Like Scorpions, Closed Records Cause Paralysis

Take a step back from the challenges that surround health information technology (HIT) interoperability and you will recognize that market forces and a desperately fragmented health care system make hospitals and vendors act the way we do.

It calls to mind the fable of the scorpion and the frog, which is worth revisiting.

Wanting to cross a river, a scorpion spies a frog in the water and asks for a ride to the other side. Naturally afraid of being stung and killed, the frog hesitates, but is finally convinced by the scorpion’s argument that stinging the frog would be the end of them both in the dark flowing water. Midway across the river, the scorpion does indeed sting the frog, dooming them both. When the frog asks why as they sink beneath the surface of the water, the scorpion says, “Because I’m a scorpion.”

Compare what the fable has to say about innate characteristics with the current state of interoperability. The predominant proprietary HIT vendors know about the interoperability gap yet engage in prolonged foot-dragging on even basic data interfacing. Yes, healthcare IT is their business. No, interoperability is not in their nature.

A recent report by health research firm KLAS underscores this less-than-ideal reality: The federal government (they use our tax dollars, I must remind) has spent more than $25 billion on EHR adoption incentives and less than half of acute and ambulatory providers say their EHR is interoperable with other systems. Indeed, only 20 percent of providers are "optimistic" about vendor collaboration initiatives like the Cerner-led Commonwell Health Alliance.

The problem (apologies for beating a dead horse) is with the business model. The prevailing proprietary HIT business model is based on making the vendor the sole source of technology. Complexity of data sharing helps create a vendor lock scenario in which opening up the records is bad for business.

This situation has not gone unnoticed in Congress. As widely reported this past summer, U.S. Rep. Phil Gingrey (R-Ga.), a physician and member of the House Energy and Commerce Committee, singled out Epic for criticism, quoting a RAND report that asserts Epic provides “closed records.”

With incentives focused on driving interoperability, Gingrey asked the obvious question:

“Is the government getting its money's worth? It may be time for the committee to take a closer look at the practices of vendor companies in this space, given the possibility that fraud may be perpetrated on the American taxpayer.”

Of course Epic founder and CEO Judy Faulkner counters that her system is actually open and interoperable. In a September interview with the New York Times, Faulkner explained that Epic’s Care Everywhere solution connects hospitals nationwide. What she did not say is that the company created this bridge to compensate for the complexity of Epic implementations, which are so unique that two distinct Epic systems cannot plug and play. Uniqueness drives complexity and dependence.

Hospital-based health systems, the primary clients of proprietary vendors, are not embracing true interoperability even when it’s mandated. Once again, our fragmented health care market drives hospitals to hold onto patients and keep them in the system. Beyond the financial carrot of Meaningful Use, what is their incentive to truly interoperate on patient care and sharing patient information? The squeeze on hospitals is only increasing; the compulsion to retain patients and provide all possible services, thereby driving up revenue, persists, ACA be damned.

I experienced these forces recently while talking with a large health system that wanted to integrate more tightly with affiliated hospitals. The health system uses a proprietary EHR that the affiliate hospitals cannot afford. When lawyers for the health system became involved in the search for a “less expensive alternative” to use at the affiliate hospitals, talks abruptly ended. Restrictive contracts? Anti-disparagement clauses? The exact cause remains a mystery.

The JASON task force, an independent scientific group that advises the federal government, provided a glimmer of interoperability hope last April in a report commissioned by the Agency for Healthcare Research and Quality. The report called for HIT to open its platforms through as many application programming interfaces (APIs) as possible, enabling EHRs to truly interoperate.

JASON Co-chair Micky Tripathi, CEO of the Massachusetts eHealth Collaborative, believes government should require “public APIs” and the market will drive outcomes oriented around true interoperability. "Federal government doesn't have to be regulatory in this model," he said, explaining that Washington could simply align its own programs around an API strategy and use its massive purchasing power to move the market.

Like the frog in the fable, the US health care system, patients and taxpayers are all paralyzed, as is Congress (still and again). Like the scorpion, large health systems and proprietary HIT vendors are doing what comes naturally. Unless something dramatic happens in the way we pay for care, the paralysis in the American health care system will endure.

Edmund Billings, MD, is chief medical officer of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: billings

EHR Design and Dissatisfaction: It’s a matter of time.

As reported last year at HIMSS and by many online news and opinion sources since, physician dissatisfaction with EHRs is growing. Indeed, while this blog post doesn’t focus on the broader picture, general physician career dissatisfaction is disconcertingly high.

The breakneck push for more and better EHR use as a component of regular medical care is a significant part of that malaise, but it is insufficient as an explanation. For the most part, doctors really don’t like what the health IT industry is giving them to work with. The HIMSS survey proves it, showing that around 40 percent of physicians would not recommend their EHR to a colleague.

One would expect an industry to develop better products and improve usability, acceptance and satisfaction over time. In health IT, the opposite has occurred, with most pointing fingers at Meaningful Use as the culprit for awkward workflows and Rube Goldberg solutions cobbled together so everyone can get paid in a timely manner. 

It seems EHRs are taking more time to use rather than less, which was the original goal.

According to a survey published this week in JAMA online, this is exactly the case. In an article called, “Use of Internist's Free Time by Ambulatory Care Electronic Medical Record Systems,” a team led by Clement J. McDonald, MD, looked at the amount of time EHRs carved out of what physicians consider their free time.

Here is a summary of their findings:

  • 411 physician respondents
  • 61 different EHRs used
  • 9 EHRs used by 20 or more physicians
  • 59.4 percent said they lost time after moving to an EHR from paper
  • 63.9 percent said note writing took longer with an EHR
  • 33.9 percent said it took longer to review EHR charts than paper
  • 32.2 percent were slower to read other clinicians’ notes

So, how much time did physicians lose to EHRs? 

On average, they lost 78 minutes a day or 6.5 hours per week.  If a clinic workday is 8 hours, these physicians were spending almost a full extra day each week on EHR-oriented stuff. Because responsibilities and lurking error potential are relentless, physicians operate in a state of constant urgency. (This is also a potential explanation for unreadable handwriting.)  It’s no surprise, really, that losing the better part of a day to the EHR will cause significant frustration. 

Naturally, since 78 minutes extra per day was the average, some EHRs took much longer and others took less time. The EHR that took the least amount of time was VA VistA, which averaged about 20 minutes per day and 100 minutes per week—80 percent less than the overall average of 6.5 hours. 

Think about that. How much more would your level of job dissatisfaction rise if technological change added 78 minutes to your day versus 20?  

Understanding why VistA requires so much less time means understanding the evolution of system design. VistA was created to be rapidly adoptable. All other goals were and have remained secondary.  Physicians interning at the VA rotate through frequently and cannot spend a day or more learning the health IT system. Generally, they get a two-hour orientation and the rest they learn on the job. The EHR has to be inherently straightforward to learn and use or efficiency is lost and the VA ends up like every other hospital in America. 

VistA’s core functions—orders, notes, notifications and chart review—are easy to manage and enable rapid workflow. In large measure, this is the product of a community development process as opposed to a company competing in the feature function wars that have bloated most EHRs. The effectiveness of VistA is validated by a recent Medscape EHR study in which VistA CPRS was rated number 1 overall for physician satisfaction, number 1 in data entry, and number 1 in usefulness as a clinical tool.

The key component in the effective use of EHRs is time. A well-worn axiom tells us it takes a long time to write a short note. So, perhaps it also takes a long time to design an EHR that generates short notes … that helps get work done efficiently. Ultimately, EHR’s should create time for patients, not take it away. Technology may make patients safer—an arguable point for many in medicine—but if it can’t improve efficiency, it will only contribute to what looks like the ongoing disintegration of American healthcare.

Edmund Billings, MD, is chief medical officer of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: billings

The squeeze is on for U.S. hospitals

Lots of financial scrambling, but the numbers still don’t add up

Is healthcare a business?

In the United States, the question has been asked time and again but never satisfactorily answered. By virtue of publically financed healthcare systems, the rest of the developed world has decided, to a greater or lesser extent, that medicine and healthcare are not pure businesses—that citizens have a right to care, even when they can’t pay all associated costs.

It’s starting to look like Americans won’t be able to duck the question for much longer.

In the last year, the profitability of U.S. hospitals eroded for the first time since the Great Recession, pushing some closer to and others over the solvency precipice. Revenues are down and costs are up.  And these issues appear systemic and entrenched, giving rise to a series of important and relevant questions: How can hospitals adapt?  If they do, will they still survive? And, do we as a nation think it’s important to make hospitals accessible, even if they lose money?

As recently reported in the New York Times, analysis by Moody’s Investors Service shows that this year nonprofit hospitals had their worst financial performance since the Great Recession. Among the 383 hospitals studied, revenue growth dipped from a 7 percent average to 3.9 percent on declining admissions.  For the last two years, expenses have grown faster than revenues, and fully one quarter of all hospitals are operating at a loss. 

In a word, Moody’s describes the situation as “unsustainable” because it is the product of what look like enduring realities:

  1. Private insurers did not increase payments to hospitals.
  2. Medicare reduced payments due to federal budget cuts.
  3. Demand for inpatient services declined as outpatient care options rose.
  4. Retail outpatient options now compete with hospital clinics.
  5. Patients with higher copays and deductibles chose not to seek care.
  6. Hospitals are buying up physician practices.
  7. The costs of electronic medical record systems are impacting the bottom line.


Will all these influencers remain constant? No. But they don’t have to. A handful should be enough to push some hospitals into the next life.

The Moody’s analysis is simply evidence of continuing weakness in the healthcare marketplace. Earlier this year Standard & Poor's evaluated 138 healthcare systems and found an operating margin of 2.2 percent for 2013, down from 2.9 percent in both 2012 and 2011. Standalone hospitals were squeezed slightly more than hospital systems because they have a narrower range of operations and services from which to profit.

While the decrease might be the point, can we pause for a moment to recognize the paltry 2.9 percent margin? Just a tremor in the operating budget of any hospital with that small a margin will probably send it over the financial cliff.

In Sebastopol, California, north of San Francisco, 37-bed Palm Drive Hospital is shutting its doors. Despite clear demand for both inpatient and outpatient care, Palm Drive has labored for years to make up for reductions in Medicare reimbursement rates with more inpatient services. Over the next ten years across California, hospitals will see a reduction of more than $23 billion in payments, including $17 billion related to prevention and readmission penalties instituted by the Affordable Care Act.

“Unfortunately, Palm Drive is not an isolated case,” said Jan Emerson-Shea, a spokesperson for the California Hospital Association. “There are hospitals across the state that are really struggling to remain open and operating.” 

Indeed, nationwide the outlook for smaller, rural and standalone hospitals is gloomy.  Moody’s sees more earth-shaking change coming when insurers move to pay for quality and not services—from a system that thrives on illness to one that rewards health and wellness. The transition is happening now, and the pace will only increase.

The knee-jerk reaction to this situation for any organization with a budget is to lower costs. For hospitals, that means reducing staff and further burdening existing employees. This may be an effective strategy in accounting or restaurants, but the result in won’t be late nights poring over spreadsheets or cold entrees.  Labor reductions in healthcare can only decrease quality and increase costs in the long run.  More errors lead to less reimbursement, and the squeeze continues until the hospital gives up the ghost.

There is a way out of the squeeze, however, available to those that can adapt by lowering costs and increasing quality. Hokey as it may sound, it is possible to redefine hospitals for a future based on best practices. 

Where does this supposedly mythical future exist even now?

How about in Wisconsin? Members of the Wisconsin Hospital Association have used quality improvement programs to decrease readmissions, lower infection rates and curtail adverse drug events, resulting in statewide savings greater than $45 million over several years.  As President Steve Brenton wrote in WHA’s 2013 Quality Report:

Health care value can be improved by either raising quality while controlling costs, or by decreasing cost while maintaining quality.  If value improves, patients, payers, providers and suppliers can all benefit while the economic sustainability of the health care system increases. When improvement work reduces hospital-associated infections and readmissions, the improvements in quality translate to cost savings, and that is a value to local employers, insurers and patients.

The WHA Partners for Patients program targets best practices and outcomes based on Institute for Health Care Improvement programs. Organized efforts across member hospitals have achieved these remarkable outcomes and savings.

Of course, these results require health IT and electronic health records for programs that create outcomes stakeholders value and will pay for. Hospitals must promote their quality metrics and negotiate rates with these stakeholders.

But, while the numbers from Wisconsin and other regions are encouraging, this is not simply a situation of making the numbers work. The savings realized when hospitals focus on quality are in the tens of millions; the reductions in payments expected to continue are in the billions. There is a yawning chasm between the two.

Currently, payers are moving to a 5/1 ratio. A survey released last month by Blue Cross/Blue Shield estimated that for every $5 in reimbursements, only $1 was a reward for improving care and lowering costs. As these and similar arrangements are negotiated, you can be certain that the smaller non-profit hospitals are last in line.

The mandate for quality care and cost savings is clear, but the numbers still don’t add up.  Can non-profit hospitals change fast enough? Until they do, or if they can’t, are we as a society willing to support them because we think the care should be available?

Edmund Billings, MD, is chief medical officer of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: billings

Physicians prefer VistA. So should decision makers.

Let’s start simply with the results. The questions will come later.

In their 2014 EHR Report—a survey of 18,575 physicians on their EHR preferences—Medscape concludes that doctors like using the VA’s Computerized Provider Record System (CPRS), the core electronic record in the broader VistA platform, more than any other solution.

Here’s what they said.

The highest-rated EHR, with a score of 3.9, is the Veterans Administration EHR: VA-CPRS. It’s regarded as one of the best overall by our physician respondents.

(Of course, Medscape said a great deal more than this about CPRS and EHRs in general. And their survey revealed much about how physicians view the use of EHRs and the vendors who provide them. I would encourage anyone who’s interested to look at the report in more detail.)

With regard to physician satisfaction, Epic finished in 8th place, Cerner was rated 15th best and Meditech 18th. Scattered among these enterprise solution providers are practice-based EHR vendors like Practice Fusion, Amazing Charts, Medent and eMD’s.

So, why is VistA CPRS the preferred choice? In a word, design. The VA built the system with two design goals: improved patient care and rapid adoptability. Physicians at the VA rotate through services and the system has to be adoptable with minimal (2 hours) training; they learn it as they take care of patients.

Other studies confirm that physicians find VistA CPRS “straightforward” to use.  Because it was designed to take better care of patients, doctors can see how the system directly and positively impacts clinical care, which is not the default product of EHR use.

A summary of categories in which VistA CPRS was rated number 1 among enterprise solutions illustrates how well the VA did in meeting physician needs.

  • #1 – Ease of data entry
  • #1 – Physician satisfaction
  • #1 – Staff satisfaction
  • #1 – Overall usefulness
  • #1 – Usefulness as a clinical tool
  • #1 – Connectivity
  • #1 – Reliability
  • #1 – Practice Situation: Hospital Network
  • #1 – Practice Situation: Independent

Maybe you’re wondering how a government-derived software system could be more highly rated than private sector alternatives. As mentioned above, the VA’s goals are to develop a system that improves care for veterans and is easy to learn. Contrast that with the natural overarching goals of proprietary EHR providers, which is to automate the enterprise and make money.

Complex systems require extensive and expensive training, and certification courses. They create dependency on an omniscient vendor for support and development.  And most enterprise systems started as administrative departmental applications and then morphed to incorporate the clinical side. Ease of use and patient outcomes were not primary concerns in their design.

Importantly, proprietary enterprise systems are also not easily interoperable, and even if they can be, proprietary vendors would often rather they not, thank you very much.

VistA CPRS was rated best for connectivity, “scoring 4.0 or better in all domains measured.”  The Medscape report also comments on the growing importance of connecting physicians to improve care coordination.

Connectivity becomes increasingly more important as concepts of “care coordination” take hold, and also as hospitals and private practices work to make their operations more efficient … According to the Office of the National Coordinator for Health Information Technology (ONC), only a minority of physicians with EHRs from different vendors are exchanging clinical summaries of patient visits with other physicians.

So, if VistA is the preferred choice, why is adoption of VistA-derived systems outside the VA so low? One explanation is lack of awareness.  How many hospitals and clinics know that VistA code is public domain and available without expensive license fees?  That private companies are succeeding by offering development and support  for VistA-based solutions?

Of course, the other explanation is that decision makers think the success of VA VistA is irrelevant—that it’s a nice story and good for veterans, but ultimately of little use in the non-federal healthcare sector.

This is simply untrue.

Well, for large academic medical centers and cash-rich nonprofit (cough, cough) healthcare systems, it may be true. I mean, who would ever stand in the way of a hospital’s right to overpay for Epic?

But most of American healthcare—independent and resource-challenged hospitals and clinics that dot the landscape and serve the most needy—does not live in that world. To increase efficiency and lower costs, America needs an affordable, customizable and robust solution that can interface with just about anything, including Epic.

As the Medscape report makes clear, there is really only one system that meets those requirements. Given the high level of dissatisfaction with EHRs, especially among physicians, and how difficult it is to realize health IT transformation in any organization, there is wisdom in adopting a system that minimizes opposition.

Edmund Billings, MD, is chief medical officer of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

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Category: billings

The VA Waitlist Fiasco: VistA should not be thrown out with the bathwater

Without a doubt, the death of American veterans as a result of the VA waitlist debacle is tragic and unacceptable. The Obama administration must move quickly and deliberately to fix the underlying problems and restore faith in the agency.

If these issues were common throughout the VA network of hospitals and clinics, it might make sense to consider dramatic, earth-shaking alternatives like moving veterans to private providers and shuttering the VA. But they are not common. Indeed, as Washington Monthly reporter Phillip Longman has documented, the VA’s challenges are regional, not pervasive.

Still, black hole media coverage of the VA sucks in everything that lingers nearby, including the VistA EHR system. I’m not saying scrutiny is unwarranted. When veterans die prematurely and unnecessarily, the review of root causes should be exhaustive.  But VistA is simply not a root cause and the suggestion of replacement with a commercial system is cynical and opportunistic. No wonder, since most large hospitals and healthcare systems have made their initial health EHR commitments and the DoD and VA are the biggest fish left in the pond.

The challenge is access to VA care, not the quality of the care itself.  Both internal and external analyses point to two root causes: supply and demand, and a corrupted local bureaucracy.

First, the demand for care is much greater than the supply in regions where veterans, particularly baby boomers, have located. The waitlist problem is particularly acute in the south and southwest with Phoenix as the epicenter. Estimates suggest as many as 20 percent of roughly 2 million Iraq and Afghanistan veterans—perhaps 400,000 soldiers—may have Post-Traumatic Stress Disorder (PTSD).

Second, the regional VA bureaucracy and administration courted failure by setting unattainable goals. The arbitrary no-more-than-14-day wait for care policy was impossible without enough available physician slots. This led to scheduling departments adopting a “fake or fail” policy and creating dummy wait lists to hide the damning real metrics.

Per both internal audits and external surveys, the culprit is not VistA or it’s scheduling package.  As reported by Modern Healthcare’s Joseph Conn, an extensive (3,772 interviews at VA facilities) internal VA audit published on June 3 showed that among all potential contributing factors, VistA was least to blame.

The lack of open provider slots scored highest with VA staffers as a specific barrier or challenge (with a mean score of 3.0), closely followed by limited clerical staffing (2.8) and the VA target that veterans have an appointment within 14 days of request (2.8) … … 
respondents describe a numbers-driven system with unrealistic performance measures as having created a highly stressful work environment that limits the focus on serving the veteran. Challenges using the scheduling module of the VA VistA electronic health-record system … ranked lowest among six choices given by the auditors.  

A VA inspector general interim report came to a similar conclusion, finding the problem was not VistA. However, the inspector general did identify interoperability, or rather lack thereof, as a problem for over a decade.

VA staff prints out paper copies of basic patient enrollment information that then has to be reentered into a VistA module for scheduling appointments. That suggests systemic problems with interoperability.

For new veterans coming into the VA system, DoD health records must be printed out and typed back into VistA, which gives rise to a host of questions: Might that slow scheduling down? Why is there no interoperability? Why don’t DoD and VA use a common EHR to ensure continuity, efficiency and quality care for every veteran?

(And will an $11 billion proprietary vendor solution whose major weakness is lack of interoperability solve the problem? But I digress …)

According to a May 31 NY Times article, veterans themselves blame the bureaucracy and praise the quality of care they receive once they are through the doors. Indeed, their complaints—repeated canceled appointments, un-returned calls, lengthy waits for appointments and rapid turnover in physicians—all fall under the management heading.

In a typical and representative response one veteran said:

It’s frustrating and infuriating that there are so many dedicated doctors who work for the V.A. but it seems impossible to get to them … They’re serving too many people.

While the HIT industry and media love the smell of scandal, a recent HIStalk comment lays out both the conventional wisdom and the actual facts.

More signs that the VA’s VistA baby will be thrown out with the agency’s dirty bath water …  Evidence is ample that that the real problem was that VistA’s scheduling system was accurate and transparent, and due to the VA’s resource and management challenges, that created a reason for users to avoid using it. In other words, the system gets thrown out because it was doing exactly what it was supposed to do.

All true. Except VistA will not be thrown out.  We don't have the luxury of spending billions of dollars and the better part of decade to replace a system that already provides the best care anywhere. The right answer for the EHR industrial complex is the wrong answer for veterans and taxpayers.

New VA leadership must revamp the local and/or regional bureaucracy to make it transparent and open. Congress must increase funding for VA health care services and increase the number of available physician slots. And VistA must endure as part of the solution, as it is not part of the problem.

Edmund Billings, MD, is chief medical officer of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: billings
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