EMR News

E-prescribing enjoying steady growth

Marla Durben Hirsch — Wed, 16 May 2012 10:52:05 -0400

More than one in two office-based physicians used electronic prescribing in 2011, up from one in 10 just three years ago, according to the recently released Surescripts 2011 National Progress Report. In 2011, 570 million prescriptions were routed electronically, versus 326 million in 2010, a 75 percent increase. Prescribers using integrated electronic health records had a 53 percent higher utilization level of e-prescribing than prescribers using stand alone e-prescribing systems. What's more, roughly 60 percent of physicians who started e-prescribing in 2008 met the e-prescribing measure for Stage 1 of Meaningful Use; 38 percent of those would meet the e-prescribing measure in the proposed rule for Stage 2. A portion of the report had been leaked in April. Executive summary

Patient review of med lists in EHRs can reduce discrepancies

Marla Durben Hirsch — Tue, 15 May 2012 15:01:44 -0400

Patient review and reporting of medications lists can reduce discrepancies and improve patient safety, according to a new study published in the Journal of the American Medical Informatics Association.

The researchers, primarily from Brigham and Women's Hospital, studied 11 primary care practices that used the same personal health record system tied to their electronic health record system. The study used a medications module that prompted patients to review the medication lists in their provider's EHRs via the PHR and identify discrepancies by generating "ejournals" that would enable the physician to quickly update the medications lists, according to a recent CMIO article. A sample of 267 patients were contacted by phone three weeks after submitting their ejournals, compared to a control sample of 274 patients that received a different PHR-linked intervention.

The researchers found that there were fewer unexplained medication discrepancies, 42 percent, in the group using the ejournal tool, versus 51 percent in the control group. The number of unexplained discrepancies with the potential for severe harm was 0.03 in the ejournal group, compared to 0.08 in the control group.

"When used, concordance between documented and patient-reported medication regimens and reduction in potentially harmful medication discrepancies can be improved with a PHR medication review tool linked to the provider's medical record," the researchers noted.

Other studies have reported that patients want to view their medication lists and other information in their provider's EHRs. Providing patients with this access also has been shown to make the information in an EHR more accurate, since patients will catch and report mistakes in their own records.

To learn more:
- here's the abstract of the study
- read the CMIO article
- check out the actual clinical trial
- here's more information on using patients to reduce EHR errors

More docs gravitating to cloud-based EHRs

Marla Durben Hirsch — Tue, 15 May 2012 14:41:23 -0400

Physician practices are turning to Software as a Service (SaaS) electronic health record systems--and have several good options to choose from, according to a new report from Orem, Utah-based healthcare research firm KLAS.

The study, in which more than 290 providers using SaaS ambulatory EHR systems were interviewed, reported that SaaS EHRs are becoming increasingly popular. "These systems appeal to small organizations that want low maintenance, a quick go live, and small up-front investment," the report noted. "Providers must also be comfortable with clinical and patient data being stored off-site and limited flexibility in the system."

Four key areas that differentiated SaaS EHR vendors from others included:

EHR response time, such as the loading time between clicks
Customer support, such as frequent updating and enhancements
Product quality/usability
"Bang for the buck", i.e. attractive pricing

The top ranked SaaS vendor/product was CureMD EMR, followed closely by Practice Fusion, athenahealth athenaClinics, MIE WebChart EMR, MedPlus/Quest Diagnostics Care 360 EMR, and Sevocity EMR.

One downside to SaaS EHR products, according to the report, is that many of them do not also offer practice management solutions. Of the top six products, only CureMD and athena sell practice management products in tandem with their EHR systems.

The report corroborates trends in hospitals, which also are embracing cloud computing for their EHR and HIE use. Gartner recently predicted that cloud computing will take center stage by 2014.

To learn more:
- here's KLAS' announcement
- purchase the study
- check out what the hospitals are doing
- read the announcement on the Gartner study

New research disputes claims EHRs improve diabetes care

Susan D. Hall - Contributing Writer — Tue, 15 May 2012 13:24:56 -0400

Contrary to previous research, the use of electronic health records failed to improve care for diabetic patients in a study published in the Annals of Family Medicine.

Robert Wood Johnson Medical School at the University of Medicine & Dentistry of New Jersey researchers compared data from 16 practices in the Northeast that used EHRs and 26 practices that did not, assessing the care for 798 patients.

They found, in fact, that patients at clinics using paper records were more likely to meet all of three targets for hemoglobin A1c levels, low-density lipoprotein cholesterol and blood pressure after two years than those in practices that used EHRs.

Having an EHR instead of paper-based records doesn't guarantee better care and suggests that many practices that have adopted EHRs have not made the necessary changes to both work processes and ways of thinking about care that would lead to improvements in chronic illness management, the authors concluded.

"Achieving truly meaningful use of this technology will require more than time and experience: it will require a recognition that until population health is improved, use does not equal success. Practices will need assistance with implementation and achieving successful use to improve care and population health outcomes, especially with regard to redesigning work processes to make the best use of these new technologies by all members of the primary care delivery team."

The findings are in direct contrast to other studies, including three FierceEMR has told you about over the past year.

In one study, type 2 diabetic patients treated by doctors who use EHRs were found to be more likely to receive "optimal care" for their condition. The researchers studied the care of 14,051 adult diabetic patients seen at 34 primary care practices.

Of those, 6,376 patients' physicians used an EHR. Those patients enjoyed better outcomes--including positive improvement in blood pressure, aspirin prescriptions and smoking cessation--than patients whose doctors did not use an EHR, researchers found.

In a 2011 study, Better Health Greater Cleveland--a group that is a member of the Robert Wood Johnson Foundation's "Aligning Forces for Quality" initiative--found that 51 percent of diabetes patients in practices using EHRs received all the care they needed to address their diabetes, compared to only 7 percent in practices with paper records during the 2009-10 period.

Researchers have also claimed success with a "diabetes dashboard" that helps physicians coordinate diabetic care on a single EHR, leading to streamlined and improved care at a lower cost, FierceEMR reported late last year.

To learn more:
- see the Annals of Family Medicine study

'Way Ahead' architecture to serve as backbone for iEHR

Dan Bowman — Tue, 15 May 2012 13:10:59 -0400

New work on the enterprise architecture (EA) created for the joint integrated electronic health record effort of the Departments of Defense and Veterans Affairs will be based on work already completed by each department, according to a DoD report.

The Military Health System's "EHR Way Ahead" architecture will serve as the backbone for the iEHR EA, according to the report. Way Ahead is the EHR system DoD plans to implement to replace the Armed Forces Health Longitudinal Technology Application (AHLTA) and the Composite Health Care System (CHCS).

"This architecture has been under development, evolution and evaluation for a number of years," the report notes. "In early 2011, the Departments agreed that MHS EHRWA architecture would be the 'presumptive' architecture.

The report adds that since then, the architecture has matured into the "target iEHR EA" because of its dual functionality.

"The joint DoD/VA functional and technical assessment of the EHRWA EA that preceded iEHR EA development is providing a springboard for current efforts," the report says.

The anticipated end result of these efforts, according to the report, are a "coordinated 'best-of-breed' approach" that mixes "SOA-compliant capabilities, commercial off-the-shelf, open source and custom systems." The report also notes that the Defense Manpower Data Center will serve as the lone "identity management" source for the iEHR.

A preliminary version of the iEHR is expected to be rolled out by the VA in 2014. Overall, the iEHR project is expected to cost around $4 billion.

Harris Corp. recently replaced ASM Research as a key contractor on the project.

To learn more:
- here's the DoD report (.pdf)

'Accountability tool' reduces CT scans in the ER

Marla Durben Hirsch — Mon, 14 May 2012 12:12:44 -0400

A tool embedded in an electronic health record can reduce the number of CT scans performed in the emergency room and help patients avoid unnecessary radiation, concludes a University of Pennsylvania Perelman School of Medicine study. Abdominal pain is the most common reason for emergency room visits in the United States; since diagnosis is often difficult, many patients receive CT scans, even though in many instances the scan--and the radiation--turns out to have been unnecessary.

In the study of 11,176 patients in two University of Pennsylvania emergency rooms, the researchers used an embedded "accountability tool" in the EHR system to walk the physicians through a series of questions that served as a checks and balances to decide whether the patient should receive a CT scan. Use of the tool caused the number of patients receiving CT scans to drop 10 percent, without increasing the number of patients admitted to the hospital, which is common when the diagnosis is unclear.

"For many patients, like those who are older or have cancer, this tool might not make a difference, but there are many abdominal patients who are younger, healthier, and who have things that are usually not life-threatening like kidney stones, for whom we are hoping this will reduce their exposure to unnecessary radiation,' Angela Mills, assistant professor of emergency medicine and medical director at the Hospital of the University of Pennsylvania, said in a statement.

Radiation overexposure in the emergency room has long been a major patient safety issue. Other studies have indicated that similar screening clinical decision support tools can help physicians improve patient health, especially in a busy environment such as an emergency room or pediatric clinic.

To learn more:
- here's the announcement from the University of Pennsylvania
- read more about the dangers of CT scans
- here's the abstract of the pediatric clinic study
- check out the Medscape Medical News article

Experts: Use patients to reduce errors in electronic records

Marla Durben Hirsch — Thu, 10 May 2012 10:07:45 -0400

Giving patients better access to their electronic health records is not only part of Stage 2 of Meaningful Use. It's also an effective way to improve the quality of the data, according to a panel of experts who spoke on a recent webinar hosted by the National e-health Collaborative, a public-private partnership established by a grant from the Office of the National Coordinator for Health IT (ONC) to foster national health information exchange (HIE).

"You can't proofread your own stuff. You have to have a second pair of eyes," said speaker Dave deBronkart, co-chair of the Society for Participatory Medicine.

DeBronkart pointed out that patients often catch mistakes in their medical records. He likened bad data to an infectious disease, which spreads like "crazy" if not fixed.

However, more research is needed to determine the best way to provide patients with access to their electronic records, said Prashila Dullabh, Health IT program area director of NORC, a research organizatrion affiliated with the University of Chicago. "There is great variety in how EHRs handle amendments," she said.

One promising way to share data with patients and correct mistakes is to use patient portals tethered to EHRs, Norman Sondeimer, Ph.D., co-director of the electronic enterprise institute at the University of Massachusetts, Amherst said during the webinar. A recent study of eight hospitals' patient portals found that the portals can encourage feedback using a feedback button embedded on the screen. Then an icon can identify that the patient suggested an edit to the data, giving the provider the opportunity to review and formally change the medical record.

While the concept of providing patients access to their digital data didn't appear controversial, there are concerns that requiring it of all hospitals to meet Stage 2 of Meaningful Use may not be practicable. The American Hospital Association (AHA) noted in its comment letter on the proposed rule for Stage 2 that the requirement raises security issues and that many hospitals do not yet have the technical capability.

To learn more:
- here's information about the webinar
- check out NeHC's website
- read the AHA's comment letter (.pdf)

Society: Give patients 'immediate' access to EHR data

Marla Durben Hirsch — Thu, 10 May 2012 09:59:17 -0400

The Society for Participatory Medicine (SPM) has expressed concern that proposed delays in allowing patients access to their EHR records under Stage 2 of the Meaningful Use EHR incentive program are "arbitrary" and will hurt patient care.

In a comment letter submitted to CMS May 4, the SPM warned that the proposed four-day grace period between the time that eligible professionals obtain patient records and when they must provide access to the patient impedes the continuity of care--as does the proposal to give providers 36 hours to provide discharge information after a patient leaves the hospital.

"Information should be available to the patient and patients' designees as soon as it is available to any clinical user of the [certificated EHR technology] other than the author of the information itself," SPM said in its letter.

Using the mantra "nothing about me without me," the SPM also recommended, among other things, that the rule allow for some automation for the accessing and downloading data to increase the likelihood that patients will access their electronic records.

In contrast, The American Hospital Association requested in its comment letter that the 36 hour delay wasn't long enough; it asked CMS to give hospitals 30 days after a patient's discharge before having to provide discharge information to patients.

The AHA's position has been lambasted by some in the industry, including Deven McGraw, director of the Health Privacy Project at the Center for Democracy and Technology and a member of ONC's HIT Policy Committee, who said hospitals shouldn't have the right to "hoard" information.

To learn more:
- here's SPM's letter to CMS
- read its letter to ONC
- here's the AHA's comment letter
- read McGraw's blog post
- read the original rule

AMA: Proposed rule discourages doc participation in EHR program

Marla Durben Hirsch — Thu, 10 May 2012 09:24:38 -0400

The proposed requirements for Stage 2 of Meaningful Use are too inflexible and difficult to attain, discouraging physician participation in the incentive program rather than encouraging it, according to a comment letter sent by the American Medical Association to the Centers for Medicare & Medicaid Services this week.

The AMA, along with 98 other state specialty medical societies, supported some of the elements of the proposed rule, but expressed concern that the criteria were cumbersome, especially since physicians are still facing challenges in meeting the measures for Stage 1 of Meaningful Use.

"Changes to the Meaningful Use program including the proposed Stage 2 criteria and penalty programs, are necessary to ensure that the Meaningful Use program lives up to its intended purpose--to help physicians adopt, implement, and meaningfully use EHRs," the organizations noted in the comment letter.

The medical groups suggested, among other things, that:

CMS evaluate Stage 1 before finalizing Stage 2;
Measures factor in relevancy and include exclusions;
The suggested thresholds are too high;
Only measures within a physician's control should be used;
Good faith efforts to meet Meaningful Use should count;
The requirements be synchronized more with other health IT programs;
Appeals processes be expanded; and that
Certain exemption categories be established, such as physicians close to retirement age

The medical groups' concerns mirror those made by other provider organizations. For instance, the American Hospital Association (AHA) and the medical groups both requested that providers be afforded more time before providing information to patients. Both the medical groups and the College of Healthcare Information Management Executives (CHIME) requested that providers need only demonstrate Meaningful Use for 90 days in the first year of Stage 2.

Meanwhile, electronic health record vendors, while supportive of the proposed rule, also expressed concern that it was overly ambitious, with the Electronic Health Records Association (EHRA) recommending a shorter reporting period in the first year of Stage 2, fewer objectives and better alignment with other health IT programs.

To learn more:
- read the AMA's comment letter
- here's the AHA's comment letter
- check out CHIME's comment letter
- read EHRA's comment letter
- read the proposed rule

Health IT groups want more alignment in MU Stage 2

Marla Durben Hirsch — Thu, 10 May 2012 07:50:24 -0400

The rule implementing Stage 2 of Meaningful Use needs to be more consistent with other reporting and quality requirements, according to several major stakeholders in the health IT provider industry.

The Healthcare Information and Management Systems Society (HIMSS), the College of Healthcare Information Management Executives (CHIME) and the American Health Information Management Association (AHIMA) all noted in their comments to the Centers for Medicare & Medicaid Services regarding the proposed rule that the requirements needed to be more consistent with other existing state and federal requirements, such as the Medicare Shared Savings Program and the Physician Quality Reporting System.

"We trust this will result in fewer reporting burdens for EPs as well as greater comparability of quality data within the medical practices as well as across federal programs," AHIMA noted in its letter.

Other groups commenting, such as the American Medical Association, also requested more alignment of government requirements, including the electronic prescribing rules.

The health IT entities suggested other steps to improve the rule, such as HIMSS' encouraging the use of mobile technology to support patient engagement; the organization noted provider concerns that using patient portals would be ineffective. AHIMA recommended that the functionality for electronic accounting for disclosures, which is a requirement enacted by the HITECH Act, not be made mandatory.

The organizations also were consistent in their concern about using clerical support as scribes for computerized physician order entry. Both HIMSS and CHIME were against it, while AHIMA requested more clarification.

To learn more:
- read this AHIMA announcement
- view HIMSS' comments
- read the AMA's comment letter
- check out CHIME's comment letter

EHR adoption rates vary drastically by state

Marla Durben Hirsch — Thu, 03 May 2012 11:01:53 -0400

The number of physicians reporting the use of electronic health record systems rose to 57 percent in 2011, up from 17 percent in 2002, according to a recent report issued by the Robert Wood Johnson Foundation. However, adoption rates differed substantially among different states. For instance, the states with the highest percentage of physician adoptees were Minnesota (60.9 percent), Wisconsin (59.9 percent) and North Dakota (57.9 percent); while the states with the lowest rates were Louisiana (15.9 percent), New Jersey (16.3 percent) and South Carolina (19.5 percent). More than half of the physicians surveyed (52 percent) intended to apply for Meaningful Use incentive money, but only 10.5 percent of those reported also having the ability to meet the incentive program requirements. Report (.pdf)

EHR alerts help recruit patients for clinical trials

Marla Durben Hirsch — Thu, 03 May 2012 10:02:03 -0400

Clinical trial alerts (CTAs) generated by electronic health records are subject to alert fatigue, but remain helpful in potential recruitment of participants in clinical trials, according to a new study published in the Journal of the American Medical Informatics Association.

The researchers, from Ohio State University and the University of Cincinnati, analyzed 907 CTAs triggered by EHRs used by 178 physicians in a 36-week study. They found that the initial response rate by the physicians to the CTAs was about 50 percent. The response rate declined significantly over time, decreasing by 2.7 percent every two weeks. However, even after 36 weeks the response rate was still between 30 and 40 percent, not as low as anticipated.

"The use of EHR-based CTAs has been demonstrated to increase participant recruitment rates to clinical trials, and is a promising approach for overcoming the major problem of inadequate and slow participant recruitment," the researchers noted.

The researchers suggested that future CTA deployments be tailored to particular settings and frequencies to maximize their benefit and reduce alert fatigue.

Other research has pointed to the high frequency of reminders causing alert fatigue, rendering them ineffective. For example, a 2005 JAMIA study on drug alerts noted that physicians overrode alerts between 49 and 96 percent of the time. Another study, published in Health Affairs in December, indicated that EHR vendors purposely set alerts overly frequently to avoid liability. The researchers noted that response rates for clinical decision support tended to be lower than those for CTAs.

For more information:
- read the JAMIA CTA study
- here's the alert fatigue study from 2005
- check out the Health Affairs abstract

GAO: CMS verification of providers in incentive program lacking

Marla Durben Hirsch — Tue, 01 May 2012 15:59:12 -0400

The Centers for Medicare & Medicaid Services has implemented some procedures to verify whether providers have met the eligibility and reporting requirements of the electronic health record incentive program, but needs to do more, according to a new report published by the Government Accountability Office (GAO).

The GAO, analyzing what measures have been instituted to check whether providers met the requirements, noted that CMS has implemented automatic checks built into its databases to verify information submitted by providers when they register and whether they're using a certified EHR system, as required by the program.

CMS is also developing its strategy to audit providers post payment. According to the report, starting in 2012, CMS plans to audit a sample of 10 percent of eligible professionals and 5 percent of hospitals to see if they meet the reporting requirements. The agency also will audit 20 percent of eligible professionals and 10 percent of hospitals to verify that they're really using certified EHRs, and is developing processes to verify that payments made to hospitals are accurate.

However, the GAO found that these processes were insufficient.

"As a new program with particular complexities--such as the number and types of measures providers must report--there are risks to program integrity, and CMS could take steps, beyond those already taken, to assess and mitigate the risk of improper payments and to improve program efficiency," the GAO stated.

The GAO appeared particularly concerned about auditing providers before they're paid incentive money so as to avoid the "pay-and-chase" method of dealing with improper payments, an issue CMS has been struggling with. CMS has been trying to move away from "pay and chase" when dealing with fraudulent payments as well in its recovery audit contractor program.

The GAO recommended, among other things, that CMS establish time frames for evaluating the effectiveness of its audit strategy, consider conducting more verification on a prepayment basis and offer states the option of having CMS collect attestations from Medicaid providers on behalf of the states. CMS disagreed with the latter recommendation.

To learn more:
- read the report (.pdf)
- here's more on CMS' effort to reduce 'pay and chase' in fighting improper payments
- here's the status of prepayment review in the RAC program

EHR incentive payments boost for-profit hospitals' revenue

Marla Durben Hirsch — Tue, 01 May 2012 15:53:47 -0400

Meaningful Use incentive payments helped to lift for-profit hospitals' earnings in an otherwise "tepid" year, according to global rating agency Fitch.

In its recent quarterly review, although patient utilization and pricing trends for for-profit hospitals were mixed in 2011, the incentive payments boosted the hospitals' earnings--before interest, taxes, depreciation and amortization--by $396 million. Cash from operations increased $440 million.

Fitch noted that the incentive payment numbers were "modest" in 2011, and expects larger payments in 2012 and 2013 as the program progresses.

"Lower cash interest expenses, electronic health record incentive payments, and sustained profitability will be tailwinds to cash generation during [2012]," the agency predicted.

The report may be more sobering than at first blush if hospitals now are relying on, or hoping that, the payments will boost their earnings. A recent report from KMPG indicates that hospitals doubt their ability to meet Meaningful Use. What's more, the American Hospital Association notes in its comments to the Centers for Medicare & Medicaid Services on the proposed rule implementing Stage 2 that the vast majority of hospitals--more than 80 percent--haven't even met the requirements for Stage 1 of Meaningful Use.

To learn more:
- read the Fitch announcement
- check out the KPMG report (.pdf)
- here's the AHA comment letter to CMS (.pdf)

EHRs hold promise for genetic testing research

Marla Durben Hirsch — Tue, 01 May 2012 15:47:49 -0400

Electronic health records hold promise in augmenting current studies of genetic testing, according to a study recently published in the Journal of the American Medical Informatics Association.

The researchers, from Massachusetts General Hospital and Harvard, analyzed the EHR data of 10,715 patients being treated by 942 physicians affiliated with academic medical centers. The study found that genetic testing was ordered by a "diverse" group of physicians, who ordered tests on 1.1 percent of their female patients of child bearing age. The tests most commonly ordered were cystic fibrosis (36.7 percent), prothrombin (13.7 percent) and Tay-Sachs (6.7 percent).

The researchers suggested that the data in the EHRs could be aggregated and used for additional functions, including the identification of patterns.

"EMRs currently serve primarily as a storage warehouse for textual reports that could potentially be transformed into meaningful structured data for next-generation clinical decision support. Further studies are needed to address the design, development, and implementation of EMRs capable of managing the critical genetic health information challenges of the future," the researchers noted.

This is not the first time that it has been suggested that EHRs can improve genetic testing and related care. The data in EHRs can be used to identify patients who should undergo the testing and to populate public registries, such as the new genetic testing registry launched by the National Institutes of Health.

EHRs also may help keep the cost of genetic testing down. A study published in March by UnitedHealth Group determined that spending on genetic testing will greatly increase over the next few years, hitting $25 billion per year by 2021.

For more information:
- here's an abstract of the study
- check out this article about the cost of genetic testing (.pdf)
- read NIH's announcement