even with this total solution for my eyesight that’s not what got me to decide. It was conversation with two very rational people not prone to exaggeration. These are people have measured responses to most questions you would ask them and they BOTH used the phrase “It changed my life”.

So I am excited about the LASEK and will be reporting on my progress from both a personal and healthcare IT prespective.

The Office of the National Coordinator for Health Information Technology (ONCHIT) will soon release a description of the “meaningful use” of electronic medical records (EMR). Until HHS releases what it will require for a EHR user to receive the EHR stimulus money, then it’s anybody’s guess just what the heck meaningful use of an EHR actually means, please forgive the pun

I can think of a number of factors that may or may not be part of this aspect of the standard:

• The number of years the practice has used the system within the practice.  Part of the way the money is being passed out is to encourage early adopters, they actual get a bigger incentive to convert to an EMR.
• Does the data on the system get passed to other systems.  In other words, is the data transparent and can other systems export and import the demographic and clinical information.  A simple example is placing a lab test and recieving the results back into the EMR.
• Does the system improve the quality of care.  Well duh, but I bet this is the hardest part to quantify but isn’t this the most important factor.

But as I’ve read the healthcare blogs I’ve seen another thought about meaningful use.  The concept evolves around that concept that “meaningful use” should somehow measure if the user(s) is/are move effective in their practive of medicine with the system.  From a productivity vantage key to measure this would be great but even more difficult to define.

In today’s ModernHealthcare.com there’s an article on EMR Usablity and CCHIT Evaluation.  The main point is simple, make the user friendly aspect of an EMR part of the certification process.   I am in total agreement, most EMR may pass the “mechanical” aspects of interoperability but are hard to use.

The stimulus act ignores the brutal  fact that traditional EHR systems will NOT solve much of the healthcare industry’s woes if doctors can’t or won’t use them. The incentives assume that “if you fund it they will come” this just isn’t the case.   I love this remark in the article “Based on the “success” of EHR systems over the past 10 years, this bet could be akin to AIG’s bets on credit default swaps.”

Here’s the problem with usability, much of this is in the eyes of the beholder.  Its not just a matter of how many clicks a task takes.  I agree with the sentiment of the author but this is a very subjective issue, classic apples and oranges.

According to the  people at Software Advice earlier this year the NAHIT established definitions for EHR, EMR and PHR. Given their authority, and the Bush administration’s plan to build an interoperable health IT infrastructure, EHR has become the standard phrase to describe an electronic patient chart. However, the majority of physicians are still searching for an EMR, and software vendors haven’t renamed their products.

Software Advise wrote their article EHR vs EMR - What’s the Difference? to explain the difference between the two systems and help physicians understand what role the acronym should have in their purchase.

I don’t remember seeing this on any of the regular IT healthcare blogs but it’s really mute.  EMR is going to stick for sometime and I wonder if NAHIT only made things more complex by trying to pigeon-hole the definitions.

I heard from Google regarding the Aspirin vs. Plavix issue.  If you put in the full dose aspirin then the warning does show up.  As I said on the Google forum this is incorrect but I am not going to split hairs here this is not medical advise.

On to the next step, as it were.  I went to my pharmacy, which in my case is Target.  I decided to ask my pharmacist to get help to get my data into my Google Health record.

I just love what happened.  My pharmacist is a very careful person.  When I pickup medication for other members of my family she will often not discuss the other person’s health issues with me, this is as it should be.  I love picking up my daughter’s birth control medication, its like talking to a monk who’s taken a vow of silence.

I explained to the pharmacist that about Google Health and how I want to get Target’s cooperation in importing the prescription data into the PHR.  The reaction from the pharmacist was and I quote “Isn’t this against HIPAA regulations?”  I had to laugh, she knows that I am in the health care field and I explained that it was not.  She managed to get me the name of the manager further up the food chain in the pharmacy division.

So I make the calls and basically they had no interest in doing this.  Their first problem is that they don’t control the data, its a third party ISP.  They were willing to get me the name of the company but I don’t think I’ll have much luck as a single consumer.

I am going to switch gears and see if I can talk to my doctors and/or hospitals and see if I have any better luck.

So I loaded up all my medications with the correct dosage information. Next I went to the drug interaction tab and I came up with no interactions. Am I doing something wrong because I know that Plavix and Aspirin can interact. They even say so in the Bristol-Myers Squibb Plavix TV commercial
Here’s the Google Health Screen shot:

This is an unhappy set of events. If I go to regular Google search I am presented with an number of regular news sources but also links that are ambulance chasers.

Here’s a CNN link from the first page of the SERPs:

http://www.cnn.com/HEALTH/library/DI/00060.html

The Plavix and Aspirin combination can represent a problem but I would rather risk the occasional nose bleed then another coronary incident.

This section needs work.

Regards,
Jordan Glogau

Now that Google Health is live I decided to give it a spin. As I said in a earlier post I don’t think much of these efforts but Google is a big name and maybe that alone will get PHR’s in the public eye. Well, its worth a try. I have used other PHR systems but I am going to approach this from scratch. I will try to keep track of my time and comment on the interface. I won’t do this all at once so it will be a number of posts. I will try to include screen grabs when I can .

Further, when I think I need data from other health organizations I will try to contact them and see if they want to join the party. Let’s see how deep the PHR rabbit hole really is!

So lets get started. I’ve decided to go right to medications. I am doing this because this is where my main concern is, drug interaction. I take a number of medications and I know that there is a risk because of the blood thinner that I take.

The first issue is, do you have the medications handy, or do you have a list that you keep with you. I have the latter, a list from my wallet.

Here’s the screen when your trying to pick out your medications.

OK, if you don’t have this list you’re lost. The real disappointment came when I finished putting in all my medications. Then I went to the Drug Interaction section. When I went there I go zero results. So I went back and only then did I realize that I need to enter the drug dosage information. Why is this a separate step, in AllScript you don’t have this separated.

So we have to go back and enter our dosage information. If you going to separate the two steps you need to inform users that all details are needed to get the interaction advice.

A small annoyance, there are an add and edit link for each medication. After trying the add button I realized it there if you take combinations of the same drug. How hard is it to explain this in plain English. I added a record and then had to delete it and “edit” it in the right place.

This could be tough, but some medicines come in multiple doses and you may take a combination of two dosage levels. Maybe just label it as dosage 1, dosage 2.

OK, now I’ve entered all my medications. At this point I am ready to see the results of the Drug Interaction. I will cover this in Part 2. In the meantime I will talk to my pharmacy, Target, and see if they are going to work with Google Health. I know I have other medications that are not active that they have in their database. This should be interesting.

Google Health is going to fail, it’s that simple. Actually since it will be in perpetual beta no one will notice.

It’s going to fail for the same reason that all PHRs are going to fail. You can’t design a system when you don’t have process and policy in place. In the US health market you have neither.

Right now we have the classic general system design philosophy being practiced. “If you don’t like the facts, get rid of them” Whether its Google Health, AllScripts, or Revolution Health its all a bunch of arrogant tech money trying to make more tech money, won’t work.

Neither the doctor nor the patient are truly at the center of any of these efforts.

Neither are most of the real stakeholders, a very long list.

Do I have a better idea, sure, who doesn’t. The question is how long will it take before the right people come to the table, some time. So in the meantime thanks for the betas, we’re all watching and learning.

Most Primary Care Physicians are more then familiar with CPT coding, or the Current Procedural Terminology (CPT) code set which is maintained by the American Medical Association.

These codes, mostly 5 digit numbers, represent the procedures that doctors, and other practitioners perform. These codes and are the basis on which payments from insurance and the Medicare are made.

This arcane system is normally reduced to a simple nomenclature based on the last digit in the CPT code. For example the CPT codes for new patient in-office visit are:

• 99201
• 99202
• 99203
• 99204
• 99205

These numbers go from 1 to 5 so they are normally referred to a Level number exam. The higher the number the more complete the examination will be. Healthcare professional will use the verbal shortcut and say “It’s a Level 3 exam”

But let’s look at what happens when its time to get paid for these services. The insurance carriers gather E&M codes on a per practice basis. They gather these statistics and then they establish ratios that they expect a doctor to maintenance for the higher coded exams. This is quota system, nothing more and nothing less.

It is not usual to our staff to establish a solid working relationship with their counterparts at the insurance company. As a large processor of claims we will often be given “advice” when a physician is getting too near the “quota” for the higher level exams.

What does this means? It means that a PCP has to be concerned with towing the carriers’ line or expect a request for further documentation or even an audit.

The Journal of the American Board of Family Medicine study, Accuracy of CPT Evaluation and Management Coding by Family Physicians study done in 2001 was quite through but came to the wrong conclusions. Physician under-code old patients because they are afraid that they will be punished for spending too much time on each patient, which is what the higher level codes actually represents.

Further, they “over-code” new patients because the higher codes are extremely restrictive. The Evaluation and Management Services Guide issued by the The Centers for Medicare & Medicaid Services (CMS) is a confusing document. Even the AMA’s CPT coding book has a section towards its back that tries to breakdown the different levels and explain them in plain English with specific examples.

Correct coding will decrease claims denials and speed up payments, as a billing company that’s what Preferred Health assists our practices to do. But if CMS and the major carriers want to move towards preventive medicine they need to move away form intimidation by CPT code.