The US Dept of Health and Human Services (HHS) outlined these criteria for Meaningful Use of EMR:
1)    Improve quality, safety, efficiency, and reduce health disparities
2)    Engage patients and families
3)    Improve care coordination
4)    Improve population and public health
5)    Ensure adequate privacy and security protections for personal health information

And although each of these has defined goals followed by specific objectives and measures for the years 2011, 2013, and 2015, these still sound a bit ambiguous. Many industry experts, however, expect these to be more fine-tuned as the dates approach, but medical practices will have to stay informed to keep ahead of the curve.

Financial Incentives

As part of the ARRA (American Recovery and Reinvestment Act of 2009), financial incentives will be given to those physicians whose practices demonstrate “meaningful use” beginning January, 2011.

The incentive payment, according to CMS, is equal to 75% of Medicare-allowable charges for covered services in a given year, and maxes out as follows:

• Year 1 – $15,000
• Year 2 – $12,000
• Year 3 – $8,000
• Year 4 – $4,000
• Year 5 – $2,000

For those practices who are early adopters of the technology and hit the threshold for meaningful use in 2011 or 2012, the first year payment would be $18,000. Note that this only applies to Medicare; there are additional incentives for healthcare providers who have a certain threshold of Medicaid patients and/or who practice in a rural area. The threshold for office-based pediatricians is lower, and so they would be more likely to qualify for those additional funds.

[table courtesy of SoftwareAdvice.com]

Even considering the fact that EMR implementation may cost anywhere from $10,000 to $50,000 per provider, these incentives would certainly make that investment more palatable.

Those practices that procrastinate, however, will be penalized with cuts in Medicare and Medicaid payments:

• 2015 – 1%
• 2016 – 2%
• 2017 – 3%
• 2020 – 5% (maximum reduction)

So, how do you know if you qualify? According to the health IT blog NetDoc, to be a “meaningful EHR user”, a physician must satisfy three criteria:

1. Must use “certified EHR [EMR] technology”
2. Must demonstrate that the certified EHR technology is connected in such a way that it provides for the electronic exchange of health  information to improve the quality of health care, such as promoting the coordination of care (using HL7 or XML standards)
3. Must submit information on clinical quality measures specified by HHS (such as PQRI)

Some physicians have told me that because there isn’t a final definition of what is considered “certified EHR technology” they are just going to wait. Big mistake. Most health care IT experts working on and advising on this issue feel fairly strongly that the Office of the National Coordinator for Health Information Technology (ONCHIT) will set CCHIT (Certification Commission for Health Information Technology) criteria as the standard for EMR certification.

CCHIT is a non-profit organization funded by various corporations and groups such as the American College of Physicians and the American Academy of Family Physicians, and was recognized by the US Dept of Health and Human Services (HHS) as a certifying body in 2006.

Some critics, however, charge that CCHIT is a shill for the Healthcare Information and Management Systems Society (HIMSS), the healthcare industry’s membership organization focused on healthcare IT. Although made up of both corporate and individual members, these critics feel that their goal is to corner the market for certain major EMR players. Nevertheless, unless or until there is an alternative, most EMR vendors are using CCHIT certification as the benchmark.

In addition to the EMR certification criteria, the ONCHIT is expected to adopt an initial set of standards and implementation specifications by the end of the year 2009.

Timeline

So, is too late to implement EMR in your practice and still qualify for the financial incentives? Well, that depends on the size of your practice, type of specialty, and how motivated your doctors and staff are to go paperless. Just don’t expect to run down to Office Depot, buy an EMR program and launch it the next day (although there is talk about WalMart getting into the EMR business, but we’ll leave that story for another day…)

According to MBA HealthGroup, these are some reasonable time frames to expect for EMR Implementation:

• Stage 1 – up to 6 months – researching vendors, getting buy-in, setting up an EMR committee, checking out demos, and making a final decision on the EMR system
• Stage 2 – up to 5 months –  time it will take to actually ‘go live’. In the meantime, adapting workflow to EMR system you chose, ordering hardware, and standardizing processes
• Stage 3 – between 6 and 12 months – amount of time it will likely take to achieve “meaningful use”, which includes ePrescribing, documenting electronically, and ability to report certain items (which are still being determined)

[timeline courtesy of MBA HealthBlog]

Smaller groups and solo doctors may be able to purchase a more basic, “out-of-the-box” EMR system and more quickly adapt their workflow to the system, rather than vice versa in the case of larger medical practices. But, the one thing you can count on with EMR implementation is that you can’t count on anything – that is why some sort of timeline is important [see EMR Implementation Rollout].

What this boils down to is that those practices that have already started implementing EMR will have a good shot at getting those higher financial incentives. On the other hand, physicians who have been wishing that the whole idea of EMR was just a fleeting fad may not only miss out on these incentives but may also face cuts in their reimbursement.

Questions? Comments? Post them below

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ProtoQue is a program which was developed in response to a problem we were having with our phone triage: we noticed that many patients were not called back in a timely fashion. This program, which is web-based, lets operators register calls automatically. The patient is then subsequently passed off from there to either medical records or a medical assistant. This program manages the ‘chain of custody’ so that the patient doesn’t slip through the cracks. The issue remains open until the problem is resolved. Every time a patient receives a return phone call, a time stamp is created, so our attempts to contact them are documented. The supervisors can use this application to monitor information flow, delegating calls to additional staff if the team falls behind, regardless of where they are located. We no longer have patients waiting until the next day to have their concerns addressed by our staff. Even though our EMR system, like most, has a messaging feature, we still find this program to be more robust and have continued to use it for over three years.

In addition to the phone triage program, we have designed some in-house programs that help us manage specific tasks, and which would not be possible without our computer network:

• The first helps calculate our eyeglass prescription capture rate, which is broken down by location and individual doctor.
• We also have an optical lab tracker program, which tracks jobs in real time, so an optician can tell a patient precisely when their order will be ready.
• Another custom application completes work-orders, and is located on a network that is accessible by IT, Human Resources, and Facilities. If supplies are needed, or a piece of equipment is damaged, an employee can complete a work-order and send it on to the right person. This facilitates full accountability while the chain of custody among the departments is being managed.
• Our Human Resources staff is working on an application that will let new employees enroll using our own electronic interface.
• A new PQRI Tools program which resulted in a significant federal incentive bonus. It attaches to the practice management system and identifies missed reporting before billing.

If you have any comments, please post them here. You can also post any questions you might have about some of our software tools.

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For subjective-objective-assessment-plan (SOAP)-based patient care, the first generation of electronic medical records (EMR) systems worked well. Medical specialties which are primarily text-oriented tended to fare better, as compared to graphic-oriented specialties such as ophthalmology. At our practice we have used an EPM since 1983. But although this software met our needs for billing and scheduling, we were still accumulating stacks of paper records which required an increasing expense just to store the paper.

As we considered a change to an electronic medical records system, our practice compared the expected costs for paper records storage to the costs of converting to a new system. We fully understood that we’d have to become more efficient to make the transition cost-effective.

System Implementation Costs include:

* Infrastructure
* Consulting
* Software
* Hardware
* Tech Support

We also included the cost of additional work-hours which will be spent training people on the new system, along with data entry. In most cases a practice uses both the old and new systems concurrently until the entire conversion is complete. In the meantime, there could be some redundant tasks.

The primary factor in our decision to switch to EMR was based on the need to reduce the growing mass of paper we were storing. And it didn’t hurt to hopefully ride the wave of financial incentives from the government for EMR implementation. Meanwhile, there was the opportunity to proactively implement new HIPAA privacy and security guidelines in a way that would work best in our practice.

System Benefits Include:

* Improved Communication
* Better Efficiency
* Improved Compliance
* Enhanced Documentation
* Justifiable Coding
* Improved Integration

At our practice, the business choice came down to the belief that we could recoup our investment in approximately five years. This calculation was based on the savings of projected storage space costs, along with reduced needs for printing expenses and services. The journal Health Affairs found that the average primary-care practice recovered its costs in 30 months.

It is more difficult to measure the value of change to job efficiency and changes in staffing patterns, but we are monitoring these factors to accurately measure returns on our investment. Some studies have shown reductions in medical records staffing of 0.25 – 0.5 full-time equivalents (FTEs) as well as significant savings in dictation costs.

The overall trend seems to be toward a world where EMR is the norm. Insurance companies and government are placing more pressure on health-care providers to standardize medical records, and EMR could soon become obligatory. Costs are dropping as more businesses adopt the technology; soon even the smallest practices may find it cost-effective to ‘go paperless’.

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First, understand that a wireless network isn’t actually totally wireless. Something must be plugged in to something else somewhere. Also consider that a wireless system has several layers of associated expense.

You should work with a wireless consultant – preferably someone with experience installing wireless networks properly. A system that is implemented incorrectly will yield poor performance. Our practice chose to go with a Cisco-certified wireless network engineer. If you aren’t able to find someone with these rare qualifications, at least go with a consultant who specializes in network installation.

An expert consultant will use special equipment to map radio frequencies within the building. This will help to determine where to put the antennas. Our consultant’s team took several days to spread the antennas out on tripods, finally producing a map which illustrated the radio frequency overlay and a list of recommended placements.

If you plan to use cordless computers, you’ll have to use long-lasting batteries with plenty of back-ups available. Unless you’re using a special battery charger dock, this can’t be managed on the laptops. You may need to carefully plan your clinics, keeping in mind that the typical battery only holds a charge for about three hours.

Have a clear understanding of what is in your building. Is there lead in the walls? How about metal in the ceiling? These sorts of factors can either improve the signal through reflection, or degrade it overall. Are other wireless signals being broadcast in the area? Even microwaves and phones can have an effect on the signal, and most wireless networks are operating on a frequency which is on a spectrum in widespread use by other devices. The object is to prevent interference.

Be sure to keep a budget. One medical practice decided to use laptop computers connected to 24-inch monitors. This let both the patient and doctor see the monitor at the same time. However, this turned out to be costly – laptops are typically the priciest devices. Usually regular desktops are the most cost-effective solution.

Are you thinking about installing the wireless network yourself? Some network solutions on the market work well for e-mail and Internet, but might not quite cut it for operating your electronic medical records (EMR) system. There are two main reasons for this:

* Consumer wireless access points generally use a signal fixed on a higher strength than a usual laptop wireless card. This may sound good, but actually means that a laptop could detect a signal which is more powerful than it can actually return, resulting in a broken connection.

* If you require more than one wireless access point, there could be a conflict. Just walking from one side of the office to the other with the laptop could cause your session to drop, requiring another login after a possible loss of data.

Regardless of your final choice for wireless EMR implementation, make sure your team is on-board. And try to justify all purchases and keep an eye on costs. Refrain from indulging on the latest gizmos when you can – instead, stay focused on serving your patients in an efficient but cost-effective way.

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Wrong! Ask any non-medical person involved with EMR implementation and his or her opinion would be that the EMR software is the last (or one of the last things) to choose.

But let’s assume that you already know that there are some basics that must be set up first, such as your building’s infrastructure, your network design, determining staff skill sets, etc. (If not, then check out this blog for previous posts on these topics before proceeding).

In this article, I¹ll discuss how to decide on both an EMR software vendor and the actual EMR software. Granted, this is somewhat of a generalization; large and small practices have different requirements and will want to base their choice of a vendor on additional criteria specific to their situation. But for the purposes of illustration, I am using the process that our seven-doctor, ophthalmology practice went through in our decision.

We had been using an electronic practice management (EPM) program called Fiscal until the late 1990s. It was clunky but fairly sophisticated compared to other EPM systems at the time. Fiscal decided it would concentrate on hospitals and would no longer service practice-based systems as of the year 2000, and our version of Fiscal was not Y2K-ready.

So the practice decided to switch to Medical Manager¹s EPM. Medical Manager was a well-established vendor and their EPM was robust and Y2K-ready (although also clunky by today’s standards). At the time we weren’t really thinking about switching to an electronic medical records (EMR) system but we knew that Medical Manager was developing one, and kept that thought on the back burner.

As physicians, we tend to easily fall in love with new toys. But you must resist the temptation to bring back the first slick-looking EMR program you see at your annual specialty meeting. Instead, you should strongly consider setting up an EMR committee, comprised of administration and representatives from information technology [IT] (or a consultant), the business office and technical staff/nursing departments. The primary goal of our EMR committee was to establish some guidelines for choosing a vendor as well as the major criteria for selecting an EMR system that would be specifically suited to our practice.

The company selling the EMR product should:

1. Have at a least a moderate market presence – you wouldn’t want to be up and running with your EMR system only to find out that the vendor went out of business
2. Have an existing EMR program, not a brand-new, untested product
3. Have a good EPM product – this can avoid a lot of finger-pointing if there is a problem
4. Have some experience in your particular field – ask for references

Suggested major criteria for the EMR system:

1. An ACID-compliant relational database for the following reasons: data protection and the ability to recover fully from failure, not just restore from backup; a “back end” that would scale well as the practice grows; an open interface for generating reports.
2. A system that could be fully supported on both thin and fat clients (remote control and direct control devices, respectively) to accommodate the lower bandwidth of satellite offices – thin client devices can also be lighter, less expensive, and generate less heat than say a laptop.
3. A system which would give us the ability to create, modify and design powerful graphically based EMR templates with normalized data (not text).
4. A product that integrates well with the EPM system. We did not want to install a system with duplicate data entry and where all patient information isn’t accessible from both the EMR and EPM.

After reviewing the products of about a dozen or so EMR vendors that had some experience with ophthalmology, we narrowed these down to a short list of about four. These vendors were then invited to make a presentation to our EMR committee. We then analyzed their capabilities and checked references from not only ophthalmology practices but also practices of other specialties.

Ultimately, we decided to switch to a company that had both an EPM and EMR system and ditched the EPM system we had been using since 2000 – that company’s EMR system was woefully inadequate and we strongly felt we needed an integrated solution. First we changed to the new EPM system and now, four years later, we are in the process of implementing the EMR module.

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1. How many people and devices need to be on the phone at one time? Don’t forget that voice calls are not the only things which tie up your phone lines. Take an inventory of any peripheral devices which could possibly be in use concurrently with your staff: modems, fax or postage machines, credit card machines, or your security system.
2. How many calls at each location do you need to receive at one time? You don’t want to limit the number of lines you have and then have patients unable to get through. This will also help you determine if you need to have an actual call center set up.
3. How many phone numbers do you need? For a large practice with one location, you may only need a few public numbers but the ability to handle many phone calls. On the other hand, you would need many internal numbers depending on the number of employees. A smaller practice with more locations may need more external numbers but relatively fewer internal numbers.
4. How many physical phones do you need at each location?
5. And how many will typically be in use at the same time? And at peak times?

Now, how many phone lines did you come up with? Save that number but don’t tell me just yet. For purposes of our discussion, the magic number is 14.

If you are a solo practitioner or in a small group, you may not need more than a few lines. In this case, you’ll have less initial costs with an analog phone system. In addition to paying for the phone system, you will also incur monthly charges for each phone line coming into your office as well as for additional features such as caller ID, call forwarding, conference calling, etc.

If you calculated that you would need 14 lines or more, a digital phone system would be more cost-effective – the up-front costs will be higher but you won’t have to pay for each separate phone line and its add-on features (the cost of which can escalate arithmetically).

For our practice, the decision was obvious. In our new administrative building, a digital phone system would be the most cost-effective solution for handling the close to 3000 calls we receive a week.

There are also several other advantages to a digital phone system:

• Through a single T1 line coming into our building, we have 22 “channels” which function just like incoming phone lines – this is known as a PRI (primary rate interface). By adding a second PRI, we gain 22 more lines. We figured that we may have as many as 35 lines in use at the same time.

• The Kevlar-sheathed fiber-optic cable is resistant to lightning strikes as well as errant back-hoes making it more reliable than standard telephone cables.

• Because the system uses what are known as “soft” numbers, it allows us to have 100 internal phone numbers, enough that each employee can have his or her own private number.

• Since we gained so many new phone numbers, we were able to eliminate almost twenty analog phone lines in the previous call center, saving over fifty dollars per line per month. Even with the cost of the new system, we have realized a significant net savings.

• Our digital system also came with more advanced features such as Call Accounting (which tracks number of calls, by which phones and by whom they were answered, and whether they were appointment-related or not) and

• ACD or Automatic Call Distribution (which automatically determines which person should get the next call based on how long her phone has been idle). These last two features, which can be expensive if purchased separately, are especially important to us since we essentially run three call centers: one for the operators, one for the practice billing, and one for the ASC billing

Lastly, make sure you take your time when making this important decision. A little planning now can save you a lot of aggravation (and money) later. Ask your local phone company to give you a proposal for a phone system that best suits your needs. Then let an independent phone vendor do the same – just make sure that they are factory-certified by the manufacturer they sell so that they have kept up with the latest technologies.

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Well, it wasn’t actually a direct hit. I was awakened early one morning last week by what sounded like a mortar going off in the back yard. There was no loss of power but several electronic devices were affected: a wireless router, two switches, a satellite receiver, a digital phone, the alarm system and, oh, yes, my desktop computer.

Not my wife’s computer, and not the kids’ computers, but mine. It was connected to a back up battery with a surge protector. The only thing that was not running through the surge protector was the ethernet cable. I am still waiting for a new power supply to arrive from Dell so I don’t know the full extent of the damage.

The electricians and technicians who have descended upon the house these past several days suspect that the lightning hit the ground and came back up through wiring such as cable or phone line and got into the network wiring. So now we are keeping several tradesmen busy trying to patch things back together. And I am trying to reconstruct my digital life. All this as we are bracing for Hurricane/Tropical Storm Fay to hit in the wee hours of the night.

So, here’s a list of things you can do to protect yourself from total chaos in the event of a disaster such as a lightning strike:

• Make sure your computer is on a good surge protector with a backup battery. Some come with software that will automatically close your applications and shut down your computer.
• Run any type of wiring (cable, telephone, ethernet) that connects to computers or sensitive electronic equipment through surge protectors as well. I neglected to do this with the network cable – still unsure if this was the cause of the failure.
• Use an automated backup system for your computer data. I use an online backup service from Mozy.com but there are several good ones out there. Every night it backs up all the types of files that I have designated.
• As double protection, I also back up files with a portable hard drive and keep it at the office. These have really come down in price – you can get 500GB of storage for less than a hundred dollars in a device the size of a deck of cards. They usually come preloaded with their own backup software.
• Don’t forget to backup files that are not routinely backed up. I keep an Outlook folder with the download links and registration keys for all downloaded applications. I regularly make a copy of my Outlook folders including contacts by exporting the .pst file and saving it in the Documents folder.
• Clone your hard drive onto another hard drive or computer. You can literally have a carbon copy of your current computer on another machine. The only hitch with this method is that certain programs (such as Quicken) can only be run on one machine at a time if it is synchronized with their online backup service.
• Install a stand-by generator. We have frequent power outages in Florida due to thunderstorms. After a triple-whammy by three hurricanes a couple of years back, we installed a stand-by generator that runs on natural gas and automatically kicks on if the power goes out. Although you can get a large one that can run an entire house, we have just enough to run essentials like refrigerators, microwave, a single air conditioner unit, and power for the master suite where the entire family can camp out. And yes, in Florida in the summer, an air conditioner is considered an essential.

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Sean Teare is president of InnovationRx, a Massachusetts-based unit of a British company which aims both to cut the cost of nagging people to take their meds and improve the rate at which they do.

Will this new service work?

As to their business model, “We’re a subset of disease management. If you don’t improve adherence you can lose the impact of other changes. Health plans are looking for short term ROI, and we can show that.”

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Choosing a Hardware Vendor
Most large vendors negotiate pricing based not only on what you are immediately purchasing but also what you anticipate purchasing in the future, so it’s important to communicate your long term order goals. Often, you can achieve better pricing on a purchase today if your vendor can count on your purchase tomorrow as well.

Repair service and warranty options are critical with network hardware. Make sure you understand
the service your vendor offers in your area. If they offer on-site service, how far do the techs have to drive to get to you? Do they outsource onsite service?

Tech support and product life cycle assurances are very important as well. Once you purchase a widget, how long can you depend on such things as bios, firmware, and driver support?

For our practice, we chose Dell. Dell has very competitive pricing, product life cycles longer than we keep hardware, and has four-hour onsite service for servers and switches in our area. In addition, we get discounts based on volume. The more we order from them, the more our discount increases.

Once you’ve chosen a vendor, your hardware decisions break down into three components:

1) Switches. Switches are the backbone of your network and what all the cables plug into. Choosing the best switch for your office depends on how much capacity (traffic) your network needs and what media (copper cable or fiber optic) you will use. In some cases a network will use both copper and fiber optic and the switches will need to be set up accordingly.

2) Servers. When shopping for a server, look for redundant systems. Does it have redundant hot swap power supplies in case one fails? Does it have a RAID array of drives so the machine doesn’t go down if a hard drive fails? How many processors does it have and how much RAM? For both of these, more is better. And make sure you get a backup device (tape drive) that is both large enough to hold your data, and fast enough to backup during your down time (usually at night).

Don’t overlook the physical configurations of your network hardware. It might make sense to install a special rack to house the equipment, especially if you end up with multiple servers, as most EMR installations will require.

3) End-user devices. For EMR, are you going to use thin client terminals or actual computers? If thin clients, do you need legacy ports? Are they firmware upgradeable? Have you looked into articulated arms for the exam rooms? In our practice, we use a combination of all of the above, so we’ve agreed upon a minimum hardware configuration for each type of device (thin client, desktop, laptop, printer, or server) based upon our needs and performance expectations. This also means that the physicians have to check with our IT staff before they go out and purchase a fancy laptop to make sure it is compatible with our network. Every few months we re-examine to compensate for changes in technology. This ensures consistent performance across the board and streamlines support.

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Another drawback to this type of system is that the staff needs to keep track of multiple phone numbers – this can get chaotic when you start adding multiple locations. If you needed to get hold of a particular doctor, for example, first you would need to find out where he or she is working that particular day and time. Then you would have to figure out which phone number to call. We have laminated cards that have all of the phone numbers we need to know. These “little” cards were getting quite large.

Fast forward to today. We now have five locations including an ambulatory surgery center and about 140 employees. Our newest location is a completely remodeled building which houses a clinic, our administrative offices, our call center, and our information technology department. So when it came time to choose a phone system for the new building, continuing to add more individual telephone lines was not going to be the right solution in the long run.

But before I tell you what system we chose and why, let’s discuss how you can decide what phone system is best for your needs, for today and the foreseeable future. First, start with a plan. A little forethought and answering a few simple questions will help you to select both the correct phone service (where the dial tone is coming from) and the correct phone system.

• How many people and devices at each location need to be on the phone at one time? Don’t forget to include your fax machines, modems, credit card machines, postage machine, security system and fire alarm systems.

• How many calls at each location do you need to receive at one time?

• How many phone numbers, both public and internal, do you need?

• How many physical phones do you need at each location?

• Do you need call accounting? (The ability to track and report on incoming and outgoing calls)

• Do you have a call center for patient appointment scheduling? If so, do you need contact center features, like ACD (automated call distribution) and operator reporting/monitoring?

• Which features are important to your business? Transferring a call to another location? Caller ID, both inbound and outbound? Voicemail? Call forwarding, probably to an answering service?

In Part 2, I’ll show you how to use the answers to these questions to select the phone service and phone system that’s right for you.

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